Medi-Cal Managed Care Performance Dashboard · 2019. 6. 22. · Medi-Cal Managed Care Performance...

Medi-Cal Managed Care Performance Dashboard Glossary

Released December 13, 2016

Glossary Page 1 of 4

Quarterly Release Notes

Figure 1-1 and 1-4: The revised figures display only the Aid code groups. Dual members are no longer extracted out as

an Aid code population because Dual eligibility is not identified by an Aid code type.

Figure 1-4: Passive + Prior includes transitioning populations, members defaulted because they were previously a

member, or if other family members were already assigned to the plan. Date is effective date of plan enrollment.

Choice/plan assignment occurred during the previous month.

July 2016 saw an increase in volume of auto assignments for Coordinated Care Initiative (CCI) eligible beneficiaries. The

increase is related to a backlog effort in which defaults were processed for CCI eligible beneficiaries into a Cal

MediConnect plan.

Figures 2-5 to 2-8: Age cohorts have been standardized for aid code group age metrics.

Figures 3-1 to 3-5 (page 3): A page has been developed to showcase Dual eligible metrics to compared to Non-Dual.

Figure 7-4 and 7-5: New grievance and appeal metrics. Measures are displayed per 1,000 member months.

Figure 10-4: Medical Exemption Request (MER) metrics have been consolidated into one metric that will be displayed

with State Fair Hearing metrics. Approved represents the total in Fee-For-Service due to an approved MER.

Figure 11-1: The HEDIS Aggregated Quality Factor Score (AQFS) has been updated for 2016 using 2015 data.

Note: Percentage metrics are displayed as whole numbers. Charts may add up to 99%, 100% or 101%.




Population Aid Code Groups

Affordable Care Act (ACA): This population consists of the following Adult Expansion aid codes: M1, M2, M3, M4, L1, and 7U.

Optional Targeted Low Income Children (OTLIC): This population consists of the following OTLIC aid codes: 2P, 2R,

2S, 2T, 2U, 5C, 5D, E2, E5, E6, E7, H1, H2, H3, H4, H5, M5, T0, T1, T2, T3, T4, T5, T6, T7, T8, and T9.

Medi-Cal only Seniors and Persons with Disabilities (SPD): This population consists of the following SPD aid codes:

10, 13, 14, 16, 17, 1E, 1H, 20, 23, 24, 26, 27, 2E, 2H, 36, 60, 63, 64, 66, 67, 6A, 6C, 6E, 6G, 6H, 6J, 6N, 6P, 6R, 6V, 6W,

6X, 6Y, C1, C2, C3, C4, C7, C8, D2, D3, D4, D5, D6, and D7.

Other Populations (Other): This population consists of all other aid codes not mentioned above.

Medicare Status

Dual: This population consists of any Medi-Cal eligible member who has active Medicare coverage. Active Medicare coverage means one or more of the following Medicare portions are active: Part A, B, or D. A Dual member is not identified by an aid code or aid code group.

Non-Dual: This population consists of any Medi-Cal eligible member who is Medi-Cal only and has no active Medicare coverage. Aid code groups are displayed as Medi-Cal only for the following measures: Utilization, Grievance and Appeals, and State Fair Hearings.




Utilization Measures for Certified Eligible Managed Care Members

Utilization is tracked by aid code population and Medicare status. Utilization metrics displayed by aid code group is Medi-

Cal coverage only (Non-Dual) and does not include Medicare coverage.

Emergency Room (ER) Visits: This measure captures the number of ER visits per month. The results from this

measure are used to calculate ER visits with an inpatient admission. A visit consists of a unique combination between

provider, member and date of service. This measure is displayed per 1,000 member months.

Emergency Room (ER) Visits with an Inpatient (IP) Admission: This measure captures the number of ER visits that

resulted in an inpatient admission per month. The results of this measure are a subset of ER visits and IP admissions.

The service date and member identification are linked to create this measure. An admission consists of a unique

combination between member and date of admission to a facility. This measure is displayed per 1,000 member months.

Inpatient (IP) Admissions: This measure captures the number of Inpatient Admissions per month. The results from this

measure are used to calculate ER visits with an inpatient admission. An admission consists of a unique combination

between member and date of admission to a facility. This measure is displayed per 1,000 member months.

Outpatient (OP) Visits: This measure captures the number of OP visits per month. A visit consists of a unique

combination between provider, member and date of service. This measure is displayed per 1,000 member months.

Prescriptions: This measure captures the number of prescriptions per month. A prescription consists of a unique

combination between National Drug Code, member, and date of service. This measure is displayed per 1,000 member

months.




