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Santa Clara Family Health Plan

Provider Advisory Council

May 22, 2013

Boardroom

S: Provider Services_PAC_Minutes (SR) 1

PAC Attendees: Thad Padua, MD, Peter L. Nguyen, DO, Kenneth Phan, MD, Bridget Harrison, MD, Paul Taylor and Connie Tucker, MD

Delegated Groups: Stephen Ho, MD, Tuyen Ngo, MD and Vivian Smith

Guest: Mark Reynolds – SMC Pharmacy

SCFHP Attendees: Matthew Woodruff, Jimmy Lin, MD, Mike Lipman, Beth Paige, Dr. Jeff Robertson, Vivian Than, Stacy Renteria, Abby

Baldovinos, and Sarah Moline

ITEM DISCUSSION ACTION RESPONSIBLE

PARTIES

DUE DATE

Meeting Called

To Order

Dr. Thad Padua, Chairperson called meeting to order at 12:22. none

Review of

Minutes

Minutes reviewed and approved none

Compliance Beth Paige, Compliance Officer, reviewed the grievance and

appeals report with the Committee. The number of grievances

has increased around the June implementation of the Senior and

Disabled Persons population. Five appeals went to a State fair

hearing. A number of these complaints were around quality of

service, office staff complaints, changing primary care provider

timeline to be in affect at the first of the following month and

not right away or 24 hour turn-around, and continuity of care

issues.

For the fiscal year 2012 grievance and appeals saw many out-of-

area referral issues. The Health Plan’s response to the out-of-

area referral issues is the referring provider has to support the

referral with medical criteria to justify the need to go out-of-

area.



May 22, 2013

Boardroom



PARTIES

DUE DATE

Dr. Harrison raised a concern about the timeline to change a

primary care provider during mid-month. Medi-Cal will send

electronic files regarding eligibility and members assigned at

the beginning of each month. Dr. Harrison then discussed a

specific case of a denial of service/product with the Health Plan

that was upheld at the State fair hearing. Beth stated that in

grievance and appeals department the Health Plan will request

medical records to research medical need. Dr. Robertson stated

in most cases of denial it is the medical group who determines

approval or denial; appeals are reviewed by the Health Plan.

Dr. Harrison would have liked to have found out what the

missing from the case. Beth will follow up with Dr. Harrison

regarding specific case.

Dr. Padua requested the percentages be presented on a graph

and a breakdown of performance by network without being

identified. Beth will present at next meeting.

B. Paige will follow-

up with Dr. Harrison

B. Paige will present

revised report.

CEO Report Matt Woodruff, COO, reported out to the Committee the

Health Plan is currently working on four different MOU’s to be

filed June 1st or at least approved by the County Board of

Supervisors in the month of June. The Health Plan is moving

forward with the Dual Demonstration – on June 3rd filing

benefits for Dual Demo and Special Need Plan (SNP), SNP is a

safety plan.

None



May 22, 2013

Boardroom



PARTIES

DUE DATE

At our board meeting the Health Plan reviewed financials

before the May revise of the State budget. The Health Plan does

not know the specifics around the contract for the Dual

Demonstration Project, is looks to be pushed back from June to

August.

Health Families is in transition 4 now, this phase does not

impact the Health Plan since our current Health Families

membership is 300 lives transitioning through December and

are not fee-for-service. Health Families will officially end

December 2013.

Medi-Cal Bridge has a start date April 2014. Change to solidify

the two plans that are in Medi-Cal.

PCP Rate Increase issue, no instruction or statement on risk

share money, Cap or no Cap. Trying to get a guideline on who

is a “qualified PCP” to be eligible for rate increase. The State

said by July 1st or August 1st it will be announced and then the

Health Plan will need to pay PCP’s retroactively.

The Committee discussed Medicare rates and the PCP Rate

Increase and the issue of every type of provider trying to be

counted as a PCP in order to get the rate increase. Committee

also discussed having no choice to participate or not participate

in the Dual Demonstration project. The rules and regulations

were changed, where it was an option last month but this



May 22, 2013

Boardroom



PARTIES

DUE DATE

month it is mandatory to participate.

DSNP will be filed now on June 3rd.

Medical

Management

Dr. Jeff Robertson, CMO introduced to Committee. Dr.

Robertson is very pleased to be at PAC as the Health Plan looks

to providers for guidance as you see patients and members of

our community. Relating to the DME RFP agenda topic, Dr.

