Quality Improvement & Utilization Management Program Evaluation

Quality Improvement & Utilization Management Program Evaluation 2012

Table of Contents 1. Introduction... 4 1.1. Executive Summary... 4 1.2. Quality Leadership... 6 2. Improving Member Health... 7 2.1. Preventive Care for Infants and Toddlers... 7 2.2. Annual Check-ups for Children and Adolescents... 7 2.3. Preventive Health for Women... 8 2.4. Nutrition and Physical Activity... 9 2.5. Initial Health Assessment (IHA)... 9 2.6. Nurse Help Line... 10 2.7. Asthma... 12 2.8. Diabetes... 12 2.9. HEDIS Results... 13 2.10. Strength in Numbers Program... 16 2.11. Health Coaching & Panel Management Training... 21 2.12. Reducing Avoidable Emergency Department Visits QIP... 22 2.13. Reducing All Cause Readmissions QIP... 23 3. Health Education, Cultural, and Linguistic Services... 24 3.1. Health Education Compensation Program (HECP)... 24 3.2. Health Education Products & Services... 24 3.3 Promoting Cultural Competency and Language Access... 27 4. Improving Health Systems... 30 4.1. Practice Improvement Program... 30 4.2 Provider Incentive Pilot to Support Patients on Persistent Medications... 31 4.3. SF Quality Culture Series... 31 4.4. Safety Net Quarterly Quality Meetings... 32 4.5 Coleman Rapid DPI Program... 33 2

5. Improving Member Experience... 34 5.1. Measuring Member Satisfaction... 34 5.2. Improving the Patient Experience QIP... 35 5.3. Action Series: Customer Service... 35 5.4. Action Series: Access... 36 5.5. Action Series: Provider Communication Training... 36 5.6. Providing Excellent Telephone Services... 37 5.7. Member Satisfaction with Customer Service... 37 5.8. Monitoring Member Grievances... 38 6. Provider Relations... 42 6.1. Provider Network Access Monitoring... 42 6.2. Clinical Quality Monitoring... 43 6.3. Medical Group Oversight Audits... 46 6.4. Provider Satisfaction Survey... 49 6.5. Provider Education and Training... 50 7. Care Management Services... 51 7.1. Utilization Management... 51 7.2. Care Support... 54 7.4. Pharmacy Services... 56 3

1. Introduction 1.1. Executive Summary The goal of the San Francisco Health Plan (SFHP) Quality Improvement Program is to assure high-quality care and services for our members by aggressively seeking opportunities to improve the performance of our health care delivery system. This report is a summary of 2012 activities to monitor and improve both the health status and experience of our members. It highlights our successes, examines lessons learned, and outlines next steps. The SFHP Quality Improvement Committee (QIC) is the main forum for oversight of SFHP s health care delivery system. It reviews and approves SFHP policies and procedures, clinical guidelines and studies, and the activities of all entities delegated for utilization management services. During 2012, the QIC met bimonthly. SFHP maintains minutes of each QIC meeting and submits them to the California Department of Health Care Services (DHCS) on a quarterly basis. SFHP also relies on its Pharmacy and Therapeutics Committee and Physician Advisory/Peer Review/Credentialing Committee to oversee its QI and UM programs. Improving Member Health - SFHP manages several interventions to encourage members to seek recommended care as measured by the Healthcare Effectiveness Data and Information Set (HEDIS). We continue to look for ways to make interventions more effective and find new opportunities for improvement. We offer preventive health programs for infants and toddlers, children, adolescents, and women. Our chronic disease programs focus on improving the care of members, including diabetes and asthma. A 24-hour Nurse Help Line ensures access to timely clinical advice for our members. These efforts have been successful, as measured by HEDIS results on key preventive care measures. In 2011, 16 out of 19 publicly reported Medi-Cal measures were above the 90 th percentile benchmark of Medicaid plans nationwide. Health Education and Cultural and Linguistic Services - These principles are actively integrated into quality improvement activities. In making decisions about quality improvement interventions, we examine the demographic characteristics of our member population to ensure delivery of culturally appropriate materials. We believe that health education is better for the member when provided by his or her primary care provider or the provider care team. For this reason, our Health Education Compensation Program reimburses health education provided to members in one-on-one and group settings. SFHP also maintains a library of health education materials in a wide range of topic areas. We make the materials available in both paper and online formats. Upon request, we also make materials available in alternative formats including large print, audio, or Braille. Our website includes an easy-to-navigate repository of educational materials that providers, members, and visitors can access and print. We continuously improve the website by uploading newly developed and revised materials. Improving Health Systems - To support improved quality, SFHP continually explores new ways to collaborate with its providers to move from a visit-based model to a population health-based model. In 2012, two pay-for-performance programs incentivized providers to improve their systems and services, Strength in Numbers and the Practice Improvement Program (PIP). Where 4

the Strength in Numbers program focuses on the population health efforts of front line staff in safety net clinics, and is a joint program of SFHP and Healthy San Francisco (our health access program for the uninsured), PIP focuses on the whole primary care network, targeting clinical quality, data quality, patient experience and key system improvements needed for high performance. Beyond incentive programs, SFHP also supports San Francisco safety net clinics in patient-centered medical home improvement efforts in preparation for healthcare reform. Two specific programs include Coleman s Rapid Dramatic Process Improvement and the San Francisco Quality Culture Series. Ensuring Member Satisfaction - One of SFHP s top four organizational goals is to offer exemplary service to our members and providers. Each year, SFHP monitors member satisfaction through member experience surveys (CG-CAHPS). Based on survey results, SFHP implements programs aimed at improving satisfaction. For 2012, this included three action series on improving patient access, customer service, and patient-provider communication. SFHP s Customer Service Department helps members understand and take full advantage of their health plan benefits. Additionally, SFHP monitors grievances on a quarterly basis to identify trends and problems, as well as to gauge timeliness and regulatory compliance. Our goal is to provide excellent service and, at a minimum, meet the California Department of Managed Health Care (DMHC) standards for responding to and resolving grievances. Provider Relations - SFHP closely monitors the adequacy of its provider network to ensure that members have access to the care they need in a timely manner. We measure network access in a variety of ways, including language capacity and availability of specialists. SFHP participated in the Industry Collaboration Effort (ICE) Timely Access Workgroup to develop a standard methodology and survey tool for monitoring appointment availability. Clinical quality monitoring is also critical to SFHP s success. We have a Memorandum of Understanding (MOU) with Anthem Blue Cross of California to review all jointly contracted primary care providers and sites, in order to ensure compliance with criteria from the California Department of Health Care Services (DHCS). In addition, SFHP delegates and oversees the facility site reviews, medical record reviews, and interim monitoring activities with its medical groups. Lastly, SFHP measured provider satisfaction in 2012, indicating that 78% of providers report high satisfaction with SFHP. Care Management Services - SFHP s Utilization Management Program uses a set of policies to ensure that effective and appropriate health care services are delivered to members. SFHP complies with strict standards for issuing denials and responding to appeals to assure member rights are protected. SFHP assures the quality of its pharmacy services by offering a generous formulary, maintaining good relationships with pharmacy providers, and overseeing the pharmacy credentialing process. Our pharmacy services and formulary are reviewed and updated by our Pharmacy and Therapeutics Committee. We monitor pharmacy usage monthly through cost and utilization reports. At San Francisco Health Plan, we take pride in the many ways we partner with our members and our provider network to improve quality and access to care. We follow the Model for Improvement; since it is not always clear what is the best way to achieve a goal, we frequently pilot interventions, measure the outcomes, and then revise our approach accordingly. 5

1.2. Quality Leadership The SFHP Quality Improvement Committee (QIC) is the main forum for oversight of SFHP s Quality Improvement and Utilization Management programs. QIC meets six times a year and contains physician and administrative representatives from our broad network. The QIC reviews and approves SFHP Medical Management Department s policies and procedures (Health Improvement, Utilization Management, Health Education and Cultural and Linguistic Services, Care Support, and Pharmacy), Provider Relations policies, clinical guidelines, the Health Improvement and Utilization Management Programs, and the activities of all entities delegated for utilization management services. All SFHP policies and procedures are reviewed biannually; however, clinical guidelines require an annual, or more frequent, review if necessary. SFHP maintains minutes of each QIC meeting and submits them to DHCS on a quarterly basis. In addition, SFHP relies on its Pharmacy and Therapeutics Committee (P&T) for formulary and pharmacy criteria review, and the Physician Advisory Committee (PAC) for peer review, review of quality incidents, and credentialing. Both committees report up to the QIC. QIC Membership Governing Board representative o Dale Butler Member Advisory Committee representatives o Irene Conway o Edward Evans Provider Network o Daniel Chan, MD North East Medical Services o Hali Hammer, MD Family Health Center o Claire Horton, MD General Medical Center o Shawna Lamb Hill Physicians Medical Group o Dexter Louie, MD Chinese Community Health Care Association o Todd May, MD San Francisco General Hospital o Carol Miller, MD UCSF Medical Center o Jaime Ruiz, MD Mission Neighborhood Health Center and SF Community Clinic Consortium o Kenneth Tai, MD North East Medical Services o Ning Tang, MD UCSF Medical Center o Albert Yu, MD Chinatown Public Health Center and DPH Community Oriented Primary Care o Richard Zercher, MD Curry Senior Center (SFCCC and DPH) 6

2. Improving Member Health Our goal is to be among the top ten percent of Medicaid health plans nationwide for getting the right care at the right time, as determined by the HEDIS measures required by the State of California for Medi-Cal plans. SFHP has multiple programs to encourage members to seek care, and every year we continue to look for ways to make our interventions more effective. For example, we have member outreach and incentive programs, and we support population health at the provider practices through two pay-forperformance programs, to encourage provider adherence to quality care measures. In addition, we are highly committed to improving the health of members with chronic conditions. To that end, SFHP started work in 2012 to enhance its offerings of chronic disease self-management resources to members. We recently updated our low-literacy, multilingual health education fact sheets and web resources on the SFHP website, and launched two new programs: a diabetes health text messaging program called DMTxt, and an evidence-based peer education program called Healthier Living. These and other programs are described at length below. 2.1. Preventive Care for Infants and Toddlers Members receive a $50 gift card for completing all immunizations by age two. An offer is mailed to families with children turning 13 and 17 months of age. In 2012, 14% (630) of members who were offered the incentive successfully participated in the program. To support members with achieving the incentive, families with children turning five and eight months of age receive an Immunization Reminder Card with educational information about vaccinations. Reminder cards include needed immunizations to receive the incentive. SFHP mailed 4,022 reminder cards in 2012. Additionally, families receive four recorded telephone calls when their child turns 12, 13, 17, and 22 months of age, reminding them of upcoming well-visits and immunizations. Families with children under the age of two who are assigned either to the Department of Public Health clinics or to clinics using the California Immunization Registry receive reminder calls for well child checks and immunizations. 2.2. Annual Check-ups for Children and Adolescents Families with a child between the ages of three and six years old receive a birthday card from SFHP, offering them a $25 gift card for bringing their child to an annual check-up. Along with the birthday card, families also receive a recorded telephone message encouraging them to take their child to their provider and take advantage of the well-child incentive. The messages were recorded in English, Spanish, Chinese and Vietnamese. Also, SFHP is in partnership with North East Medical Services (NEMS) to help promote this incentive. In 2012, 2,348 (27%) members who were offered the incentive participated in the program. 7

