Cal MediConnect Performance Dashboard Released March 2016 Health Risk Assessments (HRAs): Cumulative (April 2014 - September 2015) and Quarter 3 (July 2015- September 2015) data. See metric summary for additional information. HRAs completed within 90 days of enrollment Note: Fig 1-1 and 1-2 excludes beneficiaries who were unwilling to participate in a HRA or unreachable by the plan during the reporting period. Fig 1-1 Overall completion Completed Cumulative 88% Q3'15 80% Not Completed 12% 20% Fig 1-2 Completion per plan 71% 100% 68% 100% 82% 100% 100% 97% 96% 39% 69% 100% 91% 56% 78% 100% 100% 98% 89% 73% Fig 1-3 Members with 90 days of enrollment Note 1-3: CalOptima started voluntary enrollment during this period with 1 member enrolled during July 2015 whose 90th day of enrollment occurred within the reporting period. Cumulative Q3'15 9,966 1 11,882 6,037 10,770 34,718 26,273 19,065 19,764 7,637 1,398 1 456 185 134 2,873 1,441 2,165 717 1,895 Anthem CalOptima Care1st CHG HPSM Health Net IEHP LA Care Molina SCFHP Cumulative Q3'15 Fig 1-4 Quarterly totals Q4'14 Note 1-4: A substantial number of Dual Special Needs Plan (DSNP) and Low income subsidy (LIS) members were passively enrolled into the CMC Program with an effective date of January 1, 2015. Q1'15 Q2'15 Q3'15 Completed 5,479 33,610 9,024 5,121 Unwilling 2,497 7,422 1,754 774 Unreachable 8,182 26,915 7,119 4,069 Not Completed 949 2,884 864 1,301 - 5,000 10,000 15,000 20,000 25,000 30,000 35,000 40,000 HRAs Page 1 of 5
Transcript
Cal MediConnect Performance Dashboard
Released March 2016
Health Risk Assessments (HRAs): Cumulative (April 2014 - September 2015) and Quarter 3 (July 2015- September 2015) data.
See metric summary for additional information. HRAs completed within 90 days of enrollment
Note: Fig 1-1 and 1-2 excludes beneficiaries who were unwilling to participate in a HRA or unreachable by the plan during the reporting period.
Fig 1-1 Overall completion
Completed
Cumulative
88%
Q3'15
80%
Not Completed
12% 20%
Fig 1-2 Completion per plan
71% 100% 68% 100%
82% 100% 100% 97% 96% 39%
69% 100% 91% 56%
78% 100% 100% 98% 89% 73%
Fig 1-3 Members with 90 days of enrollment
Note 1-3: CalOptima started voluntary enrollment during this period with 1 member enrolled during July 2015 whose 90th day of enrollment occurred within the reporting period.
Cumulative
Q3'15
9,966
1
11,882
6,037
10,770
34,718
26,273
19,065
19,764
7,637
1,398
1
456
185
134
2,873
1,441
2,165
717
1,895
Anthem
CalOptima
Care1st
CHG
HPSM
Health Net
IEHP
LA Care
Molina
SCFHP
Cumulative Q3'15
Fig 1-4 Quarterly totals
Q4'14
Note 1-4: A substantial number of Dual Special Needs Plan (DSNP) and Low income subsidy (LIS) members were passively enrolled into the CMC Program with an effective date of
January 1, 2015.
Q1'15 Q2'15 Q3'15
Completed 5,479 33,610 9,024 5,121
Unwilling 2,497 7,422 1,754 774
Unreachable 8,182 26,915 7,119 4,069
Not Completed 949 2,884 864 1,301
-
5,000
10,000
15,000
20,000
25,000
30,000
35,000
40,000
HR
As
Page 1 of 5
Cal MediConnect Performance Dashboard
Released March 2016
Health Risk Assessments (HRAs): Cumulative (April 2014 - September 2015) and Quarter 3 (July 2015 - September 2015) data.
See metric summary for additional information.