Mild to Moderate Mental Health Visits: This measure captures the number of visits per month related to selected

Psychotherapy Services and Diagnostic Evaluations. The selected procedure codes aim to capture mild to moderate

mental health visits. A visit consists of a unique combination between provider, member and date of service. This

measure is displayed per 1,000 member months.

Grievance, Appeals and State Fair Hearings

Grievance and Appeals: Grievance and Appeals data is plan reported. Grievance and Appeals metrics displayed by aid

code group is Medi-Cal coverage only (Non-Dual) and does not include Medicare coverage.

State Fair Hearings: Hearing data is submitted through the Department of Social Services. Hearing metrics displayed by aid code group is Medi-Cal coverage only (Non-Dual) and does not include Medicare coverage.

CERTIFIED ELGIBLE ENROLLMENT: As of June 2016 (Data Warehouse pull November 2016)

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Per

cen

tage

Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16

OTLIC 1,061,191 1,082,372 1,099,342 1,111,101 1,125,167 1,131,130 1,130,811 1,141,500 1,154,312 1,165,982 1,174,786 1,193,813

SPD 1,558,646 1,560,001 1,562,084 1,562,524 1,560,595 1,559,759 1,555,377 1,552,121 1,549,612 1,543,601 1,539,129 1,540,359

ACA 3,084,675 3,203,337 3,310,808 3,416,406 3,520,203 3,592,346 3,668,925 3,764,880 3,856,397 3,900,658 3,964,344 4,034,955

1-1: Managed Care Enrollment by Aid Population

OTHER 4,118,716 4,097,421 4,068,541 4,036,997 4,014,605 3,992,180 4,003,026 3,995,395 3,982,236 3,931,661 3,901,740 3,899,181

Managed Care Total 9,823,228 9,943,131 10,040,775 10,127,028 10,220,570 10,275,415 10,358,139 10,453,896 10,542,557 10,541,902 10,579,999 10,668,308

Other Medi-Cal Programs

Medi-Cal Type Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16

Fee-for-Service 2,991,817 2,999,335 2,996,131 2,987,806 2,986,715 3,089,826 3,187,773 3,122,041 3,079,743 3,038,169 3,016,837 2,910,990

Speciality Plans 18,862 19,232 19,490 19,509 19,688 20,088 20,385 20,575 20,759 20,865 20,996 21,048

Medi-Cal Program Total 12,833,907 12,961,698 13,056,396 13,134,343 13,226,973 13,385,329 13,566,297 13,596,512 13,643,059 13,600,936 13,617,832 13,600,346

CMC COHS GMC RM Two-Plan

OTLIC 0 290,838 140,023 44,796 718,156

SPD 116,065 327,659 147,419 32,578 916,638

ACA 1,651 829,888 436,657 171,929 2,594,830

Other 678 748,952 405,647 136,026 2,607,878

0%10%20%30%40%50%60%70%80%90%

100%

Per

cen

tage

1-2: Aid Population by Plan Model

MC78%

FFS/Spec.22%

1-3: Medi-Cal Managed Care vs. FFS/Specialty

Medi-Cal Managed Care Performance Dashboard


Note: Data in this dashboard is preliminary and subject to change Page 1 of 11

61%65% 64% 64% 62%

57%52%

69%

61%64%

59%48%

28%25% 25% 26% 27%

30%37%

24%30%

27%33%

46%

10% 10% 11% 9% 11% 13% 10%7% 8% 9% 8% 6%

1-4: Choice and Auto-Assignment Rates

Choice Auto-Assigned Passive + Prior



ACA38%

OTHER37%

SPD14%

OTLIC11%

2-1: Aid Groups "All Managed Care"

Age < 1 Ages 1-5 Ages 6-11 Ages 12-17 Ages 18-20 Ages 21-44 Ages 45-64 Ages 65+

Male 86,275 635,530 809,096 700,380 278,857 1,294,447 902,632 298,397

Female 82,686 609,427 771,235 671,052 292,313 1,687,087 1,060,669 488,225

0%

20%

40%

60%

80%

100%

Per

cen

tage

2-2: Age by Gender "All Managed Care"

CERTIFIED ELGIBLE DEMOGRAPHICS: Managed Care demographics for June 2016 (Data Warehouse pull November 2016)

46%

21%

14%

11%

8%

Hispanic

White

sian/Pacific Islander

Other/Unknown

African-American

2:-4: Race and Ethnicity "All Managed Care"

A

2%

12%

15%

13%

5%

28%

18%

7%

Age < 1

Ages 1-5

Ages 6-11

Ages 12-17

Ages 18-20

Ages 21-44

Ages 45-64

Ages 65+

2-3: Age Cohorts "All Managed Care"

