2017 florida health care plan quality improvement … · the fhcp quality improvement program...

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2017FLORIDAHEALTHCAREPLAN

QUALITYIMPROVEMENTPROGRAMANNUALEVALUATION

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Table of Contents Page

Executive Summary ...................................................................................................................

Monitoring Quality Concerns – 2016..........................................................................................

Credentialing Summary – 2016 ..................................................................................................

Disease Management – Depression Program – 2016..................................................................

Disease Management – Diabetes Program – 2016......................................................................

Disease Management – Depression & Diabetes Integration Member Information2016 …………..

Practice Guidelines Analysis – 2016..........................................................................................

Carenet Summary – 2016...........................................................................................................

Pharmacy Service Call Evaluation Q1 through Q4 – 2016 ...........................................................

Assessing Member Understanding of Marketing Materials – 2016.............................................

Provider Access and Availability – 2016 .....................................................................................

Member Satisfaction Analysis – 2016.........................................................................................

Behavioral Health Member Satisfaction Analysis – 2016............................................................

Quality and Accuracy of Customer Service Process ....................................................................

Utilization Management Evaluation – 2016................................................................................

Utilization Management Interrater Reliability Testing – 2016 ....................................................

Case Management – 2016..........................................................................................................

Continuity and Coordination of Medical Care – 2016 .................................................................

Continuity and Coordination Between Medical Care and Behavioral Health Care –2016 …………

Appendix A – 2017 QI Work Plan Results ...................................................................................

Appendix B – 2016 2017 Commercial HEDIS CAHPS Comparison................................................

Appendix C – 2016 2017 Medicare HEDIS CAHPS Comparison....................................................

Appendix D – 2016 Commercial CAHPS .............................................................................................

Appendix E – 2016 Medicare CAHPS .................................................................................................

2017 FHCP QUALITY IMPROVEMENT PROGRAM ANNUAL EVALUATION

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Executive Summary Florida Health Care Plan, Inc. (FHCP), licensed by the State of Florida in 1974 as a staff model managed care organization, is dedicated to providing high quality, affordable healthcare and services to our members. The FHCP Quality Improvement Program Annual Evaluation (AE) is the mechanism for assessing the overall effectiveness of the 2017 Quality Improvement Program (QIP). PLAN OVERVIEW FHCP provides healthcare services and related functions in Volusia, Flagler, Brevard, and Seminole counties. FHCP’s products and enrollees include*:

Product Name Product Type Enrollees Initial date of operation Commercial HMO 35,984 June 1974 Medicare MC‐PD 14,038 June 1981 Marketplace Individual 27,644 January 2014

Total Membership 77,666 FHCP’s provider network is comprised of a total of 4,570 providers. This number includes 480 primary care physicians (PCP), 44 of which are directly employed, and 3,953 specialists of which 43 are directly employed. Behavioral health services are integrated into the staff model with 6 employed physicians. The plan also contracts with behavioral health providers in the coverage area. Other contracted providers include 30 acute care facilities, 7 home health care agencies, 22 skilled nursing facilities and one national laboratory. FHCP owns and operates dispensing retail and mail order pharmacies. The most recent race/ethnicity information taken from the FHCP 2017 Commercial Consumer Assessment of Healthcare Providers and Systems (CAHPS®) data indicates that 87.2% of the reporting population is Caucasian, 9.3% is African American, 6.4% is Hispanic/Latino, 1.9% is American Indian, 1.6% is Asian, .6% is Hawaiian and 5.1% is “Other”. 66.7% of the population is female and 33.3% is male. Data taken from the 2017 Medicare CAHPS® survey reflects that 93% of the reporting population is Caucasian, 4% is African American and 3% is Latino.** 62.1 % of the respondents are female and 37.9% are male. SCOPE The QIP, which consists of a broad range of clinical and service issues relevant to its membership, includes all Commercial, Medicare, and Marketplace products. The scope of the QIP includes developing improvement opportunities and interventions using clinical and service performance benchmarks and the review of best practices.

Activities are structured to offer optimal quality and cost effectiveness and include:

Accessibility of Services Availability of Providers Network Management CAHPS® Healthcare Effectiveness Data and Information Set (HEDIS®) Quality of Clinical Care Quality of Service

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Patient Safety Complex Health Needs Continuity and Coordination of Care Member Satisfaction Provider Satisfaction Credentialing/Recredentialing Member and Provider Communications Clinical Practice Guidelines Wellness and Health Promotion Medical Records Behavioral Health

This evaluation provides a discussion of the quality improvement activities and accomplishments for 2016 in the areas of clinical care, service, access, patient safety, and member satisfaction. The evaluation includes activities undertaken to achieve program goals and the identification of improvement opportunities while establishing the basis for the 2017 Quality Improvement (QI) Work Plan. FHCP is recognized for its many achievements, having undergone evaluation by accrediting bodies and regulatory bodies. Current status is:

Commendable Accreditation Status by the National Commission for Quality Assurance (NCQA )for Commercial and Medicare products

4.0 Star Rating by the Centers for Medicare and Medicaid Services (CMS) Each reporting year HEDIS® scores are recalculated along with CAHPS® scores.

Accreditation Summary Report 8/31/2017

Org Name: Florida Health Care Plan, Inc. Accred Code: FL08202

Last HEDIS® Review Based on HEDIS® 2017

Product Line: Combined Commercial HMO/POS Accreditation Status : Commendable

Last Survey Date: 10/1/2014 Effective Date: 8/31/2017

Next HEDIS® Review Based on HEDIS® 2018 Standards Score Expiration: 12/8/2017

* Standard Scores: 49.2236 * EOC Score: 26.9988 * CAHPS Score: 11.0760 * Total HEDIS® Score: 38.0748

Total Score: 87.2984

Points Number of Stars Access & Service 95.4 4 Getting Better 66.5 2 Living with Illness 76.8 2 Quality Providers 94.5 4 Staying Healthy 83.7 3

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Accreditation Summary Report 10/26/2017

Org Name: Florida Health Care Plan, Inc. Accred Code: FL08202

Last HEDIS® Review Based on HEDIS® 2017

Product Line: Combined Medicare HMO/POS Accreditation Status : Commendable

Last Survey Date: 10/1/2014 Effective Date: 10/27/2017

Next HEDIS® Review Based on HEDIS® 2018 Standards Score Expiration: 12/8/2017

HEDIS®/CAHPS® Results (See Appendices B, C, D and E for detailed HEDIS® and CAHPS® data) COMMERCIAL

Overall decrease in EOC score: 2.0491 (29.0479 to 26.9988) Overall decrease in CAHPS® score: 1.014 (12.09 to 11.076) HEDIS®: 32 total EOC measures (counting individual measures, leaving out the ‘averaged rate’ measures) Maintained 75th percentile in two (2) measures: Controlling High Blood Pressure and Weight

Assessment and Counseling for Nutrition and Physical Activity – Counseling for Nutrition Total Maintained 90th percentile in six (6) measures: Avoidance of Antibiotics Treatment in Adults with

Acute Bronchitis, Cervical Cancer Screening, HbA1C‐ Poorly Controlled >9, Prenatal and Postpartum Care – Post Partum Total, Use of Spirometry Testing in Assessment and Diagnosis of COPD

Increased one (1) percentile in two (2) measures: Follow‐up for Children Prescribed ADHD Medication – Initiation Phase and Weight Assessment and Counseling for Nutrition and Physical Activity for Children

Areas for improvement Decreased one percentile in seven (7) measures: Appropriate Treatment for Children with

Upper Respiratory Infection; Breast Cancer Screening; Colorectal Cancer Screening; Antidepressant ‐ Acute phase; Antidepressant – Continuation; Comprehensive Diabetes Care ‐ HbA1c Testing; WCC Weight Assessment and Counseling for Nutrition and Physical Activity for Children (Rate ‐ Counseling for Physical Activity ‐ Total)

Deceased two percentiles in one (1) measure: Follow‐Up After Hospitalization for Mental Illness (7‐day rate only)

* Standard Scores: 49.2236 * EOC Score: 25.8538 * CAHPS Score: 11.5050 * Total HEDIS® Score: 37.3588

Total Score: 86.5824

Points Number of Stars Access & Service 96.9 4 Getting Better 99.2 4 Living with Illness 73.1 2 Quality Providers 93.7 4 Staying Healthy 76.9 2

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CAHPS®: 9 total CAHPS® composites: Claims Processing, Customer Service, Getting Care Quickly, Getting

Needed Care, How Well Doctors Communicate, Rating of All Health Care, Rating of Health Plan, Rating of Personal Doctor, Rating of Specialist Seen Most Often

Claims Processing and Customer Service scored at the 75th percentile (prior year N/A) How Well Doctors Communicate, Rating of All Health Care, Rating of Health Plan and Rating of

Personal Doctor remained in the 90th percentile Areas for improvement

Getting Need Care decreased from the 75th to the 50th percentile Rating of Specialist Seen Most Often decreased from the 75th to the 25th percentile

For several measures within the Commercial HEDIS® and composite CAHPS® scores that showed an improvement, points assigned to percentiles decreased between 2016 and 2017. This impacted the total score.

MEDICARE

Overall decrease in EOC score: 4.7022 (30.5559 to 25.8537) Overall increase in CAHPS score: 1.17 (10.335 to 11.505)

HEDIS®: 23 total EOC measures (counting individual measures, leaving out the ‘averaged rate’ measures)

Maintained 90th percentile in BMI, Colorectal Screening, CDC HbA1C‐ Poorly Controlled >9, Use of Spirometry Testing in the Assessment and Diagnosis of COPD, CDC ‐ Nephropathy Monitoring

Areas for improvement Decreased one (1) percentile in seven (7) measures: Breast Cancer Screening; Flu Shots for

Older Adults; Follow‐Up After Hospitalization for Mental Illness (7‐day rate only); Comprehensive Diabetes Care ‐ HbA1c Testing; Comprehensive Diabetes Care ‐ Eye Exams; PCE Pharmacotherapy Management COPD Exacerbation (Rate ‐ Systemic corticosteroid); Antidepressant ‐ Continuation

Decreased two percentiles in three (3) measures: Controlling High Blood Pressure (overall rate); Pneumonia Vaccination Status for Older Adults; PCE Pharmacotherapy Management COPD Exacerbation (Rate ‐ Bronchodilator)

CAHPS®: 7 total CAHPS® composites: Getting Care Quickly, Getting Needed Care, How Well Doctors

Communicate, Rating of All Health Care, Rating of Health Plan, Rating of Personal Doctor, Rating of Specialist Seen Most Often

Increased from 75th to 90th percentile in five of the seven composites Areas for improvement

Getting Needed Care remained the same from 2016 (50th percentile) Rating of Specialist Seen Most Often (25th percentile)

STAR PROGRAM FHCP’s goal is to continuously improve each Star measure in order to earn a 5 Star Rating from CMS. In 2017 there were 34 Part C and 14 Part D Measures. A performance improvement project was developed for each measure that was assigned to an owner.

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In 2017, our Star rating decreased from 4.5 to 4.0. This was primarily due to an increase in measure thresholds and a decrease in numeric scores. Our overall numeric score was 3.796, compared to 4.485 in 2016. There were 9 Star‐sensitive HEDIS® measures in calendar year 2016 (2018 Star Ratings). FHCP’s HEDIS® goal is to move each member to the 90th percentile. However, for those Star Measures whose source is HEDIS®, FHCP strives for 100%. 5 Star ratings were earned for the following HEDIS® measures: Colorectal screening, Adult BMI, Diabetes Poor Control >9 and Nephropathy Screening. The following HEDIS® measure ratings decreased from 5 to 4 Star: Breast Cancer Screening, Diabetic Retinal Exam, Hypertension Treatment and Rheumatoid Arthritis Management. Readmissions within 30 days of discharge, a 3 weighted measure, dropped from a 3 to a 2 Star rating. CAHPS® and HOS survey results scored slightly higher this year. However, we received a 1 Star for the Part C Interpreter measure and the Part D interpreter measure; both measures are weighted a 1.5. We also decreased from a 5 to a 4 Star rating in Beneficiary Access and Performance Problems. Other health plan function measures such as Appeals, Grievances, Complaints and Members choosing to leave the plan retained their 5 Star rating. Part C Summary dropped from a 4.5 Star rating to a 3.5 Star Rating Part D Measures

5 Star Ratings were earned for the following Part D Adherence measures: Taking Blood Pressure Medication and Cholesterol Lowering Medication. Both measures are 3 weighted.

Drug plan prices on the CMS website improved from a 1 Star to a 3 Star

Part D Summary remained a 4.5 Star rating Opportunities to Improve include involving the Member in their care:

HealthyMe Checklist – Patient Report Card Expanded Member Portal capabilities

MEMBER SAFETY FHCP ensured the safety and quality of health care to our members by: Providing education to our members

Members received information on member and physician communication, rights and responsibilities, quality and safety resources, and electronic medical records.

Monitoring adverse events All quality of care issues identified during health plan activities were investigated, reviewed, and

when necessary, sent to peer review. Monitoring complaints

Member complaints were reviewed for possible quality of care, services, and access and availability issues. Aggregate results were reviewed for trends and opportunities for improvement.

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Pharmacy Management FHCP pharmacies ensured that processes were followed to oversee overutilization, poly pharmacy

issues, and appropriateness of prescribing, narcotic abuse, and medication management. Continuity and Coordination

Continuity and coordination are important elements of care and are monitored as part of FHCP’s commitment to quality. Patient safety and transition of care is evaluated for improvement opportunities. FHCP’s Utilization Management, Case Management, Community Resource and Behavioral Health teams meet weekly to improve coordination and quality of the care FHCP offers to our members.

Clinical Practice Guidelines Because evidenced based research provides the basis for clinical practice guidelines, all FHCP

guidelines are based on the most current scientific evidence. In accordance with the biennial requirement, clinical practice guideline were reviewed this year and approved by our Performance Improvement Committee.

Quality and Patient Safety Committee This committee comprised of physicians and departments representing multiple FHCP disciplines

met throughout 2015 to review and provide feedback on the design of patient safety initiatives implemented by the health plan.

Ambulatory Surgical Center Patient Safety Committee This committee’s purpose is to reduce and prevent medical errors and adverse events in the ASC

setting. RESOURCES Throughout 2017, staff and analytical resources were appropriate for the majority of the year. The level of participation from physicians and leadership continue to be important aspects of the quality program that will contribute to its success. QI OVERSIGHT COMMITTEE FHCP’s Performance Improvement Council (PIC) acts to plan and coordinate organization‐wide improvement in quality and safety of clinical care and service to members. The PIC is charged with responsibility for oversight of all quality related activities and processes in the following functional areas, including but not limited to: Utilization Management, Case Management, Disease Management, Behavioral Health, Wellness, Pharmacy, Member Services, and Network Relations. Committee membership was evaluated and will remain unchanged in 2018. WORK PLAN Each year FHCP develops an annual plan comprised of initiatives to improve clinical and service quality. The results of the QI Work Plan can be found in Appendix A. Initiatives for 2017 included:

Integration of new standards Member and physician outreach for chronic conditions such as asthma, diabetes, heart disease,

chronic obstructive pulmonary disease as well as HEDIS® effective of care measures, coordination of care, strategies to reduce inappropriate utilization and serving members with complex health needs via identification, outreach and complex care management programs

Wellness and health promotions that addressed worksite health and wellness and initiatives to assist with lifestyle management

Programs addressing medication adherence and reduction in medical errors particularly those related to drug prescribing and monitoring

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Physician incentive programs to promote clinical quality in the physician network Oversight of delegated relationships Evaluation of member complaints, appeals, and surveys to improve member communications,

enhance programs and improve health literacy 2018 GOALS As part of FHCP’s commitment to quality improvement, the 2018 QI Work Plan will include 2017 activities that require ongoing monitoring and new activities that include new NCQA standards such as Population Health Management. Other goals for 2018:

Develop, update and utilize project plans to improve each individual HEDIS® and CAHPS® measure Increase knowledge of project management principles to allow staff to better support HEDIS® and

STAR improvement initiatives Increase use of clinical reporting and technologies to enable quality improvement efforts Increase review and management of GAP reports through use of provider portal and face to face

discussions with providers Implement member initiatives that allow member to participate in the management of their

healthcare, e.g., member report cards Partner with other functional areas such as Risk Adjustment and Value Stream Intelligence to assist

in the identification of opportunities to improve all GAPS in care. Offer HEDIS® training to relevant staff to improve understanding of clinical measures, data

collection, medical record review and reporting methodology. Encourage use of “HEDIS 101” training documentation in practitioner offices to increase knowledge

of data and coding requirements and the impact well‐performing measures have on improving clinical quality.

Increase use of web‐based technologies to support communication, education and access to self‐service functions

Continued promotion of quality by continuing physician incentive programs Promoting member engagement in wellness and preventive care through the use of the health risk

assessments (HRA) that includes self‐management tools and health coaching Continuing focus on service improvements to improve member experience and satisfaction survey

rates

*Enrollees as of 12/06/2017 ** Members may provide more than one answer to this question or may not respond. Total responses may be greater or less than 100%.

Monitoring Potential Practitioner Quality Concerns January 1 to June 30, 2016

© Tashidy Corporation 2004, 2008

Florida Health Care Plans (FHCP) monitors member complaints involving network & staff practitioners and organizational providers on an ongoing basis. FHCP also monitors adverse events for Primary Care Practitioners and high-volume Behavioral Health providers. The Member Services Department forwards member complaints to Quality Management in order to track, trend, and investigate when appropriate.

The following categories of member complaints are included in this analysis: Quality of care (QU)Grievance (GR)Staff (ST)Policy & Procedure (PP)Access (AC)

The following categories of adverse events are included in this analysis: Surgical Site Infection after Surgery or ProcedureFalls and TraumaStage III and IV Pressure UlcersDeep Vein Thrombosis (DVT)/Pulmonary Embolism (PE)Injury to Patient

A more detailed investigation occurs when the volume of complaints within the reporting period exceeds a threshold of 10 complaints for a staff provider or 5 complaints for a contracted provider, or when a serious reportable adverse event (SRAE) occurs. When an SRAE occurs, a query is conducted in FHCP’s complaint system and incident reporting system for any combined trends. A more detailed investigation occurs when a potential quality of care issue is identified.

If complaints or adverse events do not exceed the thresholds, the data is tracked for future trends.

Trends by Practitioner Criteria This report period

January 1 to June 30, 2016 Previous report period July 1 to December 31,

2015Number of staff providers with 10 complaints 0 0

Number of staff providers with one adverse event 0 0

Number of contracted providers with 5 complaints 0 0

Number of contracted providers with an adverse event

0 0

Monitoring Potential Practitioner Quality Concerns January 1 to June 30, 2016


Analysis of practitioner trends: no member complaint thresholds were exceeded for the reporting period and no trends were identified. Any complaints that warranted a quality review were submitted by Member Services to Risk Management/Quality administration and addressed appropriately.

Analysis of facility (organizational provider) issues: While ongoing monitoring for organizational providers is not required by NCQA, FHCP trends facility complaints in order to improve customer service and quality of care.

FHCP tracks complaints on a rolling 6-month basis; for any given month, complaints are reviewed for the prior 6-month period and are monitored on an aggregate basis for that time-frame. As such, data can include complaints reported during months that extend beyond the time-frame noted on the analysis report.

For the 6 month period January 1 to June 30, 2016 no facilities exceeded complaint thresholds.

Improvements to Monitoring Process:

The process for monitoring and trending adverse events is currently under review by Quality Management and Risk Management staff in an effort to more accurately report on SRAEs. FHCP currently uses disparate complaint and event reporting systems, presenting challenges for accurate monitoring and trend reporting. A new risk/incident reporting system was implemented, effective May 2016; reports from this system are under review.

Committee Review Date Actions Credentialing & Peer

ReviewJuly 19, 2016 No issues identified;

approved as submitted.

Details by Practitioner January - June

Provider Staff or Contracted Specialty Complaints/Events

by Category Total

0 0 0

GR - n/a QU - n/a ST - n/a AC - n/a

0

Monitoring Potential Practitioner Quality Concerns July 1 to December 31, 2016


Florida Health Care Plans (FHCP) monitors member complaints involving network & staff practitioners and organizational providers on an ongoing basis. FHCP also monitors adverse events for Primary Care Practitioners and high-volume Behavioral Health providers. The Quality Management department tracks, trends, and investigates these issues as part of ongoing credentialing monitoring.

The following categories of member complaints are included in this analysis:

Quality of care (QU)Grievance (GR)Staff (ST)Policy & Procedure (PP)Access (AC)

The following categories of adverse events are included in this analysis:

Clinical Treatment ConcernComplications after surgeryDelay in CareFailure to DiagnoseFailure to ReferReadmissionWrong MedicationWrong Treatment

Member Complaint Monitoring

FHCP investigates all member complaints. Quality Management conducts a more detailed investigation when the volume of member complaints within the reporting period exceeds a threshold of 10 complaints for a staff provider or 5 complaints for a contracted provider. FHCP tracks complaints on a rolling 6-month basis; for any given month, complaints are reviewed for the prior 6-month period and are monitored on an aggregate basis for that time-frame. As such, data can include complaints reported during months that extend beyond the time-frame noted on the analysis report. If complaints do not exceed thresholds, the data is tracked for future trends.

Complaint Trends by Practitioner Type Criteria This report period

July 1 to December 31, 2016 Previous report period

January 1 to June 30, 2016Number of staff providers with 10 complaints 1 0

Number of contracted providers with 5 complaints 0 0



Analysis of 036051, MD issues: this Primary Care practitioner met the complaint threshold in July 2016 with 13 complaints in the Feb - July reporting period. This information was reported to Customer Satisfaction Committee in July, with updates for trending in August, September and December. Nine (9) complaints were made against the physician’s office staff (ST): ex. poor communication, rude behavior, etc. FHCP’s Practice Management Administrator was aware of the trend and was already addressing the issues with provider and practice manager. ST volume peaked in July with 6 complaints and declined to two in September and one in December. No trends were identified for the next highest categories of PP or AC. Two of the PP complaints and the AC complaint were related to pharmacy issues and one PP complaint was a referral issue. No quality of care issues were identified. QM staff will continue to monitor for trends and report to Committee as appropriate.

Analysis of facility (organizational provider) issues: While ongoing monitoring for organizational providers is not required by NCQA, FHCP trends facility complaints in order to improve customer service and quality of care. For the 6 month period July 1 to December 31, 2016 no facilities demonstrated complaint trends.

Adverse Event Monitoring

Adverse events are tracked for PCPs and high-volume Behavioral Health Providers. When an adverse event occurs, FHCP’s complaint and incident reporting systems are queried to determine if there are any trends for the practitioner or facility. A more detailed investigationoccurs when a trend is identified. If potential quality of care issues are identified by Risk Management or Quality Management staff, these trends are reported to the Credentialing and Peer Review Committee.

Adverse Events by Category/Month - PCP July August September October November December

Clinical Treatment Concern 0 1 1 0 0 0 Complications after surgery 0 0 0 0 0 0 Delay in Care 0 0 0 1 0 1Failure to Diagnose 1 0 0 0 0 0 Failure to Refer 0 0 0 0 0 0 Readmission 0 0 0 0 0 0 Wrong Medication 1 0 0 2 0 1Wrong Treatment 0 0 0 0 0 0Total: 2 1 1 3 0 2

There were no trends identified for any individual PCP during the reporting period.

Complaint Details by Practitioner July – December Provider Total Complaints by Category

#036051 13

GR – 0 QU - 0 ST – 9 PP – 3 AC - 1



Adverse Events by Category/Month - BH July August September October November December

Clinical Treatment Concern 0 0 0 0 0 0Complications after surgery 0 0 0 0 0 0Delay in Care 0 0 0 0 0 0Failure to Diagnose 0 0 0 0 0 0Failure to Refer 0 0 0 0 0 0Readmission 0 0 0 0 0 0Wrong Medication 0 0 0 0 0 0Wrong Treatment 0 0 0 0 0 0Total: 0 0 0 0 0 0

There were no trends identified for any individual BH provider during the reporting period.

Improvements to Ongoing Monitoring Process:

The process for monitoring and trending adverse events is being revised by Quality Management and Risk Management staff in an effort to more accurately report trends. A new risk/incident reporting system was implemented in May 2016 and reports from this system are under review. Additionally, previously monitored “SRAE” categories from the old system were frequently tied to organizational providers (facilities) instead of individual practitioners, making it difficult to identify trends. New event categories have been created in the new system that are practitioner-specific and will allow FHCP to more readily identify quality of care trends at the individual provider level.

Committee Review Date ActionsCredentialing & Peer Review January 17, 2017 No concerns identified; report

accepted.

Credentialing – 2016 Summary

Florida Health Care Plans Credentialing staff assists the organization in maintaining a constructive relationship with providers and facilities maintains and revises credentialing policies, and provides timely verification of credentials for providers and facilities to ensure that they have the requisite education, licensure and competence to provide services to FHCP members safely and effectively.

In 2016:

Florida Blue completed their desk review for delegated credentialing in October 2015; results wereprovided in January 2016. We were 100% compliant for file audit and policy review.

A new clerical credentialing position was filled in March to assist with application processing andadministrative support for credentialing functions.

The following credentialing policies were revised and approved:

o QM018 Rev_11 Continuous Quality Monitoring of FHCP Providerso QM013 Rev_15 Credentialing of Providers for Florida Health Care Plan, Inc.

New physician board National Board of Physicians and Surgeons (NPBAS) approved by Credentialing& Peer Review Committee as acceptable certifying entity for credentialing.

Three new practitioners joined the Credentialing & Peer Review Committee in the 3rd quarter:

o Awais Khan, M.D., Medical Oncology/Hematology, Halifax Health Center for Oncologyo Timothy Wierzbicki, M.D., Neurology, Brain & Spine Institute of Port Orangeo Casey Lafferty, D.O. , Family Medicine, Crouch & Dunn, MD, PA

Luckey Dunn, MD, Eugene Crouch, MD and John Shelton, MD resigned from the Committee at theend of the year.

No practitioners were terminated due to quality reasons in 2016.

Summary of provider and facility credentialing/recredentialing files processed 2015 vs. 2016:

2015 Providers 2016 Providers 2015 Facilities 2016 Facilities Initials 86 Initials 118 Initials 38 Initials 23 Recreds 31 Recreds 111 Recreds 10 Recreds 4

Total 117 Total 229 Total 48 Total 27

Depression Disease Management Program Program Description

Florida Health Care Plans 01/01/2016 to 12/31/2016

PROGRAM FOUNDATION AND SCOPE

Evidence Used to Develop the Program Florida Health Care Plans (FHCP) understands that successful treatment of depression relies on a multidisciplinary approach using evidence-based treatment guidelines for psychotherapy and drug therapy. FHCP has a dedicated Behavioral Health team with experience in psychiatry, addiction, case management, behavioral, and mental health counseling. Members who have been diagnosed with a mental health condition have access to a variety of health services to address their individual needs.

According to the American Psychiatric Association, depression is one of the most treatable mental disorders. Between 80 and 90 percent of people with depression will respond well to treatment at some point. Almost all patients are able to find some relief from their symptoms.1

Depression is associated with substantial healthcare needs, school problems, lower workplace productivity, increased absenteeism, and earlier mortality, according to a report by the Centers for Disease Control and Prevention (CDC). Depression may also increase the risk for such conditions as anxiety disorders, substance use disorders, and eating disorders. If not effectively treated, depression is likely to become a chronic disease. This makes it extremely important that effective identification and treatment plans are in place for physicians, who are often the initial contact for depressed people.2

The Institute for Clinical Systems Improvement (ICSI) notes that successful care of major depression requires active engagement at the time of diagnosis. Both patients and their families benefit from being educated. It is important that doctors utilize validated tools to identify and monitor patients with major depression. Screening and tracking tools are essential, but should be regarded as enhancing, not replacing, the clinical interview.3

FHCP annually reviews and adopts depression clinical care guidelines through its Disease Management Committee and Performance Improvement Council.

