PARTNERSHIP HEALTHPLAN OF CALIFORNIA PHYSICIAN ADVISORY COMMITTEE ~ MEETING NOTICE Members: Jeffrey Bosworth, M.D. Angela Brennan, D.O. Jeffrey Gaborko, M.D. (Chair) David Gorchoff, M.D. Steve Gwiazdowski, M.D. Michele Herman, M.D. Willard Hunter, M.D. Mills Matheson, M.D. Danielle Oryn, D.O. Thomas Paukert, M.D. Mitesh Popat, M.D. Teresa Shinder, D.O. Matthew Symkowick, M.D. Suzanne Eidson-Ton, M.D. Lisa Ward, M.D. PHC Staff: Liz Gibboney, Chief Executive Officer Robert Moore, MD, MPH, Chief Medical Officer Wendi West, Northern Executive Director Peggy Hoover, RN, Senior Director, Health Services Patti McFarland, Chief Financial Officer Mary Kerlin, Senior Dir., Provider Relations (PR) Dept. Marshall Kubota, MD, Regional Medical Director Mark Netherda, MD, Assoc. Medical Director of Quality Jeffrey Ribordy, MD, Regional Medical Director Colleen Townsend, MD, Regional Medical Director Stan Leung, Pharm.D., Director, Pharmacy Services Erika Robinson, Director, Quality & Performance Improvement (S) Debra McAllister, RN, Dir. of Utilization Mgmt. (UM) Nancy Steffen, Director, Quality & Performance Improvement (N) David Glossbrenner, MD, N. Regional Medical Director Ad Hoc PHC Sonja Bjork, Chief Operating Officer Kevin Spencer, Director of Member Services Members: Kirt Kemp, Chief Information Officer Michael Vovakes, MD, Associate Medical Director Lynn Scuri, Regional Director James Cotter, MD, Associate Medical Director Chloe Secor-Schafer, Northern Regional Manager Bettina Spiller, MD, Associate Medical Director Tahereh Daliri Sherafat, N. Region Mbr Services & PR Dir. Mark Glickstein, MD, Associate Medical Director Sharon Hoffman-Spector, RN, N. UM Manager David Katz, MD, Associate Medical Director Margaret Kisliuk, Behavioral Health Administrator Ledra Guillory, Senior Prov. Relations Rep. Manager Rebecca Boyd Anderson, RN, Director, Population Health Margarita Garcia-Hernandez, Manager, Health Analytics Katherine Barresi, RN, Director, Care Coordination Vic Patel, Pharm.D., Clinical Pharmacy Manager Diane Wong, Pharm.D., Senior Clinical Pharmacist Rachael French, Assoc. Dir., Quality & Performance Improvement Jeffrey DeVido, MD, Behavioral Health Clinical Director Doreen Crume, RN, Northern Manager, Care Coordination cc: PHC Commission Chair Gabriel Samuel Chua, MD Kali Stanger, MD Voltaire Velarde, MD Richard Fogg Jerry Douglas, MD Amy Brom, Psy.D Karen Relucio, MD David Danzeisen, MD Jeremy Austin, MD Bela T. Matyas, MD Susan Foster, MSN, FNP-BC Karen Sprague, NP – Pending Appointment FROM: Linda Largent DATE: August 5, 2020 SUBJECT: PHYSICIAN ADVISORY COMMITTEE MEETING The Physician Advisory Committee will meet as follows and will continue to meet the second Wednesday of every month (July and December are tentative.) Please review the Meeting Agenda and attached packet, as discussion time is limited. DATE: Wednesday, August 12, 2020 TIME: 7:30 a.m. – 9:00 a.m. LOCATIONS – DUE TO COVID-19 AND SOCIAL DISTANCING, ACCESS IS LIMITED See Agenda for Call-In Information: ________Via Video Conference________ Partnership HealthPlan of CA 4665 Business Center Drive (Please Park in Front of Bldg.) Fairfield, CA PHC – Sonoma Office 495 Tesconi Circle Santa Rosa PHC – Redding Office 2525 Airpark Drive Redding Please contact me at (707) 863-4228, or e-mail [email protected]if you are unable to attend.
Transcript
PARTNERSHIP HEALTHPLAN OF CALIFORNIA PHYSICIAN ADVISORY COMMITTEE ~ MEETING NOTICE
Members: Jeffrey Bosworth, M.D. Angela Brennan, D.O. Jeffrey Gaborko, M.D. (Chair) David Gorchoff, M.D. Steve Gwiazdowski, M.D.
Mitesh Popat, M.D. Teresa Shinder, D.O. Matthew Symkowick, M.D. Suzanne Eidson-Ton, M.D. Lisa Ward, M.D.
PHC Staff: Liz Gibboney, Chief Executive Officer Robert Moore, MD, MPH, Chief Medical Officer Wendi West, Northern Executive Director Peggy Hoover, RN, Senior Director, Health Services Patti McFarland, Chief Financial Officer Mary Kerlin, Senior Dir., Provider Relations (PR) Dept. Marshall Kubota, MD, Regional Medical Director Mark Netherda, MD, Assoc. Medical Director of Quality Jeffrey Ribordy, MD, Regional Medical Director Colleen Townsend, MD, Regional Medical Director Stan Leung, Pharm.D., Director, Pharmacy Services Erika Robinson, Director, Quality & Performance Improvement (S) Debra McAllister, RN, Dir. of Utilization Mgmt. (UM) Nancy Steffen, Director, Quality & Performance Improvement (N) David Glossbrenner, MD, N. Regional Medical Director Ad Hoc PHC Sonja Bjork, Chief Operating Officer Kevin Spencer, Director of Member Services Members: Kirt Kemp, Chief Information Officer Michael Vovakes, MD, Associate Medical Director Lynn Scuri, Regional Director James Cotter, MD, Associate Medical Director Chloe Secor-Schafer, Northern Regional Manager Bettina Spiller, MD, Associate Medical Director Tahereh Daliri Sherafat, N. Region Mbr Services & PR Dir. Mark Glickstein, MD, Associate Medical Director Sharon Hoffman-Spector, RN, N. UM Manager David Katz, MD, Associate Medical Director Margaret Kisliuk, Behavioral Health Administrator Ledra Guillory, Senior Prov. Relations Rep. Manager Rebecca Boyd Anderson, RN, Director, Population Health Margarita Garcia-Hernandez, Manager, Health Analytics Katherine Barresi, RN, Director, Care Coordination Vic Patel, Pharm.D., Clinical Pharmacy Manager Diane Wong, Pharm.D., Senior Clinical Pharmacist Rachael French, Assoc. Dir., Quality & Performance Improvement Jeffrey DeVido, MD, Behavioral Health Clinical Director Doreen Crume, RN, Northern Manager, Care Coordination cc: PHC Commission Chair Gabriel Samuel Chua, MD Kali Stanger, MD Voltaire Velarde, MD Richard Fogg Jerry Douglas, MD Amy Brom, Psy.D Karen Relucio, MD David Danzeisen, MD Jeremy Austin, MD Bela T. Matyas, MD Susan Foster, MSN, FNP-BC Karen Sprague, NP – Pending Appointment
FROM: Linda Largent DATE: August 5, 2020
SUBJECT: PHYSICIAN ADVISORY COMMITTEE MEETING The Physician Advisory Committee will meet as follows and will continue to meet the second Wednesday of every month (July and December are tentative.) Please review the Meeting Agenda and attached packet, as discussion time is limited.
Per Governor Newsom’s Executive Order, N-25-20 that relates to social distancing measures being taken for COVID-19: The Executive Order authorizes public meetings with Brown Act requirements to be held via teleconference or telephone. It waives
the Brown Act requirement for physical presence at the meeting for members, the clerk, and/or other personnel of the body as a condition of participation for a quorum. However, the Executive Order requires at least one public location consistent with ADA
requirements to be made available for members of the public to attend the meeting, so all PHC offices will be available for members of the public to attend the meeting in-person.
To Join by Telephone:
1-844-621-3956 Access code: 807 289 275
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PUBLIC COMMENTS Speaker 2 minutes
Speaker 2 minutes
This Brown Act meeting may be recorded. Any audio or video tape record of this meeting, made by or at the direction of PHC, is subject to inspection under the Public Records Act and will be provided without charge, if requested.
Welcome / Introductions I. Approval of Minutes – Chair 5 – 15 7:30
II. Standing Agenda Items Lead Pg # Time
A. Status Update Administration Medical / Health Services Report Regional Medical Director Reports
A1. Update from County Public Health Departments Available Representative(s)
8:07
A2. Committee Member Highlight Ms. Sprague 8:10
B. Quality / Utilization Advisory Committee (Q/UAC) Activities Report with attachments – Consent Review
Acceptance of Meeting Minutes:
Activities & Minutes of the July 15, 2020 meeting: - Pages 16-23 / 24-69 - Minutes – Internal Quality Improvement meetings 06/09/20 - Quality Improvement Update – July 2020
Approval of Committee’s Action Items & Material Reviewed:
Note – only pages with significant changes are included for policies Policies & Procedures: Policy Summary - See Pages 35-36 - Site Review Requirements and Guidelines (MPQP1022) - Excerpt - Hospice Services Guidelines (MCUP3020) Excerpt - Criteria and Guidelines for Utilization Management (MCUP3139) New - Wellness and Recovery Access Standards and Monitoring (MPNET 101) New - Population Health Management Impact Analysis - Healthcare Effectiveness Data and Information Set (HEDIS) 2020 Performance (See Agenda Item IV.B.) For Information Only - Quality Improvement Performance Improvement Activities 2019/2020 - 2020/2021 Hospital QIP Measures Summary
**********************************
Acceptance of Meeting Minutes: ***Activities & Minutes of the June 17, 2020 meeting: Pages 70-79 / 80-155 - Minutes – Internal Quality Improvement meetings 05/12/20 - Birthday Club Pilot Status Update - Quality Improvement Update – June 2020
Approval of Committee’s Action Items & Material Reviewed:
Policies & Procedures: Policy Summary - See Pages 37-38
Dr. Moore
16 - 155
8:20
Continued
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This agenda contains a brief description of each item to be considered. Except as provided by law, no action shall be taken on any item not appearing on the agenda. Government Code §54957.5 requires that public records related to items on the open session agenda for a regular committee meeting be made available for public inspection. Records distributed less than 72 hours prior to the meeting are available for public inspection at the same time they are distributed to all members, or a majority of the members of the committee. The committee has designated the Administrative Assistant to the Chief Medical Officer as the contact for Partnership HealthPlan of California located at 4665 Business Center Drive, Fairfield, CA 94534, for the purpose of making those public records available for inspection. The Physician Advisory Committee Agenda and supporting documentation is available for review from 8:00 AM to 5:00 PM, Monday through Friday at all PHC regional offices (see locations under the Meeting Notice). It can also be found online at www.partnershiphp.org.
- Provider Grievance (MPPRGR210) – See Agenda Item IV.B. - Technology Assessment (MCUP3042) - Excerpt - Preliminary Audit Report: 2019 Joint Annual Audit – Kaiser Foundation Health - InterQual Annual Review 2020 – See Agenda Item II.B.1. - ADHD Measure Results for Measurement Year 2019 - ADVANCE Program Evaluation Cohort 4
B.1. InterQual® Criteria Review (see attached) Approval under Consent Dr. Moore 156 -186
8:20
B.2. Provider Grievance Policy (MP PR GR 210) - (see attached) Approval under Consent
Ms. Kerlin 187 - 192
8:20
C. Pharmacy &Therapeutics (P&T) Committee / Consent Review Acceptance of Meeting Minutes:
Approval of Committee’s Action Items & Material Reviewed:
Policy Summary – See Page 38
Minutes / Formulary Recommendations - July 16, 2020 meeting (attached) - Pharmacy Site of Care (MCRP4067) New
Dr. Leung / Dr. Moore
193 - 230
8:20
D. Provider Advisory Group (PAG) Report – Consent Review Acceptance of Meeting Minutes:
Approval of Committee’s Action Items & Material Reviewed:
No meeting June or July
Ms. Sherafat / Ms. Kerlin
-- --
E. Credentialing Committee Meeting Summary (Committee Approved) Acceptance of Meeting Minutes:
Approval of Committee’s Action Items & Material Reviewed Summary and Credentialed List for the May 13 & June 10, 2020 meetings (attached)
Dr. Kubota 231 - 252
8:20
F. Pediatric Quality Subcommittee Acceptance of Meeting Minutes:
Approval of Committee’s Action Items & Material Reviewed Minutes / Material of the August 5, 2020 meeting to be included September
Dr. Ribordy -- --
G. Recommended Committee Appointments / Resignations for Approval:
Physician Advisory Committee (PAC) – Appointment Karen Sprague, NP, Community Medical Centers
Quality Utilization / Advisory Committee (Q/UAC) & Peer Review- Appoint Emma Hackett, MD, Open Door Community Health Centers
Quality Utilization / Advisory Committee (Q/UAC) - Resignation Andrew Threlfall, MD (Effective end of August)
Dr. Moore 253 8:20
III. Old Business Lead Pg # Time
IV. New Business
A. Pharmacy & Therapeutics (P&T) Committee Highlights from July 16th meeting No Approval Required
Dr. Leung 254 8:22
B. HEDIS® Performance Summary Communication Plan – presentation …….No Approval Required
Ms. French / Ms. Robinson
255 - 290
8:25
C. Discussion Topic: In Person vs. Virtual for Preventive Health Visits
Dr. Moore 8:40
V. Adjournment 8:55
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In compliance with the Americans with Disabilities Act, PHC meeting rooms are accessible to people with disabilities. Individuals who need special assistance or a disability-related modification or accommodation (including auxiliary aids or services) to participate in this meeting, or who have a disability and wish to request an alternative format for the agenda, meeting notice, agenda packet or other writings that may be distributed at the meeting, should contact the Administrative Assistant to the Chief Medical Officer at least two (2) working days before the meeting at (707) 863-4228 or by email at [email protected]. Notification in advance of the meeting will enable PHC to make reasonable arrangements to ensure accessibility to this meeting and to materials related to it.
PARTNERSHIP HEALTHPLAN OF CALIFORNIA (PHC) MEETING MINUTES
PAGE 1 OF 11 Committee: Physician Advisory Committee Date / Time: June 10, 2020 - 7:35 to 9:09 am
Per Governor Newsom’s Executive Order, N-25-20 that relates to social distancing measures being taken for COVID-19: The Executive Order authorizes public meetings with Brown Act requirements to be held via teleconference or telephone. It waives the Brown Act requirement for physical presence at the meeting for members, the clerk, and/ or other personnel of the body as a condition of participation for a quorum. However, the Executive Order requires at least one public location consistent with ADA requirements to be made available for members of the public to attend the meeting, so all PHC offices will be available for members of the public to attend the meeting in-person.
Members Present:
Jeffrey Bosworth, MD – W Angela Brennan, DO - TC David Gorchoff, MD - TC
Steve Gwiazdowski, MD - TC Michele Herman, MD – TC Willard Hunter, MD – W
Thomas Paukert, MD Note: via Video Conf. (VC) via WebEx (W) via Teleconference (TC)
Visitors: Karen Sprague, NP
PHC Staff Present:
Liz Gibboney, Chief Executive Officer - W Wendi West, Northern Executive Director -VC Lynn Scuri, Regional Director - VC Mary Kerlin, Sr. Dir., Provider Relations (PR) Tabereh Daliri Sherafat, N. Member Services
and PR Director- W Anthony Sackett, S. QI Project Manager – W Doreen Crume, RN, N. Mgr., Care Coord. - VC
Robert Moore, MD, Chief Medical Officer Peggy Hoover, RN, Senior Dir., Health Services -TC Colleen Townsend, MD, Regional Med. Director Mark Netherda, MD, Assoc. Medical Dir., Quality-W Jeffrey DeVido, MD, Behavioral Hlth Clinical Dir. -W Stan Leung, Pharm.D., Director, Pharmacy Svcs – W Katherine Barresi, RN, Dir., Care Coordination – W Sharon Hoffman-Spector, RN, N. UM Manager - VC Melissa Stewart, S. QI Project Manager - W
David Glossbrenner, MD, N. Regional Medical Dir. - VC Marshall Kubota, MD, Regional Medical Director - VC Jeffrey Ribordy, MD, Regional Medical Director - W Michael Vovakes, MD, Associate Medical Director - W Bettina Spiller, MD, Associate Medical Director – VC Erika Robinson, Dir., S. Quality & Perf. Improvement – W Nancy Steffen, Dir., N. Quality & Perf. Improvement - W Debra McAllister, RN, Director, Utilization Mgmt. – TC
Note – All Telephone Participants may not be listed – Unidentifiable on Report
AGENDA ITEM
DISCUSSION / CONCLUSIONS RECOMMENDATIONS / ACTION TARGET DATE
DATE RESOLVED
Public Comments
Quorum
I. Approval ofMinutes
The Committee’s Acting Chairperson, asked for public comments. None were presented.
The Committee’s Acting Chair presented the meeting minutes
N/A
Committee quorum requirements met.
MOTION: Dr. Symkowick moved to approve Agenda Item [I.] as presented, seconded by Dr. Brennan. ACTION SUMMARY: [12] yes, [0] no, [0] abstentions. Motion carried.
II.A. Status Update Administration II.A. Status Update Medical
The HealthPlan’s Chief Executive Officer (CEO), provided the following report on PHC activities. - COVID-19 – The majority of PHC staff will continue to work remotely through July, perhaps longer, while
management monitors local public health department guidance as to the direction Partnership should take. With the unfortunate death of George Floyd on top of the pandemic, team members have been additionally stressed by the current events, which bring up a lot of issues around health equity and racism, and what PHC does to advance health equity across its diverse membership. The State Budget is also extremely challenging, as they prepare for the massive deficit, which will obviously impact PHC’s budget. Staff has been revising its internal budget, in preparation of the June Board meeting. The difficulty is compounded, as the State does not yet have an approved Revised Budget, and the Governor and Legislature have different perspectives on the size of the deficit, and ways to balance the Budget. It is expected that an approved revision will come this week, to meet its Constitutional deadline of June 15.
- Wellness and Recovery Program – This program is set to launch on July 1, 2020, in 7 of PHC’s 14 counties. This comprehensive drug treatment program has been in development for over four years.
- Director, Department of Health Care Services (DHCS) – Unfortunately, Friday will be the last day for DHCS’ relatively new Director. Formerly the CEO for Inland Empire Health Plan, Dr. Bradley Gilbert started last February, primarily to assist the State in the implementation of the California Advancing and Innovating Medi-Cal (CalAIM) Waiver. This was short-lived, due to the onset of the COVID-19 pandemic, and the projected Budget shortfall, that will impact the benefits under Medi-Cal. Dr. Gilbert has decided to re-retire, to spend time with his family. His leadership during this important time will be greatly missed.
- Long-Term Care at Home – In the midst of these challenges, the State has announced its intent to start a new program, Long-Term Care (LTC) at Home, which is following the same theme of hospital programs. DHCS has stated that this program will allow more individuals to stay at home with the proper support, rather than going into a LTC facility. There are few details available regarding this program, but, DHCS would like to launch in January 2021. The program would include individual assessments, transition services (from hospital or skilled nursing facility to home), care management, and home and community-based services.
The HealthPlan’s Chief Medical Officer (CMO) presented an overview of some Health Services activities. - Medi-Cal Pharmacy Carve-Out – There has been no shift in the State’s position in terms of its carve-out plans.
There continues to be significant controversy over this change. There are plans for provider communications during the latter half of this year. Part of the pharmacy benefit PHC provides, which the State will not continue, includes certain over-the-counter (OTC) medications. These have been covered for many years, and can be grouped two ways: 1) those that save money when compared to more expensive prescription medications, and, 2) OTCs that decrease medical expenses. PHC staff is looking closely at the OTC medications currently covered and evaluating those that may need to be potentially preserved. Another area includes durable medical equipment (DME) items that are more cost effective through the pharmacy. These include blood pressure monitors, humidifiers, vaporizers, nebulizers, and also glucometers. The State’s position on not covering glucometers may get shifted, but, the other items are less likely. Switching these non-covered items over to a DME benefit through utilization management (UM) involves a lot of logistical inefficiencies. PHC staff is evaluating other possible options. Though an internal analysis is
For information only, no formal action required. For information only, no formal action required. For information only, no formal action required. For information only, no formal action required. For information only, no formal action required.
being done, input from providers (Committee members) in different regions will be beneficial, as each area may be different in terms of what will work.
- Quality Measures – The State has not given any update regarding the 2020 measurement year, and Partnership will be held accountable for. It is suspected that DHCS may not hold health plans accountable, as there will not be any benchmarks to use for financial penalties, but, they will require health plans to collect data through the Healthcare Effectiveness Data and Information Set HEDIS® process. PHC staff assumes that Partnership will be held accountable next year.
- Joint Leadership Initiative (JLI) – This initiative was started as part of PHC’s quality improvement activities, to increase quality scores. PHC leadership has been engaging the leadership of Partnership’s largest providers, who have significant opportunities of increasing scores that could help the HealthPlan’s overall scores. To assist in this endeavor, PHC repurposed some Strategic Use of Reserve funds (held in surplus from years past), in the form of small grants to help providers in these activities. Those funds, which were considerably smaller than the Quality Improvement Program (QIP) pool of funds, have been paid, and, occurred prior to the current financial stresses.
- Discussion Topics Today – There are discussion topics planned for the end of the meeting that require feedback from the Committee. One is when patients are disenrolled from a practice. How long should that penalization continue? And, at what point would their re-enrollment be considered? Another involves what PHC can do as an institution to address racism. PHC’s process for handling allegations of discrimination is another topic for discussion.
PHC’s Regional Medical Director for Napa and the Southeast (SE) counties presented a brief update. - COVID-19 – There has been a somewhat dramatic increase of cases in Napa the past few weeks, as compared to
the slow start. Last week’s 35 cases can be traced back to families who live in closed communities who are essential workers, as well as some farm workers. In Solano County, there has also been a large uptick in cases, which can be traced to community gatherings and a couple of workplace outbreaks that are not skilled nursing facility (SNF) related. Yolo County has the lowest increase of cases, but, that may be due to less testing. Overall, only Solano County is seeing persistent hospitalizations, whereas, Napa County has not seen any, nor are there deaths reported on the dashboards.
- Access – A dialysis unit has been credentialed for Napa County. Over the past four to six months, Solano County Family Health Services (SCFHS) has lost the equivalent of five full-time primary care providers (PCPs), which is a substantial loss to the community. This comes during an already difficult economic time, as they are a governmental agency and in the midst of a widespread hiring freeze that may challenge some of their recruiting efforts. However, SCFHS has increased their level of providing telemedicine during this time, and has consolidated their staff to meet the needs of their patients.
- Quality Meeting – The Southeast counties held their quarterly consortia meeting last week, which had broad representation and great presentations by PHC’s Quality team and medical directors. About one-third of the meeting focused on how the practices had pivoted to support seeing patients via telemedicine during COVID-19, and the difficulties they experienced trying to maintain office presence during the widespread unrest over the previous week. These quarterly quality improvement (QI) sessions have given area providers the opportunity to work on QI and discuss the challenges of primary care.
II.A. Status Update Medical, Continued II.A1. Update Cnty Public Health
PHC’s Regional Medical Director for the Southwestern (SW) counties presented a brief overview. - COVID-19 – Cases have increased for the SW counties, some of which can be attributed to the increase of
testing. However, the underlying increase of incidents is worrisome. - Provider Education – Staff has continued with provider education sessions by way of the JLI meetings and
targeted areas (Asthma Medication Ratio and the Perinatal QIP.) Meetings have also been held to review the changes made to the 2020 PCP QIP and the reduction in measurements.
- TeleHealth – Numerous discussions are being held with practices regarding the swing in providing telemedicine services (telephonic and video), along with how offices are handling those changes, and to what degree telehealth visits are occurring. For some practices, telemedicine accounts for 30% of their appointments, while other practices are as high as 80% in their telehealth patient visits. Smaller offices have continued with the higher number of in-person appointments. How provider sites intend to reopen is another topic being considered. Aside from logistics and social distancing, regaining the public’s trust in going back into facilities is another area of concern. How in-person visits are being handled (especially those requiring physical exams) is also being discussed (i.e. some practices are conducting portions of the visit ahead of time or in their parking lot, prior to the in-person exam.) The downside to split-visits is the repetition of doing the history. However, by using an electronic pad and taking the information from the patient while they are still in their car, the patient can then be taken into the facility for the balance of their in-person visit.
- Access – Petaluma Health Center has hired a rheumatologist, who is conducting consultations and is accepting referrals (not just for Petaluma Health patients.) Telehealth access will soon be available, allowing patients at home to remotely interact with the specialist.
PHC’s Regional Medical Director for the Northwestern (NW) counties presented a brief overview. - COVID-19 – The spike of cases at an assisted living facility discussed last month has since calmed down.
However, there have been four deaths in the county, all of whom are tied to that facility. There have been no new cases at the facility for the past two weeks. Of note, three cases the Public Health Officer has been investigating are the result of community transmission, which is concerning. The potential cases from recent protests (where social distancing and face masks were mostly being ignored) is on the watch list.
- Access – The provider network is stable at this time, but, sheltering in place may be playing a big role in that. PHC’s Northern Regional Medical Director presented a brief overview. - COVID-19 – The area is not seeing a significant impact from COVID-19 cases. However, hospitalizations are
almost where they were before the shelter in place was put into effect. So, hospitals are again busy. - Access – Shasta Community Health Center (SCHC) is moving forward on their expansion in the Enterprise
area. There was no formal epidemiology report given to the Committee. However, updates from PHC’s medical directors covered the status of the pandemic for their regions.
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II.A2. – Committee Member Highlight II.B. Quality/ Utiliz. Advisory, II.B.1. UM Program Description Amendment, II.B.2. Lactation Clinical Practice Guidelines, II.D. Provider Advisory Group II.E. Credentialing Committee, II.F. Pediatric Quality Committee
Dr. Teresa Shinder shared some of her background, which led her to her current position at Ole Health, where she is the Chief Medical Officer. Her undergraduate education was done at the University of California (UC) San Diego, taking a few years off to work in the environmental field in Hawaii. She then attended medical school at Touro University, with her pediatric residency at Kapiolani Medical Center for women and children on Oahu. Though she knew she wanted to be in some type of medicine, Dr. Shinder’s path to pediatrics was not a direct route. Adoring animals, she initially considered becoming a veterinarian, until she had the opportunity to shadow one. Her next focus was on dentistry, which was not a match either. After a period where she wanted to live the “Indiana Jones” lifestyle and take history as her major, she ultimately worked with a pediatric disease specialist, and was hooked. Aside from the children, she appreciated the families and the preventative care aspect of pediatrics. On a personal note, Dr. Shinder has a 3 1/2 year old daughter, who teaches her the values of her humanity. Their family has three cats, the latest being an older female rescue, who is testy most of the time, but, still relished by her newfound family. Dr. Shinder has been with Ole Health since November 2019, and was drawn to the practice as she wanted to be at a health center in her community. Appreciating the work at Federally Qualified Health Centers (FQHCs), Ole Health was a perfect fit for her. Ole Health has a great history, and attracts very interesting people. She has been really impressed with the outreach work done by the organization, like participating in health fairs and food drives in the community. Dr. Shinder has worked with Partnership for over six years, finds its website to be very helpful, is impressed with the HealthPlan’s responsiveness, all the work it does with its providers, and its focus around quality. She finds the quotes used by PHC’s CMO in his newsletters inspiring, with a recent one particularly poignant for her. There were no items pulled by the Committee from the Consent Calendar. (Post-Meeting Correction: The Provider Grievance Policy MP PR-GR 210 was erroneously listed under the Policy Summary [page 44 of packet.] That item had been pulled from the agenda prior to the meeting, and will be reviewed by the Physician Advisory Committee at their August meeting.)
N/A For information only, no formal action required. MOTION: Dr. Oryn moved to approve Agenda Items [II.B., II.B.1., II.B.2., II.D., II.E., and II.F.] as presented, seconded by Dr. Symkowick. ACTION SUMMARY: [12] yes, [0] no, [0] abstentions. Motion carried.
Additional Item – New Potential Member for Physician Advisory Committee IV.A. Hospital Quality Improvement Program (HQIP) – New Measure Proposal for 2020/2021
Karen Sprague, Nurse Practitioner with Community Medical Centers (CMC), attended this Committee’s meeting in May, though staff was unaware of her participation by telephone. PHC’s SE Regional Medical Director noted that Ms. Sprague is a lead clinician at CMC, which is located in Solano County. Ms. Sprague’s nomination will be included on the August agenda, as it is expected that the July meeting will be cancelled. Partnership’s CMO readdressed the CEO’s report on the State’s Budget, and the significant budget challenges expected for PHC this year. However, this agenda topic focuses on the measures, and not the underlying finances. PHC’s QI Project Manager for the Hospital QIP presented the recommended changes for the HQIP for 2020/2021, which will begin on July 1, 2020. Current year measures for 2019/2020 were used for comparison in the packet material. Gateway Measure: Health Information Exchange (HIE) and the Emergency Department Information
Exchange (EDIE) Interface – No recommended changes Gateway Measure: Delegation Reporting / All capitated hospitals – No recommended changes Plan All-Cause Readmission Rate – No recommended changes Palliative Care Capacity – Changes recommended related to the COVID-19 impact:
For full points, the threshold was lowered from 50% to 40%, and the number of patients from 20 to 10 for large hospitals.
California Hospital Patient Safety Organization (CHPSO) Participation – No changes recommended QI Capacity – Proposed change for small and large hospitals – Lowering points to 5 for attending the
Hospital Quality Symposium in 2021. California Immunization Registry (CAIR) Utilization – No changes recommended Elective Delivery before 39 weeks – No recommended changes Exclusive Breast Milk Feeding – No recommended changes Nulliparous, Term Singleton, Vertex (NTSV) Cesarean Birth Rate – No changes recommended Substance Abuse Bundle – Recommended changes:
- Overall Target – No changes recommended - Eliminate one of two Voluntary Inpatient Detox (VID) events for small and large hospitals - Eliminate the Naloxone fill / distribution - Medication Assisted Treatment (MAT) in the emergency department (ED) - No changes - MAT in inpatient setting, and the Support for Hospital Opioid Use Treatment (SHOUT) in the ED and
inpatient settings – Recommendation to Eliminate
PHC’s CMO noted that the segments eliminated were either one-time measures, those to initiate a process, or those that had unexpected major challenges with implementation. The remaining allows for reasonably good data, and what is still considered impactful. Of note, there is a committee review process used for reviewing any changes, which includes hospitals, prior to presentation to this Committee.
For information only, no formal action required.
06/10/20
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Physician Advisory Committee Minutes – 06/10/20 - Page 7 of 11 Note, for topic continuity, some comments documented out of discussion order.
AGENDA ITEM
DISCUSSION / CONCLUSIONS RECOMMENDATIONS / ACTION
DATE RESOLVED
IV.A. Hospital Quality Improvement Program (HQIP) – New Measure Proposal for 2020/2021, Continued IV.B. Final version – 5-Star Quality Strategic Plan
PHC’s Behavioral Health Clinical Director offered that, in light of the pandemic, there have been reports of people foregoing routine preventative medical care out of fear of COVID-19 exposure. Routine prenatal care is both essential and preventative in nature, and he supports PHC’s ongoing efforts to support its providers in their efforts to encourage behavioral health screenings as part of their routine work. There are three new proposed measures for 2020/2021. 1) Cal Hospital Compare – Patient Experience – All hospitals are already required to conduct patient
experience surveys. This will be the first patient experience survey measure for the QIP. All subcategory scores would be added, then compared to the sum average score for California hospitals, which would serve as the Target. If the composite score for the hospital is greater than the average California hospital score, they would receive full credit. The intent for year one of the measure is that all participating hospitals would get credit, with the exception of those that fall far below the State’s average.
2) Health Equity – This measure would be submission-based. Hospitals to submit their plan (best practice) for
addressing health equity. 3) Sexual Orientation / Gender Identity (SO/GI) in the electronic health record (EHR) – This would be a
submission of implementation plan over a 12-month period, or a screenshot of existing SO/GI in the EHR. Organizations can discuss options available with their vendor, prior to starting the implementation process. The EHR vendor may have previously created SO/GI customizations. These data fields may include: - What is your legal name? - What is your preferred name? - What sex were you assigned at birth? - What is your legal sex? (gender on ID card will be used by PHC) - What is your gender identity? - What pronouns do you use?
PHC’s CMO shared that he has had the opportunity to compare hospital pay-for-performance programs in use by other California health plans, and, is very proud of the one Partnership has developed. The variety of domains and carefulness used by PHC’s Quality team shows in the developed product. Partnership’s CMO advised that he included the final version of the 5-Star Quality Strategic Plan, as it had been reviewed and discussed at a previous meeting, and most of the major items were covered at that time. Quality staff, as well as the Board’s Quality Workgroup, evaluated the five focus areas (engaging clinical practices, engaging new members, data and informatics infrastructure, accreditation status, and access to care.) Even with the pandemic, it was determined that those focus areas were still important (though the date of this version preceded the State’s “shelter in place” order by two days.) Consequently, the details (implementation timelines, activities, and objectives) will be modified.
MOTION: Dr. Herman moved to approve Agenda Item [IV.A.] as presented, seconded by Dr. Bosworth. ACTION SUMMARY: [12] yes, [0] no, [0] abstentions. Motion carried. For information and update only, no formal action required.
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Physician Advisory Committee Minutes – 06/10/20 - Page 8 of 11 Note, for topic continuity, some comments documented out of discussion order.
AGENDA ITEM
DISCUSSION / CONCLUSIONS
IV.C. Discussion Topic – Increasing Outpatient Services: Experiences of Committee Members Additional Discussion Topic: Member Disenrollment
PHC’s CMO noted that, in addition to the discussion topic listed, there were two additional topics he would like feedback on from the Committee: Considerations for length of time a member is disenrolled from a practice and what conditions would apply for reenrollment to that practice How should Partnership address allegations of discrimination, particularly when an allegation is against a provider? Increasing Outpatient Services: Experiences of Committee Members – Dr. Brennan shared that the updates received from PHC, especially those impacting the formulary, are very helpful in her patient practice and may be as
timely as seeing a patient that day. Also, the quality measures and collaboration between organizations, sharing their best practices in areas they are succeeding at that others are struggling in, is also very beneficial.
Dr. Hunter advised that Open Door Community Health Centers (ODCHC) is trying to improve the video visit experience, and, finding it to be a really heavy lift. The organization as a whole is pushing toward improving this experience for the patient. The barrier is getting patients connected and being prepared for the video visit. Staff is trying to utilize the best ways for connecting with patients. There was an initial uptick for some providers, who were very enthusiastic with the process (achieving as high as 35% to 40% video over telephone appointments), and ODCHC’s target is 50%, but, there is a lot of work involved with patient coaching and outreach, and all staff are participating in the process (making appointments, medical assistants preparing charts, etc.) ODCHC utilizes the Zoom platform through the Epic MyChart software. It is believed that after the first appointment and the patient is more comfortable with the system, it should be a lot easier the second or third visit. Staff also feels that the video visit is more robust, and, believes that some patients are being reached who were not as easily reached before. With additional experience and work with the system, they believe improved access can be achieved. There has also been some success with group visits using this format.
Ms. Sprague reported that Community Medical Centers (CMC) had to also pivot quickly to do telehealth visits. CMC is using an application (App) called Doximity, which has worked out really well. A patient just needs a Smart Phone, and they receive a text to join the visit. The App is Health Insurance Portability and Accountability Act (HIPAA) compliant. It is very easy to use for the provider and the patient. CMC is doing approximately 50% of their visits by video.
Dr. Bosworth advised that Shasta Community Health Center (SCHC) has been utilizing a Respiratory Assessment Center the last couple of months, where they take COVID-19 positive-screened patients to a different location for evaluation. That system has been very helpful in allowing staff to feel safer to come to work, and, being willing to have in-person visits with patients. This has been flexed up and down, depending on the positive screenings in the community. SCHC conducts temperature or questionnaire screenings at their door, or even in the parking lot. If the screening is positive, the patient is sent across the street to a nursing triage / treatment area, then seen by a physician at the Respiratory Assessment Center if appropriate, or, can be taken to a separate room that is specially cleaned afterward. Patients determined to have respiratory symptoms by way of a telephone triage are also sent to this location. This has been very effective. SCHC intends to continue this system as long as needed, and is utilizing an old building that was slated for remodel. Staff has been innovative with the process.
PHC’s CMO reminded the Committee to send any best practices and updates to their PHC Regional Medical Director. The second discussion topic, considerations for length of time a member is disenrolled from a practice and what conditions would apply for reenrollment to that practice, was discussed briefly at PHC’s Quality / Utilization Advisory Committee (Q/UAC). Partnership’s CMO highlighted the context to the topic. PHC has a policy process in place for primary care providers (PCPs) who want to disenroll patients. Reasons may include violent behaviors to excessive no-shows, and actions in between. Different practices have different thresholds, which is one issue. Another issue that has come up is the amount of time a patient is disenrolled, and what conditions would that patient be permitted back into the practice. The Q/UAC recognized that the infringement by the patient would be a factor in the determination (how severe.) People do change over time, whereas, their disenrollment could be reconsidered, allowing them to be brought back under a probationary status.
IV.C. Additional Discussion Topic: Member Disenrollment Continued
What are organizations currently doing when they may reconsider re-enrolling a patient? If the issue has not come up before for your organization, what would be considered a reasonable time period and process? Dr. Bosworth shared that SCHC has a Case Review Committee to review such cases, which promotes some
consistency for these situations. They also use a robust documentation process that is tied to their electronic medical record, but, is not accessible to the patient. SCHC will first use behavioral agreements, before considering disenrollment. When it gets to the level of disenrollment, his policy is that the patient first needs to request to come back to the practice after one year. If they have a reasonable story (change in transportation, etc.) and state they will be better at keeping their appointments, then they are allowed a chance to come back, but, the patient will also sign a behavioral agreement, which places them on probation. The next category would be for those with behavioral problems, and being abusive over the telephone or with staff. Again, after at least one year (maybe longer), they would need to request to come back with a promise to do better. For incidents that were violent or with a threatening behavior, the threshold would be higher and require more time. That type of case would be reviewed more diligently (i.e. if a mental health issue, the patient was actively receiving treatment.)
PHC’s SW Regional Medical Director advised that a number of disenrollment requests are received from providers, and, some of the reasons do not fall under PHC’s policy categories, like failure to follow a treatment plan. If all noncompliant patients were disenrolled, most physicians would not have any patients. It is appreciated when practices utilize behavioral counseling and agreements for these individuals, before requesting a disenrollment. Of concern are those small isolated practices, which may be the only provider in an area. How should those requests be handled, when there is not another provider for 20 miles? One option to consider is to change the provider within the practice. Ms. Sprague shared that CMC has a Behavioral Contract for patients who merit it. CMC’s CEO is not in favor
of disenrolling any patients. Reviewing the contract with the patient reinforces the fact that yelling at the staff or aggression is unacceptable behavior. If the patient starts to escalate while they are in the clinic, staff will remind them that they signed a contract, which generally diffuses the situation.
Dr. Hunter noted that ODCHC also utilizes a Behavioral Contract. There is a wide range of what is acceptable among the providers, and he believes that some providers tend to escalate the problem. Trying to support the providers through these differences can be challenging. Changing providers for the patient sometimes helps, as was noted. Also, much of behavioral issues with patients have centered around substance abuse, which was much worse when there was little focus on the opioid crisis. Even using behavioral counseling, there have been a couple of incidents where the patient was uncontrollable. He has advocated against disenrolling patients for no-shows, reverting to a system where the individual does not get a scheduled appointment, but, comes into the clinic and gets worked into the schedule.
Partnership’s CMO will assimilate the suggestions made, and those by the Q/UAC members, and send out to the provider network.
Ms. Sprague will forward a copy of CMC’s Behavioral Contract to PHC’s CMO, who will include in one of his clinical newsletters.
IV.C. Additional Discussion Topic: How PHC Should Address Allegations of Discrimination
In light of current events, PHC’s CMO noted that his next monthly newsletter will highlight how the HealthPlan responds to potential institutional racism. PHC’s process for addressing allegations of discrimination is complicated. How Partnership might improve upon that system is the topic focus. A scenario was used for sample purposes, whereas, a member calls the HealthPlan to complain that they had been discriminated against. This starts a legal investigation, as required by the Office of Civil Rights. Once PHC’s Member Services department assimilates the details, the case is referred to the Grievance department for evaluation by an internal expert (PHC’s Senior Health Educator.) It is their communication skill and background that assists them in the process. They may reach out to the provider for their account of the incident, which is often very different from the member’s. There are certain legal requirements for what constitutes discrimination. PHC’s current practice is if the incident does not rise to the level of the federal description, the incident is categorized more as a miscommunication, which may be shortsighted. Even if the interaction does not rise to the federal level, the communication (verbal or nonverbal) breakdown may still require attention. If the patient does not feel respected, should the provider be expected to take some additional training course? Is there a recommended program used, or is there evidence that the training makes an impact on the behavior? Dr. Gorchoff offered that there were a number of trainings providers went through some time ago around cultural sensitivity, but, he believes this should be
taken to the next level. There are communities of people who have been discriminated against, and the inequities in health care are just one of many manifestations. There is more he can learn about white privilege, and how that can blind him. Something said to one patient may be completely appropriate, but, could sound condescending and offensive to another. An on-line 10 minute training is probably not sufficient. Acknowledging there is a need for better understanding is the first step.
PHC’s SE Regional Medical Director shared that the issue is not just the clinician in the exam room, but, the entire system. As noted by Dr. Gorchoff, there was an emphasis a number of years back for cultural sensitivity training. But, applying the concepts learned may have been short-lived. So, the question is, how do we systemically create a process to remind ourselves of those important beliefs (much like a Continuing Medical Education [CME] course.) How do we weave that into our practice of medicine, and, help build stronger communities through enhancing our differences and being aware of potential biases through that understanding so that it does not create more challenges? Without mentioning the organization, there is one in the region that sends clinicians to “charm school” (for lack of better term), that undoubtedly tracks the benefit of that training. It would be interesting to see the data, as it stands to reason that the organization would not continue the practice, if patient satisfaction scores were not improved. How the experience may have altered the clinician’s perspective of their patient interactions, and whether there was improved job satisfaction, would also be of interest. Taking the idea a bit further, PHC’s CMO shared that perhaps an introspective essay by the provider, who has had complaints about them, would help that individual recognize their cultural reactions through the exercise, more than completing an assigned training.
Dr. Symkowick advised that Kaiser Permanente breaks out their Member, Patient, Satisfaction (MPS) scores by ethnicity. For lower performers, there is indeed “charm school.” To his understanding, the training is not specific in addressing racial differences, but, more for low performance. However, when recognized by the right people in the organization, it will be addressed with the clinician. It is recognized that there is deeply seeded racism, in general, that is absolutely pervasive in health care. But, how is that problem addressed? Though there is agreement, finding the process to improve this systemic issue is not an easy one, but, deserves a hard look. Each patient’s opinion needs to be taken seriously. Though he does not have an answer, Dr. Symkowick will continue to ask how things can be done better at Kaiser, Vallejo. He does not believe that sensitivity training, etc., will change the social determinants of health in our society, or help the structure that produces health inequity. However, he thinks that organizations need to work with the patients and patient advisory committees to help the problem. In his role as Physician-In-Charge in Vallejo, he plans to ask a lot of questions. And, recognizes that the training received by residents can include this knowledge. New physicians have the advantage of learning these concepts around diversity and equity, and are encouraged to view implicit bias as a vital sign, regardless of the patient. If a clinician is not willing to ask the question, perhaps that is the red flag for sensitivity training. If it becomes a recurring problem for the individual, the question whether they can provide equitable, high quality care to patients needs to be considered.
IV.C. Additional Discussion Topic: How PHC Should Address Allegations of Discrimination
Additional Item: July 2020 Meeting
Adjournment
Partnership’s CMO expressed his appreciation for the insight and comments made, recognizing the importance for clinicians to have an introspective review of what biases they may be bringing into an interaction, and determining how to better communicate with that patient. PHC’s CMO reported that the Committee will not convene in July. The Committee adjourned at 8:59 AM Respectfully submitted: Linda Largent
For information and discussion purposes only, no formal action required. There will be no Physician Advisory Committee meeting in July. The next regularly scheduled meeting will be in August.
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The foregoing minutes were APPROVED AS PRESENTED on: ___________________________ ____________________________________ Date Jeffrey Gaborko, M.D., Committee Chairman The foregoing minutes were APPROVED WITH MODIFICATION on: ___________________________ ____________________________________ Date Jeffrey Gaborko, M.D., Committee Chairman
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PARTNERSHIP HEALTHPLAN OF CALIFORNIA
MEETING MINUTES
Committee: Quality and Utilization Advisory Committee (Q/UAC) Meeting Date/Time: Wednesday, July 15, 2020 / 7:30 AM – 9:00 AM Napa/Solano Room, 1st Floor
Per Governor Newsom’s Executive Order, N-25-20 that relates to social distancing measures being taken for COVID-19. The Executive Order authorizes public meetings with Brown Act requirements to be held via teleconference or telephone. It waives the Brown Act requirement for physical presence at the meeting for members, the clerk, and/ or other personnel of the body as a condition of participation for a quorum. However, the Executive Order requires at least one public location consistent with ADA requirements to be made available for members of the public to attend the meeting, so all PHC offices will be available for members of the public to attend the meeting in-person.
Members Absent: Borde, Madhusudan, MD Choudhry, Sara, MD Gwiazdowski, Steven, MD, FAAP (on PTO)
Strain, Michael, PHC Consumer Member Swales, Chris, MD
PHC Members Present: Boyd Anderson, Rebecca, RN, Director of Population Health DeVido, Jeff, Behavioral Health Clinical Director French, Rachael, Associate Director of Quality and Performance Improvement Glickstein, Mark, MD, Associate Medical Director Glossbrenner, David, MD, Regional Medical Director Hoover, Peggy, RN, Senior Director of Health Services Kubota, Marshall, MD, Regional Medical Director Leung, Stan, PharmD, Director of Pharmacy Services
McAllister, Debra, RN, Director of Utilization Management Moore, Robert, MD, MPH, MBA Chief Medical Officer – Chairman Netherda, Mark, MD, Associate Medical Director of Quality Ribordy, Jeff, MD Regional Medical Director Robinson, Erika, Director of Quality and Performance Improvement Scuri, Lynn, Regional Director Steffen, Nancy, Northern Region Director of Quality and Performance Improvement Vovakes, Michael, MD, Associate Medical Director
PHC Members Absent: Banks, La Rae, Director of Grievance and Appeals Barresi, Katherine, RN, Director of Care Coordination Cotter, James, MD, Associate Medical Director Guillory, Ledra, Manager of Provider Relations Representatives
Katz, Dave, MD, Associate Medical Director Spiller, Bettina, MD, Northern Region Associate Medical Director Townsend, Colleen, MD, Regional Medical Director
Guests: Devan, James, Manager of Performance Improvement Hackett, Emma, MD, Open Door Community Health Center Hoffman-Spector, Sharon, RN, Manager of Utilization Management Kisliuk, Margaret, Behavioral Health Administrator Lee Caron, Manager of Performance Improvement Leslie, Liz, Program Manager II, Wellness and Recovery Program Nakatani-Phipps, Stephanie, Lead Senior Provider Relations Rep
Dr. Robert Moore called the meeting to order at 7:30 a.m. No public comments were made. Internal Quality Improvement (IQI) Minutes from June 9, 2020 were reviewed and accepted with no changes. Quality and Utilization Advisory Committee (Q/UAC) Minutes from June 17, 2020 were reviewed and approved with no changes.
Motion to approve IQI Minutes: Dr. Robert Quon Second: Dr. Jennifer Wilson All members present voted yes with no exceptions. Motion to approve Q/UAC Minutes: Dr. Brian Montenegro Second: Dr. Robert Quon All members present voted yes with no exceptions.
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II. Standing Agenda Items 1. Status of Open
Action Items None. 07/15/2020
2. Quality Improvement (QI) Department Update
Erika Robinson and Nancy Steffen provided the QI update found on page 23. Erika acknowledged the Healthcare Effectiveness Data Information Set (HEDIS) project that came to a
close June 15 and complimented the team, which managed to succeed in introducing new data sources and completing the project on time. COVID did not impact medical record collection/review. Erika complimented Call Center staff participants as being integral to that success. We are also noting two significant changes in the recent, new HEDIS specifications and continuing to work closely with our internal teams, with those who are part of our advisory groups for QIP. Everyone is anticipating how the state Department of Health Care Services (DHCS) might adapt specifications and expectations. DHCS has allowed greater allowance for virtual visits, which is a great change in view of COVID. But there is also some anticipated issues in terms of new ways that they have combined certain measures that we have become accustomed to, particularly around well-child visits. There are significant new HEDIS expectations. When asked to comment, Rachael French deferred any remarks until her upcoming presentation.
Nancy had two things to highlight in the update: p. 22: on HEDIS Score Improvement, we have been fortunate to have had a good relationship with Shasta County Health and Human Services, in particular their public health group, over the last three or four years, in which we worked together to help reach our adolescent members for immunizations for seventh grade entry. This year because of COVID, the outreach calls began in mid-June (earlier than August as customary), and Shasta is appreciative. We reached out to more than 850 members by phone, and if unable to reach them, we sent postcards.
Additionally, Partnership and Population Health Management Director Rebecca Boyd Anderson opened up some discussions in other counties to see if any would be interested in similar support. Several providers, many in the northern region, are interested and PHC is doing our best to accommodate them in this outreach campaign.
Nancy added that recent changes in HEDIS’ Managed Care Accountability Set (MCAS) effectively nullified the Corrective Action Plan (CAP) that DCHS imposed on PHC in September 2018. (We met all our milestones in 2019 for the two-year CAP.) In June, DCHS communicated to us that they would be closing our CAP in July upon receipt of the report that Rachael is about to share. We can anticipate more mandated improvement work, in particular in the Northern Region. We will have a smaller subset of administrative measures and it will not be quite as rigorous in terms of our responsibility in documentation over the next year.
For information only, no formal action required.
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AGENDA ITEM DISCUSSION RECOMMENDATIONS /
ACTION DATE
RESOLVED 3. HealthPlan
Update Dr. Moore gave his HealthPlan update. First, NCQA released its annual changes and will do a final update in October. COVID necessitated
allowing quite a number of visits to be performed virtually, including prenatal and well-child visits and attention deficit disorder and depression follow-ups too. This will necessitate a few changes in the (Primary Care Provider Quality Improvement Program) PCP QIP specifications. The changes are for current year and retro back to January.
PHC switched well-child visits from a hybrid measure to an administrative measure: we have to get the claims data in order to account those visits. We’re going to have allowance for some entry of updates of visits at the end of the year but those can’t be counted for National Committee on Quality Assurance (NCQA) accreditation. We’ve got to decide how we’re going to handle that.
Because of COVID and the need to monitor patients closely at home, Partnership is currently rolling out a pilot which became active just a few days ago: Erika sent out an announcement to her whole team, which included the handout being sent out to providers. We can send that to Committee members after the meeting. This is for distribution of equipment; specifically, in the pilot phase, three types of equipment: oxygen saturation monitors; digital blood pressure monitors, and thermometers. We do recognize that the blood pressure monitors are covered also through the pharmacies, and that pharmacies have more than one variety. We anticipate that the pharmacy carveout, and the number of other devices that we currently distribute through pharmacy, will get PHC into small-scale medical equipment distribution to help our members obtain needed equipment not readily available elsewhere.
NCQA took away most restrictions regarding blood pressure monitoring: patients can be remote, take their blood pressure at home, and submit it. We’ll be updating our specs accordingly.
California did reinstate all our benefits that were supposed to be cut by the Governor’s proposed budget but they could still be cut if the federal bailout for COVID relief anticipated by the California Legislature doesn’t occur.
For information only, no formal action required. Leslie Erickson on July 20 sent the pilot program flyer to Committee members to pass on to their PCP colleagues.
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III. Old Business (Committee Members as Applicable) None
IV. New Business (Committee Members as Applicable) Consent Calendar
Care Coordination MCCP2016 – Transportation Policy for Non-Emergency Medical (NEMT) and Non-Medical Transportation (NMT) Note: Approved at the June meeting, subsequent regulatory changes necessitated a revision and so the policy came back in July. Utilization Management MCUG3008 – Bathroom Equipment Guidelines MCUG3058 – Utilization Review Guidelines ICF/DD. ICF/DD-H, ICF/DD-N Facilities MCUP3014 – Emergency Services MCUP3033 – Out-of-Area Emergency Admissions MPUP3026 – Inter-Rater Reliability Policy
Motion to approve: Dr. Robert Quon Second: Dr. Jennifer Wilson Approved with no changes. All members present voted yes with no exceptions.
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AGENDA ITEM DISCUSSION RECOMMENDATIONS /
ACTION DATE
RESOLVED V. Discussion 1. MPQP1022 – Site
Review Requirements and Guidelines
Rachel Peterson, RN reported on MPQP1022 found on page 63. Section I: Addition of MP CR 12 - Credentialing of Independent and Private Duty Nurses under
EPSDT Section IV: Addition of Attachment I. 2019 Private Duty Nursing Site Review Tool and Standards Section VI.A.2.F: Added section regarding Private Duty Site Reviews Section VII.D: Added Reference to APL 20-012
Rachel noted that PHC can review the site (i.e., the member’s home) up to every three years. The Consumer Assessment of Healthcare Providers and Standards (CAPHS) will be due within 30 days of the site review.
Motion to approve: Dr. Candy Stockton Second: Dr. Robert Quon There were no questions and the policy was approved with no changes. All members present voted yes with no exceptions.
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2. MCUP3020 – Hospice Services Guidelines
Debbie McAllister, RN, reported on MCUP3020 found on page 382. Section VI.A.1: Removed the word “family” to clarify that only the patient is admitted to hospice. Section VI.A.1.a: Updated language as per Medi-Cal guidelines to say that certification of a terminal
illness may be provided by either the patient’s physician or the hospice medical director. Also specified that supporting documentation should be provided to certify the terminal illness.
Section VI.D: Rewrote this section to describe “Hospice Periods of Care” using the language from the Medi-Cal provider manual.
Section VI.E: Added a new section to policy based on Medi-Cal guidelines to describe the requirements for hospice Patient Certification and Recertification.
Debbie noted that for this purpose, life expectancy is defined as six months or less.
Motion to approve: Dr. Candy Stockton Second: Dr. Robert Quon There were no questions and the policy was approved with no changes. All members present voted yes with no exceptions.
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3. MCUP3131 – Genetic Screening and Diagnostics
Dr. Robert Moore reported on MCUP3131 found on page 387. Section VII. References: Updated formatting of references. Attachment A:
o Pages 34, 35, 38, 42 Per Medi-Cal guidelines, added statement “Claims without documentation showing the preceding criteria have been met will be denied.” to codes 81401, 81402, 81403, 81404.
o Page 59 Code 81420 – Updated code description; added notes from Medi-Cal guidelines regarding noninvasive prenatal testing.
o Pages 60, 61 Code 81432 – This new code was added for multi-gene testing for hereditary breast cancer-related disorders.
o Page 65 Code 81507 – Frequency limit updated to no more than once per pregnancy. Note addition that concurrent or repeat use of noninvasive prenatal testing during the same pregnancy is not covered.
o Page 71 and 72 Code 81541 - This new code was added for a 46 gene expression profiling test for prostate cancer.
o Page 72 Code 81542 - This new code was added for a 22 gene expression profiling test for prostate cancer.
Dr. Moore noted that with hundreds and hundreds of potential genetic tests referenced in this document, this is the first time we’ve seen new profiles being added.
Motion to approve: Dr. Robert Quon Second: Dr. Jennifer Wilson There were no questions and the policy was approved with no changes. All members present voted yes with no exceptions.
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4. MCUP3139 – Criteria and Guidelines for
Dr. David Glossbrenner reported on MCUP3139 found on page 466. This new policy defines a standard of care and establishes an approved list of UM criteria and guidelines for reviewing TARs and hospitalizations. Q/UAC will review this list annually. The guidelines and criteria can be grouped into the following groups: Required standards as set forth by the State of California (DHCS or other agencies) where PHC is
Motion to approve: Dr. Robert Quon Second: Dr. Brian Montenegro
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AGENDA ITEM DISCUSSION RECOMMENDATIONS /
ACTION DATE
RESOLVED Utilization Management New Policy
contractually and legally obligated to follow the guidelines. Industry accepted guidelines that are used by a variety of other managed care organizations (e.g.,
InterQual® and National Comprehensive Cancer Network [NCCN]). Guidelines developed through government agencies (e.g., Center for Disease Control [CDC] or Agency
for Healthcare Research and Quality [AHRQ]). Policies developed by PHC.
Dr. Glossbrenner noted that Attachment A lists the primarily used guidelines. This will help with NCQA and also let our network of physicians know where to look to see what guidelines are being used to review requests for services. There could be few circumstances where these groups of guidelines conflict. In situations where there is a conflict, the use of the guidelines should not compromise the patient’s safety.
There were no questions and the policy was approved with no changes. All members present voted yes with no exceptions.
5. MPNET101 – Wellness and Recovery Access Standards an Monitoring New Policy
Dr. Robert Moore reported on MPNET101 found on page 469. This new policy defines access standards for substance use disorder treatment through the PHC Wellness and Recovery Program. It outlines access to providers, establishing measureable standards for the geographic distribution of each type of wellness and recovery program. It also establishes measureable standards for timely access for outpatient opioid treatment services. Specifically, this is our drug Medi-Cal fund benefit in seven of our counties and a major pilot that went live July 1. Rachael French clarified that this policy only includes DHCS Access standards for Wellness and Recovery and not those of the NCQA.
Motion to approve: Dr. John Murphy Second: Dr. Jennifer Wilson There were no questions and the policy was approved with no changes. All members present voted yes with no exceptions.
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VI. Presentations 1. Population Health
Management Impact Analysis
Rebecca Boyd Anderson, RN, presented the PHM department’s very first Impact Analysis found on page 472.
Note: After the meeting, it was discovered that an earlier draft of the report, and not the final, had been included in the meeting packet. The packet was amended with the final report and was emailed to Committee members and internal parties.
There are three major categories of program evaluation that PHC needs to perform each year. The first is a clinical measure. The second is a utilization measure. The third is member experience measures. This analysis: Looked at two well-child cohorts: those under 15 months and adolescents, comparing members who are
beneficiaries of the California Children’s Services (CCS) program to those who are not. The goal was attendance at well-child visits by PHC CCS beneficiaries will be better than for those not
enrolled. With the exception of the Northern Region, PHC’s CCS population has more frequent pediatric well-
child visits for both populations studied than do PHC’s non-CCS beneficiaries. The hope is that visits with both primary care providers (PCPs) and specialists will be strengthened going forward.
Adolescents had higher visits, which is consistent with PHC experience.
Rebecca noted that children will not be capitated to a local provider but will be encouraged to use the role of a primary care appropriately. The other item noticed through our HEDIS measures is that there is a huge drop-off between pregnant moms and their well babies where pregnant members will get their prenatal/postpartum care (but) their children do not get their wellness visits to the same degree. Thus, the Growing Together program will expand outreach from prenatal/postpartum to making sure they get their children enrolled in insurance immediately after birth.
Motion to accept the report as presented: Dr. Robert Quon Second: Dr. John Murphy
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RESOLVED
For cost and utilization measures, the report used the two case management programs that have been in effect, the first being complex case management (CCM), a standard of care that we’ve done for most of Partnership’s history. PHM utilized Partnership’s proprietary risk adjustment module that assigns risks to all the members and further risk-matched and age-matched population for those people who were not in case management compared to those who were. PHM wanted to determine whether or not CCM enrollees (p. 477) actually had fewer repeat emergency department visits than non-enrollees. The Health Analytics team concluded that, although there are locations where there is a difference, overall it is not statistically significant.
The report also lays out the Transitions of Care model using that same methodology. All-cause readmissions for those who were discharged from hospital were compared to those who did not participate in transitions of care: participants actually were readmitted much more frequently than the general population. This is probably a selection artifact because they are more likely to be readmitted to the hospital if they’ve had one discharge than if they have not. We will be revising our methodology for this particular part of the program evaluation but for this year this satisfies NCQA requirements.
Finally, for member experience, PHM implemented post program surveys for adult and pediatric members engaged in transitions of care case management program or CCM. With the adults, we exceeded the goal of 2.5 or higher member satisfaction in all of our survey questions. In the two areas where we might improve, there’s a certain amount of selection bias: members who qualify for transitions of care don’t feel their health is improving after a hospital stay regardless of a case manager presence. Further, it is likely that many of these members already do have a strong relationship with their provider and case management did not impact that. The results for the pediatric members were very similar. The report contains some anecdotal responses where members expressed their gratitude.
The CCM responses were very similar. They did exceed in every level our targeted goal of 2.5 or greater. Where they showed less agreement is having a better understanding of working with medications after working with CCM. Partnership’s Pharmacy team is working with Care Coordination to look at ways of bolstering that communication.
We are starting right now to select program evaluations for the coming year. The process is new to our organization as is the Population Health Department.
Dr. Moore commented that another way of evaluating the readmissions denominator is to divide readmissions by admissions. That is more standardized and will give better statistics. Rebecca thanked Dr. Moore for the suggestion.
2. HEDIS 2020 Summary of Performance &
3. HEDIS Summary of Performance June 2020
Rachael French presented the two HEDIS reports found on (amended packet) pages 489 and 503, respectively. HEDIS is a tool that was created by NCQA, a standardized way of measuring quality of care delivered to our members relative to national benchmarks: administrative and hybrid measures within our NCQA quality reporting library. Administrative measures look at the entire eligible population and that is where our encounter service data, our claims data is used to generate eligible population and rate. Hybrid measures are where we look at statistically relevant sample sizes; the sample size usually falls at 411 or lower, depending on the population size. (We have the opportunity to go into the medical record chart and extract data.) HEDIS is important because it helps our provider network understand the quality and care of services that are being delivered and where there is opportunity for improvement and focused interventions. It is required by the State, and as we move into NCQA accreditation first survey, we will then be required to report HEDIS where performance plays a stong role in determining overall healthplan accreditation status.
For information only, no formal action required.
07/15/2020
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AGENDA ITEM DISCUSSION RECOMMENDATIONS /
ACTION DATE
RESOLVED
PHC’s 14 counties were grouped into four geographic regions for reporting. This year, there was significant change in the MCAS: eight new measures held to the higher Minimum Performance Level (MPL) 50th percentile were added and three measures were removed (although the latter are still required for NCQA accreditation). The eight new measures are: ABA – Adult Body Mass Index Assessment AMM – Antidepressant Medication Management Acute Phase AMM – Antidepressant Medication Management Continuation Phase AWC – Adolescent Well-care Visits CHL – Chlamydia Screening in Women CIS – Childhood Immunization Status Combo 10 W15 – Well Child Visits in first 15 months of life (six or more well child visits) WCC – Weight Assessment and Counseling for Nutrition and Physical Activity for
Children/Adolescents-BMI only The three removed measures – which we must still collect data on for NCQA accreditation – are: AAB – Antibiotic use for Acute Bronchitis CDC – Screening for Diabetic Retinopathy LBP – Imaging for Low Back Pain
These additions occurred mid-year as the national minimum performance level increased from 25th percentile to the 50th percentile. COVID did not impact our ability to collect our data this year. Not all health plans were as lucky, which is why DHCS allowed plans to report hybrid rates from previous year. PHC reported current year due to the minimal to zero impact COVID had on our ability to collect medical record data. We do however anticipate an impact across our quality measure reporting in coming years due to the pandemic and change in healthcare delivery.
Rachael went through the average plan-wide scoring methodology and baselines on the new MCAS (pp. 497-498 amended packet) and disclosed that PHC in Reporting Year 2020 (Measurement Year 2019) saw 10% absolute improvement and 18% improvement from baseline. This is significant. In a year-over-year composite based on existing reportable measures, respective improvement was 9% and 14%.
Key takeaways: Overall composite MCAS measures, adjusted for population, improved from the Medi-Cal average
composite score of 60% to somewhat above average: adjusted composite score of 67% resulted from multiple interventions cross departmentally; increased provider engagement is likely a major driver.
Overall PCP QIP average score decreased from about 55% to 45% of total points. PHC introduced more rigorous thresholds/performance standards.
There is more work to do improving HEDIS outcomes at the provider level. COVID may force more DHCS accountability changes: telehealth/video visits will continue through
October when the new release is expected.