4%

2-5: Medi-Cal Only "OTLIC" Age

57%

43%

2-7: Medi-Cal Only "ACA" Age

85%

11%4%

2-8: Medi-Cal Only "OTHER" Age


96%

22%

15%

2-6: Medi-Cal Only "SPD" Age

20%

43%



Dual Status Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16

Dual 948,568 952,271 957,018 960,528 962,750 965,011 962,847 961,748 962,113 959,557 957,655 958,417

Non-Dual* 8,874,660 8,990,860 9,083,757 9,166,500 9,257,820 9,310,404 9,395,292 9,492,148 9,580,444 9,582,345 9,622,344 9,709,891

Note: Medi-Cal Only. See glossary.

CERTIFIED ELGIBLE DEMOGRAPHICS: Dual Eligible Managed Care demographics for June 2016 (Data Warehouse pull November 2016)

ACA6%

OTHER1%

SPD93%

3-1: Aid Groups "Dual"

CMC COHS GMC RM Two Plan

Dual 118,382 223,233 80,313 8,947 527,542

Non-Dual 12 1,974,104 1,049,433 376,382 6,309,960

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Per

cen

tage

3-4: Plan Model Totals

28%

28%

20%

17%

8%

White

Hispanic

Asian/PacificIslander

Other/Unknown

African-American

3-3: Dual Eligible by Race and Ethnicity

ACA41%

OTHER40%

SPD7%

OTLIC12%

3-2: Aid Groups "Non-Dual"

0%

6%

23%

71%

Age 0-18

Ages 19-39

Ages 40-64

Ages 65+

3-5: Dual Age Cohorts




UTILIZATION: Statewide January 2015 to December 2015. (Data Warehouse pull November 2016)