Fig 2-1 Q3'15 HRA breakdown
49.4%
Completed Unwilling Unreachable Not Completed
100.0%
37.9%
80.5%
54.5% 44.1%
35.9%
56.6% 67.2%
28.7%
1.9%
0.0%
9.6%
4.3%
23.9%
12.0%
6.7%
1.2%
14.8%
4.7%
28.3%
0.0%
34.4%
15.1% 9.7%
43.8% 57.3%
40.5%
15.2%
21.4%
20.4%
0.0% 18.0%
0.0% 11.9%
0.1% 0.0% 1.7% 2.8%
45.3%
Anthem CalOptima Care1st CHG HPSM Health Net IEHP LA Care Molina SCFHP
Fig 2-2 Cumulative HRA breakdown
Completed Unwilling Unreachable Not Completed
44.0%
100.0%
43.7% 48.9% 47.5% 32.4%
40.8%
68.5%
42.3% 39.0%
5.0%
0.0%
8.6% 2.8%
26.1%
18.8% 7.9%
1.3%
10.9% 4.5%
31.0%
0.0%
43.5%
10.4%
13.2% 48.8% 51.3%
29.0%
41.7%
41.7%
20.0%
0.0% 4.2%
37.9%
13.1% 0.0% 0.0% 1.2% 5.2%
14.8%
Anthem CalOptima Care1st CHG HPSM Health Net IEHP LA Care Molina SCFHP
Page 2 of 5
Cal MediConnect Performance Dashboard
Released March 2016
A Fully Favorable decision is defined as an item or service covered in whole. A Partially Favorable decision is defined as an item or service partially covered. An Adverse decision is
defined as an item or service denied in whole. Initial denials were issued due to a lack of records or medical necessity. Upon appeal and receipt of additional information from
providers, plans were able to resolve these determinations in favor of the member the majority of the time. Plans are working on strengthening their initial determination process to
improve care delivery.
Appeals by Determination: Quarter 3 (July 2015 - September 2015) data. See metric summary for additional information.
Fig 3-1 Appeal determinations
Fully Favorable
86%
Partially Favorable
9%
Adverse
5%
Fig 3-2 Appeal determinations per 1,000 members
Appeals Q3 Average 0.9
1.1
0.0
1.5
0.0
2.5
0.8
0.3
1.1 1.6
0.0
Fig 3-3 Appeal determinations by plan
Fully Favorable Partially Favorable
Adverse Q3 Plan Average 11.4
9 0
12
0
18 19
1
16 23
0 0 0
5 1
4 0
2
2
1
1
Fig 3-4 Quarterly trending
Note 3-4: HPSM had an increase of 24 appeals from the previous quarter. The increase was due to providers not responding timely to initial requests for additional information. HPSM
has offered education and outreach to providers to improve communication and response time.
Appeal determinations per 10,000 Members
Q4'14
6.2
Q1'15
4.2
Q2'15
4.4
Q3'15
9.7
0.0
2.0
4.0
6.0
8.0
10.0
12.0
Ap
pea
ls
Page 3 of 5
Cal MediConnect Performance Dashboard
Released March 2016
Hospital Discharge: Quarter 3 (July 2015 - September 2015) data. See metric summary for additional information.
Fig 4-1 Discharges that resulted in an ambulatory care follow-up visit within 30 days of hospital discharge
% of discharges w/ follow-up Q3 Average 61%
52% 41%
73%
56%
84%
55% 66% 65%
43%
72%
Note 4-1: Molina is revamping their transition of care program. This program will have a higher touch member transition focus as a key intervention to ensure proper follow up.
CalOptima has implemented a post discharge team to reach out to members following discharge from acute care to assure they have the appropriate physician follow-up coordinated.
Fig 4-2 Quarterly trending
Note 4-2: Plans were required to report on this measure starting in January 2015.
Q1'15 Q2'15 Q3'15
Discharges 5,082 4,736 4,438
Follow-up visits 3,154 3,071 2,811
Percentage 62% 65% 63%
62% 65% 63%
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Dis
char
ges
1,000
2,000
3,000
4,000
5,000
6,000
Emergency Utilization: Quarter 3 (July 2015 - September 2015) data. See metric summary for additional information.
Fig 4-3 Behavioral health-related emergency visits per 1,000 members
Visits Q3 Plan Average 8.7
0.4
7.2
12.1
16.1
8.5 7.9 10.6
6.3 7.5
10.8
Fig 4-4 Quarterly trending
Vists per 1,000 members
Q4'14
8.4
Q1'15
7.7
Q2'15
8.6
Q3'15
10.3
-
Emer
gen
cy V
isit
s
2.0
4.0
6.0
8.0
10.0
12.0
Page 4 of 5
Cal MediConnect Performance Dashboard
Released March 2016
LTSS Utilization: Quarter 3 (July 2015 - September 2015) data. See metric summary for additional information.