In 2012, SFHP began a new raffle for members ages 0-19 who receive a well visit in the measurement year or the year prior for members age 7-19. Brochures explaining the raffle and encouraging them to see their provider for a well visit were sent to members age 0-7 who have not received a well visit in 2012 and members ages 7-19 who have not received a well visit in 2011 or 2012. Raffle winners receive an Apple ipad. 2.3. Preventive Health for Women Well-Woman Preventive Health Mailing Upon enrollment and then once per year, female members 27 years and older receive a brochure with preventive health care guidelines for women such as recommended frequency for mammograms as well as other health education messages. The mailer also includes a promotion for our prenatal and postpartum incentive programs for members who may be pregnant or who have recently given birth. Your Body, Your Baby Incentive Program In 2011, SFHP initiated a member incentive program for postpartum care. The Timely Prenatal Care Incentive Program was incorporated into this new program. Together, the two perinatal incentive programs became the Your Body, Your Baby program. This program offers a $25 gift card for receiving timely prenatal care and a $25 gift card for receiving timely postpartum care per HEDIS specifications. SFHP makes live calls to members who are identified as having recently given birth or newly enrolled in SFHP due to pregnancy. The member is informed of the program and asked if she would like to participate. If the member decides to participate, she receives health education materials in the appropriate language along with an incentive voucher. In 2012, we sent 365 vouchers and received 84 back; of those members who returned an incentive voucher, 87% completed the visit as required. Cervical Cancer Screening In October 2012, all providers who had at least one SFHP member who was due for a Pap test received an outreach list with contact information for these patients. In order to drive utilization of the outreach lists, SFHP offered an incentive to providers of $25 for each member on the list who received a PAP test prior to December 31, 2012 SFHP hired a nurse practitioner contractor to work as a liaison to providers, answering questions about the program and encouraging participation. In November 2012, SFHP used an automated call service to send prerecorded messages to members due for a Pap test, encouraging them to schedule an appointment for the test. Additionally, SFHP offered $25 gift cards as an incentive for members to receive the Pap test. The gift cards were distributed to clinics participating in the provider incentive program according to the number of patients on their respective outreach lists. 8

2.4. Nutrition and Physical Activity SFHP s 2011 Health Education Group Needs Assessment (completed every five years) indicated that the top health education needs of SFHP members and providers are in the area of nutrition and physical activity, as well as in chronic disease management. In 2012, we continued our focus on improving health education resources. To support the SFHP provider network in providing tools for maintaining a healthy weight, SFHP has materials such as cookbooks, educational placemats, and measuring cups and spoons, which are available to providers upon request. These materials are disseminated to clinic sites and are used for health education and as incentives in targeted campaigns such as a Diabetes Days and Nutrition Classes. Additionally, SFHP supported its provider network in caring for new Seniors and Persons with Disabilities by financing and distributing 35 wheelchair-accessible bariatric scales and 25 wheelchair-accessible exam tables to 34 sites across its network. Addressing the obesity epidemic is a top priority for SFHP. In spring 2012, SFHP distributed Weight Assessment Toolkits at 54 provider and clinic sites through mailings and at meetings. The toolkits contained: BMI wheels Information about documenting BMI, nutrition and physical activity counseling in the patient s chart (following HEDIS specifications) Tips for communicating with patients Sample member educational materials San Francisco Childhood Obesity Taskforce In 2012, SFHP continued to participate in a citywide coalition of health care providers and managed care organizations focused on childhood obesity. The taskforce aimed to identify low-cost resources for PCPs and families to support healthy eating and physical activity. In March 2012, the coalition hosted a leadership roundtable entitled: Managing Pediatric Overweight among Medi-Cal Patients. This summit aimed to promote communication, collaboration, and the sharing of best practices. A total of seven presenters shared highlights of their various programs related to managing childhood weight and obesity. The rest of the session was devoted to group discussion and ideas for approaching collaboration. 2.5. Initial Health Assessment (IHA) SFHP sends monthly reports to its providers with demographic information about their new patients. SFHP asks providers to reach out to those members to receive an Initial Health Assessment within 120 days, as mandated by DHCS (60 days for members 0-18 months old). New members receive a mailer in their primary language encouraging them to call their providers and make an appointment to receive this service. 9

SFHP monitors performance against this requirement by reviewing administrative claims and encounter data and calculating the percentage of new members who receive an IHA visit within the DHCS-recommended periods. Below are the IHA rates for SFHP members. Rate Measure 67.98% New patients over 18 months old receiving IHA within 120 days 70.17% New patients under 18 months old receiving IHA within 60 days According to the DHCS requirement, the following exceptions apply to the expectation of a completed IHA for each new member. These reasons for not doing an IHA help to explain why member completion rate is lower than expected: The new member is assigned to a PCP who completed an IHA with the member prior to the member s enrollment at SFHP, The elements of the IHA were completed within 12 months prior to member s effective date of enrollment, The PCP has documented in the medical record that all findings have been reviewed and updated accordingly, The new member was not continuously enrolled in the plan for the required number of days, The new member disenrolled from SFHP during the IHA period, The new member or a member s parent/guardian refused to complete an IHA and this refusal is documented in the chart, The new member missed a scheduled appointment with the PCP and at least two additional documented attempts were made to reschedule the appointment, without success. In spite of the above exceptions, SFHP continuously makes every effort to assess member needs and provide them with appropriate care. Beginning with the enrollment of SPD members in 2011, SFHP contracted with Nurse Response to conduct Health Risk Assessments to SPD members. After the completion of mandatory enrollment in mid-2012, SFHP s customer service department began completing the HRAs. SFHP Care Support staff uses the information from these assessments to provide appropriate care coordination services to the members who need it most. 2.6. Nurse Help Line SFHP contracts with Nurse Response, a Nurse Help Line that is available 24 hours per day, 7 days per week. SFHP advises members to use the Nurse Help Line in the following situations: If member is unable to reach their doctor during the day or after hours If member desires to speak with a registered nurse to answer health questions, give advice, and instruct them to go to the emergency room, urgent care center, or contact their provider after being triaged with standardized McKesson protocols. 10

Members assigned to Kaiser Permanente or to a clinic with its own call center/nurse Help Line are transferred through a live voice-to-voice connection from the SFHP Nurse Help Line to the advice line operated by their provider organization. SFHP has marketed the Nurse Help Line in a variety of ways, including: Including the phone number on the back of member s SFHP ID card Mailing postcards and magnets to new members (available in 5 languages) Listing the phone number on 2012-2013 Evidence of Coverage document, mailed to all enrollees annually. The most frequent reasons adult members call the Nurse Help Line include basic medical questions, non-clinical questions (e.g. clinic hours, pharmacy info, provider info, etc.), and common symptoms such as diarrhea. The most common questions for pediatric members relate to vomiting, colds, and fevers. SFHP receives and reviews monthly statistics from Nurse Response that are reported annually to the SFHP Quality Committee (QIC) and to the Department of Managed Health Care (DMHC). DMHC s Timely Access Standard Report requires triage or screening by phone within 30 minutes of the call. Only 0.64% of calls exceeded the 30 minute threshold. The table below shows the Nurse Help Line s performance relative to this standard. In 2012, the number of abandoned calls remained extremely low, only 16 in 2012. Our 0.6% abandoned call rate is well below the 5% NCQA standard. Total # Calls Average Time to Answer (seconds) Abandon Calls 30 Seconds Abandon Rate Outlier Calls 30 min Outlier Call Rate January 134 20 0 0.00% 1 0.75% February 173 24 6 3.47% 0 0.00% March 256 28 9 3.52% 0 0.00% April 232 11 4 1.72% 2 0.86% May 282 13 3 1.06% 2 0.71% June 195 9 5 2.56% 0 0.00% July 193 8 1 0.52% 1 0.52% August 181 13 1 0.55% 3 1.66% September 204 7 0 0.00% 1 0.49% October 197 13 3 1.52% 0 0.00% November 175 7 1 0.57% 3 1.71% December 264 12 5 1.89% 3 1.14% Total/Average 2,486 14 38 1.53% 16 0.64% 11

2.7. Asthma The San Francisco Health Plan provides medical homes and health education centers serving our members with free asthma supplies. In 2012, SFHP donated over $5,690 worth of free spacers, peak flow meters, hypoallergenic pillowcases and mattress cover sets to distribute to SFHP members with asthma. Additionally, health education materials related to asthma are available in the member and provider sections of our website in English, Chinese, Spanish, Russian, and Vietnamese. SFHP is a member of the San Francisco Asthma Task Force Clinical Committee, and participates in the planning of programs and provider trainings aimed at improving the management of asthma among San Francisco residents. On October 5, 2012, The Task Force hosted its annual Networking Forum, Motivational Interviewing and Asthma Self Management, which was advertised to providers in San Francisco and included a full day of training on Motivational Interviewing by expert Steve Berg-Smith. 2.8. Diabetes Member Incentives In 2012, we continued to offer a $25 gift card incentive for completing the following six recommended services within the calendar year: HbA1c LDL Eye exam Foot exam Blood pressure Monitoring for Nephropathy (Urine micro albumin screening, prescription for ACE/ARB, or other evidence of medical attention for nephropathy) Marketing the Diabetes Incentive Program Annually, all members with diabetes are sent a diabetes reminder card with information about our incentive program. In September 2012, a contracted call center made live calls to 2,050 members with diabetes who had not yet completed all necessary exams in 2012, an increase from 2011 (1,728 live calls). The calls encouraged members to complete their regular screening tests. After the calls in September, the number of incentive vouchers returned jumped from 27 in September to 96 in October and 53 in November. Lastly, SFHP worked with our contracted eye vendor, VSP, to send letters to members with diabetes who had not received an eye exam in the past 12 months. SFHP regularly sent VSP a list of SFHP members with diabetes to ensure the most accurate outreach lists. 12

Incentive Program Results In 2012, 12% (444) of members who received cards returned them, compared to 19% (308) in 2011. Of the members who returned cards, 62% (280) of the members turning in a card qualified for the incentive. We attribute the decrease in participation to the following: 1) A decrease in outreach efforts and panel management by providers who are transitioning to electronic medical records, and 2) an increase in the number of new members with diabetes (specifically SPDs) who are not familiar with our incentive program. Health Texting Pilot: DMTxt In early 2012, SFHP started planning for the launch of a health texting program for members with diabetes, with the goal of encouraging members to get their annual diabetes-related screenings and improve self-management skills. Many studies have shown evidence for the effectiveness of using text messages to deliver health interventions. SFHP partnered with a health-focused technology startup, HealthCrowd. Members were invited to opt in to the program, DMTxt, and to expect to receive three to four texts per week, containing diabetes and general health-related messages. Many of the messages are interactive and invite a response, as a way to further engage members. As of December 2012, 175 members had enrolled in the program, which launched in early 2013. The pilot is planned to run for six months after the launch, at which point SFHP and HealthCrowd will review data to evaluate the success of the pilot phase and to make improvements to the program. Healthier Living Program In 2012 SFHP joined the San Francisco Healthier Living Coalition, a group of San Francisco agencies that have joined together to schedule, promote, and lead workshops in the Healthier Living program, an evidence-based peer education program developed by Stanford University. The program is designed to empower people with chronic conditions to self-manage their care. The six-week program builds knowledge and self-management skills in order to increase participants self-efficacy, and is taught by peers who also have chronic conditions. The classes are available in multiple languages, in locations across the city. 2.9. HEDIS Results Our quality improvement programs have been successful, as measured by our strong HEDIS results for reporting year 2012. Preventive Care Measures SFHP demonstrated improvements in most Medi-Cal measures during the 2012 reporting year (measurement year 2011). Sixteen out of 19 publicly-reported Medi-Cal measures were in NCQA s 90 th percentile benchmark for Medicaid plans, as highlighted in yellow below. By comparison, last year only had 14 out of 21 measures above the 90 th percentile. The table below shows our Medi-Cal results reported in 2012, compared to the prior year s results. Measures highlighted in pink are used by the California Department of Health Care Services to calculate the percentage of Medi-Cal enrollees assigned to SFHP when they do not choose a health plan. Based on the 2012 scores, as well as the percent of 13