Goals FHCP recognizes the importance of identification of members with a current diagnosis of depression, and promotion of evidence-based recommendations to control and prevent further complications. FHCP’s Depression Disease Management Program is designed to promote awareness and self-management through coordination with the member and the health care team. The goal is to improve member wellness and achieve positive health outcomes. Program goals include education of members about depression, early identification and intervention, adherence to pharmacotherapy regimen, improved wellness and quality of life, and reduction of health care costs.

The program supports the practitioner-patient relationship and plan of care. The plan of care is based upon the depression clinical care guidelines. Members are encouraged to communicate and actively participate with their practitioner when specific plan of care issues arise.



Product Line Commercial, Medicare and Marketplace

Ages 18 years and older

IDENTIFYING MEMBERS

Claims or Encounter Data* Claims criteria are based on a diagnosis for major depression in one of the following: outpatient visit, intensive outpatient encounter or partial hospitalization, Emergency Department visit, or acute or nonacute inpatient discharge.

Pharmacy Data* A member is identified when dispensed an antidepressant.

*We use the requirements outlined in the HEDIS® (Healthcare Effectiveness Data andInformation Set) AMM (Antidepressant Medication Management) quality measure.

Electronic Health Record Members are identified by the Electronic Health Record (EHR) through the use of defined criteria, such as a specific encounter/event type and depression screening.

Health Appraisal Results Members who complete specific sections of the Health Risk Assessment (HRA) are identified for possible inclusion for the Depression Disease Management Program. Eligible members are those who provide at least one yes response to the PHQ-2 Depression Questionnaire (Figure 1).

Figure 1

13. Over the past 2 weeks, how often have you been bothered by any of the followingproblems?

Utilization Management/Case Management Utilization Management identifies members through hospital admissions for depression or if depression is a documented comorbidity. These members are referred to the FHCP Behavioral

Yes No a) Little interest or pleasure in doing things □ □ b) Feeling down, depressed, or hopeless □ □



Health Department via tasking. Case Management identifies member through claims, hospitalization diagnoses for depression, and depression screening by the PHQ-2 (Patient Depression Questionnaire).

Wellness Programs Members in Wellness Programs are enrolled in the program unless already identified through other data sources.

Member and Practitioner Referrals Members and/or caregivers may enroll in the program via the enrollment form, or contacting the Disease Management department by either email or phone. Information on how to contact Disease Management along with any necessary forms can be found on the FHCP member website at: http://www.fhcp.com/members/memberServices/contactUs.htm

Providers screen members for depression, and any provider may contact the Disease Management department requesting a member be added to the program.

Depending on insurance product, a practitioner referral may be needed for members to participate in Behavioral Health services for depression. In addition, Behavioral Health providers have a weekly meeting to identify at-risk members for depression based on crisis evaluation.

INTEGRATING MEMBER INFORMATION

Utilization Management/Case Management These departments interact with the Disease Management Department by phone, email, or through the EHR tasking function. Figure 2 is a picture of how a note looks in the EHR (see below). This allows dissemination of relevant information immediately to appropriate health care team members within the organization to facilitate communication and coordination of care. Utilization Management documents concurrent reviews and hospital admission and discharge information in notes contained within the member’s EHR. Case Management integrates member information into the EHR including initial screening notes, hospital discharge follow-up, follow-up contacts, support service assistance, depression management, and depression screening and counseling. Complex Case Management is integrated with other program services to meet the needs of members with depression.



Figure 2

Wellness Programs/Health Screenings Members identified for the program through health screenings, wellness programs, and classes have relevant information documented in the EHR. Routine screening and preventive health information is also recorded or scanned into the EHR.

Nurse Advice Line Referrals from this source are recorded in the triage report released to Disease Management and the Primary Care Physician (PCP). The report documents pertinent details and is faxed directly to the FHCP Medical Records department. The report is scanned into EHR in the member’s chart. Disease Management receives a related task via EHR within twenty four hours. In addition, contracted providers are faxed a copy of the triage report to ensure continuity of care and immediate access to the member information.

Practitioners Relevant information is updated in the EHR by the practitioner and clinical staff to ensure availability of information to appropriate members of the health care team. This includes office visits, treatment plan, clinical results, telephone contact with a member or caregiver, current medications, or member participation in a program or class.

Behavioral Health documents in the “Behavioral Health Notes” of the EHR immediately following interactive contact with members.

Disease Management Disease Management documents in the EHR following interactive contact with members to ensure access to the health care team. Urgent information is tasked directly to staff providers or faxed to contracted providers. The Disease Management programs fully support and seek to strengthen the practitioner/patient relationship through integration of member information into the EHR.



FREQUENCY OF MEMBER IDENTIFICATION

Each month, FHCP’s Clinical Reporting department (formerly Clinical Measurement, Analysis and Reporting-CMAR) develops data to identify members newly diagnosed with depression, based on previously defined encounters and/or pharmacy utilization.

INFORMATION PROVIDED TO MEMBERS

Using Services and Eligibility All members when enrolled in the program receive educational materials. An example is an educational pamphlet with definitions, common medications used in the management of depression and the importance of adherence, communication with providers, and the need for regular follow-up care. A Member Newsletter that contains depression specific articles is sent out periodically during the calendar year. The member website at www.fhcp.com has Member Wellness topics and class information. The Welcome to Wellness Member Portal contains resources for depression, through educational materials and links. A Member Resource Guide is located online at http://www.fhcp.com/members/memberresourceguide.pdf with information on Behavioral Health services and other wellness programs, and is also mailed to members.

Members can obtain more information by contacting Behavioral Health, the Disease Management team, Member Services, Case Management, or their physician. Phone, fax, and email addresses are located on the FHCP web page under Member Wellness. Members are provided educational and support resources outside of the FHCP Depression Disease Management Program. Most educational materials include additional web site information for the member and/or identified caregiver.

Opting Out Members who do not wish to participate in the Depression Disease Management Program may request to opt out at any time. Instructions are included in the introductory letter as displayed in Figure 3.



Figure 3

Date

Dear Member,

Florida Health Care Plans is committed to helping our members achieve the best health possible. Our records indicate you have a diagnosis of depression. We want you to be aware that Florida Health Care Plans offers a free comprehensive depression program which provides education and tools needed for successful self-management.

We have made participation in this program easy and accessible by automatically enrolling you in the depression program. As a benefit of being in the program you will receive depression specific education materials through a disease management member newsletter that will be mailed to your home two to three times a year. The newsletter provides valuable information over a wide range of topics such as how to cope, things you can do to feel better, common medications used to treat depression, diet, exercise, stress reduction, and other helpful topics.

Additional related educational materials can be located on the Florida Health Care Plans website under member health and wellness at www.fhcp.com.

You also qualify to participate in counseling with the behavioral health team and can request an appointment by calling (386) 676-7175 from 8:00 AM to 5:00 PM, Monday through Friday.

Your participation in this program is voluntary. If at any time you have questions or wish to stop participating in the program please call (386) 676-7100 ext. 7242, 8:00 AM to 5:00 PM, Monday through Friday. The hearing impaired may call TRS Relay 711.

Members who opt out are documented in the internal spreadsheet/registry based on received date. Members who opt out will not be contacted for the remainder of the calendar year. All members who opt out for the current measurement year will be contacted again at the beginning of each subsequent calendar year with the opportunity to participate in the Depression Disease Management Program. For 2016, there were no opt outs from the program.

INTERVENTIONS BASED ON ASSESSMENT

FHCP recognizes the importance of stratification of members with a current diagnosis of depression, and promotion of evidence-based interventions to control and prevent further complications.



Stratification The Depression Disease Management Program identifies members monthly for inclusion with two stratifications (Table 1):

Table 1

Level Stratification Criteria Interactive Contact Level I Member with two claims in the preceding six

month period with a qualifying diagnosis for depression.

Not required

Level II Member with a qualifying diagnosis for depression, and prescribed an antidepressant medication.

Required

Level I members can be moved to Level II if their condition exacerbates. Level II members can transition to Level I if the member demonstrates disease stability, does not have an admission or discharge from an emergency department with a diagnosis of depression, or does not have a new prescription for antidepressant medication within a 12 month period. Interactive contact is required for Level II.

Interventions Based on Stratification Interventions are performed throughout many departments within the organization, as part of the overall Depression Disease Management Program. Focused interventions are provided to all members in the program including member education and provision of self-management tools. All interventions use evidence-based recommendations for care management, provider support and education.

Members in both stratification levels receive patient education materials for depression at least two times a year. The educational approaches and tools available to FHCP members in the Depression Disease Management Program were described in the Information Provided to Members section of this Program Description above.

Level II participants are defined as “higher risk” and require a greater amount of intervention, which includes interactive contact with the interdisciplinary healthcare team. Interventions are individualized and based on the member’s need due to any medical and behavioral comorbidities, psychosocial and health conditions, or family issues. The overall goal is to assess barriers to adequate disease self-management and develop an individualized plan for education and health coaching, in order to prevent exacerbation and disease progression. Through use of the assessment, the depression team prioritizes goals and builds on the member’s current level of knowledge. The focus is disease definition, signs and symptoms of worsening condition with actions to take, adherence to antidepressant medication therapy, medication regimens, completion of a depression screening, referral to additional services



such as Case Management and Behavioral Health, assessment of the patient’s support system, and coordination with the physician for follow-up care.

Interactive interventions can include a phone call, health coaching, encouraging pharmacotherapy compliance, or an educational mailing at the member’s request. Caregivers and family members are included when appropriate with the member’s consent. Members are directed to communicate with their practitioner with any concerns or changes in their condition, or difficulty adhering to treatment.

Communication with the PCP (Level I & II) Members are encouraged to communicate with their PCP. The FollowMyHealth Patient Portal enables members with a staff PCP to:

Request, cancel or reschedule appointmentsSend secure messagesView lab and test resultsRequest prescription renewals if the member runs out of refills or the prescriptionexpires

All members, whether they have contract or staff PCPs, are encouraged in the Member Resource Guide to contact their PCP with any questions or concerns about their condition and treatment needs. For example, members are reminded before they visit an urgent care clinic that “We encourage you to contact your Primary Care Physician (PCP) before visiting the clinic. Your PCP knows your history and will have helpful advice that may be useful as you seek medical attention, lab work, or other health related services.” For Specialty Care and Behavioral Health Services, members are reminded that “You and your PCP may determine that you need to see a specialist, including a behavioral health physician. Your PCP will coordinate your care and, in most cases, directly refer you to the specialist and services you need.” Members are also reminded how important physician-patient communication is, and that “You should feel comfortable talking with your Physician about your health and treatment. If you have any questions or concerns, express them.” Interdisciplinary healthcare team staff encourages members to contact their PCP as the most important link in their coordination of care and treatment plan. The PCP develops the plan of care based on an assessment for depression and any comorbidities, which may require a referral and additional treatment by specialists and/or Behavioral Health.

Wellness Programs (Level I & II) Education is a joint effort by Case Management, Disease Management, Practice Management, Behavioral Health, physicians, specialists and others. FHCP offers a variety of health, wellness and disease management programs and services at little or no cost, and there are no limitations on the number of programs in which a member may participate. Members are notified of resources through the FHCP website under Member Wellness/Disease Management. The website lists the various education programs for members such as classes on diet, smoking cessation, exercise, diabetes, heart disease, hypertension, and a Kidney Smart class by DaVita Hemodialysis. In addition, information related to specific disease states, activity, nutrition, and other pertinent material is posted. This information is also shared in newsletters, health fairs,



flat-screen TVs in facilities, the Member Resource Guide, and Member Services. Printed materials are placed in offices, pharmacies, and labs.

Educational Mailings (Level I & II) Members at risk are included in educational mailings and programs unless they opt out. An example of mailed educational material is a brochure on depression by the National Institute of Mental Health, which includes information and skills needed to successfully cope with this illness. All educational materials are accompanied by a letter with contact information for Disease Management. When a member contacts Disease Management, they are provided with information, and further encouraged by staff to contact their PCP with specific concerns or questions about their health condition.

Member Portal (Level I & II) The on-line Welcome to Wellness Member Portal is a web-based interactive site for member self-assessment and interactive learning related to depression and other co-morbid conditions. The portal includes written materials, risk assessments, quizzes, recipes, health articles in English/Spanish, interactive programs, and health videos. The portal also provides links to external resources for self-management. On the portal, members have the ability to complete a personalized Health Risk Assessment and obtain educational information and feedback specific to the member.

GAP Reports (Level II) Assigned physicians receive at least four reports each year run by staff, which identify potential ‘gaps in care’ for the PCP’s members. The PCP receives information on what is specifically needed for each patient. This enables efficient condition monitoring and adherence to treatment plans, and assists in compliance with treatment. The following is shared with physicians in the GAP Report for their members with depression who require monitoring:

Remain on an antidepressant medication for at least 6 months

Depression Screening - PCP Office Visits (Level I & II) At each office visit, PCPs use the PHQ-2 to screen members for depression. The PHQ-9 is then completed by the PCP for members answering yes to either of the two questions. For a score of 15 or greater, PCPs refer the member for additional care through Behavioral Health services.

Case Management Complex Care (Level II) Chronic Complex Care is an intensive intervention in Case Management for higher risk members who have experienced a critical event or diagnosis requiring extensive use of resources and assistance in navigating FHCP. Frequent hospitalizations and multiple chronic co-morbid conditions are a factor. Members are assessed for psychosocial issues, medical and behavioral comorbidities, polypharmacy, physical and cognitive limitations, non-compliance with care, and financial needs. Interventions include initial screenings, hospital discharge follow-up (with assistance from Utilization Management), support services and community resources, housing, psychosocial assessment, and depression screening. This focused attention facilitates



appropriate delivery of care and services. Members are closely monitored by Case Manager nurses. Interactive contact and education is performed to reinforce compliance with the treatment plan to manage the member’s depression. Because learning is not optimal until learning needs are assessed, the nurse develops an individualized plan of care using Milliman Chronic Care Guidelines and FHCP clinical protocols. Caregivers may be involved after obtaining the member’s consent. Collaboration with physicians, specialists, and Behavioral Health is ongoing and addresses the treatment plan, including medication adherence or any issues needing special attention.

Depression Screening - Case Management Complex Care (Level II) For members being followed by Case Management Complex Care, a PHQ-2 (Patient Health Questionnaire) is completed. The PHQ-2 is a validated screening tool that uses two questions to identify possible signs of depression. If the member answers “yes” to either of the two questions, a PHQ-9 screening tool is completed which outlines symptoms of depression and provides a total possible score of 0-27. If the score is 10 to 14, the Case Manager nurse introduces counseling and encourages the member to seek assistance. A task or telephone call is initiated to the PCP regarding clinical findings and possible appointment or referral to Behavioral Health. If the score is 15 or greater, the member is referred to Behavioral Health, with notification to the PCP. When a home visit is warranted, a referral is submitted to a Licensed Clinical Social Worker requesting a home visit and/or assistance.

Table 2 highlights selected interventions which are described above.



Table 2

Program Interventions - 2016

Intervention Program Content Type Addressed by Intervention M=Member P - Provider

Frequency Condition Monitoring

Patient Adherence

Other Health Conditions

Health Behaviors

Psycho-social Issues

Depression Pamphlet (M)

Upon enrollment

x x x x x

Welcome to Wellness Member Portal (M)

Always Available

x x x x x

Disease Management/ Member Wellness Website (M and P)

Always Available

x x x x x

PHQ-9 Depression Screening (M)

At least once

x

Behavioral Health Referral (M)

If indicated based on depression screening

x x x x

Case Management Referral (M)

If indicated x x x x x

ELIGIBLE MEMBER ACTIVE PARTICIPATION

Member active participation rate is determined by the total number of members eligible for the program, which is the denominator for the twelve month period. The numerator is described as the number of members who received at least one interactive contact.

PRACTITIONER EDUCATION

Physicians and other healthcare providers are notified about our program by new provider education, the Provider Services Handbook, memos, notices, committee participation and reports, Provider Newsletters, the FHCP Provider section of the website, and changes communicated through Practice Management activities. The Provider Services Handbook includes a brief program description, eligibility criteria and the referral process.



REFERENCES

1 What is Depression? American Psychiatric Association, 2016.

https://www.psychiatry.org/patients-families/depression/what-is-depression

2 Mental Illness, Depression Overview. Centers for Disease Control and Prevention, Program Performance and Evaluation Office, March 2016.

http://www.cdc.gov/mentalhealth/basics/mental-illness/depression.htm

3 Trangle M, Gursky J, Haight R, Hardwig J, Hinnenkamp T, Kessler D, Mack N, Myszkowski M. Institute for Clinical Systems Improvement. Adult Depression in Primary Care. Updated March 2016.

https://www.icsi.org/_asset/fnhdm3/Depr.pdf

REPORTING

Committee Name Committee Actions or Recommendations Disease Management Approved 8/8/17 Performance Improvement Council Approved 8/23/17

Depression Disease Management Program Member Identification Report


Table 1 contains members identified in 2016 in both Level I and Level II by Data Source and Line of Business (LOB).

Table 1- Depression Disease Management Program Member Identification by Data Source

Data sources consisting of Utilization Management, Behavioral Health, Case Management, practitioners, Nurse Advice Line, and member contact are included in Claims/Encounter/Pharmacy/ EHR totals. There were no referrals from health risk appraisals, or wellness programs.

REPORTING


Data Source by LOB

JAN 16

FEB 16

MAR 16

APR 16

MAY 16

JUN 16

JUL 16

AUG 16

SEP 16

OCT 16

NOV 16

DEC 16

ANNUAL TOTALS

Claims/ Encounter/ Pharmacy/ EHR - Total

4 110 101 140 147 139 214 72 173 101 92 115 1,408

Commercial 4 47 35 34 52 27 63 13 56 25 22 47 425

Medicare 0 33 27 43 31 42 77 27 45 37 36 28 426

Marketplace 0 30 39 63 64 70 74 32 72 39 34 40 557

Depression Disease Management Program Stratification & Interventions Report


INTERVENTIONS

Florida Health Care Plans (FHCP) recognizes the importance of stratification of members with a current diagnosis of depression, and promotion of evidence-based interventions to control and prevent further complications. Interventions are designed to promote awareness and self-management through coordination with the member and the health care team. The goal is to improve member wellness and achieve positive health outcomes.

Stratification The Depression Disease Management Program stratifies members with depression monthly into low (Level I) and high risk (Level II) groups (Table 1).

Table 1 - Stratification Levels Defined

Level Stratification Criteria Interactive Contact

Level I Qualifying diagnosis/event for major depression with no pharmacy claims.

Not required

Level II Qualifying diagnosis/event for major depression, and prescribed an antidepressant medication.

Required

Interventions Based on Stratification The multiple education methods available to FHCP members in the Depression Disease Management Program were described in the Information Provided to Members section of the Program Description. Level II participants require a greater amount of interactive contact and interventions. A detailed description of each intervention for both levels can be found in the Interventions Based On Assessment section of the Program Description.

Tables 2 and 3 outline members in the program, and interventions received, by levels.



Table 2 - Depression Disease Management Program Stratification for 01/01/2016 to 12/31/2016

Depression Diagnosis, & Stratified Level I Level II Total Commercial 192 233 425 Medicare 157 269 426 Marketplace 230 327 557 Members in Program Total 579 829 1,408

Table 3 – Received Intervention*

Educational Mailings to Newly Identified Level I Level II Commercial 192 233 Medicare 157 269 Marketplace 230 327

Phone Call Outreach for Medication Compliance Level II Commercial 2 Medicare 1 Marketplace 2

Educational Materials Mailed Per Member Request – Level I &

II** Commercial 2 Medicare 17 Marketplace 1

Interventions Total by Line of Business Total Commercial 429 Medicare 444 Marketplace 560 Interventions Total 1,433 *Members may have received more than one intervention.**Intervention directed to both levels but not separated into Level I or Level II for reporting purposes.



REPORTING


Depression Disease Management Program Active Participation Report Florida Health Care Plans

01/01/2016 to 12/31/2016

ELIGIBILITY

A member is identified for inclusion in this program via the following sources: claims and pharmacy data; electronic health record (EHR) data; Nurse Advice Line; health appraisals; and referrals from physicians, Disease Management, Case Management, Utilization Management, and Member Wellness programs and classes.

ACTIVE PARTICIPATION

Member active participation rate for 2016 (Table 1) is determined by:

The number of members with at least one interactive contact (numerator)divided by:

The number of members identified as eligible for the program (denominator).

Interactive contact is defined as an intervention with the member via a contact for health coaching, or an educational mailing per member request.

Table 1

LOB Total Eligible Population CY 2016

Total Eligible Population CY 2015

At Least One Interactive Contact CY 2016


Active Participa-tion Rate CY 2016


Commercial 425 542 2 16 0.47% 2.95%

Medicare 426 450 1 14 0.23% 3.11%

Marketplace 557 74 2 0 0.36% 0.00%

Total 1,408 1,066 5 30 0.36% 2.81%

REPORTING


Depression Disease Management Program Member Satisfaction Analysis


INTRODUCTION

Analysis of member satisfaction with the Depression Disease Management Program allows Florida Health Care Plans (FHCP) to identify aspects of performance that do not meet member expectations, and initiate actions to improve performance. FHCP monitors member satisfaction with the Depression Disease Management Program through analysis of member satisfaction surveys and member complaints.

This report describes the monitoring methodology, results, and analysis for each satisfaction data source.

MEMBER SATISFACTION SURVEY

Methodology The Depression Disease Management Program Member Satisfaction Survey population includes a random sampling of members identified as Level II during the measurement year. The written survey is administered by Disease Management staff and sent via mail annually.

Survey response rate information is summarized below in Table 1. Due to a response rate of ‹20%, survey findings cannot be generalized to all members in the Depression Disease Management Program for these product lines.

Table 1

Product # Surveys

Sent 2016

#Surveys Sent 2015

# Surveys Received

Back 2016

# Surveys Received

Back 2015

2016 Response

Rate

2015 Response

Rate

Commercial 103 80 4 6 4% 8%

Medicare 93 39 15 5 16% 13%

Marketplace 134 0* 3 N/A 2% N/A

TOTAL 330 119 22 11 7% 9%

*Random sampling did not select Marketplace for 2015.

Results and Analysis are summarized in Table 2.



Table 2 – Commercial, Marketplace and Medicare

Survey Questions Were written materials mailed to you (brochures, letters, newsletters, etc.)?

43% - Yes 57% - No

Were the written materials easy to read? 90% Positive (Agree or Strongly Agree)

Did the materials received help you to understand what anti-depressant medications do and how they are taken?

80% Positive (Agree or Strongly Agree)

If you’ve been in contact with anyone at FHCP, were these discussions helpful?

Of those in contact with FHCP, 50% responded Yes

Do you have any suggestions for ways to improve our program and/or educational materials?

94% had no suggestions

May we contact you to discuss your survey answers? 42% said Yes

Would you be interested in joining a focus group? 7% said Yes

Quantitative Analysis The total number of surveys sent for Depression was 330. The total response rate for all 3 products (Commercial, Marketplace and Medicare) is 7%. The response rate in 2016 decreased slightly from rate of 9% in 2015.

Qualitative Analysis Florida Health Care Plans Depression Disease Management Program member satisfaction goal is 80%. To identify opportunities to improve performance, an analysis was conducted by internal staff to identify the root causes of any member dissatisfaction with the Depression Disease Management Program. Below are survey questions with a summary of the responses.

Were the written materials easy to read?

The goal was met for this question. In 2015 the member satisfaction rate was 100%Positive, while in 2016 the rate was 90% Positive.

Did the materials received help you to understand what anti-depressant medications do and how they are taken?”

In 2015, the goal was not met for this question (75% Positive). In response, educationalmaterials for depression were updated and more comprehensive materials were included



in mailings. Most educational materials include additional web site information for the member and/or identified caregiver. The member satisfaction rate for this question improved in 2016 to 80% Positive and met the goal.


In 2015, a member noted that prescriptions were being filled incorrectly.

Any prescription not filled correctly and reported to the health plan is addressed through our Risk Management Department via an incident report, including follow-up and resolution.

In 2015, a member noted that therapists need to be more “invested”. In 2016, a memberexpressed dissatisfaction with the wait for an appointment.

Interdepartmental meetings are held with Behavioral Health, Quality Management, Disease Management, the Chief Medical Officer, and other staff to find ways to improve service to members with behavioral health issues. In addition to counseling appointments, a major focus is placed on interactive interventions which include phone calls, health coaching, encouraging pharmacotherapy compliance, educational mailings, and home visits. Caregivers and family members are included when appropriate with the member’s consent.

Efforts will continue to improve the response rate for surveys. The response rate decreased slightly from 2015 to 2016. A review by Disease Management staff determined that a redesign of the formatting of survey questions for 2018 may increase the response rate. This will be completed before the surveys are mailed in 2018. The font size will be increased for ease of response, along with directions on how to respond, such as “Circle One.” The goal is to improve the overall clarity of the questions for understandability and ease of response. The Disease Management Committee will continue to address issues specific to member engagement for surveys.

MEMBER COMPLAINTS

FHCP defines a complaint for the Depression Disease Management Program as any negative feedback reported to the Member Services department.

Upon receipt of verbal or written complaints, each one is assigned a category code based upon the main issue. Some complaints relate to multiple issues. Due to information system limitations, only one category code is assigned to each complaint or inquiry. Therefore, this data reflects the number of complaints about the Depression Disease Management Program received from members, but may understate the exact number of issues raised by members due to coding limitations.



Member complaints about the program are reviewed and analyzed annually. Table 3 displays trended complaint data about the Depression Disease Management Program for the last two years.

Table 3

2016 2015 # Per 1000 # Per 1000

Depression DM Complaints 0 0 0 0

Analysis There were no Depression Disease Management Program complaints in 2016 or 2015. FHCP will continue to monitor for any complaints regarding its Disease Management programs.

REPORTING


Depression Disease Management Program Effectiveness Measures Report


MEASURE DESCRIPTION AND RELEVANCE

To gauge the impact of its Depression Disease Management Program, Florida Health Care Plans (FHCP) monitors the HEDIS® (Healthcare Effectiveness Data and Information Set) Antidepressant Medication Management (AMM) measure. This quality measure examines the percentage of members 18 years of age and older with a diagnosis of major depression who were treated with antidepressant medication, and who remained on an antidepressant medication. Two rates are reported:

Effective Acute Phase Treatment. The percentage of newly diagnosed and treated memberswho remained on an antidepressant medication for at least 84 days (12 weeks).Effective Continuation Phase Treatment. The percentage of newly diagnosed and treatedmembers who remained on an antidepressant medication for at least 180 days (6 months).

The foundation of the FHCP Depression Disease Management Program is a multidisciplinary approach to include evidence-based treatment guidelines for pharmacotherapy and integration of other behavioral therapies, such as psychotherapy. When medications are prescribed, selection is based on the clinical response required to reach recovery, as well as the need for medications to be continued for specified time periods to achieve the full therapeutic effect. The goal of the program is to support the practitioner-patient relationship and plan of care. Members are encouraged to communicate with their practitioner if they are identified as non-compliant with antidepressant therapy.

Methodology The numerator specifications used for the acute phase measure are: The percentage of newly diagnosed and treated members who remained on an antidepressant medication for at least 84 days (12 weeks).

The numerator specifications used for the continuation phase measure are: The percentage of newly diagnosed and treated members who remained on an antidepressant medication for at least 180 days (6 months).

The denominator specifications used for the acute and continuation phase measures are: All eligible members 18 years of age and older identified with a major depression and prescribed antidepressant medication therapy per the HEDIS® AMM measure set specifications.

Data sources: The denominator is determined by claims data for encounters and pharmacy. The numerator is determined by pharmacy fill history.

Performance goal: FHCP has established an organizational goal to achieve the 50th percentile compared to the HEDIS® benchmark.

Results for 2016 for each Line of Business (LOB) are in Tables 1, 2, and 3.



