medi-cal managed care performance dashboard · apr-15 may-15 jun-15 jul-15 aug-15 sep-15 oct-15...

Medi-Cal Managed Care Performance Dashboard Glossary

Released March 16, 2017

Glossary of 3

Quarterly Release Notes

Utilization Figures 4-1 to 6-2: The abbreviation MO (Medi-Cal coverage only) has been added to the ACA, SPD,

OTLIC, and Other labels. This is to help better differentiate between Dual and Non-Dual member utilization. See the

Medicare Status section for addition information.

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

Population Aid Code Groups

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

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

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

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

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

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

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

Medicare Status

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



Glossary of 3

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

Utilization Measures for Certified Eligible Managed Care Members

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

Cal coverage only (MO) and does not include Medicare coverage.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

months.



Glossary of 3

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

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

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

measure is displayed per 1,000 member months.

Grievance, Appeals and State Fair Hearings

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

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

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

Medi-Cal Managed Care Performance Dashboard


CERTIFIED ELGIBLE ENROLLMENT: As of September 2016 (Data Warehouse pull February 2017)

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Per

cen

tage

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

OTLIC 1,110,557 1,124,369 1,130,237 1,129,634 1,140,254 1,152,829 1,164,363 1,172,892 1,191,501 1,190,137 1,192,129 1,195,805

SPD 1,564,371 1,562,621 1,562,008 1,557,934 1,554,990 1,552,961 1,548,237 1,544,633 1,547,071 1,546,455 1,560,659 1,557,624

ACA 3,414,767 3,518,503 3,590,708 3,667,606 3,763,497 3,855,120 3,899,024 3,962,741 4,033,091 4,061,779 4,101,389 4,123,512

OTHER 4,036,390 4,014,124 3,991,594 4,002,024 3,994,243 3,980,672 3,929,994 3,899,277 3,896,085 3,871,977 3,870,538 3,838,873

1-1: Managed Care Enrollment by Aid Population

Managed Care Total 10,126,085 10,219,617 10,274,547 10,357,198 10,452,984 10,541,582 10,541,618 10,579,543 10,667,748 10,670,348 10,724,715 10,715,814

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

Fee-for-Service 2,988,414 2,990,010 3,095,972 3,196,491 3,132,161 3,092,539 3,054,375 3,040,214 2,946,050 2,841,660 2,781,047 2,719,553

Speciality Plans 19,506 19,687 20,090 20,386 20,578 20,764 20,875 21,005 21,062 20,971 20,998 20,965

Medi-Cal Program Total 13,134,005 13,229,314 13,390,609 13,574,075 13,605,723 13,654,885 13,616,868 13,640,762 13,634,860 13,532,979 13,526,760 13,456,332

Other Medi-Cal Programs

CMC COHS GMC RM Two-Plan

OTLIC 0 297,888 142,674 45,693 709,550

SPD 111,760 328,707 150,900 33,482 932,775

ACA 1,747 840,359 467,330 173,654 2,640,422

Other 512 732,497 405,629 133,651 2,566,584

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

100%

Per

cen

tage

1-2: Aid Population by Plan Model

MC80%

FFS/Spec.20%

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

64% 62%57%

52%

69%

61%64%

59%

48% 50%

57% 53%

26% 27%30%

37%

24%30%

27%33%

46% 44%

32%38%

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

11% 9%

1-4: Choice and Auto-Assignment Rates

Choice Auto-Assigned Passive + Prior

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



CERTIFIED ELGIBLE DEMOGRAPHICS: Managed Care demographics for September 2016 (Data Warehouse pull February 2017)

86%

10%

4%

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

57%

43%

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

96%

4%

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

20%

22%

42%

16%

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

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

Male 86,357 633,075 805,606 712,061 278,213 1,295,929 897,451 301,301

Female 83,014 606,373 767,869 681,958 291,517 1,725,269 1,056,067 493,754

0%

20%

40%

60%

80%

100%

Per

cen

tage

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

2%

12%

15%

13%

5%

28%

18%

7%

Age < 1

Ages 1-5

Ages 6-11

Ages 12-17

Ages 18-20

Ages 21-44

Ages 45-64

Ages 65+

2-3: Age Cohorts "All Managed Care"