members receiving services in the safety net, our default assignment rate for 2013 increased to 89%, adjusted to 84% due to a new cost factor (awarding points for the lowercost county plan). This is an improvement from the 71% auto-assignment rate for the previous year. HEDIS Measure 2011 Medicaid 2011 2010 90th Percentile Avoidance of Inappropriate Antibiotic Treatment in Adults 45.45% 44.5% 31.6% Adolescent Well-Care Visits 65.20% 64.4% 64.1% Cervical Cancer Screening 80.19% 79.4% 78.7% Childhood Immunization Status (Combination 3) 87.04% 87.3% 82.6% Comprehensive Diabetes Care BP <140/90 78.64% 73.7% 76.0% Comprehensive Diabetes Care Eye Exam 69.72% 70.1% 70.6% Comprehensive Diabetes Care HbA1c Control <8 63.38% 64.1% 59.1% Comprehensive Diabetes Care HbA1c Testing 91.08% 90.4% 90.9% Comprehensive Diabetes Care LDL Testing 83.33% 83.2% 83.2% Comprehensive Diabetes Care LDL Control <100 48.83% 47.9% 45.9% Comprehensive Diabetes Care Monitoring for Nephropathy 83.57% 85.1% 86.9% Comprehensive Diabetes Care Poor Control >9 26.53% 26.3% 29.1% (lower rate is better) Postpartum Care 75.64% 63.6% 75.2% Prenatal Care 93.44% 90.3% 93.2% Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents - BMI Percentile 76.16% 60.7% 69.8% Weight Assessment and Counseling for Children/Adolescents Nutrition 80.56% 78.5% 72.0% Weight Assessment and Counseling Children/Adolescents Physical Activity 72.69% 70.4% 60.6% Well-Child Visits in the Third, Fourth, Fifth and Sixth Years of Life 84.95% 85.2% 82.9% Use of Imaging Studies for Low Back Pain 82.98% 82.2% 82.3% Auto Assignment Measure SFHP above NCQA s Medicaid 90th Percentile for that year We had significant increases in our rates for postpartum care and blood pressure control. In 2012 we began sending out health education materials in the appropriate language along with an incentive voucher to all women who had recently given birth, regardless of whether we were able to reach them via phone. This caused a spike in the number of members who participated in our incentive program and were compliant for this measure. Blood pressure control rate increased in 2012. This may be due in part to the 14

introduction of a new measure in the Strength in Numbers program, incentivizing clinics to raise their blood pressure control rates. Prior to 2012, Strength in Numbers only incentivized blood pressure documentation. Chronic Care Measures SFHP reached the national HEDIS 90 th percentile in all diabetes measures with the exception of LDL testing, monitoring for nephropathy, and eye exams. Although SFHP did not reach the 90 th percentile for LDL testing, we improved upon our 2011 scores from measurement year 2010. Measure 2011 2010 2011 Medicaid 90 th Percentile Eye Exam 69.72% 70.1% 70.6% HbA1c Testing 91.08% 90.4% 90.9% LDL Testing 83.33% 83.2% 83.2% Monitoring for Nephropathy 83.57% 85.1% 86.9% Blood Pressure Control (<140/90) 78.64% 73.7% 76.0% HbA1c Poor Control (>9) 26.53% 26.3% 29.1% HbA1c Good Control (<8) 63.38% 64.1% 59.1% LDL Good Control (<100) 48.83% 47.9% 45.9% SFHP above NCQA s Medicaid 90th Percentile for that year 100% Diabetes Testing Results 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Eye Exams HbA1c Testing LDL Testing Monitoring for Nephropathy MY2010 67.5% 89.4% 82.6% 85.8% MY2011 70.1% 90.4% 83.2% 85.1% MY2012 69.7% 91.1% 83.3% 83.6% MY2012 90th %ile 70.6% 90.9% 84.2% 86.9% 15

Healthy Families In measurement year 2011, 6 out of 14 Healthy Families measures were in the 90 th percentile, whereas in 2010, 9 Healthy Families measures were in the 90 th percentile. SFHP attributes this decrease to the change in the Childhood Immunization measure and also possibly to decreased appointment access at provider offices due to the implementation of electronic health records in many San Francisco safety net clinics in 2011. In our Healthy Families measures, we had a significant increase in our rate for Childhood Immunization Status. Childhood Immunization Status has continued to improve; we believe this may be attributed to our strong HEDIS incentive program for Childhood Immunizations. Measure 2011 2010 2011 Medicaid 90 th % Adolescent Well-Care Visits 80.32% 69.7% 64.1% Childhood Immunization Status - Combination 10 (New indicator) 43.86% 19.51% 23.6% Well-Child Visits in the First 15 Months of Life 75.86% 81.1% 77.1% Well-Child Visits in the Third, Fourth, Fifth and Sixth Years of Life 87.27% 87.7% 82.9% Children and Adolescents Access to PCP (12-24 months) 97.30% 96.2% 98.6% Children and Adolescents Access to PCP (25 months to 6 years) 92.44% 94.1% 92.7% Children and Adolescents Access to PCP (7 to 11 years) 94.14% 96.1% 94.7% Children and Adolescents Access to PCP (12-18 years) 94.86% 94.0% 93.4% Use of Appropriate Medication for Asthma (all ages) 87.23% 95.2% 93.2% Appropriate Testing for Children with Upper Respiratory Infection 95.67% 95.8% 94.8% Appropriate Testing for Children with Pharyngitis 50.37% 25.2% 83.3% Lead Screening in Children 70.18% 77.2% 87.6% Chlamydia Screening in Women 17.00% 19.2% 69.1% Immunizations for Adolescents 80.30% 66.4% 75.5% SFHP above NCQA s Medicaid 90th Percentile for that year 2.10. Strength in Numbers Program The Strength in Numbers program engages primary care clinics in the SFHP and Healthy San Francisco (HSF) provider networks to share quality data and improve performance in population health and access to care. Strength in Numbers rewards clinics with financial incentives for improvement in key chronic care and access measures. The program also provides technical assistance in the form of trainings to support population management 16

activities. Supplemental practice coaching is provided through a collaboration with the UCSF Center for Excellence in Primary Care. Strength in Numbers tracks population health performance for over 13,000 patients with diabetes. Clinics continue to value the opportunity to report measures and share performance results for all their patients, not just SFHP members. Community results are shared through a newsletter that highlights best practices. During the 2012 program year, Strength in Numbers underwent significant changes. The expansion of the measurement set placed increased emphasis on clinical outcomes. For example, more than half of the participating Strength in Numbers medical homes reported on blood pressure control (< 140/90), instead of reporting solely on blood pressure electronic documentation. The program also offered a number of optional measures, including preventive health screening measures such as cervical cancer screening and Hepatitis B vaccination rates. Another big change in 2012 included incentives for clinics that care for children. Pediatric practices and family medicine practices chose to participate and report on an adult health measure set, a children s health measure set, or both. The new children s measure set targets BMI documentation, anemia screening, and improved access to primary care. In addition, clinics were given the option of reporting on adolescent immunizations and clinic show rate. Data became more transparent in 2012, as clinic-specific program results were shared across all participating organizations on a quarterly basis. These unblinded data allowed sites to monitor both their internal progress as well as their improvement compared to their peer organizations. Also, by highlighting a clinic s individual highest and lowest performance within a measure, the program s comparative data built awareness of opportunities to standardize clinical practice. Looking at the Strength in Numbers program population as a whole, two measures saw significant improvement in 2012. Interestingly enough, the measures added in 2011 and 2012 saw the most improvement, likely due to clinics focusing their efforts to the new measures. The overall colorectal cancer screening rate rose steadily over the course of the year to finish at 20% above baseline in Quarter Four (October December). Smoking status documentation also improved; the average rate rose every quarter in 2012 to finish at 13% above baseline. Increased smoking status documentation is a particularly good sign as Strength in Numbers looks forward to the 2013 program year when all participants will build on this foundation to report on Smoking Cessation Counseling. Overall performance in the four core diabetes measures (A1c Testing, A1c > 9, LDL Testing, and LDL < 100) was slightly lower in late 2012 than the initial scores in 2010. This is a huge disappointment after two years of aggregate improvement in these measures. The main factor that may account for this is the loss of clinic capacity to do proactive population management during a time of electronic records implementation. This loss of capacity was 17

both a loss of primary care appointments available during the months following go-live in many sites, as well as the loss of staff time to do proactive panel management outreach. The following charts show the aggregate rates of 6 clinics, 3 of which implemented electronic health records in 2012 and 3 of which did not. In the two screening measures (HbA1c Testing and LDL Testing), the clinics that implemented EHR in 2012 saw a progressive decline in performance, where the three clinics that did not implement EHR maintained performance. Diabetic Measures for All Participating Medical Homes 100.0% 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% HbA1c Testing HbA1c > 9* LDL Testing LDL < 100 20.0% *Lower is Better 10.0% 0.0% Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 2010 2011 2012 18

100.0% HbA1c Testing 90.0% 80.0% 70.0% 60.0% 50.0% Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 2010 2011 2012 Implemented EHR Did not Implement EHR LDL Testing 100.0% 90.0% 80.0% 70.0% 60.0% 50.0% Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 2010 2011 2012 Implemented EHR Did Not Implement EHR 19

Additionally, one noteworthy subset of Strength in Numbers participants has shown progress during this time. Medical homes performing in the bottom 20% during their first quarter in the program have all achieved significant improvement over baseline. 100.0% 80.0% 60.0% 40.0% 20.0% 0.0% Overall Improvement of Medical Homes with Lowest Initial Rates Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 2010 2011 2012 HbA1c Testing HbA1c > 9 LDL Testing LDL < 100 100% Relative Improvement of Medical Homes with Lowest Initial Rates 80% 80.7% 60% 40% 20% 0% 28.9% 23.0% 11.4% HbA1c Testing HbA1c > 9 LDL Testing LDL < 100 20

2.11. Health Coaching & Panel Management Training A key component of Strength in Numbers is technical assistance. In 2012, a six-part training on health coaching and panel management trainings was made available to all participating medical homes. 25 attendees representing 10 medical homes and 3 other health providers participated in this six-week training. The San Francisco Health Plan partnered with the UCSF Center for Excellence in Primary Care (CEPC) in facilitating and coordinating a six-part (12 hour) training focused on the practices and procedures of health coaching, including a brief introduction of panel management. Training utilized a classroom style, highly-interactive approach to introducing the skills, strategies, and knowledge in working collaboratively with patients with diabetes, hyperlipidemia and hypertension. Training content included self-management skills, medication reconciliation, action planning, reading a registry report, panel risk stratification, and inreach and outreach techniques. Participants demonstrated the core competencies of health coaching using role-plays with partners. The graph below shows the improvement of participant confidence in using the ask-tellask method to engage patients in talking about their health from session 1 to session 6. The mean values are shown based on a 1-10 scale. 10 9 8 7 6 5 4 3 2 1 0 Participant Confidence to Use "Ask-Tell-Ask" Intervention Mean Score, 1-10 Scale 6.8 8.1 Session 1 Session 6 21

How much do you agree or disagree with the following statements? (n=12) This training met my expectations The materials were helpful I learned what I hoped to learn I enjoyed Format of the training 4.4 4.4 4.3 4.3 1 2 3 4 5 Participants found the trainings to be very useful, rating the training an average of 4.4 out of 5.0. Participants made the following comments, with regards to the training: I learned a lot about how to talk to patients and potential problems that may arise. I think the scenarios definitely helped me in understanding the benefits of the asktell-ask method. Diabetes is a common disease among the patients in our clinic. This training provides very helpful scenarios about coaching patients about their diabetes management. 2.12. Reducing Avoidable Emergency Department Visits QIP The Reducing Avoidable Emergency Room Visits Quality Improvement Project (ER QIP) was a DHCS-led project that started in 2008 and closed in October of 2011. SFHP continued the project through the end of 2012 because there continued to be worthwhile progress, particularly with regards to operational improvements at the clinic sites that partnered with SFHP in this project. As the formal QIP began, SFHP analysis showed that St. Luke s Hospital had the highest emergency visit rates for SFHP members when compared with other SFHP network hospitals. In addition, the majority of members with emergency visits at St. Luke s belonged to the Hill Physicians Medical Group. For the QIP, SFHP initiated a partnership with these two organizations. At St. Luke s, the two primary care clinics at the hospital were the main partners, with productive participation by the Emergency Department as well. The results for the project through 2011 follow; St. Luke s hospital changed affiliations and information systems in the middle of the project, making it too difficult to see the results from the 2012 activities (specifically, it was impossible to distinguish the location of the visits, as the reporting blended the sites of affiliated hospitals). Decreased overall emergency visit rates for SFHP members utilizing the St. Luke s Emergency department by 2% compared to baseline (from 24% CY2009 to 23.52% CY2012) Decreased avoidable emergency visit rates for SFHP members utilizing St. Luke s ER by 10% from baseline (from 5% CY2009 to 4.5% CY2012). 22