Table 1 - Results for the Commercial population Measurement Time Period

Numerator Denominator Rate Percentile

01/01/15 – 12/31/15

AMM Acute 234 374 62.57% 25th

AMM Continuation 181 374 48.40% 25th

01/01/16 – 12/31/16

AMM Acute 241 427 56.44% <10th

AMM Continuation 169 427 39.58% <10th

Commercial Re-measurement Analysis (01/01/16-12/31/16) For the re-measurement period, the rate of 56.44% for the Acute Phase ranked FHCP in the <10th percentile. The goal of the 50th percentile was not met.

The rate of 39.58% for the Continuation Phase placed FHCP at the <10th percentile. The goal of the 50th percentile was not met.

Table 2 - Results for the Medicare population Measurement Time Period


01/01/15 – 12/31/15

AMM Acute 134 217 61.75% 10th


01/01/16 – 12/31/16

AMM Acute 185 305 60.66% 25th


Medicare Re-measurement Analysis (01/01/16-12/31/16) For the re-measurement period, the rate of 60.66% for the Acute Phase placed FHCP in the 25th percentile, which was an improvement from the 10th percentile of 2015. The rate of 48.20% for the Continuation Phase placed FHCP in the 10th percentile. The organization did not meet the goal of the 50th percentile in either phase.



Table 3 - Results for the Marketplace population Measurement Time

Period Numerator Denominator Rate Percentile

01/01/15 – 12/31/15

AMM Acute 16 26 61.54% 25th


01/01/16 – 12/31/16

AMM Acute-HMO 61 102 59.80% 10th

AMM Continuation-HMO 43 102 42.16% 10th

AMM Acute - POS 3 5 60.00% 10th

AMM Continuation-POS 3 5 60% 90th

Marketplace Baseline Analysis (01/01/16-12/31/16) Marketplace is now tracked separately for HMO, and POS. For the re-measurement period, the AMM Acute percentiles decreased to the 10th percentile, from the previous year of the 25th percentile. For AMM Continuation, the HMO group remained in the 10th percentile, while the POS reached the 90th percentile. The organizational goal of the 50th percentile was achieved only in the AMM Continuation-POS.

Barriers/Opportunities for Improvement, Actions & Outcomes Based on the analysis of performance for Commercial, Medicare, and Marketplace populations, FHCP concluded there is an opportunity to improve performance. Results of a barrier analysis and actions implemented to address the identified barriers and improve the Depression Disease Management Program effectiveness are below in Table 4:

Table 4

Date Implemented

Barrier Addressed Actions Outcome

2016 Gap in member understanding regarding the importance of taking medications as directed and receiving therapy for depression.

Staff calls members non-compliant with medication therapy or at risk based on HEDIS® specifications for the AMM measure. Support and health coaching is provided as needed. Assistance in coordinating an appointment with a Behavioral Health therapist is offered if indicated.

Member feedback has been positive for all lines of business.



Date Implemented

Barrier Addressed Actions Outcome

2016 Interactive telephone calls indicate need for additional member education on how long medications take to show positive effect, what side effects to expect prior to the medication taking effect, and need for further individualized attention.

FHCP TV in staff physician offices and FHCP pharmacies are utilized to provide reinforcement of medication importance and self-management tips. A Depression Program flyer on antidepressant medications is included in the pharmacy bag for medication pick up. A weekly meeting by Behavioral Health is held to discuss interventions for at-risk members based on crisis evaluation.

Goal of 50th percentile was exceeded in AMM-Continuation for Marketplace POS. HEDIS® rates will continue to be monitored in all lines of business.

2016 During interactive telephone calls, some members indicated they don’t have depression.

Review all data sources and medical record to confirm accurate diagnoses. Analyze any complaints about the program.

There were 0 complaints about the program or opt outs for 2016.

REPORTING


Diabetes Disease Management Program Program Description


PROGRAM FOUNDATION AND SCOPE

Evidence Used to Develop the Program Diabetes is a group of diseases marked by high levels of blood glucose resulting from defects in insulin production, insulin action, or both. Untreated, diabetes can lead to serious complications, premature death, and contribute to development of additional co-morbid conditions.

According to the National Diabetes Statistics Report released in 2014 by the Centers for Disease Control and Prevention (CDC), there are 29.1 million people, or 9.3 percent of the total United States (U.S.) population, diagnosed with diabetes. This rate of diagnosis has more than tripled, from 5.6 million to 21.0 million during 1980 to 2014. The result is that diabetes is the seventh leading cause of death in the U.S. Additionally, there are approximately 8.1 million people who are underdiagnosed. Another 86 million have pre-diabetes, a condition where blood glucose levels are higher than normal, but not high enough to be called diabetes.

One in ten Floridians has diabetes which equates to 9.9 percent of the population for this state. The rate of diabetes in Florida has doubled over the last fifteen years. Assessing the prevalence of diabetes at the county level, Volusia County identifies that 10.4% of its 494,593 residents have been diagnosed with diabetes.

The cost of diabetes care is rising rapidly. In 2012, 245 billion dollars were spent for individuals with diabetes with 176 billion dollars from direct medical costs. After adjusting for population, age and sex differences, average expenditures among people with diabetes were 2.3 times higher than individuals without diabetes.1

Florida Health Care Plans (FHCP) is a health insurance company founded in 1974 in Volusia County, Florida. One scope and function of this organization is assessing the diseases and conditions that are prevalent in the member population. The diagnosis of diabetes has been included in the FHCP list of top 25 diagnoses for greater than ten years. As the age of the population increases, members with chronic conditions, including diabetes, use more health care services, supplies, and medications as compared to members without chronic conditions. Members with uncontrolled diabetes represent a subset of the total number of members who have diabetes, with even higher expenditures and rates of complications.

Scientific Basis The Diabetes Disease Management Program is designed utilizing the latest evidence-based medicine guidelines/standards from the American Diabetes Association (ADA). FHCP annually reviews and adopts diabetes clinical care guidelines through the Disease Management Committee and the Performance Improvement Council.



Goals Program goals include education of members about diabetes, early identification and intervention, adherence to medication and dietary regimens, promotion of physical activity, control of risk factors and co-morbid conditions, improved wellness and quality of life, and reduction of health care costs associated with uncontrolled disease status.

FHCP recognizes the importance of identification of members with a current diagnosis of diabetes and promotion of evidence-based recommendations to control and prevent further complications. Efforts are designed to promote awareness and self-management through coordination with the member, family and caregivers, and the health care team. Our primary goal is to empower and motivate our members with diabetes to better manage their disease, and avoid complications.

Product Line Commercial, Medicare, Marketplace

Ages 18 years of age and older

IDENTIFYING MEMBERS

Claims or Encounter Data Use of claims data is a primary source for proper identification of members with diabetes. The identification process utilizes claims during the measurement year or the prior year. We use the requirements outlined in the HEDIS® (Healthcare Effectiveness Data and Information Set) CDC (Comprehensive Diabetes Care) measure. Claims criteria are based on members who met any of the following:

At least two outpatient visits, observation visits, ED (Emergency Department) visits ornonacute inpatient encounters on different dates of service with a diagnosis of diabetes.(Visit type need not be same for the two visits).At least one acute inpatient encounter with a diagnosis of diabetes.

Pharmacy Data A member is identified when dispensed insulin or an oral hypoglycemic/hyperglycemic during the same period as claims data.

Electronic Health Record Members are identified via the Electronic Health Record (EHR) through the use of defined criteria, such as specific Hemoglobin A1c (HgbA1c) or glucose values.



Health Appraisal Results Members who complete specific sections of the Health Risk Assessment (HRA) are identified for possible inclusion for the Diabetes Disease Management Program. Eligible members are those who provide a positive response to the question pertaining to a history of diabetes, high blood sugar, or metabolic syndrome listed under the “Core Set,” or who complete the question under the “Biometric” category with a blood sugar value of 200 or greater (Figure 1).

Figure 1 Core Set 4. Have you ever been diagnosed with any of the following? Select all that apply.

O DiabetesO High blood sugarO Metabolic syndrome

Biometric 9. What was your blood sugar level?

______ (member records value if known in space)O FastingO Non-fastingO Don’t know my blood sugar level

Laboratory Results Blood HgbA1c levels are used to identify members for the Diabetes Disease Management Program. Monthly reports are generated from the Provider Database which is managed by FHCP’s Value Stream Intelligence Department. These reports are forwarded to the Diabetes Education team and include all newly identified members with a diagnosis of diabetes, and those members with an HgbA1c level greater than 9. The HgbA1c values are further utilized to stratify the member as a Level I or Level II (higher risk) participant during the measurement year.



Utilization Management/Case Management Utilization Management/Case Management clinical staff identify members with newly diagnosed diabetes, known diabetics with uncontrolled HgbA1c, or those with diabetic ketoacidosis through hospitalization and abnormal HgbA1c laboratory values. These members are referred to Diabetes Education upon discharge. In cases with multiple comorbidities or readmissions, members are referred to the Case Management Coordination of Care team for evaluation.

Diabetes Education/Wellness Programs Members in Diabetes Education and wellness programs are enrolled in the program unless already identified through other data sources.

Member and Practitioner Referrals Members and/or caregivers may enroll in the program via our enrollment form, or by contacting the Disease Management department via email or phone. Information on how to contact Disease Management along with any necessary forms can be found on the FHCP member website at: http://www.fhcp.com/members/memberServices/contactUs.htm

Any provider may contact the Disease Management department requesting a member be added to the program.

INTEGRATING MEMBER INFORMATION

Utilization Management/Case Management These departments interact with the Disease Management Department by phone, email, or through the EHR tasking function (Figure 2). This allows dissemination of relevant information immediately to appropriate health care team members within the organization to facilitate communication and coordination of care. Utilization Management documents concurrent reviews and hospital admission and discharge information in notes contained within the member’s EHR. Case Management integrates member information into the EHR including initial screening notes, hospital discharge follow-up, follow-up contacts, support service assistance, and depression screening and counseling. Complex Case Management is integrated with other program services to meet the needs of members with diabetes.

Figure 2



Diabetes Education/Wellness Programs Diabetes Education documents education, class attendance, referrals, and member contacts in the EHR. The participant’s outcomes and goals and the plan for ongoing self-management support are communicated to other members of the health care team.

Nurse Advice Line Referrals from this source are recorded in the triage report released to Disease Management and the member’s Primary Care Physician (PCP). The report documents pertinent details and is faxed directly to the FHCP Medical Records department. The report is scanned into the EHR in the member’s chart. Disease Management receives a related task via EHR within twenty-four hours. In addition, contracted providers are faxed a copy of the triage report to ensure continuity of care and immediate access to the member information.

Practitioners Relevant information is updated in the EHR by the practitioner and clinical staff to ensure availability of information to appropriate members of the health care team. This includes office visits, clinical results, treatment plan, current medications, telephone contact with a member or caregiver, or member participation in a program or class.

Disease Management Disease Management documents in the EHR following interactive contact with members to ensure access to the health care team. Urgent information is tasked directly to staff providers or faxed to contracted providers. The Disease Management programs fully support and seek to strengthen the practitioner/patient relationship through integration of member information into the EHR.

FREQUENCY OF MEMBER IDENTIFICATION

Each month, FHCP’s Clinical Measurement, Analysis and Reporting (CMAR) Department and Value Stream Intelligence Department develop data to identify members newly diagnosed with diabetes based on previously defined encounters, pharmacy utilization, and/or laboratory values.

INFORMATION PROVIDED TO MEMBERS

Using Services & Eligibility Upon enrollment into the program, all members receive written diabetes educational materials at least twice during the calendar year, by way of a Member Newsletter. The member website at www.fhcp.com has Member Wellness topics and class information. The Welcome to Wellness Member Portal contains resources for online diabetes self-management, through educational materials and links. Members are provided information on taking classes through Diabetes Education. A Member Resource Guide located online in 2016 at http://www.fhcp.com/members/memberresourceguide.pdf



with information on Diabetes Education and other wellness programs, was also mailed to members. Members can obtain more information by contacting the Disease Management team, Member Services, Diabetes Education, Case Management, or their physician. Phone, fax, and email addresses are located on the FHCP web page under Member Wellness. Members are provided educational and support resources outside of the FHCP Diabetes Disease Management Program. Most educational materials include additional web site information for the member and/or identified caregiver.

Opting Out Members who do not wish to participate in the Diabetes Disease Management Program may request to opt out at any time. Instructions are included in the introductory letter (Figure 3).

Figure 3

Date

Dear Member,

Florida Health Care Plans (FHCP) is committed to helping our members achieve optimal health. Our records indicate you have a diagnosis of diabetes. FHCP offers a free comprehensive diabetes program which provides education and tools needed for successful self-managementWe have made participation in this program easy and accessible by automatically enrolling you in the program. As a participant, two or three times a year you will receive a member newsletter that includes diabetes specific articles. The newsletter provides valuable information covering a wide range of topics such as blood sugar control, diabetes medications, diet, exercise, stress reduction, and other helpful topics.

You may also participate in one of our diabetes education or nutrition classes. To register, call (386) 226-4518, Monday through Friday, between the hours of 8:00 AM to 5:00 PM.

Additional diabetes related educational materials can be located on the Florida Health Care Plans website at www.fhcp.com under the Health tab. Select the “Health and Wellness Topics” on the blue bar.

Your participation in this program is voluntary. If at any time you have questions or no longer wish to participate, please call (386) 676-7100 ext. 7242, Monday through Friday, between the hours of 8:00 AM to 5:00 PM. The hearing impaired may call TRS Relay 711.

Members who opt out are documented in the internal spreadsheet/registry based on received date, and will not be contacted for the remainder of the calendar year. All members who opt



out for the current measurement year will be contacted again at the beginning of each subsequent calendar year with the opportunity to participate in the Diabetes Disease Management Program. For 2016, there were no opt outs from the program.

INTERVENTIONS BASED ON ASSESSMENT

FHCP recognizes the importance of stratification of members with a current diagnosis of diabetes, and promotion of evidence-based interventions to control and prevent further complications. Interventions are designed to promote awareness and self-management through coordination with the member and the health care team. The goal is to improve member wellness and achieve positive health outcomes.

Stratification The Diabetes Disease Management Program stratifies members with diabetes monthly into low (Level I) and high risk (Level II) groups, based on laboratory test results for HgbA1c, as outlined in Table 1. For members missing a test value, interventions will be aimed at obtaining a test/result. Once HgbA1c result is known, the member will be stratified based the stratification criteria.

Table 1 Level Stratification Criteria Interactive Contact Level I Qualifying Diagnosis, HgbA1c ≤ 9.0 Not required

Level II Qualifying Diagnosis, Qualifying Encounter, HgbA1c > 9.0

Required

Interventions Based on Stratification Interventions are performed throughout many departments within the organization, as part of the overall Diabetes Disease Management Program. Focused interventions are provided to all members in the program including member education and provision of self-management tools. All interventions use evidence-based recommendations for care management, provider support and education. The educational approaches and tools available to FHCP members in the program were described in the Information Provided to Members section of this Program Description above.

Level II participants are defined as “higher risk” and require a greater amount of intervention, which includes interactive contact with the interdisciplinary healthcare team. Interventions for higher risk members are designed to prevent exacerbation and disease progression. Interactive contact can include a phone call for health coaching to encourage tests or pharmacotherapy compliance, an educational mailing at the member’s request, or diabetes-specific education classes. Caregivers and family members are included when appropriate



with the member’s consent. Interventions are individualized and based on the member’s need.

The overall goal is to assess barriers to adequate disease self-management and develop an individualized plan for education and health coaching. Through use of the assessment, the diabetes team partners with the member to identify and prioritize goals and build on the member’s current level of knowledge. These goals determine the interventions the member receives related to managing diabetes. The focus is disease definition, signs and symptoms of a worsening condition with actions to take, adherence to medication therapy, activity, medication regimens, referral to additional services such as Case Management or Behavioral Health, and coordination with the member’s PCP for care. Members are directed to communicate with their practitioner with any concerns or changes in their condition, or difficulty adhering to treatment. Physicians may refer their patients with diabetes to a wide network of specialists as necessary.

Encouraging Communication with the PCP (Level I & II) Members are encouraged to communicate with their PCP. The FollowMyHealth Patient Portal enables members with a staff PCP to:

Request, cancel or reschedule appointmentsSend secure messagesView lab and test resultsRequest prescription renewals if the member runs out of refills or the prescriptionexpires.

All members, whether they have contract or staff PCPs, are encouraged in the Member Resource Guide to contact their PCP with any questions or concerns about their condition and treatment needs. For example, members are reminded before they visit an urgent care clinic that “We encourage you to contact your Primary Care Physician (PCP) before visiting the clinic. Your PCP knows your history and will have helpful advice that may be useful as you seek medical attention, lab work, or other health related services.” For Specialty Care and Behavioral Health Services, members are reminded that “You and your PCP may determine that you need to see a specialist, including a behavioral health physician. Your PCP will coordinate your care and, in most cases, directly refer you to the specialist and services you need.” Members are also reminded how important physician-patient communication is, and that “You should feel comfortable talking with your Physician about your health and treatment. If you have any questions or concerns, express them.” Interdisciplinary healthcare team staff encourage members to contact their PCP as the most important link in their coordination of care and treatment plan. The PCP develops the plan of care based on diabetes medical issues, any medical and behavioral comorbidities, and any physical and cognitive limitations, which may require a referral and additional treatment by specialists and/or Behavioral Health.

Wellness Programs (Level I & II) Education is a joint effort by Case Management, Diabetes Education, Disease Management, Practice Management, physicians, specialists and others. FHCP offers a variety of health,



wellness and disease management programs and services at little or no cost, and there are no limitations on the number of programs in which a member may participate. Members are notified of resources through the FHCP website under Member Wellness/Disease Management. The website lists the various education programs for members such as classes on diet, smoking cessation, exercise, diabetes, heart disease, hypertension, and a Kidney Smart class by DaVita Hemodialysis. In addition, information related to specific disease states, activity, nutrition, and other pertinent material is posted. This information is also shared in newsletters, health fairs, flat-screen TVs in facilities, the Member Resource Guide, and Member Services. Printed materials are placed in offices, pharmacies, and labs.

Educational Mailings (Level I & II) Members at risk are included in educational mailings and programs unless they opt out. An example of mailed educational material is “Survival Skills for Diabetes”, which includes information and skills needed to successfully cope with the disease. All educational materials are accompanied by a letter with contact information for Disease Management. When a member contacts Disease Management, they are provided with information, and further encouraged by staff to contact their PCP with specific concerns or questions about their health condition.

Member Portal (Level I & II) The on-line Welcome to Wellness Member Portal is a web-based interactive site for member self-assessment and interactive learning related to diabetes and other co-morbid conditions. The portal includes written materials, risk assessments, quizzes, recipes, health articles in English/Spanish, interactive programs, and health videos. The portal also provides links to external resources for self-management such as the American Diabetes Association and American Heart Association. On the portal, members have the ability to complete a personalized Health Risk Assessment and obtain educational information and feedback specific to the member.

Diabetes Education (Level I & II) FHCP’s Diabetes Education department conducts ADA approved classes for members with diabetes that focus on comprehensive self-management education. A Pre-Diabetes class is also offered. Class schedules are posted on the intranet and internet to promote upcoming classes, and information is included in the Provider Newsletter as well.Certified diabetes educators (CDE) include Registered Dieticians and Registered Nurses, as well as a staff Endocrinologist. Individual behavioral objectives and potential barriers to care are identified during the assessment phase. The specific needs of each participant are assessed by one or more instructors, and the participant and instructors together develop a personalized plan for ongoing self-management support. The coordinator audits completed education records, to ensure that the appropriate documentation requirement has been met. Chart audits are done quarterly and shared and reviewed in the department team meetings. Two follow-up surveys are mailed to assess the member’s ability to maintain the goal. Responses are tracked to evaluate behavior change. The outcomes and plan for continued self-management support are



communicated to the health care team, and family members and/or caregivers with the member’s consent. Diabetes Education recently revised the diabetes education electronic medical record in collaboration with an Information Systems (IS) Provider Solution Analyst for additional changes to meet the core curriculum items required by the ADA. In addition, members participating in Diabetes Education are directed as needed to classes such as Healthy Heart, Eat Right-Move Right, Diabetes Refresher courses, Hypertension Management classes, Wellness Education Lectures known as “Lunch and Learn,” Personal Health Assessments, and Health Fairs. These interventions address health behaviors that may impede a patient’s ability to manage a condition, and members are encouraged to develop healthy behaviors.

Quality Management Monitoring (Level I & II) Quality Management staff receive monthly reports from CMAR, consisting of members who are non-compliant with the HEDIS® CDC quality measure. A clinical review on each member using the EHR, Provider Database, and other sources determines the specific circumstances and action needed for compliance. Providers are notified and education provided regarding the measure and the particular non-compliance issue(s). Members are mailed letters to notify them of what particular lab test or exam is needed to prevent disease progression. Follow-up phone calls to members are also done to encourage completion of a test.

GAP Reports (Level I & II) Assigned physicians receive at least four reports each year run by staff, which identify potential ‘gaps in care’ for the PCP’s members. The PCP receives information on what is specifically needed for each patient. This enables efficient condition monitoring and adherence to treatment plans, and assists in reducing or eliminating non-compliance with treatment. In addition, Disease Management and Quality Management staff monitor GAP Report results and may call members to encourage completion of a scheduled test, or contact the PCP if a test needs to be ordered. The following are shared with physicians in the GAP Report for their members with diabetes who are not compliant with one or more of the standards in the CDC quality measure:

Controlled HgbA1c: most recent result in measurement year is <8.0%Controlled blood pressure: controlled if most recent BP <140/90Retinal eye exam: performed annually by optometrist or ophthalmologistScreening for nephropathy: annual screening test or treatment which can includeurine test for albumin or protein, nephrologist visit, or ACE Inhibitor/ARB

Depression Screening - PCP Office Visits (Level I & II) At each office visit, PCPs use the PHQ-2 to screen members with diabetes for depression. The PHQ-9 is completed by the PCP for members answering yes to either of the two questions. For a score of 15 or greater, PCPs refer the member for additional care through Behavioral Health services.

Case Management Complex Care (Level II) Chronic Complex Care is an intensive intervention in Case Management for higher risk



members who have experienced a critical event or diagnosis requiring extensive use of resources and assistance in navigating FHCP. Members with diabetes and an abnormal HgbA1c value are candidates, and frequent hospitalizations and multiple chronic co-morbid conditions are a factor. Assessment for psychosocial issues, medical and behavioral comorbidities, polypharmacy, physical and cognitive limitations, non-compliance with care, and financial needs is performed. Interventions include initial screenings, hospital discharge follow-up (with assistance from Utilization Management), support services and community resources, housing, psychosocial assessment, depression screening, and diabetes management. This focused attention facilitates appropriate delivery of care and services. Members are closely monitored by Case Manager nurses, with a focus on self-management of diabetes and improved health outcomes. The nurse tracks HgbA1c annual screens or more frequent surveillance. Proactive telephonic contact to members with a HgbA1c>13.0 focuses on assistance in all areas of need. Interactive contact and education is performed to reinforce compliance and to work with members individually in a treatment plan to manage their diabetes. Because learning is not optimal until learning needs are assessed, the nurse develops an individualized plan of care using Milliman Chronic Care Guidelines and FHCP clinical protocols. Caregivers may be involved after obtaining the member’s consent. Collaboration with physicians, specialists, and Behavioral Health is ongoing and addresses the treatment plan, including medication adherence or any issues needing special attention.

Depression Screening - Case Management Complex Care (Level II) For members with diabetes being followed by Case Management Complex Care, a PHQ-2 (Patient Health Questionnaire) is completed. The PHQ-2 is a validated screening tool that uses two questions to identify possible signs of depression. If the member answers “yes” to either of the two questions, a PHQ-9 screening tool is completed. This tool outlines nine symptoms of depression and provides a total possible score of 0-27. If the score is 10 to 14, Case Management notifies the member’s PCP. If the score is 15 or greater, the member is referred to Behavioral Health, with notification to the PCP.

ARNP Project (Level II) An intervention developed in 2015 where an Advanced Registered Nurse Practitioner (ARNP) with expertise in diabetes targets a list of Medicare patients based on HEDIS® diabetes criteria (HgbA1c over 9 and not currently under the care of an endocrinologist) was modified. In 2016, the ARNP sees diabetic patients through coordination with Case Management.



Table 2 highlights selected interventions which are described above.

Table 2

Program Interventions

Intervention Program Content Type Addressed by Intervention M=Member P - Provider

Frequency Condition Monitoring

Patient Adherence

Other Health Conditions

Health Behaviors

Psycho-social Issues

Diabetes Survival Guide (M)

Upon enrollment

x x x x x

Diabetes Education Health Coaching & Classes (M)

Offered at least once to those members with diabetes

x

Welcome to Wellness Member Portal (M)

Always Available

x x x x x

Disease Management/ Member Wellness Website (M and P)

Always Available

x x x x x

Depression Screening (M)

At least once x

Behavioral Health Referral (M)

If indicated based on depression screening

x x x x

Case Management Referral (M)

If indicated x x x x x

Case Management Nurse Coaching (M)

Offered at least once to those members with HgbA1c >13

x x x x x

ARNP Coaching (M)

From Case Manage-ment referrals

x x x x x



ELIGIBLE MEMBER ACTIVE PARTICIPATION

Active participation rates are determined by the total number of members eligible for the program, which is the denominator for the twelve month period. The numerator is the number of members who received at least one interactive contact.

PRACTITIONER EDUCATION

Physicians and other healthcare providers are notified about our Disease Management Diabetes Program by new provider education, Provider Services Handbook, memos, notices, committee participation and reports, Provider Newsletters, FHCP website, and Practice Management. The Provider Services Handbook includes a brief program description, participant eligibility criteria, and the referral process. A new flyer was posted on the intranet and internet for Diabetes Education classes and this was added to the Provider Newsletter as well.

REFERENCES

1 National Diabetes Statistics Report. National Center for Chronic Disease Prevention & Health Promotion, Centers for Disease Control and Prevention, released 2014.

http://www.cdc.gov/diabetes/pubs/statsreport14/national-diabetes-report-web.pdf

REPORTING


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Diabetes Disease Management Program Stratification & Interventions Report


INTERVENTIONS

Florida Health Care Plans (FHCP) recognizes the importance of stratification of members with a current diagnosis of diabetes, and promotion of evidence-based interventions to control and prevent further complications. Interventions are designed to promote awareness and self-management through coordination with the member and the health care team. The goal is to improve member wellness and achieve positive health outcomes.

Stratification The Diabetes Disease Management Program stratifies members with diabetes monthly into low (Level I) and high risk (Level II) groups, based on laboratory test results for HgbA1c (Table 1). For members missing a test value, interventions will be aimed at obtaining a test/result. Once HgbA1c result is known, the member will be stratified based the stratification criteria.

Table 1 - Stratification Levels Defined

Interventions Based on Stratification The multiple education methods available to FHCP members in the Diabetes Disease Management Program were described in the Information Provided to Members section of the Program Description. Level II participants require a greater amount of interactive contact and interventions. A detailed description of each intervention for both levels can be found in the Interventions Based On Assessment section of the Program Description.

Tables 2 and 3 outline members in the program, and interventions received, by levels.

Table 2 - Diabetes Disease Management Program Stratification for 01/01/2016 to 12/31/2016

Diabetes Diagnosis, & Stratified Level I Level II Total

Commercial 1,623 264 1,887

Medicare 1,751 131 1,882

Marketplace 703 142 845

Members in Program Total 4,077 537 4,614

Level Stratification Criteria Interactive Contact Level I Qualifying Diagnosis, HgbA1c ≤ 9.0 Not required

Level II Qualifying Diagnosis, Qualifying Encounter, HgbA1c > 9.0

Required



Table 3 - Received Intervention*

Educational Mailings to Newly Identified Level I Level II

Commercial 1,623 264

Medicare 1,751 131

Marketplace 703 142

Diabetes Education Classes Level I & II

Commercial 111

Medicare 100

Marketplace 90

Letters: Members-HEDIS® CDC Non-Compliance Level I & II

Commercial, Medicare, or Marketplace 1,646

Phone Calls: Members-HEDIS® CDC Non-Compliance Level I & II

Commercial 553

Medicare 219

Marketplace 202

Educational Materials Mailed Per Member Request Level I & II

Commercial 2

Medicare 30

Marketplace 2

Interventions Total** Level I Level II Level I and II Total

Commercial 1,623 264 666 2,553

Medicare 1,751 131 349 2,231

Marketplace 703 142 294 1,139

Not separated by product - - 1,646 1,646

Interventions Total 4,077 537 2,955 7,569

* Members may have received more than one intervention.** Unable to separate all results by level, and/or by product.



