Cal MediConnect Performance Dashboard - DHCS Homepage · 2019-06-21 · Cal MediConnect Performance...

Cal MediConnect Performance Dashboard Metrics Summary Released June 2019

The Cal MediConnect (CMC) pr ogram is a voluntar y demonstration operated by the Department of Health Care Servi ces (DHCS) in collaboration with the Centers for M edicare and Medicaid Services (CMS) to provide better coordinated c are for beneficiaries eligible for both Medicare and Medicaid (also kno wn as “duals”). Cal MediConnect Plans (Plans) combine and coordinate Medic are and Medi-Cal benefits for eligible members, including medic al, behavioral health, long-term institutional, and home-and-community based ser vices. Seven counties are participating in the program: Los Angeles , Orange, San Diego, San Mateo, Riverside, San Ber nardino and Santa Clara.

DASHBOA RD OVERVIEW AND KEY TRENDS This dashboard provides select data an d measur es on key aspects of the Cal MediConnect Program:

• Enrollment and Demographics: Figures 1-6Statewide enrollment in Cal MediConnect has decreased from 112,538 members in January 2018 to 110,976 inDecember 2018. In Q4 2018, 50% of enrollees spoke English and 31% spoke Spanish as their primary language, with36% of enrollees identifying as Hispanic. Males and females aged 65 and older represent 29% and 43% of the totalCMC population, respectively.

• Quality Withhold Summary: Figure 7All Plans met at least four quality withhold measures and all ten Plans received 50% or more of the quality withholdamount for Calendar Year 2016. Four of the ten Plans received 100% of their withhold.

• Care Coordination: Figures 8-15Figure 8 shows that the percentage of members with a health risk assessment (HRA) completed within 90 days ofenrollment slightly increased from 90% in Q1 2018 to 91% in Q4 2018.

• Grievances and Appeals: Figures 16-19Plans reported 69% more grievances in 2018 compared to 2017. In 2018, Plans reported 133% more appeals than in2017. Of the total appeals, Figure 16 shows that 30% of Plan decisions were either fully or partially favorable to themember. Please note that the Grievance and Appeals measure specifications changed in 2018 which may havecontributed to the increased reporting for grievances and appeals. See "Grievances and Appeals Trends" section formore details.

• Behavioral Health Services: Figures 20-21Figure 20 shows the rate of Cal MediConnect members seeking care in the emergency room for behavioral healthservices. Utilization has decreased from 24.9 visits per 10,000 member months in Q1 2018 to 19.1 visits in Q4 2018.

• Long-term Services and Supports: Figures 22-41Figure 22 shows that LTSS utilization per 1,000 members has seen little change throughout the reporting period; from anaverage of 282.7 members per 1,000 receiving LTSS in Q1 2018, to an average of 280.8 members in Q4 2018. DHCS iscontinuing to work with Plans to enhance LTSS referrals. Figures 24-41 display LTSS member referrals and utilization infive categories: In-Home Support Services (IHSS),1 Multipurpose Senior Services Program (MSSP), Community-BasedAdult Services (CBAS), Nursing Facility (NF) and Care Plan Options (CPO).

1 IHSS member referral data are not included in this dashboard due to ongoing data quality assessment.

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Data and Analysis Notes:The dashboard is a tool that displays a combination of quarterly and annual measures. Dashboard data are reported by plan, except for the enrollment and demographic data which are calculated on a county-basis by DHCS (more information below). The dashboard presents the most current data available, therefore, the reporting time periods for each metric reported may vary for each release.

• Quarterly Rolling Statewide Average: Figures 8, 10, 15, 20, 22, 24, 26, 28, 30, 32, 34, 36, 38 and 40.Metrics represent the entire CMC program broken down by calendar quarters.

• Current Quarter data by plan: Figures 9, 11, 23, 25, 27, 29, 31, 33, 35, 37, 39 and 41.Metrics represent the data for the most recent quarter broken down by plan.

• Annual data: Figures 7, 12, 13, 14, 16, 17, 18, 19 and 21.Annual data are updated once a year and are compared to previous years that are only collected in aggregate.

• Updated data: Figures 1-6, Figures 8-14, Figures 16-19 on Grievances and Appeals were updated to includethe categories in access to care, transportation, billing, and home health/personal care, Figures 20-41 havebeen updated for the June 2019 release.

• New Data: Figures 38-41 were added to show member referrals for and utilization of CPO services.

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DETAILED DASHBOARD METRICS AND TRENDS This section of the Dashboard Metrics Summary provides a detailed explanation of the performance metrics as well as a summary of key trends.

Cal MediConnect Enrollment and Demographics:Enrollment and demographic data are a point-in-time view of the Cal MediConnect population. The data come from the DHCS data warehouse and reporting system named the Medi-Cal Management Information System/Decision Support system (MIS/DSS).