Rachael went briefly into the lengthy report and said Partnership is improving across all four regions. There are a few nuances. Hybrid measures, reported regionally, did not always produce a nice denominator in a particular county, and PHC did not perform any oversampling this year. This is notated in the report where a denominator size is small and should be interpreted with caution. A summary of improvement activities is on pp. 517-521 (amended packet).
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ACTION DATE
RESOLVED
Dr. Moore said that from his perspective big difference showed in the well-child visits, the postpartum, and the blood pressure measures. He noted that we will share Kaiser specific performance in a future committee meeting. He thanked Rachael for her report.
One caller asked if there was one place to see all the HEDIS measures for 2020. Rachael replied that we are still waiting for DCHS to release the measurement set. Dr. Moore said we will be preparing a summary but suggested a more definitive way to see everything is to subscribe to NCQA. Rachael added that an annual NCQA subscription is ~$350 for an electronic copy for 3-5 users.
For Information Only
The following presentations were presented for information only to allow the meeting to end early to accommodate a full Peer Review immediately following Q/UAC. For a full discussion on these presentations, please refer to the IQI Committee minutes of June 9, 2020.
1. Quality Improvement Performance Improvement Activities 2019/2020 For information only, no formal action required.
07/15/2020
2. Hospital QIP Measures Summary For information only, no formal action required.
07/15/2020
VI. Additional Business
Next Meeting: Aug. 19, 2020 N/A N/A
Adjournment Respectfully submitted by: Leslie Erickson, Administrative Assistant II Signature of Approval: ________________________________________________ Date: ____________________________ Robert Moore, MD, MPH, MBA Chairman
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PARTNERSHIP HEALTHPLAN OF CALIFORNIA MEETING MINUTES
Members Present: Daliri Sherafat, Tahereh, NR Director of MS and PR French, Rachael, Associate Director of Quality and Performance Improvement Hoffman-Spector, Sharon, RN, Manager of Utilization Management Hoover, Peggy, RN, Senior Director, Health Services Kerlin, Mary, Senior Director of Provider Relations Kubota, Marshall, MD, Regional Medical Director Leung, Stan, PharmD, Director of Pharmacy Services McAllister, Debra, RN, Director of Utilization Management
McCartney, Melissa, Director of Care Coordination Operations Moore, Robert, MD, Chief Medical Officer Netherda, Mark, MD, Associate Medical Director of Quality Robinson, Erika, Director of Quality and Performance Improvement Steffen, Nancy, Northern Region Director of Quality and Performance Improvement Turnipseed, Amy, Senior Director of External and Regulatory Affairs Villasenor, Edna, Associate Director of Call Center
Guests: Azeltine, Diana, RN, Manager of Utilization Management Bontrager, Mark, Director of Regulatory Affairs/Program Development Cabrera, Maria, Supervisor of Member Services Campbell, Anna, Administrative Assistant II Delaney, Jessica, Project Manager I Devan, Kris, Supervisor of PR Representatives (NR) Devido, Jeffrey, MD, Behavioral Health Clinical Director Dunham, Michelle, Associate Director of Claims Enos, Mary, Associate Director of Enrollment Garnick, Karen, Project Coordinator II Glossbrenner, David, MD, Regional Medical Director Hightower, Tony, Associate Director of Pharmacy Operations Lee, Donna, Manager of Claims
Leslie, Liz, Program Manager II, Wellness and Recovery Program O’Connell, Lisa, Manager of Provider Education O’Donovan, Olevia, Executive Assistant, Finance Plascencia, Dolores, Project Manager I Poncy, Kenzie, Compliance Program Analyst Rodekohr, Dianna, Project Manager I Rosel, Melissa, RN Associate Director of Utilization Management Santos, Rose, Manager of Quality Assurance/Patient Safety Schiewe, Jane, Project Coordinator II Townsend, Colleen, MD, Regional Medical Director Veneracion, Bianca, Provider Education Specialist Vij, Namita, Provider Education Specialist
Members Absent: Banks, La Rae, Director of Grievance and Appeals Barresi, Katherine, RN, Director of Care Coordination Bjork, Sonja, JD, Chief Operating Officer Boyd Anderson, Rebecca, RN, Director of Population Health Gibboney, Elizabeth, MA, Chief Executive Officer
Ingram, Jeff, Director of Financial Planning & Analysis Scuri, Lynn, Regional Director Shafer, Chloe, Regional Manager Thomas, Catherine, Senior Health Educator
AGENDA ITEM DISCUSSION RECOMMENDATIONS / ACTION DATE
RESOLVED I. Call to Order
Approval of Minutes Dr. Robert Moore called the meeting to order at 1:30 p.m. Minutes from the May 12, 2020 IQI meeting were reviewed and approved.
Motion to Approve: Marshall Kubota, MD Second: Debbie McAllister, RN Approved with no changes.
06/09/2020
II. Standing Agenda Items 1. Status of Open
Action Items None N/A
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RESOLVED III. Old Business None N/A IV. New Business (Committee Members as Applicable) Consent Calendar
Member Services MP301 – Assisting Providers with Missed Appointments Pharmacy MCRO4018 – Pharmacy TAR Procedure Care Coordination MCCP2016 – Transportation Policy for Non-Emergency Medical (NEMT) and Non-Medical Transportation (NMT) Utilization Management MCUP3003 – Rehabilitation Guidelines for Acute and Skilled Nursing Inpatient Services MCUP3037 – Appeals of Utilization Management/Pharmacy Decisions MCUP3138 – External Independent Medical Review Discussion on MCRO4018: Anna Campbell noted in Section IV.A that there is more than one TAR form and this should state the Pharmacy TAR Services Form as that is the actual name on the attachment. Tony Hightower agreed. The committee agreed to this change. Discussion on MCUP3037: Maria Cabrera asked in Section VI.D.1.c, if a TAR was denied due to a coding issue would this prevent a member from getting services, and would the member have appeal rights? Dr. Moore advised that if the incorrect code was used then a service hasn’t actually been requested; therefore, there would be no appeal rights. Debbie McAllister advised that when the code doesn’t exist or is incorrect for the service they are asking for; the nurses do attempt to contact the provider to confirm. Dr. Moore recommended to change this from “coding issue” to “invalid procedure code (CPT or HCPSC)”. The committee agreed to this change. Discussion on MCUP3138: Dr. Netherda recommended in Section VI.F.1 to remove the closed parenthesis after IMRO as it was not needed. The committee agreed to this change. Note: Subsequent to the meeting MCCP2016 underwent a revision due to regulatory change and will be submitted once again for consent calendar approval at both IQI and Q/UAC in July.
The following policies were pulled from the Consent Calendar for discussion: MCRO4018, MCUP3037 and MCUP3138. Motion to approve: Marshall Kubota, MD Second: Peggy Hoover, RN The remaining policies were approved with no changes. Motion to approve MCRO4018: Mark Netherda, MD Second: Marshall Kubota, MD Approved with change: Section IV.A: Change the name
of the attachment to PHC Pharmacy Services TAR Form.
Motion to approve MCUP3037: Peggy Hoover, RN Second: Mary Kerlin Approved with change: Section VI.D.1.c: Change to state
due to “invalid procedure code (CPT or HCPSC)”. This will now read as: TAR or service line not accepted due to invalid procedure code (CPT or HCPSC).
Motion to approve MCUP3138: Mark Netherda, MD Second: Peggy Hoover, RN Approved with change: Section VI.F.1: Remove closed
parenthesis after “IMRO”.
06/09/2020
1. MPCR12 – Credentialing of Independent and Private Duty Nurses Under EPSDT
Lisa O’Connell reported on MPCR12 found on page 55. The policy was updated to include Private Duty Nurses per APL 20-012. Title: Changed to Credentialing of Independent and Private Duty Nurses Under EPSDT. Section II: Updated language to include Health Services.
Motion to approve: Peggy Hoover, RN Second: Mary Kerlin Approved with no changes.
06/09/2020
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RESOLVED Section III: Added the definition of Early and Periodic Screening, Diagnostic and Treatment
(EPSDT). Section V: Updated language to include Private Duty Nursing Case Management per APL 20-
012. Section VI.A-B: Updated language per APL 20-012. Section V1.C: Added the practitioner must be screened and enrolled with the Department of
Health Care Services (DHCS) as an individual provider who offers Private Duty Nursing services consistent with APL 20-012.
Section VI.E.1-5: Updated language to current process. Section VI.F: Updated language to include confirming the past five years of malpractice
settlements. Section VI.G: Added professional liability coverage in the amount of $500,000 per incident. Section VI.H: Added language regarding a passing score on a site audit prior to having
credentials presented and must pass a subsequent medical record review within 3 months of the site review.
Section VI.I Added “The Practitioner must pass an office site audit every three years as part of the re-credentialing process and that if an Independent Nurse Provider, the site audit will be in the member’s home.”
Section VI.J: Added language regarding the re-credentialing cycle of 36 months. Section VII: Added APL 20-012. Section IX: Updated position responsible for implementing procedure. Attachment A: Added “Private Duty Nurse” to the Individual Nurse Agreement.
Dr. Moore noted that MPCR12 relates to other policies yet to come. Peggy Hoover agreed, noting that this is “a work in progress.”
Dr. Kubota questioned utilizing a member’s home as a site. Dr. Moore stated that this is, in effect, a safety audit.
2. MPPRGR210 – Provider Grievance
Mary Kerlin reported on MPPRGR210 found on page 62. Mary advised that the major change to this policy is to the committee structure as noted under Section VI.C. Section I: Added MCUP3037- Appeals of Utilization Management/Pharmacy Decisions. Section II: Added Health Services. Section V: Added “or pharmacy” in the first sentence. Section V: Added wording regarding separate and distinct process from member appeals and
grievances. Section VI.A: Added “CEO is ultimately responsible” and added wording indicating provider
grievance process is managed and monitored by the Provider Relations (PR) department. Section VI.B.2: Added “or action that is the subject of the grievance”. Section VI.C: Changes made to the committee structure. The Peer Review Committee will be the
Provider Grievance Review Committee. Section VI.C: Added statement that members can not represent institution filing grievance. Section VI.D: Added: “or pharmacy” and “MCUP 3037 - Appeals of Utilization
Management/Pharmacy Decisions”. Section VI.E: Added new section; provider must exhaust all appeals.
Motion to approve: Mary Kerlin Second: Peggy Hoover, RN Approved with change: Section I: Added MPQP1053;
MPQP1016 and CGA024 as Related Policies.
Section VI.F: Add reference to MPQP1016.
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AGENDA ITEM DISCUSSION RECOMMENDATIONS / ACTION DATE
RESOLVED Section VI.G: Deleted “dispute”, added “grievance” in 2 places. Section VII: Added “DHCS All Plan Letter, APL 17-006 – Grievance and Appeal
Requirements” and “NCQA UM 7 Element C, Non-Behavioral Healthcare Notice of Appeal Rights/Process and Element I, Pharmacy Notice of Appeal Rights /Process”.
Section VIII: Added: “PHC Department Directors”. Section IX: Position Responsible: updated to Senior Director, Provider Relations. Edna Villasenor asked for clarity in Section V to confirm this was not for member grievances. Dr. Moore confirmed the second sentences clarifies this is not for the member. Typically these are cases where the provider is not paid for some reason, but the member is not notified. Rose Santos advised that MPQP1053 should be added as a related policy due to the changes in Section VI.C. Also MPQP1016 should be a related policies and also referenced in Section VI.F were Potential Quality Issues (PQIs) are mentioned. The committee agreed to these changes. Anna asked if the Member Grievance policy, CGA024, should be added as a related policy. Dr. Moore advised that it should be added. The committee agreed to this change.
3. MCUP3042 – Technology Assessment
Dr. Robert Moore reported on MCUP3042 found on page 68. Section VI.A.2: Added statement at this section for Investigational Interventions to match what
we say at section VI.B.4 for Cancer Clinical Trials; specifically that we will not authorized inpatient admission if there is no indication for acute care treatment. This language is from OIL 026-02.
Section VI.C.1.h: Clarified that when PHC reviews a physician request for new technology, all six criteria specified at the top of the policy in VI.A.1.a-f (per Title 22 CCR 51303) must be met.
Section VI.C.1.h.5): Removed the word “funded” and matched statement used above in VI.A.1.e to say that new technology interventions cannot be provided as part of a research study protocol (per Title 22 CCR 51303).
Section VI.D.1.b: Specified that Chief Medical Officer (CMO) may bring proposals for new benefits to the QUAC or Physician Advisory Committee (PAC) for feedback.
Section VI.D.1.c: Deleted this paragraph on committee review as it was more simply stated in the new sentence added above in Section VI.D.1.b.
Section VI.D.1.d: Specified that when reviewing Benefit Review Evaluation Workgroup (BREW) topics, the Executive Committee may request input from PAC before making a decision.
Section VII. C.: Updated NCQA reference to 2020.
Motion to approve: Marshall Kubota, MD Second: Mark Netherda, MD Approved with no changes.
06/09/2020
4. MPUP3078 – Second Medical Opinions
Debbie McAllister, RN reported on MPUP3078 found on page 76. Section I: Added MCUP3041 TAR Review Process as a Related Policy. Section V: Added “process” to the Purpose section. Section VI.A: Clarified that an “approved” prior authorization is required for second opinions
outside of the network and that out of network providers must be certified by Medi-Cal. Section VI.A.1: Added that questions about recommended “treatment” are a reason to seek a
second opinion. Section VI.C: Specified that out of network providers must be Medi-Cal certified and directed
reader to policy MCUP3124 RAF Policy for further discussion of out of network referrals. Also
Motion to approve: Peggy Hoover, RN Second: Marshall Kubota, MD Approved with no changes.
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AGENDA ITEM DISCUSSION RECOMMENDATIONS / ACTION DATE
RESOLVED added a sentence to say that any treatment recommended by an out of network provider would be subject to the TAR process as per policy MCUP3041.
Section VII.B: Updated NCQA reference to 2020 and changed UM 5H to UM 5E as per new guideline.
Dr. Moore noted that the changes were to clarify the out-of-network provider is to be a Medi-Cal certified provider.
V. Presentations Quality and Performance Improvement Update
Erika Robinson and Nancy Steffen provided the Quality and Performance Improvement Update. Refer to the update found on page 79 for detailed information. PHC continues to work with Primary Care Providers (PCPs) in Lake and Mendocino counties to
build relationships and better understand the challenges and constraints the providers are experiencing due to COVID-19.
PHC plans to continue hosting standing Southeast and Southwest Regional Quality meetings and will adjust expectation and project accordingly related to COVID 19 impacts.
Joint Leadership Initiative (JLI) meetings continue in June, including a kick off meeting with La Clinica de La Raza scheduled at the end of the month. Small grants for calendar years 2019 and 2020 have been approved for most of the JLI organizations.
While DHCS has waived all mandated Plan Do Study Act (PDSA) submissions for low performing HEDIS measures, our monthly Corrective Action Plan (CAP) calls have continued. In April and May, DHCS sought insight from PHC on the impact COVID-19 has had on our members and providers. Topics have ranged from COVID-19’s impact on PHC measure performance improvement activities, QI practice for depression and mental health, member access to the provider network, and how we are working with our providers to support vulnerable PHC members’ preventive care needs. It’s yet to be known what DHCS plans to do for under-performing measures. DHCS has assured PHC that the safety of PHC’s staff, providers and members are important to them.
DHCS started granting temporary Site Review extensions when state-wide shelter-in-place orders were first issued in March. Currently, this extension applies until further notice. In a recent APL, DHCS encouraged health plans to develop virtual site review processes and test on a small scale. PHC has developed a virtual site review process, and have completed two virtual site reviews and have received favorable feedback.
For information only, no formal action required.
06/09/2020
1. Kaiser Foundation Health Plan Audit Report
Kenzie Poncy presented the Kaiser Foundation Health Plan (KFHP) Audit Report. Refer to the report found on page 84 for detailed information. Highlights of the report include: For the review period July 1, 2018 – June 30, 2019, PHC conducted a joint audit with five
partner health plans that contract with Kaiser. Plans shared the responsibility of program review which includes evaluation of KFHP policies and procedures, training materials and guides.
There were more than 145 findings between all plans, those included on the report are those where a CAP was needed.
PHC and audit plan partners share responsibility for the program review. PHC subject matter experts (SMEs) have reviewed and accepted completed program review audit tools and, as applicable, CAPs.
The Grievance and Appeals CAP has not been accepted yet. New provider training always seems to be an area where audit plans differ; there were a number
of areas where Kaiser needed clarifying language.
For information only, no formal action required.
06/09/2020
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AGENDA ITEM DISCUSSION RECOMMENDATIONS / ACTION DATE
RESOLVED A CAP was expected in Population Health Management (PHM), since Kaiser does not have a
formal PHM. Kaiser expects to be accredited in PHM in 2021. Audit plan partners do not share responsibility for file review. This area of review is specific to
each plan’s membership, and in compliance with HIPAA, all plans independently conduct reviews of files, cases and reports. File review included PQI, transportation, mental health and behavioral health.
2. InterQual Criteria
Review
Debbie McAllister, RN, Jeff Devido, MD and Liz Leslie presented the InterQual® Criteria Review. Refer to the documentation found on page 130 for detailed information. PHC utilizes InterQual® criteria in its utilization management (UM) decision making process as
well as policies and procedures developed for specific situations. A summary of content for each module and arrangements can be made to provide full criteria for review upon request.
It was noted that PHC will use the Substance Use Disorder (SUD) modules for SUD TARs. Dr. Devido advised that the state uses the American Society of Addiction Medicine (ASAM)
criteria. ASAM looks at six different dimensions and is meant to be a comprehensive picture of clinical needs of the client and evaluate the level of care needed. In most places, it’s not done as formally as PHC does, and that PHC is ahead of the curve in incorporating the criteria. Ideally, InterQual® will crosswalk at some level with ASAM.
Dr. Devido and two clinicians will be reviewing the SUD TARs and have met to discuss the criteria and to ensure they are all on the same page.
Dr. Kubota asked if the SUD module includes criteria for residential treatment. Debbie confirmed that it does. Peggy advised that the residential facilities will use ASAM to determine level of care, however when it comes to NCQA requirements, PHC is using InterQual®. The two do crosswalk, but need to remain separate.
Motion to approve: Peggy Hoover, RN Second: Marshall Kubota, MD
06/09/2020
Adjournment The next meeting is July 7, 2020.
Respectfully submitted by: Leslie Erickson, Administrative Assistant II Signature of Approval: ________________________________________________ Date: ____________________________ Robert Moore, MD, MPH, MBA Chairman
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QUALITY IMPROVEMENT PROGRAMS (QIPS) NEWS- UPDATE – HIGH LEVEL
QIP PROGRAM UPDATE
PRIMARY CARE PROVIDER QUALITY IMPROVEMENT PROGRAM (PCP QIP)
PCP QIP 2021 Measure Development is on hold until the Department of Health Care Services (DHCS) announces the final Managed Care Accountability Set (MCAS).
Following re-launch of the PCP QIP Measurement Year (MY) 2020 in May, the Northern Region (NR) QI team started working to contact each NR provider organization individually to assure good understanding of the narrowed measure set. As part of this outreach, we are offering to answer questions, consult on any QIP related challenges and connect providers to telehealth details and other resources PHC has provided over the past several weeks. PCP focus on QIP incentive opportunities early in the measurement year will be key to achieving good results by year end. This outreach is being expedited through June into early July, pending provider availability.
LONG TERM CARE QUALITY IMPROVEMENT PROGRAM (LTC QIP)
The LTC QIP is being suspended and plans are underway to close out the 2020 measurement year early. A communication will be sent to providers in concurrence with Provider Relations’ communication.
PALLIATIVE CARE QUALITY IMPROVEMENT PROGRAM (PALLIATIVE CARE QIP)
No update.
PERINATAL QUALITY IMPROVEMENT PROGRAM (PERINATAL QIP)
The QIP team is preparing to launch the 2020-21 Measurement Year (MY) on 07/01/20 as well as closing out the final extended pilot period as of 06/30/20. The 2020-21 measure specifications will be posted online by the end of June to coincide with a 2020-21 kick-off webinar being offered to participating providers on 06/29/20. All of the corresponding Letters of Agreement (LOAs) to transition from a pilot to an ongoing program offering have been drafted and sent to providers for review and signature.
QI has concluded its collection of medical records as part of an audit of attestations submitted by providers over the course of the pilot period. The audit results will be used to support preliminary reporting to providers in late summer, in preparation for payment on the final pilot period in October 2020.
INTENSIVE OUTPATIENT CASE MANAGEMENT QUALITY IMPROVEMENT PROGRAM (IOPCM QIP)
Payment will be sent out at the end of July.
HOSPITAL QUALITY IMPROVEMENT PROGRAM (HQIP)
New measures for the 2020-21 measurement set were approved at the June PAC meeting.
2020-21 measurement year kicks off on 07/01/20. A Kick-Off webinar is scheduled for 07/28/20.
QI DEPARTMENT UPDATE JULY 2020
PREPARED BY ERIKA ROBINSON & NANCY STEFFEN DIRECTORS, QUALITY AND PERFORMANCE IMPROVEMENT
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QIP PROGRAM UPDATE
The 2021 Hospital Quality Symposium has been scheduled for June 2021. The Hospital QIP measure set for 2019-20 was also amended in May,
through PHC Executive approval, to accommodate provider focus on ongoing COVID-19 response. The corresponding program summary and detailed specification updates were subsequently shared plan-wide with providers. In the NR, recent joint operations meetings have provided great forums for individual follow-up reviews of the 2019-20 program changes with leadership representing seven participating hospitals.
DATA TOOL UPDATES PARTNERSHIP QUALITY DASHBOARD (PQD)
PQD User Acceptance Training (UAT) took place 06/05/20–06/12/20. Very few bugs were identified through the process.
The PQD Kick-off webinar reintroducing users to the enhanced dashboards and features for the PCP QIP took place on June 25, 2020. The session focused on updates to the home and provider pages, enhanced hovering features and icons to toggle between views and the ability to see unblinded data for the top 20 and bottom 20 program performers.
Module 2 of the Health Equity Performance Improvement Project (PIP) was validated by the Health Services Advisory Group (HSAG). Santa Rosa Community Health is our provider partner, and the focus is improving performance of Hispanic members on the Well-Child Visits in the First 15 Months of Life (W15) measure. Submitting Module 3 with plans for the three interventions is due 08/17/20.
The mandated PDSA on the asthma medication ratio measure (AMR) was submitted to DHCS in late June. The intervention provided an academic detailing session for the Lombardi clinic of Santa Rosa Community Health in mid-February.
In the June monthly HEDIS Corrective Action Plan (CAP) call, DHCS shared they will be closing PHC’s CAP in July, upon receipt of PHC’s HEDIS 2020 rates. This CAP was issued in September 2018, following DHCS review of HEDIS 2018 results. In 1Q 2019, DHCS made significant performance accountability changes in establishing its Managed Care Accountability Set (MCAS). Under MCAS, the HEDIS measures that served as the basis of PHC’s CAP were no longer part of the accountable measure set for MY2019/RY2020. In the fall of 2019, PHC demonstrated it met all of the Year 1 CAP deliverables and milestones. DHCS acknowledged these achievements but shared it would still treat PHC’s CAP as active and require close oversight of its ongoing performance improvement work while the CAP process was being updated to better correlate with MCAS. Per our discussion on the June CAP call, DHCS shared it cannot adopt a new CAP
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ACTIVITY UPDATE
process this year given the impact of COVID-19 and thus is electing an alternative course of action. While PHC should still anticipate mandated improvement activities for administrative measures with below Minimum Performance Level (MPL) rates reported in HEDIS 2020, the requirements of these activities will be adapted to be sensitive to the current environment, with priority given to assuring the safety of our providers, members, and health plan staff. Exact details on what will be required of PHC and its partners will be forthcoming by late July.
ACCELERATED LEARNING The Accelerated Learning webinar about colorectal cancer screening took place on 06/24/20. More than 50 participants registered to attend. The Accelerated Learning webinar about breast and cervical cancer screening is scheduled for 08/25/20. These are CME/CE approved activities.
HEDIS SCORE IMPROVEMENT
The next QIP/HEDIS Improvement Meeting for primary care provider organizations in Lake and Mendocino counties is scheduled for 09/11/20.
The Southeast Regional Quality meeting was held virtually on 06/04/20 and was well received. Participants from eight primary care provider organizations attended. The meeting covered the revised 2020 PCP QIP measures, telehealth flexibilities and highlighted a panel discussion re: contingency actions that primary care organizations took in relation to COVID-19.
Public Health leadership from Shasta County Health and Human Services (SCHHS) contacted PHC in early June to request support in outreaching our adolescent members needing immunizations for 7th grade entry. The NR has partnered in prior summers to outreach this member demographic to assure they are aware of local Public Health Immunization Clinic offerings. Due to COVID-19 and social distancing requirements, SCHHS has adjusted its outreach to start earlier and encourages members to seek these immunizations sooner. Regional staff started the outreach calls for 850 identified members on 06/15/20. A postcard with key details is also being prepared to mail soon. As a follow-up, PHC has also started assessing if this need exists in other counties and/or within PCP organizations.
PARTNERSHIP IMPROVEMENT ACADEMY
The first sessions of a pilot virtual ABCs of QI occurred on 06/16/20 and 06/30/20. Two more are scheduled for 07/07/20 and 07/14/20. The four sessions cover these topics: - What is Quality Improvement? - Introduction to the Model for Improvement - Creating an “aim” (project goal) statement - Using data to measure quality and drive improvement - Tips for developing change ideas for improvement - Testing changes via the Plan-Do-Study-Act cycle
JOINT LEADERSHIP INITIATIVE (JLI)
The third Joint Leadership Initiative meetings for Adventist Health, Mendocino Community Health Center (MCHC), Santa Rosa Community Health and Solano County Family Health Services occurred in June.
The kick-off meeting with La Clinica de La Raza occurred on 06/30/20. OFFERING AND HONORING CHOICES
No update.
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4
ACTIVITY UPDATE
SOCIAL DETERMINANTS OF HEALTH
No update.
Note: Detailed information and recordings of webinars are posted to the PHC Website: http://www.partnershiphp.org/Providers/Quality/Pages/PIATopicWebinarsToolkits.aspx
QUALITY ASSURANCE AND PATIENT SAFETY TEAM (CROSS REGIONAL UPDATE)
ACTIVITY UPDATE
POTENTIAL QUALITY ISSUES (PQI) FOR THE PERIOD: May 20 - June 17, 2020
Six PQI referrals were received from the following referral sources: Grievance and Appeals (3), Associate Medical Director (2), Other (1).
12 PQI cases were processed and closed to completion. Two PQI cases were presented and reviewed at the Peer Review Committee. There are currently 25 open cases between N/S.
HEALTHCARE EFFECTIVENESS DATA AND INFORMATION SET (HEDIS)
ACTIVITY UPDATE
HEDIS PHC is in the final stages of closing out our HEDIS Reporting Year 2020, measurement year 2019 (01/01/2019 – 12/31/2019).
We are targeting to release our Annual Summary of Performance Report on 06/26/2020.
FSR Region # of FSR
conducted # of MRR conducted
# of FSR CAP issued
# of MRR CAP issued
North 2 2 2 2 South 0 0 0 0
New sites opened this period: No site review on new locations done at this time. New PCP: Stallant Medical Group
PHC First Survey Accreditation is scheduled for 11/17/20. In response to the COVID-19 pandemic, NCQA is implementing exceptions applicable to organizations undergoing an accreditation survey in 2020. To support any exceptions and accommodation requests, PHC will provide a COVID-19 Impact Tracker and a Disaster Management Plan to NCQA during survey submission with details about requirements that cannot be met due to COVID-19. PHC will document modified approaches to address the requirement, mitigation efforts and steps to ensure oversight of the requirement. NCQA reviews the Disaster Management Plan to determine if exceptions should be allowed. In addition, the NCQA Program Management Team prepared a plan-wide Disaster Management Monthly Update Worksheet to track monthly impacts for each element and factor. From April through August, all business owners will monitor aspects of their evidence under a Monthly Update Worksheet to confirm if processes are being followed as written or if there were deviations that impact compliance due to COVID-19. The Monthly Update Worksheet will then be used as a guide when completing a plan-wide Disaster Management Plan.
As of 06/16/20, PHC’s overall compliance rate is 97.84%. To achieve 100% compliance, business owners are addressing findings and/or gaps pertaining to our NCQA consultant Diane Williams feedback. For requirements deemed compliant in the past, business owners are refreshing their evidence, such as data reports, grand analysis and material evidence to meet the required First Survey look-back period.
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Page 1 of 4
Policy/Procedures/Guidelines Old Number
New Assigned Number
Comments Provider Manual
Reminder - Effective January 2018, Approval Date reflects that of the Physician Advisory Committee’s meeting date.
The following documents were reviewed by the Quality / Utilization Advisory Committee (Q/UAC) in July 2020
Provider Relations
Wellness and Recovery Access Standards and Monitoring
MPNET 101 NEW X
Health Services – Quality
Site Review Requirements and Guidelines
Attachments: A. 2019 Facility Site Review Tool and
Standards B. 2019 Medical Record Review Tool &
Standards C. 2019 OB Facility Site Review Tool &
Standards D. 2019 PHC Addendum to Site Review E. Interim Review Template F. Provider Certificate G. 2019 Non-Accredited Facility Site
Review Tool & Guidelines H. Master Trainer Application I. 2019 Private Duty Nursing Site
Review Tool & Standards - New
MPQP1022 Regular review; updated per an All Plan Letter (APL) from the Department of Health Care Services (DHCS); language clarifications added; section added for Private Duty Nursing Site Reviews (as specified by DHCS); References updated
X
Health Services – Care Coordination
Transportation Policy for Non-Emergency Medical (NEMT) and Non-Medical Transportation (NMT)
MCCP2016 Regular review; language clarifications added; updated per contractual obligations; verbiage added that American Indian members may elect to receive NMT from Indian Health Services, in lieu of those offered by PHC; language struck – (when a member qualifies for public transportation, but refuses that level of service and does not meet criteria, a Notice of Action is not required to be sent to the member); References updated
Note: Approved at the June Q/UAC meeting, though subsequent regulatory changes necessitated more revision,
returned to committees in July
X
Health Services – Utilization Management
Bathroom Equipment Guidelines MCUG3008 Regular review; no changes to guideline content
MCUG3058 Regular review; no changes to guideline content
X
Emergency Services
Attachments: A. Non-Urgent Medical Conditions B. Urgent Medical Conditions C. Emergency Medical Problems
MCUP3014 Regular review; Definitions updated; references to physician updated to provider throughout document; language clarifications added; verbiage added that PHC does not use incentives to encourage barriers to care and service, which does not preclude the use of appropriate incentives for fostering efficient, appropriate care; under the Addenda – descriptions for Non-Urgent, Urgent and Emergency Medical Conditions updated
X
Out of Area Emergency Admissions
MCUP3033 Regular review; language clarifications added
X
Inter-Rater Reliability Policy
Attachments: Previous “A” split into 3 attachments (revised); B & C unchanged; D updated A. Inter-Rater Reliability (IRR) Audit
Reporting Forms – Nurse Coordinator Review 1. Inpatient Acute TARs 2. Outpatient TARs 3. Long Term Care (LTC TARs
B. IRR Audit Reporting Form – Physician Review
C. IRR Audit Reporting Form – Pharmacy Department
D. IRR Audit Reporting Form – LCSW or LMFT Review for Residential Substance Use Disorder Treatment Authorization (only)
MPUP3026 Regular review; Definitions updated; term entities replaced with managed behavioral health organization(s); language added that annual delegation oversight audit shall be presented to PHC’s Delegation Oversight Sub-Committee (DORS) for review and approval and reviewed by the Chief Medical Officer (CMO) or physician designee
X
Hospice Services
MCUP3020 Regular review: language clarifications added; section on Hospice Period of Care restructured for better understanding; section on Patient Certification and Recertification added
X
Genetic Screening and Diagnostics
Attachments: A updated, B unchanged A. Genetic Testing Requirements B. Family History Screening Tool
MCUP3131 Regular review; no changes to policy content; References updated Attachment A updated per contractual obligations and per industry standards
X
Criteria and Guidelines for Utilization Management
Attachment: A. Table of Approved Criteria and
Guidelines Referenced for Utilization Management
MCUP3139 NEW X
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Policy/Procedures/Guidelines Old Number
New Assigned Number
Comments Provider Manual
Page 3 of 4
The following documents were reviewed by the Quality / Utilization Advisory Committee (Q/UAC) in June 2020
Member Services
Assisting Providers with Missed Appointments
Attachment: unchanged A. PHC Missed Appointment Notification
Form
MP301 Regular review; Wellness and Recovery providers added
X
Provider Relations
Provider Grievance MP PR GR 210
Regular review; Definitions and Purpose updated; revised per Department of Health Care Services (DHCS) contractual requirements and those of the National Committee for Quality Assurance (NCQA); language added that the PHC’s Chief Executive Officer is ultimately responsible for the provider grievance process, which is managed by the Provider Relations department; the Provider Grievance Review Committee section updated accordingly and for clarity; language describing the process for providers retrospectively appealing a decision to deny or limit payment added, which notes that a provider grievance may not be filed until an initial appeal has been completed by the provider; References updated
X
Health Services – Care Coordination
Transportation Policy for Non-Emergency Medical (NEMT) and Non-Medical Transportation (NMT)
MCCP2016 Note: Approved at the June meeting, though subsequent regulatory changes necessitated more revision, requiring it returned to committees in July
X
Health Services – Utilization Management
Rehabilitation Guidelines for Acute and Skilled Nursing Inpatient Services
MCUP3003 Regular review; Definitions updated; language clarifications made; statement that degree of endurance required will vary, depending on the therapeutic setting
X
Appeals of Utilization Management / Pharmacy Decisions
Attachments: A. Request for Appeal/Expedited Appeal
of UM or Pharmacy Decision B. Member Authorization for Provider
Appeal C. UM and Pharmacy Appeal
Acknowledgement Letter
MCUP3037 Regular review; Definitions updated; language clarification added
X
External Independent Medical Review MCUP3138 Regular review; no changes to policy content; References updated
X
Technology Assessment
Attachment: unchanged A. Review of New Medical Technology
Form
MCUP3042 Regular review; approval process clarifications added; language added that investigational interventions will not be authorized in the inpatient setting if there is no indication for acute care treatment; as specified by DHCS, all six criteria must be fully met; References updated
X
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Policy/Procedures/Guidelines Old Number
New Assigned Number
Comments Provider Manual
Page 4 of 4
Second Medical Opinions MPUP3078 Regular review; language clarifications made; verbiage added that if a qualified professional is not available within PHC’s contracted network the member may be referred outside the network to a Medi-Cal certified provider; notation included that if any out of network treatment was recommended, it would be subject to the treatment authorization review (TAR) process per PHC’s policy
X
The following documents were reviewed by the Pharmacy & Therapeutics (P&T) Committee in July 2020
Health Services –Pharmacy
Pharmacy TAR Procedure
Attachment: A. PHC Pharmacy Services TAR Form
MCRO4018 Regular review; reference to Treatment Authorization Request (TAR) submission portal updated from PARx to PAS; language updated regarding a denied TAR for administration services (per diem)
X
Pharmacy Site of Care Policy MCRP4067 NEW X
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Policy/Procedure Number: MPQP1022 (previously QP100122) Lead Department: Health Services
Policy/Procedure Title: Site Review Requirements and Guidelines
☒ External Policy ☐ Internal Policy
Original Date: 10/30/2002 (vs. 10/16/2002)
Next Review Date: 06/10/2021 08/12/2021 Last Review Date: 06/10/2020 08/12/2020
Applies to: ☒ Medi-Cal ☐ Employees
Page 5 of 12
1) During the OB/GYN FSR, the reviewers will request documentation to determine if the provider is a Comprehensive Perinatal Services Program (CPSP) or non-CPSP provider.
2) A non-CPSP provider will be asked for documentation regarding the provider’s contractual agreement with a Certified CPSP Provider who will provide the comprehensive risk assessment, medical nutrition, and psychosocial risk assessments. A non-CPSP provider may choose to use CPSP trained staff to do the comprehensive risk assessment and make referrals to the CPSP program for interventions and completion of care plans. The reviewers will request documentation of training for a provider’s CPSP trained staff.
f. Private Duty Nursing (PDN) Site Reviews are conducted to oversee the quality of care provided by a Registered Nurses (RN) or Licensed Vocational Nurses (LVN) for in home medical services under the EPSDT Supplemental Services (SS) Program and Private Duty patient care under APL 20-012. 1) A PDN Site Review covers the following areas:
a. Access/Safety b. Personnel c. Office Management d. Clinical Services e. Infection Control
2) The nNurse must receive a passing score on a combined site and medical record audit prior to having credentials presented to the Credentialing Committee.
3) The nNurse must pass a combined site and medical record audit up to every three years as a part of the re-credentialing process.
4) For an Independent Nurse Provider, the site audit will be in the member’s home. 5) CAPs will be completed using a standard format and form. CAPS will be due within 30
days of the site review and will be verified via document submission. 6) See attachment I. 2019 Private Duty Nursing Site Review Tool and Standards for the
combined FSR/MRR tool. 3. Initial Site Review Process
a. An initial Site Review consists of an initial FSR and an initial MRR. b. The FSR is conducted first to ensure the site operates in compliance with all applicable local,
state, and federal laws and regulations. Members are not assigned to providers until the site has received a passing score and all Corrective Action Plan (CAP) items are completed and signed off. An initial FSR is not required when a new provider joins a site that has a current passing FSR score. 1) These pre Pre-contracted providers who do not pass the initial FSR within two attempts may
reapply to PHC after six months. c. An initial MRR must be completed within 90 days of the date that members were first assigned
to the site. 1) This may be deferred an additional 90 calendar days only if the new PCP does not have
enough assigned members to complete the MRR on the required minimum number of records. (Ssee section 4.a.1)d)i.)
2) If after 180 days following assignment of members and the site s till has fewer than the required number of medical records, a MRR on the total number of records available will be completed. Scoring on the MRR tool will be adjusted according to the number of medical records reviewed.
d. Additional Scenarios that require an Initial Site Review, but are not limited to, instances when: 1) A new site is added to the PHC network 2) A newly contracted provider assumes a site with a previous failing FSR and/or MRR score
within the last three years
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EXCERPT / New language added to policy per DHCS All Plan Letter
PARTNERSHIP HEALTHPLAN OF CALIFORNIA
POLICY/ PROCEDURE
Page 1 of 5
Policy/Procedure Number: MCUP3020 (previously UP100320) Lead Department: Health Services
Original Date: 12/12/1995 Next Review Date: 08/14/202008/12/2021 Last Review Date: 08/14/201908/12/2020
Applies to: ☒ Medi-Cal ☐ Employees
Reviewing Entities:
☒ IQI ☐ P & T ☒ QUAC
☐ OPERATIONS ☐ EXECUTIVE ☐ COMPLIANCE ☐ DEPARTMENT
Approving Entities:
☐ BOARD ☐ COMPLIANCE ☐ FINANCE ☒ PAC
☐ CEO ☐ COO ☐ CREDENTIALING ☐ DEPT. DIRECTOR/OFFICER
Approval Signature: Robert Moore, MD, MPH, MBA Approval Date:08/14/2019 08/12/2020
I. RELATED POLICIES:
A. MCUP3041 -TAR Review Process B. MCUP3039 - Special Case Managed Members C. MCUP3140 - Palliative Care: Pediatric Program for Members Under the Age of 21
II. IMPACTED DEPTS:
A. Health Services B. Claims C. Member Services
III. DEFINITIONS: Terminal Illness: A condition caused by injury, disease, or illness from which, to a reasonable degree of certainty, there can be no restoration of health, and which, absent artificial life-prolonging procedures, will inevitably lead to natural death.
IV. ATTACHMENTS: A. N/A
V. PURPOSE: The purpose of the guideline is to delineate the requirements for authorization of hospice services and the reimbursement mechanisms for this service.
VI. POLICY / PROCEDURE:
A. Criteria for Admission To A Hospice Program 1. A patient and family will be admitted to the hospice program when the following conditions are met:
a. The patient has a limited life expectancy of 6 months or less, if the terminal illness follows its normal course. The patient’s physician or the hospice medical director must certify that the member has a terminal illness by providing specific clinical findings or other documentation to support a life expectancy of 6 months or less.
b. Cure of the disease process is no longer the goal of treatment. (For specific pediatric Hospice guidelines, please see VI.B.3. below)
c. The primary goal for the patient is to focus on comfort, pain control, and emotional, spiritual, and psychological support.
d. It is appropriate to direct treatment to improve the quality of the remaining days for the patient and family.
e. It is agreed by doctor and patient and/or family that advanced technology is used solely for the
Original Date: 12/12/1995 Next Review Date: 08/14/202008/12/2021 Last Review Date: 08/14/201908/12/2020
Applies to: ☒ Medi-Cal ☐ Employees
Page 4 of 5
services not related to the terminal illness. 7. For members with Medicare/Medi-Cal coverage, Medicare is the first payer for the hospice daily
care. Medi-Cal (PHC) is financially responsible for medications not related to the hospice diagnosis and the room and board per diem if the member resides in a LTC facility (658 for SNF or ICF). The claim must include a copy of the Medicare Explanation of Medical Benefits (EOMB) that shows that Medicare payment was made for hospice services during the period covered.
8. For members with other coverage, Medi-Cal is the secondary payer and the hospice must submit a copy of the Explanation of Benefits (EOB) from the other insurer when billing Medi-Cal.
D. Hospice Election Periods of Care 1. Hospice is a covered Medi-Cal benefit with the following periods of care:
a. Two 90-day periods, beginning on the date of hospice election b. Followed by unlimited 60-day periods
2. A period of care starts the day the patient receives hospice care and ends when the 90-day or 60-day period ends.
1. The hospice election period shall consist of two periods of 90 days each and an unlimited number of subsequent periods of 60 days each during the individual’s lifetime and only, with respect to each such period, if the individual makes an election to receive hospice care services that are provided by, or pursuant to arrangements made by, a particular hospice program, rather than receive certain other benefits.
E. Patient Certification and Recertification Required 1. After a member has met criteria for admission to a hospice program (section VI.A. above), the
hospice provider must maintain an initial certification for the first 90-day period that the patient is terminally ill.
2. At the start of each subsequent period of care, the hospice provider must maintain a recertification that the patient is terminally ill.
3. No more than 30 calendar days prior to the start of the third benefit period, and no more than 30 calendar days prior to every subsequent benefit period thereafter, a hospice physician or nurse practitioner (NP) is required to have a face-to-face encounter with every hospice patient to determine the continued eligibility of that patient. When an NP performs the encounter, the attestation must state that the clinical findings of that visit were provided to the certifying physician for use in determining whether the patient continues to have a life expectancy of six months or less.
E.F. Revocation of Hospice Care Services 1. An individual’s voluntary election may be revoked or modified at any time during an election
period. To revoke the election of hospice care, the individual or individual’s representative must file a signed statement with the hospice agency revoking the individual election for the remainder of the election period. The effective date may not be retroactive. At any time after revocation, an individual may execute a new election for any remaining election period. An individual or representative may change the designation of a hospice provider once each election period; this is not a revocation of the hospice benefit.
VII. REFERENCES:
A. Medi-Cal /Guidelines - Hospice Care (hospic) B. Title 22, California Code of Regulations (CCR) / Hospice Care 51349 C. Title 22, CCR ICF Sections 51118, 51120 and 51510 SNF 51121, 51123, 51124, 51215, 51511 D. Title 42 Code of Federal Regulations (CFR) Sections 418.28 and 418.30 E. Social Security Act 1812(d)(1) F. Section 2302 of the Patient Protection and Affordable Care Act (ACA) G. Department of Health Care Services (DHCS) All Plan Letter (APL) 18-020 Palliative Care (12/07/2018)
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Policy Excerpt Page 4 of 5 changes
PARTNERSHIP HEALTHPLAN OF CALIFORNIA
POLICY / PROCEDURE
Page 1 of 2
Policy/Procedure Number: MCUP3139 Lead Department: Health Services
Policy/Procedure Title: Criteria and Guidelines for Utilization Management [AC1]
☒External Policy ☐ Internal Policy
Original Date: 08/12/2020 Next Review Date: 08/12/2021 Last Review Date: 08/12/2020
Applies to: ☒ Medi-Cal ☐ Employees
Reviewing Entities:
☒ IQI ☐ P & T ☒ QUAC
☐ OPERATIONS ☐ EXECUTIVE ☐ COMPLIANCE ☐ DEPARTMENT
Approving Entities:
☐ BOARD ☐ COMPLIANCE ☐ FINANCE ☒ PAC
☐ CEO ☐ COO ☐ CREDENTIALING ☐ DEPT. DIRECTOR/OFFICER
Approval Signature: Robert Moore, MD, MPH, MBA Approval Date: 08/12/2020
I. RELATED POLICIES:
A. MPQP1002 – Quality/ Utilization Advisory Committee B. MPRP4001 – Pharmacy & Therapeutics (P&T) Committee
II. IMPACTED DEPTS:
A. Health Services B. Compliance C. Provider Relations
III. DEFINITIONS:
Standard of Care: The level and type of care that a reasonably competent and skilled health care professional, with a similar background and in the same medical community, would provide under the same circumstance.
IV. ATTACHMENTS: A. Table of Approved Criteria and Guidelines Referenced for Utilization Management
V. PURPOSE: To establish an approved list of Utilization Management criteria and guidelines for reviewing Treatment Authorization Requests (TARs) and hospitalizations. [Note: The process for review and approval of criteria for pharmacy services can be found in policy MPRP4001 Pharmacy & Therapeutics (P&T) Committee].
VI. POLICY / PROCEDURE:
A. Partnership HealthPlan of California (PHC) is responsible for reviewing requests for services submitted by network providers. A key element of these reviews is the use of criteria and guidelines to assist in making decisions to approve, modify or deny service authorization requests. It is important that the criteria and guidelines used in this process be known and accessible and reflective of well accepted standards of care. This policy will establish the process of Criteria and Guideline review and approval for use by the PHC network of providers.
B. Process of Review and Approval: 1. On an annual basis, the Quality/ Utilization Advisory Committee (Q/UAC) will review a list of
criteria and guidelines to be used by PHC Utilization Management staff and PHC medical directors in performing reviews of treatment authorization requests (TARs). a. This list will be evaluated during the Chief Medical Officer (CMO)/MD meeting the month
prior to presentation to Q/UAC.
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Policy/Procedure Number: MCUP3139 Lead Department: Health Services
Policy/Procedure Title: Criteria and Guidelines for Utilization Management
☒ External Policy ☐ Internal Policy
Original Date: 08/12/2020 Next Review Date: 08/12/2021 Last Review Date: 08/12/2020
Applies to: ☒ Medi-Cal ☐ Employees
Page 2 of 2
b. To be included in this list, a criteria set or guideline must be developed by a nationally recognized entity or a PHC policy that has been approved through the standard committee process.
c. These guidelines and criteria sets should be utilized by managed care organizations throughout the country or region. (This would mean that the criteria and guidelines reflect the generally accepted standard of care.)
d. Guidelines and criteria sets should be supported by clinical literature and peer review. e. A specific guideline or criteria can be submitted for potential inclusion in the approved list by
any provider within the PHC network or by PHC staff. 1) This recommendation will be submitted to the Office of the CMO. 2) The CMO will assign the suggested criteria or guideline to a specific medical director for
evaluation. This medical director will present the review at the next CMO/MD meeting. 3) After the medical directors have completed their evaluation of the guideline or criteria set,
they will decide to either forward the document to Q/UAC with a recommendation for approval, or decide that the guideline or criteria should not be used by PHC for performing reviews.
2. Hierarchy of Guidelines and Criteria Sets: a. The guidelines and criteria can be grouped into the following groups:
1) Required standards as set forth by the State of California (Department of Health Care Services [DHCS] or other agencies) where PHC is contractually and legally obligated to follow the guidelines.
2) Industry accepted guidelines that are used by a variety of other managed care organizations (e.g. InterQual® and National Comprehensive Cancer Network [NCCN]).
3) Guidelines developed through government agencies (e.g. Center for Disease Control [CDC] or Agency for Healthcare Research and Quality [AHRQ]).
4) Policies developed by PHC. b. There should be few circumstances where these groups of guidelines conflict. In situations
where there is a conflict, the use of the guidelines should favor the patient first. c. The guidelines that are required by statute or contract should be followed at all times, as long as
the patient’s safety is not compromised. d. PHC policies should be followed as long as there is no conflict with legally required or
contractually required services. C. See Appendix A for Table of Approved Criteria and Guidelines Referenced for Utilization Management.
VII. REFERENCES:
National Committee for Quality Assurance (NCQA) Guidelines (Effective July 1, 2020) UM 2 Clinical Criteria for UM Decisions Elements A
VIII. DISTRIBUTION: A. PHC Department Directors B. PHC Provider Manual
IX. POSITION RESPONSIBLE FOR IMPLEMENTING PROCEDURE: Chief Medical Officer
X. REVISION DATES: N/A
PREVIOUSLY APPLIED TO: N/A
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PARTNERSHIP HEALTHPLAN OF CALIFORNIA POLICY / PROCEDURE
Page 1 of 3
Policy/Procedure Number: MPNET 101 Lead Department: Provider Relations
Policy/Procedure Title: Wellness and Recovery Access Standards and Monitoring
☒External Policy ☐ Internal Policy
Original Date: 08/12/20 Next Review Date: 08/11/2021 Last Review Date: 08/12/2020
Applies to: ☒ Medi-Cal ☐ Employees
Reviewing Entities:
☒ IQI ☐ P & T ☒ QUAC
☐ OPERATIONS ☐ EXECUTIVE ☐ COMPLIANCE ☐ DEPARTMENT
Approving Entities:
☐ BOARD ☐ COMPLIANCE ☐ FINANCE ☒ PAC
☐ CEO ☐ COO ☐ CREDENTIALING ☐ DEPT. DIRECTOR/OFFICER
Approval Signature: Robert Moore, MD, MPH, MBA Approval Date: 08/12/2020
I. RELATED POLICIES: A. MPNET100 – Access Standards and Monitoring
II. IMPACTED DEPTS:
A. Member Services B. Provider Relations C. Health Services D. Finance E. Compliance
III. DEFINITIONS: A. Rural Counties: Counties with a population density of <50 people per square mile (according to
current Department of Health Care Services (DHCS) standards), includes Del Norte, Humboldt, Lassen, Mendocino, Modoc, Shasta, Siskiyou, and Trinity counties.
B. Suburban or Small Counties: Counties with a population density of 51 to 200 people per square mile (according to current DHCS standards), includes Lake, Napa, and Yolo counties.
C. Urban or Medium Counties: Counties with a population density of 201 to 600 people per square mile (according to current DHCS standards), includes Marin, Solano, and Sonoma counties.
D. Triage or Screening: The assessment of a member’s health concerns and symptoms via communication, with a physician, registered nurse, or other qualified health professional acting within his or her scope of practice and who is trained to screen or triage a member who may need care, for the purpose of determining the urgency of the member’s need for care.
IV. ATTACHMENTS:
N/A
V. PURPOSE: To define access standards for substance use disorder treatment through the PHC Wellness and Recovery Program.
VI. POLICY / PROCEDURE:
Partnership HealthPlan of California is committed to ensuring that its members have the availability of and accessibility to providers to meet their health care needs. PHC has established standards for the numbers and types of clinicians and facilities, as well as for their geographic distribution, appointment accessibility and office and telephone availability. PHC monitors provider availability and accessibility on an annual basis.
Policy/Procedure Title: Wellness and Recovery Access Standards and Monitoring
☒ External Policy ☐ Internal Policy
Original Date: 08/12/20 Next Review Date: 08/11/2021 Last Review Date: 08/12/2020
Applies to: ☒ Medi-Cal ☐ Employees
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A. Access to Providers
1. Established measureable standards for the geographic distribution of each type of wellness and recovery program.
GEOGRAPHIC DISTRIBUTION OF WELLNESS AND RECOVERY PROVIDERS
Practitioner Type Standard: Geographic Distribution Performance Goal
Outpatient Services Rural Counties: 60 miles or 90 minutes from the beneficiary’s residence
Small Counties: 60 miles or 90 minutes from the beneficiary’s residence
Medium Counties: 30 miles or 60 minutes from the beneficiary’s residence
Large Counties: 15 miles or 30 minutes from the beneficiary’s residence
≥ 80%
Opioid Treatment Programs Programs Rural Counties: 60 miles or 90 minutes from the beneficiary’s residence
Small Counties: 45 miles or 75 minutes from the beneficiary’s residence
Medium Counties: 30 miles or 60 minutes from the beneficiary’s residence
Large Counties: 15 miles or 30 minutes from the beneficiary’s residence
≥ 80%
2. Established measureable standards for timely access of each type of wellness and recovery program.
TIMELY ACCESS STANDARD Provider Type Standard Performance
Goal Outpatient Services Within 10 business days from request to appointment ≥ 80% Opioid Treatment Within 3 business days from request to appointment ≥ 80%
B. Communication
1. PHC communicates access standards to: a. Members through newsletters, Evidence of Coverage (EOC) and other education
materials. Provider directories are also available to members online or upon request. b. Providers through the Provider Manual, provider newsletter and/or bulletins, initial
provider training and during monthly provider training sessions.
VII. REFERENCES: A. DHCS Contract B. Medicaid Managed Care Final All Plan Letter (20-003), 2020 – “Network Certification Requirements”
VIII. DISTRIBUTION: A. PHC Department Directors B. PHC Provider Manual
Complex Case Management (CCM) ...................................................................................................................... 5
Transitions of Care (TOC) .......................................................................................................................................... 7
Member Experience...................................................................................................................................................... 9
Transitions of Care .................................................................................................................................................... 9
Adult Experience with TOC ................................................................................................................................... 9
Pediatric Experience with TOC ............................................................................................................................ 11
Complex Case Management (CCM) ........................................................................................................................ 12
Adult Experience with CCM ................................................................................................................................ 13
Pediatric Experience with Complex Case Management ..................................................................................... 14
Next Steps ................................................................................................................................................................... 17
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Partnership HealthPlan of California Population Health Management: Impact Analysis 2020
Page 3
Objective The purpose of this report is to evaluate the Population Health Management (PHM) programs through clinical,
utilization, and member experience measures in accordance with the PHM efforts of the year.
Methodology The following data sources are used to evaluate the PHM programs:
Data sources included in this analysis are:
Data Type Data Source
Medical Claims data Amisys
California Children’s Services Beneficiaries PHC Member Core Data Set
MedImpact pharmaceutical claims data MedImpact
Member Experience Survey Results Essette
Member Risk Score PHC Health Analytics Proprietary Algorithm
Clinical Measure
Clinical Quality Performance Data PHC’s Health Analytics team provided performance data related to clinical quality measures based on revised HEDIS specifications for well-care visits. The data sets selected included performance with well-care visits, both in the first 15 months of life, as well as for adolescents. Performance rates compare members who are beneficiaries of the California Children’s Services (CCS) program to those who are not in the CCS program within the 2019 Calendar Year measurement period. Well-care visits are a key measure for the NCQA focus of Keeping Members Healthy. Not only do well-child visits allow a physician to closely monitor growth, development, and health habits of children; but well-child visits also establish a relationship of trust between children and physicians. Well-care visits can be used to monitor how frequently children visit physicians and compare these measures to national benchmarks. PHC is concerned that all pediatric members have excellent care. However, the CCS population is particularly vulnerable to adverse effects and long-term impact of delayed wellness care because children who qualify for CCS program services are medically complex. Therefore, PHC’s case management interventions are intended to ensure these members have the best possible rates of compliance for well-child visits.
Goal
Attendance at well-care visits by children under 15 months of age by PHC CCS beneficiaries will be better than for
those not enrolled in the CCS benefit.
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Methodology
Measure Description: The percentage of members who turned 15 months old during the measurement year (calendar year 2019) and who had six or more well child visits between 0 and 15 months of age.
Denominator: Members who turned 15 months of age during the measurement period
Numerator: Of denominator, those who had completed at least six well-care visits during their first 15 months of life.
Measurement Period: 2019 Measurement Year
Exclusion Criteria: Members assigned to Kaiser providers and members enrolled in PHC less than six months.
Results
Well-Child Visits for Children Under 15 Months of Age
All Members CCS Beneficiaries
Region Rate Numerator Denominator Rate Numerator Denominator Result Met
Northern 6.0% 47 785 3.1% 1 32 No
Southern 9.0% 164 1825 14.9% 10 67 Yes
TOTAL 8.1% 211 2610 11.1% 11 99 Yes
Goal
Attendance at adolescent well-child visit measures among PHC CCS beneficiaries will be better than for those not
enrolled in the CCS benefit.
Methodology
Measure Description The percentage of adolescents between 12 and 20 years of age who had at least one comprehensive well-care visit during the measurement period. Excludes Kaiser providers and members enrolled in PHC less than three months. For compliance, adolescents should have at least one well-care visit per year.
Denominator: Members who turned 12 – 20 years of age during the measurement period
Numerator: Of the members in the denominator, those who had completed at least one well-care visit in the measurement year
Measurement Period: 2019 Measurement Year
Exclusion Criteria: Members assigned to Kaiser providers and members enrolled in PHC less than six months.
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Results
Adolescent Well-Care Visits for Pediatric Members Ages 12 – 20
All Members CCS Beneficiaries
Region Rate Numerator Denominator Rate Numerator Denominator Result Met
Northern 24.8% 6230 25,159 29.8% 250 838 Yes
Southern 33.4% 20,641 61,886 35.0% 692 1,975 Yes
TOTAL 30.9% 26,871 87,045 33.5% 942 2,813 Yes
Analysis On aggregate, PHC’s CCS population has more frequent pediatric well-child visits for both children under 15
months of age and for the adolescents than do the non-CCS beneficiaries in PHC’s population. The regional
compliance for well-child visits for CCS beneficiaries is also better than the non-CCS members except for children
under 15 months of age in PHC’s Northern Region. Furthermore, adolescent well-care visits are much higher than
the those for children under 15 months of age. There are many factors that may contribute to this disparity. The
number of CCS children under 15 months of age is very low. Therefore, individual behavior has a large impact on
the averages. In addition, children under 15 months of age are not automatically enrolled into a health plan and,
by the time they select PHC as their insurer, they have lost valuable time to meet the six required visits in the first
15 months of life. In addition, prior to their transition into PHC coverage, the children enrolled in CCS were not
assigned a primary care provider (PCP). Asking these members to align their care with a local PCP has been a
major shift in their behavior, even though they are not losing any access to the specialty centers that provided
services for their CCS conditions.
Opportunity
PHC has recognized that there is an opportunity to intervene for newborn members through revisions to the
Growing Together Program (GTP). Whereas GTP has focused on the pre/post-natal period for pregnant members,
we can leverage our interactions with the member while she is pregnant to reinforce the importance of well-child
visits, educate on vaccinations and their purpose, and remind the member to enroll the baby with an insurer and
select a pediatrician as soon as possible after birth. The GTP program will be stratified into three different focus
areas: pregnant members, newly delivered members, and infants newly enrolled into the health plan.
Cumulative incentives will be used to encourage member adherence. This shift in program objectives is scheduled
to begin in September 2020.
Cost / Utilization Measures Complex Case Management (CCM) Complex Case Management (CCM) services are provided to members with complex health care needs to promote
better communication between members and their providers and to reinforce member adherence to treatment
recommendations. Presumably, CCM will result in more appropriate utilization of services for the members’ care.
Emergency Department (ED) visits are generally considered to be avoidable costs because, in many cases,
members could receive proactive care through outpatient services that would reduce the need for ED visits.
Those members enrolled in case management have the additional support of a healthcare partner who can
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facilitate timely intervention(s) by the correct provider. This measure seeks to compare the frequency of ED visits
between those members enrolled in CCM compared to like members who are not enrolled in CCM using PHC’s
proprietary risk score model.
A member’s risk level is calculated using Generalized Linear Mixed Model (GLMM) by applying a longitudinal data of PHC's membership, claims, pharmacy, case management enrollment, and external data (California's health index and census tract). The risk score generated from this model is defined as the probability that a member will become a high utilizer (i.e., utilization of >=5 ED Visits, >=15 Distinct Drugs, >=1 hospital inpatient admission or >=$50,000 medical and pharmacy claims) in the next six months. Thus, it has values ranging from zero to one. The Risk Level is the stratification of the entire PHC population based on this risk score using cluster analysis. Risk Level Groupings are assigned as follows:
No Risk: Risk score is less than 0.02004; Low Risk Risk score is between 0.02004 and 0.0742; Medium Risk Risk score is between 0.0742 and 0.20038; High Risk Risk score is above 0.20038.
Goal
Members enrolled in CCM will have fewer ED visits than matched age-range and risk level group members not
enrolled in CCM.
Methodology
Risk-Stratified
Comparison of CCM-
enrolled members vs. non-
CCM-enrolled members
Members enrolled in CCM during 2019 and their average ED visits starting from date of enrollment into CCM during 2019 compared to other members in same risk score(s) group and age-group (>21 to 50, 50 - 65, 65+) matched who were NOT enrolled in CCM in 2019 (and covered for 12 months)
Denominator: Number of members in population segment with PHC coverage for 12 months
Numerator: Of denominator people, the total number of ED visits utilized during the measurement period.
*Mean Difference is calculated as the (Average ED Visits of CCM) minus (Average ED Visits of Non-CCM)
Analysis
The test results showed that on average there is a significant reduction in ED utilization among CCM compared to
Non-CCM members with High Risk and 51-65 age, Low Risk and 21-50 age, and No-Risk and 21-50 age groups. The
results did not demonstrate statistically significant difference in ED utilization among other classifications,
although several other categories showed non-significant reductions in ED utilization. This CCM program
continues to bring value to those members who identify goals for their individualized care plans. In addition, the
factors that qualify a member for CCM services are medically challenging, and ED visits may be warranted for
these members.
Transitions of Care (TOC) PHC’s Transitions of Care (TOC) intervention is designed to assist members discharging home from acute
hospitalization to reestablish care with their providers, to ensure their medication profile is reconciled, and to
facilitate delivery of any planned discharge equipment or services as arranged by the discharging hospital.
Members enrolled in this program are adult members (over age 21) who have either had a length of stay greater
than four days or who are discharging home from a facility not in their county of residence. In addition, any
member who has had two readmissions in less than 10 days is also a candidate for this service. TOC services are
designed to reduce the risk of hospital readmission for members who participate in the program. This measure
seeks to compare the frequency of inpatient readmissions between those members enrolled in TOC compared to
like members who are not enrolled in TOC using PHC’s proprietary risk score model.
A member’s risk level is calculated using Generalized Linear Mixed Model (GLMM) by applying a longitudinal data of PHC's membership, claims, pharmacy, case management enrollment, and external data (California's health index and census tract). The risk score generated from this model is defined as the probability that a member will become high utilizer (i.e., utilization of >=5 ED Visits, >=15 Distinct Drugs, >=1 hospital inpatient admission or >=$50,000 medical and pharmacy claims) in the next six months. Thus, it has values ranging from zero to one. The Risk Level is the stratification of the entire PHC population based on this risk score using cluster analysis. Risk Level Groupings are assigned as follows:
No Risk: Risk score is less than 0.02004; Low Risk Risk score is between 0.02004 and 0.0742; Medium Risk Risk score is between 0.0742 and 0.20038; High Risk Risk score is above 0.20038.
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Goal
Members participating in TOC will have fewer 30-day all-cause hospital readmissions than matched age-range and
risk level group members not enrolled in TOC services.
Methodology
Risk-Stratified
Comparison of CCM-
enrolled members vs.
non-CCM-enrolled
members
Members who enrolled in TOC services during 2019 and their all-cause inpatient readmissions starting from date of discharge from initial hospital stay during 2019 compared to other members in same risk score(s) group and age-group (>21 to 50, 50 - 65, 65+) matched who did not participate in TOC during 2019 (and covered for 12 months)
Denominator: Number of members in population segment with PHC coverage for 12 months
Numerator: Of denominator people, the total number of ED visits utilized during the measurement period.
Measurement Period: 2019 Measurement Year
Results
Summary of Hospital Inpatient and 30 Day All-Cause Readmissions: TOC vs Non-TOC Members
*Mean Difference is calculated as the (Average Readmissions of TOC) minus (Average Readmissions of Non-CCM)
Analysis There was no observed statistical significance for reduction of hospital inpatient readmissions among TOC as
compared to non-TOC members. In fact, there were groups that showed significant increase in all-cause
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readmissions from those who were not enrolled in TOC. This finding could be due to the recruitment criteria of
TOC. If members enrolled during their inpatient admission, they have more chance of readmission compared to
the general population.