In 2012, the following activities continued: Emergency visit data from St. Luke s Hospital was reviewed weekly for project monitoring and for creation of outreach lists. A SFHP health navigator phoned patients who had a recent emergency visit to review alternatives and to promote the SFHP Nurse Help Line; health education materials were offered for parents, to help them know when to use primary care instead of the emergency department. Phone calls by SFHP ended in June 2012, as St. Luke s started outreach calls to these same members about accessing appointments in the future for urgent needs. Health education materials such as the book What to Do When Your Child Gets Sick and marketing materials for the Nurse Help Line were mailed to interested members after the phone call from the SFHP health navigator. Hill Physicians Medical Group offered case management services to members with three or more emergency visits within six months. SFHP sent an Emergency History report to the St. Luke s providers for patients who had three or more emergency visits within six months. St. Luke s clinic staff used these lists to reach out to these patients. St. Luke s clinic staff engaged the providers and staff at the St. Luke s emergency department to contact the clinic to schedule a follow-up primary care visit for the patient after an emergency visit, as necessary for the patient s care and follow-up. 2.13. Reducing All Cause Readmissions QIP The All Cause Readmission QIP is a DHCS-led project that started in 2012. This is a statewide collaborative that provides an opportunity to collect data, share knowledge and best practices, and implement changes that will help reduce readmission rates for the Medi- Cal population. In preparation for the QIP, SFHP collaborated with other health plans to develop a study proposal, including appropriate technical assistance from HSAG, California s designated external quality review organization. DHCS has mandated that each plan evaluate the readmission rate and address any disparities through barrier analysis and targeted interventions. SFHP spent much of 2012 working with outside agencies to develop effective interventions. Initially, SFHP met with San Francisco s Department of Aging and Adult Services to explore offering a care transitions program to SFHP members. SFHP also joined the Avoiding Readmissions through Collaboration Network (ARC) in order to learn best practices for decreasing readmissions utilized by other health plans, hospitals, and other health care agencies. In 2013, SFHP will implement a new measure (as part of its pay for performance program) that targets members that have been recently discharged from the hospital. Our goal is to engage our entire network of medical groups and clinics to promptly contact patients on discharge from the hospital, and ensure they get needed follow-up care. 23

3. Health Education, Cultural, & Linguistic Services Health education and cultural and linguistic competency principles are actively integrated into SFHP s quality improvement activities. In order to make decisions about quality improvement interventions, SFHP examines the demographic characteristics of its member population. Many existing projects were continued in 2012 and SFHP developed two other large-scale pilots in response to provider recommendations and member input. 3.1. Health Education Compensation Program (HECP) The Health Education Compensation Program (HECP) provides financial support for medical homes and health education centers offering health education services free of charge to SFHP members. HECP has two funding structures. The first one covers medical homes with assigned SFHP members, in which 19 PCP sites participated in 2012. The second structure covers both health education centers without an assigned SFHP membership, in addition to PCP sites providing health education services to SFHP members assigned to other medical homes. This funding supports clinics providing unique course offerings and services in SFHP s five threshold languages (Chinese, Russian, Vietnamese, Spanish, and English) that are not offered in the patient s home clinic. A total of 8 health education centers and PCP sites enrolled in this second funding structure. The 2012 participating sites provided health education classes and individual counseling on the following topics: Health Education Topics Diabetes Asthma Perinatal Care Nutrition and weight management Hyperlipidemia Hypertension Smoking Cessation Behavioral Counseling Dental hygiene/fluoride varnish Parenting/family wellness Infant/adult CPR and first aid Healthy Aging Pain Management Yoga Acupuncture Chronic disease management Walking groups =New in 2012 3.2. Health Education Products & Services SFHP maintains a library of health education materials in a wide range of topic areas. Upon request, materials are also available in alternative formats including large print, audio, or Braille. In 2012, SFHP also started work on two new projects: a health text messaging program and a collaboration to promote a chronic disease self-management program. 24

Social Media-Based Health Education The SFHP website includes an easy-to-navigate repository of educational materials that providers, members, and visitors can access and print. In response to the State s policy letter requiring English-language written health education materials to be certified at or below a sixth grade reading level (APL 11-018), SFHP developed a new library of low-literacy health education fact sheets. Starting in October 2012, they are available in English, Chinese, and Spanish. All materials are available in both paper and online formats. These online materials addressed almost 30 topics including asthma, diabetes, breastfeeding, back pain, sleep, and weight management. To assess website use, SFHP tracks the frequency of hits to the Health and Wellness pages of the website. In 2012, the provider, member, and visitor sections of the SFHP website were accessed 8,740 times, more than double the hits from 2011. Health & Wellness Web Hits to Provider Section 2012 Health Education Material for Members 2,398 Health Education Material for Providers 256 Health Education Classes 1,039 HECP 300 Total 3,993 Health & Wellness Web Hits by Language Member Section Visitor Section English 2,097 1,862 Spanish 108 104 Chinese 218 358 Total 2,423 2,324 Targeted Health Education Mailings As part of quality improvement initiatives to promote preventive care and management of chronic conditions, SFHP mails health education materials to members. In 2012, SFHP mailed information and health reminders on the following health topics: Immunizations for 0-2 year-olds Well-checks for 3-6 year-olds Cervical cancer screening Breast cancer screening Women s health Diabetes management Diabetic eye exams Initial health assessments Pregnancy education books What To Do When Your Child Gets Sick parent/caregiver education book 25

SFHP s quarterly member newsletter continues to be an important means for communicating health education messages to members. The newsletter, Your Health Matters, regularly includes articles on topics such as nutrition and physical activity ideas, child safety, member rights pertaining to language access services, stress reduction tips, and SFHP s community partnerships. Topics are chosen based on a myriad of factors, including regular input from the Member Advisory Committee, as well as relevant local and national health priorities. Group Health Education In 2012, SFHP joined the San Francisco Healthier Living Coalition, a group of San Francisco agencies that have joined together to schedule, promote, and lead workshops in the Healthier Living program, an evidence-based curriculum developed by Stanford University designed to empower people with chronic conditions to self manage their care. The six-week peer education program builds knowledge and self-management skills in order to increase participants self-efficacy. In conjunction with the Healthier Living Coalition, SFHP members were offered this free workshop eight times and in four languages (English, Spanish, Cantonese, and Russian) over the course of several months. SFHP and coalition partners conducted extensive outreach to the community and SFHP members in particular through targeted mailings, phone calls, and tabling at events. Despite high interest from members, follow-through proved challenging. Of 39 members who enrolled in the workshops, 21 graduated (meaning they completed four of six weeks). Those who graduated reported highly positive experiences with the program. Since this time, SFHP has strengthened recruitment efforts at key locations as well as trained internal leaders to increase member participation. Community Events In May 2012, two SFHP staff members led a Finding Reliable Health Information Online workshop at the Aging and Disability Technology Summit, and about 50 people attended this interactive session. The aim of this conference is to connect seniors and persons with disabilities to technology. SFHP plans to present again at the 2013 summit and continue to build a relationship with the Community Living Campaign, which organized the summit. In June 2012, three SFHP staff members led a workshop called Health Inequities How to be Part of the Solution at the Stronger Bridges to Health Forum, which is an information and resource fair for community advocates who connect the uninsured to health coverage. The event is sponsored by SFHP and is made available to participants at no cost. The 2012 theme, Bringing the Pieces Together, focusesd on harnessing community-based services to create healthier communities and complement health care coverage. 26

3.3 Promoting Cultural Competency and Language Access Cultural Awareness Training In 2012, SFHP conducted or sponsored several Cultural Awareness Trainings open to SFHP staff and contracted medical groups and providers; examples of differing trainings and their outcomes are described below. The Cultural Awareness and Humility training was held on November 19, 2012 and targeted SFHP staff; the training was conducted by Lee Mun Wah, MS, MA, Founder of StirFry Seminars & Consulting, Inc. The objectives included the following: Define culture, and why it matters for our work with members and each other Discuss how cultural factors affect health care delivery Practice noticing the intent and impact in all cross-cultural communications Learn and practice techniques on how to listen and respond to intercultural communications 96% of SFHP staff attended. Of those who completed the evaluation, 85% agreed that their cultural awareness knowledge/tools improved as a result of this seminar. In addition, 78% agree that as a result of this training, they are more confident in their ability to effectively deal with diversity issues. Some staff members felt there should be much more time spent on this topic, while others felt that this was sufficient. Reducing African-American Infant Mortality in San Francisco: A Cultural Competency Training for Providers, was held May 9, 2012 and was open to SFHP s provider network. This training was jointly conducted by Gene Ramos, Expert Consultant, and Dr. Carol Miller, UCSF pediatric faculty. The objectives included the following: Discuss infant mortality rates and disparities in San Francisco Improve culturally competent patient care Strengthen advocacy to eliminate disparities in African-American infant mortality in San Francisco A total of forty-four people attended, with a mix of case managers, counselors, nurses, and social workers. Of these participants, 98% reported they would recommend this training to others, while 97% learned new strategies, ideas, and resources and agreed that the materials covered would be useful in their jobs. Language Access SFHP monitors language access through medical group oversight audits, grievances, and provider network monitoring. The examples below better illustrate such processes, and include Medical Group Joint Administrative Meetings and our analysis of HEDIS Rates by race/ethnicity and language with the goal of reducing disparities in care. 27

Several times throughout the year, SFHP held Joint Administrative Meetings with the following contracted medical groups: Kaiser Foundation Health Plan San Francisco, Chinese Community Health Care Association, North East Medical Services, Hill Physicians Medical Group, and Brown and Toland Medical Group. At the meetings, SFHP staff educated medical group contacts on resources and requirements for complying with State mandates. These resources are available to medical groups at any time and include the following: Cultural and Linguistic Services Requirements Tips for Communicating Across Language Barriers Tips for Working with Interpreters Employee Language Skills Self-Assessment Tool Issues related to adding on members who are Seniors and Persons with Disability While we continued to make progress in improving our overall rates for almost all HEDIS measures in 2012, an analysis of HEDIS data from measurement year 2011 by race/ethnicity and language showed continued disparities in the rates for some measures. SFHP is currently working with our Quality Improvement Committee and Member Advisory Committee to determine areas for targeted interventions. Some initial findings by focus area are summarized in the chart below. Access Prevention Women s Health Diabetes African Americans had lowest rates for children s access measures. African Americans had the lowest rates across obesity prevention measures (BMI, Physical Activity, and Nutrition Counseling). Chinese speakers had the best rates of childhood immunizations. Cervical cancer screening rates were lowest for African-American women. Prenatal rates were lowest for African Americans and highest for Chinese women. Among language groups, rates were predictably lowest for English speakers and highest for Chinese speakers. Across almost every diabetes measure, African Americans and Latinos fared poorest. With these disparities identified, SFHP staff worked in 2012 to identify and engage potential partners in the predominantly African-American neighborhoods of San Francisco. Community organizations and primary care providers in these neighborhoods led SFHP to conclude that door-to-door outreach was the main way to reach particularly low-income women who were most in need of support for improved health related to pregnancy and childbirth. Based on the disparities identified, and building on community partnership efforts made in 2012, SFHP is targeting outreach for the following three health education and health 28

status improvement initiatives: community collaboration, Healthier Living workshops, diabetes texting program, and health education materials development and dissemination. Community collaboration includes outreach to and collaboration with community agencies, health care providers, and allied personnel regarding these findings in order to increase understanding of member needs and identify strategies for addressing identified gaps. Examples of community organizations and collaboratives where SFHP is building capacity to address disparities include On Lok/30 th Street Senior Center, the Bayview Child Health Center, the Centering Pregnancy Program at San Francisco General Hospital, the Adolescent Health Working Group, the San Francisco Childhood Obesity Task Force, Black Infant Health, the Chinese Community Health Resource Center, the San Francisco Department of Public Health, the San Francisco Chronic Pain Workgroup, and more. Each of these collaboration initiatives focuses on a specific population facing significant health disparity. The second initiative, Healthier Living workshops and the texting program, will focus on expanding outreach and increasing the capacity of existing self-management workshops to increase members health-related self-efficacy and health behaviors. In conjunction, SFHP is launching a pilot DMTxt health text messaging program and will analyze results after six months to determine any necessary improvements. Lastly, health education materials development and dissemination, involves continually increasing the outreach and promotion of culturally-matched educational materials regarding well-baby visits, chronic conditions, overweight/obesity, heart health, and member use of emergency department for acute symptoms. Part of this effort will include expanding the SFHP website to include broader health information, tools, and community resources. 29