In addition to the quarterly enrollment and demographic data reported in this dashboard, monthly Cal MediConnect enrollment data will now be available through the Medi-Cal Managed Care Enrollment Reports

http://www.dhcs.ca.gov/dataandstats/reports/Pages/MMCDMonthlyEnrollment.aspx


Quality Withhold MeasuresCMS and DHCS monitor Plans using quality measures relating to beneficiaries' overall experience, care coordination, fostering and support of community living, and more.1 These measures, which are required to be reported under Medicare and Medicaid, build on other required data: Healthcare Effectiveness Data and Information Set (HEDIS), Medicare Health Outcome Survey, and Consumer Assessment of Healthcare Providers and Systems (CAHPS) data.

CMS and DHCS utilize reported metrics from the combined set of core and California-specific quality measures. Core measures are common across all states participating in duals demonstrations, and were primarily developed by CMS. California-specific measures were created through a collaborative partnership between DHCS, CMS, and public stakeholders.

Based on their performance on a designated set of core and California-specific measures, called “quality withhold measures,”2 Plans may receive all or a portion of an amount withheld from their capitation payment (with the exception of Part D components), at the end of each calendar year.

All quality withhold measures have benchmarks that the Plans are required to meet in order to receive some or all of the quality withhold payment. The Quality Withhold Summary is for Calendar Year 2016.

1Core and State-Specific Reporting Requirements:https://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-Coordination-Office/FinancialAlignmentInitiative/MMPInformationandGuidance/MMPReportingRequirements.html2Core and State-Specific Quality Withhold Methodology and Technical Notes:https://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-Coordination-Office/FinancialAlignmentInitiative/MMPInformationandGuidance/MMPQualityWithholdMethodologyandTechnicalNotes.html

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https://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-Coordination-Office/FinancialAlignmentInitiative/MMPInformationandGuidance/MMPReportingRequirements.html

https://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-Coordination-Office/FinancialAlignmentInitiative/MMPInformationandGuidance/MMPQualityWithholdMethodologyandTechnicalNotes.html


Figure 7 shows the quality withhold measures for the calendar year 2016. Definitions of the measures included for Figure 7 are below:

CW stands for “core withhold”, and in most cases, a core withhold measure corresponds with a core quality measure. CAW stands for “California withhold” and usually corresponds with a state-specific quality measure. Quality withhold measures may be stand-alone, or based on HEDIS, CAHPS, or other national data sources.

Quality withhold measure results indicated with "N/A" represent measures that were not applicable for a plan due to low enrollment or the inability to meet other reporting criteria. Quality withhold measure results indicated with "*" represent measures that also utilize the gap closure target methodology.1

• Plan All-Cause Readmission: The ratio of the plan’s observed readmission rate to the plan’s expected

readmission rate. The readmission rate is based on the percent o

f plan members discharged from a hos

pital stay who were readmitted to a hospital within 30 days, either for the same condition as their recent hospital stay or for a different reason. (CW6)

• Annual Flu Vaccine:

Percent of plan members who got a vaccine (flu shot) pr

ior to flu season. (CW7)

• Follow-Up After Hospitalization for Mental Illness: Percentage of discharges for plan members 6 years of age and

older who were hospitalized for treatment of selected mental health disorders and who had an outpatient visit, an

intensive outpatient encounter or partial hospitalization with a mental health practitioner within 30 days of discharge.

(CW8)

• Controlling Blood Pressure: Percentage of plan members 18-85 years of age who had a diagnosis of hypertension

and whose blood pressure was adequately controlled (<140/90) for

members 18-59 years of age and 60-85 years of

age with diagnosis of diabetes or (150/90) for members 60-85 wi

thout a diagnosis of diabetes during the

measurement year. (CW11)

• Medication Adherence for Diabetes Medications: Percent of plan members with a pr

escription for diabetes

medication who fill their prescription often enough to cover 80%

or more of the time they are supposed to be taking the medication. (CW12)

• Encounter Data:

Encounter data for all services c

overed under the demonstration, with the exception of PDE data,

submitted timely in compliance with demonstration requirements. (CW13)

1California Medicare-Medicaid Plan Quality Withhold Analysis Results Demonstration Year 2:

https://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-Coordination-

Office/FinancialAlignmentInitiative/Downloads/QualityWithholdResultsReport_CA_DY2_06192018.pdf

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https://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-Coordination-Office/FinancialAlignmentInitiative/Downloads/QualityWithholdResultsReport_CA_DY2_06192018.pdf


• Behavioral Health Shared Accountability Outcome M easure: Reduction in emergency department (ED) use for seriously mentally ill and substance use disorder members. (California-specific m easure 4.1, CAW7) • Documentation of Care Goals: Members with documented discussions of care goals. (California-specific measure 1.6, CAW8) • Interaction with Care Team: Percent of members who have a care coordinator and have at least one care team

contact during the reporting period. (California- specific measure 1.12, CAW9)

Quality Withhold Trends:The latest data available show that all 10 Plans met at least four quality withhold measures and nine of the ten Plans received at least 75% or more of their quality withhold amount for Calendar Year 2016. Anthem, IEHP, Molina and HPSM received 100% of their withhold.