PHC developed a new TOC intervention that was implemented in July 2019. The intervention was designed to
leverage non-clinical staff to triage the discharged cases and escalate to clinical staff when certain criteria were
met. As the leadership has monitored the results of the program, they have noticed that non-clinical staff were
not identifying some red-flags that may lead to readmission and had missed an opportunity to provide more
intensive post-discharge support to the member. Therefore, this intervention has been reviewed and revised so
that clinical staff will review the cases first to determine the level of need for a member. If clinical intervention is
not required, the case will be assigned to a non-clinician. Otherwise, the clinician will perform the post-discharge
assessment and determine whether additional case management services are warranted. Other details of this
intervention will remain unchanged for the coming year, and the team will monitor the results of this intervention
against this baseline.
Member Experience
Transitions of Care PHC’s TOC intervention began in July 2019. Eligible members are:
Adult members (age > 20) and
discharging home from acute care after hospital length of stay longer than four days, or discharging home from an out-of-county hospital with any length of stay, or having more than one admission in 10 days.
Pediatric members (under age 21) and
discharging home from a hospital with an admission date > 60 days from his/her date of birth and having any length of stay.
At the close of TOC services, a PHC coordinator contacts the members by phone to complete a member-
experience survey. Responses are weighted as Agree (3 points) Neutral (2 points) Disagree (1) or No Response. In
addition to weighted responses, members have an opportunity to provide comments. Responses are tallied and
reviewed no less than annually to ensure PHC member needs are being met. For each satisfaction measure, the
goal is at least 75% of members surveyed agree with the statement, which translates to an average score of 2.5 or
greater for each response.
Adult Experience with TOC There were 122 adult members who completed the TOC Member Satisfaction Survey between July 1, 2019, and March 31, 2019. The average scores for each of the questions were:
Survey Question
Average Response
Goal Met
I am satisfied with the case management program that has helped me manage my health issues.
2.98 Yes
I am confident in the abilities of the team members who contacted me; (the team could have included: health care guide, social worker, and/or nurse case manager)
2.97 Yes
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My team referred me to medical and community resources that were valuable and helped me.
2.90 Yes
After working with the case management team, I feel my ability to manage my healthcare needs is better.
2.89 Yes
My health has improved since working with my case management team 2.66 Yes
I was able to safely transition between Providers with the help of my Care Team 2.82 Yes
The relationship that I have with the PCP and/or Specialist offices has improved since working with my case management team.
2.66 Yes
I was provided the available equipment, medication and/or services that were needed. 2.86 Yes
Analysis
Adult members who participated in the TOC intervention responded very positively to their experience with case
management. There were two areas where members showed less agreement:
My health has improved since working with my case management team
It is not surprising that a member may not identify an improvement in health following a hospital
discharge. The sequelae of a hospital stay can be complex and painful. Also, a member may attribute
improved health to many factors, and case management may not be a driver in the mind of the member.
This question may not be a good indicator of member experience for individuals who participate in the
TOC service.
119
117
110
108
86
100
86
107
3
4
12
14
31
17
31
11
0
0
0
0
5
2
5
3
1
2
1
1
1
4
1
2
I A M S A T I S F I E D W I T H T H E C A S E M A N A G E M E N T P R O G R A M T H A T H A S H E L P E D M E M A N A G E M Y H E A L T H
I S S U E S .
I A M C O N F I D E N T I N T H E A B I L I T I E S O F T H E T E A M M E M B E R S W H O C O N T A C T E D M E ; ( T H E T E A M C O U L D
H A V E I N C L U D E D : H E A L T H C A R E G U I D E , S O C I A L …
M Y T E A M R E F E R R E D M E T O M E D I C A L A N D C O M M U N I T Y R E S O U R C E S T H A T W E R E V A L U A B L E A N D H E L P E D M E .
A F T E R W O R K I N G W I T H T H E C A S E M A N A G E M E N T T E A M , I F E E L M Y A B I L I T Y T O M A N A G E M Y H E A L T H C A R E N E E D S I S
B E T T E R .
M Y H E A L T H H A S I M P R O V E D S I N C E W O R K I N G W I T H M Y C A S E M A N A G E M E N T T E A M
I W A S A B L E T O S A F E L Y T R A N S I T I O N B E T W E E N P R O V I D E R S W I T H T H E H E L P O F M Y C A R E T E A M
T H E R E L A T I O N S H I P T H A T I H A V E W I T H T H E P C P A N D / O R S P E C I A L I S T O F F I C E S H A S I M P R O V E D S I N C E W O R K I N G
W I T H M Y C A S E M A N A G E M E N T T E A M .
I W A S P R O V I D E D T H E A V A I L A B L E E Q U I P M E N T , M E D I C A T I O N A N D / O R S E R V I C E S T H A T W E R E N E E D E D .
ADULT TOC EXPERIENCE
Agree Neutral Disagree No Response
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The relationship that I have with the PCP and/or Specialist offices has improved since working with my
case management team
Similar to the question above, the member may already have a well-established relationship with their
providers and/or not recognize the interventions provided through PHC’s staff as impacting this
relationship.
Nevertheless, the member experience with TOC services exceed the target for this measure. Many of the
responses praised the support PHC staff provided. Sample feedback says:
“The team is wonderful and a great help.”
“The team has gone above and beyond my expectations.”
The member is “grateful for the help and is so thankful to be living in this part of the county to have
this type of help.”
Pediatric Experience with TOC There were 133 responses for pediatric members enrolled in the TOC intervention between July 1, 2019, and
March 31, 2019. The average responses were as follow:
Survey Question
Average Response
Goal Met
I am satisfied with the case management program that has helped me manage my child’s health issues.
2.97 Yes
I am confident in the abilities of the team members who contacted me; (the team could have included: health care guide, social worker, and/or nurse case manager).
2.97 Yes
I am satisfied with the case management program that has helped me manage my child’s health issues.
2.79 Yes
After working with the case management team, I feel my ability to manage my child’s healthcare needs is better
2.97 Yes
My child’s health has improved since working with our case management team 2.73 Yes
I was able to safely transition my child between Providers with the help of my Care Team.
2.80 Yes
The relationship that my child and I have with the PCP and/or Specialist offices has improved since working with our case management team.
2.69 Yes
My child and I were provided with the available equipment, medication and/or services that were needed.
2.93 Yes
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Analysis
The pediatric members who received TOC services responded very positively to their experience with case
management. As above, there was one question where members showed less agreement:
The relationship that I have with the PCP and/or Specialist offices has improved since working with my
case management team
As discussed for adult members, many of the hospitalized pediatric members have a well-established
relationship with their providers. While they appreciate the support offered through PHC’s case
management staff, they may not recognize the interventions provided through PHC’s staff as impacting
their relationship with their providers.
Some of the anecdotal feedback given by parents/guardians of the hospitalized members is:
“Mother feels we were very friendly and knowledgeable and referred to resources that were helpful.
Mother appreciates the help.”
Staff member “extremely professional, wonderful, kind, helpful, personable and easy to talk to.”
“Member’s father is very satisfied with the case management provided, the information was always
accurate and helpful. Member’s father shared that he always received calls back when promised and the
assistance helped with member's needs. He feels positive to call PHC back if needed as he knows will
receive help.”
This program has provided good benefit to our members and will continue.
Complex Case Management (CCM) Complex Case Management (CCM) has been a service PHC has offered for many years. The program underwent
major revision in 2018 in preparation for NCQA accreditation, and there has been concerted effort to shift staff
128
128
128
109
101
110
94
123
4
4
4
20
26
17
35
9
0
0
0
4
5
5
3
0
1
1
1
0
1
1
1
1
I A M S A T I S F I E D W I T H T H E C A S E M A N A G E M E N T P R O G R A M T H A T H A S H E L P E D M E M A N A G E M Y C H I L D ’ S …
I A M C O N F I D E N T I N T H E A B I L I T I E S O F T H E T E A M M E M B E R S W H O C O N T A C T E D M E ; ( T H E T E A M C O U L D …
I A M S A T I S F I E D W I T H T H E C A S E M A N A G E M E N T P R O G R A M T H A T H A S H E L P E D M E M A N A G E M Y C H I L D ’ S …
A F T E R W O R K I N G W I T H T H E C A S E M A N A G E M E N T T E A M , I F E E L M Y A B I L I T Y T O M A N A G E M Y C H I L D ’ S H E A L T H C A R E …
M Y C H I L D ’ S H E A L T H H A S I M P R O V E D S I N C E W O R K I N G W I T H O U R C A S E M A N A G E M E N T T E A M
I W A S A B L E T O S A F E L Y T R A N S I T I O N M Y C H I L D B E T W E E N P R O V I D E R S W I T H T H E H E L P O F M Y C A R E T E A M .
T H E R E L A T I O N S H I P T H A T M Y C H I L D A N D I H A V E W I T H T H E P C P A N D / O R S P E C I A L I S T O F F I C E S H A S I M P R O V E D …
M Y C H I L D A N D I W E R E P R O V I D E D W I T H T H E A V A I L A B L E E Q U I P M E N T , M E D I C A T I O N A N D / O R S E R V I C E S T H A T …
PEDIATRIC TOC EXPERIENCE
Agree Neutral Disagree No Response
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behavior to align with the NCQA requirements. This service is a support for members who have multiple chronic
conditions, social determinants of health barriers and/or have difficulty navigating the healthcare system without
the intensive support of a care coordinator and an individualized care plan. CC licensed staff engage member to
perform a comprehensive assessment, clarify member/caregiver's goals and desired level of involvement, and
develop an individualized care plan to overcome barriers to care and to support the member/caregiver in
reaching his/her wellness goals. Individual goals are time-bound; however, a member may remain in complex
case management for an extended period of time to ensure the member gets the care he/she needs.
Member satisfaction with the complex case management program is ascertained via telephonic survey either
annually (for multi-year interventions) or upon case closure, if the case is active for less than one year. For each
satisfaction measure, the goal is at least 75% of members surveyed agree with the statement, which translates to
an average score of 2.5 or greater for each response.
Adult Experience with CCM There were 21 members who responded to member experience surveys between January 2019 and December
2019. The average responses were as follow:
Survey Question
Average Response
Goal Met
The CM program that has helped me manage my health issues. 2.95 Yes
I am satisfied with the number of calls I received from my case management
team. 3.00 Yes
I was confident in the abilities of the team members who contacted me 2.85 Yes
My team referred me to medical and community resources that were valuable
and helped me. 2.85 Yes
I feel I can better manage my healthcare needs after working with CM. 2.75 Yes
I have a better understanding of my health conditions and/or diagnosis after
working with CM. 2.70 Yes
I have a better understanding of my medications after working with CM 2.65 Yes
My health has improved since working with CM. 2.60 Yes
My relationship with my PCP or Specialist office has improved since working with
CM. 2.70 Yes
I feel like my providers and I work together better since working with CM 2.89 Yes
I have had more success in reaching my health goals since working with CM. 2.78 Yes
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Analysis
Adult members who participated in the CCM program responded very positively to their experience with case
management. There were two areas where members showed less agreement:
I have a better understanding of my medications after working with CM
Medication management is an ongoing challenge for many members. Providers may change a member’s
prescriptions for many reasons. Members may think they understand their medication regimen, or they
may be overwhelmed by it and struggle to understand. Member medical literacy may be much lower
than the provider – or PHC staff – may realize. PHC’s pharmacy team is aligning with PHC’s case
management team to test whether adding a pharmacist may help members better navigate their
medications.
My health has improved since working with my case management team
When a member’s health status is complex enough to qualify for CCM, it is unlikely to improve regardless
of the quality of intervention or support. It may be work revising this question to reflect this reality.
Nevertheless, the member experience with CCM services exceeds the target for this measure. Many of the
responses praised the support PHC staff provided. Examples of feedback says:
“I would not be alive today if it wasn't for being given a CM.”
“My case manager was wonderful in getting me to my appointment as well as getting me my
medications.”
My case manager was “a wonderful lady and was a great help to us.”
Pediatric Experience with Complex Case Management In January 2019, PHC became responsible for case management for the CCS population within PHC’s 14 counties.
PHC’s CC staff reached out to every CCS member who transitioned to PHC after that date in order to complete a
19
20
17
17
15
15
14
15
15
16
15
1
0
3
3
5
4
5
2
4
2
2
0
0
0
0
0
1
1
3
1
0
1
1
1
1
1
1
1
1
1
1
3
3
T H E C M P R O G R A M T H A T H A S H E L P E D M E M A N A G E M Y …
I A M S A T I S F I E D W I T H T H E N U M B E R O F C A L L S I …
I W A S C O N F I D E N T I N T H E A B I L I T I E S O F T H E T E A M …
M Y T E A M R E F E R R E D M E T O M E D I C A L A N D C O M M U N I T Y …
I F E E L I C A N B E T T E R M A N A G E M Y H E A L T H C A R E N E E D S …
I H A V E A B E T T E R U N D E R S T A N D I N G O F M Y H E A L T H …
I H A V E A B E T T E R U N D E R S T A N D I N G O F M Y …
M Y H E A L T H H A S I M P R O V E D S I N C E W O R K I N G W I T H C M .
M Y R E L A T I O N S H I P W I T H M Y P C P O R S P E C I A L I S T O F F I C E …
I F E E L L I K E M Y P R O V I D E R S A N D I W O R K T O G E T H E R …
I H A V E H A D M O R E S U C C E S S I N R E A C H I N G M Y H E A L T H …
ADULT CCM EXPERIENCE
Agree Neutral Disagree No Response
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comprehensive assessment, risk stratification, and to offer enrollment into CCM. When a member’s CCM case is
ready for closure, the final activity is a member satisfaction survey, administered by a staff member not involved
in the case. Responses are weighted as Agree (3 points) Neutral (2 points) Disagree (1) or No Response. In
addition to weighted responses, members have an opportunity to provide comments. Responses are tallied and
reviewed no less than annually to ensure PHC member needs are being met. For each satisfaction measure, the
goal is at least 75% of members surveyed agree with the statement, which translates to an average score of 2.5 or
greater for each response
There were seven responses for pediatric members whose services whose cases were closed after the Complex
Case Management intervention between June 6, 2019, and March 31, 2019. The average responses were as
follow:
Survey Question
Average Response
Goal Met
The CM program helped me manage my child’s health issues. 3 Yes
I am happy with the number of calls I received from our case management team 2.67 Yes
I am confident in the abilities of the team members who contacted me 3 Yes
My team referred me to medical and community resources that were valuable and helped me.
3 Yes
I feel my ability to manage my child’s healthcare needs is better after working with CM 2.83 Yes
I have a better understanding of my child’s health conditions and/or diagnosis after working with CM
2.67 Yes
I have a better understanding of my child’s medications after working with CM. 2.33 No
My child’s health has improved since working with our case management team. 2.5 Yes
The relationship that my child and I have with the PCP and/or Specialist offices has improved since working with our case management team.
2.6 Yes
I feel like my providers and I work together better to help my child since working with our case management team.
2.5 Yes
My child and I have had more success reaching our health goals since working with our case management team.
2.67 Yes
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Partnership HealthPlan of California Population Health Management: Impact Analysis 2020
Page 16
Analysis
Member experience surveys for the children who participated in the CCM program showed very positive
responses to their experience with case management. There were two areas where members showed less
agreement:
I have a better understanding of my child’s medications after working with CM
As with the adult respondents, medication management is an ongoing challenge for many members.
Providers may change a member’s prescriptions for many reasons. Members may think they understand
their medication regimen, or they may be overwhelmed by it and struggle to understand. In the case of
the CCS population, many parents/guardians came into case management with a strong understanding of
their child’s medications. Case management intervention could not improve on the knowledge they
already had.
My child’s health has improved since working with my case management team
The CCM program is designed to provide support for members who endure chronic health problems and
whose health may never get better. In that case, the goal is to reduce the burden of the chronic condition
on the member and their parent/guardian, to the extent possible.
I feel like my providers and I work together better to help my child since working with our case
management team
Most of the children who qualify for the CCM program have been beneficiaries of CCS before the benefit
transitioned to PHC. These families have worked closely with their providers for years. PHC case
management may continue to support this relationship, but is unlikely to significantly improve the
relationship for those members who already have long-standing relationships. In coming years, when PHC
is the first team to provide support for newly diagnosed conditions, this average may shift.
6
6
6
5
4
3
3
3
3
4
4
0
0
0
1
2
2
3
2
3
2
2
0
0
0
0
0
1
0
0
0
0
0
1
1
1
1
1
1
1
2
1
1
1
T H E C M P R O G R A M H E L P E D M E M A N A G E M Y C H I L D ’ S …
I A M H A P P Y W I T H T H E N U M B E R O F C A L L S I R E C E I V E D …
I A M C O N F I D E N T I N T H E A B I L I T I E S O F T H E T E A M M E M B E R S …
M Y T E A M R E F E R R E D M E T O M E D I C A L A N D C O M M U N I T Y …
I F E E L M Y A B I L I T Y T O M A N A G E M Y C H I L D ’ S H E A L T H C A R E …
I H A V E A B E T T E R U N D E R S T A N D I N G O F M Y C H I L D ’ S H E A L T H …
I H A V E A B E T T E R U N D E R S T A N D I N G O F M Y C H I L D ’ S …
M Y C H I L D ’ S H E A L T H H A S I M P R O V E D S I N C E W O R K I N G W I T H …
T H E R E L A T I O N S H I P T H A T M Y C H I L D A N D I H A V E W I T H T H E …
I F E E L L I K E M Y P R O V I D E R S A N D I W O R K T O G E T H E R B E T T E R …
M Y C H I L D A N D I H A V E H A D M O R E S U C C E S S R E A C H I N G O U R …
PEDIATRIC CCM EXPERIENCE
Agree Neutral Disagree No Response
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Partnership HealthPlan of California Population Health Management: Impact Analysis 2020
Page 17
Despite the areas where PHC could not improve on established behaviors, the member experience with CCM
services exceed the target for this measure. There were only eight members whose CCM case closed during 2019.
Most cases remain open to CCM. The only comments provided on the survey were specific to questions on the
case.
Next Steps The Population Health Management Committee will convene no less than quarterly to review the results of the
analyses described above and to monitor the impact of the various interventions recommended. Each
intervention will have associated outcomes and measures. The group’s annual analysis will evaluate the efficacy
of the interventions and identify new opportunities for improvement.
Eureka | Fairfield | Redding | Santa Rosa (707) 863-4100 | www.partnershiphp.org
PHC’s Quality Improvement organization-wide goals for 2019-2020 included three main focus areas: Well Child Visits (W34), Asthma Medication Ratio (AMR) and Prenatal Postpartum Engagement Work Group (PPEW). Each measure was assigned to a cross functional work group including, but not limited to, Quality Improvement (QI), Care Coordination, Health Education, Claims, and Analytics. To measure success, work groups were assigned goals to achieve by June 30, 2020.
Well Child Visits (W34) • Workgroup Aim, Objectives and Focus Areas:
o Aim: HEDIS MY (measurement year) 2019 results for the W34 measure will be above the 50th percentile for at least two regions and above the 25th percentile for all regions Outcome: Based on preliminary HEDIS MY 2019, the goal was met by the two southern reporting regions
performing above the 50th percentile and the two northern reporting regions above the 25th percentile o Objective: Drive improvement in Well Child visits through focus on the many activities around well child visits
and inform the HEDIS Score Improvement Workgroup about efforts o Focus Areas: The workgroup identified more than 20 deliverables that would be tracked across the following
focus areas: Inform Well Child Work: PHC internal information, education and data analysis Track PHC Operational Changes: Follow operational changes that will impact and improve well child
performance rates (i.e., QIP, Birthday Club, ePrompts) Deploy Resources to Optimize Provider Ability to Improve: Create and update resources available to
providers that will impact and improve well child rates (i.e., training, provider informing materials, member facing materials available for providers to give to patients)
Conduct Performance Improvement Projects: Work with provider partners to conduct quality improvement projects around well child
Employ PHC-Driven Member Engagement Strategies: Identify a Plan-Wide Strategy for Member In-Reach and Outreach
• Accomplishments Contributing to Improved Performance: o Added well child measure insights to 25 provider scorecards developed by the PHC Claims department and QI. o Conducted assessment of existing health education materials related to well child. Next fiscal year will focus on
development of new materials for identified gaps. o Targeted 3 to 6-year-old members through the Birthday Club initiative in PHC’s Northern Region. Significant
efforts were made towards deploying plan-wide, including vendor evaluation. o Completed provider trainings, updated resources (Quality Measure Highlights, well care dashboard, pocket
guide, QIP program, Accelerated Learning 4/15/20 session). o Initiated Priority and Health Equity PIPs, focusing on well-child visit measures W34 and W15, respectively.
Eureka | Fairfield | Redding | Santa Rosa (707) 863-4100 | www.partnershiphp.org
Asthma Medication Ratio • Workgroup Aim and Objectives:
o Aim: Partnership HealthPlan of California (PHC) aims to increase Asthma Medication Ratio (AMR) Regional Performance composite scores by 5% from mid-year 2018 to March 2020 (Note: this goal was revised to exclude impact from COVID-19.) This goal was exceeded with a 6.28% increase. Per reporting in May 2020, the AMR plan-wide composite score improved from baseline of 59.97% to 66.25%.
o Objectives: Increase prescribers’ awareness of their patients’ asthma prescription activity: new prescriptions and refills
for all asthma medications within measured timeframe Increase members’ knowledge and engagement with managing their asthma and asthma medications,
including appropriately coding for co-morbidities and alternative diagnoses Increase community pharmacists’ knowledge for the AMR HEDIS measure and promote engagement to
improve AMR through patient consultation; increase controller medication dispensing, and monitor and reduce rescue inhaler dispensing as clinically appropriate
Increase prescription fills, including 90-day supply fill, for asthma controller medication • Accomplishments Contributing to Improved Performance:
o Developed Academic Detailing Materials, which included measure specifications and best practices; to facilitate the education of provider organization.
o Provided on-site education, in collaboration with a Medical Director, Pharmacist, and QI representative, more than 15 provider sites and seven pharmacies.
o Developed custom reports on provider sites that received academic detailing to track progress on AMR rates. o Created community outreach materials to educate members.
Eureka | Fairfield | Redding | Santa Rosa (707) 863-4100 | www.partnershiphp.org
Prenatal and Postpartum Engagement Work Group (PPEW) • Workgroup Aim and Objectives:
o Aim: The PPEW team will ensure standardized engagement visits with 15 large perinatal providers by June 30, 2020
o Objectives: All OB/Perinatal quality measures will be at or above the 50th percentile of Medicaid plans nationally, starting with MY 2019 (this year). These measures are grouped as follows: Initial OB visit, timely, depression screen Post-partum visits, timely, depression screen, contraception Vaccinations: TDap and Flu Hospital: Elective preterm delivery, NTSV C-section
• Accomplishments Contributing to Improved Performance: o Developed core curriculum and message to share with practices across the regions with a focus on: Quality Prenatal Care Current regional and local data PHC resources to support optimal outcomes.
o Provided site specific education to 22 provider organizations, of which 15 are large organizations, as of June 30, 2020.
o Developed, distributed and received responses back from 25 sites that participated in the Perinatal Practice Survey. The survey was developed to assess overall volume of perinatal services for Medi-Cal eligible patients in our network.
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2020-21 Hospital QIP Measurement Set Large hospitals (> 50 general acute beds) and Small hospitals (< 50 general acute beds) report on measures as indicated below. Each hospital may earn up to 100 points.
Measure/Requirement
Target
Points Large/Small
HIE and EDIE Interface All hospitals must complete Admission, Discharge, and Transfer (ADT) interface with a community HIE and EDIE interface by the end of MY.
Required for large and small hospitals
Delegation Reporting Capitated hospitals must submit a written Utilization Program Structure, and must submit timely and correct delegation reports (as outlined in delegation agreement): • Timely submission > 90.0% of reporting requirements for 100% of incentive. • Timely submission > 75.0% and < 90.0% of reporting requirements for 10% cut
from incentive. • Timely submission < 75.0% of reporting requirements for 20% cut from incentive.
Small Hospitals (<50 beds): • Participation in at least 1 Safe Table
Forum • Submission of 50 patient safety events
to CHPSO
Large Hospitals (>50 beds): • Participation in at least 4 Safe Table
Forums • Submission of 100 patient safety events
to CHPSO
10/5
7. QI Capacity Small hospitals (< 50 beds): • Full points for atending the Hospital Quality Symposium in 2021
Large Hospitals (> 50 beds): • Full points for atending the Hospital Quality Symposium in 2021
5/5
8. Hepatitis B Vaccination/ CAIR Utilization
All hospitals with maternity services. Excluded for non-maternity hospitals.
Target Option 1: Full Points > 20%, Partial >10-20% Option 1: Hospital with maternity services
• Numerator: # of newborn Hepatitis B vaccinations documented in CAIR • Denominator: newborn hospital births occurring between July 1, 2020 – June 30, 2021
Target Option 2: Full Points Ratio > 1.2, Partial Points Ratio > 0.2 to 1.2 Option 2: Hospital without maternity services
• Numerator: # of vaccines documented in CAIR from July 1, 2020 - June 30, 2021 • Denominator # of licensed acute inpatient beds
10/10
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9. Substance Use Disorder
All hospitals • Medication Assisted Treatment (MAT) started in the ED setting
PHC Members started on MAT in the ED setting o Small Hospitals < 50 Beds: > 2 PHC Members o Large Hospitals > 50 beds: > 5 PHC Members
10/10
10. Cal Hospital Compare – Patient Experience
All Hospitals Target: • Patient Experience average subcategory scores compared to average score for
California hospitals Full points:
• If [individual hospital composite score] is greater than [Average California Hospital score * 0.95]
10/10
11. Health Equity All Hospitals Small hospitals (< 50 beds):
• Submission of hospital plan (best practice) for addressing health equity Large Hospitals (> 50 Beds):
• Submission of hospital plan (best practice) for addressing health equity
5/5
12. Sexual Orientation/ Gender Identity (SOGI) in EHR
All Hospitals Small Hospital (< 50 beds):
• Submission of implementation plan over a 12-month period, or screenshot of existing SO/GI in EHR
Large Hospital (> 50 beds): • Submission of implementation plan over a 12-month period, or screenshot of existing SO/GI
in EHR
5/5
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PARTNERSHIP HEALTHPLAN OF CALIFORNIA MEETING MINUTES
Committee: Quality and Utilization Advisory Committee (Q/UAC) Meeting Date/Time: Wednesday, June 17, 2020 / 7:30 AM – 9:00 AM Napa/Solano Room, 1st Floor
Per Governor Newsom’s Executive Order, N-25-20 that relates to social distancing measures being taken for COVID-19. The Executive Order authorizes public meetings with Brown Act requirements to be held via teleconference or telephone. It waives the Brown Act requirement for physical presence at the meeting for members, the clerk, and/ or other personnel of the body as a condition of participation for a quorum. However, the Executive Order requires at least one public location consistent with ADA requirements to be made available for members of the public to attend the meeting, so all PHC offices will be available for members of the public to attend the meeting in-person.
Members Absent: Strain, Michael, PHC Consumer Member
Jennifer Wilson, MD
PHC Members Present: Barresi, Katherine, RN, Director of Care Coordination DeVido, Jeff, Behavioral Health Clinical Director French, Rachael, Associate Director of Quality and Performance Improvement Glickstein, Mark, MD, Associate Medical Director Glossbrenner, David, MD, Regional Medical Director Guillory, Ledra, Manager of Provider Relations Representatives Hoover, Peggy, RN, Senior Director of Health Services Katz, Dave, MD, Associate Medical Director Kubota, Marshall, MD, Regional Medical Director Leung, Stan, PharmD, Director of Pharmacy Services
McAllister, Debra, RN, Director of Utilization Management Moore, Robert, MD, MPH, MBA Chief Medical Officer – Chairman Netherda, Mark, MD, Associate Medical Director of Quality Ribordy, Jeff, MD Regional Medical Director Robinson, Erika, Director of Quality and Performance Improvement Scuri, Lynn, Regional Director Spiller, Bettina, MD, Northern Region Associate Medical Director Steffen, Nancy, Northern Region Director of Quality and Performance Improvement Vovakes, Michael, MD, Associate Medical Director
PHC Members Absent: Banks, La Rae, Director of Grievance and Appeals Boyd Anderson, Rebecca, RN, Director of Population Health
Cotter, James, MD, Associate Medical Director Townsend, Colleen, MD, Regional Medical Director
Guests: Anna Campbell, Administrative Assistant II Devan, James, Manager of Performance Improvement Fogliasso, Tara, Project Manager II French, Alison, Director of Partnerships, Beacon Health Options Hackett, Emma, MD, Open Door Community Health Center Hoffman-Spector, Sharon, RN, Manager of Utilization Management Kerlin, Mary, senior Director of Provider Relations Kisliuk, Margaret, Behavioral Health Administrator Lee Caron, Manager of Performance Improvement Leslie, Liz, Program Manager II, Wellness and Recovery Program
I. Call to Order Public Comment Approval of Minutes
Dr. Robert Moore called the meeting to order at 7:30 a.m. No public comments were made. Internal Quality Improvement (IQI) Minutes from May 12, 2020 were reviewed and accepted with no changes. Quality and Utilization Advisory Committee (Q/UAC) Minutes from May 20, 2020 were reviewed and approved with no changes.
Motion for IQI Minute acceptance: Dr. Candy Stockton Second for IQI Minute acceptance: Dr. Robert Quon All members present voted yes with no exceptions. Motion for Q/UAC Minute acceptance: Dr. Steven Gwiazdowski Second for Q/UAC Minute approval: Dr. Robert Quon All members present voted yes with no exceptions.
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II. Standing Agenda Items 1. Status of Open
Action Items Dr. Robert Moore and Nancy Steffen and Tara Fogliasso reported out on additional statistical analysis on the Birthday Club pilot, as was requested previously by Dr. Steven Gwiazdowski. Refer to pages 28-31. There were no questions.
For information only, no formal action required.
06/17/2020
2. Quality Improvement (QI) Department Update
Erika Robinson and Nancy Steffen provided the QI update found on page 32. Erika stated that we have done most of the primary development work for the Partnership Quality
dashboard and there some items still in progress. She acknowledged the ongoing work that’s happening despite being primarily virtual with our patient safety teams. We are continuing with QIP (Quality Improvement Program) and the HEDIS (Healthcare Effectiveness Data and Information Set) modules of information: both internal and external for Partnership stakeholders vs. the content and it’s the QIP information that’s visible to our provider partners. User acceptance testing was conducted from June 5 through June 12 and is complete. A June 25 kick-off meeting will introduce some of the new features on the QIP dashboards. Peer Review will look at this today and again in July.
The HEDIS project was completed as of Monday, June 15. Rachael French will present details on our HEDIS performance to Q/UAC on July 15. It was a complex year with many new measures, yet Partnership did see significant improvement over all relevant to prior years. Rachael thanked those clients who supported medical record collection, particularly in the COVID environment, and said that the pandemic did not hamper Partnership’s ability to collect medical record data this year; thus, she is confident in the performance that will be shared in July. Nancy mentioned that although the Department of Health Care Services (DHCS) has acknowledged COVID constraints, DHCS has continued to require that Partnership attend our continued Corrective Action Plan (CAP) calls on HEDIS measures, particularly in the border region. These calls have primarily focused on COVID-19 impact in our service region, both on our providers and on our members, and what Partnership has been sharing is a series of updates on overall measure performance improvement and new opportunities too.
Nancy said that DCHS has been interested in our stakeholders’ and experts’ differing approaches managing depression and mental health. Access to the provider network also is of concern to DCHS, and Partnership has shared the status of our Provider Relations (PR) teams and different ways we’ve been supporting that work. Population Health Management (PHM) is assessing and reaching out to our most vulnerable members. Erika noted that we do still have some measures that
For information only, no formal action required.
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are lagging and that we are trying to anticipate what DCHS will require of us. DHCS has consistently been concerned with the continued safety and health of providers, staff and members. Erika stated that we are about 45 site reviews behind since the schedule was suspended in March at the State’s instruction. Interestingly, DHCS is allowing for virtual site reviews and allowing us to develop our own process. Looking at doing some pre-work, asking questions at virtual meetings that follow, reviewing their medical records virtually, and then doing a virtual tour of the facility as a third meeting has really generated some good dialog with our providers and partners who will test with us. It’s been positively received. We can’t confirm all elements but we will in the appropriate environment.
Dr. Moore thanked everyone and then asked if anyone had questions. There were none. Dr. Moore said that “the substantial improvements in HEDIS that we’ll present to you next month is a great achievement and the innovative ways that our teams are working and in many ways takin the lead across the State is wonderful as well. Everyone has had to readapt their work and they pivoted very well in the face of difficulties working with the providers and working from home.”
3. HealthPlan Update
Dr. Moore gave his HealthPlan update in four parts. Dr. Moore’s first topic was the State budget that had come out mid-May with some massive cuts proposed by the Governor. It is sitting on his desk for approval and/or line item veto. So, the current budget that was passed by the Legislature June 15 may not be what happens or what is passed into law in another week. The large cuts to managed care remain intact: the single biggest one is a 1.5% retroactive decrease in our rates for the entire past fiscal year. The other big hit is a 10% increase on payments to skilled nursing facilities without any monies passed on to us to pay for that. Together, that’s more than $50 million. The Legislature decided not to enact the multiple benefit cuts that were proposed; the main rationale for this is a difference of approach towards the possibility of federal funding. The Governor’s office said ‘we’re not sure we’re going to get any bailout money from the Feds so let’s plan the cuts accordingly.’ And the Legislature said ‘let’s pretend we are going to get money from the Feds.’ The biggest assumption is that Feds will pass another big bill focused on the States. If not, then in the Legislative proposal there will be what is called ‘trigger cuts,’ essentially those cuts originally proposed by the Governor, that would kick in perhaps in October. That would cause much work to quickly unroll benefits. Partnership’s Finance Committee today is looking at a combo of dipping into reserves, administration cuts, and health care cuts.
Second, Nancy did a nice job of saying what the State is thinking. The only comment added was that the State is convening a work group. You’ll recall that about 15 months ago the State, with no input from anybody, raised their minimum performance levels for their measures from 25 to the 50th percentile. The DHCS work group will look at that threshold and other related issues related and the way the State holds the health plans accountable. It will take several months for that to wind through.
Thirdly, with all the publicity and thought about Black Lives Matter, and what we’re all doing to promote health equity: Partnership has had a health equity work group going for the last year and Dr. Colleen Townsend will be one of the medical directors representing us on that work group, looking at all different aspects of health equity and how we structure our benefits. Suggestions are welcome.
Lastly, where we are in COVID: my big summary is that in the last eight days, there was only one death in our region. There has been an increase in cases. In the last three weeks, Napa and Marin counties are the local highest numbers with 60 per 100,000, but both of those are less than California as a whole, which is being driven largely by Southern California. The hospitalizations are fairly stable in our region and statewide has been relatively stable as well. It’s super important to keep the most vulnerable people protected because that’s what drives death. We should be cautious in our interactions and avoid large gatherings. Hopefully, the increase in cases will not translate into overwhelmed hospitals. We’re not anticipating rollbacks at this time.
For information only, no formal action required.
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III. Old Business (Committee Members as Applicable) None
IV. New Business (Committee Members as Applicable) Consent Calendar
Member Services MP301 – Assisting Providers with Missed Appointments Care Coordination MCCP2016 – Transportation Policy for Non-Emergency Medical (NEMT) and Non-Medical Transportation (NMT) Utilization Management MCUP3033 – Rehabilitation Guidelines for Acute and Skilled Nursing Inpatient Services MCUP3037 – Appeals of Utilization Management/Pharmacy Decisions MCUP3138 – External Independent Medical Review
Note: Subsequent to the meeting MCCP2016 underwent a revision due to regulatory change and will be submitted once again for consent calendar approval at both IQI and Q/UAC in July.
Motion to approve: Dr. Robert Quon Second: Dr. Steven Gwiazdowski All consent policies were approved with no changes. All members present voted yes with no exceptions.
06/17/2020
V. Discussion 1. MPPRGR210 –
Provider Grievance
Mary Kerlin and Dr. Robert Moore reported on MPPRGR210 found on page 69. Section I: Added four related policies: MCUP3037, MPQP1053, MPQP1016, and CGA024. Section II: Added Health Services. Section III: Added definition of Provider Grievance. Section V: Added “or pharmacy” in the first sentence. Section V: Added wording regarding separate and distinct process from member appeals and
grievances. Section VI.A: Added “CEO is ultimately responsible” and added wording indicating provider
grievance process is managed and monitored by the PR department. Section VI.B.2: Added “or action that is the subject of the grievance”. Section VI.C: Changes made to the committee structure. The Peer Review Committee will be the
Provider Grievance Review Committee. Section VI.C: Added statement that members can not represent institution filing grievance. Section VI.D: Added: “or pharmacy” and “MCUP 3037 - Appeals of Utilization
Management/Pharmacy Decisions”. Section VI.E: Added new section; provider must exhaust all appeals. Section VI.G: Deleted “dispute” added “grievance” in 2 places. Section VII: Added “DHCS All Plan Letter, APL 17-006 – Grievance and Appeal Requirements”
and “NCQA UM 7 Element C, Non-Behavioral Healthcare Notice of Appeal Rights/Process and Element I, Pharmacy Notice of Appeal Rights /Process”.
Section VIII: Added: “PHC Department Directors”. Section IX: Position Responsible: updated to Senior Director, Provider Relations.
Mary noted that this Provider Grievance policy has been in place in the HealthPlan since 1995 but we’ve made some significant changes. We added related policies and impacted departments, which are for the most part Provider Relations (PR) and Health Services, including Pharmacy. The definition was changed to include DHCS mandated language. For the purposes of this policy, a Provider Grievance is defined as an expression of dissatisfaction from a provider that, after exhausting all Plan appeal processes, requests to have their complaint, appeal or dispute submitted to the Provider Grievance Committee for final review of the medical or pharmacy decision or how the Plan implemented a regulatory requirement. This
Motion to approve: Dr. Brian Montenegro Second: Dr. Chris Swales Approved with no changes. All members present voted yes with no exceptions.
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is about UM (Utilization Management), not about a claim payment, a very important distinction. Under Medi-Cal program, members are never financially responsible, so this is about an UM decision that may have ultimately resulted in a denied service or payment to the provider.
Mary said the most significant change is under C. Prior to this change, it was an ad hoc committee appointed by the Physician Advisory Committee (PAC) chairperson. Since 1995, there have been only six formal provider grievances. Dr. Gwiazdowski has sat in on the last three. The Provider Grievance Review Committee (PGRC) consists of the members of the Peer Review Committee (PRC) who are not PHC medical directors, excluding any members of the PRC who have a potential conflict of interest. Potential conflict of interest for provider grievances includes being a member of the active medical staff on a hospital if the hospital is the grieving party and otherwise working for a hospital or institution if the grieving party is a physician on the active medical staff of that hospital or institution. The PGRC will meet on the same date as the PRC. Dr. Moore stressed that there is a larger and more commonly used grievance process for member-related grievance. If a provider is advocating on behalf of a member, that is still a member-related grievance. A provider grievance does not involve a member denial of service. Theoretically, if someone had something completely unrelated to payment and they felt we weren’t applying something fairly and they didn’t like how we resolved it, this is another possibility of appeal. Partnership’s culture is to be responsive to our providers. PHC has had only six in 25 years, which reassures us that it will not overly impact the Peer Review workload. Support for this will be PR staff.
Dr. Gwiazdowski acknowledged these updates and had no suggested changes Dr. Moore called for a motion to approve.
2. MCUP3042 – Technology Assessment
Dr. Moore reported on MCUP3042 found on page 76. Section VI.A.2: Added statement at this section for Investigational Interventions to match what we
say at section VI.B.4: for Cancer Clinical Trials; specifically that we will not authorized inpatient admission if there is no indication for acute care treatment. This language is from OIL 026-02.
Section VI.C.1.h: Clarified that when PHC reviews a Physician request for new technology, all six criteria specified at the top of the policy in VI.A.1. a. – f. (per Title 22 CCR 51303) must be met.
Section VI.C.1.h.5): Removed the word “funded” and matched statement used above in VI.A.1.e to say that new technology interventions cannot be provided as part of a research study protocol (per Title 22 CCR 51303).
Section VI.D.1.b: Specified that CMO may bring proposals for new benefits to the QUAC or PAC for feedback.
Section VI.D.1.c: Deleted this paragraph on committee review as it was more simply stated in the new sentence added just above in Section VI.D.1.b.
Section VI.D.1.d: Specified that when reviewing BREW topics, the Executive Committee may request input from PAC before making a decision.
Section VII. C.: Updated NCQA reference to 2020.
Dr. Moore explained the difference between technology assessments and second medical opinions, saying that Medi-Cal does specifically require us to honor any requests for a second opinion. So, this policy puts the parameters around that. Technology Assessment looks at items that are not currently covered or standard medical care and how we approach that as a health plan. Not many changes were made to this policy, but specifically called out are that investigational interventions will not be authorized in inpatient settings if there is no indication for acute care treatment. So if the patient is critically ill in an inpatient setting, we cover that in the inpatient setting, but if they are only being admitted to get an experimental treatment, and they would not otherwise be admitted to the hospital, then that has to be paid for by the company that’s doing the study and not by the taxpayers of California. Future questions might be brought to this committee. Typically, when we have questions, we use
Motion to approve: Dr. Steven Gwiazdowski Second: Dr. Madhusudan Borde Approved with no changes. All members present voted yes with no exceptions.
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available resources or we consultant with our expert consultants that we have. Specifically, covering a non-covered benefit, the Executive Committee might ask PAC for a decision if they are not comfortable making one.
There were no questions of Dr. Moore and he called for a motion to approve.
3. MPUP3078 – Second Medical Opinions
Debbie McAllister, RN reported on MPUP3078 found on page 84. Section I: Added MCUP3041 TAR Review Process as a Related Policy Section V: Added “process” to the Purpose section Section VI.A: Clarified that an “approved” prior authorization is required for second opinions
outside of the network and that out of network providers must be certified by Medi-Cal. Section VI.A.1: Added that questions about recommended “treatment” are a reason to seek a second
opinion. Section VI.C: Specified that out of network providers must be Medi-Cal certified and directed
reader to policy MCUP3124 RAF Policy for further discussion of out of network referrals. Also added a sentence to say that any treatment recommended by an out of network provider would be subject to the TAR process as per policy MCUP3041. Section VII. B: Updated NCQA reference to 2020 and changed UM5 H to UM 5E as per new guideline.
Debbie presented all policy changes. Dr. Moore added that the major changes are two: to make sure that if somebody says ‘well, I want a second opinion in Florida and you have to pay for me to go to Florida for that second opinion’ no, it has to be a Medi-Cal certified provider and geographically close by. The only reason to go to Florida is if there is no other qualified expert in the entire state of California. Dr. Dave Katz asked for clarity on members who seek care on the Oregon border: Do we tell people that for second opinions they have to go south from the border and travel a long way? Dr. Moore replied that “the Referral to Specialist policy goes into that in detail and that it isn’t replicated here. A moderately large number of providers just across the border have signed up for Medi-Cal. Of those who have not signed up across the border, we can consider on a case-by-case basis based on distance. That is a criteria that gets reviewed first and it is not automatic.”
There were no questions and Dr. Moore called for a motion to approve.
Motion to approve: Dr. Steven Gwiazdowski Second: Dr. Candy Stockton Approved with no changes. All members present voted yes with no exceptions.
06/17/2020
VI. Presentations 1. Preliminary Audit
Report: 2019 Joint Annual Audit – Kaiser Foundation Health Plan
Kenzie Poncy presented the Kaiser Audit Report found on page 87.
PHC shares policy and program review with five other Northern California plans, each owning the review for a couple of programs. For file review, we conduct ourselves for privacy. Overall, Kaiser performed very well.
There were about 150 or so preliminary deficiencies, but Kaiser was able to satisfy most of our findings either through supplemental documentation or explanations on what you’ll see here under program review. There is really not a lot of deficiencies that necessitated a Corrective Action Plan (CAP). The biggest both Kaiser and Partnership expected to be of concern was Population Health Management (PHM). There were four deficiencies requiring a CAP in that area that will be open through the 4th quarter of 2020. That is because Kaiser is still implementing PHM programs for National Committee for Quality Assurance (NCQA) accreditation in 2021.
New this year under the file review category were Potential Quality Incidents (PQI), transportation, mental health and behavioral health. Of those new categories, only transportation has anything that necessitates a CAP. It was a technical error as members were directly receiving reimbursement for
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transportation (and) members can’t receive direct reimbursement. Kaiser is working that out internally and also with a delegate administering benefits.
Re Grievance and Appeals: Partnership doesn’t have a Knox Keene Licensure (KKL) license and Kaiser does, so usually there is a little discrepancy each year in how the rules are applied. This one specifically referenced IMR (Independent Medical Review) and other services: after appeal has been decided by the Plan, members are able to request that an independent party outside of the Plan review their case and determine whether to uphold of overturn their appeal. This is not applicable for Partnership because we don’t have to maintain a KKL license as a county-organized health system. Kenzie invited persons interested in the areas necessitating CAPS to review her written presentation in detail.
Dr. Moore complimented the “rigorous process,” calling it “well documented.” Dr. Moore noted that Dr. Quon is excited to hear as he is a Kaiser physician and asked him if he had any questions. He didn’t. The report was accepted as presented.
2. InterQual® Criteria Review Approval Required
Debbie McAllister, RN, Dr. Devido and Liz Leslie presented the InterQual® Criteria Review. Refer to the presentation found on page 133 for detailed information. Dr. Moore provided an introduction and explained that the annual review of InterQual® criteria is
part of the NCQA accreditation process and a formal approval from the committee is required. The InterQual® criteria is thousands of pages long, and we have provided a summary and process to review a sample of the criteria in order for the committee to feel comfortable in providing their approval.
Debbie advised that the annual review is for NCQA requirement UM 2A Clinical Criteria for UM Decisions, Factors 4 and 5. PHC utilizes InterQual® criteria in UM for the decision making process as well as policies and procedures developed for specific situations. We are currently using the 2019 version. The 2020 version was released on June 6th and we are awaiting confirmation from our IT department for the download of the upgrade. A major change with 2020 is the new Behavioral Health module that will be used for the Substance Use Disorder (SUD) TARs.
Liz advised that the new Wellness and Recovery (W&R) benefit will go live July 1st and the only level of care within that new benefit that requires an authorization is residential. PHC has hired two clinicians who will review the residential TARs; one is a Licensed Marriage and Family Therapist (LMFT) and the other is a Licensed Clinical Social Worker (LCSW). They will use the InterQual® SUD criteria module in order to facilitate the authorization process. Dr. Moore asked Liz to confirm which counties PHC will be responsible for. Liz confirmed this
new benefit would be in Solano, Mendocino, Humboldt, Siskiyou, Shasta, Modoc and Lassen counties. Dr. Moore advised that there are some counties that have implemented the benefit themselves. Those counties are Marin, Napa and Yolo.
Dr. Devido advised that the state uses the American Society of Addiction Medicine (ASAM) criteria which articulates the set of guidelines for placement, contingent stay, transfer or discharge of patients with addiction or co-occurring conditions. ASAM provides a framework for clinicians to assess individuals along a continuum of six
dimensions; everything from acute intoxication and early withdrawal potential through recovery or living environment. The dimensional analysis is utilized to match with the level of care the individual will need.
ASAM levels of care range from zero, which is no level of care, up to level 4.0 where we say we should medically manage intensive inpatient services. In between, at level 3, is the one that’s most relevant, which is the residential and inpatient services. These are the ones PHC will review.
Motion to approve: Dr. Candy Stockton Second: Dr. Randy Thomas Approved as presented with no changes.
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It’s important to remember that providers will be assessing people based on ASAM criteria and guidelines, which will get reported to PHC. PHC staff will crosswalk that into InterQual®. InterQual® provides us with the opportunity to make a more standardized way to look at TARs across the board. Dr. Moore asked Dr. Devido if he felt that the InterQual® criteria reflects ASAM well and
if they seem appropriate. Dr. Devido confirmed that his clinical opinion was that InterQual® does match ASAM criteria and the crosswalk between the two is consistent.
PHC utilizes the nine modules outlined in the summary on page 133. A summary of the content of each was provided, and arrangements can be made to provide full criteria for review upon request.
A sampling of the InterQual® criteria was shared online during the meeting to provide a general idea of what is included to ensure the committee members were comfortable in approving the rather detailed criteria. Dr. Moore advised that prior to the meeting, we requested committee members to advise if there was a specific module that they would like to see; no requests were received. Criteria reviewed included: The new criteria for SUD, which includes residential treatment. Dr. Moore commented that the
criteria is very detailed and includes diagnoses, symptoms, and vital signs. Adult criteria and Acute Coronary Syndrome was displayed, and it was noted that there is also
pediatric criteria as well as criteria for behavioral health for the both adults and children. There is also an interactive procedures module that PHC now has.
Dr. David Glossbrenner advised that the UM nurses review the criteria. The basic concept in InterQual® is to start with severity of illness and then look for intensity of service. Much of the criteria is based on severity of illness, such as if the vital signs, blood count or lab tests are unstable. Once you have severity of illness you look for intensity of service. If there’s no intensity of service, then the treatment plan is not responsive to the severity of illness, and that would need to be changed in order to meet the criteria. Debbie advised that each TAR for inpatient or outpatient services will reflect how many times
InterQual® was checked and whether there were changes in a patient’s situation. Dr. Moore asked the committee members if they were comfortable with the overview provided and asked if there was anything specific they would like to see, or if there were any questions. There were none.
3. ADHD Measure Results for MY 2019
Rachael French and Robert Moore, MD presented the Preliminary Performance on: Follow-Up Care for Children Prescribed ADHD Medication (ADD) and discussed the Results for Measurement Year 2019 found on page 164.
Rachael noted that this very complex measure looks at the percentage of newly-prescribed attention-deficit/hyperactivity disorder (ADHD) medication. Two rates are reported:
Initiation Phase: The percentage of members 6-12 years of age as of the Index Prescription Start Date (IPSD) with an ambulatory prescription dispensed for ADHD medication, who has one follow-up visit with practitioner with prescribing authority during the 30-day Initiation Phase.
Continuation and Maintenance (C&M) Phase: The percentage of members 6-12 years of age as of the IPSD with an ambulatory prescription dispensed for ADHD medication, who remained on the medication for at least 210 days and who, in addition to the visit in the Initiation Phase, had at least two follow-up visits with a practitioner within 270 days (nine months) after the Initiation Phase ended.
For information only, no formal action required.
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Rachael said Partnership performed quite low overall except for the NW region: the denominator size is quite low. This is a new measure to Partnership, so we are doing a lot of internal analysis this summer as we prepare for next year.
Dr. Moore added this is the first we’ve seen of the validated results that were preliminary last year. They are concerning for our performance because it will negatively impact our HEDIS if the scores don’t rise. Because of the low denominator, the main strategy we are working on is an internal one trying to identify (using claims data) individuals who started the medication, and then to quickly intervene to make sure they have follow-up appointments scheduled. Patients who actually start medication today will not “impact” this year’s rates as much as next year. The Pharmacy team is working on developing a process plan to focus on this very important measure. Dr. Moore summarized Stan Leung’s comments by stating that patients who start in March of this year affect next year’s data. Dr. Moore is “most worried about and doing a deep dive on the well-child visits in first 15 months of life, which NCQA is extending to the first 30 months of life as a standard measure, and the chlamydia screenings, (where) surprisingly, we are not performing as well as we thought.”
Dr. Brian Montenegro expressed curiosity in the accuracy and adequacy of telehealth in monitoring these patients. Stan Leung said that in the maintenance phase one of the two follow-ups can be telephonic. Dr. Moore qualified that because data is captured with counter data, claims data will pick up the stand code regardless of the modifier. NCQA in the next two weeks will describe 40 different measures they will be changing to respond to the COVID outbreak with telemedicine. Rachael confirmed that for the initiation phase telehealth does not count but for continuation as an outpatient, one of the visits may be a telephone visit. Dr. Moore added that we’ll be able to summarize about coming changes in July or August. Dr. Katz “is concerned that this might affect the number of primary care providers who will be willing to prescribe medication.” He wonders if tracking the access to providers that will prescribe might be part of the action plan. Dr. Moore said that is a good suggestion. Dr. Randy Thomas asked if the 30-day visit has to be done before prescriptions run out. Dr. Moore clarified that if the prescription is filled Jan. 1, they have to be seen by Jan. 30.
4. ADVANCE Program Evaluation
Farashta Zainal presented the ADVANCE Program Evaluation found on page 165. Dr. Moore prefaced her remarks by noting that ADVANCE is one of our mechanisms for doing intensive performance improvement training with sites that are willing to embark on this journey together. This is the evaluation of our 4th cohort.
Farashta then went through her report. More than 50 participants improved, with the guidance of a performance improvement coach and in their QIP (Quality Improvement Program) scores in 2019 compared to 2018. Cohort 4 was a nine-month commitment. The aim was to increase provider network capacity to execute quality improvement projects as measured by 60% of participating organizations achieving improvements on their selected projects. 75% of participants rated their overall program satisfaction as “excellent.” In 2019, nine provider sites from the southern region and four from the northern completed the program. Two providers were unable to complete the program due to changes in staffing.
Farashta went through the slides: 50% of participants exceeded their aims. 90% of participants improved QIP scores in 2019 compared to 2018. Participants gained better understanding of project management, change management, and threats to sustainability.
Leadership is key to successful project outcomes, including overcoming barriers, engaging stakeholders, and testing/implementing changes. With some delays due to COVID-19, our team is now ready to launch the Practice Facilitation Program. Improvement advisors and practice facilitators will work alongside the organization’s Quality team to provide guidance and resources with system level changes. The principles of ADVANCE will be transferred to the Practice Facilitation Program with regard to
For information only, no formal action required.
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approach. With Practice Facilitation, teams will have more real-time learning by acquiring knowledge of the QI methodology and testing changes on site. We will be able to meet primary care teams at their current phase of QI. Practice Facilitation launched its four-part series pilot during a one-hour virtual lunch on June 16 with 18 internal participants in the southern region. Farashta hopes a second round will launch in early fall.
Dr. Moore asked about ADVANCE meeting schedule. Farashta said they occurred once monthly via webinar or in-person meetings in Fairfield, Redding and Santa Rosa. In addition, monthly coaching was an option. Dr. Moore said the success of ADVANCE was a result of deep engagement: that’s the principle in looking at HEDIS outcomes in past year, a lot of commonality with our providers. The average score of 2018 was a 10% drop across all providers, so 2019 scores are impressive.
For Information Only
Dr. Moore told guest Dr. Emma Hackett that he will reach out after today’s meeting to see if she is still interested in joining as voting member of both QUAC and Peer Review. N/A 06/17/2020
VI. Additional Business
Next Meeting: July 15, 2020 N/A N/A
Adjournment Respectfully submitted by: Leslie Erickson, Administrative Assistant II Signature of Approval: ________________________________________________ Date: ____________________________ Robert Moore, MD, MPH, MBA Chairman
MCUP3127 – Dispute Resolution Between PHC and MHPs in Delivery of Behavioral Health
Services
MCUP3136 – Fecal Microbiota Transplant (FMT)
MPUD3001 – Utilization Management Program Description
MPUP3129 – Podiatry Services
Discussion on MP300:
Anna asked if the Substance Abuse Internal Quality Improvement (SUIQI) Committee should be
added in the header as a reviewing entity for those policies that are reviewed in this meeting. Dr.
Moore advised that there would be policies that would reviewed in that meeting, but should not be
considered a reviewing entity; Liz L. agreed. The committee agreed to remove SUIQI from reviewing
entities in the header.
Anna asked if Wellness and Recovery (W&R) should be defined in Section III Definitions, and not
just the acronym spelled out. Anna suggested to add the W&R definition that is used in CMP41. The
committee agreed to this change.
Discussion on MPQP1016:
Dr. Netherda advised in Section VI.E.1 and 2, the three instances where it states “CMO or designee”
should state “CMO or physician designee”, adding the word “physician”. The committee agreed to
change all three instances to state “physician designee”.
The following policies were pulled
from the Consent Calendar for
discussion:
MP300 and MPQP1016
Motion to approve: Debbie McAllister
Second: Dr. Kubota
The remaining policies were approved
with no changes.
Motion to approve MP300:
Anna Campbell
Second: Edna Villasenor
Approved with changes:
Header: Remove SUIQI as a
reviewing entity.
Section III: Add the following
definition: Wellness & Recovery
Program means PHC’s regional
Drug Medi-Cal Organized
Delivery System waivered
program in seven counties within
PHC’s service area.
Motion to approve MPQP1016:
Dr. Netherda
Second: Dr. Kubota
Approved with changes:
Section VI.E.1 and 2: Change
threes instances of “CMO or
designee” to “CMO or physician
designee”.
04/07/2020
1. MPLD7001 –
Cultural &
Rebecca Boyd Anderson reported on MPLD7001 found on page 127.
Throughout the Program Description all instances of Group Needs Assessment (GNA) have been
updated to Population Needs Assessment (PNA).
Motion to approve: Rebecca Boyd
Anderson
Second: Melissa McCartney
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AGENDA ITEM DISCUSSION RECOMMENDATIONS / ACTION DATE
RESOLVED
Linguistic Program
Description
Page 2: Removed paragraph about Appendix A, and changed Health Services Department to
PHC’s Population Health (PH) unit. Added Quality, Communications, Compliance, Information
Technology, and Regional Leadership as departments we work with on the program. Changed
Management Department to Quality and Health Analytics team.
Page 3: Changed Administration department to Communications and Compliance. Added
paragraph about Regional Leadership’s role to address cultural and linguistic needs of PHC’s
membership. Removed Health Education and Cultural and Linguistic action plan and added
corresponding actions. Removed paragraph about GNA and sentence about services.
Page 4: Added core content of the PNA for DHCS PNA goals and what PNA identifies.
Page 5: Clarified that the community health resources are found on the PHC website and that it
shows services offered.
Page 6: Removed action plan annual updates and added Population Health Program Evaluation.
Added community health fairs and outreach. Removed all references to GNA.
Appendix A: Replaced slide with new PH Management Committee Structure.
Approved with no changes.
2. MCQG1005 – Adult
Preventive Health
Guidelines
Dr. Moore reported on MCQG1005 found on page 135.
Section VII.C: Updated link
Section VII.I: Change Policy Letter to APL and added a link to the APL
Attachment A:
Updated to reflect the current guidelines for Hepatitis C and Glaucoma Screening.
Wordsmithing for clarity under Lung Cancer Screening and Diet, Behavioral Counseling in
Primary Care to Promote a Healthy Lifestyle.
Motion to approve: Dr. Moore
Second: Rachael French
Approved with no changes.
05/12/2020
3. MCQP1021 – Initial
Health Assessment
(IHA) and
Behavioral Risk
Assessment
Rachel Peterson reported on MCQP1021 found on page 146.
Section IV: Attachments were updated and added the Staying Healthy Assessment (SHA)
Frequently Asked Questions (FAQs) and the Three Attempt Outreach Tracker.
Section VI.E.3.d: Medi-Cal Managed Care Division (MMCD) was identified. Deleted sentence
regarding the website as it is not located on the PHC website.
Section VI.I.1: New monitoring process for IHA.
Section VI.I.2: Deleted “high volume” as report being pulled does not filter only high volume.
Deleted section-we are educating providers on Site Reviews in regards to IHA and emailing sites
a reminder of newly assigned members that are due for an IHA.
Section VI.S: Deleted duplicate information.
Motion to approve: Dr. Kubota
Second: Dr. Netherda
Approved with no changes.
05/12/2020
4. MPQP1022 – Site
Review
Requirements and
Guidelines
Rachel Peterson reported on MPQP1022 found on page 175. Rachel advised that the policy was
reformatted to follow the flow of APL20-006.
The policy was updated per APL 20-006 Site Reviews: Facility Site Review and Medical Record
Review (Supersedes PLs 14-004 and 03-002, and APL 03-007) published 03/04/20.
DHCS Facility Site Review and Medical Record Tools updated to 2019 version and goes live
07/01/20 (unless further guidance is received from DHCS regarding COVID).
Section IV: Attachments were updated.
Section VI: Removed Primary Care Provider (PCP) verbiage throughout the policy to follow
NCQA guidelines broadening scope to include multiple types of providers.
Section VI.A.1 Site Review Personnel Changes:
DHCS Recertifies Master Trainers (CMT) every three years.
Motion to approve: Dr. Netherda
Second: Rachel Peterson
Approved with change:
Section I: Add CGA024 as a
Related Policy.
Section VI.A.6.b: The word “a”
should be removed in the first
sentence. This should state: If the
site receives two consecutive
failing Site Review scores.
Section VI.A.8: The last sentence
under the CAP Action(s) for
Beyond 120 days from the date of
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AGENDA ITEM DISCUSSION RECOMMENDATIONS / ACTION DATE
RESOLVED
Master Trainers must complete 20 reviews and have 1 year experience as a Certified Site
Reviewer.
Certified Site Reviewer Initial Certification requires the completion of 10 reviews alongside
the CMT.
Certified Site Reviewers must complete a minimum of 20 reviews between recertification.
Section VI.A.2: Full Scope Site Review information remains the same from previous policy.
Changed formatting to follow APL flow.
Section VI.A.2.d: Pediatric and Adult Preventative Section is now required for PCP sites that
provide OB care.
Section VI.A.3.b.1): Pre-contracted providers who do not pass the initial Facility Site Review
(FSR) within two attempts may reapply to PHC within six months.
Section VI.A.3.d.5)a): A site relocation requires an initial FSR within 60 days or discovery of
completed move.
Section VI.A.4.a.1)a): Verbiage change to “assigned member population” to broaden scope to
follow NCQA guidelines.
Section VI.A.4.a.1)d): APL changed shared vs separate medical records.
Section VI.A.4.a.1)e): Multiple providers not sharing records must be reviewed individually.
Section VI.A.4: Deleted duplicate sections.
Section VI.A.5: Scoring will vary based on N/A answers.
Section VI.A.6: If site fails Medical Record Review (MRR) or FSR members will not be
assigned to the site until all Corrective Action Plan (CAP) deficiencies are corrected. Must pass
by third attempt to remain a PCP.
Section VI.A.7: Focused review is broken into sections for easier readability and table was
relocated.
Section VI.A.8: Table was added from the APL. Duplicate paragraphs were removed.
Section VI.A.12 and 13: Removed sections that were duplicates.
Section VI.A.11: Time frame was deleted. This is not in the APL.
Section VI.A.12.c: Verbiage change to midpoint to allow flexibility in multiple timeframes.
Section VI.A.17: Removed duplicate section.
Section VI.E: Added more specific reporting guidelines.
Section VII: References were updated.
Rachel advised that there were three additional changes that should be made to the policy:
Section VI.A.6.b: The word “a” should be removed in the first sentence. It should state “If the
site receives two consecutive failing Site Review scores”.
Section VI.A.8: The last sentence under the CAP Action(s) for Beyond 120 days from the date of
the FSR and/or MRR should be deleted (PHC will conduct another FSR and/or MRR within 12
months of the applicable FSR and/or MRR dates.)
Section VI.A.12.b.1): Remove the word “no”. This should state “Inform the Provider of
concern”
The committee agreed to these changes.
the FSR and/or MRR should be
deleted (PHC will conduct
another FSR and/or MRR within
12 months of the applicable FSR
and/or MRR dates.)
Section VI.A.12.b.1): Remove the
word “no”. This should state:
Inform the Provider of concern.
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AGENDA ITEM DISCUSSION RECOMMENDATIONS / ACTION DATE
RESOLVED
La Rae recommended to add CGA024 as a related policy in Section I since MPQP1022 is a related
policy on CGA024. The committee agreed to this change.
5. MPXG5009 –
Lactation Clinical
Practice Guidelines
Ron Klinger reported on MPXG5009 found on page 497. Ron advised that throughout the policy, we
have generalized the policy and removed language that essentially was reprinted from the
authoritative bodies that were referenced in the policy. This was cleaned up in favor of referencing
these which led to a new Useful Resources section.
Section V: Shortened the Purpose Statement.
Section VI.A: Updated the introduction statement under General Breastfeeding Guidelines.
Section V.B.1.d: Updated the Growing Together Program (GTP) references.