46%

21%

14%

12%

8%

Hispanic

White

Asian/Pacific Islander

Other/Unknown

African-American

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

ACA38%

OTHER36%

SPD15%

OTLIC11%

2-1: Aid Groups "All Managed Care"




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

Dual 961,100 963,825 966,998 965,390 964,540 965,183 963,598 962,057 963,275 958,274 957,900 954,377

Non-Dual* 9,164,985 9,255,792 9,307,549 9,391,808 9,488,444 9,576,399 9,578,020 9,617,486 9,704,473 9,712,074 9,766,815 9,761,437

Note: Medi-Cal Only. See glossary.

CERTIFIED ELGIBLE DEMOGRAPHICS: Dual Eligible Managed Care demographics for September 2016 (Data Warehouse pull February 2017)

CMC COHS GMC RM Two Plan

Dual 114,005 225,208 80,907 9,683 524,574

Non-Dual 14 1,974,243 1,085,626 376,797 6,324,757

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Per

cen

tage

3-4: Plan Model Totals

28%

27%

19%

19%

8%

White

Hispanic

Asian/PacificIslander

Other/Unknown

African-American

3-3: Dual Eligible by Race and Ethnicity

ACA42%

OTHER39%

SPD7%

OTLIC12%

3-2: Aid Groups "Non-Dual"

ACA7%

OTHER0%

SPD93%

3-1: Aid Groups "Dual"

0%

6%

23%

71%

Age 0-18

Ages 19-39

Ages 40-64

Ages 65+

3-5: Dual Age Cohorts




UTILIZATION: Statewide April 2015 to March 2016 (Data Warehouse pull February 2017)