Care Coordination Measures:Enhanced, person-centered care coordination is a key benefit of Cal MediConnect. The dashboard tracks different measures and aspects of that benefit, from the initial health risk assessment to start the care coordination process, to the development of an individualized care plan, to care coordinators, and post-hospital discharge follow-up care.

• Health Risk Assessments (HRAs): An HRA is a survey tool conducted by the Plans to assess a member’scurrent health risk(s) and identifies further assessment needs such as behavioral health, substance use, chronicconditions, disabilities, functional impairments, assistance in key activities of daily living, dementia, cognitive andmental status, and the capacity to make informed decisions.

o Plans must complete assessments for high risk members within 45 days of enrollment, and for low-riskmembers within 90 days. Information tracking 90-day HRA completion rates comes from a Core measure.Figures 8 & 9 do not include unwilling and unable to reach populations in calculations.

• Individualized Care Plans (ICPs): The care plan is developed by members with their interdisciplinary care teamor Plans. Engaging members in developing their own care goals and care plans is a central tenant of person-centered care. ICPs must include the member’s goals, preferences, choices, and abilities. Documentingdiscussions of care goals with members is one way to assess how Plans are engaging members in their careplanning and are monitored through multiple California-specific measures.

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• Follow-up Visits within 30 Days of Hospital Discharge: Supporting members through care transitions, particularly out of an acute hospital stay, is another measure of care coord ination activities. In 2016, DHCS released a Dual Plan

Letter on dischar ge planning in Cal MediConnect, and this continues to be an are a of focus for program improvements. Information comes from a California-specific meas ure.

• Care Coordinators and Interdisciplinary Care Teams (ICT): An ICT works with a member to develop, implement,and maintain an ICP. The ICT is c omprised of the primary care provider and care coordinator, and other providers at the discretion of the member. Information comes fr om a California-s pecific measure.

are Coordination Trends : igure 8 shows that the quarterly statewide percentage of members willing to participate in care coordination, and ho the Plan was able to locate, with an assessment completed within 90 days of enrollment has slightly increased

rom 90% in Q1 2018 to 91% in Q4 2018. Figure 9 shows that four out of ten plans (Blue Shield, HealthNet, alOptima and HPSM) are below the statewide average of 91% for Q4 2018.

igure 10 indicates that the percent of members with an ICP has increased from 65% in Q1 2018 to 70% in Q4 2018. igure 11 indicates that four out of ten Plans have a percentage of members with an ICP below the statewide average f 70% for Q4 2018. ICP performance will continue to be a focus of DHCS program improvements in the coming year,

ncluding potentially enhancing or modifying the quality measures and improving the performance improvement plans hat Plans must perform each year.

HCS will also be working with Plans to better understand the wide variation in the percentage of members with ocumented discussions of care goals, as well as variation in member to care coordinator ratios.

rievances and Appeals: his dashboar d includes data on the two ways Cal MediConnect beneficiaries can resolve issues with their lans:

• Grievances: Grievances are complaints or disputes members file with the Plans that are evaluated at the Plan-level expressing dissatisfaction with any aspect of the Plan’s operations, activities, or behavior. This includes, but is not limited to, the quality of care or services provided (such as wait times or inability to schedule appointm ents), aspects of interpersonal relationships such as rudeness of a provider or employee, or failure to respect a member’s rights. This does not include benefit determinations.

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Cal MediConnect Performance Dashboard Metrics SummaryReleased June 2019

Grievances and Appeals Trends:In an effort to refine reporting and analysis process on grievances and appeals, the following new grievances categories were introduced in 2018: access to care, transportation, billing, and home health/personal care. Figures 17 and 18 show a breakdown of a total of 15,303 grievances, by categories and by Plans, filed by members in 2018. This is an increase of 6,231 member grievances reported as compared to 20171. The Plans that contributed the most to the grievance increase are IEHP, CalOptima, L.A. Care, SCFHP, and Molina. The most common complaints were reported under the “other” category (grievances other than access to care, transportation, billing and home health/personal care). In addition to the reporting that Plans provide to CMS and DHCS, each Plan may internally categorize their grievances and appeals differently, which may account for some of the higher number of “other” grievances when reported through the CMS and DHCS.