Section VI.B.2: Updated “Timing of Lactation Support Service” to reflect early Post-partum
period of 84 days to reflect the current HEDIS standard.
Section VI.E: Created “Useful Resources” section to cite resources for information that aren’t
directly referenced in the policy.
Section VII: Removed outdated research references.
Motion to approve: Ron Klinger
Second: Dr. Kubota
Approved with no changes.
05/12/2020
6. MCCP2020 –
Lactation Policy and
Guidelines
Doreen Crume reported on MCCP2020 found on page 512.
Section III.B: Updated the definition of Women, Infant and Children (WIC) Supplemental
Nutrition Program to include services for parents and other family members.
Section V.A: Changed time frame for recommended duration for exclusive breastfeeding to “4 –
6 months.”
Section VI.A.1: Updated paragraph describing the health benefits of breastfeeding.
Section VI.B.1.d: Updated paragraph describing how the Care Coordination department will
assist members planning to breastfeed through specific programs and case management.
Removed reference to GTP program.
Section VI.B.1.f: Provided new link for UNICEF/WHO Baby Friendly Hospital Initiative.
Section VI.B.1.f.2): Changed time frame for early mother-infant contact and breastfeeding to
“within one half-hour of birth.”
Section VI.B.1.g: Changed time frame for exclusive breastfeeding to “about six months.”
Section VI.C.1:
Changed end of time frame for early postpartum period to 84 days instead of 56 and changed
start of time frame for late postpartum period to 84 days instead of 56.
Changed postpartum visits from one to two, specifying one within 21 days after delivery and
a second between 22 to 84 days after delivery.
Changed statement regarding additional lactation education and support post discharge to
occur after 84 days post-delivery instead of 56.
Section VI.C.7.a: Added clause, “in limited supplies” for availability of banked human milk.
Section VI.C.7.b: Specified that WIC will provide special infant formula “for children up to the
age of 5 if prescribed by a physician.”
Section VII: Updated reference hyperlink for the American Academy of Pediatrics, Clinical
Practice Guideline.
Dr. Moore advised that in Section VI.C.1 the first visit should be prior to 21 days and the second visit
should be between 21 and 84 days after delivery. The committee agreed to this change.
Motion to approve: Dr. Netherda
Second: Dr. Kubota
Approved with change:
Section VI.C.1: Change the
sentence regarding the two
postpartum visits to state: One
occurring prior to 21 days after
delivery and the second between
21 and 84 days after delivery.
05/12/2020
7. MPCP2017 – Scope
of Primary Care –
Margaret Kisliuk and Dr. Jeff Devido reported on MPCP2017 found on page 519. Motion to approve: Dr. Jeff Devido
Second: Rebecca Boyd Anderson
05/12/2020
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AGENDA ITEM DISCUSSION RECOMMENDATIONS / ACTION DATE
RESOLVED
Behavioral Health
and Indications for
Referral Guidelines
Section VI.B.3: Updated description of symptoms which warrant emergent or urgent psychiatric
evaluation. Dr. Devido changed this to be more specific to ascertain if symptoms are being
experienced.
Section VI.B.4: Updated language and terminology for conditions to be evaluated by PCP.
Changed term “psychological” to “psychiatric” for consistency.
Section VI.C.2.b: Clarified which entity will provide substance use disorder and substance use
misuse services in different counties as per the Wellness & Recovery benefit.
Section VI.C.3: Added “substance-related and addictive disorders” to the list of behavioral
health conditions for which a PCP may determine a provisional diagnosis.
Section VI.C.4 and 5: Clarified terminology for conditions and risk factors. Added “Inability to
adequately self-care” and “Ongoing substance misuse” as risk factors for further deterioration of
behavioral health conditions.
Section VI.C.6: Added clause, “For mental health conditions” at the start of this section
describing when a PCP should refer a Medi-Cal only member to Beacon. This was clarified
because instructions would vary by county if member required substance use disorder services.
Section VI.C.6.d: Added clause to say “not including Kaiser primary care sites” because Kaiser
has a different agreement for some members.
Section VI.C.8.b.1): Listed the 7 counties for which Beacon should be contacted to refer member
to substance use services.
Section VI.C.9: Changed “encephalopathy” to “cognitive impairment.” Added a sentence to say
that Beacon can assist providers in referring to specialists in neuropsychiatry.
Approved with no changes.
8. MCUP3101 –
Screening and
Treatment for
Substance Use
Disorders (SUD)
Liz Leslie reported on MCUP3101 found on page 529.
Section VI.A.2: This policy was updated to describe the W&R benefit through PHC.
Footer: A note was added in the footer for pages 2 -9 to clarify that the W&R benefit is not
anticipated to begin until July.
Section VI.B.1.a.4): Added that Beacon’s call center activities are another process through which
a member might be identified and referred for SUD counseling and treatment.
Section VI.C.8.b: Removed statement: “Treatment for alcohol use disorders is not currently
covered by PHC” as that statement will no longer be true with the W&R benefit.
Section VII.H-L: Added references for W&R benefit.
Motion to approve: Debbie McAllister
Second: Dr. Netherda
Approved with no changes.
05/12/2020
9. MCUG3002 –
Acupuncture
Services Guidelines
Debbie McAllister reported on MCUG3002 found on page 543. Debbie advised the policy was
modified to align with Medi-Cal guidelines.
Section VI.A and B.1: Specified that we are allowing 2 acupuncture visits/month for members
who meet Medi-Cal medical necessity guidelines. Also removed language describing services
for under age 21 as there are no age distinctions for services in the Medi-Cal guidelines.
Section VI.B.3: Removed reference to members over age 21 and removed list of specific
treatment types. Replaced with language from Medi-Cal guidelines that describes types of
acupuncture treatment services allowed.
Section VI.C: Added podiatrist as a type of physician who may administer acupuncture
according to Medi-Cal guidelines.
Section VI.D: Removed last sentence about treatment plan being developed because we have
removed the TAR requirement.
Motion to approve: Debbie McAllister
Second: Rebecca Boyd Anderson
Approved with no changes.
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AGENDA ITEM DISCUSSION RECOMMENDATIONS / ACTION DATE
RESOLVED
Section VI.E: Removed Section E that described TAR requirements. Replaced with sentence to
say “No Treatment Authorization Request (TAR) is required unless services exceed two visits
per month.”
Section VI.G: Removed section describing TAR frequency.
Section VI.I: Removed sentence describing CPT code for initial visit.
10. MCUP3114 –
Physical,
Occupational and
Speech Therapies
Debbie McAllister reported on MCUP3114 found on page 546. Debbie advised this policy was
updated per State Bulletin announcing that, effective for dates of service on or after January 1, 2020,
speech therapy services previously eliminated as part of the optional benefits exclusion are reinstated
as full Medi-Cal benefits.
Section I.C: Added policy MCCP2024 - Whole Child Model for California Children’s Services
(CCS) as a Related Policy.
Section III.E: Updated code references for the Early and Periodic Screening, Diagnostic and
Treatment (EPSDT) program.
Section VI.B.1: Specified that speech therapy and occupational therapy (OT) are limited to two
services per month per Medi-Cal guidelines.
Section VI.C: Deleted this section specifying our PHC criteria for speech therapy because speech
therapy is now a state benefit and fits the criteria already noted in this policy for OT and physical
therapy (PT).
Section VI.C.a: In the new section C, wording was updated to describe CCS referrals and explain
that CCS will determine eligibility and then PHC will authorize and case manage.
Section VI.C.b: Removed specific reference to speech therapy benefits under EPSDT and
broadened reference to include all types of therapy in this policy. Referred reader to section VI.D
for full EPSDT section.
Section VI.D.1 and 2: Updated regulatory references for EPSDT as per APL 19-010.
Section VII: References were updated.
Motion to approve: Debbie McAllister
Second: Dr. Netherda
Approved with no changes.
05/12/2020
11. MCUG3022 –
Incontinence
Guidelines
Debbie McAllister reported on MCUG3022 found on page 553. Debbie advised this policy was
updated per State Bulletin announcing that Effective March 16, 2020, the TAR requirement was
removed from incontinence cream and wash product billing codes A4335 and A6250. Additionally,
corrections were made throughout policy and attachments to reflect change in cost threshold for when
a TAR is required for incontinence supplies. (Changed from $125 to $165)
Section VI.A.2.h: Changed wording to say skin wash and cream do NOT require a TAR unless
quantities exceed supply limit stated in Attachment A.
Section VI.A.5 and 6: Changed cost limit from $125 to $165 for when incontinence supplies
require a TAR.
Attachment A: On page 2, removed TAR requirement statement “Approved only with
documented history of skin breakdown” from the Incontinence Skin Care section because a TAR
is no longer required unless quantities are exceeded. Statement was moved below to occur with a
special note. Also added to specify new frequency/quantity limits for codes A6250 and A4335.
A TAR is now only required if those limits are exceeded.
Motion to approve: Dr. Netherda
Second: Debbie McAllister
Approved with no changes.
05/12/20
12. MCUP3041-A
MCUP3049-A
MCUG3007-B
PHC TAR
Requirements List
Debbie McAllister reported on the PHC TAR Requirements List found on page 562. Debbie advised
that the PHC TAR Requirements List is the only attachment that is allowed to be approved without
the policy as it affects multiple policies. The PHC TAR Requirements List was updated to reflect the
changes made in policy MCUG3022 Incontinence Guidelines.
Motion to approve: Debbie McAllister
Second: Dr. Netherda
Approved with no changes.
05/12/20
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AGENDA ITEM DISCUSSION RECOMMENDATIONS / ACTION DATE
RESOLVED
Page 3, Section Y.11.a: Changed cost threshold from $125 to $165 for when incontinence
supplies require a TAR.
Page 3, Section Y.11.b: Changed wording to say skin washes and creams do NOT require a TAR
unless quantities exceed new frequency/quantity limits for codes A6250 and A4335.
V. Presentations
Quality and Performance
Improvement Update
Erika Robinson and Nancy Steffen provided the Quality and Performance Improvement Update.
Refer to the update found on page 570 for detailed information.
PHC continues to message members in regards Well-Child Visits in the First 15 Months of Life
(W15) measure, to encourage their well-child visits. PHC will be asking physician members of
our committees what their strategies are, what we can do better and what has been proven
effective to ensure the well-child visits take place. Providers have shared workarounds they are
currently using, which include doing a combination of telehealth and in person well-child visits,
limit the number of people at an in person visit to include the patient and one caregiver,
conducting exams in less congested areas and then usher patients to get vaccines in another area.
The Quality Incentive Program (QIP) team has integrated the Tableau-based Immunization Dose
Reports which are available within eReports. The reports give a supplemental view by age
ranges, and while we have removed adolescents from the core set, we have heard from providers
that there is still interest to track progress and they would like to continue to see these reports.
The reports will be refreshed at the beginning of each month.
Most of the northern region (NR) providers participating in the extended Birthday Club are still
participating in this member incentive offering to drive improvement in the Well-Child Visits for
3-6 Year Olds (W34) measure. This represents 37 unique PCP health center or clinic sites across
the NR. PHC will honor all members presenting their birthday cards, regardless of when this
annual visit is completed during 2020. Some providers have opted out of PHC offered birthday
club reminder calls to members, with only 2 NR providers asking to temporarily pause all
participation due to COVID-19 response priorities.
A new enhancement called ePrompts is coming to PHC’s Call Center and the member portal in
May. This new feature will grant PHC staff using Call Center and members logging into the
member portal, visibility to individual member screening needs for multiple low performing
HEDIS measures, ranging from diabetes care to specific adult preventive screening needs. This
enhancement is designed to help member facing employees engage and support our members in
staying healthy while at the same time directly supporting HEDIS score improvement. User
Acceptance Testing (UAT) completed in April and a pilot will kick off in our NR in mid-May.
The results of the 90-day pilot will be reviewed by leadership to determine if more testing or a
fuller scale implementation will be pursued. All measure specific details being presented to
members, be it verbal or online, were prepared with sensitivity to the current COVID-19
response in mind.
Dr. Moore commented that there have been a number of updates on the PHC.org blog on safety
factors for seeing patients in the office, including the American Medical Association (AMA)
recommendations. In talking to providers, the biggest factor was patient fear of going in. PHC will
need to provide education to advise what they should come in for. The availability of personal
protective equipment remains a big limitation.
For information only, no formal action
required.
05/12/2020
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AGENDA ITEM DISCUSSION RECOMMENDATIONS / ACTION DATE
RESOLVED
1. Quarterly Grievance
Report
La Rae Banks presented the Quarterly Grievance Report for Q1 2020. Refer to the report found on
page 576 for detailed information. Highlights of the report include:
There was a total of 5,440 cases closed in 2019, and through Q1 2020, 1,137 have been closed.
There has been a decrease in the number of cases so far in 2020; however, we expect this to
change with the high unemployment rate which will lead to an increase in PHC membership.
There are discussions underway to determine how we can get members to call PHC to ward off
any issues they may have.
Q1 2020 highlights include:
7 expedited cases
0 overturned State Hearings
13 COVID-19 cases
32 CCS cases
Medical Transportation Management (MTM) concerns represented 27%. In regards to MTM,
there were 111,129 trip legs serving 10,077 unique members and there are a total of 304 MTM
cases. Overall, they continue to do a good job for our members.
Top member-reported concerns are benefit disputes and issues with experience and service.
Members contest pharmacy denials more frequently than any other benefit and there is a
desired use of brand-name, non-formulary, plan exclusions and excessive day supply; 28%
are related to opioids. Solutions include clearer denial letters and provider education.
MTM gas mileage reimbursement (GMR) claims include those with missing or invalid
documentation, denied claims for non-appearance to appointments or late filing, and
incorrectly denied claims. Experience and service claims include those for missed failed
rides, including taxis too early, late or never showed, and Lyft never showed. Non-medical
transportation (NMT) solutions include new Notification of Action (NOA) letters and
provider education.
The top reported concern regarding services by providers is member disagreement with their
provider’s plan for their health. Solutions include clearer denial letters, leveraging care
coordination to assist members and provider education.
There have been 5 total cases regarding COVID-19. Members are reporting issues with access
including barriers to COVID-19 testing, delayed or rescheduled appointments and access to
specialty providers.
There have been 32 total cases for CCS members. Benefit disputes include Durable Medical
Equipment (DME) and MTM GMR issues.
Several improvements have been implemented in preparation for NCQA accreditation. NCQA
readiness include a successful mock audit, NCQA sustainability, reporting and the Grievance
&Appeals Desktop Manual.
Operational updates include new case types in Everest, pharmacy admin denials are now signed
by a PharmD, and 100% of the staff are telework capable.
Operational opportunities include the standardization of state hearings, timely acknowledgement
letters and new grievance letter templates.
Quality metrics were reviewed and PHC met its performance goals for Q1 2020. There is an
opportunity to improve timeliness on mailing acknowledgement letters which led to new
workflows being implemented to improve this metric.
For information only, no formal action
required.
05/12/2020
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AGENDA ITEM DISCUSSION RECOMMENDATIONS / ACTION DATE
RESOLVED
The Inter-rater reliability (IRR) had a 100% pass rate, indicating that accurate clinical
assessments are being done.
Dr. Kubota commented in regards to MTM, it seems that a few members uses the service quite a bit.
La Rae confirmed that each way of a trip is considered a leg. Dr. Moore advised that dialysis could
drive this number up. La Rae advised she will include trends of what the rides are for in the next
report.
Lynn commented that the gas mileage reimbursement is one area that she would like to see an
increase in utilization and hopefully the transportation team can streamline the process as it costs a
fraction of what taxis do.
2. Update on PHC
Oversight, Provision
and Coordination of
Mental Health
Services
Dr. Jeff Devido and Margaret Kisliuk presented the Update on PHC Oversight, Provision and
Coordination of Mental Health Services. Refer to the report found on page 614 for detailed
information. Highlights of the report include:
An overview of the Medi-Cal mental health benefit and services administered by PHC was
provided. PHC provides the mild to moderate benefit, and the report included a breakdown of
what the counties provide and what managed care plans provide. It was noted that Kaiser
provides for all members assigned to Kaiser.
A status of PHC monitoring of delegated Beacon services was included. The report included
delegated functions, Beacon’s 2019 performance and changes or events that took place.
A summary of services delivered in 2019 was provided. It was noted that overall access in select
counties need improvement.
Overall, more than 1 in 6 adults (16.7%) on Medi-Cal need mental health treatment each
year; about 1 in 11 (9.0%) of Medi-Cal adults with serious mental illness (SMI), the rest to
be service in other systems.
Generally 1 in 10 Medi-Cal children (10%) have a serious emotional disturbance requiring
treatment.
There is care coordination across systems (county/PHC/Beacon).
Memorandums of Understanding (MOUs) between PHC and each of the 14 county mental
health plans outline shared responsibilities.
Beacon’s Care Management staff work to address all issues and to facilitate the care of
members by county.
One key challenge has been the handling of eating disorders and there has been an increase
in effort put into this area.
The top diagnoses for 2019, and Q1 2020 were reviewed. Depressive and anxiety disorders are at
the top.
Next steps include:
Continued work to enhance delegation oversight.
Increase overall access in selected counties.
Build/enhance network resources to better address eating disorders and maternal mental
health.
Work with PCPs and behavioral health providers to promote integrated care within the
community.
Prepare for expected increase in needs projected post-COVID.
For information only, no formal action
required.
05/12/2020
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BIRTHDAY CLUB PILOT RESULTS
Q/UAC Action Item Follow-up: June 2020
Eureka | Fairfield | Redding | Santa Rosa (707) 863-4100 | www.partnershiphp.org
Topic/Performance Measure
Well Child Visits in the 3rd, 4th, 5th & 6th Years of Life (W34)
Purpose
The concept of a “Birthday Club” takes member suggestions into consideration with the added benefit of spacing the well child exams more evenly throughout the year to decrease the potential conflict of the school physical rush during the months of July, August, and September. By leveraging the adoption of the Bright Futures periodicity schedule and linking the well child exam to the child’s birthday, the appointments will be more easily remembered by the parent, especially if accompanied by a reminder phone call and mailed postcard. The child will also receive a reward for completing a well child exam at the visit’s completion.
Research
PHC hosted member focus groups in both Humboldt and Shasta Counties to explore and gain insight into the barriers of children not receiving annual well child visits. The barriers expressed were:
• Providers’ schedules are full, longer wait periods for an appointment • Forgot appointment • Not enough time with the provider • Appointments cancelled, if not confirmed by the patient in advance • Provider turn over/ attrition • Transportation issues
The members provided suggestions to improve awareness and member engagement regarding the importance of well child exams. The suggestions included:
• Reminders when the child is due for a wellness exam through either phone call, text, letter, or postcard • Transportation assistance, i.e. bus voucher • Reward the child for completing a well child exam
Provider Partner
Redwood Pediatric Medical Group (RPMG), PHC’s only pediatric provider in the northwest region. The number of children assigned to RPMG in the age range of 3-6 years of age ranges from 800 to 900 children.
Prediction
PHC predicts targeted member outreach, “Birthday Club” member incentive offering postcard and the implementation of a member incentive will result in an increase in W34 visits at RPMG. As a result of the intervention, we expect to see improved W34 rates at RPMG.
Intervention Population Selection
PHC identifies assigned PHC members 3-6 years of age assigned to RPMG who have a birthday coming in the next month and have not had a well child visit YTD in the calendar year. The birthday children are outreached by way of the postcard and reminder phone call.
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Eureka | Fairfield | Redding | Santa Rosa (707) 863-4100 | www.partnershiphp.org
Intervention Assumptions
PHC assumed the children that had birthdays prior to the start of the intervention, January 2018 to August 2018, are the control group. PHC used this period to observe well child visit completion at RPMG without any kind of PHC influence by way of the postcard or phone call.
Intervention Results
PHC evaluated whether W34 visit rates increased during the birthday and following months secondary to the outreach, over and above rates of visits that would have occurred spontaneously without the intervention. Spontaneous visit rate data for the months prior to the intervention was compared with the months during the intervention. The median for calendar year 2018 and 2019 were also compared to further support that the prediction that targeted member outreach does influence a behavior change in RPMG assigned members by way of increased visit rates and visit count each month.
Here are the Birthday Club Visit Rate results:
In examining the %Visit Completion data more closely, as shown in the next graph, the key driver of the improvement trend is increasing member visit completions in the birthday month. This suggests the Birthday Club card is creating the desired outcome of influencing members to complete their visit corresponding to their birthday. And, it also shows that for this provider partner, access to these types of visits within or shortly following the birthday month was not a barrier.
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BIRTHDAY CLUB PILOT RESULTS
Q/UAC Action Item Follow-up: June 2020
Eureka | Fairfield | Redding | Santa Rosa (707) 863-4100 | www.partnershiphp.org
Here is another overall view, showing the Birthday Club Visit results by Visit Count:
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BIRTHDAY CLUB PILOT RESULTS
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Eureka | Fairfield | Redding | Santa Rosa (707) 863-4100 | www.partnershiphp.org
A table representing the Birthday Club results before and after the intervention:
Assigned members to Redwood Pediatrics, eligible under the Well
Child Measure (W34) with a birthday in the timeframe
# of Members with a Well Child Visit Completed within the Birthday month
& 2 months following
# of Members without a Well Child Visit Completed within the Birthday month
& 2 months following
Before Intervention (Jan 2018-Aug 2018)
542 126 416
After Intervention (Dec 2018-Dec 2019)
956 443 513
In a 2 sample population proportions test of RPMG’s W34 population before and after the intervention, the Birthday Club was determined to have significantly increased (p value < 0.00001) the rate of well child visit completions within the birthday month and 2 months following for this provider’s assigned member population. This means it is a statistical impossibility that this improvement happened by chance. We cannot assign causality formally as we did not survey the members as they sought their well child visits to understand if the Birthday Club was the primary influence in their decision making.
A visual representation of the statistical analysis is shared below, showing a comparison of the well child visit completion rates before and after the intervention with corresponding confidence limits.
Prepared by: Tara Fogliasso and Nancy Steffen, Northern Region QI
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1
QUALITY IMPROVEMENT PROGRAMS (QIPS) NEWS- UPDATE – HIGH LEVEL
QIP PROGRAM UPDATE
PRIMARY CARE PROVIDER
QUALITY IMPROVEMENT
PROGRAM (PCP QIP)
The PCP QIP Team received PAC approval on 05/13/20 to amend the PCP QIP 2020 Measurement Set. The intent is to enable providers to earn incentive dollars in spite of declining office visits due to COVID-19.
The PCP QIP MY2020 Relaunch Webinar held on 05/13/20 had the highest registered attendance since program inception. Presentation materials, amended PCP QIP specifications and the recorded webinar are available for download on the PHC website.
PQD development continues post PAC approval of PCP QIP changes. There will be a relaunch in June to include a webinar and training materials.
LONG TERM CARE QUALITY
IMPROVEMENT PROGRAM
(LTC QIP)
The LTC Advisory Group meeting is scheduled for 06/09/20.
PALLIATIVE CARE QUALITY
IMPROVEMENT PROGRAM
(PALLIATIVE CARE QIP)
No updates.
PERINATAL QUALITY
IMPROVEMENT PROGRAM
(PERINATAL QIP)
The PQIP Team has initiated the audit of records tied to attestations to close out the current measurement period scheduled to end on 06/30/20. Payment on the current pilot period is targeted for October 2020.
PQD development is in progress and will provide quarterly reporting of real-time denominator, numerator compliance and estimated payout. Target go-live date is October 2020.
The 2020-21 Perinatal QIP measure set was presented and approved by PAC on 05/13/20. The transition from a pilot to standing program is on track to launch with perinatal providers (by invitation only) on 07/01/20. A corresponding transition of Letters of Agreement (LOAs) is also in progress.
INTENSIVE OUTPATIENT CASE
MANAGEMENT QUALITY
IMPROVEMENT PROGRAM
(IOPCM QIP)
The IOPCM QIP Team in collaboration with several internal PHC teams will distribute payments for MY2019 by 07/31/20.
HOSPITAL QUALITY
IMPROVEMENT PROGRAM
(HQIP)
The new measures for the 2020-21 Measurement Set will be presented to PAC for approval in June.
The 2020 Hospital Quality Symposium originally scheduled for 08/04/20 (Rohnert Park) and 08/06/20 (Redding), is postponed until August 2021. No 2021 dates have been set at this time.
DATA TOOL UPDATES
PARTNERSHIP QUALITY
DASHBOARD (PQD) EDW has completed the data development work for the 2020 PQD QIP
Dashboards. The data generated is now available for testing and dashboard design by the QI Sr. Data Analyst.
QI DEPARTMENT UPDATE JUNE 2020
PREPARED BY ERIKA ROBINSON & NANCY STEFFEN DIRECTORS, QUALITY AND PERFORMANCE IMPROVEMENT
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The HEDIS Team provided the required reports to EDW and PQD team for completing the HEDIS RY2020 Annual Summary of Performance on 05/12/20.
PQD UAT is slated to take place between 06/01/20 and 06/12/20.
EREPORTS The revised PCP QIP MY2020 measure set was translated into an updated eReports display on 05/15/20. Upon eReports log-in, the homepage now depicts measure performance under both the new Core Measure set and the Monitoring Measures (i.e. those removed from the original Core set). Although points and incentive payments will not accrue under the Monitoring Measures, providers that requested PHC continue displaying the performance data on an ongoing basis through 2020.
PERFORMANCE IMPROVEMENT (PI)
ACTIVITY UPDATE
STATE MANDATED WORK: PERFORMANCE
IMPROVEMENT PROJECT
(PIP) & PLAN-TO-DO-STUDY-ACT (PDSA) CYCLE
A revision of Module 2 of the Health Equity Performance Improvement Project (PIP) was submitted by 05/22/20. Santa Rosa Community Health is our provider partner and the focus is improving the performance of Hispanic members on the Well Child Visits in the First 15 Months of Life (W15) measure. Three interventions have been identified by the provider partner.
While DHCS has waived all mandated PDSA submissions for low performing HEDIS measures in MY2018, the monthly PHC/DHCS CAP calls have continued. In April and May, DHCS sought insight from PHC on the impact COVID-19 has had on our members and providers. The agenda topics have ranged from COVID-19’s impact on PHC measure performance improvement activities, QI practice for depression and mental health, member access to the provider network, and how we are working with our providers to support vulnerable PHC members’ preventive care needs.
Per DHCS notification in late April, PHC will only be held accountable for administrative HEDIS measure performance on MY2019/RY2020. While the PHC HEDIS team works to report the MY2019/RY2020 rates by the end of May, DHCS has agreed to further discuss the implications of low performing HEDIS measures (i.e. below Minimum Performance Level (MPL)) in the June CAP call. DHCS has assured PHC that the safety of our providers, members, and health plan staff take priority as they are considering next steps relative to mandating improvement activities.
ACCELERATED LEARNING On 04/29/20, 26 participants joined the Accelerated Learning webinar session about childhood and adolescent immunizations. Of the 10 evaluation respondents, all rated the webinar as “excellent” or “good.”
The Accelerated Learning webinar about colorectal cancer screening is scheduled for 06/24/20. These are CME/CE approved activities.
HEDIS SCORE
IMPROVEMENT
The QIP/HEDIS Improvement meeting for primary care provider organizations in Lake and Mendocino counties is scheduled for 06/19/20.
The Southeast Regional Quality meeting will be held virtually on 06/04/20. The meeting will cover the revised 2020 PCP QIP measures, telehealth
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ACTIVITY UPDATE
flexibilities and a panel discussion re: contingency actions that primary care organizations have taken due to COVID-19.
The revisions to the goals due to COVID-19 were approved by leadership for the HEDIS Measure Score Improvement team. The team is on track to meet all goals for FY19-20.
PARTNERSHIP IMPROVEMENT
ACADEMY The ABCs of QI will be offered via four webinar sessions on 06/16/20,
06/30/20, 07/07/20 and 07/14/20. This is a pilot limited to 30 registrants per session for provider organizations based in the Southern Region. CE/CME credits are pending approval.
The next post-ABCs of QI webinar in the ongoing series hosted by PHC and the northern consortia is scheduled for 06/09/20. This webinar will focus on Prioritizing Measures for Improvement Work. The purpose of this webinar series is to offer opportunities to recent ABCs of QI attendees for more devoted time to apply quality improvement methodologies and tools in provider settings.
JOINT LEADERSHIP INITIATIVE
(JLI) The third Joint Leadership Initiative meetings are scheduled in June for
Adventist Health, MCHC Clinics, Santa Rosa Community Health and Solano County Family Health Services.
The kick-off meeting with La Clinica de La Raza is scheduled for 06/30/20. Small grants for calendar years 2019 and 2020 have been approved for most
of the Joint Leadership Initiative organizations. Two more grant requests will be reviewed in late May.
At provider request, the 3rd installment of JLI with Fairchild Medical Center was postponed from 05/07/20 to June, with an exact date still to be determined.
OFFERING AND HONORING
CHOICES No update.
OTHER The Health Equity goal team will meet all stated goals and deliverables for FY19-20. Final drafts of the organization-wide health equity recommendations, health equity toolkit and repository of internal resources will be presented at the last goal team meeting in June.
Note: Detailed information and recordings of webinars are posted to the PHC Website:
QUALITY ASSURANCE AND PATIENT SAFETY TEAM (CROSS REGIONAL UPDATE)
ACTIVITY UPDATE
POTENTIAL QUALITY ISSUES
(PQI) FOR THE PERIOD: 04/20/20 – 05/20/20
4 PQI referrals were received from the following referral sources: Grievance and Appeals (3), Utilization Management (1).
12 PQI cases were processed and closed to completion. 2 PQI cases were presented and reviewed at the Peer Review Committee. There are currently 32 open cases between N/S.
Patient Safety team members participated in the TLC4C19 outcall campaign organized by the Population Health Management department. Patient Safety made 373 calls to members.
DHCS started granting temporary Site Review extensions when state-wide shelter-in-place orders were first issued in March. Currently, this extension applies until further notice. In the recently released APL 20-011, DHCS encouraged health plans to develop virtual site review processes and test on a small scale. DHCS has shared they are interested in learning from health plans, as a return to in-person site reviews may be delayed for several weeks, if not months. PHC has developed a virtual site review process for periodic site reviews that are presently due. Three (3) provider sites have agreed to pilot this process with completion of all components expected by early June. PHC will be sharing its observations, conclusions, and recommendations with DHCS as these reviews are completed.
HEALTHCARE EFFECTIVENESS DATA INFORMATION SET (HEDIS)
ACTIVITY UPDATE
HEDIS PHC is in the final stages of closing out our HEDIS Reporting Year 2020, Measurement Year 2019 (01/01/19 – 12/31/19). We received a 100% pass on our Medical Record Review Validation audit on 05/20/20.
We are targeting to release our Annual Summary of Performance Report on 06/15/20.
QUALITY COMPLIANCE AND ACCREDITATION (NCQA)
ACTIVITY UPDATE
NATIONAL COMMITTEE FOR
QUALITY ASSURANCE
(NCQA)
On 03/20/20, NCQA released a COVID-19 Memo applicable to organizations undergoing survey in 2020, recognizing that normal operations have been disrupted in many communities, which could affect organizations’ ability to meet NCQA requirements. In light of the pandemic, NCQA is implementing exceptions for the 03/01/20–09/30/20 timeframe for future surveys, including PHC’s First Survey scheduled on 11/17/20. NCQA will apply exceptions on a case by case basis, based upon each organization’s unique
Region # of FSR conducted
# of MRR conducted
# of FSR CAP issued
# of MRR CAP issued
North 0 0 0 0
South 0 0 0 0
New sites opened this period No site review on new locations done at this time - New OB – 2 - Open Door Women’s Health, Dignity Health Women’s Health
Services Clinic - New PCP – Woodland Clinic
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ACTIVITY UPDATE
situation. Exceptions include flexibility in scoring organizations and ability to remove files for the affected time period indicated above. If an organization cannot meet NCQA requirements because of changes in operations due to COVID-19, a disaster management plan for each affected standard/requirement must be submitted to NCQA during survey. Organizations still need to demonstrate oversight of standards throughout the look-back period. The disaster management plan will provide NCQA with relevant details and prevent organizations from being penalized for their emergency response efforts. NCQA is working on further guidance for the disaster management content and how surveyors will evaluate organizations affected by COVID-19. The NCQA Program Management team monitors updates on a daily basis, tracks changes, and shares up-to-date information with key stakeholders at PHC.
As of 05/12/20, PHC’s overall compliance rate is 95.50% (NCQA-related Department Goal 2, Milestone 2). To achieve 100% compliance, business owners are addressing findings and/or gaps pertaining to NCQA consultant Diane William’s feedback. For requirements which had been deemed compliant in the past, business owners are refreshing their evidence, such as data reports, grand analysis, and material evidence to meet the required First Survey look-back period.
Business owners of file review requirements conducted the third round of mock file reviews with Diane Williams in April, as part of the NCQA-related Department Goal 4. All file reviews received a MET status under NCQA’s formal scoring methodology. Impacted departments also submitted a detailed file review sustainability plan to sustain compliance for PHC’s file review throughout the look-back period (May–November 2020). The purpose of ongoing review is to uncover potential problems that may require corrective action throughout the look-back period.
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Policy/Procedure Number: MCUP3042 (previously UP100342) Lead Department: Health Services
Original Date: 04/14/1999 Next Review Date: 08/14/202008/12/2021 Last Review Date: 08/14/201908/12/2020
Applies to: ☒ Medi-Cal ☐ Employees
Page 2 of 5
A. Review of New Medical Technology Form
V. PURPOSE: To define the process utilized by Partnership HealthPlan of California (PHC) to evaluate new technologies/investigational services and interventions including medical and behavioral health procedures, pharmaceuticals and devices as well as changes in the application of existing technologies or adding new benefits for members.
VI. POLICY / PROCEDURE:
A. Investigational Interventions: 1. Department of Health Care Services (DHCS) policy [Title 22, California Code of Regulations
(CCR) Section 51303] for approval of investigational services (interventions) states that all six of the following criteria must be fully met: a. Conventional therapy will not adequately treat the intended patient’s condition. b. Conventional therapy will not prevent progressive disability or premature death. c. The provider of the proposed service has a record of safety and success with the investigational
service that is equivalent or superior to that of other providers. d. The investigational service is the lowest cost item or service that meets the patient’s medical
needs and is less costly than all conventional alternatives. e. The service is not being performed as part of research study protocol. f. There is a reasonable expectation that the investigational service will significantly prolong the
intended patient’s life and will maintain or restore a range of physical and social function suited to the activities of daily living.
2. Investigational interventions will not be authorized in the inpatient setting if there is no indication for acute care treatment.
2.3. After collection of all materials necessary to evaluate whether these criteria are met, the Chief Medical Officer (CMO) or Physician Designee will review the request. If all criteria are judged to be met, the investigational service will be approved.
4. If criteria are not met, the case may be sent for independent medical review by a relevant specialist in the area of the intervention. If, in the opinion of the specialist, criteria have been met, the procedure will be approved.
3.5. B. Coverage for Cancer Clinical Trials follows Department of Health Care Services (DHCS) Policy
Statement 2001 06, which states that PHC covers routine patient care costs for eligible members who are in any one of the four clinical trial phases as long as the following are met: 1. The treating physician recommends participation in the trial 2. Participation in the trial MUST have meaningful potential to benefit the member 3. The trial must NOT exclusively be to test toxicity, but must have a therapeutic intent 4. Trial wWill NOT occur in the inpatient setting if there is no indication for acute care treatment 5. Trials that qualify for approval include:
a. Those involving a drug exempt under federal regulation from a new drug application. b. Those approved by the National Institute of Health and The Food and Drug Administration in
the form of an investigational new drug application, the United States Department of Defense, or The United States Veterans Health Administration.
C. New technologies physician request and authorization process 1. Case-by-case review: If PHC receives a physician’s request to provide benefits of a new intervention
for a specific member the process is as follows: a. A Treatment Authorization Request (TAR) must be submitted to PHC describing the
intervention and containing medical justification for its use. Pertinent patient medical records
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lblacks
Text Box
Excerpt
Policy/Procedure Number: MCUP3042 (previously UP100342) Lead Department: Health Services
Original Date: 04/14/1999 Next Review Date: 08/14/202008/12/2021 Last Review Date: 08/14/201908/12/2020
Applies to: ☒ Medi-Cal ☐ Employees
Page 3 of 5
must be included. b. The CMO or physician designee will ask the provider for background information including
copies of clinical studies regarding the intervention. PHC staff will perform a literature search for peer reviewed studies or recommendations from professional societies regarding the use, efficacy, and safety of the proposed service. In addition, PHC will consider determinations of regulatory authorities (e.g. Centers for Medicare and Medicaid Services [CMS] or US Food and Drug Administration [FDA]) concerning the intervention.
c. The CMO or physician designee may request input from a relevant specialist prior to presenting the request to the various committees such as the Pharmacy and Therapeutics (P&T) Committee or Physician Advisory Committee (PAC). This specialist must have expertise in the technology under review.
d. All behavioral health technologies will include input from an appropriate behavioral health specialist.
e. When clinically indicated, a case may be sent for external review to a contracted independent medical review organization. (See policy MCUG3138 External Independent Medical Review.)
f. Based on input from the Utilization Management Department, P&T Committee, PAC or relevant specialist, the CMO or Physician Designee renders a determination.
g. All records concerning the review are retained by PHC’s Health Services department. h. Determination criteria used by the relevant specialist(s), P&T Committee, PAC, and the CMO
or Physician Designee must include all six criteria specified in VI.A.1. a. – f. above when reviewers will includeconsider the following: 1) Sufficient objective information regarding the safety, efficacy, and indications for the
intervention which support its use. 2) The proposed intervention is likely to lead to a better outcome than conventional
interventions currently available. 3) The provider has a record of safety and success with the proposed service which is
equivalent or superior to that of other providers of the intervention. 4) The practitioner proposing to provide the intervention is willing to accept the payment rate
offered by PHC. 5) The intervention is not provided as part of a funded research study protocol.
i. Evaluations of new and existing medications are managed by the process described in the Pharmacy and Therapeutics (P&T) Committee policy MPRP4001.
D. Addition of a new benefit: 1. A request to add a new PHC benefit may be submitted by a provider, member or PHC staff. In such
instance the following steps occur: a. The request is sent to the CMO or Physician Designee, which includes a statement explaining
why the requested service should be added as a PHC benefit, identification of the PHC member to benefit from the service and all pertinent supporting clinical information. The Senior Director of Health Services will also review the request and offer feedback.
b. PHC will perform a literature search regarding the use, efficacy and safety of the intervention and may also use the services of an external technology assessment organization such as ECRI Institute or others. As needed, materials collected relating to the request may be forwarded by the CMO or Physician Designee to an appropriate relevant specialist (or to an ad hoc physician committee) to review the material and to advise PHC regarding the use of the new technology. The reviewer or review committee is asked to recommend whether the intervention be added as a PHC benefit and to delineate criteria used to evaluate the use of the new technology. The CMO may also opt to bring the proposal to the Quality/Utilization Advisory Committee (QUAC) or PAC for feedback on the proposal.
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Policy/Procedure Number: MCUP3042 (previously UP100342) Lead Department: Health Services
Original Date: 04/14/1999 Next Review Date: 08/14/202008/12/2021 Last Review Date: 08/14/201908/12/2020
Applies to: ☒ Medi-Cal ☐ Employees
Page 4 of 5
c. Recommendations from the relevant specialist or ad hoc physician committee regarding medical criteria are reviewed by the Internal Quality Improvement Committee (IQI) and a recommendation is formulated. IQI recommendations are forwarded to the Quality/Utilization Advisory Committee (Q/UAC) for preliminary approval, the PAC, and the Finance Committee, if necessary, for their consideration. Significant benefit changes will be forwarded to the PHC Commission for their review and final determination.
d. PHC also has an operational workgroup for review of potential new benefits called the Benefit Review and Evaluation Workgroup (BREW). BREW is comprised of the Chief Medical Officer, the Senior Director of Health Services, the Chief Operating Officer and representatives from these departments: Regulatory Affairs, Provider Relations, Member Services, Finance, Claims, and Information Technology. BREW investigates and considers the medical, financial and operational issues surrounding proposed benefit changes. BREW findings are summarized and presented to the PHC Executive Committee which will determine next steps. All medical criteria changes follow the process described in VI.D.1.c above. The Executive Committee may refer a recommendation to the Board (PHC Commission) for addition of a new benefit class. The Executive Committee may also request input from the Pphysician Aadvisory Ccommittee (PAC) prior to rendering a decision. The Executive Committee may approve coverage of single CPT codes (“minor changes”) that it deems are within the general scope of medical services generally covered by PHC. The Executive Committee will also determine operational changes required such as IT and claims configuration and/or financial considerations such as recommending Medi-Cal coverage of new technologies to the California Department of Health Care Services.
2. Notification of New Benefit Addition: Once approved by the PAC and the PHC Commission (as applicable), information regarding the new benefit may be disseminated as necessary in the following manner: a. Primary Care Providers (PCPs) and relevant specialists are notified electronically by “Important
Provider Notice.” b. Internal notification is sent to PHC department leadership so that policies and procedures may
be created and information gathered to inform utilization management determinations, benefit interpretations, care coordination decisions, and the design of health educational materials.
c. PHC Members are notified of benefit additions via the Member Newsletter, updates to the Member Handbook and the PHC website.
VII. REFERENCES:
A. Title 22, California Code of Regulations (CCR) Section 51303 B. Operating Instruction Letter (OIL) 026-02 conveying DHCS Policy Statement 2001 06 C. National Committee for Quality Assurance (NCQA) Guidelines (Effective July 1, 20192020) UM 10
Evaluation of New Technology Elements A & B VIII. DISTRIBUTION:
A. PHC Department Directors B. PHC Provider Manual C. Health Services Department Heads and Staff
IX. POSITION RESPONSIBLE FOR IMPLEMENTING PROCEDURE: Senior Director, Health Services
Background: Kaiser Foundation Health Plan (KFHP) serves as both a Department of Health Care Services (DHCS) subcontractor and an National Committee for Quality Assurance (NCQA) delegate, meaning PHC has given them the authority to perform administrative responsibilities on our behalf. As such, PHC must conduct oversight, including an annual audit, to ensure compliance with regulatory and accreditation requirements, contractual obligations, and performance standards. In support of conducting a comprehensive audit, PHC collaborates with other KFHP contracted Medi‐Cal managed care plans to conduct a joint audit.
For the review period of July 1, 2018 – June 31, 2019, PHC conducted a joint audit with five plans partners; Alameda Alliance for Health (AAH), San Francisco Health Plan (SFHP), Santa Clara Family Health Plan (SCFHP), Health Plan of San Mateo (HPSM), and Health Plan of San Joaquin (HPSJ). Plans shared the responsibility of program review which includes evaluation of KFHP policies and procedures, training materials, and guides. In addition, each plan performs a review of files and reports specific to their plan’s membership. On or before January 8, 2020, plan findings for both program and file review were submitted to KFHP for their review and response.
Summary of Findings: Please note, “zero” deficiencies requiring a corrective action plan (CAP) does not mean that the plan had zero observations. Instead, it means that any deficiencies identified were able to be resolved with supplemental explanation/documentation and did not necessitate a formal CAP.
Program Review: While PHC and audit plan partners share responsibility for review and redress of cited deficiencies related to KFHP program materials, PHC retains ultimate responsibility for KFHP compliance with requirements. As such, PHC subject matter experts (SMEs) who are the authority for and responsible party of a specific program, area, or delegated function, have reviewed and accepted completed program review audit tools and, as applicable, corrective action plans.
Program/Delegated Function Reviewed
Lead Plan # Deficiencies Requiring Corrective Action Plan
Status of CAP
Grievances and Appeals AAH 1 Open (projected close date TBD) Claims/Provider Dispute Resolution AAH 0 N/A Network Management SCFHP 1 Open (projected closure Q2 2020) Compliance SCFHP 1 Closed Member Connections SCFHP 1 Closed Credentialing SFHP 1 Open (projected closure May 2020) New Provider Training SFHP 4 1 of 4 closed (3 projected closure May
2020) Transportation SFHP 0 N/A Health Education/Cultural and Linguistics
HPSM 0 N/A
Population Health Management HPSM 4 4 Open (projected closure for all in November 2020)
File Review: Audit plan partners do not share responsibility for file review. This area of review is specific to each plan’s membership, and in compliance with HIPAA, all plans independently conduct review of files, cases, and reports. Cited file review deficiencies of all delegated functions reviewed through annual audit are reflective of evaluations conducted solely by PHC SMEs through their use of the 8/30 methodology as appropriate.
Program/Delegated Function Reviewed # Deficiencies Requiring Corrective Action Plan
Status of CAPs
Complex Case Management 0 N/A Utilization Management 0 N/A Grievances and Appeals 1 Closed Claims and Provider Dispute Resolution 0 N/A Potential Quality Incidents (PQI) 0 NA NEMT/NMT 2 ClosedMental health 0 N/A Behavioral health 0 N/A
Next Steps: PHC, with plan partners as applicable, will monitor KFHP’s implementation of accepted corrective action plans (CAPs). PHC and plan partners will only close KFHP CAPs upon satisfactory demonstration of full compliance with CAP including mitigation of reoccurrence and full understanding of requirements.
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RMoore
Reviewed
RMoore
Approved
2019 Medi-Cal Audit Delegate: Kaiser Foundation Health Plan
Summary of Findings and Corrective Action Plan (CAP) Form
Page 1 of 11
Thank you for your time and collaboration during the 2019 Joint Medi-Cal Health Plans annual audit. In conducting this audit, Health Plan partners evaluated Kaiser’s compliance with delegated responsibilities established in the provider agreement. Below you will find the Health Plan’s Preliminary Audit Report. The findings in this report reflect the evaluation of all relevant information received prior to, and during the November 12 and 13, 2019 onsite audit.
Audit Conducted By (select one of the following):
☒ Alameda Alliance for Health (AAH)
☐ Health Plan of San Mateo (HPSM)
☐ Health Plan of San Joaquin (HPSJ)
☐ Partnership HealthPlan of California (PHC)
☐ San Francisco Health Plan (SFHP)
☐ Santa Clara Family Health Plan (SCFHP)
Auditor(s) / Health Plan Conducting the Audit:
Name Title E-mail
Jennifer Karmelich Alameda Alliance Director, Quality Assurance
2019 Medi-Cal Audit Delegate: Kaiser Foundation Health Plan
Summary of Findings and Corrective Action Plan (CAP) Form
Page 6 of 11
PLAN PARTNER’s CAP EVALUATION
CAP STATUS COMMENTS
☐ Approved ☐ Partially Approved ☒ Not approved
05/11/2020 Not Approve Finding #1 for GA-001: Grievance System Description:
The Plan recommends that Kaiser state in their policy that they process verbal appeals regardless of whether or not they are followed by a written appeal. See following example from AAH policy: “Appeals may be received either orally or in writing. The Alliance will make a reasonable effort to acquire the written consent from the member when a provider files on behalf of the member; however, will not delay processing of the appeal if not obtained.”
The regulation cited, Title 42 Subpart F 438.404 ( c )(3), is with regard to expedited authorization decisions, not appeals. The finding stands, the policy and procedure needs to be updated to exclude a 14 day extension for expedited complaints.
Not Approve Finding #2 for Element A: Policies and Procedures for Complaints and Appeals
The response confirms that the resolution letter includes member’s rights to obtain an external appeal, this finding is not with regard to an external appeal. In accordance with NCQA RR 2, Element A, Factor 3, the resolution letters must include the right to appeal the complaint decisions. This is an appeal provided to the member whom do not agree with an UM Appeal determination. The appeal is directed to the complaint decision which would be processed by the Plan and is not an external appeal process.
Factor 3: Notification of resolution and appeal rights Members have the right to appeal an adverse decision. If the organization makes an adverse decision, it notifies members of
the decision and of their right to appeal.
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2019 Medi-Cal Audit Delegate: Kaiser Foundation Health Plan
Summary of Findings and Corrective Action Plan (CAP) Form
Page 7 of 11
CATEGORY Grievance and Appeals File Review
FINDING CITATION RECOMMENDATION
STANDARD APPEALS:
1) 1 of the 2 Standard Appeal cases did not include a reference to the criteria used in the resolution letter
2) 1 of the 2 Standard Appeal cases did not include notification of the member’s right to obtain a free copy of the benefit provision
3) 1 of the 2 Standard Appeal cases did not indicate that a physician was involved in the case review.
STANDARD GRIEVANCES:
1) 2 out of the 28 cases did not have the correct receive date.
2) 3 out of the 28 cases did not address all grievance issues on the Resolution Letter
3) 2 out of the 28 cases did not include the non-discrimination notice on the Resolution Letter.
1) NCQA UM 9, Element D, Factor 2
2) NCQA UM 9, Element D, Factor 3 & 4
3) NCQA UM 9, Element D, Factor 5
1) CA Health and Safety Code 1368(a)(4)(A)
2) 28 CCR 1300.68(a)(4)
3) APL 17-011 Title 45, CFR, Section 92.8
Plan recommends Kaiser review their Appeals and Grievance policies and procedures to address the deficiencies and retrain staff to review Resolution letters for compliance .
CORRECTIVE ACTION PLAN (CAP)
Implementation Date (Anticipated or
completed)
Action Taken (Please include name of supporting documentation, if any are included with the response)
3/19/2020
STANDARD APPEALS:
1) 1 of the 2 Standard Appeal cases did not include a reference to the criteria used in the resolution letter
KP Response: The Plan respectfully disagrees as the member's appeal for a heavy duty hospital bed was approved so reference to the applicable criteria was unnecessary.
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2019 Medi‐Cal Audit Delegate: Kaiser Foundation Health Plan
Summary of Findings and Corrective Action Plan (CAP) Form
Page 1 of 9
Thank you for your time and collaboration during the 2019 Joint Medi‐Cal Health Plans annual audit. In conducting this audit, Health Plan partners evaluated Kaiser’s compliance with delegated responsibilities established in the provider agreement. Below you will find the Health Plan’s Preliminary Audit Report. The findings in this report reflect the evaluation of all relevant information received prior to, and during the November 12 and 13, 2019 onsite audit.
Audit Conducted By (select one of the following):
☐ Alameda Alliance for Health (AAH)
☐ Health Plan of San Mateo (HPSM)
☐ Health Plan of San Joaquin (HPSJ)
☐ Partnership HealthPlan of California (PHC)
☐ San Francisco Health Plan (SFHP)
☒ Santa Clara Family Health Plan (SCFHP)
Auditor(s) / Health Plan Conducting the Audit:
Name Title E‐mail
Angela McArthur Manager, Provider Database and Reporting
Onsite Visit: N/A Review Period: 07/01/2018 to 06/30/2019
Area of Review: Network Management Policies and Procedures Review
Audit Score: 100%
CAP Required (Y/N): Y CAP Due Date: 2/3/2020 CAP Submission Date:
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2019 Medi‐Cal Audit Delegate: Kaiser Foundation Health Plan
Summary of Findings and Corrective Action Plan (CAP) Form
Page 8 of 9
☐ Partially Approved ☐ Not approved
CATEGORY NCQA NET 5 ‐ Element A: Notification of Termination – Factor 1
FINDING CITATION RECOMMENDATION
Deficiency 4 1. Policies and procedures indicate that the organization notifies members affected by the termination of a practitioner or practice group in general, family or internal medicine or pediatrics, at least 30 calendar days prior to the effective termination date, and helps them select a new practitioner. Finding: Kaiser’s Completion of Covered Services Policy and Procedure did not state that the member's would be notified 30‐days prior to the effective termination date. No other documents were identified with this information.
NCQA NET 5A Kaiser’s Completion of Covered Services Policy and Procedure does state
Provide the organization’s policy that covers this requirement.
CORRECTIVE ACTION PLAN (CAP)
Implementation Date (Anticipated or completed)
Action Taken (Please include name of supporting documentation, if any are included with the response)
Q2 2020
The main body of the Completion of Covered Services policy (which goes along with Attachment B – Medi-Cal Continuity of Care Requirements) addresses the 30 day notice requirement under section IV Procedure, Notice to Current Enrollees, B3 reads as follows, “At least 30 days’ notice to current enrollees receiving covered services from a specialty Plan Provider (either individual or practitioner group) upon termination of the specialty care Plan Provider’s employment or contract with Health Plan or with a Plan Provider practitioner group”. We have submitted this report previously to NCQA for this standard. However, Kaiser has recently realized that more robust language is required
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2019 Medi‐Cal Audit Delegate: Kaiser Foundation Health Plan
Summary of Findings and Corrective Action Plan (CAP) Form
Page 9 of 9
pertaining to the requirements for notifying members of provider terminations and suspensions. For this reason, we are currently drafting the attached policy in accordance with the requirements of APL 16-001, Medi-Cal Provider and Subcontract Suspensions, Terminations, and Decertifications (refer to policy sections 6.2.2 and 6.3.4.1). Once the policy is fully vetted by our internal stakeholders, finalized and approved by our oversight committee, we will send a copy to the Plan Partners. We anticipate this to be in Q2 2020. APL 16-001 “DRAFT” Policy
DRAFT POLICY Medi-Cal Provider Ter
PLAN PARTNER’s CAP EVALUATION
CAP STATUS COMMENTS
☒ Approved ☐ Partially Approved ☐ Not approved
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2019 Medi-Cal Audit Delegate: Kaiser Foundation Health Plan
Summary of Findings and Corrective Action Plan (CAP) Form
Page 1 of 6
Thank you for your time and collaboration during the 2019 Joint Medi-Cal Health Plans annual audit. In conducting this audit, Health Plan partners evaluated Kaiser’s compliance with delegated responsibilities established in the provider agreement.
Below you will find the Health Plan’s Preliminary Audit Report. The findings in this report reflect the evaluation of all relevant information received prior to, and during the November 12 and 13, 2019 onsite audit.
Audit Conducted By (select one of the following):
☐ Alameda Alliance for Health (AAH)☐ Health Plan of San Mateo (HPSM)☐ Health Plan of San Joaquin (HPSJ)
☐ Partnership HealthPlan of California (PHC)☐ San Francisco Health Plan (SFHP)☒ Santa Clara Family Health Plan (SCFHP)
2019 Medi-Cal Audit Delegate: Kaiser Foundation Health Plan
Summary of Findings and Corrective Action Plan (CAP) Form
Page 3 of 6
CATEGORY Privacy and Confidentiality Element A: Privacy Policies – Factor 7
FINDING CITATION RECOMMENDATION Deficiency 1 Factor 7: Delegate reports breaches of confidentiality to Medi-Cal Managed Care Plans within 24 hours of discovery. Finding: Policy does not specify that Health Plans are to be notified of breaches of confidentiality within 24 hours of discovery. Notifications Regarding Breaches of Protected Health Information - NCAL-PRIV SEC-025 states "in addition to reference b.iii above, Medi-Cal Plan Partner notifications will consist of an e-mail to the affected Plan Partner(s) by KP Regional CMSSP designee. For additional reporting information see Appendix A." However, no timeframe of notification is included and Appendix A has been since retired.
MMCD All Plan Letter 06001 MMCD All Plan Letter 06005
Recommend Kaiser amend its policy NCAL-PRIV SEC-025 to address the timeframe of notification.
CORRECTIVE ACTION PLAN (CAP)
Implementation Date (Anticipated or
completed)
Action Taken (Please include name of supporting documentation, if any are included with the response)
02/03/2020
The NCAL -PRIV-025, policy has been updated in Section 5.3.2 KP Customer, 5.3.2.1 Government Agency Customers, under National/Regional Regulatory Administrator (CMS contact, State Agency contact) Section 1, c, i, to indicate that, “The Medi-Cal Plan Partner will be notified within 24 hours of discovery.
PLAN PARTNER’s CAP EVALUATION CAP STATUS COMMENTS
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2019 Medi-Cal Audit Delegate: Kaiser Foundation Health Plan
Summary of Findings and Corrective Action Plan (CAP) Form
Page 4 of 6
☒ Approved ☐ Partially Approved ☐ Not approved
CAP Approved by Santa Clara Family Health Plan
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2019 Medi-Cal Audit Delegate: Kaiser Foundation Health Plan
Summary of Findings and Corrective Action Plan (CAP) Form
Page 1 of 11
Thank you for your time and collaboration during the 2019 Joint Medi-Cal Health Plans annual audit. In conducting this audit, Health Plan partners evaluated Kaiser’s compliance with delegated responsibilities established in the provider agreement. Below you will find the Health Plan’s Preliminary Audit Report. The findings in this report reflect the evaluation of all relevant information received prior to, and during the November 12 and 13, 2019 onsite audit.
Audit Conducted By (select one of the following):
☐ Alameda Alliance for Health (AAH) ☐ Health Plan of San Mateo (HPSM) ☐ Health Plan of San Joaquin (HPSJ)
☐ Partnership HealthPlan of California (PHC) ☐ San Francisco Health Plan (SFHP) ☒ Santa Clara Family Health Plan (SCFHP)
2019 Medi-Cal Audit Delegate: Kaiser Foundation Health Plan
Summary of Findings and Corrective Action Plan (CAP) Form
Page 8 of 11
CATEGORY MEM 3: Personalized Information on Health Plan Services Element C: Quality and Accuracy of Information – Factor 4
FINDING CITATION RECOMMENDATION Deficiency 5 Factor 4: If deficiencies were identified, did the organization act to correct and/or improve them?
Finding: Web: Several opportunities and recommendations were identified, but no evidence of actions taken were provided.
MEM 3 - Element C - Factor 4 Provide evidence of actions taken, based on opportunities and recommendations identified.
CORRECTIVE ACTION PLAN (CAP)
Implementation Date (Anticipated or
completed)
Action Taken (Please include name of supporting documentation, if any are included with the response)
2/27/2020 and 3/13/2020
Kaiser’s Response - 5/4/2020 Upon another, and more careful review, the 2018 Usability Study specifically identified requesting an ID card and finding a PCP as opportunities pertaining to MEM 3C.
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2019 Medi-Cal Audit Delegate: Kaiser Foundation Health Plan
Summary of Findings and Corrective Action Plan (CAP) Form
Page 9 of 11
Attached, please note improved search results when members searched for an ID card or replacement. The improved search action allows ID cards to be the first result. This is directly correlated to the observations on page 8 of the aforementioned study. Kaiser respectfully requests reconsideration of SCFHP’s CAP status as not approved. There were no identified issues with determining how and when to obtain referrals and authorizations or determining benefit and financial responsibility, so no additional follow-up was conducted for those activities. Attachment: Refer to MEM 3C document
MEM 3C Supporting Evidence.pdf
KP RESPONSE (4/21/2020): In the MEM 3 (C) Web document previously submitted during the audit, NCQA accepted the “Recommendations” found on PDF page 26 in the 2018 Usability Report, as meeting the requirements for Factor 4. However, we have subsequently been able to determine that corrective actions were taken and implemented and will provide this information to SCFHP by Friday, March 13, 2020 Supporting Documentation: • MEM 3C Web • MEM 3B and 3C Phone KP RESPONSE on 3/13/2020 : Upon further review, it’s determined that KP cannot provide the documents noted by March 13, information on specific actions taken based on Recommendations in the MEM 3 C (4) Web, 2018 Usability Report. The “Recommendations” in the 2018 Usability Report were not mandatorily required for implementation and therefore the Deficiency 5 cited for MEM 3 C (4) is not warranted.
PLAN PARTNER’s CAP EVALUATION CAP STATUS COMMENTS ☒ Approved ☐ Partially Approved
SCFHP Response on 5/5/2020: SCFHP reconized the improvement in the search results for ID card or replacement. SCFHP accepted Kaiser’s evidence of actions as presented. No further action is required.
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2019 Medi‐Cal Audit Delegate: Kaiser Foundation Health Plan
Summary of Findings and Corrective Action Plan (CAP) Form
Page 1 of 8
Thank you for your time and collaboration during the 2019 Joint Medi‐Cal Health Plans annual audit. In conducting this audit, Health Plan partners evaluated Kaiser’s compliance with delegated responsibilities established in the provider agreement. Below you will find the Health Plan’s Preliminary Audit Report. The findings in this report reflect the evaluation of all relevant information received prior to, and during the November 12 and 13, 2019 onsite audit.
Audit Conducted By (select one of the following):
☐ Alameda Alliance for Health (AAH) ☐ Health Plan of San Mateo (HPSM) ☐ Health Plan of San Joaquin (HPSJ)
☐ Partnership HealthPlan of California (PHC) ☒ San Francisco Health Plan (SFHP)
Onsite Visit: November 12, 2019 Review Period: 7/1/2018‐6/31/2019
Area of Review: Credentialing –
Policies and Procedures
File Review
Audit Score: 90%
CAP Required (Y/N): Y CAP Due Date: 2/3/2020 CAP Submission Date:
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2019 Medi‐Cal Audit Delegate: Kaiser Foundation Health Plan
Summary of Findings and Corrective Action Plan (CAP) Form
Page 3 of 8
CATEGORY Policies and Procedures
FINDING #01 CITATION RECOMMENDATION
Policies and procedures did not specify a process for reporting practitioner suspension or termination to contracted health plans.
R3 Grid Executed May 31, 2018; CR 5: Ongoing Monitoring and Interventions, D. The Contractor must notify Plan immediately when practitioners are identified on any sanctions or reports for removal from the network.
1. Develop policies and procedures to include a process for reporting practitioner suspension or termination to contracted health plans.
CORRECTIVE ACTION PLAN (CAP)
Implementation Date (Anticipated or completed)
Action Taken (Please include name of supporting documentation, if any are included with the response)
May 2020
Kaiser will address this finding by inserting language to our existing delegation oversight policy which states we will share suspension and terminations with entities that delegate credentialing to Kaiser Permanente. Therefore, the process will include reporting practitioner suspension and terminations to the contracted Medi-Cal Plans. Policies are updated on an annual basis with committee approval occurring in April or May each year. We will send a copy of the policy to the Plan Partner once the policy is approved for distribution.
PLAN PARTNER’s CAP EVALUATION
CAP STATUS COMMENTS
☐ Approved ☒ Partially Approved ☐ Not approved
Catherine Hayward 04/08/2020 – Plan approved. CAP will be closed when new policy language has been reviewed and approved.
117 of 290
2019 Medi-Cal Audit Delegate: Kaiser Foundation Health Plan
Summary of Findings and Corrective Action Plan (CAP) Form
Page 1 of 8
Thank you for your time and collaboration during the 2019 Joint Medi-Cal Health Plans annual audit. In conducting this audit, Health Plan partners evaluated Kaiser’s compliance with delegated responsibilities established in the provider agreement. Below you will find the Health Plan’s Preliminary Audit Report. The findings in this report reflect the evaluation of all relevant information received prior to, and during the November 12 and 13, 2019 onsite audit.
Audit Conducted By (select one of the following):
☐ Alameda Alliance for Health (AAH) ☐ Health Plan of San Mateo (HPSM) ☐ Health Plan of San Joaquin (HPSJ)
☐ Partnership HealthPlan of California (PHC) ☒ San Francisco Health Plan (SFHP) ☐ Santa Clara Family Health Plan (SCFHP)
2019 Medi-Cal Audit Delegate: Kaiser Foundation Health Plan
Summary of Findings and Corrective Action Plan (CAP) Form
Page 3 of 8
CATEGORY Policies and Procedures
FINDING #01 CITATION RECOMMENDATION The Medi-Cal Provider Training Attestation Form Guideline specifies that training is completed no later than 10 days of hire date. The requirement per DHCS states "Contractor shall conduct training for all new providers within ten (10) working days after the Contractor places a newly contracted provider on active status". It is unclear if hire date and active status are the same. REPEAT FINDING
DHCS Contract Exhibit A, Attachment 7 PROVIDER RELATIONS 5. Provider Training A. Contractor shall conduct training for all providers within ten (10) working days after the Contractor places a newly contracted provider on active status.
1. Revise Medi-Cal Provider Training Attestation Form Guideline to include a definition for "hire date" or explain that it is synonymous with "active status". Refer to recommendation and CAP from 2018 Audit.
CORRECTIVE ACTION PLAN (CAP)
Implementation Date (Anticipated or
completed)
Action Taken (Please include name of supporting documentation, if any are included with the response)
March 2020
The Medi-Cal Provider Training Attestation Form Guideline will be updated to clarify that, for purposes of provider training, “hire date” is synonymous with “active status.”