Fig 5-2 Quarterly trending for members receiving LTSS
Q4'14 Q1'15 Q2'15 Q3'15
IHSS 17537 32070 29410 27252
CBAS 1068 2236 1669 1262
MSSP 363 562 526 539
Nursing Facility 2865 5182 4866 4690
Uti
lizat
ion
0
5000
10000
15000
20000
25000
30000
35000
Case Management: 2014 data. This metric is reported annually. See metric summary for additional information.
Fig 5-3 Members contacted by their case manager or care team
Contact % Average 85%
Anthem
94%
Care1st
98%
CHG
100%
HPSM
100%
Health Net
80%
IEHP
59%
LA Care
52%
Molina
98%
Note on 5-3 L.A. Care has hired additional care staff and revised its care management workflow to ensure all CMC high risk members are assigned a dedicated Care Manager. IEHP held
training sessions with delegated physician groups on HRAs and care management best practices. IEHP has developed a QA process that reviews timeliness of care management
contacts.
Page 5 of 5
Cal MediConnect Performance Dashboard Metrics Summary
Page 1 of 2
Plan Key Plan Name
Anthem Blue Cross Partnership of California
CalOptima
Care1st
Community Health Group
Health Net
Health Plan of San Mateo
Inland Empire Health Plan
LA Care
Molina Healthcare
Santa Clara Family Health Plan
Plan abbreviation on Dashboard
Anthem
CalOptima
Care1st
CHG
Health Net
HPSM
IEHP
LA Care
Molina
SCFHP
Metric Summary
Health Risk Assessments (HRAs): An HRA is a survey tool conducted by the Medicare-Medicaid Plan (MMP) that assesses an enrollee’s current health risk and identifies further assessment needs such as behavioral health, substance use, chronic conditions, disabilities, functional impairments, assistance in key activities of daily living, dementia, cognitive and mental status, and the capacity to make informed decisions. This metric is a Centers for Medicare & Medicaid Services (CMS) Core Measure. For this measure data is compared cumulatively and quarterly. See Dashboard figures 1-1 to 2-2.
Appeals (Reconsiderations) by Determinations: An organization determination is a MMPs response to a request for coverage (payment or provision) of an item or service – including auto-adjudicated claims, prior authorization requests, and requests to continue previously authorized ongoing courses of treatment. It includes requests from both contract and non-contract providers. If a MMP denies an enrollee's request for an item or service in whole or in part (issues an adverse organization determination), the enrollee may appeal the decision to the MMP by requesting reconsideration. Reconsideration is a plan’s review of an adverse or partially favorable organization determination. This metric is a CMS Core Measure. See Dashboard figures 3-1 to 3-4.
Cal MediConnect Performance Dashboard Metrics Summary
Page 2 of 2
Hospital Discharge: The Hospital Discharge metric measures ambulatory follow-up visits. Ambulatory care follow-up visits assess the member’s health following a hospitalization. A higher percentage is an indicator of better care coordination. This metric is a California Specific CMS Core Measure. See Dashboard figures 4-1 to 4-2.
Emergency Utilization: The Emergency Utilization metric measures behavioral health-related emergency visits. A visit is comprised of a revenue code for an emergency department visit and a principal diagnosis related to behavioral health. This metric is a CMS Core measure. See Dashboard figure 4-3 to 4-4.
Long Term Care Services and Supports (LTSS) Utilization: LTSS Utilization is reported by each MMP. LTSS
services include In-Home Supportive Services (IHSS), Nursing Facility Services, Community Based Adult Services
(CBAS), and Multi-Purpose Senior Services Program (MSSP). This metric measures the total number of members
receiving LTSS for the reporting period. This metrics is a California Specific CMS Core Measure. See Dashboard figures
5-1 to 5-2.
Case Manager Contact: The Case Manager Contact metric measures the percentage of members with a case manager
who received contact by their case manager or care team during the reporting period. This measure is reported annually
and reflects the 2014 reporting period. This metrics is a California Specific CMS Core Measure. See Dashboard figures 5-