The number of appeals varies greatly by Plans, as well as the percentage of decisions that are adverse versus partially or fully favorable. Figures 16 shows that a total of 3,484 appeals were filed by members in 2018, an increase of 1,987 appeals when compared to 20171. The Plans that contributed the most to the increase in appeals are HealthNet, Molina and IEHP. Figure 16 also shows that 30% of Plan decisions were either fully or partially favorable to the member’s appeal filed in 2018. Figure 19 shows that few Plans had appeals related to mental health services.

DHCS and CMS will continue to work with the Plans to better understand the trends in grievances and appeals to ensure beneficiary access to services.

1Cal MediConnect Performance Dashboard March 2019: https://www.dhcs.ca.gov/Documents/CMCDashboard3.19.pdf

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• Appeals: If a Plan denies, reduces, or terminates benefits or services for a member, the member can appealeither through internal processes or an external process through Medi-Cal or Medicare. Appeals can bedetermined as “adverse” (denying the member’s appeal) or partially or fully favorable to the member’s appeal.This dashboard only includes data regarding appeals determined at the Plan’s level.

https://www.dhcs.ca.gov/Documents/CMCDashboard3.19.pdf

https://www.dhcs.ca.gov/Documents/CMCDashboard9.18.pdf


Behavioral Health Emergency Room Utilization:This 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 Core measure.

Behavioral Health Emergency Room Utilization Trends:One goal for Plans is to improve the coordination of behavioral health services for their members, including between the mental health and substance use disorder (SUD) treatments covered by the Plans and the specialty mental health services provided by county behavioral health departments. Figure 20 shows the overall trend of Cal MediConnect members seeking care in the emergency room for behavioral health services has decreased from 24.9 visits per 10,000 member months in Q1 2018 to 19.1 visits in Q4 2018. In mid-2017, Plans began to receive additional and more accurate behavioral health data that may begin to affect how Plans report. DHCS and CMS are monitoring the effects of this change.

Long-term Services and Supports (LTSS) Utilization:A central goal of Cal MediConnect is to improve access to and coordination of long-term services and supports for members in order to help more members live in the community. DHCS has worked closely with Plans to improve referrals to LTSS programs, particularly home and community-based services, as well as to encourage Plans to help their members transition out of nursing facilities and into the community where appropriate. DHCS now collects more detailed data on LTSS utilization and referrals, which will be added to the performance dashboard as it becomes available.

• LTSS Utilization and Referrals: LTSS Utilization and Referrals are reported by each Plan for LTSS Serviceswhich includes In-Home Support Services (IHSS) (carved out beginning in 2018), Community-based AdultServices (CBAS), Multi-purpose Senior Services Program (MSSP), Nursing Facility Services (NF) and CarePlan Options (CPO).

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LTSS Trends:

DHCS is working with the Plans to enhance LTSS referrals, and encouraging Plans to support members in transitioning out of nursing facilities and into the community with home- and community-based LTSS services, as appropriate. In 2019 in particular, the CMS-DHCS contract management teams are working closely with the plans to review their MSSP and CPO referral rates, and to identify best practices to ensure members are being connected with needed services.

Figure 22 shows that LTSS utilization per 1,000 members has seen little change throughout reporting period, from an average of 282.7 members per 1,000 receiving LTSS in Q1 2018, to an average of 280.8 members in Q4 2018.

Figure 24 shows that IHSS utilization per 1,000 members has similarly changed little throughout reporting period from an average of 236.9 members per 1,000 receiving IHSS in Q1 2018, to an average of 237.6 members in Q4 2018.

Figure 26 shows that CBAS referrals per 1,000 members have slightly increased from an average of 1.8 member referrals per 1,000 in Q1 2018 to an average 1.9 member referrals per 1,000 in Q4 2018. HPSM reported the highest number of CBAS referrals of 4.4 per 1,000 members in Q4 2018, as shown in Figure 27. Figure 28 shows that CBAS utilization per 1,000 members has remained steady at an average of 10 members per 1,000 receiving CBAS between Q1 2018 – Q4 2018.

Figure 30 shows that MSSP referrals per 1,000 members have remained steady at an average of 0.6 per 1,000 in throughout the reporting period. Figure 31 shows that HPSM reported the highest number of MSSP referrals of 2.4 per 1,000 members in Q4 2018. Figure 32 shows that MSSP utilization per 1,000 members has increased slightly from 5.5 members per 1,000 in Q1 2018 to 5.7 members per 1,000 in Q4 2018. DHCS worked closely with the Plans in 2019 to better understand MSSP referral policy and procedures, as well as how plans are providing enhanced care coordination and other supports to members on MSSP wait lists. A best practices summary of those efforts was provided to the plans to encourage increased referrals to MSSP.