4. Improving Health Systems 4.1. Practice Improvement Program In 2012, SFHP rolled out the second year of its pay for performance program, the Practice Improvement Program (PIP). The overall goal of PIP is to reward system improvements and drive better outcomes in clinical care and patient experience by providing financial incentives and technical assistance. Each measure selected allows for improvement opportunities. An advisory board governs PIP, with member representatives from our entire provider network. This board meets several times per year to develop and approve measurement sets and advise on issues of both feasibility and clinical relevance of each proposed measure. SFHP s Governing Board and Executive Team determine funding streams for the PIP program on an annual basis. Incentive payments were provided to PIP participants on a semi-annual basis. Each medical group and clinic s potential earnings in the program were based on capitation rates and enrolled membership. In 2012, payments were based on 18.5% of Medi-Cal capitation, 7.5% of Healthy Families capitation, and 5% of Healthy Kids capitation. The incentive pool was set to be sufficiently generous to truly drive system improvements in the delivery system. The second year of PIP continued to focus on measures in four main domains: Clinical Quality, Data Quality, Patient Experience, and Systems Improvement. The table below lists some examples of measures within each domain. Domain Clinical Quality Data Quality Patient Experience Systems Improvement Example of a Measure within Domain Demonstrate relative improvement on a QI Project focused on one of the participant s three lowest scoring HEDIS measures. Submit 90% of encounter data within 90 days of the service date. Conduct a project for improving patient experience. Select at least three members of the staff, including a senior leader to participate in SF Quality Culture Series, or a similar leadership-training program; adopt meaningful use standards for electronic health records implementation. Participants in the second year of the program included 20 community health centers, six medical groups, and three individual providers. A few highlights of the 2012 program year s success include: 30

All eligible sites (n=28) submitted a QI project plan related to a clinical area of focus, chosen from clinical quality indicators where the most improvement is needed 89% of eligible sites (n=26) engaged in a patient experience improvement project, which targeted improving either patient-provider communication, clinic staff customer service, or reducing wait times for primary care appointments 89% of eligible sites (n=17) adopted or made plans to adopt at least five meaningful use measures to better use electronic health record technology to achieve health, quality and efficiency goals 4.2 Provider Incentive Pilot to Support Patients on Persistent Medications In September 2012, SFHP piloted a provider incentive program targeting the HEDIS measure, Annual Monitoring for Patients on Persistent Medications. The eligible population for this measure is all members over 18 years of age who have received at least 180 days of treatment with an ACE inhibitor or ARB, digoxin, or a diuretic. To be compliant in this measure, a member must receive at least one serum potassium and either a serum creatinine or a blood urea nitrogen therapeutic monitoring test each year. Providers who participated in the pilot received an outreach list of their patients who were not compliant in the measure. In order to receive the incentive, providers scheduled the appropriate screening test for their patients and documented the date that the test results were received and reviewed. The goal of this intervention was to increase screening rates for patients with persistent medications while raising provider awareness of the intervention. Participation in the pilot incentive program was very low. However, we believe that by targeting different providers and increasing our communication efforts, future iterations of the incentive would see higher participation rates. 4.3. SF Quality Culture Series San Francisco clinics face major challenges in preparation for healthcare reform: ensuring timely access to care despite a primary care shortage, developing patient-centered medical homes in order to improve quality and patient experience, and implementing Electronic Health Records (EHR). Studies on high-performing organizations frequently name leadership commitment and alignment as the foundation for success. Redwood Community Health Coalition, a consortium of clinics in four North Bay counties, created the Quality Culture Series and saw a dramatic acceleration of improvements in the areas of chronic care, access, EHR, and patient experience, after 100% of their clinic leadership teams went through the training together. They attribute their success to the fact that the entire leadership team attended all sessions, then spread the training to their clinic staff. 31

San Francisco s Quality Culture Series was based on this model. The initial year-long program consisted of 8 full-day interactive sessions, focusing on leadership and management skills, quality improvement, and project management. Each clinic was assigned a practice coach, and all clinics participated with their senior leadership teams. The series has been credited with increasing the pace of improvement in safety net clinics related to access, chronic care, and patient experience. In addition, clinic leaders had the opportunity to network and share best practices. The series has been so successful that San Francisco Health Plan continues to sponsor the SF Quality Culture Series on an ongoing basis. In 2012, three follow-up sessions were sponsored for clinic leadership teams. The January session was focused on leading and managing change, and sharing data. 90 attendees from 22 clinics attended. In May 2012, the session featured Kumar Rajarum, Ph.D., from the UCLA Anderson School of Management, who taught clinic leaders on key strategies to improve operations management. Clinic leaders learned how to improve and manage processes, and explored tools to measure and analyze wait times, productivity, as well as decrease variations. 120 attendees from 27 clinics attended the session. The September 2012 session focused mostly on team-based care, and included topics such as creating teamlets (consistent providermedical assistant pairs), defining the role of a nurse, legal scope of medical assistants, and standing orders. 100 attendees from 26 clinics attended the session. The SF Quality Culture Series has proved to be a transformative experience for clinic leadership teams. The excellent attendance rate, active engagement and program ratings across clinic participants demonstrate the high value they place on their experience. People cannot drive quality improvements without being able to manage people, change, and conflict, among other leadership, teamwork, and management skills. Thus, the fusion of the learning session content (management training, leadership development, quality improvement basics) with training (learning skills to teach adult learners) was particularly effective. 4.4. Safety Net Quarterly Quality Meetings The Safety Net Care Teams Quarterly Quality Meeting is collaboratively hosted by the San Francisco Health Plan, The San Francisco Community Clinic Consortium, and San Francisco Department of Public Health clinics, both those at San Francisco General Hospital, and off-campus clinics. This meeting brings together clinic staff of all levels including medical assistants, clinic managers, providers, and medical directors from safety net clinics across the city. This is a unique forum where all clinics are welcomed to come together to learn as a group and network, as well as share best practices. Examples of Topics from Quarterly Quality Meetings Implementing Huddles Standing Orders Safety in the Ambulatory Setting Effective Communication Giving and Receiving Feedback Panel Management Best Practice Sharing 32

4.5 Coleman Rapid DPI Program In 2012, SFHP sponsored nine clinics in its provider network to participate in Coleman Associates' Rapid DPI (Dramatic Performance Improvement) program. In this intense program, 3 to 5 consultants work side-by-side with clinic staff for one week, redesigning clinic processes to improve teamwork, patient access, and visit efficiency. This week is followed by two months of coaching, monitoring and reporting of performance measures, and continuous quality improvement. The Coleman Rapid DPI program led to measurable operational improvements. For example, one clinic cut its new patient first-visit waitlist down by 67% (from 300 patients to 100) in three months and decreased its no-show rate from 30% to 24% over the same period. Another clinic made so much progress that it reset its goal of achieving NCQA Level I Patient-Centered Medical Home certification to achieving the Level III certification. The Coleman Rapid DPI program also led to improvements in teamwork and patient centeredness. One clinic noted that tensions between front and back office staff faded away as their roles became more integrated and they started using walkie-talkies to communicate. Another clinic greatly appreciated Coleman's suggestion of using small gestures in order to make patients feel cared for during their visit and improve the overall patient experience. To ensure that the changes implemented during the Rapid DPI process are sustained, SFHP is sponsoring a data reporting and improvement incentive program, as well as quarterly webinars for clinics to share best practices and compare their progress. 33

5. Improving Member Experience Experience surveys assist us in evaluating the quality of service our members receive from SFHP and from our provider network. In 2012, SFHP implemented strategies to improve health plan services and provider-level care, using SFHP s scores on the member experience survey as a guide. Specifically, SFHP addressed three target areas for improvement: rating of all health care, customer service, and getting needed care. Our interventions to address this survey feedback are described in the following sections. 5.1. Measuring Member Satisfaction In November and December 2011, San Francisco Health Plan conducted a patient experience survey of its members, which was based on the Clinician & Group Consumer Assessment of Healthcare Providers and Systems survey (CG-CAHPS). Participation in the SFHP administered survey (or an independent survey that met specific requirements) was a 2011 deliverable for SFHP s Pay for Performance Program, the Practice Improvement Program (PIP). Patients enrolled in four programs (Medi-Cal, Healthy Families, Health Kids, and Healthy San Francisco) who had a visit with a participating provider in the last 12 months, were included in the survey population. The survey was completed over the telephone using Interactive Voice Response (IVR) technology in three languages: English, Chinese, and Spanish. This survey gave SFHP and its providers statistically valid data at the practice level for the first time. Fifteen sites participated in the SFHP-administered survey. This group included two individual providers, eleven clinics, and two medical groups. Each participating site received scores calculated using a risk adjustment model. This model was used to account for the differences in patient case mix across sites, and served to level the playing field when comparing data across groups. In addition to receiving survey results, each site also received a series of priority matrices identifying high need areas for improvement, and a list of some recommended, targeted improvement activities. The results showed that the highest performance across all San Francisco survey respondents was on the question of overall rating of providers, with 86% of respondents giving their providers the highest scores. This value was comparable to a benchmark survey conducted in the Massachusetts state Medicaid program in 2008, where the score was 85%. The survey also revealed that across all participating sites, appointment access was the top improvement opportunity. (See table below for a graphical representation of the results.) Below we will describe the ongoing SFHP sponsored efforts to address these improvement opportunities. 34

SFHP will be fielding a 2013 patient experience survey and disseminating results to clinics by June 2013. The standard 12 month CG CAHPS survey with the supplemental Patient Centered Medical Home set will be administered by mail. 100% 80% 60% 40% 20% 0% Provider rating 2011 CG-CAHPS results with Massachusetts Comparison Provider-Patient Communication Access Office Staff SFHP network Mass Medicaid 5.2. Improving the Patient Experience QIP SFHP s plan-specific Quality Improvement Project (QIP) targets patient experience. SFHP has consistently received patient experience scores that lag behind other health plans in California. Members are particularly dissatisfied with provider communication, shared decision making, and timely access to appointments. To address these disparities, SFHP launched several Action Series in 2012 that intend to improve member satisfaction in a significant way. These Action Series are described below in sections 5.3 to 5.5. The QIP study will use the indicator, Rating of Overall Health Care from the CG-CAHPS survey to know the success of the interventions. 5.3. Action Series: Customer Service The Customer Service Development Training focused on making measurable and sustainable improvements in patient experience using practical service and communication techniques. The CG-CAHPS survey measures patient satisfaction on a national level. Results consistently show that San Francisco clinics perform below the state Medi-Cal average on patient experience measures. The Customer Service Development Training was created to support the improvement of the patient experience in the San Francisco Safety Net. Each clinic training included two, two-hour training sessions taught by a consultant from SullivanLuallin, a healthcare service improvement firm. The training focused on proven techniques for treating patients with empathy and respect, telephone etiquette, managing difficult patient encounters, handling multiple priorities, teamwork, and professionalism. 35

The training was a part of a highly-structured training program that incorporated oneon-one technical assistance. SFHP worked with participating clinics in capturing employee and clinic leadership data using a baseline survey, pre-sustainability assessment, and postsustainability assessment. The information captured by the surveys evaluated employee confidence in their ability to deescalate and handle difficult patient interactions at each stage of the training program (pre-training, pre- sustainability and post-sustainability intervention) along with a measure of employee satisfaction. Clinics that participated in the training rated it 91% in usefulness and 95% in quality. Sustainability was a large focus of the training and each clinic made a commitment to focus on a specific area of improvement during the sustainability portion of the training program. Many clinics chose to use point-of-service surveys as way to measure their baseline and improvement over time. The training was initially intended for approximately five clinics. Due to the overwhelming positive response and success of the program, a total of 12 training sessions targeting 10 clinics were completed in 2012. More are planned for 2013. 5.4. Action Series: Access In November 2012, the Appointment Access Improvement Series started with a half-day training on the principles of Advanced Access scheduling. Representatives from two San Francisco clinics and two medical groups attended, along with Department of Public Health leadership, and a group of SFHP employees. This half-day training was followed by six monthly webinars to go into depth with specific Access Improvement topics and promote discussion among participants. The two health centers participating in the Action Series are working with a SFHP practice coach to help them collect access improvement data and implement recommended changes, like robust confirmation calls and group visits for chronic disease patients. 5.5. Action Series: Provider Communication Training For the Provider-Patient Communication Action Series, a master trainer from the Institute for Healthcare Communication gave two day-long training sessions for providers on how to improve communication and patient centeredness while using an Electronic Health Record. CME/CEU credits were offered to fifty-four providers who attended one of the trainings. 100% of participants rated the training as effective and were likely to recommend the training to colleagues. Following the training, seven clinics implemented sustainability activities to reinforce the skills presented in the training, including peer coaching, discussing communication techniques in staff meetings, and implementing agenda setting forms to make visits more patient centered. 36