REPORTING


Diabetes Disease Management Program Active Participation Report Florida Health Care Plans

01/01/2016 to 12/31/2016

ELIGIBILITY

A member is identified for inclusion in this program via the following sources: claims for encounters; pharmacy data; laboratory data; electronic health record (EHR); Nurse Advice Line; health appraisals; and referrals from physicians, Disease Management, Case Management, Utilization Management, and Member Wellness programs and classes.

ACTIVE PARTICIPATION

Member active participation rate for 2016 (Table 1) is determined by:

The number of members with at least one interactive contact (numerator) divided by:

The number of members identified as eligible for the program (denominator).

Interactive contact is defined as an intervention with the member via a phone call for health coaching; class attendance; or an educational mailing per member request.

Table 1

LOB Total Eligible Population CY 2016

Total Eligible Population CY 2015





Commercial 2,535 2,452 112 106 4.4% 4.3%

Medicare 2,171 1,771 143 156 6.6% 8.8%

Marketplace 991 298 90 9 9.1% 3.0%

Total 5,697 4,521 345 271 6.1% 6.0%

REPORTING


Diabetes Disease Management Program Member Satisfaction Analysis


INTRODUCTION

Analysis of member satisfaction with the Diabetes Disease Management Program allows Florida Health Care Plans (FHCP) to identify aspects of performance that do not meet member expectations, and to initiate actions to improve performance. FHCP monitors member satisfaction with the Diabetes Disease Management Program through analysis of diabetes member satisfaction surveys and member complaints. This report describes the monitoring methodology, results, and analysis for each satisfaction data source.

MEMBER SATISFACTION SURVEY

Methodology The Diabetes Disease Management Program Member Satisfaction Survey population includes a random sampling of members identified as Level II during the measurement year. The written survey is administered by Disease Management staff and sent via mail annually.

Results of the survey are summarized below in Tables 1 and 2. Due to a response rate of ‹20%, survey findings cannot be generalized to all members in the Diabetes Disease Management Program for these product lines.

Table 1 - Number of Surveys Sent and Response Rate

Product # Surveys

Sent 2016

#Surveys Sent 2015

# Surveys Received

Back 2016

# Surveys Received

Back 2015

2016 Response

Rate

2015 Response

Rate

Commercial 376 131 25 15* 7% 7%

Medicare 383 101 59 18 15% 18%

Marketplace 160 95 7 * 4% *

TOTAL 919 327 91 33 10% 10%

*Unable to separate Commercial and Marketplace surveys received back for 2015



Table 2 – Commercial, Marketplace and Medicare Survey Results

Survey Questions Have you received a call from FHCP regarding your Diabetes?

34% - Yes 66% - No

Were you able to manage your Diabetes better after a discussion with an FHCP team member?

63% Positive (Agree or Strongly Agree)

Were written materials mailed to you (brochures, letters, newsletters, etc)?

48 % -Yes 52% - No

Were the written materials helpful and easy to read? 84% Positive (Agree or Strongly Agree)

Did you participate in any Diabetes classes offered by FHCP?

55% - Yes 45% - No

Did those classes help you manage your Diabetes? 74% Positive (Agree or Strongly Agree)


24% - Yes 76% - No

May we contact you to discuss your survey answers? 59% - Yes 41% - No

Would you be interested in joining a focus group? 22% - Yes 78% - No

Quantitative Analysis The total number of surveys sent for the Diabetes Disease Management Program was 919. The total response rates for all 3 products (Commercial, Marketplace and Medicare) is 10%. The response rate remained the same from 2015 to 2016.

Qualitative Analysis Florida Health Care Plans Diabetes Disease Management Program member satisfaction goal is 80%. To identify opportunities to improve performance, an analysis was conducted by internal staff to identify the root causes of any member dissatisfaction with the Diabetes Disease Management Program. Below are survey questions with a summary of the responses.

Were the written materials easy to read?

In both 2015 and 2016, this goal was met. There was a slight improvement in 2016 (84%Positive) when compared to 2015 (83% Positive).



Did those classes help you manage your Diabetes?

In 2015, the member satisfaction goal for this question was met (100% Positive). In 2016,the response dropped to 74% Positive. The Diabetes Education Department conducts aseparate survey for members attending classes, and feedback received consistently metthe goal.

Were you able to manage your Diabetes better after a discussion with an FHCP team member?

The satisfaction rate improved from 43% Positive in 2015, to 63% Positive in 2016. TheDiabetes Education Department conducts a separate survey for members attendingclasses, and responses received consistently met the goal.


Offer refresher courses each year to provide the most up to date information/issuesIf you can see in either EHR or another means that a person's A1C is being managed or incheck, stop mailing the info as it will save FHCP $. Love the recipes though!The instructions given by FHCP are easy to follow and workI do not have diabetes, I hate surveysKeep sending materialOffer better hours for people who work full timeI am an RN, what I have read seems adequateI am not diabeticEncourage refresher classesGreat ClassScrap the pyramid diet. Low carbs has always helped me much more.Great Job! :-)Brittle diabetes some solutionsFHCP is so great!

Educational materials for diabetes were updated and more comprehensive materials were included in mailings. Materials are reviewed annually for currency. Most educational materials include additional web sites for the member and/or identified caregiver.

The Disease Management Committee seeks ways to improve services to diabetic members. This is based on member survey responses, actively working non-compliant lists and performing analysis of HEDIS® quality measures, physician and specialist input at committee meetings such as Quality and Patient Safety, and input from Case Management staff and all members of the healthcare team. For example, an intervention was developed in 2015 where an Advanced Registered Nurse Practitioner (ARNP) with



expertise in diabetes targeted a list of Medicare patients based on HEDIS® diabetes criteria (HgbA1c over 9 and not currently under the care of an endocrinologist). In 2016, the ARNP saw diabetic patients through coordination with Case Management. Physicians have also been provided with an improved and more frequent report which shows specific gaps in care (tests, labs, exams) for their diabetic members.

For patients who indicate they do not have diabetes, a clinical review of their chart is performed to determine what diagnosis claim placed them in this category. If the diagnosis on the claim was entered in error, the record is corrected. The member is always contacted to discuss the issue and resolution.

For members who work full-time, evening and Saturday sessions are offered. Classes are planned monthly; if there is an increase of referrals, classes are added as indicated.

Efforts will continue to improve the response rate for surveys. The response rate decreased slightly from 2015 to 2016. A review by Disease Management staff determined that a redesign of the formatting of survey questions for 2018 may increase the response rate. This will be completed before the surveys are mailed in 2018. The font size will be increased for ease of response, along with directions on how to respond, such as “Circle One.” The goal is to improve the overall clarity of the questions for understandability and ease of response. The Disease Management Committee will continue to address issues specific to member engagement for surveys.

The goal of 80% member satisfaction was met in the Diabetes Education Satisfaction Survey, which is sent by the Diabetes Education staff (results below).

DIABETES EDUCATION SATISFACTION SURVEY

Methodology The Diabetes Education component of the program conducts a separate Satisfaction Survey specific to members who participated in Diabetes Self-Management Education classes. This patient satisfaction survey is the Continuous Quality Improvement (CQI) project for Diabetes Education. The goal is a 100% satisfaction rate. Below are the results for 2016:

Table 3 - CQI: Satisfaction survey

Our patient satisfaction survey continues to be our Continuous Quality Improvement (CQI) project. Results indicated for 2016 data period were excellent with participants who complete the program very satisfied with the classes, instructors, and teaching materials.



Table 3 - Participants are asked the following questions:

Post Class Program Evaluation Satisfied Not Satisfied

The classes motivated me to take action to control my diabetes 96%

The classes have given me ways to manage my diabetes better 97%

The class manuals and handouts were useful 98%

Yes No answer Were you satisfied with the program and educators? 97% 8

Table 4 - Other outcome measures

(This information is based on follow up responses from our mail-outs)

Topic Target Actual Rating For Compliance

Nutritional Management 75% 95%

Physical Activity/Being Active 75% 63%

Monitoring 75% 98%

CQI Project – Pre/Post Test

Each participant takes a pre-test during the assessment phase; at the end of class 3 the same test is given to the participant to see if there is improvement in their score.

If the score is less than 80%, a one on one remediation is done with the participant.

The following is data collected for 2016. The target rate of 85% was exceeded in all quarters:



Table 5

Reporting Review -2016

Jan-Mar Apr-Jun Jul-Sep Oct-Dec

Target 85% 85% 85% 85%

Outcome 94% 89% 96% 95%

Review Outcomes 94% had an improvement in their post-test result.

89% had an improvement in their post-test result.

96% had an improvement in their post-test result.

95% had an improvement in their post-

test result.

MEMBER COMPLAINTS

FHCP defines a complaint regarding the Diabetes Disease Management Program as any negative feedback reported to the Member Services department.

Upon receipt of verbal or written complaints, each one is assigned a category code based upon the main issue. Some complaints relate to multiple issues. Due to information system limitations, only one category code is assigned to each complaint. Therefore, this data reflects the number of complaints about the Diabetes Disease Management Program received from members, but may understate the exact number of issues raised by members due to coding limitations. Member complaints about the Diabetes Disease Management Program are reviewed and analyzed annually.

Analysis There were no complaints for the Diabetes Disease Management Program in 2016 or 2015 (Table 5). FHCP will continue to monitor program complaints.

Table 6 2016 2015

# Per 1000 # Per 1000 Diabetes DM Complaints 0 0 0 0



REPORTING


Diabetes Disease Management Program Effectiveness Measures Report


Measure Description and Relevance To gauge the impact of its Diabetes Disease Management Program, Florida Health Care Plans (FHCP) monitors Hemoglobin A1c (HgbA1c) poor control, greater than 9.0. This is a specification in the HEDIS® (Healthcare Effectiveness Data and Information Set) Comprehensive Diabetes Care (CDC) quality measure. This measure examines the percentage of members 18–75 years of age with diabetes (type 1 and type 2) who had HgbA1c testing with a result greater than 9.0 within the measurement year.

The foundation of the FHCP Diabetes Disease Management Program is improving glycemic control by assisting members in successful self-management of their diabetes as evidenced by an HgbA1c value that is less than 9. The goal of the program is to support the practitioner-patient relationship and focus on prevention of cardiovascular disease, nephropathy, retinopathy, and neuropathy.

Methodology The numerator specifications used for this measure are: number of members in the eligible population who have an HgbA1c level greater than 9.0 on the most recent testing. When analyzing the HgbA1c poor control measure, a lower rate is desired.

The denominator specifications used for this measure are: all eligible members between the ages of 18-75 years of age identified for the diabetes population per the HEDIS® CDC quality measure.

Sample Population: Sampling methodology and sample size is determined according to the HEDIS® 2016 specifications. Hybrid rate is reported.

Data sources: The denominator is determined by claims/encounter data and pharmacy data. The numerator is determined by laboratory results.

Performance goal: FHCP has established an organizational goal to achieve the 90th percentile compared to the HEDIS® benchmark.



Table 1 - Results for the Commercial population – CDC HgbA1c poor control >9% Measurement Time Period


01/01/15-12/31/15 77 407 18.92% 90th 01/01/15-12/31/16 75 403 18.61% 90th

Re-measurement Analysis (01/01/16-12/31/16) For the re-measurement period, the rate of 18.61% again placed FHCP in the 90th percentile. Results in 2016 for the Commercial population met the performance goal.

Table 2 - Results for the Medicare population - CDC HgbA1c poor control >9% Measurement Time Period


01/01/15-12/31/15 19 360 5.28% 90th 01/01/16-12/31/16 37 321 11.53% 90th

Re-measurement Analysis (01/01/16-12/31/16) For the re-measurement period, the Medicare rate of 11.53% again placed FHCP in the 90th

percentile, which met the performance goal.

Table 3 - Results for the Marketplace population - CDC HgbA1c poor control >9% Measurement Time Period


01/01/15-12/31/15 25 147 21.77% 75th 01/01/16-12/31/16 91 401 22.69% 75th

Re-measurement Analysis (01/01/16-12/31/16) The percentile is based on Commercial thresholds. This measure is not reported for Marketplace as percentiles have not yet been developed. The 75th percentile was maintained. The performance goal of the 90th percentile was not met.

Barriers/Opportunities for Improvement, Actions and Outcomes To identify opportunities to improve performance, FHCP conducted a barrier analysis of the Diabetes Disease Management program to identify any root causes. Based on the analysis of performance and surveys, FHCP concluded there was an opportunity to improve performance.



Results of a barrier analysis and actions implemented to address the identified barriers and improve the Diabetes Disease Management Program effectiveness are noted below in Table 4.

Table 4

Date Barrier Addressed Actions Outcome

2016 Consistent and understandable communication to physicians for missing HEDIS® CDC quality measure requirements.

Gaps in adherence to HEDIS® CDC guidelines are identified via reports which are released to the assigned PCP for their members identified as needing intervention. The GAP report was revamped for better understanding. The GAP is now available daily to staff providers.

HEDIS® CDC rates and satisfaction surveys will continue to be tools for monitoring improvement, and physician comments will be evaluated at committee meetings.

2016 Ensuring the most up-to-date information is provided in Diabetes Education classes, and continued availability of classes to members.

The required curriculum is reviewed and the 10-hour diabetes manual is updated annually. A quarterly all-day class is offered as well as evening sessions. Healthy Interactions Maps are used in small classes and the Saturday sessions. Classes are planned monthly; if there is an increase of referrals, classes are added as indicated.

HEDIS® CDC rates will be monitored for improvement, as well as class participation numbers and surveys.

2016 Increase participation in Diabetes Education classes.

Flyers are posted on the intranet and internet to promote classes and this information was added to the Provider Newsletter as well.

HEDIS® CDC rates will be monitored for improvement, as well as class participation numbers and surveys.



Date Barrier Addressed Actions Outcome

2016 High risk patients with multiple co-morbidities are difficult to manage. Coordination of care needs improvement.

Physicians are encouraged to engage all available resources when encountering difficult or hard to manage patients. Case Management’s Coordination of Care program engages the patient early, especially those with multiple illnesses, medications, ER visits, or non-compliant with care. In 2016, the plan began using equipment from Care Innovations for transitional care. Staff is sent to the house if technical assistance is needed. Members receive an oximeter, blood glucose monitor, scale, and blood pressure machine. In 2016 there was a pilot program of 100 members. The Home Docs extension is an interactive tool for disease process self-management and to allow medical staff to understand what is going on in the home. In daily interactive health sessions, members are asked questions. Bluetooth peripherals allow biometric readings to be uploaded in real-time to the CM portal. Individual parameters are set for each member based on physician orders. An alert is sent via email to the CM RN when biometrics are outside set parameters. I Pad has capability of



REPORTING


Depression and Diabetes Disease Management Programs Integrating Member Information


INTEGRATING INFORMATION - USE OF EHR

Florida Health Care Plans (FHCP) ensures that each department can view reports in other departments to facilitate access to member health information for continuity of care. FHCP’s Electronic Health Record (EHR) is available throughout the entire organization to appropriate staff. All reports are housed in the EHR for immediate and timely access. The screen shots in this report are from the EHR.

FHCP has a health information line for all members. The Nurse Advice Line is available 24 hours a day, 7 days a week. All calls are followed up and evaluated by clinical staff for quality control to ensure they were appropriately handled.

The Nurse Advice Line Triage Call Report and the Disease Management follow-up reports are accessible to Behavioral Health, physicians, Case Management, Utilization Management, Diabetes Education, wellness programs, and other staff who are part of the interdisciplinary health care team.

Figure 1 shows an example of the Nurse Advice Line triage report that is scanned into the EHR.

Figure 1



Figure 2 is the Disease Management tasking list for follow-up to the Nurse Advice Line triage reports.

Figure 2

The Disease Management Programs document in the EHR immediately following interactive contact with members to ensure availability of information to Behavioral Health, physicians, Case Management, Utilization Management, Diabetes Education, wellness programs, and other staff who are part of the interdisciplinary health care team (Figure 3). Urgent information is also tasked directly to staff providers and faxed to contracted providers.

Utilization Management documents concurrent reviews and hospital admission and discharge information in notes contained within the member’s EHR under “Case Management Notes” labeled CM-Hospital Discharge note (Figures 4 & 5) to allow dissemination of relevant information to appropriate health care team members. These reports are immediately available to Behavioral Health, physicians, Disease Management, Case Management, Diabetes Education, wellness programs, and the entire health care team.

Figure 3 3



Figure 4

Figure 5



Case Management integrates member information into the EHR to facilitate communication with the interdisciplinary health care team. Initial screening notes, hospital discharge follow-up, follow-up contacts, support service assistance, diabetes management, depression screening, and counseling are documented under “Case Management Notes” (Figures 6 & 7) and are immediately available to Behavioral Health, physicians, Disease Management, Utilization Management, Diabetes Education, wellness programs, and the entire health care team.

Figure 6



Figure 7



For wellness programs, participation is documented in the member’s EHR and is immediately available to Behavioral Health, physicians, Disease Management, Utilization Management, Case Management, Diabetes Education, and the entire health care team (Figure 8). This is an EHR note documenting a member’s participation in a wellness program, which in this example is a Diabetes class.

Figure 8

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2016 Annual Carenet Summary

Data Summary: Comparison of 2016 and 2015 (Totals reported by Carenet)

2016 Total Calls Triaged 113 123 151 143 150 116 141 121 129 114 126 93 1520

2016 Total Calls Answered

216 252 259 250 250 205 248 212 223 285 256 268 2924 2016 Percentage of calls Triaged from Total Calls 52% 49% 58% 57% 60% 57% 57% 57% 58% 40% 49% 35% 52%

2016 Total Calls Triaged 113 123 151 143 150 116 141 121 129 114 126 93 1520

Recommended disposition "See ED Immediately" 2016

13 8 25 11 24 12 13 18 10 21 17 13 172

2016 Percentage of calls with Disposition to EDfrom total triaged

12% 7% 17% 8% 16% 10% 9% 15% 8% 18% 13% 14% 11%

Call Metric Jan Feb MarApril May June July Aug Sept Oct Nov Dec Total

2016 Total Calls answered 216 252 259 250 250 205 248 212 223 285 256 268 2924

2015 Total Calls answered 264 227 254 216 295 218 266 218 182 186 236 224 2800

Percentage increase /decrease of Total calls comparing 2016 to 2015

-18%

+11%

+2%

+16%

-15%

-6%

-7%

-3%

+23%

+53%

+8%

+20%

+4%

2016 total calls triaged 113 123 151 143 150 116 141 121 129 114 126 93 1520

2015 total calls triaged 150 137 140 127 177 138 141 131 95 104 129 109 1578

Percentage increase /decrease of triage calls comparing 2016 to 2015

-25%

-10%

+8%

+13%

-15%

-16%

0%

-8%

+36%

+10%

-2%

-15%

-4%

Dev 1/11/2017 BV

Analysis:

• 52% of total calls in 2016 were triaged• 11% of total calls triaged in 2016 were advised “See ED Immediately”• 4% increase in total calls between 2015 and 2016• 4% decrease in total triaged call between 2015 and 2016• 12% decrease in triage disposition “See ED Immediately” between 2015 and 2016• Utilization is 4.82% in 2016 compared to 5.5% in 2015. This is a decrease of 12.7%

From January through April, there were periodic problems with eligibility file loading and receiving multiple errors. We chose to relax eligibility criteria for that period as to not turn away a member in need of triage. Files were corrected by IT and the original process was put back into place.

Member complaints:

1/2016 Call made to Carenet-24 hour nurse line. Carenet was unable to verify member’s eligibility, triage was not completed. Research was conducted by FHCP IT department, findings showed an issue with eligibility file. Error was corrected by FHCP IT department. Enrollment verified member was current. Member was called and informed of correction and told they may use the 24 hour nurse line as needed.

7/2016 Complaint made to member Services. “Member stated Carenet asked too many questions, the call back time was too long and ultimately they were advised to see their own physician”. Follow up was completed by Quality from Carenet triage report. After review, it was determined time in queue before call back was seven minutes. The triage nurse made 2 attempts to reach member but no contact was made. Voice message left by triage nurse: “if you still need assistance from the nurse please call us back”. All actions taken, case closed.


13 8 25 11 24 12 13 18 10 21 17 13 185


25 18 16 18 22 18 10 15 13 16 20 20 211

Percentage increase /decrease "See ED Immediately" comparing 2016 to 2015

-48%

-56%

+56%

-39%

+9%

-33%

+30%

+20%

-23%

+31%

-15%

-35%

-12%

Increase Statistics reported by Carenet Decrease

Dev 1/11/2017 BV

Barriers:

Interventions: DateInitiated

Action Implemented BarriersAddressed

A 4/2016

8/2016

9/2016

Workforce Wellness - extended hours and designated locations- forwarded to Carenet requesting they direct members as appropriate to these facilities after hours and not to Ed or Urgent Care.

Doctor on Demand telemedicine services information forwarded to Carenet requesting they direct members as appropriate

Updated list for Workforce Wellness - extended hours and designated locations was forwarded to Carenet along with list of participating Hospitals and Urgent Care facilities.

1

B Ongoing We continue to have a multi-touch outreach processes to engage and educate our members about Carenet services. Some of the initiatives currently in place include: all new members receive information regarding the 24 hour Nurse Line in their enrollment welcome packet; information is placed on our internet site, flat screen televisions in various locations and in our quarterly newsletters mailed to members.

2

C 4/2016 Updated list of programs available to FHCP members forwarded to Carenet for implementation.

3

Outcome of Actions: Action Assessed Outcome

(A) Carenet directingMembers to ED/UCC.Workforce wellness not beingutilized when appropriate

Carenet- Information was forwarded to Change Control for implementation of extended hours and after hour facilities. Staff was re-educated

(B) Members not aware ofCarenet Service

Continue with initiatives currently in place

(C) Members who are triagedwith disease specificquestions are not directed toavailable programs providedby FHCP

Carenet- Information was forwarded to Change Control for implementation

Barrier Opportunity1 Carenet directing Members to ED/UCC. Workforce

wellness and Doctor on Demand not being utilized when appropriate

Inform Carenet of available hours and facilities to direct members to after hours when appropriate

2 Members not aware of Carenet service Inform members of the availability of services

3 Members who are triaged with disease specific questions are not directed to available programs provided by FHCP

Inform members of the availability of services

Dev 1/11/2017 BV

Committee Reporting: The results, analysis and actions reported in this summary report were reported to the following QI committees on:

Committee Receiving Report Report Dates Customer Satisfaction Performance Improvement

Florida Health Care Plans

End of Year Results 2016 Member Satisfaction Survey 1. Overall satisfaction with health information line services:Goal – 92%Actual – 96%

2. Satisfaction with ability to reach health information line:Goal – 92%Actual – 92 %

3. Satisfaction with interaction from health information line staff:Goal – 92%Actual – 97 %

4. Satisfaction with advice received from the health information line staff:Goal – 92%Actual – 95%

All goals met, action items not required

Staff Call Monitoring Report Goal is 90%

Aggregate results of staff call monitoring for criteria assessed and comparison to internal performance goal

2016 Results for Nurses is 94 % 2016 Results for Care Coordinators is 95%

Evidence of action taken to improve results if performance did not meet goal: Not applicable

This report annually summarizes the measurement methods, results and analysis pertaining to the assessment of quality and accuracy of responses to customer service calls (specifically relating to pharmacy benefits or pharmacy issues). Methods for correcting deficiencies, when indicated, are also discussed.

Measurement MethodologyA quarterly report is prepared by the Assistant Administrator of Pharmacy Services – Operations. Each of the four pharmacy service representatives (PSR) interact with Members and pharmacies or other departments on a Member’s behalf, via the telephone. The quarterly report is comprised of a monthly sampling of ten (10) Member calls per pharmacy services representative. The sampling method is accomplished utilizing “silent monitoring” via FHCP’s Cisco Compliance Recording System during incoming Member calls to the Pharmacy Services Department. Monitored calls constituted 4.2% of all incoming calls to the Pharmacy Services Department in 2016. Each call is categorized by call typeas follows: pharmacy inquiry, medical inquiry, or behavioral health inquiry. Each monitored call is assessed utilizing a monitoring tool checking for the following:

Accuracy of response and Call handled appropriately if sent to anothersourceWhether the issue was addressed in one contactWhether the call was forwarded to another person and the pharmacyrepresentative stayed on the line until the next person answeredEnsuring that HIPAA protocol was followed

All FHCP Member calls for all FHCP lines of business are monitored using the same measurement methodology.

Pharmacy inquiries include:Determining the financial responsibility for a drug based on the pharmacybenefit.Requesting early refill authorization for mail order and walk-inprescriptions.Determining potential drug-drug interactions.Answering questions regarding medication side effects.Determining the availability of generic substitutes.Answering billing and processing questions from outside pharmacies.Finding the location of an in network pharmacy by name and zip code.Completing prescription record requests for tax, housing, and legalpurposes.

Benefit questions and inquiries include:Determining how and when to obtain exceptions, referrals, andauthorizations for specific medications, as applicable.Determining plan-specific information related to benefits and exclusion ofpharmacies or products.

Answering formulary questions.Answering Transition Benefit questions.Assisting members with complaints, refund requests, and co-pay waiverinformation.Answering questions about co-pay and co-insurance, deductible andmaximum out of pocket status.Assisting Members with Member Portal questions, accuracy, andcustomer satisfaction comments related to member portal navigation.

Every attempt is made to provide information related to pharmacy benefit and operations in one call. If information is not available to the pharmacy services representative answering the telephone, the Member is warm transferred to theClaims Department, Member Services, Referrals, a Retail Pharmacist or a Clinical Pharmacist as necessary for assistance with these inquiries.

ResultsThe table below displays the number of calls that met each criterion in the reporting period, and the percent compliant for each criterion.

Quality and Accuracy of Pharmacy and Benefit Pharmacy Service Calls 2016

PharmQ1

PharmQ2

PharmQ3

PharmQ4

Total # calls monitored

120 100* 130** 120

Accurate response given by PSR and handled appropriately

120 100 130 120

Compliance 100% 100% 100% 100%HIPAA Compliant 120 100 130 120Compliance 100% 100% 100% 100%Handled in one contact

119 100 130 120

Compliance 99.2% 100% 100% 100%Forward call Stayed on line

119 100 130 120

Compliance 99.2% 100% 100% 100%Appropriate Action Taken

120 100 130 120

Compliance 100% 100% 100% 100%Overall Compliance Rate

99.7% 100% 100% 100%

*Total calls monitored for Q4 was decreased by 10 calls in May and June due toan error in the Cisco System that did not record calls for one of the officerepresentatives.**An additional pharmacy representative was added this quarter. While she wastraining, the outgoing representative answered 5 questions per month for Julyand August.

Total % Pharmacy Compliance Q1-Q2 2016



99.9% 100% 99.95%

Analysis and ActionIn 2016, the plan established a performance goal of 100% compliance in all categories annually. Calls pertaining to pharmacy benefits were rated as compliant in two (3) of the five (5) categories.

Criteria which met the performance goal of 100% pharmacy benefit calls are:Accurate response by pharmacy service representativeHIPAA compliantAppropriate action taken

Based on this analysis, there are opportunities to improve performance in the following categories:

Member call handled in one contactForward call and Pharmacy Service Department resource stayed on line

The Pharmacy Services Office received a total of 11,419 calls in 2016 compared to a total of 11,195 calls in 2015. The increase can be attributed to an overall increase in FHCP membership. Inquiries from Outside Pharmacies (211) wereonce again the top reason given for calls in 2016. This was mainly due to trouble at outside pharmacies processing new ACA cards. The second highest amount of calls (118) came in from Members wanting an Early Prescription Refill. These calls were mostly due to Members going on vacation and are tracked centrally in the Administration Office.