Figure 34 shows that NF referrals per 1,000 members has increased from an average of 3.9 member referrals per 1,000 in Q1 2018 to an average 4.7 member referrals per 1,000 in Q4 2018. Figure 35 shows Anthem and HPSM reported the highest number of NF referrals of 13.9 and 13.7 per 1,000 members respectively in Q4 2018. Figure 36 shows that NF utilization per 1,000 members has decreased from 29.9 members per 1,000 in Q1 2018 to 27.4 members per 1,000 in Q4 2018.

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Figure 38 shows that CPO referrals per 1,000 member s has increased from an average of 16.0 member referrals per 1,000 in Q1 2018 to an av erage 19.3 member r eferrals per 1,000 in Q4 2018. Figure 39 shows CHG reported the highest number of CPO refer rals of 189 per 1,000 members in Q4 2018. Figure 40 shows that CPO utilization per 1,000 members has increased from 31.9 members per 1,000 in Q1 2018 to 39.9 members per 1,000 in Q4

2018. DHCS is currently reviewing Plan CPO utilization data and definitions with the Plans, as Plan misinterpretation of CPO service definitions

may have resulted in inflated CPO utilization data. DHCS will work with the Plans to

ensure better understanding of the definition of CP O services, the benefits of providing those s ervices, and best practices on referring and supporting members who c ould benefit from CPO services.

Plan Key:

Plan Name Plan Abbreviation on Dashboard Anthem Bl ue C ross Partnership of California Anthem

Blue Shield of California Promise Health Plan* Blue Shield CalOptima CalOptima

Community Health Group CHG Health Net Health Net Health Plan of San Mateo HPSM

Inland Empire Health Plan IEHP L.A. Care L.A. Care

Molina Healthcare Molina Santa Clara Family Health Plan SCFHP

*Formerly Care1st Health Plan.

Cal MediConnect Performance Dashboard - Released June 2019

Cal MediConnect Enrollment and Demographics Figure 1: Breakdowns of Dual Populations (As of 12/1/2018) See metric summary for additional information

112,538 112,110

111,670 110,815 111,045 111,182 111,116 111,381 111,631 111,505 111,418

110,976

100,000

105,000

110,000

115,000

Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18

Fig. 1: Monthly Enrollment

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Cal MediConnect Enrollment and Demographics Figure 2: Breakdowns of Dual Populations (As of 12/1/2018) See metric summary for additional information

3,201

2,880

10,076

15,890

2,271

14,202

13,181

1,911

12,717

1,899

2,128

5,967

1,619

4,253 8,896

2,501

7,384

- 10,000 20,000

CareMore

Blue Shield

Health Net

L.A. Care

Molina

CalOptima

IEHP

Molina

IEHP

Molina

Blue Shield

CHG

Health Net

Molina

HPSM

Anthem

SCFHP

Fig. 2: Count and Percentage of Total Active Enrollments, by County and Plan as of December 2018

34,318; 31%

County total(s) and percentage(s) of active enrollments

14,202; 13%

15,092; 14%

14,616; 13%

13,967; 13%

8,896; 8%

9,885; 9% Santa Clara

San Mateo

San Diego

San Bernardino

Riverside

Orange

Los Angeles

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Cal MediConnect Enrollment and Demographics Figure 3 - 6: Breakdowns of Dual Populations (As of 12/1/2018) See metric summary for additional information

9%

15%

21%

20%

36%

African-American

Asian/Pacific Islander

Other/Unknown

Non-Hispanic/White

Hispanic

0% 25% 50%

Fig. 3: Quarter 4 Enrollment by Race/Ethnicity

1%1%

1%1%2%

5%6%

31%50%

0% 25% 50%

FarsiOther Non-English

CantoneseMandarinTagalog

VietnameseUnknownSpanishEnglish

Female56%

Male44%

2%

11%

43%

3%

12%

29%

0% 25% 50%

Ages 19-39

Ages 40-64

Ages 65+

Fig. 4: Quarter 4 Enrollment by Age

Male Female

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Fig. 5: Quarter 4 Enrollment by Threshold Language Spoken

Fig. 6: Quarter 4 Enrollment by Gender


9 100% 100%

100% 100%975% 75%6

100%

57% 50%

75%8

94

78%7

75%Met Met Met 9

77

N/A Met Met 8 88% 100%Not Met Met Met 9 78% 75%7

78% 75%

Met Met Met

Met MetMet N/A

Met Not Met Met 9 78%

Not MetMet Met Met MetMet Met Met Met

Met Met Met

Cal MediConnect Figure 7: Quality Withhold Summary Table (CY 2016) See metric summary for additional information

Medicare-Medicaid Plan

Anthem

CW6 – Plan All-Cause

ReadmissionsBenchmark: 1.00

CW7 – Annual Flu Vaccine*

Benchmark: 69%

Met Met

Met Not Met

Not Met

CAW7 Behavioral Health Shared Accountability Outcome Measure*

Benchmark: 10% Decrease

CW13 Encounter Data Benchmark:

80%

CW11 – Controlling

Blood Pressure*

Benchmark: 56%

CW12 Medication Adherence for Diabetes

Medications* Benchmark: 73%

CW8 – Follow-Up After Hospitalization for Mental Illness* Benchmark: 56%

Not Met Met Met MetMet

Met Met

Not MetMet MetMet Met

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Total # of Measures Met

MetMet Not Met

Not Met Met Met Met MetMet Met Met Met

Not Met Met Met Met

Blue ShieldCHG

Health NetIEHP

L.A. CareMolina

CalOptimaHPSMSCFHP

Medicare-Medicaid Plan

AnthemBlue Shield

CHGHealth Net

IEHP

Met Met Met

Met Met Met 9 89%

MetMet Met Met Not Met

CAW8 Documentation of

Care Goals* Benchmark: 55%

% of WithholdReceived

% of Measures

Met

Total # of Measures in Analysis

CAW9 Interaction with Care Team* Benchmark: 78%

HPSMSCFHP

L.A. CareMolina

CalOptima

N/A Met Not Met 8

Met Met Not Met 9

N/A Not Met Not Met 7Met Met

Met 9Met

Met

Met

7 82% 83%9California Averages

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Care Coordination Figure 8 & 9: Percent of Members Willing to Participate and who the Plan was able to Locate with an Assessment Completed Within 90 Days of Enrollment (01/2018-12/2018)

See metric summary for additional information

90% 91% 89% 91%

0%

50%

100%

Q1 2018 Q2 2018 Q3 2018 Q4 2018

Fig. 8: Quarterly Rolling Statewide Percentage of Members Willing to Participate and who the Plan was able to Locate with an Assessment Completed Within 90 Days of Enrollment

95% 87% 99%76%

91% 100% 100% 90% 83% 95%

91%

0%

50%

100%

Anthem Blue Shield CHG Health Net IEHP L.A. Care Molina CalOptima HPSM SCFHP

Fig. 9: The Percentage of Members Willing to Participate and who the Plan was able to Locate with an Assessment Completed Within 90 Days of Enrollment for Quarter 4 of 2018

Plan Percentage Statewide Percentage

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Care Coordination Figure 10 & 11: Percentage of Members with an Individualized Care Plan (ICP) (01/2018-12/2018) See metric summary for additional information

82%

53%77%

62% 72%58%

75% 76% 82%58%

70%

0%

50%

100%


Plan Member Percentage Statewide Percentage

65% 65% 69% 70%

0%

50%

100%

Q1 2018 Q2 2018 Q3 2018 Q4 2018

Fig. 10: Quarterly Rolling Statewide Percentage of Members with an ICP

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Fig. 11: Percentage of Members with an ICP for Quarter 4 of 2018


Care Coordination Figure 12: Percentage of Members Who Have a Care Coordinator and Have at Least One Care Team Contact During the Reporting Period (01/2018-12/2018) See metric summary for additional information

75% 88% 96% 87%67% 63%

80% 94% 99%

59%

81%

0%

50%

100%


Fig. 12: Annual (2018) Percentage of Members who have a Care Coordinator and have at least One Care team Contact During the Reporting PeriodPlan Percentage Statewide Percentage

4710

279

37100 55

15675 130

250114

0

100

200

300

400


Care Coordination Figure 13: Member to Care Coordinator Ratio (01/2018-12/2018) See metric summary for additional information

Fig. 13: Annual (2018) Number of Members to Care Coordinator RatioPlan Ratio Statewide Average Ratio

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Care Coordination Figure 14: Percentage of Members with Documented Discussions of Care Goals (01/2018-12/2018) See metric summary for additional information

100%

58%73%

100%84%

100% 89% 82%

40%

100%

83%

0%

50%

100%


Fig. 14: Annual (2018) Percentage of Members with Documented Discussions of Care Goals Plan Percentage Statewide Percentage

77% 76% 77% 74%

0%

50%

100%

Q1 2017 Q2 2017 Q3 2017 Q4 2017

Care Coordination Figure 15: Percentage of Members with First Follow-up Visit within 30 Days after Hospital Discharge (01/2017-12/2017) See metric summary for additional information

Fig. 15: Quarterly Rolling Statewide Percentage of Members with First Follow-Up Visit within 30 Days after Hospital Discharge

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Appeal Figure 16: Count of Appeals (01/2018-12/2018) See metric summary for additional information

18

49

329

70

36

209

75

47

176

1

1

2

1

5

8

13

3

2

13

28

994

256

78

736

231

61

38

32

78

4

1325

327

119

953

319

111

216

0 100 200 300 400 500 600 700 800 900 1000 1100 1200 1300 1400 1500

Anthem

Blue Shield

CHG

Health Net

IEHP

L.A. Care

Molina

CalOptima

HPSM

SCFHP

Fig. 16: Annual Count of Appeals Broken Down by OutcomeNumber where the Plan Decision was Fully FavorableNumber where Plan Decision was Partially FavorableNumber where Plan Decision was AdverseTotal number of appealsMember