Robertson reviewed our current situation which is the Health

Plan is contracted or pays out to 200 DME providers. Many of

these are small mom/pop shops others are large companies.

The Health Plan has decided to curb DME waste and

unnecessary related expense and would like a single entity to

handle DME services and supplies. The Health Plan sent out a

process in a thirty page RFP regarding services we needed and

what we did not need to contracted DME providers. The

Health Plan fielded 30-40 related phone calls and received 5

proposals and narrowed it down to 3 finalists. Dr. Robertson

wanted to present it here for transparency purposes. No matter

how thoroughly the Health Plan proceeds with this. There will

be some dust-up/blowback on our decisions. This is a capitated

agreement that will only affect medical groups not Kaiser or

Valley Health Plan.

The Committee discussed DME issues of members paying cash

for an alternative more expensive DME item than what

providers prescribed. DME needs to be monitored. This is one

problem Dr. Robertson hopes to resolve with a one source DME

None

Dr. Robertson will

follow up on DME

discussion at next

meeting.



May 22, 2013

Boardroom



PARTIES

DUE DATE

Pharmacy

provider with a capitated agreement.

Sarah Moline, Pharmacy Director gave the Committee an

update on the ForaCare transition via Powerpoint presentation.

Sixty percent of our claims come from Valley around Diabetic

Care. Sarah reported the transition is saving the Health Plan a

lot of money. Matt stated the Health Plan is still reconciling the

claims and at the June 11th P&T Committee we should have a

dollar amount on savings with ForaCare.

The Committee would like to see the results of the TeleHealth

process with ForaCare. Matt stated TeleHealth module is

coming online the second half of this year.

Sarah reported out a change in the formulary to cover Ventolin

HFA instead of ProAir HFA. This change became effective

September 2012 and she reviewed a secondary Powerpoint

presentation with the Committee. The Pharmacy and

Therapeutics Bulletin will be distributed 30 days after every

P&T meeting date.

None

IT/Claims

Issues

Mike Lipman, VP of Provider Operations reviewed the

misdirected claims issue. Regarding the returning of claims to

those organizations financially responsible will now be able to

go to the FTP site to retrieve. The Health Plan is to make claims

data available electronically instead of mailing paper claims to

the correct payor.

There was also a secondary compliance issue around returning



May 22, 2013

Boardroom



PARTIES

DUE DATE

paper claims to the correct payor because it was not done in a

timely manner because it was a manual process. It was a bigger

issue when it was all paper claims. Now 80% are electronic

claims. Timely filing exceeds is a compliance issue when these

claims are not given to the IPA’s in a timely manner.

Yes the State still wants a paper PM160 even though the Health

Plan has electronic claims submission in effect. Dr. Padua asked

if the Health Plan’s providers are complying with the paper

PM160 requirement to the State. Matt replied yes for the most

part. Mike stated the Health Plan is encouraging providers to

utilize an electronic claims process as this will also be

submitting encounter data. Dr. Padua stated, the doctor does

not need to submit to the IPA. Mike responded, correct the

IPA’s will be able to download the file from the site.

Other PAC Calendar – The Committee briefly discussed next meeting

date, proposed August 14th but not definitely decided. Agreed

to meet in August and the second Wednesday in November.

PAC calendar to be revised and distributed to reflect proposed

revisions and voted on next meeting.

Dr. Robertson asked for more community providers seated on

PAC.

Revise PAC Calendar Stacy Renteria August 21, 2013

Adjournment Adjourned at 2:00 pm



May 22, 2013

Boardroom


Signature:_______________________________________________________________ Date:________________________________________

1

To: Santa Clara Family Health Plan Provider

From: Jeff Robertson MD, Chief Medical Officer

Date: August 15, 2013

Subject: DME Transition

Dear Provider:

Just a friendly reminder to Santa Clara Family Health Plan Providers, effective September 3, 2013, Lifecare

Solutions is the primary vendor for standard home medical and respiratory equipment, enteral nutrition and

medical supplies.

IMPORTANT EXCEPTIONS:

1) Valley Health Plan (NT20) and Kaiser (NT30) are excluded from this agreement.

2) If member has a primary payer before Medi-Cal (eg. Medicare/Commercial) they may remain with their current DME provider.

3) Not every DME item is covered in the capitation. Exempt items can continue to be supplied by the member’s current DME supplier.

WHAT IS IN THE CAPITATION?