PLAN PARTNER’s CAP EVALUATION CAP STATUS COMMENTS ☒ Approved ☐ Partially Approved ☐ Not approved
Catherine Hayward 04/08/2020 – Please submit the revised Medi-Cal Provider Training Attestation Form Guideline. Once the document has been received and approved, the CAP will be closed. Catherine Hayward 04/17/2020 – Reivewed the revised Medi-Cal Provider Training Attestation Form Guideline. New version is approved and this CAP is closed.
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2019 Medi-Cal Audit Delegate: Kaiser Foundation Health Plan
Summary of Findings and Corrective Action Plan (CAP) Form
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CATEGORY Medi-Cal Managed Care Program and Benefits Training Content
FINDING #02 CITATION RECOMMENDATION Information about the following Medi-Cal services are in the 2019 TPMG Annual Provider Letter-sent Dec 2018, however it is not included in the TPMG Provider Training given to new providers. Provider training on Medi-Cal services must be done no later than 10 days after active status or no more than 6 months prior to active status. • Medi-Cal medical benefits • Medi-Cal mental health benefits • Medi-Cal vision benefits • The organization’s referral process, prior
authorization requests, and appeals to UM decisions
DHCS Contract Exhibit A, Attachment 7 PROVIDER RELATIONS 5. Provider Training A. Contractor shall ensure that all providers receive training regarding the Medi-Cal Managed Care program in order to operate in full compliance with the Contract and all applicable Federal and State statutes and regulations. Contractor shall ensure that provider training relates to Medi-Cal Managed Care services, policies, procedures and any modifications to existing services, policies or procedures. Training shall include methods for sharing information between Contractor, provider, Member and/or other healthcare professionals. Contractor shall conduct training for all providers within ten (10) working days after the Contractor places a newly contracted provider on active status.
1. Update TPMG Provider Training to include information about: • Medi-Cal medical benefits • Medi-Cal mental health benefits • Medi-Cal vision benefits • The organization’s referral process, prior
authorization requests, and appeals to UM decisions
CORRECTIVE ACTION PLAN (CAP)
Implementation Date (Anticipated or
completed)
Action Taken (Please include name of supporting documentation, if any are included with the response)
May 29, 2020
Kaiser will update the Medi-Cal training content for new physician providers to contain all required training elements (e.g. mental health benefits, vision benefits, referral process, Regional Centers, Early Start Program, Women, Infants, and Children (WIC) Program, Medi-Cal Waiver Programs, Local Education Agencies, California Children Services (CCS), etc.) as stipulated by the contract. Following stakeholder review, approval and system testing, the revised training material will be deployed to newly contracted physician providers in May 2020.
PLAN PARTNER’s CAP EVALUATION CAP STATUS COMMENTS ☐ Approved Catherine Hayward 04/08/2020 – Plan to resolve the finding is approved. The CAP will be closed once the new training materials
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2019 Medi-Cal Audit Delegate: Kaiser Foundation Health Plan
Summary of Findings and Corrective Action Plan (CAP) Form
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☒ Partially Approved ☐ Not approved
have been received and approved.
CATEGORY Medi-Cal Managed Care Program and Benefits Training Content
FINDING #03 CITATION RECOMMENDATION 2019 TPMG Annual Provider Letter-sent Dec 2018 and TPMG Provider Training are missing some information about Member Rights and Responsibilities from DHCS Contract, Exhibit A, Attachment 13 Member Services (i.e. Minor Consent Services).
DHCS Contract Exhibit A, Attachment 7 PROVIDER RELATIONS 5. Provider Training A. Contractor shall ensure that provider training includes information on all Member rights specified in Exhibit A, Attachment 13, Member Services, including the right to full disclosure of health care information and the right to actively participate in health care decisions. Contractor shall ensure that ongoing training is conducted when deemed necessary by either the Contractor or the State.
1. Update 2019 TPMG Annual Provider Letter-sent Dec 2018 and TPMG Provider Training to include all Member rights specified in DHCS Contract, Exhibit A, Attachment 13, Member Services.
CORRECTIVE ACTION PLAN (CAP)
Implementation Date (Anticipated or
completed)
Action Taken (Please include name of supporting documentation, if any are included with the response)
May 29, 2020
In response to this finding, Kaiser has developed a TPMG Provider Manual. The final draft of the Provider Manual was submitted to DHCS on February 14, 2020. Enclosed with this response, is a copy of the manual (TPMG Medi-Cal Provider Manual). Going forward, the provider manual will be the primary vehicle for informing TPMG practitioners of Medi-Cal specific services. The TPMG provider communication letter will no longer include Medi-Cal specific content. Kaiser will update the Medi-Cal training content for new physician providers to contain all required training elements (e.g. mental health benefits, vision benefits, referral process, Regional Centers, Early Start Program, Women, Infants, and Children (WIC) Program, Medi-Cal Waiver Programs, Local Education Agencies, California Children Services (CCS), etc.) as stipulated by the contract. Following stakeholder review, approval and system testing, the revised training material will be deployed to newly contracted physician providers in May 2020. Attachment: • TPMG Medi-Cal Provider Manual
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2019 Medi-Cal Audit Delegate: Kaiser Foundation Health Plan
Summary of Findings and Corrective Action Plan (CAP) Form
Page 6 of 8
PLAN PARTNER’s CAP EVALUATION CAP STATUS COMMENTS ☐ Approved ☒ Partially Approved ☐ Not approved
Catherine Hayward 04/08/2020 – Documentation provided is approved. CAP will be closed when the process for distributing the provider manual and notifying providers of updates to its content is shared.
CATEGORY Medi-Cal Managed Care Program and Benefits Training Content
FINDING #04 CITATION RECOMMENDATION 2019 TPMG Annual Provider Letter-sent Dec 2018 and TPMG Provider Training do not explain the services offered, who is eligible, or how to refer a member to the following programs: • Regional Centers • Early Start Program • Women, Infants, and Children (WIC) Program • Medi-Cal Waiver Programs • Local Education Agencies • California Children Services (CCS)
DHCS Contract Exhibit A, Attachment 7 PROVIDER RELATIONS 5. Provider Training A. Contractor shall ensure that all providers receive training regarding the Medi-Cal Managed Care program in order to operate in full compliance with the Contract and all applicable Federal and State statutes and regulations. Contractor shall ensure that provider training relates to Medi-Cal Managed Care services, policies, procedures and any modifications to existing services, policies or procedures. Training shall include methods for sharing information between Contractor, provider, Member and/or other healthcare professionals.
1. Update 2019 TPMG Annual Provider Letter-sent Dec 2018 and TPMG Provider Training to include explanation of the services offered, who is eligible, and how to refer members to the following programs: • Regional Centers • Early Start Program • Women, Infants, and Children (WIC)
Program • Medi-Cal Waiver Programs • Local Education Agencies • California Children Services (CCS)
CORRECTIVE ACTION PLAN (CAP)
Implementation Date (Anticipated or
completed)
Action Taken (Please include name of supporting documentation, if any are included with the response)
Anticipated May 2020
In response to this finding, Kaiser has developed a TPMG Provider Manual. The final draft of the Provider Manual was submitted to DHCS on February 14, 2020. Enclosed with this response, is a copy of the manual (TPMG Medi-Cal Provider Manual). Going forward, the Medi-Cal provider manual will be the primary vehicle for informing TPMG practitioners of Medi-Cal specific services.
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2019 Medi-Cal Audit Delegate: Kaiser Foundation Health Plan
Summary of Findings and Corrective Action Plan (CAP) Form
Page 7 of 8
The TPMG provider communication letter will no longer include Medi-Cal specific content.
In addition, Kaiser is updating the TPMG Provider Training to include more robust information about Medi-Cal services, benefits and programs. The updated manual is currently being vetted with internal stakeholders. Following stakeholder review, approval and system testing, the revised training material will be deployed to newly contracted physician providers in May 2020.
Attachment: • TPMG Medi-Cal Provider Manual
PLAN PARTNER’s CAP EVALUATION CAP STATUS COMMENTS ☐ Approved☒ Partially Approved☐ Not approved
Catherine Hayward 04/08/2020 – Documentation provided is approved. CAP will be closed when the process for distributing the provider manual and notifying providers of updates to its content is shared.
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2019 Medi-Cal Audit Delegate: Kaiser Foundation Health Plan
Summary of Findings and Corrective Action Plan (CAP) Form
Page 1 of 15
Thank you for your time and collaboration during the 2019 Joint Medi-Cal Health Plans annual audit. In conducting this audit, Health Plan partners evaluated Kaiser’s compliance with delegated responsibilities established in the provider agreement. Below you will find the Health Plan’s Preliminary Audit Report. The findings in this report reflect the evaluation of all relevant information received prior to, and during the November 12 and 13, 2019 onsite audit.
Audit Conducted By (select one of the following):
☐ Alameda Alliance for Health (AAH) ☒ Health Plan of San Mateo (HPSM) ☐ Health Plan of San Joaquin (HPSJ)
☐ Partnership HealthPlan of California (PHC) ☐ San Francisco Health Plan (SFHP) ☐ Santa Clara Family Health Plan (SCFHP)
2019 Medi-Cal Audit Delegate: Kaiser Foundation Health Plan
Summary of Findings and Corrective Action Plan (CAP) Form
Page 3 of 15
CATEGORY NCQA PHM 2 – Population Health Element A Factor 1 - 7
FINDING CITATION RECOMMENDATION No documentation was provided for the policy review.
NCQA PHM 2, Element A, Factor 1-7
Implement policy and procedure that integrates the following factors in their population health management functions:
• medical and behavioral claims or encounters • pharmacy claims • laboratory results • health appraisal results • electronic health records • health services programs within the
organization • advanced data sources
If a policy or procedure is already in place, please update policy language to include this information.
CORRECTIVE ACTION PLAN (CAP)
Implementation Date (Anticipated or
completed)
Action Taken (Please include name of supporting documentation, if any are included with the response)
Completed
Kaiser’s 2/26/2020 Response to HPSM’s three questions and Root Cause Analysis: Question #1: Can Kaiser explain what the “mock survey” is and how this is relevant to the missing policies?
KPNC response: As part of Kaiser Permanente Northern California (KPNC) NCQA triennial accreditation renewal readiness activities, NCQA mock surveys are conducted on site at KPNC by internal and external consultants. The purpose of this review process is to help ensure to the best extent possible that KPNCs NCQA standards compliance documentation are meeting NCQA requirements. This is relevant to the missing PHM policies because at the time of the Plan Partner oversight audit in November 2019, our PHM compliance policies were still in “draft” status and had not undergone review at our initial mock survey which was scheduled for later in November 2019 following the oversight audit. As a result, and as previously explained to the Plan Partners, the PHM policies could not be released for review during the oversight audit in November.
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2019 Medi-Cal Audit Delegate: Kaiser Foundation Health Plan
Summary of Findings and Corrective Action Plan (CAP) Form
Page 4 of 15
Question #2: Can Kaiser inform us of the frequency of their oversight committee meetings?
KPNC Response: KPNCs Quality Oversight Committee meets on a monthly basis throughout the year.
Question #3: The NCQA standards that we audited them against are from 2018, why did the mock survey not occur and why did these policies not get approved by 2019?
KPNC Response: The PHM standards were not effective until July 1, 2018 under NCQAs newly released 2018 Standards. KPNC had just recently completed our NCQA triennial accreditation renewal submission in March 2018 under NCQAs 2017 standards. Following our renewal submission in March 2018, KPNC required ramp up time to continue development of PHM activities and policies and did so throughout the remainder of 2018 and 2019 so that PHM compliance documentation could be ready for review during our initial mock survey held in November 2019 as previously mentioned.
The year’s 2019 and 2020 are in KPNCs look back period for our next triennial accreditation renewal submission to NCQA. Plans wisely use this time to review and fine tune compliance documentation leading up to their next NCQA accreditation renewal submission. For these reasons, it was not reasonably possible or necessary for KPNC to have full approval of our PHM policies by the beginning of 2019.
Root Cause Analysis
To ensure full remediation of cited deficiencies, understanding of requirements, and prevention of reoccurrence that shall include at minimum:
A. Root cause analysis of the deficiency which may include a description of programmatic or operational failures (policies/procedures, systems, training, etc.);
KPNC Response: A deficiency does not exist. Kaiser did not provide PHM documentation due to the timing of KPNC’s development of the PHM policies and processes and the occurrence of the Plan Partner’s Oversight Audit as explained above.
B. Steps taken or planned to resolve the deficiency;
KPNC Response: Even though as stated above, this is not a deficiency, the PHM program policies are currently being reviewed for compliance with NCQA requirements and Quality Oversight Committee (QOC) approval.
C. Implementation method of corrective action;
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2019 Medi-Cal Audit Delegate: Kaiser Foundation Health Plan
Summary of Findings and Corrective Action Plan (CAP) Form
Page 5 of 15
11/01/2020
KPNC Response: Not applicable
D. Evidence in demonstration of compliance;
KPNC Response: KPNC is providing the attached agenda as evidence that PHM standards documentation was reviewed for compliance during our November 2019 Mock Survey, following the Plan Partner Oversight Audit
E. Actual or anticipated resolution date.
KPNC Response: Issue resolved November 21, 2019.
Documents were not made available during the 2019 audit because they had not gone through mock survey and approval by our oversight committees. The 2019 and 2020 documentation will be made available during the 2020 Plan Partner Audit.
PLAN PARTNER’s CAP EVALUATION CAP STATUS COMMENTS ☒ Approved ☐ Partially Approved ☐ Not approved
2/21/2020-For the Population Health Management CAP on P&P’s Health Plan of San Mateo requires Kaiser to provide more detail in the CAP as the response isn’t sufficient. HPSM has a few questions and would like a revised CAP to reflect the answers provided. Upon review, Kaiser’s response is not sufficient and HPSM would like more information:
1. Can Kaiser explain what the “mock survey” is and how this is relevant to the missing policies? 2. Can Kaiser inform us of the frequency of their oversight committee meetings? 3. The NCQA standards that we audited them against are from 2018, why did the mock survey not occur and why did these
policies not get approved by 2019? To ensure full remediation of cited deficiencies, understanding of requirements, and prevention of reoccurrence that shall include at minimum: A. Root cause analysis of the deficiency which may include a description of programmatic or operational failures (policies/procedures, systems, training, etc.); B. Steps taken or planned to resolve the deficiency;
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2019 Medi-Cal Audit Delegate: Kaiser Foundation Health Plan
Summary of Findings and Corrective Action Plan (CAP) Form
Page 6 of 15
C. Implementation method of corrective action; D. Evidence in demonstration of compliance; and E. Actual or anticipated resolution date. 2/27/2020- Health Plan of San Mateo approves Kaiser’s response. HPSM recommends that Kaiser revisits their documentation production processes so that it aligns with the oversight audit in order give the plans an opportunity to review policies and procedures before the onsite audit. The Plans will reassess in the upcoming annual audit.
CATEGORY NCQA PHM 5 - Complex Case Management Element A Factor 1-4
FINDING CITATION RECOMMENDATION Kaiser was unable to provide any documentation for the policy review.
NCQA PHM 5, Element A, Factor 1 - 4 The plan recommends Kaiser to have sufficient documention for 2020.
CORRECTIVE ACTION PLAN (CAP)
Implementation Date (Anticipated or
completed)
Action Taken (Please include name of supporting documentation, if any are included with the response)
Completed
Kaiser’s 2/26/2020 Response to HPSM’s three questions and Root Cause Analysis: Question #1: Can Kaiser explain what the “mock survey” is and how this is relevant to the missing policies?
KPNC response: As part of Kaiser Permanente Northern California (KPNC) NCQA triennial accreditation renewal readiness activities, NCQA mock surveys are conducted on site at KPNC by internal and external consultants. The purpose of this review process is to help ensure to the best extent possible that KPNCs NCQA standards compliance documentation are meeting NCQA requirements. This is relevant to the missing PHM policies because at the time of the Plan Partner oversight audit in November 2019, our PHM compliance policies were still in “draft” status and had not undergone review at our initial mock survey which was scheduled for later in November 2019 following the oversight audit. As a result, and as previously explained to the Plan Partners, the PHM policies could not be released for review during the oversight audit in November.
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2019 Medi-Cal Audit Delegate: Kaiser Foundation Health Plan
Summary of Findings and Corrective Action Plan (CAP) Form
Page 7 of 15
Question #2: Can Kaiser inform us of the frequency of their oversight committee meetings?
KPNC Response: KPNCs Quality Oversight Committee meets on a monthly basis throughout the year.
Question #3: The NCQA standards that we audited them against are from 2018, why did the mock survey not occur and why did these policies not get approved by 2019?
KPNC Response: The PHM standards were not effective until July 1, 2018 under NCQAs newly released 2018 Standards. KPNC had just recently completed our NCQA triennial accreditation renewal submission in March 2018 under NCQAs 2017 standards. Following our renewal submission in March 2018, KPNC required ramp up time to continue development of PHM activities and policies and did so throughout the remainder of 2018 and 2019 so that PHM compliance documentation could be ready for review during our initial mock survey held in November 2019 as previously mentioned.
The year’s 2019 and 2020 are in KPNCs look back period for our next triennial accreditation renewal submission to NCQA. Plans wisely use this time to review and fine tune compliance documentation leading up to their next NCQA accreditation renewal submission. For these reasons, it was not reasonably possible or necessary for KPNC to have full approval of our PHM policies by the beginning of 2019.
Root Cause Analysis
To ensure full remediation of cited deficiencies, understanding of requirements, and prevention of reoccurrence that shall include at minimum:
F. Root cause analysis of the deficiency which may include a description of programmatic or operational failures (policies/procedures, systems, training, etc.);
KPNC Response: A deficiency does not exist. Kaiser did not provide PHM documentation due to the timing of KPNC’s development of the PHM policies and processes and the occurrence of the Plan Partner’s Oversight Audit as explained above.
G. Steps taken or planned to resolve the deficiency;
KPNC Response: Even though as stated above, this is not a deficiency, the PHM program policies are currently being reviewed for compliance with NCQA requirements and Quality Oversight Committee (QOC) approval.
H. Implementation method of corrective action;
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2019 Medi-Cal Audit Delegate: Kaiser Foundation Health Plan
Summary of Findings and Corrective Action Plan (CAP) Form
Page 8 of 15
11/01/2020
KPNC Response: Not applicable
I. Evidence in demonstration of compliance;
KPNC Response: KPNC is providing the attached agenda as evidence that PHM standards documentation was reviewed for compliance during our November 2019 Mock Survey, following the Plan Partner Oversight Audit
J. Actual or anticipated resolution date.
KPNC Response: Issue resolved November 21, 2019.
Documents were not made available during the 2019 audit because they had not gone through mock survey and approval by our oversight committees. The 2019 and 2020 documentation will be made available during the 2020 Plan Partner Audit.
PLAN PARTNER’s CAP EVALUATION CAP STATUS COMMENTS ☒ Approved ☐ Partially Approved ☐ Not approved
2/21/2020-For the Population Health Management CAP on P&P’s Health Plan of San Mateo requires Kaiser to provide more detail in the CAP as the response isn’t sufficient. HPSM has a few questions and would like a revised CAP to reflect the answers provided. Upon review, Kaiser’s response is not sufficient and HPSM would like more information:
4. Can Kaiser explain what the “mock survey” is and how this is relevant to the missing policies? 5. Can Kaiser inform us of the frequency of their oversight committee meetings? 6. The NCQA standards that we audited them against are from 2018, why did the mock survey not occur and why did these
policies not get approved by 2019? To ensure full remediation of cited deficiencies, understanding of requirements, and prevention of reoccurrence that shall include at minimum: A. Root cause analysis of the deficiency which may include a description of programmatic or operational failures (policies/procedures, systems, training, etc.); B. Steps taken or planned to resolve the deficiency; C. Implementation method of corrective action;
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2019 Medi-Cal Audit Delegate: Kaiser Foundation Health Plan
Summary of Findings and Corrective Action Plan (CAP) Form
Page 9 of 15
D. Evidence in demonstration of compliance; and E. Actual or anticipated resolution date. 2/27/2020- Health Plan of San Mateo approves Kaiser’s response. To prevent future deficiencies when NCQA changes occur, HPSM recommends that Kaiser revisit their documentation production processes so that it aligns with the oversight audit in order give the plans an opportunity to review policies and procedures before the onsite audit. The Plans will reassess in the upcoming annual audit.
CATEGORY NCQA PHM 5 - Complex Case Management Element B Factor 1-3
FINDING CITATION RECOMMENDATION Kaiser was unable to provide any documentation for the policy review.
NCQA PHM 5, Element B, Factor 1 - 3 The plan recommends Kaiser to have sufficient documention for 2020.
CORRECTIVE ACTION PLAN (CAP)
Implementation Date (Anticipated or
completed)
Action Taken (Please include name of supporting documentation, if any are included with the response)
Completed
Kaiser’s 2/26/2020 Response to HPSM’s three questions and Root Cause Analysis: Question #1: Can Kaiser explain what the “mock survey” is and how this is relevant to the missing policies?
KPNC response: As part of Kaiser Permanente Northern California (KPNC) NCQA triennial accreditation renewal readiness activities, NCQA mock surveys are conducted on site at KPNC by internal and external consultants. The purpose of this review process is to help ensure to the best extent possible that KPNCs NCQA standards compliance documentation are meeting NCQA requirements. This is relevant to the missing PHM policies because at the time of the Plan Partner oversight audit in November 2019, our PHM compliance policies were still in “draft” status and had not undergone review at our initial mock survey which was scheduled for later in November 2019 following the oversight audit. As a result, and as previously explained to the Plan Partners, the PHM policies could not be released for review during the oversight audit in November.
131 of 290
2019 Medi-Cal Audit Delegate: Kaiser Foundation Health Plan
Summary of Findings and Corrective Action Plan (CAP) Form
Page 10 of 15
Question #2: Can Kaiser inform us of the frequency of their oversight committee meetings?
KPNC Response: KPNCs Quality Oversight Committee meets on a monthly basis throughout the year.
Question #3: The NCQA standards that we audited them against are from 2018, why did the mock survey not occur and why did these policies not get approved by 2019?
KPNC Response: The PHM standards were not effective until July 1, 2018 under NCQAs newly released 2018 Standards. KPNC had just recently completed our NCQA triennial accreditation renewal submission in March 2018 under NCQAs 2017 standards. Following our renewal submission in March 2018, KPNC required ramp up time to continue development of PHM activities and policies and did so throughout the remainder of 2018 and 2019 so that PHM compliance documentation could be ready for review during our initial mock survey held in November 2019 as previously mentioned.
The year’s 2019 and 2020 are in KPNCs look back period for our next triennial accreditation renewal submission to NCQA. Plans wisely use this time to review and fine tune compliance documentation leading up to their next NCQA accreditation renewal submission. For these reasons, it was not reasonably possible or necessary for KPNC to have full approval of our PHM policies by the beginning of 2019.
Root Cause Analysis
To ensure full remediation of cited deficiencies, understanding of requirements, and prevention of reoccurrence that shall include at minimum:
K. Root cause analysis of the deficiency which may include a description of programmatic or operational failures (policies/procedures, systems, training, etc.);
KPNC Response: A deficiency does not exist. Kaiser did not provide PHM documentation due to the timing of KPNC’s development of the PHM policies and processes and the occurrence of the Plan Partner’s Oversight Audit as explained above.
L. Steps taken or planned to resolve the deficiency;
KPNC Response: Even though as stated above, this is not a deficiency, the PHM program policies are currently being reviewed for compliance with NCQA requirements and Quality Oversight Committee (QOC) approval.
M. Implementation method of corrective action;
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2019 Medi-Cal Audit Delegate: Kaiser Foundation Health Plan
Summary of Findings and Corrective Action Plan (CAP) Form
Page 11 of 15
11/01/2020
KPNC Response: Not applicable
N. Evidence in demonstration of compliance;
KPNC Response: KPNC is providing the attached agenda as evidence that PHM standards documentation was reviewed for compliance during our November 2019 Mock Survey, following the Plan Partner Oversight Audit
O. Actual or anticipated resolution date.
KPNC Response: Issue resolved November 21, 2019.
Documents were not made available during the 2019 audit because they had not gone through mock survey and approval by our oversight committees. The 2019 and 2020 documentation will be made available during the 2020 Plan Partner Audit.
PLAN PARTNER’s CAP EVALUATION CAP STATUS COMMENTS ☒ Approved ☐ Partially Approved ☐ Not approved
2/21/2020-For the Population Health Management CAP on P&P’s Health Plan of San Mateo requires Kaiser to provide more detail in the CAP as the response isn’t sufficient. HPSM has a few questions and would like a revised CAP to reflect the answers provided. Upon review, Kaiser’s response is not sufficient and HPSM would like more information:
7. Can Kaiser explain what the “mock survey” is and how this is relevant to the missing policies? 8. Can Kaiser inform us of the frequency of their oversight committee meetings? 9. The NCQA standards that we audited them against are from 2018, why did the mock survey not occur and why did these
policies not get approved by 2019? To ensure full remediation of cited deficiencies, understanding of requirements, and prevention of reoccurrence that shall include at minimum: A. Root cause analysis of the deficiency which may include a description of programmatic or operational failures (policies/procedures, systems, training, etc.); B. Steps taken or planned to resolve the deficiency; C. Implementation method of corrective action; D. Evidence in demonstration of compliance; and E. Actual or anticipated resolution date.
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2019 Medi-Cal Audit Delegate: Kaiser Foundation Health Plan
Summary of Findings and Corrective Action Plan (CAP) Form
Page 12 of 15
2/27/2020- Health Plan of San Mateo approves Kaiser’s response. To prevent future deficiencies when NCQA changes occur, HPSM recommends that Kaiser revisit their documentation production processes so that it aligns with the oversight audit in order give the plans an opportunity to review policies and procedures before the onsite audit. The Plans will reassess in the upcoming annual audit.
CATEGORY NCQA PHM 5 - Complex Case Management Element C Factor 1-8
FINDING CITATION RECOMMENDATION Kaiser was unable to provide any documentation for the policy review.
NCQA PHM 5, Element C, Factor 1 - 8 The plan recommends Kaiser to have sufficient documention for 2020.
CORRECTIVE ACTION PLAN (CAP)
Implementation Date (Anticipated or
completed)
Action Taken (Please include name of supporting documentation, if any are included with the response)
Completed
Kaiser’s 2/26/2020 Response to HPSM’s three questions and Root Cause Analysis: Question #1: Can Kaiser explain what the “mock survey” is and how this is relevant to the missing policies?
KPNC response: As part of Kaiser Permanente Northern California (KPNC) NCQA triennial accreditation renewal readiness activities, NCQA mock surveys are conducted on site at KPNC by internal and external consultants. The purpose of this review process is to help ensure to the best extent possible that KPNCs NCQA standards compliance documentation are meeting NCQA requirements. This is relevant to the missing PHM policies because at the time of the Plan Partner oversight audit in November 2019, our PHM compliance policies were still in “draft” status and had not undergone review at our initial mock survey which was scheduled for later in November 2019 following the oversight audit. As a result, and as previously explained to the Plan Partners, the PHM policies could not be released for review during the oversight audit in November.
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2019 Medi-Cal Audit Delegate: Kaiser Foundation Health Plan
Summary of Findings and Corrective Action Plan (CAP) Form
Page 13 of 15
Question #2: Can Kaiser inform us of the frequency of their oversight committee meetings?
KPNC Response: KPNCs Quality Oversight Committee meets on a monthly basis throughout the year.
Question #3: The NCQA standards that we audited them against are from 2018, why did the mock survey not occur and why did these policies not get approved by 2019?
KPNC Response: The PHM standards were not effective until July 1, 2018 under NCQAs newly released 2018 Standards. KPNC had just recently completed our NCQA triennial accreditation renewal submission in March 2018 under NCQAs 2017 standards. Following our renewal submission in March 2018, KPNC required ramp up time to continue development of PHM activities and policies and did so throughout the remainder of 2018 and 2019 so that PHM compliance documentation could be ready for review during our initial mock survey held in November 2019 as previously mentioned.
The year’s 2019 and 2020 are in KPNCs look back period for our next triennial accreditation renewal submission to NCQA. Plans wisely use this time to review and fine tune compliance documentation leading up to their next NCQA accreditation renewal submission. For these reasons, it was not reasonably possible or necessary for KPNC to have full approval of our PHM policies by the beginning of 2019.
Root Cause Analysis
To ensure full remediation of cited deficiencies, understanding of requirements, and prevention of reoccurrence that shall include at minimum:
P. Root cause analysis of the deficiency which may include a description of programmatic or operational failures (policies/procedures, systems, training, etc.);
KPNC Response: A deficiency does not exist. Kaiser did not provide PHM documentation due to the timing of KPNC’s development of the PHM policies and processes and the occurrence of the Plan Partner’s Oversight Audit as explained above.
Q. Steps taken or planned to resolve the deficiency;
KPNC Response: Even though as stated above, this is not a deficiency, the PHM program policies are currently being reviewed for compliance with NCQA requirements and Quality Oversight Committee (QOC) approval.
R. Implementation method of corrective action;
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2019 Medi-Cal Audit Delegate: Kaiser Foundation Health Plan
Summary of Findings and Corrective Action Plan (CAP) Form
Page 14 of 15
11/01/2020
KPNC Response: Not applicable
S. Evidence in demonstration of compliance;
KPNC Response: KPNC is providing the attached agenda as evidence that PHM standards documentation was reviewed for compliance during our November 2019 Mock Survey, following the Plan Partner Oversight Audit
T. Actual or anticipated resolution date.
KPNC Response: Issue resolved November 21, 2019.
Documents were not made available during the 2019 audit because they had not gone through mock survey and approval by our oversight committees. The 2019 and 2020 documentation will be made available during the 2020 Plan Partner Audit.
PLAN PARTNER’s CAP EVALUATION CAP STATUS COMMENTS ☒ Approved ☐ Partially Approved ☐ Not approved
2/21/2020-For the Population Health Management CAP on P&P’s Health Plan of San Mateo requires Kaiser to provide more detail in the CAP as the response isn’t sufficient. HPSM has a few questions and would like a revised CAP to reflect the answers provided. Upon review, Kaiser’s response is not sufficient and HPSM would like more information:
10. Can Kaiser explain what the “mock survey” is and how this is relevant to the missing policies? 11. Can Kaiser inform us of the frequency of their oversight committee meetings? 12. The NCQA standards that we audited them against are from 2018, why did the mock survey not occur and why did these
policies not get approved by 2019? To ensure full remediation of cited deficiencies, understanding of requirements, and prevention of reoccurrence that shall include at minimum: A. Root cause analysis of the deficiency which may include a description of programmatic or operational failures (policies/procedures, systems, training, etc.);
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2019 Medi-Cal Audit Delegate: Kaiser Foundation Health Plan
Summary of Findings and Corrective Action Plan (CAP) Form
Page 15 of 15
B. Steps taken or planned to resolve the deficiency; C. Implementation method of corrective action; D. Evidence in demonstration of compliance; and E. Actual or anticipated resolution date. 2/27/2020- Health Plan of San Mateo approves Kaiser’s response. To prevent future deficiencies when NCQA changes occur, HPSM recommends that Kaiser revisit their documentation production processes so that it aligns with the oversight audit in order give the plans an opportunity to review policies and procedures before the onsite audit. The Plans will reassess in the upcoming annual audit.
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2019 Medi‐Cal Audit Delegate: Kaiser Foundation Health Plan
Summary of Findings and Corrective Action Plan (CAP) Form
Page 1 of 9
Thank you for your time and collaboration during the 2018 Joint Medi‐Cal Health Plans annual audit. In conducting this audit, Health Plan partners evaluated Kaiser’s compliance with delegated responsibilities established in the provider agreement. Below you will find the Health Plan’s Preliminary Audit Report. The findings in this report reflect the evaluation of all relevant information received prior to, and during the November 12, 2019 onsite audit.
Audit Conducted By (select one of the following):
Alameda Alliance for Health (AAH) Health Plan of San Mateo (HPSM) Health Plan of San Joaquin (HPSJ)
Partnership HealthPlan of California (PHC) – Lead Plan
San Francisco Health Plan (SFHP) Santa Clara Family Health Plan (SCFHP)
Auditor(s) / Health Plan Conducting the Audit:
Name Title E‐mail
Eric Becerra (PHC) Grievance & Appeals Compliance Manager
Onsite Visit: November 12, 2019 Review Period: 07/01/2018 to 06/30/2019
Area of Review: Grievance & Appeals Audit Score:
CAP Required (Y/N): Y CAP Due Date: CAP Submission Date: 3/27/2020
Total Number of Findings Total CAPs Closed Total CAPs Open
12
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2019 Medi‐Cal Audit Delegate: Kaiser Foundation Health Plan
Summary of Findings and Corrective Action Plan (CAP) Form
Page 6 of 9
CATEGORY Appeal File Review
DEFICIENCY NUMBER AND FINDING
CORRECTIVE ACTION PLAN (CAP) Auditor’s Comments to CAP
Action Taken (response summary; be sure to include name of supporting documentation, if attached)
CAP Implementation
Date (Anticipated or completed)
(Approved / partially approved / not approved, comments, or request(s) for
additional information)
Deficiency 4 Enrollee protections Finding 1 of 2 Member’s rights Finding: In a number of appeal cases,the acknowledgement letters all include the State Hearing rights. These rights should only be included with NARs when the member has exhausted their appeal rights. This includes cases: 9350736 9432735 9644570 9407159 9718244 9672149 Finding 2 of 2: Language assistance Finding: All appeal cases reviewed ‐ The Laotian tagline translations are incorrect incorrect in all the Appeal Acknowledgment
KFHP Response: Finding 1 of 2: The Plan respectfully disagrees as NARs are generated with Appeal Acks per direction of DHCS. During FR #10, Kaiser Permanente received instruction from the DHCS on 8/18/2017 to include the NAR "Your Rights" attachment with the Appeal Ack template. Finding 2 of 2: Please see attached Language Assistance form with the corrected Laotian tagline in Deficiency #1 above.
NOLA_Comm_FEHBP_SF_NM_1557.pdf
03/10/2020
4/6/2020 Finding 1‐ Corrective action is not approved as presented, further action required. Submit the 8/18/2017 instruction from DHCS that demonstrates that the State Hearing rights should be included as an attachment in the Appeal Ack letters. Submit by 4/30/2020 5/10 Finding 1‐ Corrective action approved as presented, no further action required. Finding 2‐ Corrective action approved as presented, no further action required.
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2019 Medi‐Cal Audit Delegate: Kaiser Foundation Health Plan
Summary of Findings and Corrective Action Plan (CAP) Form
Page 7 of 9
and Appeal Resolution letters for both the standard or expeditied cases. Citation: APL 17‐006 and APL 17‐011 RECOMMENDATION(S): Remove the State Hearing rights attachement from the Acknowledgement letters and provide copies of the language assistance taglines with corrected Laotian tagline
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2019 Medi-Cal Audit Delegate: Kaiser Foundation Health Plan
Summary of Findings and Corrective Action Plan (CAP) Form
Page 1 of 8
Thank you for your time and collaboration during the 2018 Joint Medi-Cal Health Plans annual audit. In conducting this audit, Health Plan partners evaluated Kaiser’s compliance with delegated responsibilities established in the provider agreement. Below you will find the Health Plan’s Preliminary Audit Report. The findings in this report reflect the evaluation of all relevant information received prior to, and during the November 12, 2019 onsite audit.
Audit Conducted By (select one of the following):
Alameda Alliance for Health (AAH)
Health Plan of San Mateo (HPSM)
Health Plan of San Joaquin (HPSJ)
Partnership HealthPlan of California (PHC) – Lead Plan
2019 Medi-Cal Audit Delegate: Kaiser Foundation Health Plan
Summary of Findings and Corrective Action Plan (CAP) Form
Page 3 of 8
CATEGORY Non-Medical Transportation (NMT)
DEFICIENCY NUMBER AND FINDING
CORRECTIVE ACTION PLAN (CAP) Auditor’s Comments to CAP
Action Taken (response summary; be sure to include name of supporting documentation, if
attached)
CAP Implementation
Date (Anticipated or completed)
(Approved / partially approved / not approved, comments, or request(s)
for additional information)
Deficiency 3 Factor #: Documentation and Reports Finding: 1) The universe report provided for review does not include any trips made via gas mileage reimbursement (GMR), public transportation, air or train travel, or ancillary services. 2) The universe report provided for review does not include denied trips. Reviewer is unable to validate whether proper Notice of Action (NOA) and denial procedures are being followed by delegate. 3) Six files reviewed fall outside of the specified audit timeframe:
KPNA1811525
KPNA1813940
KPNA1918388
KPNA1813900
KPNA1811294
KPNA1817207
3/11/2020 Kaiser CAP Response: Each gas mileage reimbursement (GMR) claim was reviewed and it was confirmed that payment was released to the member as the payee. The following actions have been taken to ensure future compliance with APL 17-010: MTM’s GMR Error report has been reviewed and
updated to ensure trips scheduled for GMR with the member as the payee will be flagged. These trips will then be reworked to ensure the trip is being completed in compliance with protocol.
We’ve verified that protocol language has been updated to clarify that GMR trips are not to be set with the member as the payee. Per our vendor, MTM, this language was updated last week and is available to all MTM staff.
Staff process reminder – A protocol reminder is scheduled for this week, this reminder will highlight the updated protocol language and remind the CSR to communicate the appropriate payee options when member’s request themselves as the payee.
The MTM Contact Center will also reach out to the members associated with the majority of the GMR
Completed by March 2020
2/25/20 Corrective action partially
approved as presented, further action
required.
Please review following GMR trip
numbers for compliance as it seems that
the member is being reimbursed directly
which is not allowable. Pursuant to APL
17-010 FAQs, members cannot be the
driver for NMT. Provide documentation
of GMR payee in each case. If member
was reimbursed directly, please work
with delegated vendor to bring this into
compliance.
KPNA1916402
KPNA1916946
KPNA1917112
KPNA1917436
KPNA1918393
KPNA1918564
KPNA1918845
KPNA1919735
KPNA1919952
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2019 Medi-Cal Audit Delegate: Kaiser Foundation Health Plan
Summary of Findings and Corrective Action Plan (CAP) Form
Page 4 of 8
Citation: Requested universe of NMT files for the period of July 1, 2018 to June 30, 2019 included:
Prior Authorization and Eligibility
Trip Scheduling
Trip Information
Notice of Action
requests to educate them and explain the payee requirements.
Previous Kaiser Response dated 1/29/2020:
An additional universe of gas and bus trips is being provided. See: Kaiser Trip Inquiry_GMR.Bus_Final 01282020
An additional universe of denied trips is being provided. See: Kaiser Trip Inquiry_Denied PHC Trips
Claims are pulled based on claim submission date and not appointment date.
Each of these claims were received on the following dates:
KPNA1811525 – Claim received 7/2/2018
KPNA1813940 – Claim received 9/24/2018
KPNA1918388 – Claim received 5/17/2019
KPNA1813900 – Claim received 7/15/2018
KPNA1811294 – Claim received 7/3/2018
KPNA1817207 – Claim received 9/27/2018 These claim received dates are documented on the claims universe report originally submitted.
KPNA1920614
KPNA1920726
KPNA1920898
KPNA1921892
KPNA1921894
KPNA1925506
KPNA1925507
KPNA1926609
KPNA1926612
KPNA1927038
KPNA1927039
KPNA1928252
KPNA1929700
KPNA1929701
KPNA1929702
KPNA1930555
KPNA1930558
KPNA1930559
Please provide documentation and findings by March 11, 2020 5/26/20 Corrective action partially approved as presented, further action required. Please provide proof of the communication and trainings received by MTM staff as it relates to the referenced update to the protocols.
RECOMMENDATION(S): 1) Provide universe of files for the specified period to include GMR, public transportation, air, train and ancillary services. 2) Provide universe of files for the specified period to include all denials.
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2019 Medi-Cal Audit Delegate: Kaiser Foundation Health Plan
Summary of Findings and Corrective Action Plan (CAP) Form
Page 5 of 8
CATEGORY Non-Emergency Medical Transportation (NEMT)
DEFICIENCY NUMBER AND FINDING
CORRECTIVE ACTION PLAN (CAP) Auditor’s Comments to CAP
Action Taken (response summary; be sure to include name of supporting documentation, if
attached)
CAP Implementa
tion Date (Anticipated
or completed)
(Approved / partially approved / not approved, comments, or request(s) for
additional information)
Deficiency 5 Factor #: Determinations and Notifications Finding: 1) Provided documentation is insufficient to
determine the following information:
Date of decision
# of days received to decision
Was the case pended
Date of initial notification
Date of written confirmation
# of days decision to notification
Reasons for denial if necessary
If denied, was Notice of Action submitted and were correct attachments included
2) Trip statuses are confusing when trying to follow the path for determination
Citation: KFHP Med-Cal Transportation policy does not reference decisions and actions when making determinations
Kaiser’s 3/11 Updated CAP Response: Kaiser would like to explain the reasons why the HUB
does not issue NOAs to Medi-Cal Managed Care
Members. When a member contacts the NCAL
Ambulance Hub to schedule transportation, NEMT
has already been pre-authorized by the ordering
physician. Therefore, the member is pre-confirmed to
have the NEMT benefit and to be eligible for NEMT
as deemed by their ordering physician. For this
reason, NEMT is never denied by the Hub because the
trip is prior authorized by the physician before the
member contacts the Hub. Kaiser is therefore in
compliance with APL 17-006 because we never issue
ABDs that would require a written notice to the
member.
Kaiser’s Previous Response: The transportation HUB has defined each bulleted item below and in addition, we are submitting 1) a complete cross-walk between the PCS data elements and the VectorCare Application as well as a sample PHC member’s VectorCare summary and detailed trip summary (this is what exist for each member selected).
2/25/20 Corrective action not approved,
further action required. Pursuant to DHCS
APL 17-006, the denial or limited authorization
of a requested service, including
determinations based on the type or level of
service, medical necessity, appropriateness,
setting, or effectiveness of a covered benefit,
consistuents an adverse benefit determination
(ABD). Further, the MCP is required to provide
the member with written notice of the ABD.
Stating that the HUB does not issue NOAs for
ABD is not in compliance with APL 17-006.
5/26/2020 Corrective action approved as
presented, no further action required
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2019 Medi-Cal Audit Delegate: Kaiser Foundation Health Plan
Summary of Findings and Corrective Action Plan (CAP) Form
Page 6 of 8
RECOMMENDATION(S): 3. Please provide definitions of the trip
statuses: a. Completed b. Accepted c. Will Call d. Canceled e. All Declined f. Broadcast_accepted
4. Please provide documentation of decision
timeframe for each file submitted. 5. If trip was denied, please submit
documentation which includes the reason for denial, reference criteria, and attachments sent to the member.
We are also happy to demo the VectorCare System Application.
Date of decision – In the VectorCare System in the detailed view there is a date and time stamp for when the trip was created.
# of days received to decision – The physician must first authorize transportation. When the HUB receives authorization, (usually within 24 hours or less) the scheduling of the member’s trip is instant.
Was the case pended – KP does not pend cases
Date of initial notification – When the HUB receives the authorization this is the notification to schedule the trip which is done instantly.
Date of written confirmation – There is no written comfirmation to the member. Member is provided with verbal confirmation via the phone.
# of days decision to notification – Transportation is confirmed the same day it is ordered.
Reasons for denial if necessary – We do not deny medical necessary transportation. If member is not assigned to KP, we refer the member to the Plan Partner. If the trip is more appropriate for NMT, we refer the member to our vendor, MTM.
If denied, was Notice of Action submitted and were correct attachments included – KP HUB does not do NOA on transportation
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2019 Medi-Cal Audit Delegate: Kaiser Foundation Health Plan
Summary of Findings and Corrective Action Plan (CAP) Form
Page 7 of 8
Recommendations:
a. Completed – The date and time that the vendor arrives at the pick-up location.
b. Accepted – The date and time the vendor accepts the trip assignment
c. Will Call – When the return leg of the transport request is pending, i.e. member unsure of what
d. time appointment will be finished. Member has to call vendor/or HUB for the return trip.
e. Canceled – When the member, HUB or vendor cancels the trip. This can be done for a variety of reasons (i.e. trip not needed by member, duplicate trip order)
f. All Declined – The vendor declined the trip assignment. The HUB broadcasts the trip to multiple vendors simultaneously. If a vendor declines the trip, there are multiple vendors that may accept the trip.
g. Broadcast accepted – The vendor accepting a trip assignment
1. Please provide documentation of decision
timeframe for each file submitted. Kaiser’s Response: Once the KPHC referral is received by the Hub, the Hub clerk immediately starts the process of assigning a vendor to the transportation request (usually less than 24 hours). The decision to transport the member via
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2019 Medi-Cal Audit Delegate: Kaiser Foundation Health Plan
Summary of Findings and Corrective Action Plan (CAP) Form
Page 8 of 8
NEMT is made by the authorizing MD (listed in KPHC). 2. If trip was denied, please submit
documentation which includes the reason for denial, reference criteria, and attachments sent to the member. – Not applicable for KP
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HEDIS Reporting Year 2020; Measurement Year 2019
(January 1, 2019- December 31, 2019)
Preliminary Performance on: Follow-Up Care for Children Prescribed ADHD Medication (ADD)
Measure Description: The percentage of newly prescribed attention-deficit/hyperactivity disorder (ADHD) medication who had at least three follow-up care visits within a 10 month period, one of which was within 30 days of when the first ADHD medication was dispensed. Two rates are reported.
1. Initiation Phase: The percentage of members 6-12 years of age as of the Index Prescription Start Date (IPSD) with an ambulatory prescription dispensed for ADHD medication, who had one follow-up visit with practitioner with prescribing authority during the 30-day initiation phase.
2. Continuation and Maintenance (C&M) Phase: The percentage of members 6-12 Years of age as of the IPSD with an ambulatory prescription dispensed for ADHD medication, who remained on the medication for at least 210 days and who, in addition to the visit in the Initiation Phase, had at least two follow-up visits with a practitioner within 270 days (9 months) after Initiation Phase ended.
Regional Performance relative to National Medicaid Benchmarks
Initiation Phase:
Region Denominator Numerator Rate Percentile Ranking
• Provide an overview of the ADVANCE program• Discuss evaluation findings • Share plans for engaging with provider practices
Objectives
2
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• ADVANCE is a training vehicle to equip individuals within provider practices to lead health care quality improvement (QI) initiatives. – Expanded QI knowledge & real-time application
• Identify, plan, and execute improvement projects
• Deliver successful results
• Spread changes and learnings throughout the system
– A 9 month commitment • Monthly learning sessions
• Bi-weekly/monthly coaching check-ins
• Coach guidance in applying knowledge to QI project
– No charge to participants (excluding staff and travel time)
What is ADVANCE?
3
Global Aim:PHC will increase provider network capacity to execute quality improvement projects, as measured by:
– 60% of participating organizations achieving improvement* on their selected project
– 75% of participants rate overall program satisfaction as excellent
*Improvement is defined as any improvement made on at least one outcome measure
What is the Goal of ADVANCE?
4
The primary objective of the ADVANCE program is to increase quality improvement capacity and capability in PHC’s provider network.
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3
Southern Region
• Adventist Health Ukiah Valley• Community Medical Center• Marin City Health and Wellness
• Marin Community Clinics• NorthBay Healthcare
• Ole Health• Ritter Center• River Bend• West County Health Center
2019 Participants
5
Northern Region
• Fairchild Medical Center• Mountain Valley Health Centers
• Shingletown Medical Center• United Indian Health Services
Evaluation: Strong Value Attributed to ADVANCE
6
• Participants’ evaluation of ADVANCE: increased understanding of the Model for Improvement, better knowledge and use of tools in QI, and a stronger relationship with PHC.
• Over 70% of teams saw some improvement on their outcome measure, and over 50% of all teams met or exceeded their goal.
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4
High Overall Program Satisfaction
7
0%
20%
40%
60%
80%
Excellent Good Fair Poor
ADVANCE 2019Participants' Overall Rating of Program
On our way . . . Seeing progress through measureableimprovement in process measures or PDSA measures,
but not yet in outcome measure
Think we're getting better . . . Data doesn’t currently show results
Never really got started . . . Still collecting baselinedata
Other
Which statement best describes your project status at the end of ADVANCE?
n=30
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5
• More than 50% of ADVANCE participants exceeded their project aim
Project Aim Achieved?
9
Organization Measure Aim Aim Achieved?
Adventist Health Ukiah Valley, Fort Bragg
Well Child Increase Well Child rates from 14.5% to 75%
Yes
Community Medical Center CCS Increase CCS rates 63% to 70% for women seen in the last 12 mos.
Yes
Fairchild AMR Increase AMR rates from 74% to 85% Yes
Marin City CCS Increase CCS rates for PHC pts. from 35% to 59%
No
Marin Community Clinic A1C Increase A1C control within Dr. Magliocco’s panel from 62% to 70%
Yes
Mountain Valley A1C Increase A1C control for all adult pts. From 62% to 71%
Yes
Northbay, Vacaville Diabetic Retinal Exam
Increase compliance of diabetic retinal exam from 33% to 50%
No
Ole Health, Hartle Ct. CIS‐10 Increase CIS‐10 for Dr. Wyborny from 42% ‐ 60%
No
Ritter Center CCS Increase CCS from 20% to 30% No
River Bend Diabetic Retinal Exam
Increase the percentage of in‐house retinopathy screenings completed from 0 patients to 166
No
Shingletown Diabetic Retinal Exam
Increase Diabetic Retinopathy screening from 16% to 50%
Yes
United Indian Health Diabetic Retinal Exam
Increase Diabetic Retinopathy screening from 9% to 36% for pts. Assigned to Dr. Martinez
Yes
West County CCS Increase CCS from 59% to 65% No
• 90% of participants improved QIP Scores in 2019 compared to 2018
2018 vs. 2019 QIP HEDIS Benchmarks
10
Organization Measure 2018 QIP
Performance
2018
Benchmark
2019 QIP
Performance
2019
Benchmark
Improvement
Over 2018?
Adventist Health Ukiah Valley, Fort Bragg
Well Child 66.23 25th 87.01 90th Yes
Community Medical Center
CCS 57.04 25th 64.93 50th Yes
Fairchild AMR Peds Only 64.81 75th ‐‐‐
Marin City CCS 25.00 Below MPL 49.82 Below MPL Yes
Marin Community Clinic
A1C 71.15 90th 73.81 90th Yes
Mountain Valley A1C 64.00 75th 80.00 90th Yes
Northbay, Vacaville Diabetic Retinal Exam
71.62 90th 82.96 90th Yes
Ole Health, Hartle Ct. CIS‐3 Excluded 75.36 75th ‐‐‐
Ritter Center CCS 26.47 Below MPL 30.23 Below MPL Yes
River Bend Diabetic Retinal Exam
44.44 Below MPL 37.50 Below MPL No
Shingletown Diabetic Retinal Exam
64.00 75th 82.35 90th Yes
United Indian Health Diabetic Retinal Exam
15.15 Below MPL 45.10 Below MPL Yes
West County CCS 62.21 50th 69.08 75th Yes
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• Would you describe your project successful?
Qualitative Results
Big systemic organizational changes were made. Even though numbers don’t show success with outcome measures, changes were made culturally and throughout the organization.
11
• Overall, provider organizations have increased knowledge of QI compared to previous ADVANCE cohorts
• Top rated topics: Project Management, Change Management and Spread/Sustainability
• Participants with internal leadership (executive level and clinical operations) support were more successful at testing and implementing change into their system
Top 3 Lessons
12
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Road Ahead
13
WHAT
• Practice Facilitation ‐ assist primary care practices in the application of evidence‐based best practices to quality improvement activities
WHY
• Lower intensity – in‐person, hands‐on training• Meet Provider Practice teams at their current phase• Deeper dive into the provider practice QI infrastructure• Collaboration and support from PHC / Provider Practice leadershipWHO
• Joint Leadership Initiative Participants • High volume, low‐ to mid‐performing
HOW
• Use of assessment tool• On‐site training and coaching• Leverage Joint Leadership Initiative meetings as communication vehicle
Partnership HealthPlan of California (PHC) utilizes InterQual® criteria in its utilizationmanagement (UM) decision making process as well as policies and procedures developed forspecific situations. PHC’s UM policies are developed by PHC Medical Directors and subjectmatter expert specialists. Specific UM policies may be created when the following situationsapply:
1. InterQual® does not have criteria available for a particular service/procedure2. The most current clinical information in recent nationally recognized literature conflic ts with
InterQual® criteria3. The California Department of Health Care Services (DHCS) Provider Manuals or “All Plan Letter”
directives require development of a policy to provide additional information to Providers
All PHC UM policies are reviewed annually by the Quality/Utilization Committee (Q/UAC) and the Physician Advisory Committee (PAC) which also include board-certified specialists.
Partnership HealthPlan of California utilizes the following InterQual® criteria modules in itsUM decision making process. A summary of content for each module is provided in this document. Arrangements can be made to provide full criteria for review upon request.
InterQual® Clinical Content
Summary of Acute Criteria Review Process Pages 2 – 4
1. InterQual® Level of Care Criteria Acute Adult 2019 Pages 5 - 6(System update to 2020 Criteria is scheduled for 06/09/2020)
2. InterQual® Level of Care Criteria Acute Pediatric 2019 Pages 7 - 8(System update to 2020 Criteria scheduled 06/09/2020)
InterQual® Acute Level of Care Criteria provide support for determining the medical appropriateness of hospital admission, continued stay, and discharge. Acute Adult Criteria address the Observation, Acute, Intermediate, and Critical levels of care. Acute Pediatric Criteria include these levels of care and five additional levels of nursery care (Transitional Care, Newborn Level I, Special Care Level II, Neonatal Intensive Care Level III, and Neonatal Intensive Care Level IV).
Adult criteria are for review of patients ≥ 18 years of age. Pediatric criteria are for review of patients < 18 years of age.
Important: The Criteria reflect clinical interpretations and analyses and cannot alone either resolve medical ambiguities of particular situations or provide the sole basis for definitive decisions. The Criteria are intended solely for use as screening guidelines with respect to the medical appropriateness of healthcare services and not for final clinical or payment determinations concerning the type or level of medical care provided, or proposed to be provided, to a patient.
When evidence in the medical literature to support the effectiveness of an intervention or service is mixed or unclear, the criteria point reflects current best evidence and practice. It is the product of a peer review process involving multiple clinicians with diverse expertise in varied practice and geographic settings.
When conducting reviews, the issue of gender may be relevant. InterQual content contains numerous references to gender. Depending on the context, these references may refer to either genotypic or phenotypic gender. At the individual patient level, a variety of factors, including but not limited to gender identity and gender reassignment via surgery or hormonal manipulation, may affect the applicability of some InterQual criteria. This is most often the case with genetic testing and procedures that assume the presence of gender-specific anatomy. With these considerations in mind, all references to gender in InterQual have been reviewed and modified when appropriate. InterQual users should carefully consider issues related to patient genotype and anatomy, especially for transgender individuals, when appropriate.
2019 Acute Adult / Pediatric Criteria
Licensed for use exclusively by Partnership Health Plan of California.
Acute Criteria Review Process Page 1 of 3
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Acute Criteria Review Process How to conduct a review
General subsets If a patient has a condition, symptom, or finding not addressed in a condition-specific subset, then refer to one of the following general subsets.
If the patient has a condition, symptom, or finding that is included in a condition-specific subset, it is not appropriate to apply criteria within a general subset. Redirection links to condition-specific subsets have been added in general subsets to reinforce this process.
General subsets (Medical)
Acute Adult
General Medical
General Trauma
Acute Pediatric
General Medical
General Trauma
Nursery
General Surgical subset
The General Surgical subset is to be used when a patient requires an inpatient surgical or solid organ transplant procedure or management of a complication related to an ambulatory procedure.
Refer to the Bone Marrow Transplant or Stem Cell Transplant subset to conduct a review for a bone marrow or stem cell transplant.
Criteria for patients who have an ambulatory procedure complication requiring Observation can be found on Operative Day or Post-op Day 1, under the Observation level of care within the General Surgical subset. For complications requiring treatment at a higher level of care, apply criteria using the Intermediate or Critical level of care. For complications not included in the General Surgical subset, see the most appropriate condition-specific or general subset based on the patient’s symptoms or findings. For example, criteria for deep vein thrombosis can be found in the Deep Vein Thrombosis (DVT) subset.
Extended Stay subsets When the episode days within a condition-specific subset or end-points within a general subset are exhausted and a patient requires continued stay, refer to the Extended Stay subset.
When using the Extended Stay subset, consider the following:
The Extended Stay subset cannot be used on admission.
The criteria within the Extended Stay subset does not contain specific episode days and maycontinue to be used until:
– the designated end points are fulfilled
– the condition or symptom resolves and Responder criteria are met
– a condition-specific or general subset would be more appropriate (for example, if apatient develops a new condition)
If a patient develops a new condition necessitating continued stay, the reviewer should refer to Episode Day 1 or Operative Day of the most appropriate subset. For example, if
2019 Acute Adult / Pediatric Criteria
Licensed for use exclusively by Partnership Health Plan of California.
Acute Criteria Review Process Page 2 of 3
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Acute Criteria Review Process How to conduct a review
an adult patient develops cellulitis during the extended hospitalization, refer to the Infection: Skin subset. If a patient requires surgical intervention during the extended hospitalization, refer to the General Surgical subset.
If criteria are not met within the Extended Stay subset, refer for secondary review.
Criteria in the Extended Stay subset may be associated with a time-limited endpoint. Theseendpoints indicate that the criterion may be used for no more than the specified timeframe.
For example, in the criterion “Culture pending ≤ 2d,” “≤ 2d” indicates that this criterion canbe used for up to (but no more than) two days.
When the endpoint includes the language “since initiation,” the criterion can only be applied for the total number of days specified and includes the time treatment was delivered in another subset. For example, in the criterion “Anti-infective (includes PO) ≤ 4d since initiation,” “since initiation” indicates that this criterion can be used for up to (but no more than) four days since the initiation of the anti-infective.
Redirection to the Extended Stay subset is a standard option for patients meeting Non-responder criteria. The Extended Stay subset comprises conditions, diagnoses, andsymptoms. Occasionally, the actual condition or diagnosis may not be specified in thecriteria. For example, criteria for pneumonia are not specified in the Extended Stay subset.The reviewer should look for criteria based on what is driving the patient’s need forcontinued stay and select criteria under either “Infection” or “Respiratory.” For conditions,diagnoses, or symptoms not addressed in the Extended Stay subset, secondary review isappropriate.
Step 2: Select Initial review or the appropriate episode day Select Initial review or the appropriate episode day.
Initial reviewSome Acute Adult subsets include Initial review criteria. Initial review criteria are a level of caredetermination tool, intended to be used as real-time decision support in the emergency department to identify if observation or inpatient hospital-level services are warranted. They may help the reviewer assess whether a patient is appropriate for observation or inpatient status at the time a decision to hospitalize the patient is being made. Initial review criteria evaluate only data that are available at the time the decision is being made. This may include previously provided interventions or the results of laboratory, imaging, and other tests. Initial review may be appropriate when “bridge” or “holding” orders (e.g., “Admit to telemetry”) are in place. These orders are intended to address the patient’s needs until full treatment and medication orders are written.
While Initial review enables identification of the level of care, it is not intended to, and should not be used as, a substitute for an Episode Day 1 review, which will generally include specific, evidence-based interventions and intensity of service requirements.
2019 Acute Adult / Pediatric Criteria
Licensed for use exclusively by Partnership Health Plan of California. Page 6 of 1914
Acute Criteria Review Process Page 3 of 3
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InterQual® Level of Care Criteria 2019 Acute Adult
Table of Contents
Review Process 1Selected Subset Details: 22 Acetaminophen Overdose 23 Acute Coronary Syndrome (ACS) 44 Acute Kidney Injury 90 Anemia/Bleeding 116 Antepartum 158 Arrhythmia 187 Asthma 227 Bone Marrow Transplant/Stem Cell Transplant (BMT/SCT) 255 Bowel Obstruction 274 Carbon Monoxide Poisoning 287 Cholecystitis 309 COPD 318 Cystic Fibrosis 360 Deep Vein Thrombosis 388 Dehydration or Gastroenteritis 405 Diabetes Mellitus 419 Diabetic Ketoacidosis 440 Electrolyte or Mineral Imbalance 471 Epilepsy 505 Extended Stay 526 General Medical 575 General Surgical 671 General Trauma 756 Heart Failure 819 Hematology/Oncology: Acute Leukemia or Lymphoma 867 Hematology/Oncology: Brain Malignancy or Metastasis 878 Hematology/Oncology: Chemotherapy 896 Hematology/Oncology: Hemolytic Uremic Syndrome 913 Hematology/Oncology: Malignant disease 941 Hematology/Oncology: Tumor Lysis Syndrome 968 Hospital in the Home 1000 Hyperosmolar Hyperglycemic State 1026 Hypertension 1066 Hypertensive Disorders of Pregnancy 1088 Hypoglycemia 1117 Infection: CNS 1145 Infection: Endocarditis 1188 Infection: General 1228 Infection: GI/GYN 1278 Infection: Musculoskeletal 1338
Licensed for use exclusively by Partnership Health Plan of California.
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Page 1 of 1
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2020 Child and Adolescent Psychiatry Criteria Child and Adolescent Psychiatry - Released Mar 2020(1, 2, 3)
Select Level of Care
Inpatient(4)
Observation(5)
Residential Crisis Program(6)
Subacute Care(7)
Residential Treatment Center(8)
Supervised Living(9)
Partial Hospital Program(10, 11)
Day Treatment Program(12)
Intensive Community-Based Treatment(13)
Intensive Outpatient Program(11, 14)
Outpatient(15)
Select Level of Care
Select Level of CareInpatient(4)
Symptom or finding is due to a psychiatric or co-occurring substance use disorderEpisode Day 1, ≥ One:
Assaultive within last 24 hours and high risk of re-occurrence, ≥ One:(16)
Access to firearms or weaponsCurrent interpersonal stressor(17)
Poor impulse control(18)
Positive psychotic symptoms(19)
Psychomotor agitation(20)
Support system unavailable(21)
Violation of protection or restraining orderCatatonia(22, 23)
Command hallucinations with direction to harm self or others within last 24 hours(24)
Co-occurring medical condition, All:(25)
Physical health condition with actual or potential for exacerbation, All:Medical hospital admission within last 30 days and at risk of readmission(26)
Patient or caregiver unable to follow medical care plan and deterioration in functioning(
27)
Requires multiple daily treatments or nursing assessment at least 3 times per daySerious emotional disturbance or autism spectrum disorder or intellectual developmental
disability, ≥ One:(28)
2020 Child and Adolescent Psychiatry CriteriaChild and Adolescent Psychiatry - Released Mar 2020
Symptom or finding is due to a substance use or co-occurring psychiatric disorderEpisode Day 1, Both:
Co-occurring medical or psychiatric condition interferes with ability to participate in substanceuse treatment at a less intensive level of care, ≥ One:
Active treatment or monitoring required for pregnancy (70, 71)
Co-occurring psychiatric condition, ≥ One:Assaultive within last 24 hours and high risk of re-occurrence, ≥ One:(72)
Access to firearms or weapons Current interpersonal stressor(73)
Poor impulse control(74, 75)
Positive psychotic symptoms(76, 77)
Psychomotor agitation(78)
Support system unavailable(79)
Violation of protection or restraining order Catatonia (80, 81)
Command hallucinations with direction to harm self or others within last 24 hours(82)
Destruction of property within last 24 hours and poor impulse control(75, 83)
Disorganized behavior and history of bipolar disorder with rapid onset of symptoms(84)
Drug-induced hallucinations or delusions persistent and not expected to resolve within48 hours(85, 86)
Eating disorder symptom unstable, ≥ One:(87)
2020 Substance Use Disorders CriteriaSubstance Use Disorders - Released Mar 2020
Licensed for use exclusively by Partnership Health Plan of California.