5.6. Providing Excellent Telephone Services Our members find it easiest to reach us by telephone. Therefore, we are committed to ensuring that we provide excellent customer service over the phone. We monitor our performance in several ways and continue to work on improving our processes. One way we do this is by using real time performance to track and monitor calls. Real time performance allows up-to-the-moment tracking and is displayed in the call center area so that Customer Service Representatives are aware of their performance as well as current call traffic. The electronic wallboard tracks the following metrics: 1) service level, 2) total call volume handled, 3) abandonment rate, 4) abandoned calls, 5) calls waiting in different language queues, and 6) number of agents available at each language queue. SFHP s Customer Service team members speak our four threshold languages: English, Chinese (Cantonese and Mandarin), Spanish, and Vietnamese, as well as Russian and Burmese. In 2012, we received 82,643 incoming calls through our telephone automated distribution system. We met or exceeded our performance standards on the following metrics: Our service level, which measures efficiency and speed of service, was 95.3%, exceeding our goal of 90% by 5.3%. Our service level improved by 2% compared to last year. The industry benchmark for call abandonment is 5%, whereas SFHP s average abandonment rate in 2012 was 0.94%; this rate improved by 33% compared to 2011. 5.7. Member Satisfaction with Customer Service SFHP s Customer Service Department conducted its eleventh annual member satisfaction survey in the last quarter of 2012. The purpose of this survey is to assess the level of satisfaction with the services provided by the Customer Service Department and to improve our services based on feedback from members. Methodology The survey was conducted in English, Spanish, and Chinese. Members were asked to score SFHP performance in the following areas: My call to SFHP Customer Service Call Center was answered quickly. I received polite service from the Call Center Representative. I received the information that I needed. 7,839 survey cards were sent to members who contacted Customer Service by phone during the months of October through December 2012. The response rate for the survey cards was 12%, with Chinese-speaking members having the highest response rate. Survey Results An average of 95.8% of our members reported overall satisfaction with the services provided by Customer Service team. 96.14% scored SFHP high for quick service, 97.09% for 37

Satisfaction Percentage polite service, and 94.3% for receiving needed information. The overall results were consistent with those achieved in previous years. SFHP received excellent, useful results from this survey through the years. These positive responses indicate that they were highly satisfied with the services they received from the SFHP Customer Service team in 2012. 100% 95% 90% 85% 80% 75% 70% 65% 60% 55% 50% 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% 2012 Member Satisfaction Results with Telephone Services 96.1% 97.1% 94.3% Quick Service Polite Service Information A new managed care platform called QNXT was implemented in 2012. Now, Customer Service staff can assist members with basic authorization and claims inquiries without transferring members to other departments. The information provided to members is more accurate and specific to the member. Additionally, Customer Service staff track calls and documents member activities more effectively. With this greater efficiency, Customer Service staff have the ability to resolve member issues quicker and easier. Besides resolving member inquiries, Customer Service staff are also proactive to resolve issues before they occur. For example, they monitored PCP assignments for new SPD members to ensure members are assigned to their preferred doctors. Additionally, they help to monitor members eligibility and research potential problems. 5.8. Monitoring Member Grievances In order to improve service to our members, SFHP monitors grievances each quarter to identify trends in member-identified challenges with the health system. To identify patterns and changes in our grievances, we report grievance rates by line of business, medical group, and grievance category. 38

Grievance Rate (per 1000 members) Member Grievance Rates, 2010-2012 0.90 0.80 0.70 0.60 0.50 0.40 0.30 0.20 0.10 0.00 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 2012 0.14 0.23 0.36 0.37 0.34 0.48 0.46 0.23 0.47 0.30 0.33 0.30 2011 0.16 0.23 0.10 0.14 0.16 0.17 0.21 0.13 0.23 0.24 0.31 0.32 2010 0.26 0.09 0.14 0.22 0.19 0.12 0.13 0.18 0.10 0.13 0.15 0.16 Line of Business Looking at the comparison of SFHP annual rates below, Medi-Cal has the highest rate of grievances. The rate increased in 2012 from 2010, which is attributed largely to the transition of SPD Medi-Cal recipients into managed care. Both Healthy Workers and Healthy Families saw a slight increase in their grievance rates, however there were no trending patterns identified. Healthy Kids rate saw a dramatic decrease of 75% compared to last year. Grievance Rates by Line of Business, per 1,000 members Line of Business 2010 Grievance Rates 2011 Grievance Rates 2012 Grievance Rates Medi-Cal 0.16 0.23 0.38 Healthy Workers 0.21 0.19 0.30 Healthy Families 0.06 0.05 0.08 Healthy Kids 0.16 0.23 0.06 Medical Group Little variation exists by medical group, with the exception of the Community Health Network. The Community Health Network is not actually a medical group, but rather a group of public health clinics and Federally Qualified Health Centers. 39

Grievance Rates by Medical Group, per 1,000 members Medical Groups 2010 Grievance Rates 2011 Grievance Rates 2012 Grievance Rates Community Health Network 0.16 0.25 0.17 UC San Francisco 0.40 0.48 0.09 Kaiser Permanente 1.93 0.06 0.03 North East Medical Services 0.08 0.05 0.03 Hill Physicians 0.21 0.35 0.02 Chinese Community Health Care 0.12 0.09 0.02 Brown & Toland Physicians N/A 0.47 0.01 Grievance Category The top categories across all lines of business were Denials/Refusals, Quality of Service, Access, and Quality of Medical Care. Denials/Refusals remained the top category and increased to 189 grievances in comparison to 64 grievances in 2011. Enrollment saw the biggest drop in 2012, as there was only one grievance in comparison to 13 grievances in 2011. Grievances by Category Category 2010 Grievances 2010 % of Total 2011 Grievances 2011 % of Total 2012 Grievances 2012 % of Total Denials, 54 49% 64 40% 189 62% Refusals Quality of 26 23% 53 33% 55 18% Service Access 9 8% 10 6% 17 6% Quality of 7 6% 9 6% 17 6% Care Benefits/ 2 2% 6 4% 14 5% Coverage Billing 6 5% 5 3% 7 2% Cultural & 1 1% 1 1% 2 1% Linguistic Other 1 1% 0 0% 2 1% Enrollment 5 5% 13 8% 1 0% Total 111 100% 161 100% 304 100% SFHP Grievance Response Time In addition to looking for trends in our grievances, we also monitor the way we handle grievances for timeliness and regulatory compliance. Our goal is to provide excellent service and at a minimum, meet DMHC standards for responding to and resolving grievances (i.e. 40

resolution within 30 calendar days). Below is an overview of the grievances received in 2012 and key indicators showing compliance with regulatory standards: 333 member grievances were processed by SFHP and Kaiser Permanente (the one medical group in our network that is delegated for grievance processing and resolution). 304 of these grievances were non-delegated and therefore handled directly by SFHP. Of these, only 4 grievances were not resolved within the 30-day period as mandated by DMHC. Two grievances handled by SFHP had a Cultural and Linguistic Component. 41

6. Provider Relations 6.1. Provider Network Access Monitoring SFHP closely monitors the adequacy of our provider network to ensure that our members have access to the care they need in a timely manner. We measure network access in a variety of ways to assess language capacity, wait times, and availability of specialists and PCPs. SFHP joined the ICE (Industry Collaboration Effort) Workgroup to develop a standard methodology and survey tool for monitoring appointment availability. Access to Primary Care Providers Our stable network of PCPs is more than adequate to care for our approximately 79,000 members. Regulatory requirements set forth in our Knox-Keene license guide our accessibility standards. State regulations require that a primary care physician panel should contain no more than 2,000 patients. While our ratio of members to PCPs falls well within those standards, we cannot accurately measure true PCP panel size because our PCPs see patients from several different payors as well as care for the uninsured. Below is a table that shows a snapshot of our PCP and member counts: Medical Group Members < age 18 PCPs caring for children Members > age 18 PCPs caring for adults BTP 1,370 38 1,368 51 CCHCA 4,396 32 4,822 48 UCSF 3,458 42 2,980 60 NEMS 8,324 45 8,567 56 HILL 3,022 30 1,862 26 CHN 10,641 164 25,217 206 Note: PCPs caring for children include physician and mid-level PCPs designated as adolescent medicine, family medicine, family practice, general practice, pediatric adolescent medicine, or pediatrics. PCPs caring for adults include physician and mid-level PCPs designated as family medicine, family practice, general practice, geriatric medicine, internal medicine, or Ob/Gyn. Access to Specialists We regularly monitor the number of physicians in our network in specialty areas that our members access the most. UCSF provides the bulk of specialty care even for members assigned to other medical groups. The table below shows that each of our medical groups had at least one specialist in every key specialty in 2012: 42

Specialty BTP CCHCA CHN NEMS HILL UCSF Total Cardiology 24 11 23 4 7 37 106 Endocrinology 10 1 9 1 4 19 44 Gastroenterology 19 11 12 6 2 18 68 Ob/Gyn 22 14 28 12 9 61 146 Ophthalmology 5 11 30 8 8 66 128 Pulmonary Disease 1 1 14 2 1 19 38 Radiology 7 4 13 14 6 44 88 Total 88 53 129 47 37 264 618 PCP Language Concordance SFHP works to ensure that our members have access to either a primary care provider who speaks their language or have access to professional interpreter services. We monitor the number of PCPs who speak Chinese, Spanish, Vietnamese and Russian because they are the most common non-english languages spoken by our members. Members are encouraged to choose a PCP when they enroll, but if they do not choose a PCP, our systems help optimize the number of members who are assigned to a PCP who speaks their language. The table below shows the number of PCPs who speak one of the predominant SFHP threshold languages at the end of 2012: Medical Group Chinese- Speaking PCPs Spanishspeaking PCPs Vietnamesespeaking PCPs Russianspeaking PCPs BTP 18 23 4 4 CCHCA 59 5 4 0 CHN 25 135 9 1 NEMS 62 16 6 2 HILL 6 22 1 3 UCSF 6 27 2 1 Total 176 228 26 11 6.2. Clinical Quality Monitoring San Francisco Health Plan (SFHP) has a Memorandum of Understanding with Anthem Blue Cross of California to review all jointly contracted primary care providers and sites, in order to comply with California Department of Health Care Services (DHCS) policies. SFHP delegates and oversees the full scope reviews (Facility Site and Medical Record), Facility Site Review-Attachment C (FSR-C), and Interim Monitoring for its medical groups. 43