Barrier Opportunity Intervention Date Implemented

All calls cannot be answered in one call. Pharmacy Services only has access to pharmacy systems.

Continue to monitor accuracy of calls answered by Pharmacy Services andappropriateness of transfers to another source.

Continuoustraining on whocan best meetmember needsin Pharmacyand in FHCP.Clarified policythat a warmtransfer toanother FHCPDepartment isthe standard ofquality.

Ongoing

Need another pharmacy services representative to replace one thatmoved to the PBM department

An increase in membership and the movement of one staff member to the PBM department led to the decision to hire another representative.

One pharmacyservices repwas hired inJune 2016 inorder to handleincreased callvolume and toreplace theother repchanging depts.

June 2016 and ongoing training.

Results:

Committee Reporting Summary

The results, analysis and actions reported in this summary report were reported to the following Performance Improvement committees on:

Committee Receiving Report Report DatesPharmacy and Therapeutics Committee – Phone Monitoring Tool

3/1/16, 6/7/16, 9/6/16, 12/6/16Quality and Accuracy – 3-21-2017

Performance Improvement Council Quality and Accuracy - April 2017

Marketing Materials Evaluation

Report Period: November 2016 – October 2017

Purpose: To ensure that communication with prospective members correctly and thoroughly represents the benefits and operating procedures of the organization.

Evaluation Process:

(1) As with prior years, customized online presentations are created for each large groupbenefit plan describing plan benefits, access, customer service, online tools available tomembers and how to interact with the plan 24x7. These presentations are madeavailable to Group HR Departments who may place the presentation on their internalbenefits or web intranet sites. Members are provided a survey at the end of thepresentation and completion is voluntary.

(2) Due to a redesigned enrollment packet in October 2016 and poor response to the FHCPpostcards and Brainshark presentations used in prior years, FHCP now sends an emailinvitation to new members inviting them to participate in the Marketing Survey throughSurvey Monkey. This was reported as an Action Plan last year. The survey iscomprised of 7 questions which allow members to rate the effectiveness of themarketing materials provided to them. Completion is voluntary.

Survey response to date has been poor.

Data Summary:

Annual 2016/2017 Report period results:

Total of 57 Surveys were returned in the reporting period. Respondents were asked how effectively FHCP's marketing materials educated them on PCP selection/change, provider network, referrals and pharmacy/drug locations and costs:

Question 1 regarding how to choose or change PCP resulted in 82.15% positive response, while 17.85% of respondents were negative.

i. 30.36% strongly agreed.

ii. 51.79% agreediii. 10.71% disagreediv. 7.14% strongly disagreedv. 0% not applicable

Question 2 regarding how to see a Provider Out of Network, resulted in 51.78% positive response, while 48.22% were negative.

vi. 10.71% strongly agreedvii. 41.07% agreedviii. 33.93% disagreedix. 14.29% strongly disagreedx. 0% not applicable

Question 3 regarding how to find a Provider In Network resulted in 78.58% positive response, while 19.65% were negative.

xi. 26.79% strongly agreedxii. 51.79% agreedxiii. 14.29% disagreedxiv. 5.36% strongly disagreedxv. 0% not applicable

Question 4 regarding which services do not require a referral resulted in 50% positive response, while 50% were ngative.

xvi. 8.93% strongly agreedxvii. 41.07% agreedxviii. 30.36% disagreedxix. 19.64% strongly disagreedxx. 0% not applicable

Question 5 regarding how to obtain services after hours resulted in 62.5% positive response, while 37.5% were negative.

xxi. 7.14% strongly agreedxxii. 55.36% agreedxxiii. 26.79% disagreedxxiv. 10.71% strongly disagreedxxv. 0% not applicable

Question 6 regarding which pharmacies to use for prescriptions resulted in 75% positive response, while 25% were negative.

xxvi. 17.86% strongly agreedxxvii. 57.14% agreedxxviii. 12.50% disagreedxxix. 10.71% strongly disagreedxxx. 1.79% not applicable

Question 7 regarding steps to lower pharmacy costs resulted in 44.64% positive response, while 56.9% were negative.

xxxi. 8.93% strongly agreedxxxii. 35.71% agreedxxxiii. 37.50% disagreedxxxiv. 19.4% strongly disagreedxxxv. 0% not applicable

Analysis of Results:

The overall survey resulted in 63.52% positive responses and 36.44% negative. The positive responses were centered around PCP selection/change and in- network provider and pharmacies and obtaining in-network services. The areas that received the most negative responses included the understanding the referral process and steps to lowering pharmacy costs.

Challenges/Barriers:

(1) Survey completion continues to be a challenge. Florida Blue changed presentationvendors from Brainshark to Knovio in early 2017. Since this change, there have beenno responses from the surveys.

(2) Since inception, the Survey Monkey surveys have been very poor.

Action Plan:

Based on the responses received were more than 30% negative, we have implemented the following changes:

(1) The emailed, online surveys will be made available in the redesigned FHCP MemberPortal along with the FHCP Member Resource Guide beginning the first quarter 2018.

(2) In October 2017, we also redesigned our new member enrollment packet. The newWelcome Flyer and cover letter promotes member registration for the Member Portal,as well as the FHCP website. Individuals without email/computer access are instructed

to contact Member Services for printed copies of the information in the Member Portal which will include the survey.

Submitted by:

Cynthia S. Martinez Administrator of Membership Growth & Retention

Committee Name Meeting Date Actions or Recommendations Customer Satisfaction December 19, 2017 Approved

Practitioner Availability Analysis JJanuary 2016 to December 2016

Commercial, Marketplace and Medicare

Introduction Because managed care plans require members to utilize a designated practitioner and provider network, FHCP must ensure there are adequate numbers and geographic distribution of primary care, behavioral health, and specialty care practitioners to meet member needs as well as providers. FHCP monitors practitioner and provider availability annually against its standards, and initiates actions as needed to improve practitioner and/or provider availability. This report describes the monitoring methodology, results, analysis, and action.

Member Cultural Needs and Preferences

FHCP analyzes data about member cultural needs and preferences annually to determine whether the current practitioner network is meeting these needs unless there are significant changes in either membership or Network composition.

Member cultural needs and preferences are assessed through: CAHPS survey results on respondent race and ethnicityMember complaints regarding cultural needs and preferencesUS census data on resident race distribution for FHCP’s service area, as availableUS census data on proportion of residents that speak a language other than English, asavailableMember complaints regarding language needs

The following are the CAHPS survey results on respondent’s race for the Commercial, Marketplace/Qualified Health Plan (QHP) and Medicare surveys:

Commercial HMO Membership: Trended CAHPS Data: Racial Composition of Respondents

2014 2015 2016 Total Number answering question 478 351 295

White 89.8% 86.9% 90.4% Black or African-American 9.0% 13.1% 6.0%

Hispanic 7.6% 3.9% 6.1% Asian 1.4% 2.6% 2.5% Other 3.1% 4.8% 3.2%

Marketplace/QHP Membership: Trended Survey Data: Racial Composition of Respondents

2014 2015 2016 Total Number answering question N/A 201 110

White N/A 89.7% 84.55% Black or African-American N/A 7.2% 0.0%

Hispanic N/A 0.0% 0.0% Asian N/A 0.0% 0.0% Other N/A 0.0% 0.0%

Medicare HMO Membership: Trended CAHPS Data: Racial Composition of Respondents

2014 2015 2016 Total Number answering question 391 378 397

White 93.0% 92.7% 94.8% Black or African-American 7.0% 6.4% 4.7%

Hispanic 5.0% 0.0% 0.0% Asian 1.0% 6.8% 0.0% Other 0.0% 3.0% 0.0%

The 2016 CAHPS Commercial percentage of White members increased slightly to 90.4% in 2016 compared to 86.9% in 2015. However, Black/African American members decreased significantly to 6.0% in 2016 from 13.1% in 2015 while the percentage of Hispanic/Latino members increased to 6.1% in 2016 from 3.9% in 2015.

The CAHPS survey was performed for Marketplace/QHP membership. The 2016 CAHPS results reported that 84.55% of the respondents were White which was slightly less than 89.7% reported in 2015. However, no other race was reported by the respondents in 2016. Thus significantly less Black/African American members were surveyed in 2016 compared to 7.2% in 2015.

The 2016 CAHPS Medicare percentage of White members remained steady at 94.8% in 2016 compared to 92.7% in 2015, while Black/African American members slightly decreased to 4.7% in 2016 from 6.4% in 2015. Asian members dropped significantly to 0.0% from 6.8% in 2015 and Hispanic/Latino members remained at 0.0%.

There were no member complaints in 2016 about practitioners not meeting racial, ethnic, or cultural needs.

U.S. Census data from the 2010 Census for FHCP’s service area of Volusia, Seminole, Flagler and Brevard Counties, Florida, provides racial composition data. The U.S. Census Bureau also provides estimates for future years based on the 2010 Census results. There was no estimate for 2016, so FHCP utilized the last year currently available which was 2015. The estimated racial compositions are as follows:

Volusia County:

Category 2010 % of Total Estimated

2015 % Total: 494,593 503,719 White 408,256 82.5% 82.9%

Black or African American

51,791 10.5% 10.5%

Hispanic/Latino 55,217 11.2% 12.1% American Indian and

Alaska Native 1,778 0.4% 0.4%

Asian 7,567 1.5% 1.7% Native Hawaiian and

Other Pacific Islander alone

204 0.0% 0.0%

Two or more races: 10,510 2.1% 2.0%

Flagler County:

Category 2010 % of Total Estimated 2015 %

Total: 95,696 100,783 White 78,710 82.3% 81.4%

Black or African American 10,884 11.4% 11.2%


Alaska Native 267 0.3% 0.1%



59 0.1% 0.0%


Seminole County:


Total: 422,718 437,346 White 330,664 78.2% 79.6%


Hispanic/Latino 72,457 17.1% 18.8%American Indian and

Alaska Native 1,386 0.3% 0.2%



285 0.1% 0.1%


Brevard County:


Total: 543,376 553,591 White 450,927 83.0% 83.1%



Alaska Native 809 0.1% 0.3%



514 0.1% 0.1%


A comparison of FHCP member racial data from CAHPS to the US census data for Volusia, Seminole, Flagler, and Brevard Counties reveals that FHCP’s membership racial composition is less diverse than Census data especially for Marketplace/QHP and Medicare products. For example, Census data reflects a higher percentage of Black/African American and Hispanic/Latino populations than does FHCP’s membership. FHCP only reflects 6.0% Black or African American and 6.1% Hispanic/Latino under Commercial products, 0% under Marketplace/QHP, and only 4.7% Black/African American under Medicare products.

The proportion of households in the service area that speak a language other than English was also obtained from US 2010 census data. Results indicated that 13.1% of the Volusia County population speaks a language other than English, with 67.0% able to speak English “very well”. For Flagler County, 15.0% of the total population speaks a language other than English, with 55.2% able to speak English ‘very well”. For Seminole County 19.8% of the population speaks a language other than English, with 70.1% able to speak English “very well”. For Brevard County 10.5% of the population speaks a language other than English, with 67.9% able to speak English “very well”.

Spanish is typically the language most frequently spoken other than English within the FHCP Service Area. However in Flagler County, Indo-European languages are spoken slightly more often at 6.7% compared to 6.4% Spanish. Since FHCP’s Hispanic population is significantly less than that of its service area, it would appear that higher populations of FHCP members speak English in comparison to the population of the FHCP service area.

FHCP examines available data about network practitioner’s ability to meet member’s cultural and linguistic needs. Today, FHCP does not have reliable data on practitioner race, as this data point is an optional item on the practitioner credentialing application. However, FHCP does have reliable data on practitioners who speak languages other than English. The results of this analysis are below:

Language Number Language NumberSpanish 199 Tamil 2Hindi 55 Chinese, Mandarin 2French 28 Tagalog 2Italian 28 Armenian 1Urdu 19 Bengali 1Gujarati 16 Burmese 1

Russian 13Chinese, Yue (Cantonese) 1

Punjabi 11 Creole 1Arabic 10 Croatian 1Ukrainian 10 Faroese 1 Hindustani 9 Hebrew 1Chinese 9 Hungarian 1Portuguese 6 Lithuanian 1Greek 6 Macedonian 1Castilian 5 Malayalam 1Filipino 5 Polish 1German 4 Sindhi 1Vietnamese 4 Swahili 1Romanian 4 Taiwanese 1Persian/Farsi 3 Telugu 1Korean 2

Upon comparing data for practitioners who speak languages other than English with the proportion of individuals in the service area who speak other languages, it was determined that FHCP’s network meets member needs. 6.1% of the FHCP Commercial members responding to the CAHP’s survey indicated that they were of Hispanic/Latino origin while 0.0% of Marketplace and Medicare members indicated they were of Hispanic/Latino origin.

Currently, 199 of FHCP practitioners speak Spanish. This proportion of Spanish speaking practitioners also is comparable to the overall population of FHCP’s service area. Also, per the Census data, 6.7% of the population in Flagler County speaks an Indo-European language. FHCP currently has 28 practitioners who speak French, 28 who speak Italian, 13 who speak Russian, 6 who speak Portuguese, 4 who speak Romanian, and 4 who speak German.

There were no member complaints in 2016 regarding language needs or linguistic barriers.

Analysis Results

In sum, based on available data, we conclude that members have the following cultural and linguistic needs which should be met by network practitioners:

Black/African American practitioners in all countiesHispanic/Latino practitioners in Seminole CountyPractitioners that speak Spanish in Seminole CountyPractitioners that speak Indo-European languages in Flagler County

FHCP will take in consideration the foregoing when recruiting additional practitioners to its networks.

Availability Standards and Methodology

Practitioner availability monitoring is completed for primary care practitioners, high volume and high impact specialty care practitioners, and high volume behavioral health practitioner types.

FHCP defines primary care practitioners as family practitioners, pediatrics, internal medicine and general practitioners.

FHCP identifies High Volume Specialties through analysis of the number of visits by specialty. For 2016, FHCP identified High Volume Specialties for Commercial and Marketplace products as Obstetricians/Gynecologists. The High Volume Specialty for Medicare was Gynecology.

High Impact Specialties are defined as Practitioners who treat conditions that have high mortality and morbidity rates and where such treatment requires significant resources. For 2016, FHCP identified High Impact Specialties for Commercial, Marketplace and Medicare as Medical and Radiation Oncology Practitioners.

FHCP identifies High Volume Behavioral Health Practitioner types for Commercial, Marketplace and Medicare through analysis of encounters/number of visits. For 2016, identified High Volume Behavioral Health Practitioner types were: Psychiatrists, Licensed Mental Health Counselors, and Licensed Clinical Social Workers.

Table 1a lists the standards, measurement method, and measurement frequency for each Practitioner type or discipline for which Availability is monitored. Monitoring takes place at the Commercial, Marketplace and Medicare product line.

COMMERICAL Table 1a: Availability Standards and Measurement Methods by Practitioner Type Practitioner Type Standard Measurement

Method Measurement

Frequency Primary Care Practitioners – Pediatricians

1 Pediatrician for every 2500 members age birth to 18 years

At least 75% of Pediatric PCP panels will be open to new members

80% or more of Members age birth to 18 years will have a Pediatric PCP office within 20 miles of member residence

Ratio of PCPs per members

Ratio of open PCP panels per total number of PCP panels

GeoAccess

Annually

Annually

Annually

Primary Care Practitioners – Internal Medicine

1 Internal Medicine PCP for every 2500 members age 18 years and older

At least 75% of Internal Medicine PCP panels will be open to new members

85% or more of Members age 18 and older will have an Internal Medicine PCP office within 20 miles of member residence



GeoAccess

Annually

Annually

Annually


Method Measurement

Frequency Primary Care Practitioners – Family Practice or General Practice

1 FP or GP PCP for every 2500 members ages 2 years and older

At least 75% of PCP panels will be open to new members

85% or more of Members ages 2 and older will have a FP or GP PCP office within 20 miles of member residence



GeoAccess

Annually

Annually

Annually

All Primary Care Practitioners

1 PCP for every 2500 members


85% or more of Members will have a PCP office within 15 miles of member residence



GeoAccess

Annually

Annually

Annually

OB/GYN At least 90% will be open to accepting new HMO members

90% or more of Members will have an OB/GYN office within 20 miles of member residence

Percent of open Network Practitioners per total Practitioners of Specialty

GeoAccess

Annually

Annually


Method Measurement

Frequency Medical Oncology At least 95% will be

open to accepting new HMO members

90% or more of Members will have a Medical Oncology office within 20 miles of member residence

Percent of open Network Practitioner per total par Practitioners of specialty

GeoAccess

Annually

Annually

Radiation Oncology

At least 95% will be open to accepting new HMO members

90% or more of Members will have a Radiation Oncology office within 20 miles of member residence

Percent of open Network Practitioners per total par Practitioners of specialty

GeoAccess

Annually

Annually

High volume behavioral health prescribing Practitioners: Psychiatrist (MD/DO)


90% or more of Members will have a psychiatrist office within 30 miles of member residence

Percent of open Network Practitioners per total par Practitioners of Specialty

GeoAccess

Annually

Annually


Method Measurement

Frequency High volume behavioral health Practitioner: Licensed Mental Health Counselor (LMHC)


90% or more of Members will have a LMHC office within 30 miles of member residence


GeoAccess

Annually

Annually

High volume behavioral health Practitioner: Licensed Clinical Social Worker (LCSW)


90% or more of Members will have a LCSW office within 30 miles of member residence


GeoAccess

Annually

Annually

Emergency Care 90% or more of Members will have Emergency Care available within 30 miles of member residence

GeoAccess Annually

Urgent Care Centers

90% or more of Members will have a Urgent Care Center within 30 miles of member residence

GeoAccess Annually

MARKETPLACE Table 1b: Availability Standards and Measurement Methods by Practitioner Type Practitioner Type Standard Measurement

Method Measurement

Frequency Primary Care Practitioners – Pediatricians



80% or more of Members age birth to 18 years will have a pediatric PCP office within 20 miles of member residence



GeoAccess

Annually

Annually

Annually







GeoAccess

Annually

Annually

Annually


Method Measurement

Frequency Primary Care Practitioners – Family Practice or General Practice






GeoAccess

Annually

Annually

Annually







GeoAccess

Annually

Annually

Annually

OB/GYN At least 90% will be open to accepting new HMO members



GeoAccess

Annually

Annually


Method Measurement

Frequency Medical Oncology At least 95% will be



Percent of open Network Practitioner per total Spec 1 par Practitioners of specialty

GeoAccess

Annually

Annually

Radiation Oncology



Percent of open Network Practitioners per total Spec 2 par Practitioners of specialty

GeoAccess

Annually

Annually





GeoAccess

Annually

Annually


Method Measurement

Frequency High volume behavioral health Practitioner: Licensed Mental Health Counselor (LMHC)




GeoAccess

Annually

Annually

High volume behavioral health Practitioner: Licensed Clinical Social Worker (LCSW)




GeoAccess

Annually

Annually


GeoAccess Annually

Urgent Care Centers


GeoAccess Annually

MEDICARE Table 1C: Availability Standards and Measurement Methods by Practitioner Type Practitioner Type Standard Measurement

Method Measurement

Frequency Primary Care Practitioners – Internal Medicine






GeoAccess

Annually

Annually

Annually

Primary Care Practitioners – Family Practice or General Practice






GeoAccess

Annually

Annually

Annually


Method Measurement

Frequency All Primary Care Practitioners






GeoAccess

Annually

Annually

Annually

Gynecology At least 90% will be open to accepting new HMO members



GeoAccess

Annually

Annually

Medical Oncology At least 95% will be open to accepting new HMO members


Percent of open Network Practitioner per total Spec 1 par Practitioners of specialty

GeoAccess

Annually

Annually


Method Measurement

Frequency Radiation Oncology At least 95% will be



Percent of open Network Practitioners per total Spec 2 par Practitioners of specialty

GeoAccess

Annually

Annually





GeoAccess

Annually

Annually

High volume behavioral health Practitioner: Licensed Mental Health Counselor (LMHC)




GeoAccess

Annually

Annually


Method Measurement

Frequency High volume behavioral health Practitioner: Licensed Clinical Social Worker (LCSW)




GeoAccess

Annually

Annually

PCP 70% of Members will have access via Public Transportation when same is available within the community

GeoAccess Annually

Emergency Care 100% of Members will have access via Public Transportation when same is available within the community

GeoAccess Annually

Urgent Care Centers

90% of Members will have access via Public Transportation when same is available within the community

GeoAccess Annually

Availability Results:

COMMERICAL Table 2a: Availability Measurement Results and Comparison to Performance Goals by Practitioner Type Practitioner Type Standard Results Goal Met?

(Yes/No) Primary Care Practitioners – Pediatricians



80% or more of Members will have a pediatric PCP office within 20 miles of member residence

1 PCP/43 members

99% of PCP panels that are open

100% of members have at least 1 pediatric PCP within 20 miles

Yes

Yes

Yes





1 PCP/384 members


99.6% of members have at least 1 IM PCP within 20 miles

Yes

Yes

Yes





1 PCP/169 members


100% of members have at least 1 FP or GP PCP within 20 miles

Yes

Yes

Yes


(Yes/No) All Primary Care Practitioners




1 PCP/78 members


99.9% of members have at least 1 PCP within 15 miles

Yes

Yes

Yes

High Volume Specialty: Obstetrics and Gynecology


90% or more of Members will have a OB/GYN office within 20 miles of member residence

98% are accepting new HMO members

99.6% of members have at least one OB/GYN within 20 miles

Yes

Yes

High Impact Specialty: Medical Oncology




99.7% of members have at least one Medical Oncologist within 20 miles

Yes

Yes

High Impact Specialty: Radiation Oncology


90% or more of Members will have a Radiation Oncology specialty office within 20 miles of member residence


99.4% of members have at least one Radiation Oncologist within 20 miles

Yes

Yes


(Yes/No) High volume behavioral health prescribing Practitioner. Psychiatrist (M.D./D.O.)




100% of members have at least one psychiatrist within 30 miles

No

Yes

High volume behavioral health Practitioner - Licensed Mental Health Counselor (LMHC)




100% of members have at least one LMHC within 30 miles

Yes

Yes

High volume behavioral health Practitioner - Licensed Clinical Social Worker (LCSW)




100% of members have at least one LCSW within 30 miles

Yes

Yes

Emergency Care 90% or more of Members will have a Specialty office within 30 miles of member residence

100% of members have access to at least one emergency care facility within 30 miles

Yes

Urgent Care Centers

90% or more of Members will have a Specialty office within 30 miles of member residence

100% of members have access to at least one urgent care facility within 30 miles

Yes

MARKETPLACE Table 2B: Availability Measurement Results and Comparison to Performance Goals by Practitioner Type Practitioner Type Standard Results Goal Met?

(Yes/No) Primary Care Practitioners – Pediatricians



80% or more of Members will have a pediatric PCP office within 20 miles of member residence

1 PCP/23 members


100% of members have at least 1 pediatric PCP within 20 miles

Yes

Yes

Yes





1 PCP/ 277 members



Yes

Yes

Yes





1 PCP/ 176 members



Yes

Yes

Yes


(Yes/No) All Primary Care Practitioners


At least 75% of PCP panels will be open to new membres


1 PCP/ 81 members



Yes

Yes

Yes

High Volume Specialty: Obstetrics and Gynecology





Yes

Yes






Yes

Yes






Yes

Yes


(Yes/No) High volume behavioral health prescribing Practitioner. Psychiatrist (M.D./D.O.)





No

Yes

High volume behavioral health Practitioner - Licensed Mental Health Counselor (LMHC)





Yes

Yes






Yes

Yes


100% of members have access to at least one emergency care facility within 30 miles

Yes

Urgent Care Centers


100% of members have access to at least one urgent care facility within 30 miles

Yes

MEDICARE Table 2c: Availability Measurement Results and Comparison to Performance Goals by Practitioner Type Practitioner Type Standard Results Goal Met?

(Yes/No) Primary Care Practitioners – Internal Medicine




1 PCP/ 123 members



Yes

Yes

Yes





1 PCP/ 79 members



Yes

Yes

Yes





1 PCP/ 48 members



Yes

Yes

Yes


(Yes/No) High Volume Specialty: Gynecology





Yes

Yes






Yes

Yes






Yes

Yes

High volume behavioral health prescribing Practitioner. Psychiatrist (M.D./D.O.)





Yes

Yes


(Yes/No) High volume behavioral health Practitioner - Licensed Mental Health Counselor (LMHC)





Yes

Yes






Yes

Yes

Table 7 – Medicare Network Locations Accessible via Public Transportation

Practitioner Type & County

Standard Results Goal Met?

(Yes/No) Volusia County PCP, Emergency Department and Urgent Care Center Locations in relation to public transportation

At least 70% of PCP, and

100% of Emergency, and

90% of Urgent Care

Locations can be accessed by Public Transportation, where such transportation is available in the community

74% of PCP Offices

100% of Emergency Departments

100% of Urgent Care Center

Yes

Yes

Yes

Flagler County PCP, Emergency Department and Urgent Care Center Locations in relation to public transportation

Flagler County does not offer general public transportation. However, public transportation specifically for access to medical services is available on a sliding scale basis.



90% of Urgent Care


97% of PCP Offices



Yes

Yes

Yes

Seminole County PCP, Emergency Department and Urgent Care Center Locations in relation to public transportation



90% of Urgent Care


85% of PCP Offices



Yes

Yes

Yes

Practitioner Type & County

Standard Results Goal Met?

(Yes/No) Brevard County PCP, Emergency Department and Urgent Care Center Locations in relation to public transportation



90% of Urgent Care


75% of PCP Offices



Yes

Yes

Yes

Analysis of Results

For Commercial and Marketplace/QHP members, the FHCP Network meets all standards and measurements for availability for PCP, High Volume, High Impact Practitioners, High Volume Behavioral Health – Non-Prescribing, Emergency Care, and Urgent Care Centers.

However, currently only 81% of the High Volume Behavioral Health – Prescribing Practitioners is open to accepting new HMO members even though members have geographic access within 30 miles of their residence. Eighty-one percent (81%) does not meet the 90% standard for accepting new members. Further investigation revealed that access to prescribing Behavioral Health providers is a community issue in our service areas.

For Medicare members, the FHCP Network meets all standards and measurements for availability for PCP, High Volume and High Impact Practitioner. Further, Medicare members have required access for PCP, Emergency Department and Urgent Care Centers in relation to public transportation.

Action

As an identified issue, FHCP has taken the following actions to address this issue: As a staff model HMO, FHCP directly employs practitioners to render services inclinics owned and operated by FHCP. In 2016, FHCP has recruited two newpsychiatrists to its practice. One is located in Volusia County and the other providesservices to residents of both Volusia and Brevard Counties.

FHCP also added psychiatry and psychology specialties to the services offered by ourtelemedicine vendor, Doctor on Demand. FHCP members can use this service toaccess both prescribing and non-prescribing Behavioral Health providers for carefrom any location via a secure online application. This service is available to allFHCP members.

FHCP continues to identify potential Behavioral Health prescribing providers withinour service area either via contracting with existing Practitioners in the communityor by recruiting a Practitioner(s) to its staff.

Reporting Table 8 Committee Reporting

Committee Name Meeting Date Committee Actions or Recommendations Contracting Committee

4/5/2017 Continue to enhance and seek additional Behavioral Health Practitioners who can prescribe.