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Behavioral Health Procedures Q & A 2020
BH Procedures Q & A Page 1 of 1
BH:Procedures Q & A InterQual 2020 03-31-2020
BH:Procedures Q & A InterQual 2020 03-31-2020
BH:Procedures Q & A InterQual 2020 03-31-2020
BH:Procedures Q & A InterQual 2020 03-31-2020
BH:Procedures Q & A InterQual 2020 03-31-2020
BH:Procedures Q & A InterQual 2020 03-31-2020
BH:Procedures Q & A InterQual 2020 03-31-2020
BH:Procedures Q & A InterQual 2020 03-31-2020
BH:Procedures Q & A InterQual 2020 03-31-2020
BH:Procedures Q & A InterQual 2020 03-31-2020
BH: Procedures Q & A
InterQual 2020
Applied Behavior Analysis (ABA) for Autism Spectrum Disorder
Electroconvulsive Therapy (ECT)
Multi-Gene Panels for Autism Spectrum Disorder (ASD) Neuropsychological and Developmental Testing Outdoor Behavioral Healthcare (OBH) Residential Wilderness Program Pharmacogenomic Testing for Psychotropic Medication Drug Response
Psychological Testing
Stereotactic Introduction, Subcortical or Cortical Electrodes
Transcranial Magnetic Stimulation (TMS)
Urine Drug Testing
Vagus Nerve Stimulation BH:Procedures Q & A InterQual 2020 03-31-2020
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PARTNERSHIP HEALTHPLAN OF CALIFORNIA
POLICY/ PROCEDURE
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Policy/Procedure Number: MP PR GR 210 Lead Department: Provider Relations
A. N/A MCUP3037 – Appeals of Utilization Management/Pharmacy Decisions B. MPQP1053 – Peer Review Committee C. MPQP1016 – Potential Quality Issue Investigation and Resolution D. CGA024 – Med-Cal Member Grievance System
II. IMPACTED DEPTS:
A. Provider Relations A.B. Health Services
III. DEFINITIONS: N/AProvider Grievance:; For the purposes of this policy, a Provider Grievance is defined as an expression of requestdissatisfaction from a provider that, after exhausting all Plan appeal processes, requests to have their complaint, appeal or dispute still disagrees with the Plan’s decision and has exhausted all Plan appeal processes, to have the submitted to theability to request a final review of the issue bythe Provider Grievance Committee for final review of a dispute ofthe amedical or pharmacy decision or how the Plan implemented a regulatory requirement.
IV. ATTACHMENTS: A. N/A
V. PURPOSE: To describe the process for resolving provider grievances related to determinations of medical or pharmacy decisions made by Partnership HealthPlan of California, the Plan’s implementation of DHCS Regulatory or other State and Federal requirements, or contractual disputes between the Health Plan and providers. A provider may request a grievance after all applicable PHC Appeal processes have been exhausted. To describe the process for resolving provider grievances related to determinations of medical or pharmacy decisions made by Partnership HealthPlan of California, the Plan’s implementation of DHCS Regulatory or other State and Federal requirements, or contractual disputes between the Health Plan and providers. The provider grievance process is not applicable to provider appeals filed on behalf of members and as such, is separate and distinct from the member appeal and grievance and appeal process. and are not on behalf of the member A provider may request a grievance after all applicable PHC Appeal processes have been exhausted.
VI. POLICY / PROCEDURE:
A. The Partnership HealthPlan of California, (PHC) Chief Executive Officer is ultimately responsible for
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Policy/Procedure Number: MP PR GR 210 Lead Department: Provider Relations
Original Date: 04/25/1994 Next Review Date: 01/13/2021086/126/2021 Last Review Date: 01/08/2020068/127/2020
Applies to: ☒ Medi-Cal ☐ Employees
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the provider grievance process and has primary responsibility for maintenance, review, formulation of policy changes and procedural improvements of the grievance review system. The Chief Executive Officer is assisted by the PHC Chief Medical Officer, Senior Health Services Director and Senior Provider Relations Director. The provider grievance process is managed and monitored by the Provider Relations department.
B. Providers must be given an opportunity to have their grievance heard and evaluated. Two mechanisms, an informal and a formal grievance procedure, have been established for that purpose. 1. Informal grievances may be registered by the provider, by telephone, letter or visit to the PHC
office. The provider should contact the Provider Relations Department to register a grievance. The grievance is immediately recorded. If a satisfactory solution has not been reached through discussion with the parties within ten (10) working days after an informal grievance is registered, the grievance automatically becomes a formal grievance.
2. Formal grievance is filed in writing at the PHC offices or by mail within 45 working days of the final appeal determination or action that is the subject of the grievance. There is a fifteen (15) working day resolution period during which time the PHC staff proposes a resolution to the provider. If the proposed resolution is not satisfactory, the provider may request in writing Provider Grievance Review Committee hearing.
Decisions of the Provider Grievance Review Committee are binding unless reversed by the Partnership HealthPlan of California Board of Commissions. The Provider Grievance Committee will meet within forty-five (45) working days of receipt of the written provider request of a Provider Grievance Review Committee meeting.
C. The Provider Grievance Review Committee has been established to provide a formal grievance
mechanism. The Provider Grievance Review Committee (PGRC) consists of five members:the members of the
Peer Review Committee (PRC) who are not PHC medical directors, excluding any members of the PRC who have a potential conflict of interest. Potential conflict of interest for provider grievances includes being a Physician members may not be members of the active medical staff on a hospital if the hospital is the grieving party and non-physician providers may not beotherwise working for representative of a hospital or institution if the grieving party is a physician on the active medical staff of that hospital or a representative of the .provider filing the grievanceor institution. PGRC will meet on the same date as the Peer Review Committee.
Any person involved in the initial evaluation of the issue may not serve as a member of the Committee but may provide information on the issue as appropriate.
1. a. The PHC Chief Medical Officer or an alternative physician selected by the Chief Medical
Officer. b. The PHC Chief Executive Officer or an alternative non-physician selected by the Chief
Executive Officer. c. Three members selected by the Physician Advisory Committee on an ad hoc basis. They are
one physician member, one non-physician provider ie: a mid-levelnon-physician clinician practitioner or ancillary provider, and a third member who represents the provider type or specialty type of the party raising the issue(s).
2.1. The Provider Grievance Review Committee members selected should have the ability to be fair and impartial. As an example; Physician members may not be members of the active medical staff on a hospital if the hospital is the grieving party and non-physician providers may not be representative of a hospital if the grieving party is a physician on the active medical staff of that hospital.
3.1.
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Policy/Procedure Number: MP PR GR 210 Lead Department: Provider Relations
Original Date: 04/25/1994 Next Review Date: 01/13/2021086/126/2021 Last Review Date: 01/08/2020068/127/2020
Applies to: ☒ Medi-Cal ☐ Employees
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4.1. Any person involved in the initial evaluation of the issue may not serve as a member of the Committee but may provide information on the issue as appropriate.
5. The Physician Advisory Committee appoints the Chairperson of the Provider Grievance Review Committee. The chairperson is responsible for conducting the meeting.
6. PHC staff is responsible for selecting a recording secretary, setting the date, time, and location for the meeting. PHC will forward all correspondence and documents submitted by the provider and PHC which are relevant to the grievance to the Committee Members five (5) working days prior to the Grievance Committee hearing.
7.2. The Committee meets as needed. The Committee's meeting is documented in minutes and the provider and PHC are advised in writing of the Committee's decision within ten (10) working days of the meeting.
D. Providers appealing utilization management or pharmacy decisions on behalf of members must follow the procedure outlined in health services policies and procedures “Appeals/Expedited Appeals of UM Decisions” MCUP3037, Appeals of Utilization Management/Pharmacy Decisions prior to filing a request for a Provider Grievance Review hearing.
D.E. Providers retrospectively appealing a decision to deny or limit payment for a service based on application of UM criteria, for which the member is not financially responsible, should first submit an appeal (which is not on behalf of a member, but on behalf of the billing provider), with additional documentation responding to the reason for the initial denial or limitation. A provider grievance may not be filed until an initial appeal has been completed, which the provider disagrees with.
E.F. If during the review process, the Provider Grievance Review Committee determines that a provider may be deficient in rendering or managing care, or problem areas are discovered, this information is referred to the Performance Improvement Clinical Specialist as a Potential Quality Issue (PQI), see MPQP1016 - Potential Quality Issue Investigation and Resolution..
F.G. The plan or the plan’s capitated provider shall not discriminate or retaliate against a provider (including but not limited to the cancellation of the provider’s contract) because the provider filed a contracted provider dispute grievance or a non-contracted provider dispute grievance.
VII. REFERENCES:
A. NCQADHCS All Plan Letter, APL 17-006 Grievance and Appeal Requirements B. PHC Board of Commissioners NCQA UM 7 Element C, Non-Behavioral Healthcare Notice of Appeal
Rights/Process and Element I, Pharmacy Notice of Appeal Rights /PrRocess VIII. DISTRIBUTION:
A. PHC Provider Manual A.B. PHC Department Directors
IX. POSITION RESPONSIBLE FOR IMPLEMENTING PROCEDURE: Provider Relations Director
A. MCUP3037 – Appeals of Utilization Management/Pharmacy Decisions B. MPQP1053 – Peer Review Committee C. MPQP1016 – Potential Quality Issue Investigation and Resolution D. CGA024 – Med-Cal Member Grievance System
II. IMPACTED DEPTS:
A. Provider Relations B. Health Services
III. DEFINITIONS: Provider Grievance: For the purposes of this policy, a Provider Grievance is defined as an expression of dissatisfaction from a provider that, after exhausting all Plan appeal processes, requests to have their complaint, appeal or dispute submitted to the Provider Grievance Committee for final review of the medical or pharmacy decision or how the Plan implemented a regulatory requirement.
IV. ATTACHMENTS: A. N/A
V. PURPOSE: To describe the process for resolving provider grievances related to determinations of medical or pharmacy decisions made by Partnership HealthPlan of California, the Plan’s implementation of DHCS Regulatory or other State and Federal requirements, or contractual disputes between the Health Plan and providers. The provider grievance process is not applicable to provider appeals filed on behalf of members and as such, is separate and distinct from the member grievance and appeal process. A provider may request a grievance after all applicable PHC Appeal processes have been exhausted.
VI. POLICY / PROCEDURE:
A. The Partnership HealthPlan of California, (PHC) Chief Executive Officer is ultimately responsible for the provider grievance process and has primary responsibility for maintenance, review, formulation of policy changes and procedural improvements of the grievance review system. The Chief Executive Officer is assisted by the PHC Chief Medical Officer, Senior Health Services Director and Senior Provider Relations Director. The provider grievance process is managed and monitored by the Provider Relations department.
B. Providers must be given an opportunity to have their grievance heard and evaluated. Two mechanisms, an informal and a formal grievance procedure, have been established for that purpose.
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Policy/Procedure Number: MP PR GR 210 Lead Department: Provider Relations
Original Date: 04/25/1994 Next Review Date: 08/12/2021 Last Review Date: 08/12/2020
Applies to: ☒ Medi-Cal ☐ Employees
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1. Informal grievances may be registered by the provider, by telephone, letter or visit to the PHC office. The provider should contact the Provider Relations Department to register a grievance. The grievance is immediately recorded. If a satisfactory solution has not been reached through discussion with the parties within ten (10) working days after an informal grievance is registered, the grievance automatically becomes a formal grievance.
2. Formal grievance is filed in writing at the PHC offices or by mail within 45 working days of the determination or action that is the subject of the grievance. There is a fifteen (15) working day resolution period during which time the PHC staff proposes a resolution to the provider. If the proposed resolution is not satisfactory, the provider may request in writing Provider Grievance Review Committee hearing.
Decisions of the Provider Grievance Review Committee are binding unless reversed by the Partnership HealthPlan of California Board of Commissions. The Provider Grievance Committee will meet within forty-five (45) working days of receipt of the written provider request of a Provider Grievance Review Committee meeting.
C. The Provider Grievance Review Committee has been established to provide a formal grievance
mechanism. 1. The Provider Grievance Review Committee (PGRC) consists of the members of the Peer Review
Committee (PRC) who are not PHC medical directors, excluding any members of the PRC who have a potential conflict of interest. Potential conflict of interest for provider grievances includes being a member of the active medical staff on a hospital if the hospital is the grieving party and otherwise working for a hospital or institution if the grieving party is a physician on the active medical staff of that hospital or institution. PGRC will meet on the same date as the Peer Review Committee.
2. The Committee's meeting is documented in minutes and the provider and PHC are advised in writing of the Committee's decision within ten (10) working days of the meeting.
D. Providers appealing utilization management or pharmacy decisions on behalf of members must follow the procedure outlined in health services policies and procedures MCUP3037, Appeals of Utilization Management/Pharmacy Decisions prior to filing a request for a Provider Grievance Review hearing.
E. Providers retrospectively appealing a decision to deny or limit payment for a service based on application of UM criteria, for which the member is not financially responsible, should first submit an appeal (which is not on behalf of a member, but on behalf of the billing provider), with additional documentation responding to the reason for the initial denial or limitation. A provider grievance may not be filed until an initial appeal has been completed, which the provider disagrees with.
F. If during the review process, the Provider Grievance Review Committee determines that a provider may be deficient in rendering or managing care, or problem areas are discovered, this information is referred to the Performance Improvement Clinical Specialist as a Potential Quality Issue (PQI), see MPQP1016 - Potential Quality Issue Investigation and Resolution.
G. The plan or the plan’s capitated provider shall not discriminate or retaliate against a provider (including but not limited to the cancellation of the provider’s contract) because the provider filed a contracted provider grievance or a non-contracted provider grievance.
VII. REFERENCES:
A. DHCS All Plan Letter, APL 17-006 Grievance and Appeal Requirements B. NCQA UM 7 Element C, Non-Behavioral Healthcare Notice of Appeal Rights/Process and Element I,
Pharmacy Notice of Appeal Rights/Process
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Policy/Procedure Number: MP PR GR 210 Lead Department: Provider Relations
Members Excused: Tatum Urrutia, PharmD PHC Staff Excused: Bettina Spiller, MD David Katz, MD James Cotter, MD Michael Vovakes, MD Erin Montegary, PharmD
Ominder Mehta, PharmD Eva Lopez, CPhT
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Minutes: P&T 07/16/2020
AGENDA ITEM
DISCUSSION / CONCLUSIONS RECOMMENDATIONS / ACTION TARGET DATE
DATE RESOLVED
Opening Comments
I. Approval of minutes
II. Standing Agenda 1. PHC Update
1. Stan announced that meeting is being recorded per PHC
Policy. 2. Introductions 3. Housekeeping
Quorum Reached. Minutes approved as submitted. . Topic 1: Pharmacy Carve Out The pharmacy carve-out target still remains as January 1, 2021. State budget left this program intact. The state is making adjustments to support the member experience. State is creating new processes to reduce the risk of adverse consequences to the members such as by extending prior authorization to 5 years and grandfathering in large amounts of medications that patients have been on previously. Topic 2: State budget: Governor’s original proposal of the May Revise cut a large # of optional benefits (assuming Federal bailout would not happen) but the Legislature is assuming the bailout will happen and reduced immediate cuts. Instead put in “trigger cuts” for later. Budget is balanced but only based on the expected federal dollars. Topic 3: State approved a retrospective 1.5% decrease in funding to health plans for all of 2020. PHC Board budget approved forward using some reserves, reduced administrative and reduced health care costs. Topic 4: NCQA Changes Changes and specifications to support the COVID outbreak. Allowing video visits and phone visits such as: prenatal, postpartum and other visits that previously had to be in-person. We are in the process of putting these through our pay-for-performance programs Topic 5: Drug Medi-Cal Benefit -- Wellness and recovery program launched in seven counties, which provides
Presented by: Stan Leung, PharmD Presented by: Robert Moore, MD, MPH, MBA
N/A N/A
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3. DUR Update
outpatient and rehabilitation inpatient services for patients being treated for substance abuse disorder Dr. Leung’s additional comments on Rx Carve-Out: The approved budget didn’t remove all 340B clinic funds. Yesterday’s State meeting on the carve-out indicated they remain on track for Jan 1 despite Covid. Transition period for grandfathering concurrent medications extended from 120 days to 180 days (through end of June). Drug Utilization Review: Four parts to APL Prospective DUR --Messages when there is a potential
problem with the prescription Retrospective DUR -- review the claims to identity fraud
waste and abuse and looking for opportunities to improve safety.
Educational --send out educational articles to pharmacies and providers on how to improve and optimize prescribing practices
Annual summary report.
PHC’s FFY 2019 CMD DUR highlights The Insulin Stewardship imitative consisted of three
webinars to help educate and set best practices for prescribers on optimal use and cost-effective prescribing of insulin products
The 2019/2020 Asthma Medication Ratio Provider Academic Detailing project focuses on outreach to PHC providers to help deliver high quality care to our members living with persistent asthma.
Educational webinars relating to substance use disorder and treatment of benzodiazepine withdrawal
Updates were made to PHC’s Hepatitis C Virus treatment matrix to maximize cost savings based on generic availability of sofosbuvir/velpatasvir (Epclusa) and ledipasvir/sofosbuvir (Harvoni) and due to the significant cost reduction of Zepatier.
Retrospective DUR Educational Outreach activities started during FFY 2019 and continuing into FFY 2020 include:
Interventions for high risk members with concurrent opioid and antipsychotic use
New programs planned for FFY 2020:
Presented by Stan Leung, PharmD
N/A
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4. Drug Review
In partnership with PHC’s Population Health Management department, the Pharmacy department is working to address diabetes medication adherence for members who also take antipsychotic medications.
The Pharmacy department is working with PHC’s Care Coordination department to support Complex Case Management (CCM) by providing medication review and consultation for CCM cases.
Prior to class reviews, Dr. Wong reviewed the Site of Care optimization policy implementation in regards to integration with TAR criteria. Standard verbiage was presented which will be added to drug criteria when the drug is appropriate for a lower level of care intensity such as home infusion or pharmacy infusion suite: Medical benefit (claims submitted direct to PHC): Per Policy MCRP4067, Pharmacy Site of Care, the preferred site of care is home infusion or pharmacy infusion suite, with medication billed as a pharmacy claim. Requests for alternative sites of care will be evaluated on a case-by-case basis; for IV infusion at other sites, include rationale for site requirement on the TAR.
In addition, a similar approach to self-injectable therapies will also be applied, in which self-administration will be preferred with drug provided through the pharmacy benefit, rather than billed as a medical benefit. Exceptions will be allowed for first dose instruction and observation by the medical provider, or when there is documentation that the member is unable to self-administer. The standard verbiage will be included on TAR criteria for drugs that are FDA approved for self-administration: Medical Benefit (claims submitted direct to PHC): <insert drug name> is FDA approved as a self-administered maintenance drug, and as such, is required to be fulfilled at a pharmacy with direct dispensing to the member. Exceptions may be made for a one-time request for medical clinic/clinician reimbursement when necessary for first dose administration instructions &/or monitor the member’s response to the initial dose. Subsequent doses must be provided by issuing a prescription for pharmacy dispensing to the member.
Presented by: Diane Wong, Pharm D & Marlana Ogawa, PharmD.
N/A N/A
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The following First Data Bank general therapeutic classes were presented for review by committee, with approved actions shown at right.
Behavioral Health – Antidepressants (no actions) Cardiovascular Disease - Miscellaneous Agents Cardiovascular Disease – Vasodilation (no actions) Diabetes (no actions) Endocrine Disorder - Fertility Endocrine Disorder - Other Endocrine Disorder – Thyroid (no actions) Fluid Replacement (no actions) Hematological Disorders Infectious Disease – Parasitic (no actions) Local Anesthesia (no actions) Medical Supplies (no actions) Miscellaneous Agents Neurological Disease - Miscellaneous Pain Management – Analgesics (no actions) Urinary Tract - Functional Disorders (no actions) Vaginal Disorders (no actions)
Discussion items: Osteoporosis: Dr. Kubota noted that (1b) in other criteria should be ≤ -2.5, rather than <-2.5. Dr. Netherda requested that “High Risk Fracture” be revised to “High Fracture Risk”. Enzyme deficiency diseases: Dr. Kubota asked if wastage is a concern due to the high cost and limited vial sizes. Dr’s Wong and Leung confirmed that waste is considered during TAR review and pharmacist reviewers check to ensure that dose consolidation is optimized and waste minimized, including outreach to provider for rounding down instead of rounding up when appropriate. PHC’s waste policy and State Waste allowance are followed. Hematology: Promacta criteria – Dr. Ogawa corrected the requirement of platelets <20K to platelets <30K.
Formulary Changes Drug Restrictions
Alirocumab (Praluent™) Add labeler restrictions to PBM and criteria
Evolocumab (Repatha™) Add labeler restrictions to PBM and criteria
Hydroxychloroquine (Plaquenil™)
Allow taxonomy override for board certified rheumatologist on the TAR requirement.
Omeprazole ODT No restrictions
Dulaglutide (Trulicity™)
Remove step requirement in the step edit for Victoza™ (still requires [metformin + 2nd oral] or basal insulin)
Lansoprazole ODT (Prilosec Solutab™)
No restrictions
Tafluprost 0.0015% o/s (Zioptan™)
Correction to QL to match package size for unit dose product
PAD Changes Add Restrictions Q5108 (Fulphila™) 12 unit limit per DOS Revise ICD-10s J0882 (Aranesp™, ESRD)
Dialysis center can bill with either N18.6 or D63.1
Multiple Sclerosis: Dr. Wong proposed correction to Tysabri step therapy requirement – from T/F 2 prior agents, to T/F 2 prior agents, one of which must be Ocrevus. Dr. Glickstein noted a typo in Tysabri prescriber requirements – change nephrologist to neurologist. All actions at right were approved by the committee as presented, unless otherwise noted as “approved as modified”. See Target Date for dates changes will go into effect. Following class reviews, the consent items were presented (formulary maintenance, informational only):
Omeprazole ODT Lansoprazole ODT Tafluprost 0.0015% o/s (Zioptan™) Dulaglutide (Trulicity™) OTC Cough/Cold (selected items per State FFS
notification) Standard criteria wording for Site of Care Optimization and Self-Injected medications: When those were the only changes to criteria in the class reviews, the full criteria were not included in the packet since there were no changes to the therapeutic requirements. A summary list of all drugs in which either the SOC or Self-Injection verbiage are to be added to criteria was presented to the committee after the drug reviews and included in the packet. The committee was informed of the scheduled class reviews for the next P & T Committee meeting in October.
Revised Criteria. See PA Criteria section for details. Abaloparatide 80 mcg (Tymlos™) – approved as modified Alirocumab 75 mg/ml pen, PFS; 150 mg/ml pen, PFS (Praluent™) Belimumab inj (Benlysta™) Darbepoetin alfa, 1 mcg (Aranesp) (non-ESRD use) Edaravone inj (Radicava™) Epoetin alfa, 1000 units (Procrit, Epogen) (non-ESRD use) Epoetin alfa-epbx, biosimilar (Retacrit) (non-ESRD use), 1000 units
10/1/2020
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III. Old Business
a. Policy Updates
Two policies to review: MCRO4018 – Pharmacy TAR Procedure - Section IV: Updated title of Attachment A. - Section VI: Updated reference to PHC ‘online TAR portal from PARx to PAS. - Section VI.L: Added language addressing scenario when a TAR is denied for administration services (per diem) when an approval for a corresponding medication or total parenteral nutrition product is not in place.
Pending changes – drugs with imminent launch but no yet on the market or codes that the State has not yet sent coverage confirmation on. Drug Comments Q5150 Pegfilgrastim-bmez, biosimilar (Ziextenzo™)
Non-formulary for pharmacy, can apply Fulphila & Udenyca criteria. For PAD, will add to Amysis to mirror Fulphila & Udenyca when State sends out code coverage notice.
Glatiramer Depot inj (name TBD)
Will mirror existing glatiramer (Copaxone™) criteria upon market launch.
Monomethyl Fumarate capsules (Bafiertam™)
Will mirror existing oral MS agent criteria upon market launch.
Ozanimod capsules (Zeposia™)
Will mirror existing oral MS agent criteria upon market launch.
Pegfilgrastim (Neulasta™)
Will be updated to prefer new biosimilar, Ziextenzo™, when DHCS issues code coverage information.
Presented by: Tony Hightower, B.A., CPhT
10/1/2020
1/1/2021
All TBD, pending market launch, will be effective no sooner than 10/1/2020.
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IV. New Business
V. Additional Items VI. Adjournment
MCRP4067 - This policy establishes the requirement for medication infusion therapies to be rendered at a Site of Care with the least intensive setting that is appropriate for the delivery of the service.
None 1. Dr. Balano requested review of hydroxychloroquine, for
consideration of adding back to the formulary because the rheumatology department is finding the TAR requirement burdensome. Dr. Wong said they can talk more offline to come up with a solution, but that it may be best to leave as NF since State FFS also requires a TAR – meaning, there would be an enhanced grandfathering period of PHC TARs (up to lifetime), while if an item is F with PHC but NF with State FFS, the grandfathering is limited to April 2021. After speaking outside of the meeting, it was decided to leave as NF since that is how DHCS has it (to be consistent), except that PHC will add a specialist override (by taxonomy) so that rheumatology can be exempt from the TAR requirement. Doesn’t solve the short-term grandfathering, and Dr. Balano understood that if the State leaves HCQ as NF, they will need to submit TARs in 2021 for claims that paid without a PA at PHC in 2020. However, the hope is that DHCS will lift the TAR requirement before then. She also mentioned that our online HCQ criteria do not specify that it is for new starts only – PHC will make that change in wording.
2. Dr. Balano suggested including one of the RN managers
from Petaluma Health Center on the committee to assist with issues surrounding medication administration, for both patient advocate and medical provider insights for PAD reviews. Amy Anderson will attend the October meeting as a guest (followed by invitation to join).
Adjourned at 10:08 am
See revised criteria. An edit will be placed in which the PA requirement will be overridden when the prescriber is a board-certified rheumatologist. This was discussed offline (Dr. Wong & Dr. Balano participating) and this was accepted as a good approach since DHCS still does require a TAR for hydroxychloroquine.
10/1/2020
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Partnership HealthPlan of California 3Q20 P & T Committee, July 16, 2020 Minutes -- Approved Criteria
1. Site of Care Optimization:a. Standard text to be added to criteria when home & pharmacy suite infusion site of care is appropriate:
Medical benefit (claims submitted direct to PHC): Per Policy MCRP4067, Pharmacy Site of Care, the preferred site of care is home infusion or pharmacy infusion suite, with medication billed as a pharmacy claim. Requests for alternative sites of care will be evaluated on a case-by-case basis; for IV infusion at other sites, include rationale for site requirement on the TAR.
2. Self-administered injectable medications:a. When injectable products are labeled for self-administration, the preference for fullfillment will be through the pharmacy benefit rather than the medical benefit.
Many self-administered drugs are already classified by DHCS as being non-benefits for medical claims yet available through pharmacy claims. However, there aremany self-administered injections that are provided to members by both pharmacies and in medical settings.
b. PHC will be preferring that self-administered medication be fullfilled through the pharmacy benefit when a member or caregiver is capable of administering themedication as instructed.
c. Standard text to be added to criteria for self-administered drugs:
Medical Benefit (claims submitted direct to PHC): <insert drug name> is FDA approved as a self-administered maintenance drug, and as such, is required to be fulfilled at a pharmacy with direct dispensing to the member. Exceptions may be made for a one-time request for medical clinic/clinician reimbursement when necessary for first dose administration instructions &/or to monitor the member’s response to the initial dose. Subsequent doses must be provided by issuing aprescription for pharmacy dispensing to the member.
P & T Committee, July 16, 2020: Approved TAR criteria Effective Dates: Criteria will become effective October 1, 2020, except for hydroxyprogesterone caproate (Makena™), which will be effective Jan 1, 2021.
II. Standing verbiage for site-of-care optimization and self-injectable therapies:
A. The following is a list of drug criteria to which the above wording has been applied and approved by the committee:
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Partnership HealthPlan of California 3Q20 P & T, July 16, 2020 Minutes -- Approved Criteria
Check mark indicates which standing criteria verbiage will be applied:
Specialty & Drug Self-Injection dosage forms -- pharmacy fulfillment preferred for member self-administration
Site of Care Optimization-- with IV home infusion or pharmacy suite infusion preferred
II. Approved Drug Criteria (Class Reviews)A. Revisions to existing criteria are shown in redline, as proposed by PHC to P & T.B. Revisions made to any proposed criteria, by the Committee in the course of Committee review are shown
in blue font.
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Partnership HealthPlan of California 3Q20 P & T Committee, July 16, 2020 Minutes -- Approved Criteria
Prefilled syringes have been discontinued PROPOSED CRITERIA: Alirocumab pens, PFS (Praluent™) Criteria applies to new starts only (new to treatment on or after effective date of criteria requirements).
PA Document Title: Requirements for Praluent New Vs Revision: Revision
Covered Uses For use as adjunct to diet and maximally tolerated statin therapy for the treatment of adults with (1) heterozygous familial hypercholesterolemia (HeFH) OR (2) clinical atherosclerotic cardiovascular disease.
Reasons for Exclusion Lack of documentation of adequate trial of preferred alternatives and lifestylechanges. Lack of documentation of FDA approved indication (eg, claims for statins intolerance in the absence of heterozygous familial hypercholesterolemia or cardio-vascular disease with CV events while on maximum statin therapy).
Required Medical Documentation
Clinic notes confirming diagnosis of (a) heterozygous familial hypercholesterolemia OR (b) clinical atherosclerotic cardiovascular disease, including symptoms and CV events despite maximum dose statin treatment. Fill history to confirm adherence to treatment. Labs to document lack of LDL response to formulary alternatives.
Age Restriction 18 years and older. Prescriber Restriction Cardiology Coverage Duration Initial: 6 months. Renewal: 12 months
Other Requirements
Documentation of trial and failure (statin failure as defined per ACC Guidelines) of maximum doses of formulary atorvastatin AND rosuvastatin in combination with formulary ezetimibe (Zetia) for at least 12 weeks and with documented compliant use and lifestyle changes. If patient has confirmed contraindication to use of a statin, documentation of CVD high risk is required. Renewal criteria: Continued concomitant use of statin (if no contraindications). Approvals are limited to quantities not exceeding 2 pre-filled injection pen devices per 28 days. Medical Benefit (claims submitted direct to PHC): Alirocumab (Praluent™) is FDA approved as a self-administered maintenance drug, and as such, is required to be fulfilled at a pharmacy with direct dispensing to the member. Exceptions may be made for a one-time request for medical clinic/clinician reimbursement when necessary for first dose administration instructions &/or to monitor the member’s response to the initial dose. Subsequent doses must be provided by issuing a prescription for pharmacy dispensing to the member. Labeler (NDC) Restriction: Claims and TARs are limited to labeler 72733 (Sanofi-Aventis U.S. LLC). Submit requests using NDC 72733-5902-02 (150 mg) or 72733-5901-02 (75 mg).
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Partnership HealthPlan of California 3Q20 P & T Committee, July 16, 2020 Minutes -- Approved Criteria
PROPOSED CRITERIA: Evolocumab pens, PFS, & cartridges (Repatha™, Repatha Pushtronex™) Criteria applies to new starts only (new to treatment on or after effective date of criteria requirements).
PA Document Title: Requirements for Repatha New Vs Revision: Revision
Covered Uses (1) As adjunct to diet and other lipid-lowering therapies (e.g. statin, ezetimibe) for adults with primary hyperlipidemia (including HeFH). (2) Asadjunct to diet and other lipid-lowering therapies (e.g. statin, ezetimibe) for adults with homozygous familial hypercholesterolemia (HoFH). (3)Reduce risk of MI, stroke and coronary revascularization in adults with established CVD.
Reasons for Exclusion Lack of documentation of adequate trial of preferred alternatives and lifestyle changes. Lack of documentation of FDA approved indication (eg, claims for statins intolerance in the absence of heterozygous familial hypercholesterolemia or cardiovascular disease with CV events while on maximum statin therapy).
Required Medical Documentation
Clinic notes confirming diagnosis of (a) heterozygous familial hypercholesterolemia OR (b) homozygous familial hypercholesterolemia OR (c) clinical atherosclerotic cardiovascular disease, including symptoms and CV events despite maximum dose statin treatment. Fill history to confirm adherence to treatment. Labs to document lack of LDL response to formulary alternatives.
Age Restriction 18 years and older. Prescriber Restriction Cardiology Coverage Duration Initial: 6 months. Renewal: 12 months
Other Requirements
Documentation of trial and failure (statin failure as defined per ACC Guidelines) of maximum doses of formulary atorvastatin AND formulary rosuvastatin in combination with formulary ezetimibe (Zetia) for at least 12 weeks and with documented compliant use and lifestyle changes. If patient has confirmed contraindication to use of a statin, documentation of CVD high risk is required. Renewal criteria: Continued concomitant use of statin (if no contraindications). Approvals for HeFH and ASCVD risk reduction are limited to quantities not exceeding 2 pre-filled injection pen devices or syringes per 28 days. Approvals for HoFH are limited to quantities not exceeding 3 pre-filled injection pen devices or syringes per 28 days. Medical Benefit (claims submitted direct to PHC): Evolocumab (Repatha™) is FDA approved as a self-administered maintenance drug, and as such, is required to be fulfilled at a pharmacy with direct dispensing to the member. Exceptions may be made for a one-time request for medical clinic/clinician reimbursement when necessary for first dose administration instructions &/or to monitor the member’s response to the initial dose. Subsequent doses must be provided by issuing a prescription for pharmacy dispensing to the member. Labeler (NDC) Restriction: Claims and TARs are limited to labeler 72511 (Amgen USA). Submit claims and TARs with NDC 72511-0760-01 (140 mg/ml, 1 ml Pen), 72511-0751-01 (140 mg/ml, 1 ml PFS), 72511-0760-02 (140 mg/ml, 2 x pens) or 72511-0770-01 (420 mg/3.5ml cartridge).
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PROPOSED CRITERIA: Hydroxyprogesterone Caproate 250 mg/ml IM vials and SC auto-injector (Makena™ and generics) Type: ☒ Revised Existing Criteria PA Group Name: Requirements for Hydroxyprogesterone Caproate (Makena) Applies to: ☒ New Starts Only Effective date: Jan 1, 2021
Covered Uses To reduce the risk of preterm birth in women with a singleton pregnancy (single fetus) who have a history of singleton spontaneous preterm birth.
Reasons for Exclusion Per FDA package labeling, Makena™ hydroxyprogesterone caproate is not intended for use in women with multiple gestations or other risk factors for preterm birth.
Required Medical Documentation
Documented history of prior singleton spontaneous preterm birth (delivery at less than 37 weeks’ gestation). Treatment start date, treatment end date and the corresponding gestational week numbers.
Age Restriction Prescriber Restriction Coverage Duration Exact duration is dependent on start date. Will be extended up to & including gestational week 36.
Other Requirements
Member with a single fetus and documented history of spontaneous preterm delivery of singleton fetus. Treatment to start between 16 wks, 0 days and 20 weeks, 6 days, and continuing treatment through day 6 of week 36 or delivery, whichever occurs first. Requests to start treatment at 21 weeks or greater will require clinical data studies supporting efficacy with late treatment initiation. Note that brand Makena™ is PHC’s preferred product. Requests for generic hydroxyprogesterone caproate must include reasons why brand cannot be used, such as vials being necessary and yet brand not available, or the subcutaneous autoinjector is not indicated or is unavailable.
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PROPOSED CRITERIA: Teriparatide Subcutaneous Pen 20 mcg/dose (Forteo™) ☒ New Starts Only ☒ Revised Existing Criteria
Covered Uses Treatment of severe osteoporosis in members who are at high risk for osteoporotic fracture and are intolerant to other available osteoporosis therapy; increase bone mass in men with primary or hypogonadal osteoporosis at high risk for fracture; treatment of men and women with glucocorticoid-induced osteoporosis at high risk for fracture.
Reasons for Exclusion Risk for osteosarcoma (Paget’s disease of bone, history of prior radiation therapy, unexplained elevation of alkaline phosphatase, open epiphyses, prior external beam or implant radiation therapy involving the skeleton). Primary or secondary hyperparathyroidism. Other hypercalcemic disorders. Member hasalready received 24 months total paratide use (Tymlos &/or Forteo).
Required Medical Documentation
Include with TAR submission – 1. Clinic notes documenting osteoporotic fracture history and/or fragility fractures.2. BMD T-Score.3. Documentation of adherence with a formulary bisphosphonate (oral or IV) or and/or* denosumab (Prolia™), AND one of 2 preferred anabolicagents: abaloparatide (Tymlos™) OR romosozumab (Evenity™). *Number of agents as prerequisite therapy depends on severity, see “Other”,below.4. Documentation of treatment failure defined as a decline in T-score of greater than or equal to 5 percent after < 2 years of adherent use withabaloparatide or 1 year of adherent use with romosozumab. formulary bisphosphonate and/or non-formulary Prolia therapy. Note that a TAR isrequired for Prolia™, Tymlos™ and Evenity™, and members must meet criteria for those agents.
Age Restriction 18 years and older. Prescriber Restriction Prescribed by or recommended by an Endocrinologist. Coverage Duration 2 years 24-month maximum combined treatment duration per lifetime with parathyroid hormone analogs (Forteo plus any prior use of Tymlos). Other Requirements Limited to the FDA approved indications with the following criteria: (see “Covered Uses”, above), and in addition:
1.Treatment failure, intolerance or contraindication to formulary bisphosphonates AND non-formulary Prolia with a confirmed diagnosis of osteoporosis. Documented historyof one of the following is required: Osteoporotic vertebral or hip fracture, Fragility fracture, hip or lumbar spine T-Score of -2.5 or less, OR if T-score is between -1 and -2.5must have FRAX score of greater than or equal to 3 percent for hip fracture or greater than or equal to 20 percent for combined major osteoporotic fracture. 2. Treatmentfailure to either formulary zoledronic acid OR non-formulary Prolia with a confirmed diagnosis of severe osteoporosis defined as hip or lumbar spine T-score of -3.5 or belowor T-score of -2.5 or below plus a fragility fracture. Authorization is limited to 24 months of cumulative, lifetime PTH analog and/or PTH-related protein analog therapy.1. High Fracture Risk: Trial and failure (or contraindication) to both a bisphosphonate AND denosumab are required, and also either
Tymlos™ or Evenity™. In addition, one of the following is also required:a. History of a prior spine fracture, hip fracture, or fragility fracture; ORb. Femoral neck, total hip, or lumbar spine T-Score < -2.5; ORc. Femoral neck, total hip, or lumbar spine T-Score between -1 and -2.4, together with a FRAX score ≥ 3% for hip fracture risk or ≥ 20% for
major osteoporotic fracture risk2. Very High Fracture Risk: Trial and failure with a bisphosphonate OR denosumab, and either Tymlos™ or Evenity™. In addition, one of the
following is required:a. Femoral neck, total hip, or lumbar spine T-Score < -2.5, with spine, hip, or fragility fracture, ORb. Femoral neck, total hip, or lumbar spine T-Score < -3.5, regardless of fracture history or status.
Medical Benefit (claims submitted direct to PHC): Teriparatide is FDA approved as a self-administered maintenance drug, and as such, is required to be fulfilled at a pharmacy with direct dispensing to the member. Exceptions may be made for a one-time request for medical clinic/clinician reimbursement when necessary for first dose administration instructions &/or monitor the member’s response to the initial dose. Subsequent doses must be provided by issuing a prescription for pharmacy dispensing to the member.
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Approved as modified: Reasons for exclusion to include paratide use of 24 mo; in Other, 1b, changed < -2.5 to </= -2.5.
Partnership HealthPlan of California 3Q20 P & T Committee, July 16, 2020 Minutes -- Approved Criteria
PROPOSED CRITERIA: Abaloparatide 80 mcg SQ injection pen (Tymlos™) ☒ Revised Existing Criteria ☒ New Starts Only
Covered Uses Treatment of severe osteoporosis in members who are at high risk for osteoporotic fracture and are intolerant to other available osteoporosis therapy. Reasons for Exclusion
Risk for osteosarcoma (Paget’s disease of bone, history of prior radiation therapy, unexplained elevation of alkaline phosphatase, open epiphyses, prior external beam or implant radiation therapy involving the skeleton). Primary or secondary hyperparathyroidism. Other hypercalcemic disorders.
Required Medical Documentation
Include with TAR submission – 1. Clinic notes documenting osteoporotic fracture history and/or fragility fractures.2. BMD T-Score.3. Documentation of adherence with a formulary bisphosphonate (oral or IV) or and/or* denosumab (Prolia). *Depending on severity
a) Documentation of treatment failure defined as a decline in T-score of greater than or equal to 5 percent after 2 years of adherent use withformulary bisphosphonate and/or non-formulary Prolia therapy (both if failure to one; just one if there’s a contraindication to the other)
Age Restriction 18 years and older. Prescriber Restriction Prescribed by or recommended by an Endocrinologist. Coverage Duration 12 months 24-month maximum combined treatment duration per lifetime with parathyroid hormone analogs (Tymlos™ plus any prior use of Forteo™). Other Requirements Limited to the FDA approved indications with the following criteria: (see “Covered Uses”, above), and in addition:
1.Treatment failure, intolerance or contraindication to formulary bisphosphonates AND non-formulary Prolia with a confirmed diagnosis of osteoporosis.Documented history of one of the following is required: Osteoporotic vertebral or hip fracture, Fragility fracture, hip or lumbar spine T-Score of -2.5 or less, OR ifT-score is between -1 and -2.5 must have FRAX score of greater than or equal to 3 percent for hip fracture or greater than or equal to 20 percent for combined major osteoporotic fracture. 2. Treatment failure to either formulary zoledronic acid OR non-formulary Prolia with a confirmed diagnosis of severe osteoporosis defined as hip or lumbar spine T-score of -3.5 or below or T-score of -2.5 or below plus a fragility fracture. Authorization is limited to 24 months of cumulative, lifetime PTH analog and/or PTH-related protein analog therapy.
1. High Fracture Risk: Trial and failure (or contraindication) to both preferred treatments (bisphosphonate AND denosumab). In addition, one of the following is also required:
a. History of a prior spine fracture, hip fracture, or fragility fracture; ORb. Femoral neck, total hip, or lumbar spine T-Score </= - 2.5; ORc. Femoral neck, total hip, or lumbar spine T-Score between -1 and -2.4, together with a FRAX score ≥ 3% for hip fracture risk or ≥ 20%
for major osteoporotic fracture risk2. Very High Fracture Risk: Trial and failure with a bisphosphonate OR denosumab. In addition, one of the following is required:
a. Femoral neck, total hip, or lumbar spine T-Score </= -2.5, with spine, hip, or fragility fracture, ORb. Femoral neck, total hip, or lumbar spine T-Score </= -3.5, regardless of fracture history or status.
Medical Benefit (claims submitted direct to PHC): Abaloparatide is FDA approved as a self-administered maintenance drug, and as such, is required to be fulfilled at a pharmacy with direct dispensing to the member. Exceptions may be made for a one-time request for medical clinic/clinician reimbursement when necessary for first dose administration instructions &/or monitor the member’s response to the initial dose. Subsequent doses must be provided by issuing a prescription for pharmacy dispensing to the member.
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Dr. Kubota: (b) should be </= -2.5
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Approved as modified
Partnership HealthPlan of California 3Q20 P & T Committee, July 16, 2020 Minutes -- Approved Criteria
PROPOSED CRITERIA: Romosozumab-aqqg 1 mg prefilled syringe for SQ injection (Evenity™) ☒ New Criteria ☒ New Starts Only
Covered Uses Treatment of severe osteoporosis in members who are at high risk for osteoporotic fracture, defined as a history of osteoporotic fracture, or who have multiple risk factors for fracture.
Reasons for Exclusion
Risk for osteosarcoma (Paget’s disease of bone, history of prior radiation therapy, unexplained elevation of alkaline phosphatase, open epiphyses, prior external beam or implant radiation therapy involving the skeleton). Primary or secondary hyperparathyroidism. Other hypercalcemic disorders. Members who have significant cardiovascular risk such as myocardial infarction or stroke in the preceding 12 months.
Required Medical Documentation
Include with TAR submission – 1. Clinic notes documenting osteoporotic fracture history and/or fragility fractures.2. BMD T-Score.3. Documentation of adherence with a bisphosphonate (oral or IV) and/or* denosumab (Prolia). *Depending on severity
a) Documentation of treatment failure defined as a decline in T-score of greater than or equal to 5 percent after 2 years ofadherent use with a bisphosphonate and/or denosumab (Prolia) therapy (both if failure to one; just one if there’s acontraindication to the other)
Age Restriction ≥ 18 yrs Prescriber Restriction Prescribed by or recommended by an Endocrinologist. Coverage Duration 12 months maximum treatment duration per lifetime.Other Requirements 1. High Fracture Risk: Trial and failure (or contraindication) to both preferred treatments (bisphosphonate AND denosumab). In addition,
one of the following is also required:a. History of a prior spine fracture, hip fracture, or fragility fracture; ORb. Femoral neck, total hip, or lumbar spine T-Score </= - 2.5; ORc. Femoral neck, total hip, or lumbar spine T-Score between -1 and -2.4, together with a FRAX score ≥ 3% for hip fracture risk or ≥
20%for major osteoporotic fracture risk
2. Very High Fracture Risk: Trial and failure with a bisphosphonate OR denosumab. In addition, one of the following is required:a. Femoral neck, total hip, or lumbar spine T-Score </= -2.5, with spine, hip, or fragility fracture, ORb. Femoral neck, total hip, or lumbar spine T-Score </= -3.5, regardless of fracture history or status.
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Approved as modified (correction in Other, 1b: from < -2.5 to </= -2.5
Partnership HealthPlan of California 3Q20 P & T Committee, July 16, 2020 Minutes -- Approved Criteria
Covered Uses Treatment of secondary hyperparathyroidism (HPT) in adults with chronic kidney disease (CKD) on hemodialysis.
Reasons for Exclusion Adults with parathyroid carcinoma, primary hyperparathyroidism (HPT) or with CKD not on hemodialysis
Required Medical Documentation (new starts)
• Current labs to confirm diagnosis of secondary HPT of renal origin and CKD/ESRD on hemodialysis• Dose will be administered at time & location of hemodialysis sessions (following dialysis)• Documentation of inadequate response, significant adherence difficulty that cannot be overcome, or history of adverse reaction tocinacalcet.• 2 lab reports showing PTH is consistently at least 2 times over the PTH assay upper limit.
Age Restriction 18 years and older Prescriber Restriction Nephrology Coverage Duration Initial: 3 months for titration. Maintenance: 12 months when dose is stable (6 months with dose increase).
Other Requirements
TAR renewals with dose increase: Submit current labs to indicate parathyroid level and corrected calcium with renewal requests. Recommended dosing per the FDA package labeling:
Initial dose: 5 mg, 3 times per week at end of hemodialysis. Titration of dose: 2.5 mg or 5 mg increments no more frequent than once per 4 weeks Maximum dose: 15 mg, 3 times per week. Dose should not be given if hemodialysis is missed, and resume dose with next dialysis treatment. If doses are missed between 2 -3 weeks then treatment needs to be restarted at initial dose of 5 mg, 3 times per week. Start at 2.5 mg, 3 times a week if > 3 weeks have been missed.
Treatment Goals for secondary hyperparathyroidism (K/DOQI clinical practice guidelines 2017, UpToDate) • Serum Phosphate between 3.5 -5.5 mg/dL (1.13 to 1.78 mmol/L)• Serum corrected Ca <9.5 mg/dL (<2.37 mmol/L)• PTH < 2-9 times the upper limit for the PTH assay (ie, treated when PTH is consistently 2-9 times higher than the PTH assay upper limit).
PROPOSED CRITERIA: Etelcalcetide injection (Parsabiv™) ☒ New Criteria ☒ New Starts Only
Partnership HealthPlan of California 3Q20 P & T Committee, July 16, 2020 Minutes -- Approved Criteria
PROPOSED CRITERIA: Enzyme Replacement Drugs ☒ New Criteria ☒ New Starts Only
The criteria below are consistent with State Medi-Cal TAR requirements and will incorporate Site of Care optimization where appropriate. Covered Uses Aldurazyme: Mucopolysaccharidosis I (MPS I) types: (1) Hurler, (2)
Hurler-Scheie, and (3) Moderate to severe Scheie form. Lumizyme: Pompe Disease
Mepsevii: Mucopolysaccharidosis VII (MPS VII, Sly Syndrome)
Cerezyme, Vpriv: Gaucher Disease Type 1 (Cerezyme may be used off-label for Type 3)
Naglazyme: Mucopolysaccharidosis VI (Maroteaux-Lamy syndrome)
Elaprase: Hunter syndrome (mucopolysaccharidosis II, MPS II) Vimizim: Mucopolysaccharidosis IV (Morquio Syndrome) Fabrazyme: Fabry Disease
Reasons for Exclusion (none) Required Medical Documentation
For all products -- Clinic notes which include: Documentation of the FDA approved indication Subjective findings (complaints) Objective findings (Enzyme levels, DNA mutation analysis, medical history, physical exam, member weight) Complications (eg, bony changes or kidney failure) Quality of life issues (eg, severe, unremitting pain or extreme fatigue) Treatment plan: Identify the licensed practitioner who will administer the infusion and coordinate care, genetic evaluation & counseling
information for the patient and family members Goals: Include specific information about the desired outcome, for example: slow progression, allow regular attendance at work or school,
or to significantly improve quality of life.Age Restrictions Vpriv: ≥ 4 yrs Brineura: 3-18 yrs All others: none Prescriber Restrictions Neurologist, Endocrinologist, Cardiologist or other appropriate genetic disease specialist. Coverage Duration Initial & Renewal: 6 months
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Partnership HealthPlan of California 3Q20 P & T Committee, July 16, 2020 Minutes -- Approved Criteria
Enzyme replacement therapies, continued
Other Requirements Renewal TARs must include follow-up information such as any significant changes in physical findings, laboratory parameters, symptoms and/or quality of life.
Dose greater than that recommended by the manufacture will require documentation of the medical necessity of the requested dose. Maximum recommended doses: Agalsidase Beta (Fabrazyme) 5 mg & 35 mg SDV 1 mg/kg every 2 weeks Alglucosidase Alfa (Lumizyme) 50 mg SDV 20 mg/kg every 2 weeks Cerliponase Alfa (Brineura) 150 mg/5ml kit (2 vials) 300 mg every other week (via aseptic intraventricular infusion into CSF) Elosulfase Alfa (Vimizim) 1 mg/ ml, 5 ml SDV 2 mg/kg once weekly Galsulfase (Naglazyme) 5 mg/5 ml SDV 1 mg/kg once weekly Idursulfase (Elaprase) 2 mg/ml, 3ml SDV 0.5 mg/kg once weekly Imiglucerase (Cerezyme) 400 unit SDV Individualized based on response. Some pts need more frequent dosing (up
to TIW) while others can be dosed every other week. Doses range from 2.5 u/kg TIW to 60 u/kg QOW. State Medical maximum daily dose is 818 billed units (8,180 dose units), without documentation that weight is over 300 lbs.
Laronidase (Aldurazyme) 2.9 mg/5 ml SDV 0.58 mg/kg once weekly Velaglucerase Alfa (Vpriv) 400 unit SDV 60 units/kg every other week Vestronidase Alfa-vjbk (Mepsevii) 2 mg/ml 5 ml vials 4 mg/kg every 2 weeks
Pharmacy benefit (claims submitted to PBM): Lumizyme & Vpriv only: ☒ LD/SP: Limited to dispensing by AllianceRx/Walgreen’s Prime
Medical benefit (claims submitted direct to PHC): Site of care, Aldurazyme, Cerezyme, Elaprase, Fabrazyme, Lumizyme: Per Policy MCRP4067, Pharmacy Site of Care, the preferred site of care is home infusion or pharmacy infusion suite, with medication billed as a pharmacy claim. Requests for alternative sites of care will be evaluated on a case-by-case basis; for IV infusion at other sites, include rationale for site requirement on the TAR.
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Partnership HealthPlan of California 3Q20 P & T Committee, July 16, 2020 Minutes -- Approved Criteria
PROPOSED CRITERIA: Voxelotor (Oxbryta™) 500 mg tablets ☒ New Criteria ☒ New Starts Only
Covered Uses Sickle Cell Disease
Reasons for Exclusion None
Required Medical Documentation
TAR documentation is to include: 1) Number of events within the past 365 days prior to request for voxelotor (Oxbryta).2) Documentation of adherent use of hydroxyurea for a minimum of 3 months (pharmacy claim history).3) Documentation that the member continues to have >/= 2 events annually or no decrease in events while using hydroxyurea for a minimum of
3 months.
Age Restriction 12 years and older Prescriber Restriction Prescribed or recommended by a hematologist
Coverage Duration Initial request: 6 months. Renewal: 12 months when benefit of treatment is documented.
Other Requirements Initial renewal request: Clinic notes to indicate benefit to treatment such as reduction of vaso-occlusive events. Qty Limit: 3 per day
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Partnership HealthPlan of California 3Q20 P & T Committee, July 16, 2020 Minutes -- Approved Criteria
PROPOSED CRITERIA: Crizanlizumab-tmca vials (Adakveo™) ☒ New Criteria ☒ New Starts Only
Covered Uses Sickle Cell Disease Reasons for Exclusion None
Required Medical Documentation
1) Current weight (kg) within the last 4 weeks, summited with initial request and each renewal request.2) Number of events in the past 365 days, prior to treatment with Adakveo.3) Documentation of an inadequate response after at least a 3-month trial each of both hydroxyurea AND voxelotor (Oxbryta), despite
compliant use. An inadequate response would be demonstrated when the member continues to have >/= 2 events annually or no decreasein number of events prior to start of Adakveo.
Age Restriction 16 years and older Prescriber Restriction Prescribed by a hematologist Coverage Duration 6 months
Other Requirements
Initial dosing limited to 5 mg/kg on week 0 and week 2. Maintenance dosing limited to 5 mg/kg once every 4 weeks. For missed doses – if administered within 2 weeks after missed dose, continued dosing according to original schedule, however if missed dose is administered greater than 2 weeks then then continue dosing every 4 weeks using last date of dosing.
Renewal requests: Current weight (kg) within the last 4 weeks and benefit to treatment such as reduction of events.
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Partnership HealthPlan of California 3Q20 P & T Committee, July 16, 2020 Minutes -- Approved Criteria
Type: ☒ New Criteria Applies to: ☒ New Starts Only
Covered Uses RhD-postive non-splenectomized children with acute ITP, RhD-postive non-splenectomized children and adults with chronic ITP, ITP secondary to HIV infection.-
Reasons for Exclusion RhD- negative type or cause of thrombocytopenia other than ITP or in splenectomized patients or Hgb < 8 g/dl.
Required Medical Documentation
Clinical documentation to confirm diagnosis of ITP with platelet count < 30,000/microL, or platelets count between 30,000 – 50,000/microL in patients with high risk for bleeding (peptic ulcer, use of anticoagulants, high risk of falling) vs malignancy or other determinate cause of thrombocytopenia AND inadequate response to oral glucocorticoids (dexamethasone, prednisone), including length of treatment and labs to confirm inadequate response or reason(s) for failure/clinical contraindication to treatment. Current weight and CBC, within past 30 days of request.
Age Restriction None Prescriber Restriction Gastroenterology, Hematology, Hepatologist
Coverage Duration TBD – Dosing can be given as a single IV dose or divided into 2 separate days and frequency is determined by desired clinical response.
Other Requirements
Renewal requests: Current weight (kg) within the last 30 days and current CBC to indicate inadequate response from initial dose.
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Partnership HealthPlan of California 3Q20 P & T Committee, July 16, 2020 Minutes -- Approved Criteria
PROPOSED CRITERIA: Romiplostim (Nplate™) inj
Type: ☒ New Criteria Applies to: ☒ New Starts Only PA Group Name: Thrombopoietin (TPO) receptor agonist
Covered Uses Immune thrombocytopenia (ITP) with risk for bleeding Reasons for Exclusion Used to normalize platelet count, any cause of thrombocytopenia other than ITP
Required Medical Documentation
Clinical documentation to confirm diagnosis of ITP with platelet count < 30,000/microL, or platelets count between 30,000 – 50,000/microL in patients with high risk for bleeding (peptic ulcer, use of anticoagulants, high risk of falling) vs malignancy or other determinate cause of thrombocytopenia AND inadequate response to oral glucocorticoids, AND with either IVIG (e.g. Gammagard™) or Anti-D immunoglobulin [Rho(D) immune globulin] AND Eltrombopag (Promacta) including length of treatment and labs to confirm inadequate response or reason(s) for failure/clinical contraindication to treatment or splenectomy. Current weight, within past 30 days of request.
Age Restriction ≥ 1 year Prescriber Restriction Hematologist
Coverage Duration Initial: 2 months. Renewal: 6 months with current CBC included to indicate benefit with treatment
Other Requirements
Max dose up to 10 mcg/kg/week.
Note: Nplate should be discontinued if an increase platelet count has not been achieved after 4 weeks at maximum allowed/tolerated dose for ITP.
Comments: Romiplostim increases platelet production through binding and activation of the thrombopoietin (TPO) receptor, a mechanism analogous to endogenous TPO. Dosing: Adjust dose by 1 mcg/kg/week increments to achieve platelet count of at least 50 × 109/L to reduce the risk for bleeding. If the platelet count is less than 50 × 109/L, increase weekly dose by 1 mcg/kg. If the platelet count is more than 200 × 109/L to 400,000 × 109/L or less for 2 consecutive weeks, reduce weekly dose by 1 mcg/kg. If the platelet count is more than 400 × 109/L, withhold dose and continue to assess the platelet count weekly; when platelet count is less than 200 × 109/L, resume with the weekly dose reduced by 1 mcg/kg. Median dose needed to achieve response in clinical trials was 2 mcg/kg/week.
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Partnership HealthPlan of California 3Q20 P & T Committee, July 16, 2020 Minutes -- Approved Criteria
PROPOSED CRITERIA: Eltrombopag (Promacta™) 12.5 mg, 25 mg, 50 mg, 75 mg tablets ☒ New Criteria ☒ New Starts Only
Comments: Eltrombopag is a small molecule thrombopoietin (TPO) agonist. Promacta has a black box warning for hepatotoxicity and monitored every 2 weeks during doseadjustment and monthly following established stable dose. Initial dose of 25 mg - 50 mg once per day for treatment of chronic ITP and chronic Hep-C associated thrombocytopenia maybe adjusted to achieve and maintain a platelet count of ≥50 x 109. Target platelet count with treatment is to maintain 50,000 -200,000/mm3.
Covered Uses Chronic immune thrombocytopenia (ITP), Chronic Hep – C associated thrombocytopenia, Severe Aplastic anemia in combination with standard immunotherapy
Reasons for Exclusion Treatment for myelodysplastic syndrome (MDS)
Required Medical Documentation
Baseline liver enzymes levels dated within one month prior to request. Documentation to confirm chronic ITP with platelet count < 30,000/microL,or platelets count between 30,000 – 50,000/microL in patients with high risk for bleeding (peptic ulcer, use of anticoagulants, high risk of falling) or chronic Hep. C associated thrombocytopenia with inadequate response to oral glucocorticoids, AND with either IVIG (e.g. Gammagard™) or Anti-D immunoglobulin [Rho(D) immune globulin] or splenectomy including length of treatment and labs to confirm inadequate response or reason(s) for failure/clinical contraindication to treatment OR documentation of severe aplastic anemia in combination with standard immunosuppressive therapy (eg. antithymocyte globulin [equine], Atgam and cyclosporine).
Age Restriction ≥ 1yr for Chronic ITP, ≥ 2 yrs for aplastic anemia, ≥ 18 yrs for Chronic Hep-C associated thrombocytopenia Prescriber Restriction Gastroenterology, Hematology, Hepatologist Coverage Duration Initial: 2 months. Renewal: 6 months with CBC and liver enzymes included to indicate benefit and safety with treatment
Other Requirements
Maximum dosing: • ITP: 75 mg per day. Note: Promacta should be discontinued if an increase platelet count has not been achieved after 4 weeks at maximum
allowed or tolerated doses for ITP. • Hepatitis C: 100 mg per day• Severe aplastic anemia: 150 mg per day.
PROPOSED CRITERIA: Eltrombopag (Promacta™) 12 mg/packet, 25 mg/packet ☒ New Criteria ☒ New Starts OnlyCovered Uses (Same as above) Reasons for Exclusion (Same as above) Required Medical Documentation
Same as above, and in addition: Documentation regarding inability to swallow, eltrombopag (Promacta) tablets.
Age Restriction Same as above Prescriber Restriction Same as above Coverage Duration Same as above Other Requirements Same as above
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Partnership HealthPlan of California 3Q20 P & T Committee, July 16, 2020 Minutes – Approved Criteria
PROPOSED CRITERIA: Pegfilgrastim-bmez injection (Ziextenzo™) Criteria applies to new starts only (new to treatment on or after effective date of criteria requirements).
PA Document Name: Requirements for Pegfilgrastim-jmdb (Fulphila) and Pegfilgrastim-cbqv (Udenyca)Pegfilgrastim biosimilars
No change to criteria – adding Ziextenzo™ to existing PA group for Fulphila & Udenyca, and renaming the PA group to more generically include any new biosimilars going forward.
Covered Uses Prevention of chemotherapy-induced neutropenia.
Reasons for Exclusion Use for mobilization of peripheral blood progenitor cells for hematopoietic stem cell transplantation. Dosed more frequently than every 14 days for prevention of chemotherapy-induced neutropenia.
Required Medical Documentation
Clinic notes documenting diagnosis, specific chemotherapy regimen with dose and frequency, current and past absolute neutrophil count (ANC) lab report documenting history of severe neutropenia secondary to chemotherapy (if applicable), and any member-specific risk factors for developing neutropenia. For chemotherapy regimens not identified as having high risk (greater than 20%) or intermediate risk (10-20%) of febrile neutropenia (FN) in the absence of any associated patient risk factor, clinical literature supporting intermediate to high risk of FN may be required.
Age Restriction None
Prescriber Restriction Prescribed by, or in consultation with, an oncologist or hematologist.
Coverage Duration TBD based on chemotherapy regimen, up to a maximum of 6 months per authorization.
Other Requirements
For prevention of chemotherapy-induced neutropenia, must meet ONE of the following: (1) Primary prophylaxis of febrile neutropenia in patients receiving myelosuppressive chemotherapy with an expected incidence of febrile neutropenia of greater than 20% (high risk) or at least 10-20% (intermediate risk) if patient has at least one risk factor for developing neutropenia as summarized in the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for use of Myeloid Growth Factors. (2) Secondary prophylaxis of febrile neutropenia in patients who experienced neutropenic complication from prior chemotherapy and did not receive primary prophylaxis with a myeloid growth factor and a reduced dose or frequency of chemotherapy may compromise treatment outcome. NOTE: Request for off-label use will be reviewed on a case-by-case basis.
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Partnership HealthPlan of California 3Q20 P & T Committee, July 16, 2020 Minutes – Approved Criteria
PROPOSED CRITERIA: Pegfilgrastim (Neulasta, Neulasta Onpro) Criteria applies to new starts only (new to treatment on or after effective date of criteria requirements).
PA Document Name: Requirements for Neulasta & Neulasta Onpro
Covered Uses Prevention of chemotherapy-induced neutropenia. Hematopoietic Syndrome of Acute Radiation Syndrome [H-ARS].
Reasons for Exclusion Use for the mobilization of peripheral blood progenitor cells for hematopoietic stem cell transplantation. Dosed more frequently than every 14 days for prevention of chemotherapy-induced neutropenia.
Required Medical Documentation
Clinic notes documenting diagnosis, specific chemotherapy regimen with dose and frequency, current and past absolute neutrophil count (ANC) lab report documenting history of severe neutropenia secondary to chemotherapy (if applicable), and member specific risk factors for developing neutropenia (if any). For chemotherapy regimens not identified as having high risk (greater than 20%) or intermediate risk (10-20%) of febrile neutropenia (FN) in the absence of any associated patient risk factors, clinical literature supporting intermediate to high risk of FN may be required.
Age Restriction None
Prescriber Restriction Prescribed by, or in consultation with, an oncologist or hematologist.
Coverage Duration TBD based on chemotherapy regimen, up to a maximum of 6 months per authorization.
Other Requirements
For prevention of chemotherapy-induced neutropenia, clinical documentation supporting inadequate response with to preferred Pegfilgrastim-jmdb (Fulphila) and Pegfilgrastim-cbqv (Udenyca®) with laboratory evidence or medical rationale as to why Pegfilgrastim-jmdb (Fulphila) and Pegfilgrastim-cbqv (Udenyca®)a preferred biosimilar product (Fulphila™, Udenyca™, or Ziextenzo™) cannot be used must be provided. ALSO must meet ONE of the following: (1) Primary prophylaxis of febrile neutropenia in patients receiving myelosuppressive chemotherapy with an expected incidence of febrile neutropenia of greater than 20% (high risk) or at least 10-20% (intermediate risk) if patient has at least one risk factor for developing neutropenia as summarized in the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for use of Myeloid Growth Factors. (2) Secondary prophylaxis of febrile neutropenia in patients who experienced neutropenic complication from prior chemotherapy and did not receive primary prophylaxis with a myeloid growth factor and a reduced dose or frequency of chemotherapy may compromise treatment outcome. NOTE: Request for Hematopoietic Syndrome of Acute Radiation Syndrome [H-ARS] and off-label use will be reviewed on a case-by-case basis.