Full Scope Reviews include on-site inspection and interviews with site personnel. Reviewers use reasonable evidence available during the review to determine if practices and systems on site meet survey criteria. Compliance levels include: Exempted Pass: 90% or above without deficiencies in Critical Elements, Pharmaceutical, or Infection Control Conditional Pass: An overall score of: 80-89%; or a score above 90% but with deficiencies in either Critical Elements, Pharmaceutical or Infection Control Not Pass: below 80% Compliance rates are based on 150 total possible points. The number of points is adjusted if there are items that do not apply to a specific provider. The medical record review portion evaluates 32 criteria in the areas of chart format, documentation, continuity and coordination of care, and preventive care. A corrective action plan is required for a total score less than 90%, or if there are any deficiencies in items under Critical Elements, Pharmaceutical Services, or Infection Control regardless of score. Interim Monitoring is an FSR that occurs between full scope reviews and is conducted approximately 18 months following the last Facility Site Review. Twelve were completed in 2012. For a new primary care provider to open a SFHP panel, they must pass a FSR. PCPs that do not pass the 18-month Interim Monitoring are closed to seeing new members and must complete an extensive Corrective Action Plan with a nurse reviewer. Facility Site Review and Medical Record Review Summary There were 80 Facility Site Reviews and 59 Medical Record Reviews completed by San Francisco Health Plan and its delegated medical groups in calendar year 2012. 28 initial reviews were conducted in clinics that had not been in our network previously. 95% of the Facility Site Reviews (FSR) scored over 90%; 3 scored Not pass and were reported to providers participating medical groups 61% of the medical record reviews (MRR) scored 90% or better; 4 scored Not pass and were reported to the providers participating medical groups With the exception of a provider that terminated with San Francisco Health Plan, the three primary care providers that scored below 80% were reviewed at SFHP s February 14, 2013 Physician Advisory/Peer Review Committee meeting. A new PCP with Chinese Community Health Care Association and Brown and Toland (FSR score of 73% and MRR score of 63%) underwent extensive nurse intervention and earned approval for the Corrective Action Plan on 5/25/2012. A PCP with Chinese Community Health Care Association who scored 75% on his Medical Record Review was closed to new members during his CAP and review process. The Corrective Action Plan (CAP) was approved on 12/13/12. A PCP with Hill Physicians Medical Group received a 79% on his MRR and 98% on his FSR. SFHP closed the PCP to new members during the CAP and review process. The nurse reviewer assisted with CAP implementation and the CAP was approved on 10/11/12. 44

Summary of Facility Site Reviews Medical Group # Sites Reviewed Scores 90-100% Scores 80-89% Scores <80% BTP 13 11 1 2 CCHCA 28 26 1 1 CHN 12 12 0 0 HILL 13 13 0 0 NEMS 8 8 0 0 UCSF 6 6 0 0 Total 80 76 2 3 Summary of Medical Record Reviews Medical Group # Sites Reviewed Scores 90-100% Scores 80-89% Scores <80% BTP 11 6 3 2 CCHCA 19 15 1 2 CHN 10 6 4 0 HILL 15 5 10 0 NEMS 1 1 0 0 UCSF 3 3 0 0 Total 59 36 18 4 Summary of Interim Monitoring Reviews Medical Group # Sites Reviewed BTP 1 CCHCA 5 CHN 4 HILL 2 NEMS 0 UCSF 0 Total 12 Facility Site Review Attachment C Per DHCS policy, plans are required to use FSR Attachment C to assess the physical accessibility of primary care provider sites, including specialist and ancillary service providers that serve a high volume of seniors and persons with disabilities (SPDs). As of December 31, 2012, San Francisco Health Plan (SFHP) completed a total of 161 FSR-Cs for primary care sites. SFHP placed highest priority on reviewing primary care 45

providers to make access information available to members, especially the population of Seniors and Persons with Disabilities (SPD) mandated into managed care plans. The results of these surveys have been shared in the following ways: Posted on SFHP website where they are searchable by members, providers, and staff Included in the SFHP Medi-Cal Provider Directory Shared with SFHP Member Advisory and Quality Improvement Committees Summary of FSR-Cs Calendar Year PCP Sites High Volume High Volume Reviewed Specialists Ancillary Providers 2011 136 7 0 2012 6 9 3 Total 142 16 3 Changes with regards to the Facility Site Reviews occurred in 2012. DHCS released new facility site and medical record review tools and guidelines in January 2012. In response to the new tools and guidance, SFHP executed the following activities: Distributed electronic FSR and MRR tools that calculate scores Created a new 2012 FSR Work Plan on an external SharePoint site in order for medical groups and Anthem Blue Cross to access site review scores, dates/deadlines, and site IDs Created personalized work flow procedures for each medical group on how to use the external SharePoint site, including on-site education on effective uses of the site Uploaded 2012 site reviews to external SharePoint site, available to medical groups and Anthem Blue Cross 6.3. Medical Group Oversight Audits Medical Group Delegation Structure SFHP contracts with medical groups to provide health care services to plan members. SFHP delegates certain functions and activities to these medical groups. SFHP further delineates the functions delegated to the medical groups in an annual Responsibilities and Reporting Requirement (R3) Agreement. SFHP monitors medical groups compliance with their Delegation Agreement through an annual oversight audit. In addition, medical groups submit weekly, monthly, quarterly, biannual, and annual reports, which are reviewed by SFHP staff. SFHP staff meet with the medical group in a Joint Administrative Meeting (JAM) to discuss any issues as needed. These meetings generally occur twice a year. It is SFHP s policy to conduct a full-scope review and audits of a medical group that is planning to enter into a delegation agreement. The medical group must implement corrective actions if any deficiencies are determined. Under SFHP s Delegation Agreement, medical groups have the authority to carry out a specific function on SFHP s behalf. SFHP 46

retains the responsibility for ensuring that the delegated functions are performed according to Federal and State standards. SFHP contracts with the following medical groups: Brown and Toland Physicians (BTP), Chinese Community Health Care Association (CCHCA), Hill Physicians Medical Group (HPMG), North East Medical Services (NEMS), and Kaiser Foundation Health Plan San Francisco. All functions are fully delegated, except for grievances and member rights. As a Knox-Keene Licenses Health Plan, Kaiser is delegated grievances and member rights. Medical Groups and Delegated Functions In addition to medical groups, SFHP directly contracts with community clinics and public/private hospitals to provide primary care and hospitalization services to plan members. These entities include San Francisco Department of Public Health, San Francisco General Hospital, and the University of California San Francisco Medical Center. SFHP delegates credentialing functions to these organizations, while SFHP performs other functions such as utilization management, quality improvement, and claims. SFHP monitors clinic and hospital compliance with credentialing standards through an annual oversight audit. Medical Group Audits Dates The 2012 audit season took place between July and December. SFHP staff worked with the delegated network to review policies and procedures. Functions reviewed include Quality Improvement (QI), Utilization Management (UM), Case Management (CM), and Health Education, Cultural and Linguistic Services (HECLS). By conducting file reviews and staff interviews, SFHP identified areas that needed a corrective action plan that included specific recommendations for improvement. Below is a chart with the date and function of audits in 2012. 47

Summary of Oversight Audit Findings The results from the annual audits are shared with SFHP s Quality Improvement Committee. All audit deficiencies are followed up throughout the year until resolved, and are reviewed at the subsequent oversight audit. Below are general findings from the 2012 oversight audits; details of audit results by delegated entity are provided in Attachment 1. Timely Access Regulations: Medical Groups informed their practitioners and staff about the regulations. During 2012, SFHP developed a Timely Access Regulation Training Manual for providers, which served as a review guide and a training tool for new providers and medical group staff. All medical groups were found compliant with this requirement. Health Education and Cultural and Linguistic Services (HECLS): During the course of the audit we found some deficiencies in this area, including: absence of a training sign-in sheet (for which SFHP issued a CAP), and the need for health education materials to be written at a 6 th grade reading level (resolved by adding a link to SFHP s health education materials to the group s website). The remaining groups were found compliant with this function. 48

Grievances (delegated only to Kaiser Permanente): Only one deficiency was found: in one out of 20 files reviewed, the Acknowledgement Letter was not sent in a timely manner. A CAP was not issued since this occurred in September of 2011 and no other files presented this deficiency. Dwell/Wait Time Studies: Two of SFHP s newest medical groups are developing primary care provider dwell studies (the total amount of time a patient waits from their scheduled appointment time to the moment the provider enters the exam room to start the visit). SFHP is helping the medical groups by sharing tools, reports, and processes. The remaining medical groups were found compliant with this requirement. Credentialing: SFHP reviewed newly credentialed and re-credentialed practitioners files for all the delegates. Deficiencies were found at one medical group and one medical center audit, where new primary care practitioners did not sign the Summary of Key Information Attestation within 10 business days of initial credentialing approval date. A CAP was issued and submitted to DHCS for consideration and approval. The remaining medical groups were found compliant with requirements for this function. Utilization Management: Minor deficiencies regarding Timeliness of UM Decision were found in two of the medical groups, where decisions were made past the five-day required timeframe. One medical group was deficient on the Provider Notification timeframe required for communicating member complaints (24-hours). In both cases, CAPs were issued to the groups and approved by SFHP. The remaining medical groups were found compliant with requirements for this function. DHCS Addendum: Two groups did not submit policies and procedures for services provided through Early Start and Golden Gate Regional Center. SFHP is currently working with these groups in developing such policies. SFHP will continue to monitor and request this document at the following oversight audit. Claims: In general, groups met standards for claims processing and payment. One group was found deficient for the lack of clarity on the date stamped on the claim. CAP from this medical group is pending. 6.4. Provider Satisfaction Survey Annually, SFHP conducts a Provider Satisfaction Survey to gather information about network provider issues and concerns with SFHP and our services. For the 2012 survey, SFHP contracted with The Myers Group (TMG), a nationally-known company specializing in healthcare surveys and research. This is the first year SFHP used an outside agency to conduct this survey, bringing greater transparency and the ability to compare itself with other similar health plans. The survey targeted primary care and high-volume specialty care providers and office staff to measure their satisfaction. Using The Myers Group s standardized survey tool, with some customized SFHP questions, providers were asked to 49

rate their satisfaction as compared to other health plans with which they participate. The survey was designed to support the following NCQA Standards for Health Plan Accreditation: 1) Satisfaction with the Utilization Management process, 2) Continuity and Coordination of Medical Care, and 3) Continuity and Coordination between Medical and Behavioral Healthcare. It also included questions to assess compliance with California DMHC Timely Access requirements. The survey was conducted January through March 2013. A mixed-method approach was used, including a two-wave e-mail blast, mailed hard copies to all non-responders to the internet survey, and finally, all non-responding providers were contacted by phone. Of the 735 PCP and high-volume specialists contacted, one hundred and seventy-seven completed the survey, for a total response rate of 24%. While this is lower than in previous years, this is the first year that specialists were included in the sample and the first year of utilizing an external company to conduct the survey. We are hopeful that increased recognition and familiarization with this new methodology will result in increased response rates in the future. A proportionate representation from respondents was achieved, including specialist vs. PCPs, clinical vs. office staff, and delegated vs. non delegated providers. Preliminary results indicate a 78% overall satisfaction with SFHP (compared with 75% in 2011). Three areas where SFHP did particularly well are health improvement, provider relations, and ancillary providers. Opportunities for improvement include pharmacy, finance, and coordination of care. We continue to work towards making meaningful impacts on increased provider satisfaction with SFHP. 6.5. Provider Education and Training In response to feedback from our Provider Satisfaction Survey, we continued to work to make more resources and training available to our providers. In 2012, we expanded the content for providers on our website with the following: Health education materials in our threshold languages that can be downloaded and printed for distribution at the provider office Updated best practices in key practice areas such as access, chronic care, office management, pain management, standing orders, clinical guidelines, etc., to determine authorization for safely net providers Updated community resources and key summary of information for providers Managed Care 101 SFHP maintained a curriculum to inform new providers about the basics of working with managed care plans. Training content includes information about SFHP history, lines of business, network structure, membership figures, benefits (medical, pharmacy, vision, dental and behavioral health), how to obtain authorizations, website resources, health education, and more. We provide this training to clinics and Medical Groups as requested. 50