Respiratory: Enteral Nutrition:

Home Oxygen Systems/Oximetry Tube Feeding Formula

C-PAP/Bi-PAP Tube Feeding Supplies/Pumps

Ventilators/Vent Management Evaluations by Registered Dietitians

Nebulizers and Related Supplies

Durable Medical Equipment: Medical Supplies:

Hospital Beds Incontinence Products / Supplies

Wheelchairs Ostomy Supplies

Walkers, Seating, Crutches, Canes Wound Care Supplies

Breast Pumps Urologicals /Catheters

Bath Equipment Support Stockings

For above items: - Beginning September 3, 2013, all new and renewal authorizations must be referred to the

local San Jose Branch of Lifecare Solutions at (877) 595-2312, FAX (877)-595-2327.

2

Any Authorization questions should be directed to the Utilization Management Supervisor at Lifecare Solutions

at: (800) 700-6461 x2006.

This is not an all-inclusive list of items; if you have questions you may contact SCFHP Provider Services

Department at (408) 874-1788.

WHAT’S NOT IN THE CAPITATION?

Air Fluidized Beds

Bili-Blanket/Bili-bed

Bone Growth Stimulators

Cold Therapy Units

Custom Compression Hosiery

Continuous Glucose Monitor

CPM Machines

Cranial Helmets

Diabetic Testing & Supplies

Dynamic Splint

Electric Patient Lifts

Electric Seat Lift Chairs

High Frequency Compression Vests

Home Infusion Therapy

Insulin Pumps

Mastectomy Related Accessories

Negative Pressure Wound Therapy

Nursing Visits

Ocular Prosthetics

Orthotics & Prosthetics (custom)

Power Wheelchair & Mobility Devices

Sequential Compression Devices (Lymphedema Pumps)

Speech Generating Devices

Vest Airway Clearance System

Beginning June 10, 2013, all new and renewal authorizations are set to expire on September 2, 2013. Any

authorization questions should be directed to the Utilization Management Supervisor at LifeCare Solutions at:

(800) 700-6461 X 2006. LifeCare Solutions began contacting members in June.

If you have any questions regarding contracting/billing please email Provider Services at

[email protected]. We appreciate your cooperation and continued support in providing quality health

care to all Santa Clara Family Health Plan members.

57 61

88

82

90

57

33 38

50

43

37 39 34

38 35 36

50

14

23 23

38 42

28

41

0

10

20

30

40

50

60

70

80

90

100

Num

ber o

f Cas

es

Month

Total Grievances Q1 & Q2 2013

Total Grievances

Cases Opened

Cases Closed

Pending EOM

HEDIS 2013 Medi-Cal

SUMMARY 15 measures

2 new measures introduced CBP – Controlling High Blood Pressure MMA – Medication Management for People With Asthma

1 measure retired AWC – Adolescent Well-Care Visits

First year with SPD included in measures State required stratification of Non-/SPD on 5 measures

AMB – Ambulatory Care MPM – Annual Monitoring for Patients on Persistent Medications

(w/o Anti-convulsant indicator) CAP – Children & Adolescents’ Access to Primary Care PCR – Plan All Cause Readmissions CDC – Comprehensive Diabetes Care