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Partnership HealthPlan of California 3Q20 P & T Committee, July 16, 2020 Minutes -- Approved Criteria
PROPOSED CRITERIA: Belimumab 10 mg vial for IV infusion; pens and prefilled syringes for subcutaneous injection (Benlysta™) Type: ☒ Revised Existing Criteria Applies to: ☒ New Starts Only PA Group Name: Requirements for Benlysta
Covered Uses For the treatment of active, autoantibody- positive, systemic lupus erythematosus (SLE) in combination with standard therapy Reasons for Exclusion
Use is not recommended in patients with severe active lupus nephritis, severe active CNS lupus, or in combination with other biologics, including B- cell targeted therapies or IV cyclophosphamide.
Required Medical Documentation
Required lab reports: CBC, Creatinine, Sed Rate, Anti-DS DNA, Complement (C3 and C4). In the event that lab results do not support the diagnosis of active disease, an in-office second opinion is required. Requested dose does not exceed the FDA approved dose and frequency per manufacturers labeling.
Age Restriction Pens & PFS: 18 years and older; Vials (IV): 5 yrs and older Prescriber Restriction None
Coverage Duration 6 months
Other Requirements
Approval is limited to those requests for adult members with SLE, which document: Active, Antibody positive musculo-skeletal or cutaneous systemic lupus erythematosus. Member does not have severe active lupus nephritis Member does not have severe active CNS lupus Member is currently receiving standard therapy such as NSAIDs, corticosteroids, antimalarials (eg, chloroquine, hydroxychloroquine) or immunosuppressives (eg, cyclophosphamide, azathioprine, mycophenolate or methotrexate), and requires the equivalent of at least 10 mg prednisone per day in combination with either azathioprine or mycophenolate. Treatment will not be in combination with other biologics, nor in combination with IV cyclophosphamide. Approval duration is limited to 6 months, with clinical reassessment prior to renewal request. Renewals are limited to those which document improvement. Adults: Subcutaneous route of administration is preferred. TARs for IV vials must include reasons why member cannot use self-administered pens or syringes. Pharmacy Benefit (claims submitted to PBM): Must be dispensed by AllianceRx/Walgreens Prime. Medical Benefit (claims submitted direct to PHC): Benlysta™ is FDA approved as a self-administered maintenance drug in adults, and as such, subcutaneous pens and prefilled syringes are required to be fulfilled at a pharmacy with direct dispensing to the member. Exceptions may be made for a one-time request for medical clinic/clinician reimbursement when necessary for first dose administration instructions &/or monitor the member’s response to the initial dose. Subsequent doses must be provided by issuing a prescription for pharmacy dispensing to the member. IV infusion requests: Preferred site of care is home infusion or pharmacy infusion suite, with medication billed as a pharmacy claim. For IV infusion at other sites, include rationale for site requirement on the TAR.
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PROPOSED CRITERIA: Edaravone IV (Radicava™) ☒ New Starts Only ☒ Revised Existing Criteria
Covered Uses For the treatment of amyotrophic lateral sclerosis (ALS).
Reasons for Exclusion Required Medical Documentation
Initial therapy: Documentation showing: (1) definite or probable ALS based on El Escorial revised criteria, AND (2) score of 2 or more on all items of the ALS Functional Rating Scale-Revised ALSFRS-R, AND (3) normal respiratory function (FVC equal to or greater than 80%). Prescriber notes and/or pharmacy claims documenting concurrent use of Riluzole or reason(s) why Riluzole cannot be used. Continuing therapy: Documentation of ALSFRS-R with a score of 2 or more on all items.
Age Restriction 20 18 years and older Prescriber Restriction Neurologist Coverage Duration 6 months Other Requirements The initial treatment cycle is daily dosing for 14 days, followed by 14 days off the drug. Subsequent treatment cycles are daily dosing for 10 days
out of 14-day periods, followed by 14 days off the drug. Quantity limited to 2800 ml for a 28 day supply per fill.
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Partnership HealthPlan of California 3Q20 P & T Committee, July 16, 2020 Minutes -- Approved Criteria
Medical benefit (claims submitted direct to PHC): Site of care: Per Policy MCRP4067, Pharmacy Site of Care, the preferred site of care is home infusion or pharmacy infusion suite, with medication billed as a pharmacy claim. Requests for alternative sites of care will be evaluated on a case-by-case basis; for IV infusion at other sites, include rationale for site requirement on the TAR.
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Partnership HealthPlan of California 3Q20 P & T Committee, July 16, 2020 Minutes -- Approved Criteria
PROPOSED CRITERIA: Patisiran IV 10 mg/5 ml vials (Onpattro™) Type: ☒ New Criteria Applies to: ☒ New Starts Only
Covered Uses Polyneuropathy of hereditary transthyretin-mediated amyloidosis (hereditary TTM).
Reasons for Exclusion Concurrent use with inotersen (Tegsedi™), diflunisal, tafamidis meglumine (Vyndaqel™), or tafamidis (Vyndamax™)
Required Medical Documentation
Submit medical records with TAR. Must have all of the following documented in the medical record:
Biopsy verification of amyloidosis
Genetic testing results confirming a TTR gene mutation
Patient is experiencing clinical signs and symptoms of the disease such as peripheral sensorimotor polyneuropathy, autonomic neuropathy,motor disability, etc.
Coverage Duration Initial: 6 months. Renewal: 12 months with documentation of response to treatment
Other Requirements
Requires trial and failure/inadequate response, or contraindication to therapeutic alternatives: 1. A GABA analog such as gabapentin or pregabalin, or2. A tricyclic antidepressant such as nortriptyline or amitriptyline
HCPCS code: J0222 (injection, patisiran, 0.1 mg) Maximum dose: 30 mg (300 billing units). Frequency: Every 3 weeks.
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Class Review Action Items
Partnership HealthPlan of California 3Q20 P & T Committee, July 16, 2020 Minutes -- Approved Criteria
PROPOSED CRITERIA: Inotersen 284 mg/1.5 ml single dose prefilled syringes (Tegsedi™)
Type: ☒ New Criteria Applies to: ☒ New Starts Only PA Group Name: Requirements for Inotersen (Tegsedi)
Covered Uses Polyneuropathy of hereditary transthyretin-mediated amyloidosis.
Reasons for Exclusion Platelet count < 100 x 109/L; history of acute glomerulonephritis caused by Tegsedi™; history of hypersensitivity reaction to Tegsedi™. Concurrent use with patisiran (Onpattro™), diflunisal, tafamidis meglumine (Vyndaqel™), or tafamidis (Vyndamax™).
Required Medical Documentation
Submit medical records with TAR. Must have all of the following documented in the medical record:
Biopsy verification of amyloidosis
Genetic testing results confirming a TTR gene mutation
Patient is experiencing clinical signs and symptoms of the disease such as peripheral sensorimotor polyneuropathy, autonomicneuropathy, motor disability, etc.
Labs prior to treatment: platelets, serum creatinine, eGFR, urine protein to creatinine ratio (UPCR), urinalysis.
REMS: Prescriber is certified and member has enrolled
Member will be using appropriate contraception when of child-bearing age (both males and females).
Age Restriction ≥ 18 yrs
Prescriber Restriction Neurologist
Coverage Duration 6 months. Submit recent labs as noted above with renewal requests.
Other Requirements
Treatments should be held if member develops UPCR ≥1000 mg/g, or eGFR < 45 mL/min/1.73m2 pending further evaluation of the cause.
Tegsedi™ is FDA approved as a self-administered maintenance drug in adults, and as such, subcutaneous pens and prefilled syringes are required to be fulfilled at a pharmacy with direct dispensing to the member. Exceptions may be made for a one-time request for medical clinic/clinician reimbursement when necessary for first dose administration instructions &/or monitor the member’s response to the initial dose. Subsequent doses must be provided by issuing a prescription for pharmacy dispensing to the member.
HCPCS: J3490. TARs and claims must include NDC.
Units: Billed in ML, with 1 dose=1.5 ml.
Medical claim limit: 1 dose, not to be repeated without justification for medical provider administration (subsequent claims fulfilled by pharmacy).
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Partnership HealthPlan of California 3Q20 P & T Committee, July 16, 2020 Minutes -- Approved Criteria
PROPOSED CRITERIA: Alemtuzumab 12 mg/1.2 ml SDV for IV infusion (Lemtrada™) ☒ New Criteria ☒ New Starts Only
Covered Uses Indicated for the treatment of relapsing forms of multiple sclerosis (MS), to include relapsing-remitting disease and active secondary progressive disease, in adults. Because of its safety profile, the use of LEMTRADA should generally be reserved for patients who have had an inadequate response to two or more drugs indicated for the treatment of MS.
Reasons for Exclusion
Concurrent Use with Other Disease-Modifying Agents Used for Multiple Sclerosis (MS), either oral or injectable Concurrent HIV infection or positive test for tuberculosis infection.
Required Medical Documentation
Diagnosis of a relapsing form of multiple sclerosis (MS), such as relapsing-remitting or secondary progressive with a negative HIV lab result and had inadequate response or is unable to tolerate at least two first line treatment (injection and oral) disease-modifying agents used for MS (e.g., Avonex, Rebif, Betaseron, Extavia, Copaxone, Plegridy, Gilenya, Glatopa, glatiramer acetate injection, Aubagio, Tecfidera, or Ocrevus), one of which must be Ocrevus.
Age Restriction 18 years and older Prescriber Restriction Must be prescribed by, or in consultation with, a neurologist or under the guidance of a neurologist
Coverage Duration Initial: 5 days’ total treatment. First Renewal: 3 days’ total treatment not to be dosed sooner than 12 months from last cycle dosed. Subsequent renewal: Case by case basis considering neurologist’s recommendation for additional dosing beyond standard 2 years and not to exceed 3 days’ treatment per 12-month cycle.
Other
Dosing Limitation: Maximum 5 total infusions of 12 mg each during first cycle of 5 consecutive days (5 vials=6mL=60mg). After the first infusion cycle, a maximum of 3 total infusions of 12 mg during subsequent cycles of 3 consecutive days (3 vials=3.6mL=36mg) may be considered medically necessary when documentation (including chart notes) indicate that there is disease stability or improvement.
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Partnership HealthPlan of California 3Q20 P & T Committee, July 16, 2020 Minutes -- Approved Criteria
PROPOSED CRITERIA: Natalizumab IV infusion (Tysabri™) ☒ New Criteria ☒ New Starts Only
Covered Uses Induce or maintain remission of moderate to severe Crohn’s disease (CD) and relapsing form of multiple sclerosis (RRMS).
Reasons for Exclusion
Prior or current diagnosis of PML. Concurrent use of immunosuppressants (eg, azithromycin, methotrexate, 6-mercaptopurine) or concomitant TNF inhibitors such as but not limited to: etanercept (Enbrel), infliximab (Remicade), adalimumab (Humira). Dose requested greater than 300 mg every 4 weeks.
Required Medical Documentation
For diagnosis of CD or MS: Current lab report of liver function tests (LFTs), eye exam AND baseline quantitative serum anti-JCV antibody test results with index value to assess risk of PML prior to start of treatment.
Additional for CD: Documented failure to compliant trial of oral immunomodulators: azathioprine, 6 –mercaptopurine or methotrexate AND an anti-TNF agent adalimumab (Humira) or infliximab (Inflectra or Renflexis).
Additional for RRMS: Documented failure (one or more relapses, two or more unequivocally new MRI detected lesions or increased disability on exam over a one-year period) to compliant use of two first-line/preferred treatments, one of which is ocrelizumab (Orcrevus).
Age Restriction 18 years and older Prescriber Restriction Gastroenterologist, Neurologist
Renewal request after initial approval for CD: Clinical documentation regarding response to treatment (If there is no therapeutic benefit by 12 weeks of treatment or chronic steroids prior to start of natalizumab and steroids cannot be tapered off within 6 months of treatment R if patient requires additional steroid use that greater than 3 months within the past 365 days, natalizumab should be discontinued).
Renewal request for both CD and MS for maintenance: Updated LFTs, eye exam and JVC antibody level
Pharmacy benefit (claims submitted to PBM): Must be dispensed by AllianceRx/Walgreens Prime.
Medical benefit (claims submitted direct to PHC): Site of care: Per Policy MCRP4067, Pharmacy Site of Care, the preferred site of care is home infusion or pharmacy infusion suite, with medication billed as a pharmacy claim. Requests for alternative sites of care will be evaluated on a case-by-case basis; for IV infusion at other sites, include rationale for site requirement on the TAR.
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Approved as modified
Partnership HealthPlan of California 3Q20 P & T Committee, July 16, 2020 Minutes -- Approved Criteria
PROPOSED CRITERIA: Ocrelizumab (Ocrevus™): ☒ Revised Criteria ☒ New Starts Only PA Group Name: Requirements for Ocrevus
Covered Uses For the treatment of relapsing-remitting forms of MS, including Clinically Isolated Syndrome (CIS), active secondary progressive, and primary progressive forms of MS.
Reasons for Exclusion
Submitted documentation is not consistent with a diagnosis of MS FDA approved indications. Concurrent use of other disease modifying therapies or immunosuppressives.
Required Medical Documentation
New Starts: Clinic notes which include: Clinical evaluation by a neurologist, imaging reports and any relevant lab reports such as CSF. Documentation from the member’s medical record that member has a confirmed diagnosis of either Relapsing MS or Primary Progressive MS. TAR Renewal: TAR renewals require annual assessment by neurologist which documents the member continues to benefit from the medication. New Starts, MS or CIS: Clinical evaluation by neurologist, brain MRI reports, lab reports. Include documentation of any planned diagnostic workup that has not yet been completed. MRI must show at least one demyelinating event. Submission of CSF study with oligoclonal banding &/or other diagnostic workup results (such as spinal MRI) should be included if brain MRI report is inconclusive. Renewals: Include any diagnostic workup that was still pending at time of prior request (additional imaging, CSF evaluation, etc).
Age Restriction Greater than or equal to 18 yrs. Prescriber Restriction Prescribed or recommended by a Neurologist
Coverage Duration 1 yr when adequate documentation is received which meets criteria for ongoing us 3 months when additional diagnostic workup is pending. 12 months if all supporting documentation is complete at time of initial TAR submission. Renewals for continuation of care: 12 months.
Other Requirements
Limited to the treatment of Multiple Sclerosis or Clinically Isolated Syndrome for members who have been evaluated and diagnosed by a neurologist. Pharmacy claims: Must be dispensed through PHCs contracted specialty pharmacy (AllianceRx Walgreens Prime). Primary Progressive MS: Limited to members who have been evaluated by a neurologist. Requests which document that the member continues to benefit from therapy are approved on a yearly basis. Relapsing MS: As above, and in addition, documentation of a previous trial with at least one first-line MS treatment: Interferon Beta-1A (Avonex, Rebif), Interferon Beta-1B (Betaseron, Extavia), Glatiramer Acetate (Copaxone/Glatopa), Teriflunomide (Aubagio), Dimethyl Fumarate (Tecfidera), Fingolimod (Gilenya). Failure with a first line agent would include reasons such as: disease progression (based on symptoms or imaging), intolerable side effects, or difficulty adhering to the regimen. Note: TAR is required for both pharmacy claims and medical claims.
Medical benefit (claims submitted direct to PHC): Site of care: Per Policy MCRP4067, Pharmacy Site of Care, the preferred site of care is home infusion or pharmacy infusion suite, with medication billed as a pharmacy claim. Requests for alternative sites of care will be evaluated on a case-by-case basis; for IV infusion at other sites, include rationale for site requirement on the TAR.
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Partnership HealthPlan of California 3Q20 P & T Committee, July 16, 2020 Minutes -- Approved Criteria
PROPOSED CRITERIA: First-line MS therapies ☒ Revised PA group ☒ New Starts Only PA Group already includes: Aubagio™, Avonex™, Betaseron™, Extavia™, Gilenya ™, Glatiramer (Copaxone™), Rebif™, and Tecfidera™
To be added to the PA Group: Diroximel Fumarate 231 mg capsules (Vumerity™) Glatiramer Depot inj (name TBD) Peginterferon beta-1a (Plegridy™). Monomethyl Fumarate 95 mg capsules (Bafiertam™) Siponimod 0.25 mg & 2 mg tabs (Mayzent™) Ozanimod 0.23, 0.46, 0.92 mg caps (Zeposia™)
Covered Uses
For the treatment of relapsing-remitting multiple sclerosis to reduce the frequency of relapses & slow accumulation of physical disability. Efficacy has been shown for several agents even when initiated after first clinical episode when MRI has features consistent with multiple sclerosis (MS). Glatiramer Depot:
For the treatment of Clinically Isolated Syndrome (CIS) and Relapsing Remitting Multiple Sclerosis (RRMS or RMS). All others: For the treatment of Clinically Isolated Syndrome (CIS), Relapsing Remitting MS (RRMS or RMS), and active Secondary Progressive Multiple Sclerosis (SPMS).
Reasons for Exclusion Concurrent use with other disease modifying therapies for multiple sclerosis.
Required Medical Documentation
New Starts, MS Diagnosis Confirmed or or CIS: Clinical evaluation by neurologist, brain MRI reports, lab reports. Include documentation of any planned diagnostic workup that has not yet been completed. MRI must show at least one demyelinating event. Submission of CSF study with oligoclonal banding &/or other diagnostic workup results (such as spinal MRI) should be included if brain MRI report is inconclusive. New Starts, Clinical diagnosis based on Initial/Isolated Episode: Completed Neurologist evaluation, diagnostic plan (which tests are pending/scheduled). Initial Renewal after the above: Subsequent imaging, lab reports and any follow-up clinic notes since treatment initiation must accompany the request to continue treatment. Renewals: confirmed diagnosis/Continuing Care: Documentation supporting the diagnosis of multiple sclerosis. Include any diagnostic workup that was still pending at time of prior request (additional imaging, CSF evaluation, etc). TAR renewals require annual assessment by neurologist.
Age Restriction Gilenya: ≥ 10 yrs. All others: ≥ 18 yrs Prescriber Restriction Prescribed or recommended by a neurologist
Coverage Duration 1 year when adequate documentation is received which meets criteria for ongoing use. 3 months when additional diagnostic workup is pending. 12 months if all supporting documentation is complete at time of initial TAR submission. Renewals for continuation of care: 12 months.
Other Requirements
Limited to the treatment of Multiple Sclerosis or CIS for members who have been evaluated and diagnosed by a neurologist. Requests which document that the member continues to benefit from therapy are approved on a yearly basis. For neurologists wishing to initiate treatment following presentation of first clinical episode, prior to completion of objective workup for definitive diagnosis: A one-time authorization will be considered based on the clinical evidence submitted along with the plan for further diagnostic work-up (see Required Medical Documentation). Aubagio, Gilenya, Plegridy, Tecfidera--PBM claims: To be dispensed by PHC’s contracted specialty pharmacy, AllianceRX/Walgreens Prime.Medical Benefit (claims submitted direct to PHC): The injectable drugs (as well as orals) in this PA group are FDA approved as a self-administered maintenance drugs, and as such, are required to be fulfilled at a pharmacy with direct dispensing to the member. Exceptions may be made for a one-time request for medical clinic/clinician reimbursement when necessary for first dose administration instructions &/or monitor the member’s response to the initial dose. Subsequent doses must be provided by issuing a prescription for pharmacy dispensing to the member. (remaining drugs in this PA group are not covered as medical benefits)
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PARTNERSHIP HEALTHPLAN OF CALIFORNIA
POLICY/ PROCEDURE
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Policy/Procedure Number: MCRP4067 Lead Department: Health Services
Policy/Procedure Title: Pharmacy Site of Care Policy ☒External Policy ☐ Internal Policy
Original Date: 08/12/2020 Next Review Date: 08/12/2021 Last Review Date: 08/12/2020
Applies to: ☒ Medi-Cal ☐ Healthy Kids ☐ Employees
Reviewing Entities:
☒ IQI ☒ P & T ☐ QUAC
☐ OPERATIONS ☐ EXECUTIVE ☐ COMPLIANCE ☐ DEPARTMENT
Approving Entities:
☐ BOARD ☐ COMPLIANCE ☐ FINANCE ☒ PAC
☐ CEO ☐ COO ☐ CREDENTIALING ☐ DEPT. DIRECTOR/OFFICER
Approval Signature: Robert Moore, MD, MPH, MBA Approval Date: 08/12/2020
I. RELATED POLICIES:
MCRO4018 - Pharmacy TAR Procedure
II. IMPACTED DEPTS: A. Health Services B. Member Services C. Provider Relations D. Finance E. RAC
III. DEFINITIONS: A. Site of Care - A facility or physical location where medication infusion administration and associated
ancillary services are directly provided to members. Site of Care settings include, but are not limited to, hospital outpatient, community office, ambulatory infusion site, and home-based infusion.
B. Hospital Outpatient Department (HOPD) – A portion of a hospital’s main campus or a portion of an off-campus hospital provider-based department which provides diagnostic, therapeutic (both surgical and nonsurgical), and rehabilitation services to sick or injured persons who do not require hospitalization or institutionalization.
C. Home Infusion –Medication infusion therapy and associated ancillary services directly provided to members in the member’s home setting. Medications administered in the home infusion setting are furnished by the infusion pharmacy.
D. Pharmacy Infusion Suite – An infusion center or facility operated by the infusion pharmacy to directly provide medication infusion therapy and associated ancillary services to members. Medications administered in the pharmacy infusion suite are furnished by the infusion pharmacy.
E. Treatment Authorization Request (TAR): A request which will be considered based on medical necessity, clinical prior authorization criteria &/or nationally recognized treatment guidelines (for example, but not limited to, National Comprehensive Cancer Network [NCCN], Infectious Diseases Society of America [IDSA], American Dental Association [ADA], American Heart Association [AHA], National Institutes of Health [NIH]).
IV. ATTACHMENTS:
A. N/A
V. PURPOSE: Partnership HealthPlan of California (PHC) recognizes Site of Care optimization as a vital program and strategy to improve member experience, reduce provider administrative burden, and reduce healthcare cost
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Policy/Procedure Number: MCRP4067 Lead Department: Health Services
Policy/Procedure Title: Pharmacy Site of Care Policy ☒ External Policy ☐ Internal Policy
Original Date: 08/12/2020 Next Review Date: 08/12/2021 Last Review Date: 08/12/2020
Applies to: ☒ Medi-Cal ☐ Employees
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associated with medication infusion therapies. Site of Care optimization is based on the principles of utilizing a Site of Care that is clinically appropriate, cost-effective, and member-centric. This policy establishes the requirement for medication infusion therapies to be rendered at a Site of Care with the least intensive setting that is appropriate for the delivery of the service.
VI. POLICY / PROCEDURE:
A. PHC Site of Care requirements - PHC requires medication infusion therapies to be administered in the least intensive setting that is appropriate for the delivery of the service.
B. Transition of medication infusion therapies from the HOPD setting to alternative Site of Care facilities including home infusion and non-hospital affiliated outpatient infusion. 1. Selection of medication infusion therapies for transition to alternative Site of Care facilities will be
based on member’s medication history, member request, and referral by prescriber or PHC internal staff.
2. Member Consent - Member outreach will be conducted by PHC Pharmacy to obtain consent to transition medication infusion therapy from HOPD setting to the appropriate alternative Site of Care facility
3. Prescriber Consent - Prescriber outreach will be conducted by PHC Pharmacy to inform prescriber on member’s consent and to request approval for transition to alternative Site of Care facility, including request to provide prescription to Infusion Pharmacy
4. PHC Pharmacy will inform Infusion Pharmacy on member and prescriber consent to transition medication infusion therapy to alternative Site of Care facility. Infusion Pharmacy will have full and final responsibility for obtaining the prescription from the prescriber and coordinating infusion therapy services with prescriber and member.
C. New medication treatment requests and referrals to alternative Site of Care facilities: 1. Medication infusion therapy requests must meet any PHC established treatment criteria or medical
necessity based on case-by-case review, and must be approved by PHC clinical staff. 2. Approved medication request will be subject to PHC’s preferred Site of Care set forth in this policy.
a. Prescriber Notice of Action for the approval of the medication request will include the requirement for the drug to be administered at PHC’s preferred Site of Care. HOPD Site of Care must meet the criteria set forth in section VI.D.
D. HOPD Site of Care approval must meet at least one of the following criteria (submission of medical supporting records is required) 1. Documentation that the individual is medically at risk for administration of the prescribed
medication at the alternative Sites of Care as determined by any of the following: a. Complex medical status or therapy requires enhanced monitoring and potential intervention
above and beyond the capabilities of the alternative care site; or b. Documented history of significant comorbidity (e.g. cardiopulmonary disease) or fluid overload
status that precludes treatment at an alternative Site of Care (i.e. additional supportive care not available from infusion nurse, more intensive medical services required); or
c. Clinically significant physical or cognitive impairment presents a health risk associated with home infusion treatment and pharmacy infusion suite is not available; or
d. Establishing and/or maintaining patient vascular access is difficult. 2. Clinical documentation of episodes of severe or potentially life threatening adverse events (e.g.
anaphylaxis, seizures, thromboembolism, myocardial infarction, renal failure) that have not been responsive to acetaminophen, steroids, diphenhydramine, fluids, infusion rate reduction or other pre-medications, or required more intensive medical services, thereby increasing risk when infusions are given in the home or pharmacy infusion suite.
3. Home health or infusion provider has determined that patient, caregiver or home environment is not suitable for home infusion therapy and pharmacy infusion suite is not available.
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Policy/Procedure Number: MCRP4067 Lead Department: Health Services
Policy/Procedure Title: Pharmacy Site of Care Policy ☒ External Policy ☐ Internal Policy
Original Date: 08/12/2020 Next Review Date: 08/12/2021 Last Review Date: 08/12/2020
Applies to: ☒ Medi-Cal ☐ Employees
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4. Other situations not listed above will be reviewed on a case-by-case basis when sufficient clinical documentation is provided. Such scenarios may include (but not limited to) a drug that is not appropriate for home infusion based on lack of safety data for the home setting, or drugs with limited distribution through only certain suppliers (thus not widely available to infusion pharmacies in a member’s geographical area).
VII. REFERENCES:
A. Checkley LA, Kristofek L, Kile S, Bolgar W. Incidence and Management of Infusion Reactions to Infliximab in an Alternate Care Setting. Dig Dis Sci. 2019;64(3):855-862. doi:10.1007/s10620-018-5319-6
B. American Society of Health-System Pharmacists. ASHP guidelines on evaluating and using home or alternate-site infusion service providers. Am J Health-Syst Pharm. 2016; 73:922–6. https://www.ashp.org/-/media/assets/policy-guidelines/docs/guidelines/evaluating-using-home-or-alternate-site-infusion-providers.ashx
C. Le Masson G, Solé G, Desnuelle C, et al. Home versus hospital immunoglobulin treatment for autoimmune neuropathies: A cost minimization analysis. Brain Behav. 2018;8(2):e00923. Published 2018 Jan 26. doi:10.1002/brb3.923
D. Gretchen Ayer, Nizar Souayah Efficacy and Safety of Home Infusion of Intravenous Immunoglobulin in Multifocal Motor Neuropathy: A Longitudinal Study. (P7.111) Neurology Apr 2014, 82 (10 Supplement) P7.111
VIII. DISTRIBUTION:
A. PHC Department Directors B. PHC Provider Manual
IX. POSITION RESPONSIBLE FOR IMPLEMENTING PROCEDURE:
Director, Pharmacy Services
X. REVISION DATES: N/A PREVIOUSLY APPLIED TO:
N/A XI. POLICY DISCLAIMER:
A. In accordance with the California Health and Safety Code, Section 1363.5, this policy was developed with involvement from actively practicing health care providers and meets these provisions: 1. Consistent with sound clinical principles and processes; 2. Evaluated and updated at least annually; 3. If used as the basis of a decision to modify, delay or deny services in a specific case, the criteria will
be disclosed to the provider and/or enrollee upon request. B. The materials provided are guidelines used by PHC to authorize, modify, or deny services for persons
with similar illnesses or conditions. Specific care and treatment may vary depending on individual need and the benefits covered under PHC.
C. PHC’s authorization requirements comply with the requirements for parity in mental health and substance use disorder benefits in 42 CFR 438.910.
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CREDENTIALING COMMITTEE SUMMARY FOR PARTNERSHIP HEALTHPLAN OF CALIFORNIA
PHYSICIAN ADVISORY COMMITTEE Pg. 1 of 5 * = by phone conference
Committee: Credentialing Committee Date/Time: June 10, 2020, 7:00 A.M. – 7:30 A.M. Members Present: Steven Gwiazdowski, MD*; David Gorchoff, MD*; Madeleine Ramos, MD*; Bradley Sandler,
MD*; Susan Foster, FNP* Michelle Herman, MD* PHC Staff: Marshall Kubota, MD*, PHC Regional Medical Director; Robert Moore, MD, MPH, MBA, PHC
Chief Medical Officer*; Bettina Spiller, MD* PHC Northern Region Medical Director; Michael Vovakes, MD* PHC Northern Region Medical Director; David Glossbrenner, MD* PHC Northern Region Medical Director; Mark Netherda, MD*; PHC Medical Director; Mary Kerlin, Senior Director*; Lisa O’Connell*, Senior Manager of Provider Network Education and Credentialing, Brooke Vance*, Senior Lead Auditor; Erika Roach*, Credentialing Specialist I; J’aime Seale*, Credentialing Specialist I; Dani Alfaro* Credentialing Specialist I.
I. Meeting called to order. a. Voting member reminder.
I. PHC Regional Medical Director Marshall Kubota, MD called the meeting to order at 7:00 AM. Dr. Kubota reminded everyone that all items discussed are confidential. a. Marshall Kubota, MD, Regional Medical Director, reminded The Committee of who the voting members are, and voting is restricted to non-PHC staff. Dr. Kubota reminded the committee that all information discussed is confidential in nature. He also welcomed new members to the committee and thanked them for being part of the advisory.
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II. Review and approval of May 13, 2020 Credentialing Meeting Minutes.
II. The Credentialing Committee meeting minutes for May 13, 2020 were reviewed by the Committee. No changes were made.
II. Minutes were reviewed with no revisions. A motion for approval of the minutes was made by: David Gorchoff, MD and seconded by: Steven Gwiazdowski, MD. Meeting minutes were unanimously approved without changes.
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III. Old Business a. Provider
III. Old Business a. Provider presented November 2019 to Committee.
Chart Review after 6-months was scheduled for review by Committee at June meeting. UPDATE; Provider no longer with Health Clinic and has been terminated from the PHC network. No further action required.
a. Informational Only.
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FINAL
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b. Provider c. Provider
b..Provider presented at May meeting to Committee. The Committee deferred decision to re-credential for additional information from the Osteopathic Medical Board of California regarding an allegation of unprofessional conduct. UPDATE: Provider is no longer with Clinic and has been terminated from the PHC network. No further action required. Committee members had additional discussion regarding the outcome of the two physicians in question. Staff suggested adding notes in the PHC credentialing software system and documenting the prior findings should these providers re-apply under a different provider group. Staff confirmed there were notes in the credentialing system already. Dr. Kubota stated that no motion needed to be taken for this discussion. c. Dr. Kubota reviewed with the Committee that this provider did not meet criteria of PHC Policy MPCR 17, Standards for Primary Care Providers. The provider was previously approved subject to the following: Practice limited to Adults Only, 18-years of age and older. May practice Prenatal and Women’s Health care for all ages. No Pediatric Preventive and Pediatric Periodic Care. Practice for children limited to Immunizations and Urgent Care when no other provider is available. A medical chart review was required for re-evaluation. Dr. Kubota completed the file review. His findings included; chart notes were inefficient and contained very little information, with no preventative care noted. Provider was approved under the old MPCR17 policy, with stipulations and Dr. Kubota’s recommendation was that the provider should be approved under the new MPCR17 policy and required to take the Provider Retraining and Reentry (PRR) Program offered at UC San Diego and be re-reviewed. Dr. Moore agreed and said that the course is more intensive and since this is an issue of documentation and quality of care, the provider should take the course. Dr. Moore said once the physician completed the course PHC could require a review of the charts after completion and bring back the results to the Committee for
b. Informational Only. c. The motion to approve pending the provider’s completion of the PRR course within six months and subsequent chart review three months after the course completion was made by: Steven Gwiazdowski, MD and seconded by: David Gorchoff, MD. The Committee unanimously approved. PHC will send a letter to the provider and clinic outlining the requirements per Credentials Committee. Provider must reply that they accept the conditions and agree to comply with requirements by January 1, 2021. Credentials Committee will be given update on the status of this provider’s credentialing activities at next meeting.
Notification 6/12/2020 Program Completion 1/1/2021 Update to Committee 7/8/2020
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discussion. IV. New Business a. Review and Approval of Routine Practitioner List. b. Exceptions: Provider c. Review of MPCR200 Clean/Routine Practitioners and Ancillaries Practitioners list. d. Review and Approval of Revised Policies.
IV. New Business a. Dr. Kubota referred the Committee to pages 14-21, and asked the Committee to review the routine list of practitioners. b. Dr. Kubota called the Committee’s attention to pages 22-27 of the packet and asked the committee to read over the documents regarding Provider and the investigation which led to a subsequent resignation from previous practice. The Committee members agreed and suggested a phone interview be conducted with the physician. Dr. Kubota asked for a motion to defer to the next meeting and conduct a phone interview. c. Dr Kubota called the Committee’s attention to Page 28 of the packet, a list of providers who were approved by Dr. Kubota under MPCR 200. This policy allows the CMO or his designee to review and approve the credentials of those who meet PHC’s credentialing criteria before the Credentialing Committee is scheduled to meet. d. Dr. Kubota turned the Committee’s attention to pages 29-34 for review and approval of revised policies. Lisa O’Connell gave an update to policy MPCR12 – Credentialing of Independent and Private Duty Nurses Under EPSDT and MPCR12 – Attachment A – Individual Nurse Agreement. Per APL 20-012 the policy will be updated to include Private Duty Nurses.
IV. New Business a. The Committee reviewed the list of practitioners. A motion to approve the list of practitioners was made by: Steven Gwiazdowski, MD and seconded by: Bradley Sandler, MD. The Committee unanimously approved the routine list. b. A motion was made to defer to July meeting and have Dr. Kubota conduct a phone interview with the provider. Motion was made by: Michelle Herman, MD, and seconded by David Gorchoff, MD. The Committee unanimously approved the motion for a phone interview. c. A motion to approve the list of Clean/Routine Practitioners and Ancillaries Practitioners was made by David Gorchoff, MD and seconded by: Steven Gwiazdowski, MD. The Committee unanimously approved. d. A motion was made to approve the revised policies MPCR12 – Credentialing of Independent and Private Duty Nurses Under EPSDT and MPCR12 – Attachment A – Individual Nurse Agreement by: David Gorchoff, MD and seconded by: Madeleine Ramos, MD. The Committee unanimously approved.
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V. Ongoing Monitoring of Sanctions Report and Practitioner Monitoring List. a. Review and Approval of Ongoing Monitoring of Sanctions Report. b. Practitioner Monitoring List.
V. Review and Approval of Ongoing Monitoring of Sanctions Report. a. The Committee was asked to review and approve the Ongoing Monitoring of Sanctions Report, page 35. Dr. Kubota mentioned the findings are of providers PHC is currently monitoring and asked for the Committee’s approval of the ongoing monitoring of sanctions report. b. Dr. Kubota directed the Committee to pages 35-36 the practitioner monitoring list for informational purposes only.
a. The Committee members reviewed the reports. A motion for approval of the Ongoing Monitoring of Sanctions Report was made by: Steven Gwiazdowski, MD and seconded by: Bradley Sandler, MD and was unanimously approved. b. Practitioner Monitoring List. Informational Only.
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VI. Review and Approval of Consent Calendar Items. a. Review and Approval of Consent Calendar Items.
VI. Review and Approval of Consent Calendar Items. a. Dr. Kubota asked the Credentialing Committee members to review and approve consent calendar items: Report of Long Term Care Facility, Hospital, and Ancillary provider list, Page 40 and the Delegated Quarterly credentialing and re-credentialing activities on Pages 41-51.
a. Committee members reviewed the consent calendar items and delegated quarterly credentialing and re-credentialing activities. A motion for approval was made by David Gorchoff, MD and seconded by: Bradley Sandler, MD. Consent calendar items unanimously approved by the Credentialing Committee.
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VII. Discussion VII. Lisa O’Connell reminded the committee that there would be a July committee meeting on July 8th and to please let PHC staff know if Committee members could attend.
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VI. Meeting Adjourned. VII. Meeting adjourned at 7:30 AM. 6/10/2020
Credentialing Meeting Minutes for June 10, 2020 respectfully prepared and submitted by Erika Roach Credentialing Specialist I. Chairman Signature of Approval _____________________________________________ Date______________________________ Marshall Kubota, M.D., PHC Credentialing Chairman
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June 2020 Routine Clean File List
App. Type Full Name
Provider Type Code Name/Street
County Name Specialty Description Board Name Initial Cert Date
Board Cert. Hospital Name
IAbrojena, Amalia O.,SUDCC II W&R County of Mendocino (Ukiah) Wellness and Recovery Mendocino Wellness and Recovery California Association of DUI Treament Programs 02/21/2020 Yes
I Ales, Jill CADC II W&R County of Mendocino (Ukiah) Wellness and Recovery Mendocino Wellness and RecoveryCalifornia Consortium of Addiction Programs Professionals 04/10/2018 Yes
RAllen, Anthony E.,MD SPEC Skilled MD, Inc. Solano SNFist None No Admitting Agreement
RAllmeyer-Green, Rita M.,PT Allied
Shasta Orthopedics & Sports Medicine - Liberty Physical Therapy Shasta Physical Therapy None No
I Alnajjar, Eva M.,MD SPEC Sutter Lakeside Community Clinic LakeObstetrics and Gynecology Confirmed per AMA or Residency Letter Yes Admitting Agreement
IAnglen, Catherine M.,CAODC W&R Ford Street Project - Ukiah Recovery Center Mendocino Wellness and Recovery California Association of DUI Treament Programs 03/29/2018 Yes
RAnkenmann, Janice G.,FNP BOTH Napa Valley Nephrology Napa Family Nurse Practitioner
American Academy of Nurse Practitioners Certification Board 08/01/2002 Yes
IAzare, Collier RADT W&R Visions of the Cross/ Women's Residential Treatment Shasta Wellness and Recovery
California Consortium of Addiction Programs Professionals 04/08/2020 Yes
R Bach, Philip M.,MD SPEC Sacramento Heart & Vascular Medical Associates Yolo Cardiovascular Disease ABMS of Internal Medicine 11/09/1983 Yes Admitting Agreement
IBares, Alanna D.,MD PCP Communicare Health Centers-Hansen Family Medical Center Yolo Pediatrics ABMS of Pediatrics 10/09/2015 Yes Admitting Agreement
IBartolomeu, Helder CADC CAS W&R Bi-Bett Corporation Southern Solano Alcohol Council Solano Wellness and Recovery
California Consortium of Addiction Programs Professionals 07/11/2013 Yes
IBaumann, Mary Jo NP SPEC Planned Parenthood Northern California: San Ramon
Contra Costa Nurse Practitioner
I Bennett, Carl E.,NP PCP Lassen Medical Clinic - Cottonwood Shasta Family Nurse PractitionerAmerican Academy of Nurse Practitioners Certification Board 09/06/2019 Yes
RBieselin, Ronald G.,MD SPEC Ronald Bieselin, M.D. Solano Surgery ABMS of Surgery 03/14/1990 Yes
Sutter Solano Medical Center
IBlomquist, Shakuntala M.,FNP PCP Adventist Health Ukiah Valley Mendocino Family Nurse Practitioner American Nurses Credentialing Center 06/20/2019 Yes
R Bly, KC CNM SPEC Communicare Health Centers - Davis Community Clinic Yolo Certified Nurse Midwife American Midwifery Certification Board 08/01/2010 Yes
ICaprini, Millie CADC II W&R Visions of the Cross/ Women's Residential Treatment Shasta Wellness and Recovery
California Consortium of Addiction Programs Professionals 07/11/2016 Yes
ICarter, Jimmy R.,RADT W&R Bi-Bett Corporation Southern Solano Alcohol Council Solano Wellness and Recovery
California Consortium of Addiction Programs Professionals 07/01/2019 Yes
ICetina, Alisha A.,CADC II W&R Visions of the Cross/ Women's Residential Treatment Shasta Wellness and Recovery
California Consortium of Addiction Programs Professionals 02/14/2019 Yes
RChahal, Resham S.,MD SPEC Mission Hills Eye Center, Medical Associates, Inc. Solano Ophthalmology ABMS of Ophthalmology 10/18/1992 Yes
John Muir Medical Center
RChang, Margaret A.,MD SPEC
Retinal Consultants Medical Group: DBA Retina Center of Chico, Inc- Shasta Ophthalmology ABMS of Ophthalmology 10/28/2007 Yes
Sutter Medical Center Sacramento
RCordes, Susan R.,MD SPEC Adventist Health Ukiah Valley Mendocino Otolaryngology ABMS of Otolaryngology 05/10/1999 Yes
Ukiah Valley Medical Center
ICrum, Toby CADC CAS W&R Visions of the Cross/ Women's Residential Treatment Shasta Wellness and Recovery
California Consortium of Addiction Programs Professionals 11/19/2014 Yes
I
Darbyshire, Suzanne G.,CADTP W&R Bi-Bett Corporation Shamia Recovery Center Solano Wellness and Recovery California Association of DUI Treament Programs 02/01/2019 Yes
RDe Pala, Armando V.,Jr., MD PCP Annadel Medical Group Sonoma Pediatrics ABMS of Pediatrics 11/13/1991 Yes
Petaluma Valley Hospital
RDeeik, Ramzi K.,MD SPEC
Northern California Minimally Invasive Cardiothoracic Surgery, Inc. Sonoma
Thoracic & Cardiovascular Surgery ABMS of Thoracic Surgery 06/11/2004 Yes
Santa Rosa Memorial Hospital
REickhoff, Leo E.,III, MD SPEC Leo Eickhoff, MD Inc Shasta Gastroenterology ABMS of Internal Medicine 11/09/1995 Yes
Shasta Regional Medical Center
RErickson, Laura M.,OT Allied
Shasta Orthopedics & Sports Medicine - Liberty Physical Therapy Shasta Occupational Therapy None No
Pain Management & Rehabilitation None No St Joseph Hospital
I Fialk, James L.,LAc Allied James Fialk ND, LaC Sonoma Acupuncture None No
RFinnegan, Maria CNM SPEC Mendocino Community Health Clinic: Hillside Health Center Mendocino Certified Nurse Midwife American Midwifery Certification Board 01/01/1998 Yes
R Gary, Erika D.,FNP PCP Mendocino Community Health Clinic: Little Lake Health Center Mendocino Family Nurse PractitionerAmerican Academy of Nurse Practitioners Certification Board 03/26/2014 Yes
RGreene, David A.,MD SPEC Northern California Medical Associates Inc.- SNFist Sonoma SNFist ABMS of Internal Medicine 09/16/1987 Yes
R Groppo, Eli R.,MD SPEC Sacramento Ear Nose and Throat Yolo Otolaryngology ABMS of Otolaryngology 06/01/2012 YesMercy San Juan Hospital
RHamblin, Basil C.,MD PCP West Marin Medical Center (Colin Hamblin, A Prof. Med. Corp) Marin Family Medicine ABMS of Family Medicine 07/11/2003 Yes
Petaluma Valley Hospital
RHao, Minghua A.,MD SPEC Capital Pediatric Cardiology Associates, Inc. Yolo Pediatric Cardiology ABMS of Pediatrics 11/02/2016 Yes
Sutter Medical Center Sacramento
RHartley, Laurence W.,MD SPEC Mendocino Community Health Clinic: Hillside Health Center Mendocino
Obstetrics and Gynecology ABMS of Obstetrics and Gynecology 11/07/1975 Yes
Ukiah Valley Medical Center
IHathaway, Alison S.,ANP SPEC Planned Parenthood Northern California
Contra Costa Nurse Practitioner
American Academy of Nurse Practitioners Certification Board 06/01/2012 Yes
IHayward, Mark J.,CADTP W&R Aegis Treatment Centers, LLC - Redding Shasta Wellness and Recovery California Association of DUI Treament Programs 12/17/2019
RHofberg, Dawn B.,PA BOTH Mendocino Coast Clinic Mendocino Physician Assistant
National Commission on Certification of Physician Assistants 06/12/1997 No
IHolcomb, Dana L.,SUDCC II W&R Aegis Treatment Center LLC - Eureka Wellness and Recovery California Association of DUI Treament Programs 10/03/2019 Yes
California Consortium of Addiction Programs Professionals 03/14/2017 Yes
RJames, Gregory D.,PA-C SPEC Adventist Health Physicians Network: Adventist Heart Institute Napa
Physician Assistant Certified
National Commission on Certification of Physician Assistants 03/30/2015 Yes
IJohnson, Kelly R.,CADC-CS W&R County of Mendocino (Ukiah) Wellness and Recovery Mendocino Wellness and Recovery
California Consortium of Addiction Programs Professionals 04/02/2007 Yes
RJumper, James M.,MD SPEC West Coast Retina Medical Group-San Francisco Marin Ophthalmology ABMS of Ophthalmology 11/16/1997 Yes
Dignity Health St Marys Medical Center
R Kako, Rony Y.,MD PCP Rony Kako MD Napa Internal Medicine ABMS of Internal Medicine 09/22/1993 Yes Queen of the Valley
I Kan, David Y.,MD W&RBright Heart Health - MAT (Suboxone), Wellness and Recovery Solano Wellness and Recovery Admitting Agreement
I Kaur, Ramnik MD PCP Northeastern Rural Health Clinics, Inc. Lassen Family Medicine ABMS of Family Medicine 07/01/2019 YesBanner Lassen Medical Center
IKeck, Steven RADT W&R Visions of the Cross/ Women's Residential Treatment Shasta Wellness and Recovery
California Consortium of Addiction Programs Professionals 06/27/2019 Yes
IKenney, Sara A.,CADTP W&R Aegis Treatment Centers, LLC - Redding Shasta Wellness and Recovery California Association of DUI Treament Programs 02/01/2019 Yes
RKhaira, Herkanwal S.,MD SPEC NBHG: Center for Specialty Care, A NorthBay Affiliate Solano Urology ABMS of Urology 02/28/2008 Yes
Northbay Medical Center
RKim, Christian K.,MD SPEC Marin Eyes Marin Ophthalmology ABMS of Ophthalmology 06/07/1998 Yes
Marin General Hospital
R Kim, Michael P.,MD PCP Live Well Medical Center Yolo Family MedicineMeets MPCR#17, Previously Board Certified in FM, IM, or PEDs No Admitting Agreement
R Kim, Paul H.,MD SPEC California Orthopedics & Spine, Inc Marin Orthopaedic Surgery ABMS of Orthopaedic Surgery 07/27/2017 YesMarin General Hospital
IKing, Marquita RADT W&R MedMark Treatment Centers- Fairfield, Inc. Solano Wellness and Recovery
California Consortium of Addiction Programs Professionals 02/08/2017 Yes
RKlingman, Robert R.,MD SPEC Napa Valley Cardiothoracic and Cardiovascular Surgery, Inc. Napa
Thoracic & Cardiac Surgery ABMS of Thoracic Surgery 06/04/1993 Yes Queen of the Valley
IKoester, Russell J.,LAc Allied Sonoma County Indian Health Project, Inc. Sonoma Acupuncture None No
R Korver, Keith F.,MD SPEC Keith F. Korver, MD A Professional Medical Corp SonomaThoracic & Cardiovascular Surgery ABMS of Thoracic Surgery 06/07/1991 Yes
Santa Rosa Memorial Hospital
RKreger, Jonathan B.,DPM SPEC Ukiah Podiatry Group Mendocino Foot Surgery AB of Foot and Ankle Surgery 08/10/1995 Yes
Ukiah Valley Medical Center
RLaughton, Frances A.,FNP PCP Adventist Health Ukiah Valley Mendocino Family Nurse Practitioner American Nurses Credentialing Center 08/11/2016 Yes
June 2020
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ILee, Katherine B.,MD PCP Lassen Medical Clinic- Red Bluff Shasta Internal Medicine
Meets MPCR#17, Previously Board Certified in FM, IM, or PEDs 11/05/2003 No
St Elizabeth Community Hospital
ILee, Sandra Y.,FNP PCP ODCHC - Fortuna Community Health Center Humboldt Family Nurse Practitioner American Nurses Credentialing Center 05/25/2016 Yes
ILeeds, Shauna K.,PT Allied Western Physical Therapy, Inc.: Baas Physical Therapy Shasta Physical Therapy None No
ILeininger, Meghan C.,DO SPEC Dignity Health Women's Health Services Clinic - OB/GYN Tehama
Obstetrics and Gynecology None No
St Elizabeth Community Hospital
I Lewis, Emily PA-C PCP Northeastern Rural Health Clinics, Inc. LassenPhysician Assistant Certified
National Commission on Certification of Physician Assistants 12/02/2019 Yes
RLiana, Jennifer I.,NM SPEC Mendocino Community Health Clinic: Hillside Health Center Mendocino Nurse - Midwifery None No
ILipinski, Amanda BCBA BHP Juvo Autism + Behavioral Health Services Alameda Behavioral Health Behavior Analyst Certification Board 08/31/2014 Yes
I Little, Dale P.,PT Allied Proactive Spine and Sports Physical Therapy Shasta Physical Therapy None No
R Loftus, John P.,MD SPEC Bay Area Surgical Specialists, Inc. Napa Vascular Surgery ABMS of Surgery 05/08/1996 Yes Queen of the Valley
RLouwrens, Neil A.,MD SPEC Neil Louwrens, MD Shasta Wound Care None No
Mercy Medical Center of Redding
RLowry, Caroline A.,PA-C PCP ODCHC - North Country Clinic Humboldt
Physician Assistant Certified
National Commission on Certification of Physician Assistants 04/24/2014 Yes
ILucarelli, Tianna CADC I W&R Visions of the Cross/ Women's Residential Treatment Shasta Wellness and Recovery
California Consortium of Addiction Programs Professionals 02/10/2016 Yes
IMachado Cramer, Luz M.,RADT W&R County of Mendocino (Ukiah) Wellness and Recovery Mendocino Wellness and Recovery
California Consortium of Addiction Programs Professionals 12/18/2019 Yes
IMackey, Margaret L.,NP SPEC Personalized Care, MD Napa Nurse Practitioner None No
IMacMorran, William S.,MD W&R Ujima Hope Solano Solano Wellness and Recovery
Not Applicable Admitting Agreement
RManske, Mary Claire B.,MD SPEC Shriners Hospitals for Children Yolo Orthopaedic Surgery ABMS of Orthopaedic Surgery 07/24/2018 Yes
Shriners Hospital for Children
IMartin, Joseph E.,PA SPEC North Coast Family Health Center Mendocino Physician Assistant Previously Board Certified 04/25/2001 No
IMartin, Nicole RADT W&R Visions of the Cross/ Women's Residential Treatment Shasta Wellness and Recovery
California Consortium of Addiction Programs Professionals 08/07/2017 Yes
IMartin, Richard D.,CADC II W&R Visions of the Cross/ Women's Residential Treatment Shasta Wellness and Recovery
California Consortium of Addiction Programs Professionals 01/30/2018 Yes
IMase, James B.,MD SPEC Sutter Coast Community Clinic (PCP/SPEC) Del Norte Pain Management Confirmed per AMA or Residency Letter No Sutter Coast Hospital
IMatthews, Joshua M.,MD SPEC Sutter Lakeside Community Clinic Lake Orthopaedic Surgery Confirmed per AMA or Residency Letter No Admitting Agreement
RMatthews, Linnea M.,FNP PCP Mendocino Coast Clinic Mendocino Family Nurse Practitioner American Nurses Credentialing Center 05/01/2001 Yes
RMcIntyre, Paige A.,CNM SPEC Mendocino Community Health Clinic: Hillside Health Center Mendocino Certified Nurse Midwife American Midwifery Certification Board 01/01/2004 Yes
RMcLeod, Dennis M.,MD SPEC Dennis McLeod, MD Sonoma Otolaryngology ABMS of Otolaryngology 10/22/1978 Yes
Petaluma Valley Hospital
IMendoza, Richard RADT W&R Visions of the Cross/ Women's Residential Treatment Shasta Wellness and Recovery
California Consortium of Addiction Programs Professionals 04/14/2016 Yes
IMertens, Leanne K.,FNP PCP Northeastern Rural Health Clinics, Inc. Lassen Family Nurse Practitioner
American Academy of Nurse Practitioners Certification Board 06/24/2019 Yes
RMetzger, Alex S.,MD SPEC Marin Cancer Care Inc. Marin Medical Oncology ABMS of Internal Medicine 11/13/2007 Yes
Marin General Hospital
R Miner, David J.,DC SPEC Southshore Chiropractic Lake Chiropractic None No
IMiranda, Paul RADT W&R Visions of the Cross/ Women's Residential Treatment Shasta Vitreoretinal Surgery
California Consortium of Addiction Programs Professionals 11/30/2017 Yes
RMockel, Cynthia A.,NP PCP Mendocino Community Health Clinic: Hillside Health Center Mendocino Nurse Practitioner None No
IMolina, Rheannah RADT W&R Ford Street Project - Ukiah Recovery Center Mendocino Wellness and Recovery
California Consortium of Addiction Programs Professionals 04/09/2020 Yes
June 2020
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IMonroe, Michelle CAODC W&R Ujima Family Recovery Services Solano Wellness and Recovery California Association of DUI Treament Programs 09/06/2018 Yes
RMraz, Serena M.,MD SPEC Solano Dermatology Associates, Inc. Solano Dermatology ABMS of Dermatology 10/14/2002 Yes
Sutter Solano Medical Center
IMurray, Chris RADT W&R Bi-Bett Diablo Valley Ranch
Contra Costa Wellness and Recovery
California Consortium of Addiction Programs Professionals 10/19/2015 Yes
IMyrick, Evelyn FNP Shriners Hospitals for Children Yolo Family Nurse Practitioner
INeely, David CADC III W&R Visions of the Cross/ Women's Residential Treatment Shasta Wellness and Recovery
California Consortium of Addiction Programs Professionals 03/19/2020 Yes
INicholson, Christina RADT W&R Ujima Family Recovery Services Solano Wellness and Recovery
California Consortium of Addiction Programs Professionals 02/27/2019 Yes
INorris-Skinner, Charla CADC CAS W&R Visions of the Cross/ Women's Residential Treatment Shasta Wellness and Recovery
California Consortium of Addiction Programs Professionals 01/11/2016 Yes
RNunnally, Janet A.,FNP PCP Marin Community Clinic: San Rafael Clinic Marin Family Nurse Practitioner American Nurses Credentialing Center 11/01/1999 No
American Academy of Nurse Practitioners Certification Board 09/03/2014 Yes
R Ordal, John C.,MD SPEC Asante Physician Partners: Pulmonary Consultants Clinic Siskiyou Pulmonary Diseases ABMS of Internal Medicine 06/17/1980 Yes
Asante Rogue Regional Medical Center
IOwens, Charles L.,Jr., CADC II W&R Visions of the Cross/ Women's Residential Treatment Shasta Wellness and Recovery
California Consortium of Addiction Programs Professionals 01/29/2010 Yes
RPearlman, Joel A.,MD SPEC Retinal Consultants Medical Group Yolo Ophthalmology ABMS of Ophthalmology 05/13/2001 Yes
Mercy General Hospital of Sacramento
RPiersol, Patricia E.,CNM SPEC Alliance Medical Center Sonoma Certified Nurse Midwife American Midwifery Certification Board 07/01/1993 Yes
I Pratap, Arati MD SPEC QVMA: Queen of the Valley Medical Associates - Gastro Napa Gastroenterology ABMS of Internal Medicine 10/23/2007 Yes Admitting Agreement
RQuilala, Marlene Q.,MD PCP Lake County Tribal Health Center Lake Pediatrics ABMS of Pediatrics 10/19/1999 Yes
Sutter Lakeside Hospital
IQuinn, Rindi SUDRC W&R Visions of the Cross/ Women's Residential Treatment Shasta Wellness and Recovery California Association of DUI Treament Programs 01/22/2018 Yes
IRamsey, Judith A.,NP PCP Stallant Medical Group Inc Del Norte Nurse Practitioner None No
RRidley, Courtney P.,MD SPEC Sutter Coast Community Clinic (PCP/SPEC) Del Norte
Obstetrics and Gynecology ABMS of Obstetrics and Gynecology 12/11/1992 Yes Sutter Coast Hospital
IRoberts, Carol L.,CADC CAS W&R Bi-Bett Corporation Southern Solano Alcohol Council Solano Wellness and Recovery California Association of DUI Treament Programs 05/22/2018 Yes
RRodenberg, Kathleen I.,PA-C SPEC California Orthopedics & Spine, Inc Marin
Physician Assistant Certified
National Commission on Certification of Physician Assistants 09/03/2015 Yes
IRouhe, Helena L.,LMFT W&R
Bright Heart Health - MAT (Suboxone), Wellness and Recovery Solano Wellness and Recovery
RRudnick, Eric M.,MD SPEC Eric M. Rudnick MD Shasta Wound Care None No
St Elizabeth Community Hospital
IRunyon, Ryan CADC CAS W&R Hilltop Recovery Services - The Ranch Lake Wellness and Recovery
California Consortium of Addiction Programs Professionals 04/02/2007 Yes
ISaghaian, Zane H.,PA-C PCP Sutter Coast Community Walk-In Clinic Del Norte
Physician Assistant Certified
National Commission on Certification of Physician Assistants 05/20/2019 Yes
ISanders, Kenneth C.,MD SPEC Marin Pregnancy Clinic- Family Planning only Marin Family Planning None
Not Applicable Admitting Agreement
RSandys, James M.,MD PCP North Coast Family Health Center Mendocino Family Practice
Meets MPCR#17, Previously Board Certified in FM, IM, or PEDs 07/11/1980 No
Mendocino Coast District Hospital
ISchneider, James J.,MD SPEC Annadel Medical Group: General Surgery Sonoma General Surgery ABMS of Surgery 12/06/2014 Yes Admitting Agreement
R Shaw, Amy E.,MD SPEC Annadel Medical Group: Oncology Sonoma Oncology None NoSanta Rosa Memorial Hospital
IShubin, James A.,MD PCP Round Valley Indian Health Center Mendocino Family Medicine
Meets MPCR#17, Previously Board Certified in FM, IM, or PEDs 08/27/1978 No Admitting Agreement
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RSilva, Heather N.,PA-C SPEC Northern California Medical Associates Inc.- DERM. Sonoma
Physician Assistant Certified
National Commission on Certification of Physician Assistants 07/10/2002 Yes
RSimard, Jane K.,PA-C PCP Anderson Walk-In Medical Clinic Shasta
Physician Assistant Certified
National Commission on Certification of Physician Assistants 05/08/2001 Yes
ISmith, Clara L.,RADT W&R Visions of the Cross/ Women's Residential Treatment Shasta Wellness and Recovery
California Consortium of Addiction Programs Professionals 06/26/2019 Yes
RSmith, Larry A.,DPM SPEC Larry Smith, DPM Sonoma Podiatry None No Admitting Agreement
ISt. Germain, Sunny E.,NP PCP Marin Community Clinic: Campus Clinic Marin Nurse Practitioner None No
ISteffens, Randall L.,DO PCP Stallant Medical Group Inc Del Norte Family Medicine AOB-Family Medicine 07/01/1998 Yes Admitting Agreement
RStiles, Thomas E.,MD SPEC Thomas E. Stiles MD Napa Endocrinology None No St Helena Hospital
RSugarman, Jeffrey L.,MD SPEC Northern California Medical Associates Inc.- DERM. Sonoma Dermatology ABMS of Dermatology 10/14/2002 Yes Admitting Agreement
I Tarran, Eddy RADT W&R Ford Street Project - Ukiah Recovery Center Mendocino Wellness and RecoveryCalifornia Consortium of Addiction Programs Professionals 09/03/2019 Yes
RTaylor, Stephen J.,DC SPEC S. Jeffrey Taylor, D.C. Napa Chiropractic None No
RThomas, James A.,III, PA-C BOTH Mendocino Coast Clinic Mendocino
Physician Assistant Certified
National Commission on Certification of Physician Assistants 12/22/2000 Yes
R Thu, Ye MD SPEC Annadel Medical Group (Infectious Disease) Sonoma Infectious Disease ABMS of Internal Medicine 11/15/2017 YesSanta Rosa Memorial Hospital
RThurman Woodruff, Hannorah O.,BCBA BHP Gateway Learning Group Sonoma Behavioral Health Behavior Analyst Certification Board 11/30/2009 Yes
RTito, Elizabeth P.,MD SPEC Annadel Medical Group: Breast Surgery Sonoma Surgery ABMS of Surgery 09/13/1999 Yes
Santa Rosa Memorial Hospital
ITravis, Jamie D.,RADT W&R Bi-Bett Corporation Shamia Recovery Center Solano Wellness and Recovery
California Consortium of Addiction Programs Professionals 07/22/2019 Yes
IValle, Dalyn SUDRC W&R Aegis Treatment Centers, LLC - Redding Shasta Wellness and Recovery California Association of DUI Treament Programs 10/31/2019 Yes
I Vaynberg, Dina MD SPEC Annadel Medical Group SonomaObstetrics and Gynecology Confirmed per AMA or Residency Letter No
American Academy of Nurse Practitioners Certification Board 09/01/2010 Yes
IWashington, Wayne A.,SUDCC W&R Bi-Bett Diablo Valley Ranch
Contra Costa Wellness and Recovery California Association of DUI Treament Programs 12/27/2019 Yes
RWeeks, John A.,MD PCP Adventist Health Clearlake Lake Family Medicine ABMS of Family Medicine 07/08/1979 Yes
St Helena Hospital- Clearlake
RWeeks, Roger D.,MD SPEC North Bay Eye Associates Inc. Sonoma Ophthalmology ABMS of Ophthalmology 10/15/1978 Yes
Petaluma Valley Hospital
RWendel, Robert T.,MD SPEC Retinal Consultants Medical Group Yolo Ophthalmology ABMS of Ophthalmology 10/20/1984 Yes
Mercy General Hospital of Sacramento
IWenerstrom, David RADT W&R Visions of the Cross/ Women's Residential Treatment Shasta Wellness and Recovery
California Consortium of Addiction Programs Professionals 06/27/2019 Yes
IWilliams, John RADT W&R Aegis Treatment Centers, LLC - Redding Shasta Wellness and Recovery
California Consortium of Addiction Programs Professionals 07/06/2016 Yes
June 2020
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June 2020 Routine Clean File List
IWilson, Dewight RADT W&R Bi-Bett Corporation Southern Solano Alcohol Council Solano Wellness and Recovery
California Consortium of Addiction Programs Professionals 01/20/2016 Yes
IWunner, Vesta B.,LCSW W&R County of Humboldt - Healthy Moms Program Humboldt Wellness and Recovery
RWyatt, Carolyn M.,NP SPEC Mendocino Community Health Clinic: Hillside Health Center Mendocino Nurse Practitioner None No
RWyble, Angela R.,PA-C SPEC Northern California Medical Associates Inc.- DERM. Sonoma
Physician Assistant Certified
National Commission on Certification of Physician Assistants 10/30/2003 Yes
R Ziady, Mary S.,NP SPEC Mendocino Community Health Clinic: Hillside Health Center Mendocino Nurse Practitioner None No
IZsarnay, Lois F.,LMFT W&R
Bright Heart Health - MAT (Suboxone), Wellness and Recovery Solano Wellness and Recovery None No
June 2020
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Page 1 of 4
CREDENTIALING COMMITTEE SUMMARY FOR PARTNERSHIP HEALTHPLAN OF CALIFORNIA
PHYSICIAN ADVISORY COMMITTEE
Pg. 1 of 4 * = by phone conference
Committee: Credentialing Committee Date/Time: May 13, 2020, 7:00 A.M. – 7:30 A.M. Members Present: Steven Gwiazdowski, MD*; David Gorchoff, MD*; Jeffrey Gaborko, MD; Madeleine Ramos,
MD*; Bradley Sandler, MD*; Susan Foster, FNP* Michelle Herman, MD* PHC Staff: Marshall Kubota, MD*, PHC Regional Medical Director; Robert Moore, MD, MPH, MBA, PHC
Chief Medical Officer; Bettina Spiller, MD* PHC Northern Region Medical Director; Michael Vovakes, MD* PHC Northern Region Medical Director; David Glossbrenner, MD* PHC Northern Region Medical Director; Mark Netherda, MD*; PHC Medical Director; Mary Kerlin, Senior Director; Lisa O’Connell*, Senior Manager of Provider Network Education and Credentialing, Brooke Vance*, Senior Lead Auditor; Erika Roach*, Credentialing Specialist I; J’aime Seale*, Credentialing Specialist I; Dani Alfaro* Credentialing Specialist I.