Enrollment

7,384

8,896

14,202

10,334

15,890

25,898

11,695

5,967

5,008

5,702

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Grievance Figure 17: Count Grievances by type, Except "Other" (01/2018-12/2018) See metric summary for additional information

54

184

762

305

384

280

81

101

4

36

18

31

552

143

315

635

208

85

3

142

78

136

364

114

615

89

212

0

0

32

26

0

2

4

0

7

232

19

293

1482

838

813

1532

382

398

0 400 800 1200 1600

Anthem

Blue Shield

CHG

Health Net

IEHP

L.A. Care

Molina

CalOptima

HPSM

SCFHP

Fig. 17: Annual Count of Grievances Broken Down by Type, besides "Other"

Access to care Transportation Billing Home health/personal care

MemberEnrollment

7,384

8,896

14,202

10,334

15,890

25,898

11,695

5,967

5,008

5,702

20


Grievance Figure 18: Count of "Other" Grievances (01/2018-12/2018) See metric summary for additional information

466

164

50

359

4,357

985

692

1,739

192

303

931

- 1,000 2,000 3,000 4,000 5,000

Anthem

Blue Shield

CHG

Health Net

IEHP

L.A. Care

Molina

CalOptima

HPSM

SCFHP

StatewideAverage

Fig. 18: Annual Count of "Other" Grievances

MemberEnrollment

7,384

8,896

14,202

10,334

15,890

25,898

11,695

5,967

5,008

5,702

21


Appeals Figure 19: Total Number of Appeals Related to the Denial or Limited Authorization of Mental Health Services (01/2018-12/2018) See metric summary for additional information

0.3 0.3

0.81 1 3

1

0

1

2

3

4


Fig. 19: Annual (2018) Total of all Appeals Related to the Denial or Limited Authorization of Mental Health Services

Plan Average Plan Total Count Statewide Average

24.9

20.522.4

19.1

0.0

10.0

20.0

30.0

Q1 2018 Q2 2018 Q3 2018 Q4 2018

Behavioral Health Figure 20: Emergency Room Behavioral Health Services Utilization per 10,000 Member Months (01/2018-12/2018) See metric summary for additional information

Fig. 20: Quarterly Rolling Statewide Average Count of Emergency Room Behavioral Health Services Utilization per 10,000 Member Months

22


Behavioral Health Figure 21: Emergency Room Behavioral Health Services Utilization per 10,000 Member Months (01/2018-12/2018) See metric summary for additional information

16.6

28.6

10.3

28.1

22.8

13.2

19.6

19.8

36.5

22.5

21.8

0.0 10.0 20.0 30.0 40.0 50.0

Anthem

Blue Shield

CHG

Health Net

IEHP

L.A. Care

Molina

CalOptima

HPSM

SCFHP

Statewide Average

Fig. 21: Annual Count of Emergency Room Behavioral Health Services Utilization per 10,000 Member Months

23


Long Term Services & Supports (LTSS) Figure 22 & 23: Utilization of Members Receiving LTSS per 1,000 Members (01/2018-12/2018) See metric summary for additional information

296 275 240 269333

189281

208

368 347

280.8

0

100

200

300

400


Plan Rate Statewide Quarterly Average

282.7 278.6 279.9 280.8

0.0

100.0

200.0

300.0

400.0

Q1 2018 Q2 2018 Q3 2018 Q4 2018

Fig. 22: Quarterly Rolling Statewide Average of Members Receiving LTSS per 1,000 Members

24

Fig. 23: Count of Members Receiving LTSS per 1,000 members for Quarter 4 of 2018


Long Term Services & Supports (LTSS) Figure 24 & 25: Count of IHSS per 1,000 Members (01/2018-12/2018) See metric summary for additional information

236.9 234.8 236.1 237.6

0.0

100.0

200.0

300.0

Q1 2018 Q2 2018 Q3 2018 Q4 2018

Fig. 24: Quarterly Rolling Statewide Average of Members Receiving IHSS per 1,000 Members

242 221 226 217309

155249

174

292 292

237.6

0

100

200

300

400


Fig. 25: Count of Members Receiving IHSS per 1,000 members for Quarter 4 of 2018


25


Long Term Services & Supports (LTSS) Figure 26 & 27: Count of CBAS per 1,000 Members (01/2018-12/2018) See metric summary for additional information

1.81.9

1.61.9

0.0

1.0

2.0

3.0

Q1 2018 Q2 2018 Q3 2018 Q4 2018

Fig. 26: Quarterly Rolling Statewide Average of CBAS Member Referrals per 1,000 Members