AMB – AMBULATORY CARE

40.38%

24.50% 26.75%

4.29% 3.35% 3.50%

0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

30.00%

35.00%

40.00%

45.00%

SPD Non Full Population

OutpatientED Visits

MPM - ANNUAL MONITORING FOR PATIENTS ON PERSISTENT MEDICATIONS

88.7

9%

84.6

7%

87.6

0%

89.3

3%

77.7

8%

88.1

0%

90.0

7%

83.2

0%

88.0

8%

50.00%

60.00%

70.00%

80.00%

90.00%

100.00%

SPD Non Combined

Ace InhibitorsDigoxinDiuretics

CAP – CHILDREN & ADOLESCENTS ACCESS TO PCP’S

96.3

0%

96.8

7%

96.8

7%

88.7

4%

88.9

1%

88.9

0%

86.1

6%

88.9

1%

88.9

2%

89.5

5%

87.7

4%

87.8

1%

50.00%

60.00%

70.00%

80.00%

90.00%

100.00%

SPD Non Combined

12-24 Mos25 mos - 6 Yrs7-11 yrs12-19 yrs

PCR – PLAN ALL CAUSE READMISSIONS

16.54%

8.26%

13.80%

0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

30.00%

2013

SPDNon-SPDFull Pop

CDC – COMPREHENSIVE DIABETES CARE 40

.15%

84.6

7%

47.9

3%

89.0

5%

29.2

0%

61.0

7%

87.8

3%

53.5

3%

38.2

0%

73.7

2%

35.7

7%

82.7

3%

41.6

1%

48.1

8%

74.9

4%

55.7

2%

41.8

5%

79.0

8%

42.8

2%

86.6

2%

34.7

9%

55.4

7%

79.8

1%

53.5

3%

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

80.00%

90.00%

100.00%

Eye Exam LDL-CScreenin

LDL-CControl

HbA1cTesting

HbA1c PoorControl

HbA1cControl

Nephropathy BP Control

SPD Non Combined

AMB – AMBULATORY CARE

29.28%

3.59%

24.50%

3.35%

0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

30.00%

35.00%

Outpatient ED Visits

2012 2013 (Non-SPD)

MPM – ANNUAL MONITORING FOR PATIENTS ON PERSISTENT MEDICATIONS

86.05% 87.18%

84.85% 84.67%

77.78%

83.20%

70.00%

75.00%

80.00%

85.00%

90.00%

95.00%

100.00%

Ace Inhibitors Digoxin Diuretics

2012 2013 (Non-SPD)

CAP – CHILDREN AND ADOLESCENTS ACCESS TO PCP’S

96.2

2%

88.6

3%

89.6

9%

86.7

8%

96.8

7%

88.9

1%

88.9

1%

87.7

4%

70.00%

75.00%

80.00%

85.00%

90.00%

95.00%

100.00%

12-24 Mos 25 Mos - 6 Yrs 7 - 11 Yrs 12 - 19 Yrs

2012 2013 (Non-SPD)

CDC – COMPREHENSIVE DIABETES CARE 47

.69%

81.0

2%

37.9

6%

86.6

2%

40.8

8%

51.0

9%

80.0

5%

45.0

1%

38.2

0%

73.7

2%

35.7

7%

82.7

3%

41.6

1%

48.1

8%

74.9

4%

55.7

2%

25.00%

35.00%

45.00%

55.00%

65.00%

75.00%

85.00%

95.00%

Eye Exam LDL-CScreening

LDL-CControl

HbA1cTesting

HbA1c PoorControl

HbA1cControl

Med Attn ForNephropathy

BP Control

2012 2013 (Non-SPD)

AAB – AVOIDANCE OF ANTIBIOTIC TREATMENT IN ADULTS WITH ACUTE BRONCHITIS

25.81% 26.43%

20.00%

25.00%

30.00%

AAB

20122013

LBP – USE OF IMAGING STUDIES FOR LOW BACK PAIN

80.37%

82.42%

75.00%

80.00%

85.00%

LBP

20122013

MMA – MEDICATION MANAGEMENT FOR PEOPLE WITH ASTHMA (NEW MEASURE)

58.61%

35.95%

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

MMA

50% Compliance75% Compliance

CCS – CERVICAL CANCER SCREENING

71.29%

68.13%

65.00%

70.00%

75.00%

CCS

20122013

CIS – CHILDHOOD IMMUNIZATION STATUS (COMBO 3)

80.05%

73.72%

70.00%

75.00%

80.00%

85.00%

CIS - Combo 3

20122013

IMA – IMMUNIZATIONS IN ADOLESCENTS

69.34%

75.67%

65.00%

70.00%

75.00%

80.00%

IMA

20122013

PPC – PRENATAL AND POSTPARTUM CARE

40.00%

50.00%

60.00%

70.00%

80.00%

90.00%

100.00%

Prenatal Postpartum

20122013

WCC – WEIGHT ASSESSMENT & COUNSELING FOR NUTRITION & PHYSICAL ACTIVITY FOR CHILDREN & ADOLESCENTS

30.00%

40.00%

50.00%

60.00%

70.00%

80.00%

BMI Nutrition PhysicalActivity

20122013

W34 – WELL CHILD VISITS IN THE 3RD, 4TH, 5TH & 6TH YEARS OF LIFE

75.67%

72.75%

65.00%

70.00%

75.00%

80.00%

W34

20122013

CBP – CONTROLLING HIGH BLOOD PRESSURE (NEW MEASURE)