7. Care Management Services 7.1. Utilization Management Inpatient Admissions SFHP tracks Medi-Cal members who are seniors and people with disability (SPDs) separately from family aid code Medi-Cal. The acute hospital admission rate for Medi-Cal non-spd members averaged 3.38 inpatient admissions per 1,000 in 2012, continuing a mild downward trend from the previous year. Medi-Cal SPD Inpatient Admissions averaged 20.83 per 1,000 in 2012 compared to an average rate of 18.17 per 1,000 in 2011. In 2011, SFHP had proportionally fewer SPDs that were mandated into Medi-Cal. SFHP s voluntary SPDs had lower utilization than the mandatory SPDs. Healthy Workers Inpatient Admissions decreased in 2012, averaging 2.19 per 1,000. Healthy Families inpatient admissions are low volume, and had no significant change from 2011, averaging 0.51 Inpatient Admissions per 1,000. Healthy Kids inpatient admissions averaged 0.94 per 1,000 in 2012. Inpatient Bed Days The Medi-Cal non-spd inpatient bed days averaged 14.47 per 1,000 in 2012, a decrease from the previous year. The Medi-Cal SPD inpatient bed days averaged 137.93 days per 1,000, compared to an average of 135.03 in 2011. Healthy Families averaged 2.05 per 1,000 in 2012, remaining relatively flat from 2011. Healthy Kids averaged 2.13 per 1,000 compared to 2.61 in 2011. Healthy Workers inpatient bed days averaged 9.81 per 1,000 in 2012, a significant decrease from 15.13 in 2011. This decrease may be attributed to improved application of UM medical criteria for inpatient review, and stricter attention to definitions of medical necessity. Complex medical cases are also referred to the health plan s internal care management team who then work closely with the hospital s case managers in developing appropriate care plans. In addition, the UM team implemented a new process to transfer members admitted to out-of-medical-group hospitals back to their home hospital. This practice improves continuity of care by ensuring all of their inpatient care, primary care and subspecialty care are located and coordinated within one facility. Emergency Department Visits The Medi-Cal non-spd emergency department (ED) visits decreased in 2012, averaging 24.06 per 1,000. The Medi-Cal SPD ED visits averaged 79.76 per 1,000 compared to 74.18 in 2011. Healthy Workers averaged 12.01 ED visits per 1,000 in 2012, slightly higher than 11.88 in 2011. Healthy Families averaged 7.84 per 1,000, down from an average 9.00 in 2011. Healthy Kids averaged 10.15 per 1,000 in 2012; the trend from 2011 remained essentially flat. 51

Medi-Cal Non-SPD Inpatient Admissions per 1,000 per Month 5 4.5 4 3.5 3 2.5 4.124.16 4.28 4.53 4.57 4.26 3.96 3.89 3.97 4.07 4.16 3.93 3.67 3.70 3.55 3.66 3.40 3.35 3.36 3.12 3.10 3.22 3.14 2 1.5 1 0.5 1.28 0 Medical - NonSPD Linear (Medical - NonSPD) Average Days Medi-Cal SPD Inpatient Admissions per 1,000 per Month 30 25 20 15 10 5 17.64 11.88 17.00 14.45 11.35 16.17 22.42 23.11 22.10 20.31 20.5121.15 20.05 18.72 25.60 22.8622.88 22.18 20.73 21.35 20.03 18.18 15.28 6.75 0 Medical - SPD Linear (Medical - SPD) Average Days 52

Healthy Workers Inpatient Admissions per 1,000 per Month 6 5 4 4.80 3 2 1 0 2.57 1.64 2.87 2.622.70 3.67 2.05 3.11 3.10 2.92 1.69 1.32 1.24 1.77 2.38 2.37 2.63 3.58 2.44 2.43 3.03 1.90 1.21 Healthy Workers Linear (Healthy Workers) Average Days 1.2 1 Healthy Families Inpatient Admissions per 1,000 per Month 0.8 0.6 0.4 0.2 0 0.26 0.79 0.26 0.79 0.26 0.66 0.53 0.27 0.67 0.94 0.41 0.27 0.68 0.41 0.69 0.41 0.41 0.27 0.55 0.28 0.98 0.56 0.41 0.42 Healthy Families Linear (Healthy Families) Average Days 53

3 Healthy Kids Inpatient Admissions per 1,000 per Month 2.5 2.79 2 1.5 2.32 2.33 2.04 1.46 1.87 1.57 1 1.03 1.08 1.11 1.18 0.5 0.69 0.70 0.74 0.74 0.78 0 0.33 0.33 0.35 0.38 0.00 0.40 0.40 0.00 Healthy Kids Linear (Healthy Kids) Average Days 7.2. Care Support The CareSupport department at San Francisco Health Plan is now in its second year. Starting in February 2012, CareSupport shifted from a time-limited telephonic intervention for members identified as high risk by their Health Risk Assessment, to a longer-term, phone and in-person based model focused on individuals with heavy use of inpatient and emergency room services over the prior 12 months. The CareSupport population has high rates of behavioral health diagnoses, homelessness, lack of social support, and need for assistance with basic day-to-day tasks. To best accommodate the needs of the population, we have moved away from a nursebased model and have a team of social workers and bachelor-level care managers, with oversight from the Associate Medical Director. In addition, SFHP consults with a public health physician with a history of running a successful New York Medicaid program to help shape the focus of the care support program. The care managers complete in-depth baseline assessments, formulate individual care plans, and perform community-based outreach, as well as coordinate with other care providers. After restructuring the CareSupport program, SFHP has increased the number of 54

members receiving CareSupport services. For the first half of 2012, SFHP engaged with only 52% of those eligible for CareSupport, while reaching 72% for the second half of 2012. Delegated CareSupport The Delegated CareSupport (DCS) program was launched in 2012 as a two-year pilot aimed to support medical groups and clinics in their efforts to provide case management to high-risk SPD members. Each medical group and clinic that participates in DCS receives five dollars per month for every SPD member enrolled in their medical group or clinic. In 2012, 4 medical groups and 2 clinics participated in the DCS program. In the first year, each participating site was required to: Develop an infrastructure for care management Provide case management services for any member identified as high-risk based on utilization Provide SFHP with quarterly reports on activity and outcomes It is too early to assess the impact of the program on quality and utilization metrics. Coordination of Care with Community Agencies and Waiver Programs SFHP members requiring specialty care are referred by their primary care practitioners to specialists who provide these services. Members may also receive services from many agencies in the community with which SFHP has Memorandums of Understanding. These community programs include California Children s Services (CCS), Golden Gate Regional Center (GGRC), Early Start, Women, Infants and Children (WIC), Community Behavioral Health Services, Sexually Transmitted Disease/Infections Services and the Tuberculosis- Direct Observed Therapy (TB-DOT) Assistance Program. SFHP has streamlined access to the CCS website to assess member eligibility and they continue to work closely with CCS to coordinate care for members. In addition, SFHP receives monthly shared member reports from GGRC and as needed reports from the Targeted Case Management programs. SFHP members are also eligible for services from the federal waiver programs: HIV/AIDS Waiver Program, the Multipurpose Senior Services Program, Nursing Facility/Acute Hospital Waiver, and Home and Community Based Services Waiver for the Developmentally Disabled. SFHP is responsible for assuring that there is comprehensive care coordination when PCPs make referrals. SFHP informs its members and practitioners about these services and how to access them through the following mechanisms: SFHP Provider Referral Contacts brochure Joint Administrative Meetings with Medical Groups PCP Meetings Featured articles in Provider Newsletters 55

7.4. Pharmacy Services SFHP assures the quality of its pharmacy services by offering a generous formulary, maintaining good relationships with pharmacy providers, and overseeing the pharmacy credentialing process. Our pharmacy services and formulary are constantly reviewed and updated by our Pharmacy and Therapeutics Committee, a sub-committee of our Quality Improvement Committee. We monitor pharmacy usage monthly through cost and utilization reports. SFHP manages pharmacy costs through its generic-preferred formularies and prior authorization process. Pharmacy Costs per Member per Month (PMPM) Medi-Cal 2011 2012 % Variance SPD Total Members 4,202 11,858 182.2% Total Medication Costs PMPM $146.58 $149.97 2.3% Total Cost per Prescription $53.51 $52.80-1.3% Cost per Prescription PMPM 2.74 2.84 3.7% Generic Dispensing Rate 85.7% 89.1% 3.4% Non-SPD Total Members 36,404 41,141 13.0% Total Medication Costs PMPM $13.64 $14.28 4.7% Total Cost per Prescription $29.59 $31.84 7.6% Cost per Prescription PMPM 0.46 0.45-2.7% Generic Dispensing Rate 86.6% 87.8% 1.2% SFHP s per member per month (PMPM) costs increased by 63% overall ($44.64 in 2012 versus $27.39 in 2011) primarily due to the mandatory enrollment of Seniors and Persons with Disabilities (SPDs) starting June 1, 2011. Pharmacy Costs by Lines of Business 2011 2012 % Variance Medi-Cal $27.39 $44.64 63.0% Healthy Families $3.46 $3.96 14.4% Healthy Kids $3.66 $4.00 9.2% The 2012 pharmacy cost PMPM for Healthy Families and Healthy Kids increased by 14.4% and 9.2% respectively due to an increase in overall specialty drug utilization. These lines of business represent 1.7% of total pharmacy cost for 2012. As compared to non-spds, SPDs are higher risk members that require more prescriptions per member, particularly specialty drugs. In 2012, specialty medications represented 28.2% of SPD PMPM costs, though SPDs only represented 3.7% of the 56

membership. The SPD average cost per specialty prescription drug was $1,714 in 2012. To address high specialty drug costs, SFHP has undergone a bid process to select a specialty pharmacy vendor to enhance case management efforts and to ensure the most aggressive pharmacy network pricing. The vendor selection will be announced in 2013. To address the growing costs of medications overall, in late 2012, SFHP entered into a joint bid process for pharmacy benefit management (PBM) services with two other health plans: Alameda Alliance and Cencal Health. The bid process is intended to test the market and leverage the best pricing for 1) prescription drug claim processing, 2) pharmacy network management, and 3) pharmacy clinical support. The process was defined such that each plan can individually select their own PBM and negotiate their own contract. After an aggressive and iterative bid process, SFHP has chosen PerformRx to provide PBM services effective July 1, 2013. Opiod Use for Chronic Pain Management The use of opiates for chronic pain management continues to be a major issue, from several vantage points. The overdose rate nationally continues to climb, with prescription medications being the leading cause of death. In addition, providers cite challenges with pain management patients as one of the biggest contributors to stress and burnout. When analyzing SFHP member data specifically, SFHP identified that 67% of SFHP highest utilizers (defined by use of emergency department and hospital) use daily opiates. To combat the issues resulting from opiate use, San Francisco Health Plan launched a Pain Management Safety Net Provider Workgroup. This workgroup is co-led with a medical director from the Department of Public Health, and includes primary care providers, behaviorists, pharmacists, and leaders in substance use treatment. This collaborative approach increases the likelihood that improvements remain sensible and doable. The workgroup identified four priorities: 1) identify and spread pain management best practices, 2) integrate behavioral health into pain management, 3) improve communication between primary care providers and emergency departments, and 4) improve patient education on appropriate use of pain medications. 1. Identify and spread pain management best practices. This includes each clinic adopting a protocol to ensure consistent management of concerning behaviors, early refills, and new patients presenting for opiate therapy. This priority is supported by the SFHP Practice Improvement Program (PIP) pain management measure, which rewards sites for adopting a protocol, and for using a population management approach to ensure pain management patients all have recent pain management agreements and at least one random urine drug screen annually. 2. Integrate behavioral health approaches. This intervention specifically focuses on preventing overdoses and ensuring better access to substance use treatment. There is a new initiative in San Francisco to prescribe naloxone as a safety measure, teaching patients and friends of patients how to use intranasal naloxone to prevent 57

death from accidental or deliberate opiate overdose. SFHP supported this by putting naloxone on its formulary. 3. Improving communication between PCPs and emergency departments. SFHP is supporting this by organizing meetings between primary care providers and emergency department physicians, and encouraging emergency departments to adopt consistent, conservative policies regarding how to manage requests for opiate refills. 4. Improving education for patients, staff and providers. SFHP supported this by hosting a Pain Management Education Day in April 2012, which was attended by over 200 safety net providers. SFHP will be repeating this program with new material, focused on the overlap between chronic pain and addiction. SFHP also developed brochures for patients to help them better understand safe chronic pain management. In addition to sponsoring and supporting the initiatives described above, SFHP is also taking the following measures to improve appropriate use of opioids. Conducting outreach to prescribers of Oxycontin, encouraging them to switch to formulary options, and working with providers to taper down from high dose levels. Sending providers reports of patients who have at least two opiate fills a month, specifically flagging instances when there are multiple prescribers. This is a useful way for providers to identify patients who may be using the emergency department or outside prescribers for opiates, in violation of a pain management agreement. Providing technical assistance to clinics to support the use of a pain management registry, and to support implementation of protocols and best practices. 58