0.21.4 1.0 1.2

3.9

0.8

2.31.5

4.4

2.0

1.9

0.0

1.0

2.0

3.0

4.0

5.0


Fig. 27: Count of CBAS Member Referrals per 1,000 members for Quarter 4 of 2018


26


Long Term Services & Supports (LTSS) Figure 28 & 29: Count of CBAS per 1,000 Members (01/2018-12/2018) See metric summary for additional information

10.3 9.7 10.0 10.0

0.0

5.0

10.0

15.0

Q1 2018 Q2 2018 Q3 2018 Q4 2018

Fig. 28: Quarterly Rolling Statewide Average of Members Receiving CBAS per 1,000 Members

4

12

6

16

6

1210

13 138

10.0

0

5

10

15

20


Fig. 29: Count of Members Receiving CBAS per 1,000 members for Quarter 4 of 2018 Plan Rate Statewide Quarterly Average

27


Long Term Services & Supports (LTSS) Figure 30 & 31: Count of MSSP per 1,000 Members (01/2018-12/2018) See metric summary for additional information

0.6 0.60.7

0.6

0.0

0.2

0.4

0.6

0.8

1.0

Q1 2018 Q2 2018 Q3 2018 Q4 2018

Fig. 30: Quarterly Rolling Statewide Average of MSSP Member Referrals per 1,000 Members

0.2 0.6 0.3 0.1 0.6 0.2 0.5

2.4

0.9

0.6

0.0

1.0

2.0

3.0


Fig. 31: Count of MSSP Member Referrals per 1,000 members for Quarter 4 of 2018


28


Long Term Services & Supports (LTSS) Figure 32 & 33: Count of MSSP per 1,000 Members (01/2018-12/2018) See metric summary for additional information

5.5 5.55.7 5.7

0.0

2.0

4.0

6.0

Q1 2018 Q2 2018 Q3 2018 Q4 2018

Fig. 32: Quarterly Rolling Statewide Average of Members Receiving MSSP per 1,000 Members

7 7

2

63

7

3

6

9

7

5.7

0

2

4

6

8

10


Fig. 33: Count of Members Receiving MSSP per 1,000 members for Quarter 4 of 2018


29


Long Term Services & Supports (LTSS) Figure 34 & 35: Count of NF per 1,000 Members (01/2018-12/2018) See metric summary for additional information

3.94.0 3.8

4.7

0.0

1.0

2.0

3.0

4.0

5.0

Q1 2018 Q2 2018 Q3 2018 Q4 2018

Fig. 34: Quarterly Rolling Statewide Average of NF Member Referrals per 1,000 Members

13.9

4.0 0.24.2 5.6

0.1 2.0 1.8

13.7

1.4

4.7

0.0

5.0

10.0

15.0


Fig. 35: Count of NF Member Referrals per 1,000 members for Quarter 4 of 2018


30


Long Term Services & Supports (LTSS) Figure 36 & 37: Count of NF per 1,000 Members (01/2018-12/2018) See metric summary for additional information

29.9 28.6 28.2 27.4

0.0

10.0

20.0

30.0

40.0

50.0

Q1 2018 Q2 2018 Q3 2018 Q4 2018

Fig. 36: Quarterly Rolling Statewide Average of Members Receiving NF per 1,000 Members

42 35

7

3015 14 20 16

5441

27.4

0

10

20

30

40

50

60


Fig. 37: Count of Members Receiving NF per 1,000 Members for Quarter 4 of 2018


31


Long Term Services & Supports (LTSS) Figure 38 & 39: Count of CPO per 1,000 Members (01/2018-12/2018) See metric summary for additional information

16.0

9.6 9.2

19.3

0.0

5.0

10.0

15.0

20.0

Q1 2018 Q2 2018 Q3 2018 Q4 2018

Fig. 38: Quarterly Rolling Statewide Average of CPO Member Referrals per 1,000 Members

3.00

189

0.04 0.13 0.29 0.22 0.54

19.3

0.00

50.00

100.00

150.00

200.00


Fig. 39: Count of CPO Member Referrals per 1,000 members for Quarter 4 of 2018


32


Long Term Services & Supports (LTSS) Figure 40 & 41: Count of CPO per 1,000 Members (01/2018-12/2018) See metric summary for additional information

31.9

19.3 18.6

39.9

0.0

10.0

20.0

30.0

40.0

50.0

Q1 2018 Q2 2018 Q3 2018 Q4 2018

Fig. 40: Quarterly Rolling Statewide Average of Members Receiving CPO per 1,000 Members

10.4

377.7

0.2 0.1 3.5 7.2 0.4

39.9

0.0

100.0

200.0

300.0

400.0

500.0


Fig. 41: Count of Members Receiving CPO per 1,000 Members for Quarter 4 of 2018


33

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