-

5

10

15

20

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

Vis

its


MO-SPD 15 16 15 14 14 14 11 12 13 13 11 11

Dual 5 5 5 5 4 4 3 4 4 4 4 4

MO-ACA 4 4 4 4 4 3 3 3 3 3 2 2

MO-Other 1 1 1 1 1 1 1 1 1 1 1 1

MO-OTLIC 1 1 1 1 1 1 1 0 1 1 1 0

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

-

20

40

60

80

100

120


Vis

its


MO-SPD 97 100 95 94 94 92 83 82 85 90 88 86

Dual 34 34 33 37 37 37 37 35 37 39 38 38

MO-ACA 47 48 47 47 46 45 40 39 41 44 42 42

MO-Other 45 45 39 36 37 39 36 36 37 40 44 39

MO-OTLIC 24 25 20 18 20 21 20 19 19 22 26 22

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





-

10

20

30

40

50


Vis

its


MO-SPD 38 39 38 39 39 38 36 35 37 37 34 34

Dual 35 34 34 36 43 40 40 43 42 41 37 31

MO-ACA 10 10 9 9 9 9 8 8 8 8 8 8

MO-Other 5 5 5 4 4 5 4 4 4 4 4 4

MO-OTLIC 2 2 2 2 2 2 2 2 2 2 2 2

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

-

500

1,000

1,500

2,000

2,500

3,000


Vis

its


MO-SPD 2,523 2,464 2,374 2,278 2,282 2,495 2,461 2,230 2,293 2,365 2,432 2,518

Dual 1,607 1,547 1,591 1,549 1,535 1,574 1,496 1,414 1,512 1,531 1,508 1,540

MO-ACA 709 670 711 695 673 671 651 599 632 636 642 690

MO-Other 587 551 502 469 489 540 540 482 489 514 558 562

MO-OTLIC 465 431 377 354 381 441 455 398 389 414 467 464

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





-

500

1,000

1,500

2,000

2,500

3,000

3,500


Pre

scri

pti

on

s


MO-SPD 3,158 3,066 3,182 2,990 2,994 3,128 3,141 3,035 3,096 3,010 3,008 3,207

Dual 364 356 369 317 327 369 384 370 375 377 381 401

MO-ACA 990 953 978 890 892 959 965 926 909 924 920 980

MO-Other 483 449 411 349 364 400 400 400 392 402 454 427

MO-OTLIC 257 242 211 174 191 223 223 230 215 229 294 264

6-1: Prescriptions per 1,000 Member Months

-

5

10

15

20

25

30


Vis

its


MO-SPD 14 13 15 15 15 16 16 15 16 16 17 17

Dual 25 22 23 24 22 22 22 19 22 22 21 22

MO-ACA 12 11 12 13 12 12 13 11 12 12 13 13

MO-Other 5 5 5 5 5 5 5 5 5 5 6 6

MO-OTLIC 6 5 6 6 6 6 6 5 5 6 6 7

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




Grievance Demographics: Q3 2016 (July to September 2016) Statewide

33%

31%

15%

14%

7%

White

Hispanic

African - American

Other/Unknown


7-1: Grievances by Ethnicity

48%

22%

16%

11%3%

7-2: Grievances by Population

ACA

SPD

OTHER

DUAL

OTLIC

0.9

0.4

1.0

0.6

0.3

White

Hispanic

African -American

Other/Unknown


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

0.7

1.9

0.2

0.6

0.1

ACA

SPD

OTHER

DUAL

OTLIC

7-5: Grievances by PopulationPer 1,000 Member Months


6%

18%

33%

5%

8%

8%

19%

3%

Age 0-18

4

Ages 65+

es 40-6Ag

es 19-Ag 39

Male Female

7-3: Grievances by Age



Grievance and Appeals Outcomes: Q3 2016 (July to September 2016) Statewide

64%

46%

59%

52%

58%

29%

48%

28%

38%

35%

7%

7%

14%

10%

7%

Accessibility

Benefits

Other

Quality Of Care

Referral

8-1: Grievance Resolution by Type

Resolved in Favor of Member Resolved in Favor of Plan Unresovled

54%

46%

43%

49%

50%

17%

21%

23%

23%

27%

21%

14%

17%

17%

16%

6%

17%

14%

9%

4%

3%

3%

4%

3%

2%

Accessibility

Benefits

Other

Quality ofCare

Referral

8-2: Grievances by Population and Type

ACA SPD OTHER DUAL OTLIC

Quality Of Care44%

Benefits18%

Other18%

Accessibility12%

Referral8%

8-3: Grievances by Type

0.9

0.6

0.4

0.3

GMC

Two Plan

RM

COHS

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




State Fair Hearing Demographics: Q3 2016 (July to September 2016) Statewide

2015Q4 2016Q1 2016Q2 2016Q3

ACA 406 368 389 421

DUAL 118 96 89 97

OTHER 111 143 136 117

SPD 275 246 280 405

Total 910 853 894 1040

0

50

100

150

200

250

300

350

400

450

500

9-4: Hearings by Population

0.5

0.4

0.3

0.3

0.2

GMC

RM

Two Plan

CMC

COHS

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

37%

25%

16%

14%

9%

White

Hispanic

African-American

Other/Unknown


9-1: Hearings by Ethnicity

41%

39%

11%

9%

9-2: Hearings by Population

ACA

SPD

OTHER

DUAL

3%

17%

35%

5%

6%

9%

21%

3%

Age 0-18

Ages 19-39

Ages 40-64

Ages 65+

9-3: Hearings by Age

Male Female




State Fair Hearing Reasons/Outcomes: Q3 2016 (July to September 2016) Statewide

43%

35%

44%

36%

39%

45%

57%

24%

18%

36%

35%

51%

36%

35%

23%

51%

25%

16%

9%

9%

11%

14%

14%

2%

14%

12%

13%

4%

14%

6%

6%

22%

Billing

Dispute of Services

Medication/Prescription

MER/EDR

Other

Referral

Surgery/Treatment

Wheelchair/PowerWheelchair/Scooter

10-1: Hearing Reasons by Population

ACA SPD Other Dual

36%

27%

16%

9%

3%

3%

2%

2%

1%

Withdrawal

Denied

Non-Appearance

Dismissed

Granted

Redirect

Other

Granted in Part

Duplicate Case

10-2: Hearing Outcomes

61%

39%38%

62%

Approved Denied

10-4: Medical Exemption Requests

All SPD338

173

126

7451

10-3: Top 5 Hearing Reasons




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

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

State Average is 60%.

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10%

20%

30%

40%

50%

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

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


medi-cal managed care performance dashboard · apr-15 may-15 jun-15 jul-15 aug-15 sep-15 oct-15...

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