52.80%

30.00%

40.00%

50.00%

60.00%

70.00%

CBP

2013

2013

HYBRID MEASURES/HPL/MPL

68.13% 73.72% 75.67%

82.97%

67.40% 66.91% 67.88%

41.85%

72.75%

52.80% 61.81%

64.72%

50.36%

80.54%

58.70%

29.20%

42.82%

31.63%

65.51%

50.00%

78.51% 82.48% 80.91%

93.33%

74.73% 77.13% 77.61%

64.87%

83.04%

69.11%

20.00%25.00%30.00%35.00%40.00%45.00%50.00%55.00%60.00%65.00%70.00%75.00%80.00%85.00%90.00%95.00%

100.00%

CCS CIS IMA PPC - Pre PPC - Post WCC-BMI

WCC -Nutrition

WCC -Phys Act

W34 CBP

Rate MPL HPL

HYBRID MEASURES/HPL/MPL – CONTINUED

41.85%

79.08%

42.82%

86.62%

34.79%

55.47%

79.81%

53.53%

45.03%

70.34%

28.47%

78.54%

50.31%

42.09%

73.48%

54.48%

69.72%

83.45%

46.44%

91.13%

28.95%

59.37%

86.93%

75.44%

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

80.00%

90.00%

100.00%

Health Plan MPL HPL

ADMIN MEASURES/MPL/HPL 87

.60%

88.1

0%

88.0

8%

26.43%

96.8

7%

88.9

0%

88.9

2%

87.8

1%

82.4

2%

58.6

1%

35.95%

83.72% 87.93%

83.19%

18.98%

95.56%

86.62% 87.56% 86.04%

72.04%

47.31%

24.62%

91.33% 95.56%

91.30%

33.33%

98.39% 92.63% 94.51% 93.01%

82.04%

62.39%

40.17%

15.00%20.00%25.00%30.00%35.00%40.00%45.00%50.00%55.00%60.00%65.00%70.00%75.00%80.00%85.00%90.00%95.00%

100.00%

MPM -Ace

MPM -Dig

MPM -Diu

AAB CAP -12 - 24

CAP -25 - 6

CAP - 7- 11

CAP -12 - 19

LBP MMA -50%

MMA -75%

Rate MPL HPL

AUTO ASSIGNMENT MEASURES – MPL/HPL

68.13%

73.72%

82.97%

72.75%

86.62%

61.81% 64.72%

80.54%

65.51%

78.54%

78.51% 82.48%

93.33%

83.04% 91.13%

0.00%10.00%20.00%30.00%40.00%50.00%60.00%70.00%80.00%90.00%

100.00%

CCS CIS - Combo3

PPC - Pre W34 CDC -HbA1c

Health Plan MPL HPL

WHAT'S NEXT? Initial HEDIS Post Mortem Discussion took place

Monday August 12 Interim Run

Rate Review HEDIS Workgroup August 27

Development and implementation of Improvement Plans based on Interim Run data

Review Post Mortem Discussion items to establish goals for HEDIS 2014

05 22 13 minDME_Reminder Memo_LCS_08. 2013Grievance Tracking Graphs 2Q 2013 -PACChart_Ttl Grvcs

HEDIS 2013 PPTHEDIS 2013SummaryAMB – Ambulatory CareMPM - Annual Monitoring for Patients on Persistent MedicationsCAP – Children & Adolescents Access to PCP’sPCR – Plan All Cause ReadmissionsCDC – Comprehensive Diabetes CareAMB – Ambulatory CareMPM – Annual Monitoring for Patients on Persistent MedicationsCAP – Children and Adolescents access to PCP’sCDC – Comprehensive Diabetes CareAAB – Avoidance of Antibiotic Treatment in Adults with Acute BronchitisLBP – Use of Imaging Studies for Low Back PainMMA – Medication Management for People With Asthma (new measure)CCS – Cervical Cancer ScreeningCIS – Childhood Immunization Status (Combo 3)IMA – Immunizations in AdolescentsPPC – Prenatal and Postpartum CareWCC – Weight Assessment & Counseling for Nutrition & Physical Activity for Children & AdolescentsW34 – Well Child Visits in the 3rd, 4th, 5th & 6th Years of LifeCBP – Controlling High Blood Pressure (New measure)Hybrid Measures/HPL/MPLHybrid Measures/HPL/MPL – ContinuedAdmin Measures/MPL/HPLAuto Assignment Measures – MPL/HPLWhat's Next?

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