Customer Satisfaction

6/19/2017 Approved

Performance Improvement /Committee

6/21/2017 Approved

Appendix I - CMS Required Reports

CMS Standards for Medicare Network Practitioner Availability

For Medicare membership in Volusia, Flagler, Seminole and Brevard Counties, FHCP must annually demonstrate that it offers an adequate Network to provide access for Medicare covered services, as required by 42 CFR 422.122(a)(1). Standards for the number (quantity) and geographic distribution (time and distance) of Medicare Network Practitioners and Providers are set forth by CMS annually in the CMS Health Service Delivery (HSD) Reference file for each County within FHCP’s Medicare product service area. This Reference file sets forth the following:

a. Standards for Number of Practitioners and Providers. The CMS requirements forminimal number of Practitioners and Providers by county in the Medicare service area asdetailed below for 2016:

Practitioner Specialty 2016 CMS Practitioner Quantity Standard

Volusia Medicare

Flagler Medicare

Seminole Medicare

Brevard Medicare

Primary Care

Allergy and Immunology Cardiology 5 2 3 5

Chiropractor 2 1 1 2

Dermatology 3 1 2 3

Endocrinology 1 1 1 1

ENT/Otolaryngology 2 1 1 2

Gastroenterology 3 1 2 3

General Surgery 5 2 3 6

Gynecology, OB/GYN 1 1 1 1

Infectious Diseases 1 1 1 1

Nephrology 2 1 1 2

Neurology 3 1 2 3

Neurosurgery 1 1 1 1

Oncology - Medical, Surgical 4 1 2 4

Oncology - Radiation 2 1 1 2

Ophthalmology 5 1 3 5

Practitioner Specialty 2016 CMS Practitioner Quantity Standard

Volusia Medicare

Flagler Medicare

Seminole Medicare

Brevard Medicare

Orthopedic Surgery 4 1 2 4

Physiatry, Rehabilitative Medicine 1 1 1 1

Plastic Surgery 1 1 1 1

Podiatry 4 1 2 4

Psychiatry 3 1 2 3

Pulmonology 3 1 2 3

Rheumatology 2 1 1 2

Urology 3 1 2 3

Vascular Surgery 1 1 1 1

Cardiothoracic Surgery 1 1 1 1

Acute Inpatient Hospital Beds 208 51 112 221

Cardiac Surgery Program 1 1 1 1

Cardiac Catheterization Services 1 1 1 1

Critical Care Services/Intensive Care 1 1 1 1

Outpatient Dialysis 1 1 1 1

Surgical Services (Outpatient or ASC) 1 1 1 1

Skilled Nursing Facilities 1 1 1 1

Diagnostic Radiology 1 1 1 1

Mammography 1 1 1 1

Physical Therapy 1 1 1 1

Occupational Therapy 1 1 1 1

Speech Therapy 1 1 1 1

Inpatient Psychiatric Facility Services 1 1 1 1

Orthotics & Prosthetics 1 1 1 1

Home Health 1 1 1 1 Durable Medical Equipment 1 1 1 1 Outpatient Infusion/Chemotherapy 1 1 1 1

b. Standard for Geographic Access. The CMS requirements for travel time and distanceto Practitioners and Providers by county in the Medicare service area as detailedbelow for 2016. The standards require FHCP to demonstrate that ninety percent(90%) of Medicare Members (or more) have access to at least onePractitioner/Provider, for each specialty type, within CMS established time anddistance requirements for the period being measured.

CMS Practitioner Time & Distance Standards 2016 Volusia Flagler Seminole Brevard

Primary Care -

Allergy and Immunology

Cardiology

Chiropractor

Dermatology

Endocrinology

ENT/Otolaryngology

Gastroenterology

General Surgery

Gynecology, OB/GYN

Infectious Diseases

Nephrology

Neurology

Neurosurgery

Oncology - Medical, Surgical

Oncology - Radiation/ Radiation Oncology

Ophthalmology

Orthopedic Surgery

Physiatry, Rehabilitative Medicine

Plastic Surgery

Podiatry

Psychiatry

Pulmonology

Rheumatology

Urology

Vascular Surgery

Cardiothoracic Surgery

Acute Inpatient Hospital

Cardiac Surgery Program

Cardiac Cath Services

Critical Care/ICU Services

Outpatient Dialysis

Surgical Services (Outpatient or ASC)

Skilled Nursing Facilities Diagnostic Radiology

Mammography

Physical Therapy

Occupational Therapy

Speech Therapy

Inpatient Psychiatric Facility Services

Orthotics & Prosthetics Outpt. Infusion/ Chemotherapy

Tables 3-7 below provide results for monitoring against the standards for adequate numbers and distance of practitioners and providers by county for the Medicare network. The Access Requirements columns show the proportion of members who met the time and distance geographic location standards. The Provider Requirements columns show whether the number of practitioners or providers met the minimum number standards for that county.

Table 3 – Volusia County Medicare Network Availability Results Table 4 – Flagler County Medicare Network Availability Results Table 5 – Seminole County Medicare Network Availability Results Table 6 – Brevard County Medicare Network Availability Results

Table 3 – Volusia County Medicare Practitioner Network Availability Results

Spec Code Specialty Description

Pct With Access

Pct Without Access

Avg Dist

Avg Time

Met Access

Required Prvs

Servicing Prvs

Met Prvs

Met Overall

Table 4 – Flagler County Medicare Practitioner Network Availability Results


Pct With

Access

Pct Without Access

Avg Dist

Avg Time

Met Access

Required Prvs

Servicing Prvs

Met Prvs

Met Overall

Table 5 – Seminole County Medicare Practitioner Network Availability Results


Pct With

Access

Pct Without Access

Avg Dist

Avg Time

Met Access

Required Prvs

Servicing Prvs

Met Prvs

Met Overall

Table 6 – Brevard County Medicare Practitioner Network Availability Results


Pct With

Access

Pct Without Access

Avg Dist

Avg Time

Met Access

Required Prvs

Servicing Prvs

Met Prvs

Met Overall

FHCP meets the number and geographic availability required by CMS for Medicare for each service area county

FFlorida Health Care Plans Practitioner Access Analysis

January 1, 2016 to December 31, 2016 Commercial, Marketplace and Medicare

IntroductionConsumers value timely access to medical care. Florida Health Care Plans (FHCP) monitors primary care, behavioral health, and high-volume and high-impact specialty care practitioner access for routine and urgent appointments as well as primary care after-hours access accessibility annually against its standards, and initiates actions as needed to improve. This report describes access monitoring methodology, results, analysis, and action.

Section I: Primary Care Physician Appointment Access Standards and Methodology

FHCP monitors primary care physician (PCP) appointment accessibility and after-hours’ access to ensure members have access to primary care 24 hours a day, 7 days a week.

FHCP does so by utilizing responses captured in the annual CAHPS survey for Commercial, Marketplace/ACA and Medicare members, recording and following up on member complaints and appeals regarding access to their primary care physician, and telephone surveys conducted by staff to ensure after-hour care information is available to members.

The following are the CAHPS questions utilized in this standard:

For Commercial and Medicare:

“6. In the last 12 months, how often did you get an appointment for a check-up or routine care at a doctor’s office or clinic as soon as you needed?”

“4. In the last 12 months, when you needed care right away, how often did you get care as soon as you needed?”

For Marketplace/ACA:

“6. In the last 6 months, how often did you get an appointment for a check-up or routine care at a doctor’s office or clinic as soon as you needed?”

“4. In the last 6 months, when you needed care right away, how often did you get care as soon as you needed?”

Table 1 lists the PCP standards, measurement method, and measurement frequency for each aspect of performance that is monitored.

Table 1: Standards and Measurement Methods by Access Measure Access Measure Standard and

Performance Goal Measurement

Method Measurement

Frequency Primary care routine appointments

At least 80% of members report they always or usually obtained check-up or routine care as soon as they needed (CAHPS question 6)

CAHPS member satisfaction survey

Annually

Primary care urgent appointments

At least 80% of members report they always or usually obtained urgent appointments as soon as they needed (CAHPS question 4)


Annually

Access complaint analysis for appointments

Rate of member complaints about appointment access is less than 0.5 per 1000 Members

Complaint analysis Annually

Access appeal analysis appointments

Rate of member appeals about appointment access is less than 0.5 per 1000 Members

Appeal analysis Annually

Primary care after hours care

100% of PCP offices surveyed have an after- hours access mechanism that meets health plan standards

Calls to PCP offices after hours (details below)

Annually

Results

Table 2: Measurement Results and Comparison to Performance Goal by Appointment Type and Product Line

Access Measure Standard Results Goal Met? (Yes/No)

Primary care routine appointments

80% or more results of members report they always or usually obtained check-up or routine care as soon as needed

Commercial – 83.5% Marketplace – 79.7% Medicare – 84.6%

Yes Yes Yes

Primary care urgent appointments

80% or more results of members report they always or usually obtained urgent appointments as soon as needed

Commercial – 94.0% Marketplace – 87.3% Medicare – 87.4%

Yes Yes Yes

PCP Access complaint analysis

Rate of member complaints about appointment access is less than 0.5 per 1000 members

Commercial Member complaints = 0.34 per 1000 members Marketplace member complaints = 0.37 per 1000 members Medicare member complaints = 1.05 per 1000 members

Yes Yes No

PCP Access appeal analysis

Rate of member appeals about appointment access is less than 0.5 per 1000 members

Commercial Member appeals = 0.03 per 1000 members Marketplace member appeals = 0.00 per 1000 members Medicare member appeals = 0.00 per 1000 members

Yes Yes Yes

Table 2: Measurement Results and Comparison to Performance Goal by Appointment Type and Product Line


Primary care after hours care

100% of PCP offices surveyed have an after- hours access mechanism that meets health plan standards

96% of PCP offices have an after-hours access mechanism that meets health plan standards (See details of survey below)

No

Analysis of PCP Appointment Access Results

CAHPS results reported that for routine appointment access, 84% of Commercial members, 80% of Marketplace/ACA members, and 85% Medicare members reported they usually or always obtained care when needed, not when needed right away. This meets FHCP’s performance goal of at least 80%. For urgent appointment access, 94% of Commercial members, 87% of Marketplace/ACA members, and 87% of Medicare members CAHPS respondents reported that they usually or always obtained needed care right away (urgent appointments). Again, this meets and exceeds FHCP’s performance goal of at least 80%. FHCP’s monthly average membership in 2016 was 29,025 Commercial members, 18,842 Marketplace/ACA members, and 13,335 Medicare members. The overall average was 61,202 members. This is a noteworthy increase of twenty-three percent (23%) in membership from 2015 due to a significant increase in Marketplace/ACA members from a monthly average of 3,475 in 2015. In reviewing member complaints, FHCP received ten from Commercial members, seven from Marketplace/ACA members for a total of 17 concerning access to care. The number of complaints increased in comparison to ten in 2015. However, this is accounted for in the increased Marketplace/ACA membership. This is proven out in that the rate per 1,000 members remained under 0.5. Commercial member complaints were most commonly related to perception about a delay in service related to referrals to specialists, DME and/or prescriptions. Marketplace complaints related to new members having difficulty with transition of care and establishing with new PCP. All complaints were resolved to the member’s satisfaction by FHCP Member Services staff FHCP received 14 complaints from Medicare members concerning access to care compared to eight in 2015. This was a considerable increase as Medicare membership remained fairly consistent from 2015 to 2016 which resulted in a complaint rate of 1.02 per 1,000 members. Ten of the complaints were for Family Practice PCP access and four were for Internal Medicine PCP access. Six complaints were against FHCP staff PCPs. Medicare member complaints were related to the same issues as the Commercial

members. All complaints were resolved to the member’s satisfaction by FHCP Member Services staff. There was only one appeal from a Commercial member related to primary care access in 2016. This complaint was a request to continue to see a primary care physician who was out of network. PCP After-Hours Access Measurement Methodology A universe of all Participating PCP group practice offices was used to assess whether the offices have an after-hours access mechanism which meets FHCP standards. FHCP surveyed 134 PCP practices in FHCP’s HMO networks for Medicare, Commercial, and Marketplace/QHP Members. Most PCP’s participate in all three networks, so where there is overlap that PCP group practice can count for each Network’s results. FHCP staff completed the Group Demographics cells, filling in the group name, telephone number (use the number published in the practitioner directory), practice location address and names of PCPs in the practice. One call covers all PCPs practicing at the practice location. Staff completed the Survey Data Collection Information cells, filling in the date and time of data collection, the name of the staff person conducting the survey, and the survey type. Calls are made AFTER normal business hours, OR on weekends or holidays only and not during the business day. The FHCP After-Hours Access Survey Protocol is organized into three sections based on the type of after-hours access the office location has: answering service, answering machine, or no response. Also, the answering service and answering machine sections have two sub-categories: urgent requirement, and emergency requirement. Results from each surveyed practice are calculated to determine the office’s score in relation to the following criteria. a. Answering service response standard for urgent situations: The answering service

will either offer to page the doctor on call, so that the doctor can call Member back; or offer to telephonically transfer Member’s call directly to the doctor on call.

b. Answering service response standard for emergency situations: The answering service will direct the Member to contact 911 or go to nearest ER if he/she feels it is too emergent to wait for doctor to call them.

c. Recorded response standard for urgent or emergency care: The PCP office telephone recording shall provide instructions on how to page the doctor if a situation is urgent; or instructs the Member to call 911 for emergencies or go to the nearest ER or urgent care center if the situation cannot wait until the next business day.

PCP After-Hours Access Results FHCP surveyed all of the PCP offices which totaled 134, and 128 or 96% of them had an acceptable method of providing after-hours access for members. However, six PCP Practices had no method of answering after-hours calls and directing members for care. Of the 128 compliant practices, 53 utilize an answering service, 73 use a recorded message, and two forward their office phones directly to themselves via a cell phone for after hour coverage. The PCPs who answer their own calls results are counted under Answering Service. Please see a more detailed analysis of the results below:

Number of PCP Offices Number Surveyed

Completed On % Surveyed Completed

134 134 100%

Table 3 After-Hours Access Detailed Results Criteria # & % Compliant Comments

Answering service urgent situations: The service will either offer to page the doctor on call, so that the doctor can call member back; or offer to telephonically transfer member’s call directly to the doctor on call

55 of applicable PCP Offices Compliant 100% of PCP Offices Compliant

All PCP offices met the criterion.

Answering service emergency situations: The service will direct the member to contact 911 or go to nearest ER if he/she feels it is too emergent to wait for doctor to call them



Recorded response urgent or emergency care: The recording shall provide instructions on how to page the doctor if a situation is urgent; or instructs the member to call 911 for emergencies or go to the nearest ER or urgent care center if the situation cannot wait until the next business day



Access Barrier Analysis

While Commercial and Marketplace members have appropriate access for both routine and urgent appointments, there could be an improvement in Marketplace members’ access to routine appointments as the CAHPS result was less than one percentage point below goal.

The Medicare members who participated in the CAHPS survey felt they had appropriate access to both routine and urgent appointments. However, Medicare member complaints regarding access to routine appointments did not meet the standard of 0.5 or less per 1,000 members. FHCP Provider Services staff reviewed the complaint data. No additional barriers, trends or patterns could be identified related to same. Six PCP practices did not have after-hours methodology in place and were sent a corrective action notice. FHCP will re-survey their practices to ensure corrective action is taken for after-hours standards.

Table 4 Access Barrier Analysis Results Barrier Opportunity Selected for

Improvement? Increased demand for annual health assessments due to increase in Marketplace/QHP membership and PCP practices are reluctant to schedule due to many plan structures having a high deductible benefit

Educate PCPs that annual health assessments have no member cost share so it is a good way to establish new patients with their practice

Yes

Members are not taking advantage of telemedicine services available to them

Educate members regarding FHCP’s telemedicine service – Doctor on Demand whereby members can receive care for non-life threatening urgent or routine care via an online application. Expanded use of Doctor on Demand should free up participating PCP schedules to improve routine appointment access

Yes

Limited Office Hours for higher demand of appointments

Expand extended care clinics at FHCP locations through Service Area to provide access

Yes

New PCP practices are less aware of after-hour access requirements

Re-educate PCPs on need for either answering services or recorded message to direct members on how to access care after hours

Yes

Below is a summary of the actions FHCP will implement:

Table 5 Planned Actions Date

Initiated Action Implemented Barriers Addressed

2/2017 Educate PCPs that annual health assessments have no member cost share so it is a good way to establish new patients with their practice

Increased demand for annual health assessments due to increase in Marketplace/QHP membership and PCP practices are reluctant to schedule due to many plan structures having a high deductible benefit

5/2017 Educate members regarding FHCP’s telemedicine service – Doctor on Demand whereby members can receive care for non-life threatening urgent or routine care via an online application. Expanded use of Doctor on Demand should free up participating PCP schedules to improve routine appointment access

Members are not taking advantage of telemedicine services available to them

3/2017 Re-educate PCPs on need for either answering services or recorded message to direct members on how to access care after hours

New PCP practices are less aware of after-hour access requirements

8/2016 Expand extended care clinics at FHCP locations through Service Area to provide access

Limited Office Hours for higher demand of appointments

ReportingThis QI activity was reported to the following FHCP committees:

Table 6 Committee Reporting Committee Name Meeting Date Committee Actions or Recommendations Contracting Committee

4/5/2017 Approved

Customer Satisfaction

6/19/17

Performance Improvement Council

Section II: Behavioral Health Appointment Access FHCP monitors behavioral health appointment access to determine whether members can receive timely appointments based on severity of illness. FHCP does so by conducting telephone surveys by staff to ensure appointment access to both prescriber and non-prescriber behavioral health Practitioners is available to members, recording and following up on member complaints and appeals regarding access to behavioral health services, and utilizing responses captured in the annual CAHPS ECHO survey for Commercial and Medicare members. Table 7 sets forth the appointment access standards, measurement method, and measurement frequency for each aspect of performance that is monitored for both prescribing and non-prescribing Practitioners.

Table 7: Behavioral Health Standards and Measurement Methods by Appointment and Practitioner Type

Access Measure Standard and Performance Goal

Measurement Method

Measurement Frequency

Prescriber behavioral health non-life threatening emergency appointments

95% will provide access to care for a non-life-threatening emergency within 1 business day or refers to the ER

Appointment access survey

Annually

Prescriber behavioral health urgent appointments

85% of offices report a first available urgent appointment is open for a patient within 48 hours of patient request


Annually

Prescriber behavioral health new patient routine appointments

80% of offices report a third available routine appointment is open for a new patient within 10 business days of patient request


Annually

Prescriber behavioral health established patient routine follow-up appointments

80% of offices report a third available routine appointment is open for an established patient within 14 days.


Annually

Table 7: Behavioral Health Standards and Measurement Methods by Appointment and Practitioner Type


Measurement Method

Measurement Frequency

Non-prescriber behavioral health non-life threatening emergency appointments

95% will provide access to care for a non-life-threatening emergency within 1 business day or refers to the ER


Annually

Non-prescriber behavioral health urgent appointments



Annually

Non-prescriber behavioral health new patient routine appointments



Annually

Non-prescriber behavioral health established patient routine follow-up appointments

80% of offices report a third available routine appointment is open for an established patient within 14 days


Annually

Complaints about behavioral health access

Rate of member complaints about behavioral health appointment access is less than 0.5 per 1000 members


Appeals about behavioral health access

Rate of member appeals about behavioral health appointment access is less than 0.5 per 1000 members

Appeals analysis Annually

ECHO survey results re routine and urgent appt access for Getting Treatment Quickly

Rate of member responses about behavioral health Getting Treatment Quickly ECHO Plan summary rate is at or greater than 70%.

ECHO Member Satisfaction Survey Q3, Q5,and Q8

Annually

FHCP measures behavioral health access to Routine and Urgent Appointments through a survey of Practitioner offices. Provider Services surveys all applicable network (Medicare, Commercial & Marketplace) Practitioner office locations for self-reporting. Response to the survey is monitored, with repeat surveys sent to those practices that do not respond to the initial survey. Follow-up to obtain completed surveys from non-responsive practices continues over a six week period with a response rate goal of sixty percent (60%). The Appointment Access survey questions are asked once for each office location, and data is recorded for the open appointments, regardless of the Practitioner who has open appointments. For routine appointments, data is gathered on first, second and third available appointments. Our routine appointment standard is based on the date of the third available appointment because it is the most sensitive method for detecting offices which have access issues since first and second available appointments often represent cancellations and while those open appointment slots frequently are available in a timely fashion, they often do not work for members. Urgent appointment data is gathered for the first available urgent appointment slot in the office. Results Table 8 displays the survey response rate data.

Table 8: Response Rate Data

Practitioner Type

# Office locations

w/Practitioner type

# Office locations

responding to survey

# Practitioners represented

by offices responding

to survey

# Practitioners of this type

in the Network

% of Practitioner type results

represent out of total contracted

practitioners of that type

BH Prescribers

11 9

17

20 85%

BH Non-Prescribers

39 37 73

75 97%

Table 9: Behavioral Health Standards and Measurement Results by Appointment and Practitioner Type


Results Goal Met? (Yes/No)

Prescriber behavioral health non-life threatening emergency appointments

95% will provide access to care for a non-life-threatening emergency within 1 business day or refers member to the ER

56% of offices report a first available non-life-threatening emergency appointment within 1 business day

No




Prescriber behavioral health urgent appointments



No

Prescriber behavioral health new patient routine appointments



Yes

Prescriber behavioral health established patient routine follow-up appointments

80% of offices report a third available routine appointment is open for an established patient within 14 days of patient request


Yes

Non-prescriber behavioral health non-life threatening emergency appointments

95% will provide access to care for a non-life-threatening emergency within 1 business day or refers member to the ER

73% of offices report a first available non-life-threatening emergency appointment within 1 business day

No

Non-prescriber behavioral health urgent appointments



No

Non-prescriber behavioral health new patient routine appointments



Yes




Non-prescriber behavioral health established patient routine follow-up appointments



Yes

Complaints about behavioral health access

Rate of member complaints about behavioral health appointment access is less than 0.5 per 1000 members

Commercial 0.03 per 1,000 members Marketplace 0.05 per 1,000 members Medicare 0.00 per 1,000 members

Yes Yes Yes

Appeals about behavioral health access

Rate of member appeals about behavioral health appointment access is less than 0.5 per 1000 members

Commercial 0.00 per 1,000 members Marketplace 0.00 per 1,000 members Medicare 0.00 per 1,000 members

Yes Yes Yes

ECHO survey results re routine and urgent appt access for Getting Treatment Quickly

Rate of member responses to ECHO Getting Treatment Quickly composite will be at or greater than 70%

Commercial - 60.4% Q3 – 48.0% Q5 – 59.2% Q8 – 73.9% Medicare - 63.6% Q3 – 28.9% Q5 – 77.3% Q8 – 84.5%

No No

BH prescriber offices met the standard for routine and follow-up appointment access for both new and established patients. However, only 67% could meet 48 hour access standard for established patient urgent appointments and even fewer (56%) could meet the within one business day standard for non-life threatening emergency appointments. No office reported referring members to the emergency department if they could not accommodate. These findings are not surprising given that there are fewer BH prescribers available in the network and within our four county service area and there is presently a state-wide shortage of psychiatrists. BH non-prescriber offices also met the standard for routine and follow-up appointment access for both new and established patients. BH non-prescriber offices also had difficulty meeting the 48 hour standard for urgent visits but had slightly better access than prescribers at 78% and non-life threatening emergency appointments at 73%. However, none again reported referring members to the emergency department if they could not accommodate. From the foregoing, it can be determined that it is difficult for both prescribing and non-prescribing practices to work in patients with urgent and/or non-life threatening emergencies into their schedules due to high volume of patients being treated. There were only 2 member complaints about access to routine appointments during the review period - one from a Commercial member and the other from a Marketplace/QHP member. There were no complaints from Medicare members regarding access to same. Both complaints were relative to members who needed to establish with a BH Practitioner and ensuring their medications would be renewed or prescribed prior to appointment. There were no recorded Appeals during the review period related to access to behavioral health appointments or care. ECHO survey results for both Commercial and Medicare members did not meet the composite standard of 70% with Commercial scoring at 60.4% and Medicare at 63.6%. The lowest scoring results for Commercial members indicated that they did not feel they had received professional counseling needed by telephone (Q3) (at only 48%) and that they did not feel they received counseling or treatment as soon as desired (Q5) (at only 59.2%). However, they did indicate they received other counseling or treatment as soon as desired (Q8) at a much higher rate of 73.9%. Medicare members also did not feel they received professional counseling needed by telephone (Q3) at a very low rate of 28.9% However, Medicare members did feel they received desired counseling or treatment when desired (Q5 and Q8). The behavioral health appointment access data identified offices that could not provide urgent and non-life threatening emergency appointments within the performance goal at the time the measurement was completed. It is worth noting demand has increased for behavioral health services with the coverage of more individuals through Marketplace/ACA plans.

A group of internal staff completed the initial barrier analysis. Participants included the behavioral health clinical director, chief medical officer, and two provider relations representatives. The group brainstormed the following potential barriers and opportunities for improvement:

Table 11 Barrier Analysis Results Barrier Opportunity Selected for

Improvement? Limited number of behavioral health prescribers in Brevard County who are accepting new patients and working with managed care companies

Recruit and hire FHCP employed psychiatrists with office hours in Volusia and Brevard Counties

Yes

Limited number of behavioral health prescribers in the service area and network and their schedules tend to be full

Determine if there are any additional Practitioners in the service area available for contracting

Yes

Limited access to counseling services by telephone

Add telephonic psychiatry services to the Doctor on Demand participating providers.

Yes

BH Practitioner and members are unaware that members have telemedicine benefits where they could refer members for routine care which would allow them more time on their schedule to “work in” non-life threatening emergency patients

Educate members and network Behavioral Health providers regarding the availability of telemedicine psychiatry services and encourage use of same for routine care.

Yes

Action



10/17/2016 Hired staff psychiatrist for Edgewater and Titusville FHCP clinical locations.

Limited number of BH providers in Brevard County

12/5/2016 Hired staff psychiatrist for Holly Hill FHCP clinical location

Limited number of BH providers in service area



10/1/2016 Approach behavioral health practitioners within service area and offer contracts for participation

Still working on finalizing contracts and credentialing

11/1/2016 Initiated project to add psychiatry services to Doctor on Demand

Access to counseling by telephone

2017 Initiate education and outreach activities to BH practitioners and members regarding the availability of new practitioners locally and through Doctor on Demand

Awareness of telephonic services for routine, non-life threatening care and counseling

Reporting This QI activity was reported to the following QI committees:

Table 13 Committee Reporting Committee Name Meeting Date Committee Actions or Recommendations Customer Service Committee

6/19/2017 Reviewed monitoring results, analysis, and proposed actions. Recommended action plan activities.

Quality Improvement Committee

Reviewed monitoring results, analysis, and proposed actions. Approved action plan.

Section III: Specialty Care Physician Appointment Access Standards and Methodology

FHCP monitors OB/GYN, medical oncology and radiation oncology routine and urgent appointment accessibility to ensure members have access to high volume and high impact specialty medical care in a timely fashion. FHCP does so by utilizing responses captured in the annual CAHPS survey for Commercial, Marketplace/QHP and Medicare members, recording and following up on member complaints and appeals regarding access to Specialty, and telephone surveys conducted by staff to ensure appointments are available to Members. The following are the CAHPS questions related to specialist appointment access are utilized in this standard:

Commercial – (Q25) “In the last 12 months, how often did you get an appointment to see a specialist as soon as you needed?” Marketplace/ACA – (Q33) “In the last 6 months, how often did you get an appointment to see a specialist as soon as you needed?” Medicare – (Q35) “In the last 6 months, how often was it easy to get appointments with specialists?”