I. Meeting called to order. a. Voting member reminder.
I. PHC Regional Medical Director Marshall Kubota, MD called the meeting to order at 7:02 AM. Dr. Kubota reminded everyone that all items discussed are confidential. a. Marshall Kubota, MD, Regional Medical Director, reminded The Committee of who the voting members are, and voting is restricted to non-PHC staff. Dr. Kubota reminded the committee that all information discussed is confidential in nature. He also welcomed new members to the committee and thanked them for being part of the advisory.
5/13/2020
5/13/2020
II. Review and approval of April 8, 2020 Credentialing Meeting Minutes.
II. The Credentialing Committee meeting minutes for April 8, 2020 were reviewed by the Committee. No changes were made.
II. Minutes were reviewed with no revisions. A motion for approval of the minutes was made by: Steven Gwiazdowski, MD and seconded by: Jeffrey Gaborko, MD. Meeting minutes were unanimously approved without changes.
5/13/2020
III. Old Business III. Old Business - No old business to report. 5/13/2020
IV. New Business a. Review and Approval of Routine Practitioner
IV. New Business a. Dr. Kubota referred the Committee to pages 6-12, he asked the Committee to review the routine list of
IV. New Business a. The Committee reviewed the list of practitioners. A motion to approve the list of practitioners was made by:
5/13/2020
5/13/2020
Final
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Page 2 of 4
AGENDA ITEM DISCUSSION / CONCLUSIONS RECOMMENDATIONS / ACTION TARGET DATE
DATE RESOLVED
List. b. Exceptions: Provider
practitioners. Dr. Kubota explained that the routine practitioners list are the providers that either have no findings or minor infractions. He went on to explain that when reviewing these providers he looks for patterns of incompetent behavior, minor incidences, and considers the severity when deciding whom to add to the routine list or bring to the committee. b. Dr. Kubota called the Committee’s attention to pages 13-19 of the packet and asked the committee to read over the documents regarding the provider. Dr. Kubota mentioned that there is a concern of unprofessional conduct that occurred on 2/15/2018 that included improper touching on two separate occasions. He was fired from Medical Group over these incidents. Dr. Kubota asked the Committee to read over the clinician’s statement. Dr. Kubota pointed out that PHC staff had researched the NPDB report which is included on page 16. He confirmed that an inquiry was made to the Osteopathic Medical Board (OMB) about why these instances were not reported. The OMB responded that they had reviewed the case internally but were going to re-review the matter to see if it should have been posted on the Licensee’s profile page. Dr. Kubota requested a discussion on the provider. Dr. Ramos said she appreciated Dr. Kubota’s credentialing explanation and mentioned that she has seen many referrals to this doctor and it seemed to her that this was the only issue reported. Her question to the Committee was is it enough to deny re-credentialing at this point? Dr. Kubota explained that there are options the Committee may consider.. Dr. Gwiazdowski asked if there was a timeline to this issue since it was self-reported and asked if the allegations come before he self-reported. He was concerned with integrity issues. Dr. Kubota confirmed that PHC did not have that information. Dr. Gaborko agreed that a timeline would be helpful. Dr. Spiller noted that we only have the provider’s point of view and she doesn’t see any explanation on why he would need to do a breast exam on this patient not once but on two separate occasions. Dr.
Steven Gwiazdowski, MD and seconded by: David Gorchoff, MD. The Committee unanimously approved the routine list. b. There was detailed discussion by The Committee to not approve re-credential until hearing more form the OMB. A motion was made to reconsider re-credentialing at the June meeting so that more information could be obtained. Motion was made by: Steve Gwiazdowski, MD, and seconded by David Gorchoff, MD. Majority approved the motion for not re-credentialing until further information is reported.
6/10/2020
5/13/2020
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Page 3 of 4
AGENDA ITEM DISCUSSION / CONCLUSIONS RECOMMENDATIONS / ACTION TARGET DATE
DATE RESOLVED
c. Provider d. Review of MPCR200 Clean/Routine Practitioners and Ancillaries Practitioners approved, Pre-Committee Meeting.
Gaborko asked if PHC could try to get more information from Prima. Mary Kerlin said that Lisa O’Connell has reached out for more information and we could reach out again to bring back more information next month. Dr. Moore said that if the Committee feels the doctor should not be re-credentialed due to the nature of the incident we can choose to not re-credential until there is further investigation. Dr. Gwiazdowski said that he would err on the side of the patient. Dr. Gorchoff agreed to holding off on re-credentialing until the OMB could give the Committee results of the investigation. c. Dr. Kubota reviewed his approval of the provider and the completed MPCR 17 Criteria Form and Review. d.. Dr Kubota called the Committee’s attention to Page 15. The MPCR 200 Clean/Routine Practitioners and Ancillaries Practitioners approved, Pre-Committee Meeting. Information Only.
c. Informational only. d. Informational only.
5/13/2020 5/13/2020
V. Ongoing Monitoring of Sanctions Report and Practitioner Monitoring List. a. Review and Approval of Ongoing Monitoring of Sanctions Report.
V. Review and Approval of Ongoing Monitoring of Sanctions Report. a. The Committee was asked to review and approve the Ongoing Monitoring of Sanctions Report, page 30. Dr. Kubota mentioned the finding of the provider on pages 31-34 who was reported to have a non-disciplinary action.
a. The Committee members reviewed the reports. A motion for approval of the Ongoing Monitoring of Sanctions Report was made by: Jeffrey Gaborko, MD and seconded by: Michele Herman, MD and was unanimously
5/13/2020
5/13/2020
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DATE RESOLVED
b. Practitioner Monitoring List.
Dr. Kubota has reviewed it and deemed it as informational only. Dr. Kubota asked for The Committee’s approval of the ongoing monitoring of sanctions report. b. Dr. Kubota directed the Committee to pages 35-36 the practitioner monitoring list for informational purposes only.
approved. b. Practitioner Monitoring List. Informational Only
5/13/2020
VI. Review and Approval of Consent Calendar Items. a. Review and Approval of Consent Calendar Items.
VI. Review and Approval of Consent Calendar Items. a. Dr. Kubota asked the Credentialing Committee members to review and approve consent calendar items: Report of Long Term Care Facility, Hospital, and Ancillary provider list. Page 37-38.
a. Committee members reviewed the consent calendar items. A motion for approval of Consent Calendar items was made by Jeffrey Gaborko, MD and seconded by: Madeleine Ramos, MD. Consent calendar items unanimously approved by the Credentialing Committee.
5/13/2020
5/13/2020
VI. Meeting Adjourned. VII. Meeting adjourned at 7:30 AM. 5/13/2020
Credentialing Meeting Summary for May 13, 2020 respectfully prepared and submitted by Erika Roach Credentialing Specialist I. Chairman Signature of Approval _____________________________________________ Date______________________________ Marshall Kubota, M.D., PHC Credentialing Chairman
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App. Typ Full Name
Provider Type Name/Street
County Name
Specialty Description Board Name
Initial Cert Date
Board
Hospital Name Staff Cat
Specialty Order
IAjuria, Michael J.,MD
SPECEast Bay Nephrology
Solano NephrologyConfirmed per AMA or Residency Letter
NoAlta Bates Summit
Provisional
Primary Specialty
R Ali, Ruby S.,MD SPEC NBHG: Neurology Solano NeurologyABMS of Psychiatry & Neurology
09/28/2009 YesNorthbay Medical
Active Attendin
Primary Specialty
IAlicbusan, Jennifer C.,FNP
PCPQVMA: Queen of the Valley Medical
NapaFamily Nurse Practitioner
American Academy of Nurse
03/21/2019 YesPrimary Specialty
RAncellotti, Loretta J.,FNP
PCPAdventist Health Clearlake
LakeFamily Nurse Practitioner
American Nurses Credentialing Center
01/06/2005 YesPrimary Specialty
IArnell, Courtnie M.,FNP
PCPSCHC: Shasta Community Health
ShastaFamily Nurse Practitioner
American Academy of Nurse
06/28/2019 YesPrimary Specialty
I Arnold, Kellie L.,FNP PCPNortheastern Rural Health
LassenFamily Nurse Practitioner
American Academy of Nurse
02/03/2020 YesPrimary Specialty
I Badu, Paul CADC II W&RVisions of the Cross/ Women's
ShastaWellness and Recovery
California Consortium of
04/12/2005 YesPrimary Specialty
IBaggese, Steve A.,BCBA
BHPGenesis Behavior Center, Inc.
YoloBehavioral Health
Behavior Analyst Certification Board
05/31/2014 YesPrimary Specialty
IBains, Madilynn S.,RADT
W&RModoc County Alcohol and Drug
ModocWellness and Recovery
California Consortium of
11/05/2019 YesPrimary Specialty
IBarden, Margaret D.,NP
PCPMendocino Coast Clinic
Mendocin o
Nurse Practitioner
American Nurses Credentialing Center
07/09/2013 YesPrimary Specialty
I Barrow, Sandra MD SPECNephrology Associates
Sonoma NephrologyABMS of Internal Medicine
10/02/2014 YesSanta Rosa
Provisional
Primary Specialty
I Bayan, Ruby P.,MD W&RWaterfront Recovery
Humboldt
Wellness and Recovery
Admitting Agreemen
NonePrimary Specialty
RBeaudoin, Alicia M.,BCBA
BHP Learning ARTS YoloBehavioral Health
Behavior Analyst Certification Board
05/31/2016 YesPrimary Specialty
RBehrens, Paula M.,PT
AlliedNBHG: Northbay Rehab Services-
SolanoPhysical Therapy
None NoPrimary Specialty
RBonatto, Justin BCBA
BHPGateway Learning Group
MarinBehavioral Health
Behavior Analyst Certification Board
02/28/2017 YesPrimary Specialty
IBosserman, Mariel A.,NP
PCPODCHC - North Country Clinic
Humboldt
Adult-Gerontology
American Nurses Credentialing Center
12/07/2015 YesPrimary Specialty
IBotelho, Ronald J.,MD
SPECAdventist Health Clearlake
LakePain Management
Admitting Agreemen
NonePrimary Specialty
RBradley, Marina M.,FNP
PCPNBHG: Center for Primary Care-
SolanoFamily Nurse Practitioner
American Nurses Credentialing Center
06/12/2013 YesPrimary Specialty
IBrazil-Harris, Jamie L.,RADT
W&RModoc County Alcohol and Drug
ModocWellness and Recovery
California Consortium of
06/30/2016 YesPrimary Specialty
IBrooks, Dionne P.,LCSW
BHPBurnett Therapeutic
NapaBehavioral Health
None NoPrimary Specialty
IBrushwyler, Elizabeth D.,PT
AlliedCapuchino Therapy Group
YoloPhysical Therapy
None NoPrimary Specialty
I Burji, Carla BCBA BHPBehavior Matters California, LLC
SolanoBehavioral Health
Behavior Analyst Certification Board
08/31/2019 YesPrimary Specialty
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ICabanne, Marc B.,DO
SPECMarc Cabanne, DO Inc
YoloNeurological Surgery
AOS of Neurological Surgery
12/20/2019 YesMercy General
Provisional
Primary Specialty
ICapuchino, Lula M.,OT
AlliedCapuchino Therapy Group
YoloOccupational Therapy
None NoPrimary Specialty
ICaryotakis, Carissa A.,FNP
PCPElica Health Centers-Halyard
YoloFamily Nurse Practitioner
American Academy of Nurse
12/14/2016 YesPrimary Specialty
ICasavant, William A.,PA
SPECGreenville Rancheria
ShastaPhysician Assistant
None NoPrimary Specialty
I Chan, Albert D.,MD SPECSutter Lakeside Community Clinic
LakeOrthopaedic Surgery
None NoSutter Lakeside
Provisional
Primary Specialty
IChaney, Sally T.,FNP
SPECWomen's Health Specialists
ShastaNurse Practitioner
American Nurses Credentialing Center
06/03/2011 YesPrimary Specialty
R Cheung, Eric L.,MD SPECNephrology Associates
Sonoma NephrologyABMS of Internal Medicine
10/02/2014 YesSanta Rosa
ActivePrimary Specialty
IChico, Patricia D.,MD
PCPODCHC: Redwood
Humboldt
Family MedicineABMS of Family Medicine
07/01/2015 YesAdmitting Agreemen
NonePrimary Specialty
R Cho, Peter Y.,MD BOTHAdventist Health Ukiah Valley
Mendocin o
Family MedicineABMS of Family Medicine
07/14/1995 YesUkiah Valley
ActivePrimary Specialty
IConnelly, Kristen A.,FNP
PCPMendocino Coast Clinic
Mendocin o
Family Nurse Practitioner
American Nurses Credentialing Center
06/02/2016 YesPrimary Specialty
ICounts, Shaheen MD
SPECHumboldt Medical Specialists -
Humboldt
Otolaryngology,Head, and Neck
ABMS of Otolarynology -
06/01/2013 YesAdmitting Agreemen
NonePrimary Specialty
ICunningham, Jason L.,DO
PCPWest County Health Centers,
Sonoma Family MedicineABMS of Family Medicine
07/16/2004 YesAdmitting Agreemen
NonePrimary Specialty
I Curry, Emerald PA SPECPacific Skin Institute
YoloPhysician Assistant
National Commission on
09/30/2019 YesPrimary Specialty
I Dalton, Emily L.,MD PCPODCHC - Eureka Community Health
Humboldt
Pediatrics ABMS of Pediatrics 03/03/2016 YesAdmitting Agreemen
NonePrimary Specialty
IDeuel, Christopher J.,MD
PCPAdventist Health Ukiah Valley :PCP
Mendocin o
Family MedicineABMS of Family Medicine
07/01/2017 YesAdventist - Ukiah
ActivePrimary Specialty
I Diaz, Xavier RADT W&RMedMark Treatment
SolanoWellness and Recovery
California Consortium of
03/22/2019 YesPrimary Specialty
IDietz, Suzanne M.,NP
PCPHumboldt Medical Specialists
Humboldt
Nurse Practitioner
None NAPrimary Specialty
IDittman, Taylor N.,FNP
PCPSCHC: Shasta Community Health
ShastaFamily Nurse Practitioner
American Academy of Nurse
12/30/2018 YesPrimary Specialty
R Fay, Mark T.,MD SPECKlamath Eye Center
Siskiyou OphthalmologyABMS of Ophthalmology
11/18/1990 YesModoc Medical
Provisional
Primary Specialty
RFeinberg, Howard L.,DO
PCPSolano County Health & Social
SolanoInternal Medicine
AOB of Internal Medicine
09/17/1992 YesAdmitting Agreemen
NonePrimary Specialty
R Field, Bobby G.,MD SPECAnnadel Medical Group
Sonoma Gynecology None NoAdmitting Agreemen
ActivePrimary Specialty
I Fields, Alaina N.,MD PCPMendocino Community Health
Mendocin o
Family MedicineMeets MPCR #17, Verified Residency
NoAdmitting Agreemen
NonePrimary Specialty
I Freeman, Jed L.,MD SPECSt Elizabeth Community
Tehama HematologyABMS of Internal Medicine
11/03/1999 YesSt Elizabeth
ActivePrimary Specialty
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I Froz, Rashad PA-C PCP Ole Health NapaPhysician Assistant
National Commission on
01/27/2020 YesPrimary Specialty
IGalloway, Erin BCBA
BHPAutism Advocacy and Intervention,
LakeBehavioral Health
Behavior Analyst Certification Board
05/31/2019 YesPrimary Specialty
IGifford, Laurinda RADT
W&RAegis Treatment Centers, LLC -
ShastaWellness and Recovery
California Consortium of
11/19/2018 YesPrimary Specialty
R Glyer, John R.,MD PCPAdventist Health Howard Memorial
Mendocin o
Family MedicineMeets MPCR#17, Previously Board
10/30/1977 NoFrank R. Howard
ActivePrimary Specialty
IGoettman, Mitchell A.,DO
SPEC Adventist Health Shasta General SurgeryConfirmed per AMA or Residency Letter
NoAdventist Health
Temporary
Primary Specialty
RGomez-Mira, Christina MD
PCPPetaluma Health Center
Sonoma Family MedicineABMS of Family Medicine
07/01/2016 YesAdmitting Agreemen
NonePrimary Specialty
IGreenlee, James K.,NP
PCPAdventist Health Clearlake
LakeNurse Practitioner
American Nurses Credentialing Center
09/01/1997 YesPrimary Specialty
I Griffin, Brittany PA-C SPECRedwood Orthopaedic
SonomaPhysician Assistant
National Board of Certification &
10/03/2019 YesPrimary Specialty
IGriffith, Salvacion G.,PT
AlliedNBHG: Neurosurgery, A
SolanoPhysical Therapy
None NoPrimary Specialty
IHalligan, Sommer A.,LM
SPECUIHS - Potawot Health Village
Humboldt
Licensed Midwife
Primary Specialty
R Hariri, Mazen F.,DO PCPSutter Coast Community Clinic
Del Norte
Family MedicineABMS of Family Medicine
11/14/2016 YesAdmitting Agreemen
NonePrimary Specialty
IHarms, Debra R.,SLP
AlliedCapuchino Therapy Group
YoloSpeech & Language
National Commission on
NoPrimary Specialty
IHawkins, Candice M.,OT
AlliedCapuchino Therapy Group
YoloOccupational Therapy
None NoPrimary Specialty
IHawkins, Peter G.,MD
SPECRohnert Park Cancer Center
SonomaRadiation Oncology
Confirmed per AMA or Residency Letter
NoAdmitting Agreemen
NonePrimary Specialty
IHeidarzadeh, Taban BCBA
BHPCenter for Autism and Related
SolanoBehavioral Health
Behavior Analyst Certification Board
08/31/2019 YesPrimary Specialty
IHenriques, Robert W.,MD
PCPODCHC - Willow Creek Community
Humboldt
Family MedicineABMS of Family Medicine
07/13/1990 YesAdmitting Agreemen
NonePrimary Specialty
RHobson, Jessica A.,PhD
BHPPatrick D. MacLeamy, PsyD
SonomaBehavioral Health
None NoPrimary Specialty
IHockridge, Blain BCBA
BHPBurnett Therapeutic
NapaBehavioral Health
Behavior Analyst Certification Board
05/31/2019 YesPrimary Specialty
RHolmes, Jarrod P.,MD
SPECAnnadel Medical Group
Sonoma HematologyABMS of Internal Medicine
11/14/2007 YesSanta Rosa
ActivePrimary Specialty
I Holst, David G.,MD PCPDignity Health - Mercy Mt. Shasta
Siskiyou Family MedicineABMS of Family Medicine
07/09/1993 YesMercy Medical
ActivePrimary Specialty
RHutchings, Donovan K.,DC
SPECChurn Creek Chriropractic
Shasta Chiropractic None NoAdmitting Agreemen
NonePrimary Specialty
RJansma, Jessa BCBA
BHP Learning ARTS YoloBehavioral Health
Behavior Analyst Certification Board
05/31/2015 YesPrimary Specialty
I Jensen, Lois A.,MD W&RAegis Treatment Centers, LLC -
ShastaWellness and Recovery
Admitting Agreemen
NonePrimary Specialty
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I Jensen, Lois A.,MD W&RAegis Treatment Centers, LLC -
I Joorabchi, Nisa FNP PCP Ole Health NapaFamily Nurse Practitioner
American Nurses Credentialing Center
03/10/2016 YesPrimary Specialty
R Kao, Samuel D.,MD SPECSamuel Kao, M.D., Ste A
Solano Hand Surgery None NoAdmitting Agreemen
NonePrimary Specialty
I Keiser, Aimee L.,OT Allied Aimee Keiser, OTHumboldt
Occupational Therapy
None NoPrimary Specialty
RKhambatta, Shanaz F.,DO
PCPNBHG: Center for Primary Care-
Solano Family MedicineAOB-Family Medicine
10/25/2002 YesAdmitting Agreemen
NonePrimary Specialty
RKlimist-Zingo, Susan PA-C
PCPAdventist Health Ukiah Valley
Mendocin o
Physician Assistant
National Commission on
01/15/1986 YesPrimary Specialty
IKoster, Nancy K.,MD
SPECHumboldt Medical Specialists -
Humboldt
Cardiovascular Disease
ABMS of Internal Medicine
11/01/2006 YesAdmitting Agreemen
NonePrimary Specialty
RLance, Erinn B.,CNM
SPECMarin Community Clinic: Campus
MarinCertified Nurse Midwife
American Midwifery Certification Board
10/01/1998 YesPrimary Specialty
ILarson, Penny L.,MD
SPECElica Health Centers
YoloObstetrics and Gynecology
ABMS of Obstetrics and Gynecology
11/07/2003 YesAdmitting Agreemen
NonePrimary Specialty
R Leavitt, Lisa A.,MD PCPMarin Community Clinic: San Rafael
Marin Pediatrics ABMS of Pediatrics 10/09/1996 YesMarin General
ActivePrimary Specialty
I Lee, Chong S.,MD SPECBanner Health Clinic
Lassen General Surgery ABMS of Surgery 12/11/1995 YesBanner Lassen
Consulting
Primary Specialty
ILee, Christopher J.,MD
SPECHumboldt Medical Specialists-
Humboldt
General Surgery ABMS of Surgery 02/15/2000 YesAdmitting Agreemen
NonePrimary Specialty
I Lee, Ellen K.,PA-C SPECPacific Skin Institute
YoloPhysician Assistant
National Commission on
05/23/2019 YesPrimary Specialty
I Lee, Rodith V.,PT AlliedFeather River Tribal Health
ButtePhysical Therapy
None NoPrimary Specialty
I Lee, Sandra Y.,FNP PCPODCHC - Fortuna Community Health
Humboldt
Family Nurse Practitioner
American Nurses Credentialing Center
05/25/2016 YesPrimary Specialty
ILessenger, James MD
W&RGenesis House Inc.
SolanoWellness and Recovery
NoAdmitting Agreemen
NonePrimary Specialty
ILombardi, Donald P.,MD
SPECMendocino Coast District Hospital
Mendocin o
Internal Medicine
ABMS of Internal Medicine
09/13/1989 YesMendocino Coast
ActivePrimary Specialty
I Lopez, Elena R.,MD PCPElica Health Centers-Halyard
Yolo Family MedicineMeets MPCR #17, Verified Residency
NoAdmitting Agreemen
NonePrimary Specialty
ILopez-Clark, David B.,BCBA
BHPGenesis Behavior Center, Inc.
YoloBehavioral Health
Behavior Analyst Certification Board
08/31/2019 YesPrimary Specialty
ILucarelli, Steve CADC-CS
W&RVisions of the Cross/ Women's
ShastaWellness and Recovery
California Consortium of
05/30/2013 YesPrimary Specialty
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IMackey, Margaret L.,NP
SPECPersonalized Care, MD
NapaNurse Practitioner
None NoPrimary Specialty
IMahan, Marcelle O.,MD
PCPHumboldt Medical Specialists
Humboldt
Family PracticeMP CR# 17 Received Medical
NAAdmitting Agreemen
NonePrimary Specialty
RMajlessi, Azadeh-aka L.,MD
SPECAdventist Health Clearlake
Lake RheumatologyABMS of Internal Medicine
11/04/1998 YesAdmitting Agreemen
NonePrimary Specialty
IManuntag, Wilfredo P.,MD
PCPSutter Coast Community Clinic
Del Norte
Family MedicineMeets MPCR#17, Previously Board
07/12/1996 NoSutter Coast
Provisional
Primary Specialty
IMarcoulides, Demetrius D.,ANP
PCPPetaluma Health Center
SonomaAdult-Gerontology
American Academy of Nurse
02/22/2018 YesPrimary Specialty
IMartin, Joseph E.,PA
SPECNorth Coast Family Health
Mendocin o
Physician Assistant
Previously Board Certified
04/25/2001 NoPrimary Specialty
IMartin, Karley CADC II
W&RHumboldt County Programs of
Humboldt
Wellness and Recovery
California Consortium of
02/02/2018 YesPrimary Specialty
RMarty, Talitha L.,PA-C
PCPMendocino Community Health
Mendocin o
Physician Assistant
National Commission on
12/17/2001 YesPrimary Specialty
R Matalon, Eran MD PCPAnnadel Medical Group
SonomaInternal Medicine
ABMS of Internal Medicine
09/25/1991 YesSanta Rosa
ActivePrimary Specialty
IMatthews, Joshua M.,MD
SPECSutter Lakeside Community Clinic
LakeOrthopaedic Surgery
Confirmed per AMA or Residency Letter
NoAdmitting Agreemen
NonePrimary Specialty
RMcDaniel, Candice O.,MD
SPECShriners Hospitals for Children
YoloOrthopaedic Surgery
ABMS of Orthopaedic Surgery
07/24/2014 YesShriners Hospital
ActivePrimary Specialty
IMendel, Sandra G.,MD
PCPNorth Coast Family Health
Mendocin o
Internal Medicine
ABMS of Internal Medicine
09/10/1986 YesMendocino Coast
ActivePrimary Specialty
R Miller, Julie A.,PT AlliedNBHG: Northbay Rehab Services-
SolanoPhysical Therapy
None NoPrimary Specialty
R Mirda, Daniel P.,MD SPECQVMA: Queen of the Valley Medical
NapaMedical Oncology
ABMS of Internal Medicine
11/07/1989 YesQueen of the Valley
ActivePrimary Specialty
RMolden, Jaime J.,MD
SPECSutter Lakeside Community Clinic
LakeCardiovascular Disease
ABMS of Internal Medicine
11/04/2009 YesSutter Lakeside
ActivePrimary Specialty
IMolina, Steven CADC CAS
W&RMedMark Treatment
SolanoWellness and Recovery
California Consortium of
04/16/2013 YesPrimary Specialty
IMorrison, Tara M.,FNP
SPECAnnadel Medical Group
SonomaFamily Nurse Practitioner
American Academy of Nurse
05/20/2015 YesPrimary Specialty
RMouratoff, John G.,MD
SPECEast Bay Nephrology
Solano NephrologyABMS of Internal Medicine
11/03/1999 YesSutter Solano
CourtesyPrimary Specialty
IMyrick, Evelyn C.,FNP
SPECShriners Hospitals for Children
YoloFamily Nurse Practitioner
American Academy of Nurse
06/25/2014 YesPrimary Specialty
IO'Neal, Shannan L.,ACSW
W&RCounty of Humboldt - Health
Humboldt
Wellness and Recovery
None NAPrimary Specialty
ROechsel, Michael J.,MD
SPECMarin Community Clinic: South
MarinOrthopaedic Surgery
ABMS of Orthopaedic Surgery
07/10/1992 YesMarin General
ActivePrimary Specialty
I Oven, Sarah J.,MD PCPSutter Lakeside Medical Practice
Lake Family MedicineABMS of Family Medicine
07/14/2000 YesAdmitting Agreemen
NonePrimary Specialty
R Palmieri, Tina L.,MD SPECShriners Hospitals for Children
Yolo Surgery ABMS of Surgery 03/23/1994 YesShriners Hospital
ActivePrimary Specialty
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I Peak, Daniel T.,NP PCPElica Health Centers-Halyard
YoloNurse Practitioner
None NoPrimary Specialty
RPearson, Chelsea PA-C
PCPModoc Medical Clinic
ModocPhysician Assistant
National Commission on
06/13/2013 YesPrimary Specialty
RPeterson, Scott P.,MD
PCPAnnadel Medical Group
SonomaInternal Medicine
ABMS of Internal Medicine
09/16/1987 YesSanta Rosa
ActivePrimary Specialty
I Phillips, Irving J.,MD PCPCommunicare Health Centers -
Yolo PediatricsMeets MPCR #17, Verified Residency
NoSutter Davis
Provisional
Primary Specialty
IPipitone, Jessica BCBA
BHPCenter for Behavioral
SolanoBehavioral Health
Behavior Analyst Certification Board
03/09/2020Primary Specialty
R Portnoff, Jon S.,MD SPECAdventist Health Ukiah Valley
Mendocin o
CardiologyConfirmed per AMA or Residency Letter
NoUkiah Valley
ActivePrimary Specialty
I Puri, Parul FNP SPECPacific Skin Institute
YoloFamily Nurse Practitioner
American Nurses Credentialing Center
01/30/2020 YesPrimary Specialty
IQuider, Yakima K.,NP
SPECPlanned Parenthood
ButteNurse Practitioner
None NoPrimary Specialty
I Rader, Mark D.,MD SPECKimaw Medical Center
Humboldt
Obstetrics and Gynecology
ABMS of Obstetrics and Gynecology
11/11/1977 YesAdmitting Agreemen
NonePrimary Specialty
I Raisoni, Snehal MD PCPRound Valley Indian Health
Mendocin o
Internal Medicine
Meets MPCR #17, Verified Residency
NAAdmitting Agreemen
NonePrimary Specialty
IRodgers, Margaret L.,MD
SPECQVMA: Queen of the Valley Medical
NapaObstetrics and Gynecology
ABMS of Obstetrics and Gynecology
12/09/1988 YesAdmitting Agreemen
NonePrimary Specialty
RRowley, Kimberly BCBA
BHP Learning ARTS YoloBehavioral Health
Behavior Analyst Certification Board
05/31/2015 YesPrimary Specialty
ISaavedra, Ingrid BCBA
BHPBehavior Matters California, LLC
SolanoBehavioral Health
Behavior Analyst Certification Board
11/30/2019 YesPrimary Specialty
ISaffier, Kenneth A.,MD
W&RBi-Bett Diablo Valley Ranch
Contra Costa
Wellness and Recovery
None NAAdmitting Agreemen
NonePrimary Specialty
ISalazar, Alyssa BCBA
BHPAutism Intervention
SolanoBehavioral Health
Behavior Analyst Certification Board
08/31/2018 YesPrimary Specialty
ISamonte, Kimberly Claire BCBA
BHPCenter for Autism and Related
SolanoBehavioral Health
Behavior Analyst Certification Board
02/28/2020 YesPrimary Specialty
ISanderson, Robin S.,FNP
PCPMarin Community Clinic: Campus
MarinNurse Practitioner
American Academy of Nurse
05/20/2016 YesPrimary Specialty
RSanto Domingo, Noel E.,MD
SPECNorthern California Medical
SonomaCardiovascular Disease
ABMS of Internal Medicine
11/08/2000 YesSanta Rosa
CourtesyPrimary Specialty
RSchwartz, Andrew I.,DO
PCPSutter Lakeside Community Clinic
Lake Family MedicineAOB-Family Medicine
09/15/2006 YesSutter Lakeside
ActivePrimary Specialty
R Scipione, Paul J.,MD SPECRedding Rancheria: Churn
ShastaBuprenorphine Treatment - YES
NoMercy Medical
CourtesyPrimary Specialty
R Scott, Alan B.,MD SPECNorth Bay Eye Associates Inc.
Sonoma OphthalmologyABMS of Ophthalmology
10/18/1963 YesCalifornia Pacific
ActivePrimary Specialty
IShabaik, Salma A.,MD
PCPCommunicare Health Centers -
Yolo Family MedicineABMS of Family Medicine
07/01/2012 YesAdmitting Agreemen
NonePrimary Specialty
IShepherd, Raevan M.,SUDCC
W&RFord Street Project - Ukiah
Mendocin o
Wellness and Recovery
California Association of DUI
11/22/2019 YesPrimary Specialty
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ISibley, Sonnier F.,PA
BOTHSutter Coast Community Walk-
Del Norte
Physician Assistant
National Commission on
05/15/2017 YesPrimary Specialty
ISidhu, Gurinder S.,MD
SPECQVMA: Queen of the Valley Medical
NapaMedical Oncology
ABMS of Internal Medicine
10/28/2008 YesQueen of the Valley
Provisional
Primary Specialty
ISmith, Chelsea A.,DPM
SPEC Adventist Health Shasta Podiatry None NoAdventist Health +
ActivePrimary Specialty
RSponzilli, Ernest H.,MD
SPECCalifornia Orthopedics &
MarinPhysical Medicine &
ABMS of Physical Medicine &
07/01/1998 YesMarin General
ActivePrimary Specialty
I Steil, Regan M.,FNP SPECWomen's Health Specialists
ShastaFamily Nurse Practitioner
ABMS of Family Medicine
11/18/2019 YesPrimary Specialty
RStevens, Scott K.,MD
SPECKlamath Eye Center
Siskiyou OphthalmologyABMS of Ophthalmology
11/07/2010 YesLake District
CourtesyPrimary Specialty
RSumsion, Sean M.,MD
SPECRiverside EyeCare
Shasta OphthalmologyABMS of Ophthalmology
10/07/2018 YesMercy Medical
CourtesyPrimary Specialty
ITimothy, Parker D.,PA-C
SPECRedwood Orthopaedic
SonomaPhysician Assistant
National Commission on
09/26/2019 YesPrimary Specialty
ITirado, Gabriela A.,CNM
SPECPlanned Parenthood
NapaCertified Nurse Midwife
American Midwifery Certification Board
04/01/2019 YesPrimary Specialty
RTito, Elizabeth P.,MD
SPECAnnadel Medical Group: Breast
Sonoma Surgery ABMS of Surgery 09/13/1999 YesSanta Rosa
Provisional
Primary Specialty
RTodd, Angela R.,FNP
SPECPlanned Parenthood
NapaFamily Nurse Practitioner
American Nurses Credentialing Center
09/25/2012 YesPrimary Specialty
ITodd, Debbie K.,CADC II
W&RHumboldt County Programs of
Humboldt
Wellness and Recovery
California Consortium of
02/28/2011 YesPrimary Specialty
ITool, Franklin D.,FNP
PCPMarin Community Clinic: San Rafael
MarinFamily Nurse Practitioner
American Academy of Nurse
07/21/2015 YesPrimary Specialty
ITrevor, Kristin M.,FNP
SPECShasta Orthopedics &
ShastaFamily Nurse Practitioner
American Nurses Credentialing Center
07/29/2009 YesPrimary Specialty
ITurner, Christiana BCBA
W&RCenter for Autism and Related
ShastaBehavioral Health
Behavior Analyst Certification Board
11/30/2018 YesPrimary Specialty
RUpadhyaya, Darshna OT
AlliedNBHG: Northbay Rehab Services
SolanoOccupational Therapy
None NoPrimary Specialty
RValdez, Emerson A.,DPM
SPECAlliance Medical Center
SonomaPodiatric Surgery
None NoAdmitting Agreemen
NonePrimary Specialty
RVelasquez de Hickerson, Ana
PCPLassen Medical Clinic- Red Bluff
ShastaPhysician Assistant
National Commission on
03/08/2012 YesPrimary Specialty
R Wahi, Gaurav DO SPECDignity Health Women's Health
TehamaObstetrics and Gynecology
None 05/10/2017 NOSt Elizabeth
ActivePrimary Specialty
RWatters, Laura E.,MD
SPECCapital OB/GYN, Inc.
YoloObstetrics and Gynecology
ABMS of Obstetrics and Gynecology
12/11/2015 YesMethodist Hospital of
ActivePrimary Specialty
IWebster-Longin, Maria L.,MD
PCPMarin Community Clinic: Campus
MarinInternal Medicine
Meets MPCR#17, Previously Board
08/24/2004 NAAdmitting Agreemen
NonePrimary Specialty
R Weeks, John A.,MD PCPAdventist Health Clearlake
Lake Family MedicineABMS of Family Medicine
07/08/1979 YesSt Helena Hospital-
ActivePrimary Specialty
IWest, Raena D.,LCSW
W&RHumboldt County Programs of
Humboldt
Wellness and Recovery
Primary Specialty
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IWhalen, Sarah D.,PA-C
SPECPacific Skin Institute
YoloPhysician Assistant
National Commission on
10/07/2019 YesPrimary Specialty
RWilliams, John P.,DO
PCPJohn Williams, DO
Mendocin o
Osteopathic Manipulative
Frank R. Howard
Affiliate Staff
Primary Specialty
RWong, Andrew K.,MD
SPECQVMA: Queen of the Valley Medical
NapaCardiovascular Disease
ABMS of Internal Medicine
11/04/1993 YesQueen of the Valley
ActivePrimary Specialty
RYambao, Annabelle A.,PT
AlliedNBHG: Northbay Rehab Services
SolanoPhysical Therapy
None NoPrimary Specialty
R Yoon, David W.,MD PCPDignity Health - Mercy Family
Shasta Family MedicineABMS of Family Medicine
11/06/2017 YesMercy Medical
ActivePrimary Specialty
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AGENDA ITEM: II.G. DATE: 08/12/2020
PARTNERSHIP HEALTHPLAN OF CALIFORNIA
TO: Physician Advisory Committee FROM: Robert Moore, MD, MPH, Chief Medical Officer DATE: 08/12/2020 SUBJECT: PHC Committee Memberships
Physician Advisory Committee Appointment: Karen Sprague, Nurse Practitioner, Community Medical Centers, has requested appointment to the Physician Advisory Committee. Ms. Sprague’s appointment is recommended.
Quality / Utilization Advisory & Peer Review Committees Appointment: Emma Hackett, MD, Open Door Community Health Centers, has requested appointment to the Quality / Utilization Advisory and Peer Review committees. Dr. Hackett’s specialty is in Obstetrics and Gynecology. Her appointment is recommended.
Quality / Utilization Advisory Committee Resignation: Andrew Threlfall, MD, Chief of Psychiatry with Santa Rosa Community Health, has submitted his resignation (effective end of August) for the Quality / Utilization Advisory Committee. Dr. Threlfall has accepted the Chief of Psychiatry position for Santa Cruz County Behavioral Health Services. His resignation is recommended.
Hydroxychloroquine remains non-formulary, but added taxonomy override for board certified rheumatologist
PHC’s Site of Care policy establishes the requirement for medication infusion therapies -to be administered at the least intensive setting that is appropriate for the drug’s administration
Drugs that are U.S. Food and Drug Administration (FDA) approved for self-administration will be preferred to be provided through the pharmacy benefit
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Healthcare Effectiveness Data and Information Set
(HEDIS)
2020Summary of Performance
Measuring quality of care and services
provided to our members!
Presented by:
Rachael French, Associate Director, Quality and Performance Improvement
• Reporting Year 2020 HEDIS Performance• “New Measures” Baseline performance
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Overview
• What is HEDIS?• Healthcare Effectiveness Data Information Set• Administrative vs. Hybrid Measures
• Why is HEDIS Important?• Evaluates clinical quality in a standardized way• Identifies opportunities for improvement • Regional‐level performance is publicly reported and Required by DHCS
• HEDIS/CAHPS performance drives NCQA Accreditation Status
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HEDIS Overview
High Performance in HEDIS Translates to Improved Health Outcomes for Our
SetSignificant change in the Managed Care Accountability Set (MCAS) formerly known as the External Accountable Set (EAS):
• 8 New Measures
• Introduced the Adult & Child Core Set measures governed by CMS 8 new measures held to the Minimum Performance Level (MPL) 50th percentile:‐ ABA‐Adult Body Mass Index Assessment ‐ AMM‐Antidepressant Medication Management Acute Phase‐ AMM‐Antidepressant Medication Management Continuation Phase‐ AWC‐Adolescent Well‐Care Visits ‐ CHL‐Chlamydia Screening in Women ‐ CIS‐Childhood Immunization Status Combo 10 ‐W15‐Well Child Visits in First 15 Months of Life Six or more well child visits‐WCC‐Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents: BMI 3 measures removed from MCAS (but still required for NCQA Accreditation):
‐ AAB‐Antibiotic use for Acute Bronchitis‐ CDC‐Screening for Diabetic Retinopathy‐ LBP‐Imaging for Low Back Pain
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Changes in Clinical Quality Measures-Accountability
• Change in Minimum Performance Level (MPL) from the National Medicaid 25th to the 50th percentile
• Sanctions applied where performance falls below the newly established MPL (50th percentile)
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COVID -19 Impact
• With the onset of COVID‐19, we recognize and appreciate the impact in which our members and providers faced.
• DHCS released guidance allowing plans to report prior year hybrid rates, where medical record retrieval was impacted by COVID‐19
• PHC observed zero impact in the ability to retrieve medical record data in support of Hybrid measure reporting. PHC chose to report current hybrid rates.
• DHCS removed Managed Care Plans (MCP’s) accountability on Hybrid measure performance relative to the new MPL (50thpercentile)
• DHCS continues to hold MCPs accountable for Administrative measures relative to the new MPL (50th percentile)
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Average Plan-wide Composite HEDIS Performance
• Average Plan‐wide Scoring Methodology: • A weighted Plan‐wide average is calculated for each measure. The weighted regional rate is calculated by multiplying the region rate by the region eligible population, then dividing by the total eligible population across all regions. The weighted region rates are then summed to produce the weighted Plan‐wide rate.
• Each measure, Plan‐wide, is then assigned a score from 1‐10 based on their percentile ranking using the NCQA Quality Compass National HMO benchmarks
• A Plan‐wide score is calculated by dividing earned points by the maximum number of points available to arrive at a single performance statistic across all measures and regions
Baseline plan‐wide average composite scoreTotal Points Possible
Total Points Earned
Plan‐wide Composite
% Absolute Improvement
% Improvement from Baseline
100 64 0.64HEDIS Measurement Year 2019/Reporting Year 2020 plan‐wide average composite score
100 73 0.73 9% 14%
Baseline plan‐wide average composite score (HEDIS Measurement Year 2018/Reporting Year 2019)
Total Points Possible
Total Points Earned
Plan‐wide Composite
% Absolute Improvement
% Improvement from Baseline
160 88 0.55HEDIS Measurement Year 2019/Reporting Year 2020 plan‐wide average composite score
160 104 0.65 10% 18%
Baseline Composite based on “NEW” MCAS Measure Set
Year over Year Composite based on existing reportable measures
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Performance below the Minimum Performance Level (50th Percentile)
Measure Northeast Northwest Southeast Southwest
Adolescent Well Care (AWC)‐ NEW Measure
Asthma Medication Ratio (AMR)
Breast Cancer Screening (BCS)
Cervical Cancer Screening (CCS)
Childhood Immunizations Status (CIS)‐ Combo 10
Chlamydia Screening in Women (CHL)‐NEW Measure
Immunizations for Adolescents (IMA) –Combo 2
Well‐Child Visits in the 3rd, 4th, 5th, and 6th years of live (W34)
Well‐Child Visits in the First 15 months of life (W15)‐NEW Measure
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Key Takeaways
• Overall composite MCAS measures, adjusted for population, improved from the Medi‐Cal average composite score of 60% to somewhat above average, adjusted composite score of 67%
• Resulting from multiple interventions cross departmentally; increased provider engagement is likely a major driver
• Activities launched in the past year or planned in the near future will be critical to continue momentum
• Overall PCP QIP average score decreased from about 55% to 45% of total points. PHC made introduced more rigorous thresholds/performance standards
• More work to do in improving HEDIS outcomes at the provider level
• COVID‐19 Impact• Anticipating lower performance in future year reporting• Most likely DHCS will release accountability on a subset of measures• Forthcoming changes to new measure specifications, including acknowledging telehealth/video visits
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Comprehensive Performance Reports
HEDIS Report Year 2020; Measurement Year 2019 ‐Summary of Performance Released
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Contact Us
Rachael French
Associate Director, Quality and Performance Improvement
Partnership HealthPlan of California Report Year 2020 - Measurement Year 2019
The Healthcare Effectiveness Data and Information Set (HEDIS®) is a registered trademark of NCQA. P a g e | 4
Composite HEDIS Performance by Reporting Year The below graph represents PHC’s regional and plan-wide composite score relative to prior year including only measures where DHCS holds Managed Care Plans accountable for and remained in the measurement set over the last three years. The methodology for calculating is noted below, along with the measures included/excluded from the calculations. Score = Points Earned/ Possible Points. Points are awarded per measure based on percentile ranking: 1 point for <10th percentile, 2 for the 10th, 3 for the 17.5, 4 for the 25th, 5 for the 37.5, 6 for the 50th, 7 for the 62.5, 8 for the 75th, 9 for the 82.5, and 10 for the 90th
Note: The MPL changed from the 25th percentile in RY2019 to the 50th percentile in RY2020.
HEDIS MY 2018 / RY 2019 - Total Points Earned: 239 Points out of 400 Total Points (10 measures included)
HEDIS MY 2019 / RY 2020 - Total Points Earned: 279 Points out of 400 Total Points (10 measures included)
Measures included due to being held accountable to MPL for both HEDIS MY 2018 / RY 2019 and HEDIS MY 2019 / RY 2020: AMR, BCS, CBP, CCS, CDC-H9, CDC-HT, IMA-2, PPC-Pre, PPC-Pst, W-34
Measures excluded due to NOT being held accountable to MPL for HEDIS MY 2018 / RY 2019 or HEDIS MY 2019 / RY 2020: AMB-ED, CAP-1219, CAP-1224, CAP-256, CAP-711, DSF, MPM-ACE, MPM-DIU, PCR
Measures excluded due to no longer being reported for HEDIS RY 2020: AAB, AMB-OP, CDC-BP, CDC-E, CDC-H8, CDC-N, CIS-3, DSF, LBP, WCC-N, WCC-PA
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Partnership HealthPlan of California Report Year 2020 - Measurement Year 2019
The Healthcare Effectiveness Data and Information Set (HEDIS®) is a registered trademark of NCQA. P a g e | 5
Composite HEDIS Performance; Reporting Year 2020 Baseline The below graph represents PHC’s regional and plan-wide composite score including all measures for which DHCS holds Managed Care Plans Accountable. Note: The MPL changed from the 25th percentile in RY2019 to the 50th percentile in RY2020.
HEDIS MY 2019- Total Points Earned: 475 out of 720 total points (18 measures included) Measures included due to being held accountable to MPL for the NEW HEDIS MY 2019 MCAS
Measures excluded due to NOT being held accountable to MPL for HEDIS MY 2019: AMB-ED, ADD-initiation, ADD-C&M, CAP, CCW, CCP, CDF, COB, DEV, HVL, MPM Ace/Arb, MPM Diu, OHD, PCR
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Partnership HealthPlan of California Report Year 2020 - Measurement Year 2019
The Healthcare Effectiveness Data and Information Set (HEDIS®) is a registered trademark of NCQA. P a g e | 6
Summary of Performance by Region
Measures At or Above the High Performance Level (HPL) - 90th Percentile
Measures Below the Minimum Performance Level (MPL) - 50th Percentile Note: The MPL changed from the 25th percentile in RY2019 to the 50th percentile in RY2020.
*- Administrative Measures. The entire eligible population is used in calculating performance (versus a systematic sample drawn from the eligible population for the hybrid measures). NOTES: Report excludes measures reported to DHCS where DHCS does not hold Managed Care plans accountable for meeting specific performance targets (i.e. Plan-wide All Cause Readmission, Ambulatory Care, Children & Adolescents Access to Primary Care Practitioners, Screening for Clinical Depression).
Regional Distribution of Measures by Percentile Ranking
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Partnership HealthPlan of California Report Year 2020 - Measurement Year 2019
The Healthcare Effectiveness Data and Information Set (HEDIS®) is a registered trademark of NCQA. P a g e | 7
Performance Relative to Quality Compass® Medicaid Benchmarks Note: The MPL changed from the 25th percentile in RY2019 to the 50th percentile in RY2020.
*- Administrative Measures. The entire eligible population is used in calculating performance (versus a systematic sample drawn from the eligible population for the hybrid measures).
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Partnership HealthPlan of California Report Year 2020 - Measurement Year 2019
The Healthcare Effectiveness Data and Information Set (HEDIS®) is a registered trademark of NCQA. P a g e | 8
Percentage Difference from Prior Year
*- Administrative Measures. The entire eligible population is used in calculating performance (versus a systematic sample drawn from the eligible population for the hybrid measures). CDC-HbA1c Poor Control (>9) – Decrease indicates performance improvement. Note: New measures excluded due to it being the first year that PHC is reporting: ABA – Adult BMI Assessment, AMM – Acute Phase, AMM – Continuations Phase, AWC – Adolescent Well-Care Visits, CHL – Chlamydia Screening in Women, CIS Combo 10, W15 Six or more well child visits, WCC BMI. RY 2020 will be PHC’s baseline reporting year for these measures.
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Partnership HealthPlan of California Report Year 2020 - Measurement Year 2019
The Healthcare Effectiveness Data and Information Set (HEDIS®) is a registered trademark of NCQA. P a g e | 9
Percentile Ranking Change from Prior Year Note: The MPL changed from the 25th percentile in RY2019 to the 50th percentile in RY2020.
*- Administrative Measures. The entire eligible population is used in calculating performance (versus a systematic sample drawn from the eligible population for the hybrid measures). Note: New measures excluded due to it being the first year that PHC is reporting: ABA – Adult BMI Assessment, AMM – Acute Phase, AMM – Continuations Phase, AWC – Adolescent Well-Care Visits, CHL – Chlamydia Screening in Women, CIS Combo 10, W15 Six or more well child visits, WCC BMI. RY 2020 will be PHC’s baseline reporting year for these measures.
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Partnership HealthPlan of California Report Year 2020 - Measurement Year 2019
The Healthcare Effectiveness Data and Information Set (HEDIS®) is a registered trademark of NCQA. P a g e | 10
Summary of Performance by County
Distribution of Percentile Rankings by County Note: The MPL changed from the 25th percentile in RY2019 to the 50th percentile in RY2020.
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Partnership HealthPlan of California Report Year 2020 - Measurement Year 2019
The Healthcare Effectiveness Data and Information Set (HEDIS®) is a registered trademark of NCQA. P a g e | 11
Northeast Region: Modoc, Trinity, Siskiyou, Shasta and Lassen Counties
Note: The MPL changed from the 25th percentile in RY2019 to the 50th percentile in RY2020.
*- Administrative Measures. The entire eligible population is used in calculating performance (versus a systematic sample drawn from the eligible population for the hybrid measures).
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Partnership HealthPlan of California Report Year 2020 - Measurement Year 2019
The Healthcare Effectiveness Data and Information Set (HEDIS®) is a registered trademark of NCQA. P a g e | 12
Northwest Region: Del Norte and Humboldt Counties
Note: The MPL changed from the 25th percentile in RY2019 to the 50th percentile in RY2020.
*- Administrative Measures. The entire eligible population is used in calculating performance (versus a systematic sample drawn from the eligible population for the hybrid measures).
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Partnership HealthPlan of California Report Year 2020 - Measurement Year 2019
The Healthcare Effectiveness Data and Information Set (HEDIS®) is a registered trademark of NCQA. P a g e | 13
Southeast Region: Solano, Yolo and Napa Counties
Note: The MPL changed from the 25th percentile in RY2019 to the 50th percentile in RY2020.
*- Administrative Measures. The entire eligible population is used in calculating performance (versus a systematic sample drawn from the eligible population for the hybrid measures).
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Partnership HealthPlan of California Report Year 2020 - Measurement Year 2019
The Healthcare Effectiveness Data and Information Set (HEDIS®) is a registered trademark of NCQA. P a g e | 14
Southwest Region: Lake, Marin, Mendocino and Sonoma Counties
Note: The MPL changed from the 25th percentile in RY2019 to the 50th percentile in RY2020.
*- Administrative Measures. The entire eligible population is used in calculating performance (versus a systematic sample drawn from the eligible population for the hybrid measures).
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Partnership HealthPlan of California Report Year 2020 - Measurement Year 2019
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Summary of Measures in the Primary Care Provider Quality Improvement Program (PCP QIP) included in the Managed Care Accountability Set (MCAS) for Medi-Cal Managed Care Plans Measurement Year 2019 | Reporting Year 2020.
HEDIS Measures 2019
PCP QIP Measures
2020 PCP QIP
Measures
Alternate Measure in PCP QIP Measures
Adolescent Well-Care Visits (AWC) Monitoring Measure Only in 2020 due to COVID-19
Adult Body Mass Index (BMI) Assessment (ABA) Antidepressant Medication Management: Acute Phase Treatment (AMM-Acute)*
Breast Cancer Screening (BCS)* X Monitoring Measure Only in 2020 due to COVID-19
Cervical Cancer Screening (CCS) X Monitoring Measure Only in 2020 due to COVID-19
Childhood Immunization Status (CIS) – Combo 10 X Expanded from Combo 3 in QIP 2019
Chlamydia Screening in Women (CHL)* Comprehensive Diabetes Care (CDC-H9) – HbA1c Poor Control (>9.0%)*
QIP measures: Good Control, HbA1c ≤9.
Comprehensive Diabetes Care (CDC-HT) – HbA1c Testing
Controlling High Blood Pressure (CBP) X X
Immunizations for Adolescents (IMA) – Combo 2 X Monitoring Measure Only in 2020 due to COVID-19
Prenatal and Postpartum Care (PPC) – Postpartum Care Similar measure in Perinatal QIP.
Prenatal and Postpartum Care (PPC) – Timeliness of Prenatal Care
Similar measure in Perinatal QIP.
Weight Assessment and Counseling for Children/Adolescents (WCC) – BMI Assessment
Well-Child Visits in the First 15 Months of Life: Six or More Well-Child Visits (W15) X
Well-Child Visits in the Third, Fourth, Fifth, and Sixth Years of Life (W34) X
Monitoring Measure Only in 2020 due to COVID-19
*-Administrative Measures. The entire eligible population is used in calculating performance (versus a systematic sample drawn from the eligible population for the hybrid measures). PCP QIP Measurement Set: http://www.partnershiphp.org/Providers/Quality/Pages/PCPQIPLandingPage.aspx
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Partnership HealthPlan of California Report Year 2020 - Measurement Year 2019
The Healthcare Effectiveness Data and Information Set (HEDIS®) is a registered trademark of NCQA. P a g e | 16
Measurement Year 2019 Measurement Set Descriptions HEDIS Measure Measure Indicator Measure Definition
Adult BMI Assessment (ABA)
• Percentage of members 18-74 years With documented body mass index in measurement year or prior year
The percentage of members 18–74 years of age who had an outpatient visit and whose body mass index (BMI) was documented during the measurement year or the year prior to the measurement year.
*Antidepressant Medication Management (AMM)
• Effective Acute Phase Treatment
• Effective Continuation Phase Treatment
The percentage of members 18 years of age and older who were treated with antidepressant medication, had a diagnosis of major depression and who remained on an antidepressant medication treatment.
• Effective Acute Phase Treatment. The percentage of members who remained on an antidepressant medication for at least 84 days (12 weeks).
• Effective Continuation Phase Treatment. The percentage of members who remained on an antidepressant medication for at least 180 days (6 months).
*Asthma Medication Ratio (AMR)
• The ratio of controller medications >0.50
The percentage of members 5–64 years of age who were identified as having persistent asthma and had a ratio of controller medications to total asthma medications of 0.50 or greater during the measurement year.
• Total. The sum of the age stratifications (ages 5–64) as of December 31 of the measurement year.
Adolescent Well-Care Visits (AWC)
• Percentage of enrolled members 12-21 years with one visit in the measurement year
The percentage of enrolled members 12–21 years of age who had at least one comprehensive well-care visit with a PCP or an OB/GYN practitioner during the measurement year.
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• Percentage of women 52-74 years with screening as of 12/31 of the measurement year
The percentage of women 52–74 years of age who had a mammogram to screen for breast cancer as of December 31 of the measurement year.
Controlling High Blood Pressure (CBP)
• Percentage of members 18-85 years with hypertension & BP <140/90mm Hg during measurement year
The percentage of members 18–85 years of age who had a diagnosis of hypertension (HTN) and whose BP was adequately controlled (<140/90 mm Hg) during the measurement year.
Cervical Cancer Screening (CCS)
• See measure definition
The percentage of women 21–64 years of age who were screened for cervical cancer using either of the following criteria:
• Women 21–64 years of age who had cervical cytology performed within the last 3 years
• Women 30–64 years of age who had cervical high-risk human papillomavirus (hrHPV) testing performed within the last 5 years
• Women 30–64 years of age who had cervical cytology/high-risk human papillomavirus (hrHPV) cotesting within the last 5 years
Comprehensive Diabetes Care (CDC)
• Hemoglobin A1c (HbA1c) testing
• HbA1c poor control (>9.0%)
The percentage of members 18–75 years of age with diabetes (type 1 and type 2) who had each of the Measure Indicators performed.
• Hemoglobin A1c (HbA1c) testing. An HbA1c test performed during the measurement year.
• HbA1c poor control (>9.0%). The most recent HbA1c level is >9.0% or is missing a result, or if an HbA1c test was not done during the measurement year.
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• Percentage of women 16-24 Years, sexually active with one test during measurement year
The percentage of women 16–24 years of age who were identified as sexually active and who had at least one test for chlamydia during the measurement year.
• Total. The sum of the age stratifications.
Childhood Immunization Status (CIS) • Combination 10
The percentage of children 2 years of age who had four diphtheria, tetanus and acellular pertussis (DTaP); three polio (IPV); one measles, mumps and rubella (MMR); three haemophilus influenza type B (HiB); three hepatitis B (HepB), one chicken pox (VZV); four pneumococcal conjugate (PCV); one hepatitis A (HepA); two or three rotavirus (RV); and two influenza (flu) vaccines by their second birthday. The measure calculates a rate for each vaccine and nine separate combination rates.
• Combination 10. Children who have had all ten indicators (DTaP, IPV, MMR, HiB, HepB, VZV, PCV, HepA, RV and Influenza).
Immunizations for Adolescents (IMA) • Combination 2
The percentage of adolescents 13 years of age who had one dose of meningococcal vaccine, one tetanus, diphtheria toxoids and acellular pertussis (Tdap) vaccine, and have completed the human papillomavirus (HPV) vaccine series by their 13th birthday. The measure calculates a rate for each vaccine and two combination rates.
• Combination 2. Adolescents who have had all three indicators (meningococcal, Tdap and HPV).
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The percentage of deliveries of live births on or between October 8 of the year prior to the measurement year and October 7 of the measurement year. For these women, the measure assesses the following facets of prenatal and postpartum care.
• Timeliness of Prenatal Care. The percentage of deliveries that received a prenatal care visit in the first trimester, on or before the enrollment start date or within 42 days of enrollment in the organization.
• Postpartum Care. The percentage of deliveries that had a postpartum visit on or between 7 and 84 days after delivery.
Well-Child Visits in the First 15 Months of Life (W15)
• Six or more well-child visits
The percentage of members who turned 15 months old during the measurement year and who had well-child visits with a PCP during their first 15 months of life.
• Six or more well-child visits. Seven separate numerators are calculated, corresponding to the number of members who received 0, 1, 2, 3, 4, 5, 6 or more well-child visits.
Well-Child Visits in the Third, Fourth, Fifth and Sixth Years of Life (W34)
• Percentage of members 3-6 years With one or more visits during measurement year
The percentage of members 3–6 years of age who had one or more well-child visits with a PCP during the measurement year.
Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents (WCC)
• BMI Percentile Documentation
The percentage of members 3–17 years of age who had an outpatient visit with a PCP or OB/GYN and who had evidence of the following during the measurement year.
• BMI Percentile Documentation. Because BMI norms for youth vary with age and gender, this measure evaluates whether BMI percentile is assessed rather than an absolute BMI value.
*-Administrative Measures. The entire eligible population is used in calculating performance (versus a systematic sample drawn from the eligible population for the hybrid measures).
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PHC’s Quality Improvement organization wide goals for 2019-2020 included three main focus areas: Well-Child Visits (W34), Asthma Medication Ratio (AMR) and Prenatal Postpartum Engagement Work Group (PPEW). Based on the measure(s) of focus, there was a cross-functional work group including department representation from: Health Analytics, Care Coordination, Claims, Health Education, Medical Directors, Pharmacy, Population Health Management, Provider Relations, and Quality Improvement. To measure success, work groups were assigned goals to achieve by June 30, 2020.
Well Child Visits (W34) • Workgroup Aim, Objectives and Focus Areas:
o Aim: Measurement year 2019 HEDIS results for the W34 measure will be above the 50th percentile for at least 2 regions and above the 25th percentile for all regions. Outcome: Based on preliminary HEDIS MY 2019, the goal was met with the
2 southern reporting regions performing above the 50th percentile and the 2 northern reporting regions above the 25th percentile.
o Objective: Drive improvement in Well Child visits through focus on the many activities around well child visits and inform the HEDIS Score Improvement Workgroup about efforts.
o Focus Areas: The workgroup identified over 20 deliverables that would be tracked across the following focus areas: Inform Well Child Work: PHC internal information, education and data
analysis. Track PHC Operational Changes: Follow operational changes that will
impact and improve well child performance rates (i.e. QIP, Birthday Club, ePrompts).
Deploy Resources to Optimize Provider Ability to Improve: Create and update resources available to providers that will impact and improve well child rates (i.e. training, provider informing materials, member facing materials available for providers to give to patients).
Conduct Performance Improvement Projects: Work with provider partners to conduct quality improvement projects around well child.
Employ PHC-Driven Member Engagement Strategies: Identify a Plan-Wide Strategy for Member In-Reach and Outreach.
• Accomplishments Contributing to Improved Performance:
o Well child measure insights were added into the provider scorecard developed by the PHC Claims department with QI were added in 25 NR provider scorecards.
o Conducted assessment of existing health education materials related to well child. Next fiscal year will focus on development of new materials for identified gaps.
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o The Birthday Club targeting 3-6 year old members was implemented across PHC’s Northern Region. Significant efforts made towards deploying plan-wide, including vendor evaluation.
o Provider trainings completed, resources developed and updated (Quality Measure Highlights, well care dashboard, pocket guide, QIP program, Accelerated Learning 4/15/20 session).
o Initiated Priority and Health Equity PIPs, focusing on well-child visit measures W34 and W15, respectively.
Asthma Medication Ratio • Workgroup Aim and Objectives:
o Aim: Partnership HealthPlan of California (PHC) aims to increase Asthma Medication Ratio (AMR) Regional Performance composite scores by 5% from mid-year 2018 to March 2020 (Note, this goal was revised to exclude impact from COVID-19). This goal was exceeded with a 6.28% increase. Per reporting in May 2020, the AMR plan-wide composite score improved from baseline of 59.97% to 66.25%.
o Objectives: Increase prescriber’s awareness of their patient’s asthma prescription
activity. New prescriptions and refills for all asthma medications within measured timeframe.
Increase member’s knowledge and engagement with managing their asthma and asthma medications, including appropriately coding for co-morbidities and alternative diagnoses.
Increase community pharmacists’ knowledge for the AMR HEDIS measure and promote engagement to improve AMR through patient consultation, increase controller medication dispensing, and monitor and reduce rescue inhaler dispensing as clinically appropriate.
Increase prescription fills, including 90 day supply fill, for asthma controller medication.
• Accomplishments Contributing to Improved Performance:
o Developed Academic Detailing Materials, which included measure specifications and best practices; to facilitate the education of provider organization.
o In collaboration with a Medical Director, Pharmacist, and QI representative, provided on-site education to over 15 Provider Sites and 7 Pharmacies.
o Developed custom reports on provider sites that received academic detailing to track progress on AMR rates.
o Created community outreach materials to educate members.
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Prenatal and Postpartum Engagement Work Group (PPEW) • Workgroup Aim and Objectives:
o Aim: The PPEW team will ensure standardized engagement visits with 15 large perinatal providers by June 30, 2020.
o Objectives: All OB/Perinatal quality measures will be at or above the 50th percentile of Medicaid plans nationally, starting with MY 2019 (this year). These measures are grouped as follows: Initial OB visit, timely, depression screen Post-partum visits, timely, depression screen, contraception Vaccinations: TDap and Flu Hospital: Elective preterm delivery, NTSV C-section
• Accomplishments Contributing to Improved Performance:
o Developed core curriculum and message to share with practices across the regions with focus on: Quality Prenatal Care Current regional and local data PHC resources to support optimal outcomes.
o By June 30th, 2020 PPEW group will have provided site specific education to 22 provider organizations of which 15 are large organizations.
o Developed, distributed and received responses back from 25 sites that participated in the Perinatal.
o Practice Survey. The survey was developed to assess overall volume of perinatal services for Medi-Cal eligible patients in our network.