-

20

40

60

80

100

120

Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15

Vis

its


SPD 106 95 103 97 100 95 94 94 92 83 81 85

Dual 41 32 34 34 34 33 37 37 37 37 35 37

ACA 51 45 49 47 48 47 47 46 45 40 39 41

Other 54 49 51 45 45 39 36 37 39 36 36 37

OTLIC 27 26 27 24 25 20 18 20 21 20 19 19

4-1: Emergency Room Visits per 1,000 Member Months

-

5

10

15

20


Vis

its


SPD 16 13 15 15 16 15 14 14 14 11 12 13

Dual 5 4 5 5 5 5 5 5 4 4 4 5

ACA 4 3 4 4 4 4 4 4 3 3 3 3

Other 1 1 2 1 1 1 1 1 1 1 1 1

OTLIC 1 1 1 1 1 1 1 1 1 1 0 1

4-2: Emergency Room Visits with an Inpatient Admission per 1,000 Member Months



-

10

20

30

40

50


Vis

its


SPD 40 35 39 38 39 38 39 39 38 36 34 36

Dual 44 35 37 35 34 34 36 43 40 40 43 42

ACA 10 9 10 10 10 9 9 9 9 8 8 8

Other 5 5 5 5 5 5 4 4 5 4 4 4

OTLIC 2 2 3 2 2 2 2 2 2 2 2 2

5-1: Inpatient Admissions per 1,000 Member Months

-

500

1,000

1,500

2,000

2,500

3,000


Vis

its


SPD 2,457 2,383 2,595 2,523 2,464 2,374 2,277 2,282 2,494 2,458 2,224 2,284

Dual 1,601 1,486 1,593 1,607 1,547 1,591 1,548 1,534 1,574 1,495 1,411 1,508

ACA 698 663 730 709 670 712 695 673 671 652 599 631

Other 602 578 623 587 551 502 469 489 540 541 482 487

OTLIC 463 458 496 465 431 377 354 380 441 455 398 388

5-2: Outpatient Admissions per 1,000 Member Months






-

500

1,000

1,500

2,000

2,500

3,000

3,500


Vis

its


SPD 2,980 2,821 3,263 3,158 3,066 3,182 2,990 2,992 3,126 3,137 3,031 3,093

Dual 394 369 384 364 356 369 317 327 369 382 366 367

ACA 980 940 1,028 990 953 978 890 893 960 967 928 911

Other 564 510 533 483 449 411 349 364 401 400 400 393

OTLIC 304 284 297 257 242 211 174 191 223 223 230 215

6-1: Prescriptions per 1,000 Member Months

-

5

10

15

20

25

30


Vis

its


SPD 12 12 14 14 13 15 15 15 15 16 15 16

Dual 24 23 24 25 22 23 24 22 22 22 19 22

ACA 9 10 12 12 11 12 13 12 12 13 11 12

Other 4 4 5 5 5 5 5 5 5 5 5 5

OTLIC 4 5 6 6 5 6 6 6 6 6 5 5

6-2: Mild to Moderate Mental Health Visits per 1,000 Member Months





Grievance Demographics: Q2 2016 (April-June 2016) Statewide

6%

19%

33%

5%

8%

8%

19%

2%

Age 0-18

Ages 19-39

Ages 40-64

Ages 65+

7-3: Grievances by Age

Male Female

35%

30%

17%

14%

5%

White

Hispanic

Other/Unknown

African-American

Asian/Pacific Islander

7-1: Grievances by Ethnicity

47%

22%

18%

10%3%

7-2: Grievances by Population

ACA

SPD

OTHER

DUAL

OTLIC

2.5

1.0

1.7

2.7

0.8

White

Hispanic

Other/Unknown

African-American


7-4: Grievances by EthnicityPer 1,000 Member Months

2.0

5.7

0.7

1.8

0.5

ACA

SPD

OTHER

DUAL

OTLIC

7-5: Grievances by PopulationPer 1000 Member Months




Grievance and Appeals Outcomes: Q2 2016 (April-June 2016) Statewide

63%

49%

63%

53%

56%

32%

46%

29%

42%

40%

6%

5%

8%

5%

4%

Accessibility

Benefits

Other

Quality Of Care

Referral

8-1: Grievance Resolution by Type

Resolved in Favor of Member Resolved in Favor of Plan Unresovled

51%

45%

44%

48%

50%

17%

20%

23%

23%

27%

23%

15%

17%

18%

17%

6%

17%

12%

9%

4%

3%

3%

5%

3%

2%

Accessibility

Benefits

Other

Quality ofCare

Referral

8-2: Grievances by Population and Type

ACA SPD OTHER DUAL OTLIC

Quality Of Care43%

Benefits20%

Other19%

Accessibility11%

Referral7%

8-3: Grievances by Type

0.9

0.6

0.3

0.3

GMC

Two-Plan

RM

COHS

8-4: Grievances by Plan Model per 1,000 Member Months




State Fair Hearing Demographics: Q2 2016 (April-June 2016) Statewide

0.5

0.3

0.3

0.3

0.2

GMC

RM

CMC

Two-Plan

COHS

9-5: Hearings by Plan Model per 10,000 Member Months

39%

20%

19%

14%

8%

White

Hispanic

Other/Unknown

African-American


9-1: Hearings by Ethnicity

44%

31%

15%

10%

9-2: Hearings by Population

ACA

SPD

OTHER

DUAL

3%

15%

34%

5%

7%

8%

25%

2%

Age 0-18

Ages 19-39

Ages 40-64

Ages 65+

9-3: Hearings by Age

Male Female

2015Q3 2015Q4 2016Q1 2016Q2

SPD 296 275 246 280

Dual 117 118 96 89

ACA 350 406 368 390

OTHER 144 111 143 136

Total 907 910 853 895

0

50

100

150

200

250

300

350

400

450

500

9-4: Hearings by Population




State Fair Hearing Reasons/Outcomes: Q2 2016 (April-June 2016) Statewide

33%

60%

39%

48%

46%

36%

50%

28%

13%

23%

34%

30%

34%

36%

23%

63%

29%

13%

4%

16%

15%

15%

20%

7%

25%

4%

22%

6%

5%

13%

7%

2%

Billing

Diagnostic Testing

Dispute of Services

Medication/Prescription

MER/EDR

Other

Surgery/Treatment

Wheelchair/PowerWheelchair

10-1: Hearing Reasons by Population

ACA SPD Other Dual

38%

27%

16%

7%

5%

3%

3%

2%

Withdrawal

Denied

Non-Appearance

Dismissed

Granted

Redirect

Other

Duplicate Case

69%

31%

58%

42%

Approved Denied

10-4: Medical Exemption Requests

All SPD

203

145137

89

63

10-3: Top 5 Hearing Reasons


10-2: Hearing Outcomes



Note: The Aggregated Quality Factor Score (AQFS) is a single score that accounts for plan performance on all DHCS-selected Health Effectiveness Data and Information Set (HEDIS)

indicators. It is a composite rate calculated as percent of the National High Performance Level (HPL). The High Performance Level is 100%. The Minimum Performance Level is 40%. The

State Average is 60%.

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20%

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11-1: 2016 HEDIS Aggregated Quality Factor Score (AQFS)

AQFS HPL - 100% MPL - 40% MCMC Weighted Average - 60%


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