The specialty care physician appointment access standards, measurement method, and measurement frequency for each aspect of performance that is monitored is listed in Table 14 below:



Method Measurement

Frequency OB/GYN new patient routine appointments

70% of offices report a third available routine appointment is open for a new patient within 14 days of patient request

Office appointment access survey

Annually

OB/GYN established patient routine appointment



Annually



Method Measurement

Frequency OB/GYN new patient urgent appointment

85% of offices report the first available urgent appointment is open for a new patient within 48 hours of patient request


Annually

OB/GYN established patient urgent appointment

85% of offices report the first available urgent appointment is open for an established patient within 48 hours of patient request


Annually

Medical Oncology new patient routine appointments



Annually

Medical Oncology established patient routine appointment



Annually

Medical Oncology new patient urgent appointment



Annually

Medical Oncology established patient urgent appointment



Annually

Radiation Oncology new patient routine appointments



Annually



Method Measurement

Frequency Radiation Oncology established patient routine appointment



Annually

Radiation Oncology new patient urgent appointment



Annually

Radiation Oncology established patient urgent appointment



Annually

Complaints Rate of member complaints

about appointment access is less than 0.5 per 1000 members


Appeals Rate of member appeals about appointment access is less than 0.5 per 1000 members

Appeal analysis Annually

Specialty appointments

At least 80% of members report they always or usually obtained appointments as soon as they needed


Annually

FHCP measures high volume and high impact medical specialty appointment access through a survey of Practitioner offices. FHCP’s Provider Services Department surveys all applicable network (Medicare, Commercial & Marketplace) Practitioner office locations surveys for self-reporting. Response to the survey is monitored, with repeat surveys sent to those practices that do not respond to the initial survey. Follow-up to obtain completed surveys from non-responsive practices continues over a 6 week period with a response rate goal of sixty percent (60%). The survey questions are asked once

for each office, and data is recorded for the open appointments, regardless of the Practitioner who has open appointments. For routine appointments, data is gathered on first, second and third available appointments. Our routine appointment standard is based on the date of the third available appointment because it is the most sensitive method for detecting offices which have access issues since first and second available appointments often represent cancellations and while those open appointment slots frequently are available in a timely fashion, they often do not work for members. Urgent appointment data is gathered for the first available urgent appointment slot in the office.

Table 15: Response Rate Data

Practitioner Type

# Office locations

w/Practitioner type

# Office

locations responding

to survey

# Practitioners represented

by offices responding

to survey

# Practitioners of this type

in the Network

% of Practitioner type results

represent out of total contracted

practitioners of that type

OB/GYN 34 34 74 74 100% Medical

Oncology 28 28 145 145 100%

Radiation Oncology

10 9 29 31 94%

Results

Table 16: Measurement Results and Comparison to Performance Goal by Access Measure


OB/GYN new patient routine appointments



Yes

OB/GYN established patient routine appointment



Yes



OB/GYN new patient urgent appointment



Yes

OB/GYN established patient urgent appointment



Yes

Medical Oncology new patient routine appointments



Yes

Medical Oncology established patient routine appointment



Yes

Medical Oncology new patient urgent appointment



No



Medical Oncology established patient urgent appointment



Yes

Radiation Oncology new patient routine appointments



Yes

Radiation Oncology established patient routine appointment



Yes

Radiation Oncology new patient urgent appointment



Yes

Radiation Oncology established patient urgent appointment



Yes



Complaints - Appointment Access – OB/GYN


Commercial 0.00 complaints per 1,000 members Marketplace 0.00 complaints per 1,000 members Medicare 0.00 complaints per 1,000 members

Yes Yes Yes

Complaints Appointment Access – Medical Oncology



Yes Yes Yes

Complaints Appointment Access – Radiation Oncology



Yes Yes Yes



OB/GYN Appeals related to Access

Rate of member appeals about Access is less than 0.5 per 1000 members

Commercial 0.03 appeals per 1,000 members Marketplace 0.05 appeals per 1,000 members Medicare 0.00 appeals per 1,000 members

Yes Yes Yes

Medical Oncology Appeals related to Access

Rate of member appeals about Access is less than 0.5 per 1000 members


Yes Yes Yes

Radiation Oncology Appeals related to Access

Rate of member appeals Access is less than 0.5 per 1000 members


Yes Yes Yes



Specialty appointments

At least 80% of members report they always or usually obtained appointments as soon as they needed

Commercial – 90% Marketplace/QHP – 85% Medicare – 85%

Yes Yes Yes

Analysis One hundred percent (100%) of OB/GYN practices met the access standards for both new and established patients for routine and urgent appointments. The medical oncology practices met the access standards for established patients for both routine and urgent appointments as well as routine appointments for new patients but had difficulty in meeting the new patient urgent appointment measurement within 48 hours. With 5 practices not meeting this measurement, it resulted in only 82% of the practices meeting this measurement which is less than the 85% standard. It was disclosed when surveying the medical oncology practices that another health plan in our service area which employed its medical oncologists has closed, so the other oncology practices in the community are now receiving the patients from this insurance/group and causing new patient scheduling delays due to sudden increase in volume of requests. One hundred percent (100%) of the radiation oncology practices met all access standards including new patient urgent appointments. The volume of member complaints about specialty care access is very low and there were 0 complaints about OB/GYN and 0 complaints about radiation oncology access during this measurement period. There was only 1 Medicare member complaint regarding access to routine appointment for medical oncology wherein the member’s medical situation devolved to require a more urgent appointment date/time. The complaint was resolved to the member’s satisfaction. There was one Commercial member appeal and one Marketplace member appeal regarding OB/GYN access. There was two Medicare member appeals regarding access to medical oncology providers, and no appeals related to radiation oncology. However, CAHPS data does not support these findings as all met the requirement of at least 80% are able to get specialty care when needed.

A group of internal staff completed the initial barrier analysis. Participants included Chief Medical Officer and 2 provider relations representatives. The group brainstormed the following potential barriers and opportunities for improvement:

Table 18 Barrier Analysis Results Barrier Opportunity Selected for

Improvement? Limited number of medical oncologists available in service area to contract with, particularly resulting in delay for new patient appointments

Explore alternative methods to increase access to oncology, including telemedicine

No

Influx of new population previously serviced by private medical oncology group

Re-survey access in 4 months to determine if new patient access improves as practices absorb new patient population

Yes

Action



5/2017 Re-survey medical oncology practices to determine if access for new patient improves and stabilizes

Reporting This QI activity was reported to the following QI committees:

Table 20 Committee Reporting Committee Name Meeting Date Committee Actions or Recommendations Customer Service Committee

6/19/2017 Reviewed monitoring results, analysis, and proposed actions. Recommend action plan.

Quality Improvement Committee

Reviewed monitoring results, analysis, and proposed actions. Approved action plan.

Florida Health Care Plans Member Satisfaction Analysis

(January 01, 2016 – December 31, 2016)

Introduction

Member Complaints

(or verbal in the case of a Fast or Urgent)

Table 1 Complaint Categories

Commercial

Analysis

COMMERCIAL Appeals

denied: pre-service/prior authorization request in advance of obtaining the service; concurrent discontinued service review or post claim/service that has already been rendered).

Analysis

Medicare

Analysis

MEDICARE Appeals

Analysis

Member Satisfaction Survey Commercial CAHPS Survey

CAHPS

Table 12: Commercial CAHPS Survey response rates for the last two-years

Survey Population 2016 Response Rate

2015 Response Rate

2014 Response Rate

Table 12a: Summary of Trend and Benchmark Comparisons for 2016 SPH Analytics Book of Business (Non-PPO) Mean and Percentiles

Note: Significance Testing - Cells highlighted in red denote the current year score is significantly lower when compared to trend and/or benchmark data; Cells highlighted in green denote the current year score is significantly higher when compared to trend and/or benchmark data; No shading denotes that there was no significant difference between the scores or that there was insufficient sample size to conduct the statistical test. All significance testing is performed at the 95% significance level (Dicesare & Holte, 2016)

Table 12.b: Commercial Benchmark Comparisons for 2016 SPH Analytics Book of Business (Non-PPO) Mean and Percentiles

Note: Significance Testing - Cells highlighted in red denote the current year score is significantly lower when compared to trend and/or benchmark data; Cells highlighted in green denote the current year score is significantly higher when compared to trend and/or benchmark data; No shading denotes that there was no significant difference between the scores or that there was insufficient sample size to conduct the statistical test. All significance testing is performed at the 95% significance level. (Dicesare & Holte, 2016)

Table 12.c: Commercial Trended Survey Results

Getting Care Needed, Getting Care Quickly, How well Doctors Communicate Attitude & Service Customer Service

Claims ProcessingRating of Health Care, and Rating of

Health Plan Rating of personal doctor Rating of specialist

Rating of Health Plan

Medicare CAHPS Survey

CAHPS

Table 13: Medicare CAHPS Survey response rates for the last two-years


2015 Response Rate

2014 Response Rate

Table 13a: Summary of Medicare Trend and Benchmark Comparisons 2016 Star Domains: Scaled Mean Scores

Table 13.b: Medicare Trended Survey Results Star Domains: Scaled Mean Scores

Table 13.c: Key Drivers of Overall Ratings

Customer Service Composite

Getting Needed Care

Opportunities Analysis

Table 14: Opportunities Identified Across Satisfaction Data Sources Commercial Members Improvement Opportunity

Member Complaints Member Appeals CAHPS Satisfaction Survey

Table 15: Opportunities Identified Across Satisfaction Data Sources Medicare Members

Improvement Opportunity

Member Complaints Member Appeals CAHPS Satisfaction Survey

Table 16: 2016 Billing and Financial Barrier Analysis Results

Barrier Opportunity Selected for Improvement?

Table 17: Attitude and Service Barrier Analysis Results

Barrier Opportunity / Action Selected for Improvement?

Table 18: Access to Care Barrier Analysis Results

Barrier Opportunity / Action Selected for Improvement?

Table 19: Planned Actions- Billing and Financial

Date Initiated

Action Implemented Billing and Financial

Barriers Addressed

Table 19c: Planned Action- Attitude and Service Date

Initiated Action Implemented Attitude and Service

Barriers Addressed

Table 19b: Planned Actions- Access Date

Initiated Action Implemented

Access Barriers Addressed

Date Initiated

Action Implemented Access

Barriers Addressed

Works Cited 2016 CAHPS® Commercial Adult.2016 Medicare CAHPS®.

Committee Name Meeting Date Committee Actions or Recommendations Customer

Satisfaction 04/17/2017 Approved and sent to PI Council

Performance Improvement

Council

0 /2 /2017 Approved by PI

Measurement year July 1, 2016 – June 30, 2017

Florida Health Care PlansBehavioral Health Member Satisfaction Analysis

July 1, 2016 – June 30, 2017

Introduction

Member Complaints

(or verbal in the case of a Fast or Urgent)

Table 1

Table 1: Complaint Categories

Commercial Population Analysis

Commercial Complaints: Table 2: Commercial Population trended Complaint Data

Analysis

Table 2a: Commercial Quality Complaints

Table 2b: Commercial Access

Table 2c: Commercial Attitude/Service Complaint

Table 2d: 2016 Commercial Billing and Financial Matters

Commercial Appeals

denied: pre-service/prior authorization request in advance of obtaining the service; concurrent discontinued service review or post claim/service that has already been rendered).

Table 3: Commercial Appeals Data

Medicare Population Analysis Medicare Complaints: Table 4: Medicare Member Complaints

Analysis

Table 4a: Medicare Attitude/Service complaints

Table 4b: Medicare Access complaints

Table 4c: Medicare Quality complaints

Table 4d: Medicare Billing and Financial complaints

Medicare Appeals:

Table 5: Medicare Appeals Data

Marketplace Population Analysis

Marketplace Complaints:

Table 6: Marketplace Complaint Data

Analysis

Table 6a: Marketplace Attitude and Service complaints

Table 6b: Marketplace Access Complaints

Table 6c: Marketplace Quality Complaints

Table 6d: Marketplace Billing and Financial Complaints

Marketplace Appeals:

Table 7: Appeals Data

Commercial Member Behavioral Health Satisfaction Survey

Table 7: Commercial ECHO Survey response rates

Survey Population 2017 Response 2016 Response 2015 Response

Table 7a: Commercial Echo Survey Results

Commercial ECHO® Survey Results

2017 Results

2017 Percentile

2016 SPHA Book of Business Benchmark

2016 Percentile

2015 Percentile

Getting Treatment Quickly Composite

Access to Treatment and Information from Health Plan Composite

How Well Clinicians Communicate Composite

Informed About Treatment Options

Medicare Member Behavioral Health Satisfaction Survey

Table 8: Medicare ECHO Survey response rates


2016 Response Rate 2015 Response Rate

Table 8a: Medicare Echo Survey Results

Medicare 2017

Results 2017

Percentile

2016 SPHA Book of Business

Benchmark

2016 Percentile

2015

ECHO ® Survey Results Percentile

How Well Clinicians Communicate

Informed About Treatment Options

<

Access to Treatment and Information from Health Plan

Office Wait Time (within 15 minutes)

Marketplace Member Behavioral Health Satisfaction Survey

Table 9: Marketplace Survey response rates

Survey Population 2017 Response 2016 Response 2015 ResponseRate

Table 9a: Marketplace Survey Results

Marketplace Survey Results

2017 Results

2016 Results

2015 Results

Getting Treatment Quickly Composite

How Well Clinicians Communicate Composite

Analysis

Opportunities Identified Across Satisfaction Data Sources Table 10: Opportunities Identified Across Satisfaction Data Sources Commercial Members

Improvement Opportunity Member Complaints Member Appeals ECHO Satisfaction

Survey

Table 10a: Opportunities Identified Across Satisfaction Data Sources Medicare MembersImprovement Opportunity

Member Complaints Member Appeals ECHO Satisfaction Survey

Table 10b: Opportunities Identified Across Satisfaction Data Sources Marketplace Members

Improvement Opportunity

Member Complaints Member Appeals Satisfaction Survey

Table 11: Attitude and Service


Table 12: Access


Table 13: Planned Actions

Committee Name Meeting Date Committee Actions or Recommendations

of 7

Total # calls monitored 26 33 38 29 289 282 277 286 Accurate response given by CSR and handled appropriately 26 32 38 28 280 274 265 273

Compliance 100% 97% 100% 97% 97% 97.1% 95.6% 95.4%

HIPAA Compliant 26 33 38 29 288 282 277 286

Compliance 100% 100% 100% 100% 99% 100% 100% 100%

Handled in one contact 26 33 38 29 283 278 269 282

Compliance 100% 100% 100% 100% 98% 98.5% 97% 98.6% Forward call Stayed on line 8 6 5 6 63 37 51 85

Informational

Had to leave voicemail 0 0 0 0 6 4 8 4 Sent to a Counselor 3 2 2 1 23 16 27 18 Overall Compliance Rate 100% 99% 100% 99% 98% 98.5% 97.5% 98%

of 7

2016 2015 2016 2015 2016 2015 2016 2015 2016 2015CALL

TIMELINESS

of 7


Due to new product lines (Medicare, Commercial and QHP expansion), call volume was greater than anticipated with inquires that required longer handle times and necessitated transfers due to issues with the enrollment and finance.

Continue to monitor accuracy of calls answered by CSR and appropriateness of transfers to another source. Evaluate current MS workflow processes that contribute to prolonged handle time and abandonment rates, i.e.) Technical support for Web/mobile base issues and Transition of Care needs. Initiate planning for increase temporary staffing and associated training earlier, (July).

Continuous CSR Training on New Product lines and Benefits in order to meet member needs. Utilize MS Counselors to take overflow calls Increase staffing with two temporary employees. Establish a separate phone line and dedicated CSR to manage calls related to technical support issues associated with Member Portal, FHCP mobile app, and FollowMy Health. Establish a separate phone line and dedicated CSR to manage Transition of Care needs for newly enrolled members. Interviewed, hired, and initiated training on four Temporary CSR’s

January 2014 and Ongoing January 2014 and Ongoing November 2015 January 2016 January 2016 July 2016

of 7


An increase in call volume and in documentation of calls for all members, especially for QHP members slowed process for answering calls in a timely manner

Initiate planning for increase temporary staffing and associated training earlier, (July). Evaluate current MS document workflow processes that contribute to prolonged handle time and abandonment

Grievance and appeals counselors serve as backup for CSR. Increase staffing with two temporary employees. Request IT to prioritize system/software revisions to streamline MS documentation workflow

Jan 2015 and ongoing

July 2016

July 2016

Increase in enrollment into Follow My Health , Doctors on Demand, FHCP mobile application and member portal

Route technical calls to expert.

Assigned 2 CSR’s to provide exclusive technical support Establish a dedicated phone line and CSR to manage calls related to technical support issues associated with Member Portal, FHCP mobile app, and FollowMy Health. Establish a dedicated phone line and dedicated CSR to manage Transition of Care needs for newly enrolled members.

Jan 2015 and ongoing January 2016 January 2016

Increase handle time for the management of technical issues related to FHCP applications

Streamline process for managing technical assistance calls

Restructure of the phone tree to route inquires related to technical issues to a dedicated line with voice mail capability

2016

Increase in product lines and geographical expansion, increased the volume of members requiring transition of care assistance.

Streamline process for managing transition of care calls

Restructure of the phone tree to route inquires related to transition of care issues to a dedicated line with voice mail capability

2016

Name: _______________________________ DOB: _____________

FHCP#: ________________ Date: _____________

Member Services Satisfaction Survey

Please complete the following survey to provide feedback so that we can assess your recentMember Services experience. Please return this form to our Member Services department in the enclosed, self- addressed envelope.

1. Was the Member Services Representative courteous and respectful? YesNo

2. Did you feel that the Customer Service Representative fully addressed your concern or request?

YesNo

3. Was your issue resolved by the Member Services Representative or were you transferred to another department?

ResolvedTransferred

4. Overall, how satisfied are you with the response from the Member Services Representative?

SatisfiedDissatisfied

Comments: _____________________________________________________

__ _______________________________________________________

__ _______________________________________________________

Table 7b: Marketplace Pre-service / Prior Authorization Determinations Total Processed

Marketplace Marketplace Benefits

Denials Marketplace Medical

Necessity Denials Marketplace Denial

Rate 2016

2015

2014

Concurrent review

Table 8: Commercial Concurrent Determinations (Inpatient)

Total Concurrent authorizations

Benefits Denials Medical Necessity Denials

Denial Rate

2016

2015

2014

Case Management Effectiveness, Action Measure Re-measurement Report Florida Health Care Plans

Flu Vaccination Adherence 2016

Measure Specifications

Commercial, Medicare, and Marketplace Populations:

data sources

Performance Goal:


Results and Analysis

COMMERCIAL

Measurement Time Period Numerator Denominator Rate

Goal

Medicare


Goal

Marketplace


Goal


Measurement Analysis


Identifying Opportunities for Improvement

Barrier Opportunity Selected for improvement


Lipid Lowering Agents

Relevant Process

Valid Methods and Measure Specifications

Medicare Population:


Commercial Population:

Marketplace Population:

Data Sources

Performance Goal:

Data Collection and Analysis



Barriers Opportunities for Improvement

Selected for improvement


Hemoglobin A1C Adherence

Relevant Process

Valid Methods and Measure Specifications

Medicare Population:


Commercial Population:

Marketplace Population:

Data Sources

Data Collection and Analysis

Reporting Period 20140701-20150630 – Completed HbA1c Screen

PRODUCT MEMBERS COMPLIANT % COMPLIANT Goal met

Y/N

GRAND TOTAL 87 73 83.91%

Performance Goal:



Barriers Opportunities for Improvement

Selected for improvement

Florida Healthcare Plans

Case Management Member Satisfaction Analysis

1/1/2016-12/31/2016

Introduction

Analyzing Member Feedback

Analyzing Member Complaints

Sample



1/1/2016-12/31/2016

Table 1: Summary of Survey Response Rate

Table Definitions: Surveys Released:

Surveys Completed:

Percentage of Response Rate:

Product LineTotal In Complex

Care 2016

Suveys Released

Surveys Completed

Surveys Not Returned

Response Rate 2016

Response Rate 2015

Response Rate 2014

Medicare 232 38 26 12 68.4% 74.5% 97.6%Commercial 65 7 7 0 100.0% 60.0% 100.0%Marketplace 43 9 1 10 11.1% 28.5% 100.0%Total 340 54 34 22 63.0% 68.3% 99.0%



1/1/2016-12/31/2016

Table 2: Medicare

Survey Statements Most of the Time Some of the Time Not at All Goal Met

Overall, I was satisfied with my Nurse/Case

Explained the reasons for my Case Management

Supported my Values and beliefs

Explained my condition(s)/health care

needs clearly.Helped me set goals to manage my condition(s) and health care needsProvided verbal and/or written information that

helped me reach my goals. Helped me to understand when to call my physician



1/1/2016-12/31/2016

Table 3: Commercial

Survey StatementsMost of the

TimeSome of the

Time Not at AllGoal Met 2016

Goal Met 2015

Goal Met 2014

Explained the reasons for my Case

Management services.




helped me reach my goals.

Helped me to understand when to call

my physicianOverall, I was satisfied

with my Nurse/Case Manager.



1/1/2016-12/31/2016

Table 4: Marketplace

Survey Statements Most of the TimeSome of the Time Not at All Goal Met

Overall, I was satisfied with my Nurse/Case Manager.

Helped me set goals to manage my condition(s) and

health care needsProvided verbal and/or written information that

helped me reach my goals. Helped me to understand when to call my physician

Explained the reasons for my Case Management services.


Explained my condition(s)/health care needs



1/1/2016-12/31/2016

Quantitative Analysis Table: 5 Combined Survey Results

Survey StatementsMost of the

TimeSome of the

TimeNot at

AllGoal Met

2016Goal Met

2015Goal Met

2014

Overall, I was satisfied with my Nurse/Case

Manager.

Explained the reasons for my Case Management

services.




helped me reach my goals.

Helped me to understand when to call my physician



1/1/2016-12/31/2016

Member Complaints

Qualitative Analysis Opportunities for Improvement

Barriers identified Corrective actions Selected For Action



1/1/2016-12/31/2016




1/1/2016-12/31/2016


Reporting


QI 5 Element C CM Identification Report Florida Health Care Plans

Report Period 07/01/2016 - 06/30/2017

Measure Description and Relevance

Methodology


Report Period 07/01/2016 - 06/30/2017

Table 1: QI7 Element C - Unique Members by Data Reports

Product Members

>= 16

Medications

Stroke Late Effect

(EHR)

>= 14

LOS

Readmit

within 30

Days

>= 3 ER

Stays 90

Days

Grand

Total 462 185 56 60 157 59

Table 1: Members Identified by Data Report


Report Period 07/01/2016 - 06/30/2017

Table 2: QI5 Element C - Unique Members by other ID source

ProductSelf-

Referred

Admission DataUR Practitioner

Data supplied

by Self/care

giver IDT/EHR

Table 2: Unique Members by other ID source

Conclusion:


Report Period 07/01/2016 - 06/30/2017 Reporting

Committee Name Meeting Date

Committee Actions or Recommendations

QI7D Access to Case Management Report Florida Health Care Plans

Report Period: 01/01/2016-12/31/2016

Measure Description and Relevance

Methodology


Report Period: 01/01/2016-12/31/2016

Referral Sources

Commercial and Marketplace ,

one thousand , fifty-eight

Table 1

Table 1: Commercial and Marketplace

Commercial and Marketplace Referral Sources

0 257 536 22 235 8 1058


Report Period: 01/01/2016-12/31/2016

Medicare

Table 2: Medicare Members

Medicare Referral Sources

0 213 764 44 99 46 1166

Conclusion:


Report Period: 01/01/2016-12/31/2016

Reporting


Report Period: 01/01/2016-12/31/2016


Florida Health Care Plans Complex Care Case Management

QI 5 Element A Population Assessment

Table of Contents

Table A: Membership by Product Line

Table B: Hospital Admissions by Product Line.

Table C: Hospitalizations by Membership

Methodology:

Table 1: Commercial Inpatient Diagnoses by Unique Count

Analysis:

Table 2: Commercial Inpatient Diagnoses by Resource Expenditure

Table 3: Commercial ED Diagnoses by Encounter Volume

Table 4: Commercial ED Diagnoses by Resource Expenditure

Table 5: Medicare Inpatient Diagnoses by Unique Count

Table 6: Medicare Inpatient Diagnoses by Resource Expenditure

Table 7: Medicare ED Diagnoses by Unique Count

Table 8: Medicare ED Diagnoses by Resource Expenditure:

Table 9: Marketplace Inpatient Diagnoses by Unique Count:

Table 10: Marketplace Inpatient Diagnoses by Resource Expenditure:

Table 11: Marketplace ED Diagnoses by Unique Count:

Table 12: Marketplace ED Diagnoses by Resource Expenditure:

Table C: Disabled Members by Product Line and Age

Table 13: Disabled Commercial IP Diagnoses by Unique Count:

Table 14: Disabled Commercial ER Diagnoses by Unique Count:

Table 15: Disabled Commercial IP Diagnoses by Resources Expenditure:

Table 16: Disabled Commercial ER Diagnoses by Resources Expenditure:

Table 17: Disabled Marketplace IP Diagnoses by Unique Member Count:

Table 18: Disabled Marketplace ER Diagnoses by Unique Member Count:

Table 19: Disabled Marketplace IP Diagnoses by Resource Expenditure:

Table 20: Disabled Marketplace ER Diagnoses by Resource Expenditure:

Table 21: Disabled Medicare IP Diagnoses by Unique Member Count:

Table 22: Disabled Medicare ER Diagnoses by Unique Member Count:

Table 23: Disabled Medicare IP Diagnoses by Resource Expenditure:

Table 24: Disabled Medicare ER Diagnoses by Resource Expenditure:

Table E: Unique SPMI Members by Product Lines and Age Group

Table 25: Behavioral Health: Commercial Inpatient Diagnoses by Unique Count

Table 26: Behavioral Health: Commercial Inpatient Diagnoses by Resource Expenditure:

Table 27: Behavioral Health: Commercial ER Diagnoses by Unique Count:

Table 28: Behavioral Health: Commercial ER Diagnoses by Resource Expenditure:

Table 29: Behavioral Health: Medicare Inpatient Diagnoses by Unique Count

Table 30: Behavioral Health: Medicare Inpatient Diagnoses by Resource Expenditure:

Table 31: Behavioral Health: Medicare ER Diagnoses by Unique Count

Table 32: Behavioral Health: Medicare ER Diagnoses by Resource Expenditure

Table 33: Behavioral Health: Marketplace Inpatient Diagnoses by Unique Count

Table 34: Behavioral Health: Marketplace Inpatient Diagnoses by Resource Expenditure:

Table 35: Behavioral Health: Marketplace ER Diagnoses by Unique Count:

Table 36: Behavioral Health: Marketplace ER Diagnoses by Resource Expenditure:

Table D: Children and Adolescent Membership by Product Line

Children and Adolescent (age 2-19)

Memebrship by product line

Table E: Children and Adolescent Membership by Product Line

Table 37: Commercial Inpatient Diagnoses by Unique Count:

Table 38: Commercial Inpatient Diagnoses by Resource Expenditure:

Table 39: Commercial ED Diagnoses by Unique Count:

Table 40: Commercial ED Diagnoses by Resource Expenditure:

Table 41: Marketplace IP Diagnoses by Unique Count:

Table 42: Marketplace IP Diagnoses by Resource Expenditure:

Table 43: Marketplace ER Diagnoses by Unique Count:

Table 44: Marketplace ER Diagnoses by Resource Expenditure:

Table 45: Behavioral Health: Commercial Inpatient Diagnoses by Unique Count (age 2-19)

Table 46: Behavioral Health: Commercial Inpatient Diagnoses by Resource Expenditure (age 2-19)

Table 47: Behavioral Health: Commercial ER Diagnoses by Unique Count (age 2-19)

Table 48: Behavioral Health: Commercial ER Diagnoses by Resource (age 2-19)

Table 49: Behavioral Health: Marketplace Inpatient Diagnoses by Unique Count (2-19)

Table 50: Behavioral Health: Marketplace Inpatient Diagnoses by Resource (age 2-19)

Table 51: Behavioral Health: Marketplace ER Diagnoses by Unique Count (age 2-19)

Table 52: Behavioral Health: Marketplace ER Diagnoses by Resource (age 2-19)

Table 53: Disabled Children and Adolescents (Age 2 -19) IP Diagnoses by Count

Table 54: Disabled Children and Adolescents (Age 2 -19) IP Diagnoses by Resource

Table 55: Disabled Children and Adolescents (Age 2 -19) ER Diagnoses by Count

Table 56: Disabled Children and Adolescents (Age 2 -19) ER Diagnoses by Resource

Table 57: Inpatient Top 3 Admission Related Diagnosis

Members age 20 and Older

Members age 2-19

Table 58: Emergency Room: Top 3 Visit Related Diagnosis


Members age 2-19

Table 59: Inpatient Top 3 Diagnosis by Resource Expenditure

Members age 2-19

Table 60: Emergency Room: Top 3 by Resources Expenditure


Inpatient Utilization

Emergency Room Utilization

Introduction

Methodology

Analysis by Membership

Table A: Membership by Product Line MEMBERSHIP BY PRODUCT LINE

Product Line Commercial Medicare Marketplace

# members

% of enrollment

Table B: Hospital Admissions by Product Line. HOSPITAL ADMISSIONS BY PRODUCT LINE


# admissions

% of admissions

Table C: Hospitalizations by Membership HOSPITALIZATIONS BY MEMBERSHIP


# members

# of admissions

% of Admissions

Analysis by Product Line

Methodology:

Commercial

Table 1: Commercial Inpatient Diagnoses by Unique Count

Analysis:

Table 2: Commercial Inpatient Diagnoses by Resource Expenditure

Table 3: Commercial ED Diagnoses by Encounter Volume

Table 4: Commercial ED Diagnoses by Resource Expenditure

Medicare

Table 5: Medicare Inpatient Diagnoses by Unique Count

Table 6: Medicare Inpatient Diagnoses by Resource Expenditure

Table 7: Medicare ED Diagnoses by Unique Count

Table 8: Medicare ED Diagnoses by Resource Expenditure:

Marketplace

Table 9: Marketplace Inpatient Diagnoses by Unique Count:

Table 10: Marketplace Inpatient Diagnoses by Resource Expenditure:

Table 11: Marketplace ED Diagnoses by Unique Count:

Table 12: Marketplace ED Diagnoses by Resource Expenditure:

Inpatient Admissions and Resource Analysis

Emergency Room Utilization and Resources Analysis

Summary and Trends

Disabled Members by Product Lines-

Table C: Disabled Members by Product Line and Age Disabled Members by Product Lines and Age Group


# members

# Adults # Children & Adolescents

Commercial Members Table 13: Disabled Commercial IP Diagnoses by Unique Count:

Table 14: Disabled Commercial ER Diagnoses by Unique Count:

8,378

Table 15: Disabled Commercial IP Diagnoses by Resources Expenditure:

Table 16: Disabled Commercial ER Diagnoses by Resources Expenditure:

$216,753.00,

Marketplace MembersTable 17: Disabled Marketplace IP Diagnoses by Unique Member Count:

Table 18: Disabled Marketplace ER Diagnoses by Unique Member Count:

Table 19: Disabled Marketplace IP Diagnoses by Resource Expenditure:

Table 20: Disabled Marketplace ER Diagnoses by Resource Expenditure:

Medicare MembersTable 21: Disabled Medicare IP Diagnoses by Unique Member Count:

Table 22: Disabled Medicare ER Diagnoses by Unique Member Count:

Table 23: Disabled Medicare IP Diagnoses by Resource Expenditure:

Table 24: Disabled Medicare ER Diagnoses by Resource Expenditure:

Summary and Trends

Behavioral Health

Severe and Persistent Mental Illness by Product line

Table E: Unique SPMI Members by Product Lines and Age Group Unique SPMI Members by Product Lines and Age Group


# members

# Adults # Children & Adolescents

Table 25: Behavioral Health: Commercial Inpatient Diagnoses by Unique Count

Table 26: Behavioral Health: Commercial Inpatient Diagnoses by Resource Expenditure:

Table 27: Behavioral Health: Commercial ER Diagnoses by Unique Count:

Table 28: Behavioral Health: Commercial ER Diagnoses by Resource Expenditure:

Table 29: Behavioral Health: Medicare Inpatient Diagnoses by Unique Count

Table 30: Behavioral Health: Medicare Inpatient Diagnoses by Resource Expenditure:

Table 31: Behavioral Health: Medicare ER Diagnoses by Unique Count

Table 32: Behavioral Health: Medicare ER Diagnoses by Resource Expenditure

Table 33: Behavioral Health: Marketplace Inpatient Diagnoses by Unique Count

Table 34: Behavioral Health: Marketplace Inpatient Diagnoses by Resource Expenditure:

Table 35: Behavioral Health: Marketplace ER Diagnoses by Unique Count:

Table 36: Behavioral Health: Marketplace ER Diagnoses by Resource Expenditure:

Summary and Trends

Children and Adolescent population (2-19 years of age) by Product Line

Table D: Children and Adolescent Membership by Product Line CHILDREN AND ADOLESCENT (age 2-19)

MEMBERSHIP BY PRODUCT LINE


# members

% of enrollment

Table E: Children and Adolescent Membership by Product Line CHILDREN AND ADOLESCENT (age 2-19)

HOSPITALIZATIONS BY MEMBERSHIP


# members

# of admissions

% of Admissions

Methodology

Table 37: Commercial Inpatient Diagnoses by Unique Count:

Table 38: Commercial Inpatient Diagnoses by Resource Expenditure:

Table 39: Commercial ED Diagnoses by Unique Count:

Table 40: Commercial ED Diagnoses by Resource Expenditure:

Table 41: Marketplace IP Diagnoses by Unique Count:

Table 42: Marketplace IP Diagnoses by Resource Expenditure:

Table 43: Marketplace ER Diagnoses by Unique Count:

Table 44: Marketplace ER Diagnoses by Resource Expenditure:

Summary and Trends

Behavioral Health Children and Adolescent population (2-19 years of age) by Product Line

CommercialTable 45: Behavioral Health: Commercial Inpatient Diagnoses by Unique Count (age 2-19)

Table 46: Behavioral Health: Commercial Inpatient Diagnoses by Resource Expenditure

(age 2-19)

Table 47: Behavioral Health: Commercial ER Diagnoses by Unique Count (age 2-19)

Table 48: Behavioral Health: Commercial ER Diagnoses by Resource (age 2-19)

MarketplaceTable 49: Behavioral Health: Marketplace Inpatient Diagnoses by Unique Count (2-19)

Table 50: Behavioral Health: Marketplace Inpatient Diagnoses by Resource (age 2-19)

Table 51: Behavioral Health: Marketplace ER Diagnoses by Unique Count (age 2-19)

Table 52: Behavioral Health: Marketplace ER Diagnoses by Resource (age 2-19)

Summary and Trends

Disabled Children and Adolescents (Age 2-19)Table 53: Disabled Children and Adolescents (Age 2 -19) IP Diagnoses by Count

Table 54: Disabled Children and Adolescents (Age 2 -19) IP Diagnoses by Resource

Table 55: Disabled Children and Adolescents (Age 2 -19) ER Diagnoses by Count

Table 56: Disabled Children and Adolescents (Age 2 -19) ER Diagnoses by Resource



Summary and Trends

Comparative Analysis Across all Product Lines and Age Groups

Inpatient by Encounter

Table 57: Inpatient Top 3 Admission Related Diagnosis


Members age 2-19

Emergency Room by Encounter Table 58: Emergency Room: Top 3 Visit Related Diagnosis


Members age 2-19

Inpatient by Resources Expenditure Table 59: Inpatient Top 3 Diagnosis by Resource Expenditure

Members age 2-19

Emergency Room by Resources ExpenditureTable 60: Emergency Room: Top 3 by Resources Expenditure


Members age 2-19

Conclusion:

Inpatient Utilization

Emergency Room Utilization

Complex Case Management Processes and Resources

Identified High Risk Populations in need of Complex Case Management

and Proposed Program Adjustments Existing and Newly

Identified High Risk

Populations & Diagnosis

Identified

Barriers

Corrective

Actions

Reporting


Florida Health Care Plan Case Management Program Description

Updated: January 2017

Program Philosophy, Aims and Goals

Program Metrics and Goals



Evidence Used to Develop the Program

Population Assessment



Eligibility Criteria



Referral Sources



Services Offered

Case Management Process



Case Management Integration



to provide classes in Smoking C (Appendix 2)



Complex Case Management Infrastructure

Clinical Leadership:

Dr. Wendy Myers:

Dr. Joseph Zuckerman:

Susan Lautenschlager, RN, BSN:

Sandra Sanderson RN, BHCS, MHCA:

Case Management Delivery Team: Department Manager (1):



StaffCase Management Nurse Care Coordinators

Case Management Office Coordinator

Case Management Community Resource Coordinators

Reporting


Florida Health Care Plan, Inc.2017 Quality Improvement Work Plan

Activity Responsible Party

Start Date

Committee Reported To

Completion Date

QUALITY IMPROVEMENT STANDARDS



Start Date


Completion Date



Start Date


Completion Date

NET STANDARDS



Start Date


Completion Date

UTILIZATION MANAGEMENT STANDARDS



Start Date


Completion Date

MEMBER RIGHTS AND RESPONSIBILITIES STANDARDS

MEMBER CONNECTION STANDARDS

Other ActivitiesResponsible

PartyStartDate

Committee and Report Date

CompletionDate


Biennial QI ActivitiesResponsible

PartStartDate

Committee and Report Date

CompletionDate

Measures

Effectiveness of Care Reported Rate (Adjusted) Points Score National Threshold

Meets or ExceedsReported Rate

(Adjusted) Points Score National Threshold Meets or Exceeds

Adult BMI Assessment 96.00% 1.6818 1.6818 90th Percentile which was 91% 96.27% 1.7619 1.7619 90th Percentile which was 91%

Appropriate Testing for Children with Pharyngitis 74.73% 0.3364 0.3364 Less than 25th Percentile 74.60% 0.3524 0.3524 Less than 25th Percentile

Appropriate Treatment for Children with Upper Respiratory Infection 86.79% 0.6727 0.9082 25th Percentile which was 84% 89.38% 1.1981 1.3743 50th Percentile which was 88%

Avoidance of Antibiotic Treatment in Adults With Acute Bronchitis 53.61% 1.6818 1.6818 90th Percentile which was 39% 41.59% 1.7619 1.7619 90th Percentile which was 38%

Breast Cancer Screening 75.76% 1.4800 1.4800 75th Percentile which was 75% 80.82% 1.7619 1.7619 90th Percentile which was 80%

Cervical Cancer Screening 82.19% 1.6818 1.6818 90th Percentile which was 81% 85.77% 1.7619 1.7619 90th Percentile which was 82%

Childhood Immunization Status (Combo 2) 82.84% 1.1436 1.1436 50th Percentile which was 78% 78.53% 1.1981 1.1981 50th Percentile which was 78%

Chlamydia Screening in Women (Total Rate) 47.49% 1.1436 1.1436 50th Percentile which was 43% 46.87% 1.1981 1.1981 50th Percentile which was 43%

Cholesterol Management for Patients With Cardiovascular Conditions (Screening rate only) NA NA NA No Benchmark Available NA NA NA No Benchmark Available

Colorectcal Cancer Screening 68.37% 1.4800 1.4800 75th Percentile which was 66% 75.70% 1.7619 1.7619 90th Percentile which was 72%

Comprehensive Diabetes Care—HbA1c Poorly Controlled (>9.0%) 18.61% 1.6818 1.6818 90th Percentile which was 22% 18.92% 1.7619 1.7619 90th Percentile which was 22%

Controlling High Blood Pressure (overall rate) 71.04% 1.4800 1.4800 75th Percentile which was 66% 72.22% 1.5505 1.5505 75th Percentile which was 69%

Flu Vaccinations for Adults Ages 18-64 36.03% 0.3364 0.3364 Less than 25th Percentile 42.24% 0.3524 0.5286 Less than 25th Percentile

Follow-Up After Hospitalization for Mental Illness (7-day rate only) 56.60% 1.1436 1.3118 50th Percentile which was 50% 67.57% 1.7619 1.7619 90th Percentile which was 67%

Medical Assistance With Smoking Cessation (Advising Smokers to Quit only) NA NA NA No Benchmark Available NA NA NA No Benchmark Available

Persistence Beta-Blocker Treatment After a Heart Attack NA NA NA No Benchmark Available NA NA NA No Benchmark Available

Prenatal & Postpartum Care - Postpartum Care 88.59% 1.6818 1.6818 90th Percentile which was 87% 88.44% 1.7619 1.7619 90th Percentile which was 88%

Use of Imaging Studies for Low Back Pain 71.43% 0.6727 1.0764 25th Percentile which was 70% 74.21% 0.7048 1.1276 25th Percentile which was 71%

Use of Spirometry Testing in the Assessment and Diagnosis of COPD 55.67% 1.6818 1.6818 90th Percentile which was 52% 63.86% 1.7619 1.7619 90th Percentile which was 52%

Antidepressant Medication Management - Averaged Rate 0.3364 0.9514

Antidepressant - Acute phase 56.44% 0.3364 0.3364 Less than 25th Percentile 62.57% 0.7048 0.9514 25th Percentile which was 62%

Antidepressant - Continuation 39.58% 0.3364 0.3364 Less than 25th Percentile 48.40% 0.7048 0.9514 25th Percentile which was 46%

2017 2016

Commercial HEDIS CAHPS HMO/POS Combined2017-2016 Comparison

Effective 8/31/2017

HEDIS/CAHPS Scoring Comparison 2016-17 Page 1 of 2

Measures




2017 2016

Commercial HEDIS CAHPS HMO/POS Combined2017-2016 Comparison

Effective 8/31/2017

Comprehensive Diabetes Care - Averaged Rate 2.7358 3.0070

Comprehensive Diabetes Care - HbA1c Testing 93.30% 1.4800 1.4800 75th Percentile which was 92% 94.84% 1.7619 1.7619 90th Percentile which was 94%

Comprehensive Diabetes Care - Eye Exams 54.34% 1.1436 1.3118 50th Percentile which was 49% 57.25% 1.1981 1.3743 50th Percentile which was 49%

Comprehensive Diabetes Care - LDL-C Screening NA NA NA No Benchmark Available NA NA NA No Benchmark Available

Comprehensive Diabetes Care - Nephropathy Monitoring 90.57% 1.1436 1.3118 50th Percentile which was 89% 90.91% 1.1981 1.3743 50th Percentile which was 89%

Follow-up for Children Prescribed ADHD Medication - Averaged Rate 1.3118 0.3524

Follow-up for Children Prescribed ADHD Medication – Initiation 40.00% 1.1436 1.3118 50th Percentile which was 39% 30.51% 0.3524 0.3524 Less than 25th Percentile

Follow-up for Children Prescribed ADHD Medication – Continuation NA NA NA No Benchmark Available NA NA NA No Benchmark Available

PCE Pharmacotherapy Mgmt COPD Exacerbation - Averaged Rate 0.3364 NA

PCE Pharmacotherapy Mgmt COPD Exacerbation (Rate - Systemic corticosteroid) 56.52% 0.3364 0.3364 Less than 25th Percentile NA NA NA No Benchmark Available

PCE Pharmacotherapy Mgmt COPD Exacerbation (Rate - Bronchodilator) 56.52% 0.3364 0.3364 Less than 25th Percentile NA NA NA No Benchmark Available

WCC Weight Assessment and Counseling for Nutrition and Physical Activity for Children - Averaged Rate 1.4912 1.5505

WCC Weight Assessment and Counseling for Nutrition and Physical Activity for Children(Rate - BMI Percentile - Total)

87.43% 1.6818 1.6818 90th Percentile which was 82% 79.85% 1.5505 1.5505 75th Percentile which was 70%

WCC Weight Assessment and Counseling for Nutrition and Physical Activity for Children (Rate - Counseling for Nutrition Total)


WCC Weight Assessment and Counseling for Nutrition and Physical Activity for Children (Rate - Counseling for Physical Activity - Total)


26.9988 out of 37

29.0479 out of 37

CAHPS® Reported Rate (Adjusted)

Score Reported Rate (Adjusted)

Score

Claims Processing 2.4612 1.1440 NA NACustomer Service 2.5950 1.1440 NA NAGetting Care Quickly 2.4838 0.8840 2.4883 1.1050Getting Needed Care 2.4450 0.8840 2.4880 1.4300How Well Doctors Communicate 2.7478 1.3000 2.7646 1.6250Rating of All Health Care 2.5177 1.3000 2.5078 1.6250Rating of Health Plan 2.3950 2.6000 2.4296 3.2500Rating of Personal Doctor 2.6424 1.3000 2.6231 1.6250Rating of Specialist Seen Most Often 2.5294 0.5200 2.6136 1.4300

11.076 out of 13

12.09out of 13

38.0748 of 50 41.1379 of 50

* Total scores may not appear to total as all numbers are truncated for display purposes only. All total scores and star calculations are based on actual, not truncated, numbers.

Total EOC Score Total EOC Score

Total HEDIS® Score* Total HEDIS® Score*

90th Percentile which was 2.790th Percentile which was 2.590th Percentile which was 2.3890th Percentile which was 2.6175th Percentile which was 2.58

National Threshold Meets or Exceeds

Total CAHPS ® Score

No Benchmark AvailableNo Benchmark Available

50th Percentile which was 2.4675th Percentile which was 2.48


75th Percentile which was 2.45





50th Percentile which was 2.4190th Percentile which was 2.790th Percentile which was 2.48

HEDIS/CAHPS Scoring Comparison 2016-17 Page 2 of 2

Measures




1 Adult BMI Assessment 100.00% 2.3125 2.3125 90th Percentile which was 99% 99.00% 2.1765 2.1765 90th Percentile which was 98%

2 Breast Cancer Screening 81.73% 2.0350 2.0350 75th Percentile which was 79% 84.04% 2.1765 2.1765 90th Percentile which was 83%

3 Cholesterol Management for Patients With Cardiovascular Conditions (Screening rate only) NA NA NA No Benchmark Available NA NA NA No Benchmark Available

4 Colorectcal Cancer Screening 81.54% 2.3125 2.3125 90th Percentile which was 81% 81.60% 2.1765 2.1765 90th Percentile which was 77%

5 Comprehensive Diabetes Care—HbA1c Poorly Controlled (>9.0%) 11.53% 2.3125 2.3125 90th Percentile which was 12% 5.28% 2.1765 2.1765 90th Percentile which was 12%

6 Controlling High Blood Pressure (overall rate) 78.17% 1.5725 1.8038 50th Percentile which was 70% 84.23% 2.1765 2.1765 90th Percentile which was 83%

7 Flu Shots for Older Adults 69.92% 0.9250 1.2488 25th Percentile which was 68% 74.77% 1.4800 1.4800 50th Percentile which was 74%

8 Follow-Up After Hospitalization for Mental Illness (7-day rate only) 46.81% 2.0350 2.0350 75th Percentile which was 43% 57.58% 2.1765 2.1765 90th Percentile which was 56%

9 Glaucoma Screening NA NA NA No Benchmark Available NA NA NA No Benchmark Available

10 Medical Assistance With Smoking Cessation (Advising Smokers to Quit only) NA NA NA No Benchmark Available 90.00% 2.1765 2.1765 75th Percentile which was 90%

11 Osteoporosis Management in Women Who Had a Fracture 41.57% 1.5725 1.5725 50th Percentile which was 36% 47.96% 1.4800 1.4800 50th Percentile which was 36%

12 Persistence Beta-Blocker Treatment After a Heart Attack 80.56% 0.4625 0.4625 Less than 25th Percentile 87.18% 0.4353 0.4353 Less than 25th Percentile

13 Pneumonia Vaccination Status for Older Adults 77.46% 1.5725 1.5725 50th Percentile which was 76% 82.45% 2.1765 2.1765 90th Percentile which was 82%

14 Use of High-Risk Medications in the Elderly Rate 1 20.17% 0.4625 0.4625 Less than 25th Percentile 19.44% 0.4353 0.8688 Less than 25th Percentile

15 Use of Spirometry Testing in the Assessment and Diagnosis of COPD 56.61% 2.3125 2.3125 90th Percentile which was 50% 62.33% 2.1765 2.1765 90th Percentile which was 49%

Antidepressant Medication Management - Averaged Rate 0.4625 0.6529

16 Antidepressant - Acute phase 60.66% 0.4625 0.4625 Less than 25th Percentile 61.75% 0.4353 0.4353 Less than 25th Percentile

17 Antidepressant - Continuation 48.20% 0.4625 0.4625 Less than 25th Percentile 50.69% 0.8706 0.8706 25th Percentile which was 49%

Comprehensive Diabetes Care - Averaged Rate 4.2550 4.3529

18 Comprehensive Diabetes Care - HbA1c Testing 96.57% 2.0350 2.0350 75th Percentile which was 95% 99.72% 2.1765 2.1765 90th Percentile which was 97%

19 Comprehensive Diabetes Care - Eye Exams 80.06% 2.0350 2.0350 75th Percentile which was 77% 83.61% 2.1765 2.1765 90th Percentile which was 82%

20 Comprehensive Diabetes Care - LDL-C Screening NA NA NA No Benchmark Available NA NA NA No Benchmark Available

21 Comprehensive Diabetes Care - Nephropathy Monitoring 98.13% 2.3125 2.3125 90th Percentile which was 98% 98.06% 2.1765 2.1765 90th Percentile which was 98%

PCE Pharmacotherapy Mgmt COPD Exacerbation - Averaged Rate 0.6938 1.6976

22 PCE Pharmacotherapy Mgmt COPD Exacerbation (Rate - Systemic corticosteroid) 62.29% 0.9250 0.9250 25th Percentile which was 62% 74.81% 1.48 1.4800 50th Percentile which was 74%

23 PCE Pharmacotherapy Mgmt COPD Exacerbation (Rate - Bronchodilator) 59.93% 0.4625 0.4625 Less than 25th Percentile 85.93% 1.9153 1.9153 75th Percentile which was 85%

25.8537out of 37

30.5559out of 37

2017 2016

Medicare HEDIS CAHPS HMO/POS Combined2017-2016 Comparison

Effective 10/27/2017

Total EOC Score Total EOC Score

Medicare HEDIS/CAHPS Scoring Comparison 2016-17 Page 1 of 2

CAHPS® Reported Rate (Adjusted)

Score Reported Rate (Adjusted)

Score

1 Getting Care Quickly 2.6945 1.6250 2.6122 1.43002 Getting Needed Care 2.5956 1.1050 2.5965 1.10503 How Well Doctors Communicate 2.7766 1.6250 2.7660 1.43004 Rating of All Health Care 2.6326 1.6250 2.6083 1.43005 Rating of Health Plan 2.6990 3.2500 2.6314 2.86006 Rating of Personal Doctor 2.7868 1.6250 2.7340 1.43007 Rating of Specialist Seen Most Often 2.6277 0.6500 2.6250 0.6500

11.505out of 13

10.335out of 13

37.3588 of 50 40.8909 of 50



50th Percentile which was 2.5590th Percentile which was 2.7790th Percentile which was 2.6290th Percentile which was 2.6890th Percentile which was 2.75



* Total scores may not appear to total as all numbers are truncated for display purposes only. All total scores and star calculations are based on actual, not truncated, numbers.

Total HEDIS® Score* Total HEDIS® Score*

75th Percentile which was 2.675th Percentile which was 2.7125th Percentile which was 2.57



75th Percentile which was 2.650th Percentile which was 2.5575th Percentile which was 2.7375th Percentile which was 2.56

Medicare HEDIS/CAHPS Scoring Comparison 2016-17 Page 2 of 2

Benchmarks Significance Testing***

Composite/Attribute/Measures/Rating Item Valid n Your Plan Summary Rate*

2017 SPH Analytics BoB** 2016 PR (Non-PPO)** To SPH

Analytics BoB To Public Report

Getting Needed Care 89.0% 86.3% 86.4% Not sig. Not sig.

Q14. Ease of getting necessary care, tests, or treatment needed 280 91.8% 89.5% 89.1% Not sig. Not sig.

Q25. Getting appointments with specialists as soon as needed 189 86.2% 83.1% 83.7% Not sig. Not sig.

Getting Care Quickly 88.2% 84.6% 84.7% Not sig. Not sig.

Q4. Got care as soon as needed when care was needed right away 132 89.4% 87.6% 87.9% Not sig. Not sig.

Q6. Got check-up/routine care appointment as soon as needed 270 87.0% 81.6% 81.9% Above Above

How Well Doctors Communicate 95.5% 95.2% 95.1% Not sig. Not sig.

Q17. Personal doctor explained things in an understandable way 250 96.4% 96.1% 96.1% Not sig. Not sig.

Q18. Personal doctor listened carefully to you 250 94.8% 95.1% 94.9% Not sig. Not sig.

Q19. Personal doctor showed respect for what you had to say 249 96.4% 96.2% 96.2% Not sig. Not sig.

Q20. Personal doctor spent enough time with you 250 94.4% 93.5% 93.0% Not sig. Not sig.

Customer Service 91.5% 87.7% 87.5% Not sig. Not sig.

Q35. Customer service provided information or help 100 87.0% 81.2% 81.2% Not sig. Not sig.

Q36. Customer service treated member with courtesy and respect 100 96.0% 94.3% 93.9% Not sig. Not sig.

Claims Processing 87.4% 88.4% 87.0% Not sig. Not sig.

Q40. Claims handled quickly 103 86.4% 86.3% 85.8% Not sig. Not sig.

Q41. Claims handled correctly 103 88.3% 90.5% 88.4% Not sig. Not sig.

Shared Decision Making 86.5% 81.8% 81.3% Not sig. NA

Q10. Doctor/health provider talked about reasons you might want to take a medicine 127 95.3% 94.1% 94.3% Not sig. Not sig.

Q11. Doctor/health provider talked about reasons you might not want to take a medicine 127 79.5% 73.0% 72.8% Not sig. Not sig.

Q12. Doctor/health provider asked you what you thought was best when starting or stopping a prescription medicine 124 84.7% 78.4% 76.9% Not sig. Above

Plan Information on Costs (Rolling Average) 69.9% 63.4% 63.6% Not sig. Not sig.

Q31. Able to find out from health plan cost of health care service or equipment 99 70.7% 63.7% 63.3% Not sig. Not sig.

Q33. Able to find out from health plan cost of prescription medicines 136 69.1% 63.1% Not Available Not sig. NA

Plan Information on Costs (Current Year) 72.6% 63.3% 63.6% Not sig. Not sig.

Q31. Able to find out from health plan cost of health care service or equipment 54 72.2% 63.1% 63.3% Not sig. Not sig.

Q33. Able to find out from health plan cost of prescription medicines 78 73.1% 63.5% 64.1% Not sig. Not sig.

Health Promotion and Education (Q8) 281 83.3% 76.2% 75.1% Above Above

Coordination of Care (Q22) 155 81.3% 83.6% 82.6% Not sig. Not sig.

Providing Needed Information (Q29) 120 77.5% 65.6% 64.8% Above Above

Ease of Filling out Forms (Q38) 314 93.6% 95.5% 95.4% Not sig. Not sig.

Rating Items (Summary Rate = 8 + 9 + 10)

Rating of Health Care (Q13) 282 81.9% 78.2% 77.4% Not sig. Not sig.

Rating of Personal Doctor (Q23) 288 85.4% 85.1% 84.5% Not sig. Not sig.

Rating of Specialist (Q27) 187 80.7% 85.4% 83.8% Not sig. Not sig.

Rating of Health Plan (Q42) 319 74.3% 68.2% 63.9% Above Above

Rating Items (Summary Rate = 9 + 10)

Rating of Health Care (Q13) 282 59.2% 53.2% 51.5% Above Above

Rating of Personal Doctor (Q23) 288 71.5% 68.1% 66.6% Not sig. Not sig.

Rating of Specialist (Q27) 187 64.7% 68.1% 66.4% Not sig. Not sig.

Rating of Health Plan (Q42) 319 53.3% 45.1% 40.0% Above Above

Effectiveness of Care Measures (Rolling Average)

Flu Vaccinations (Adults 18–64) 297 36.0% 50.8% Not Available Below NA

Advising Smokers and Tobacco Users to Quit 81 86.4% 77.0% 75.7% Above Above

Discussing Cessation Medications 80 58.8% 52.3% 49.0% Not sig. Not sig.

Discussing Cessation Strategies 81 55.6% 46.3% 43.3% Not sig. Above

Effectiveness of Care Measures (Current Year)

Flu Vaccinations (Adults 18–64) 297 36.0% 52.7% Not Available Below NA

Advising Smokers and Tobacco Users to Quit 41 87.8% 79.5% 75.7% Not sig. Not sig.

Discussing Cessation Medications 40 62.5% 52.9% 49.0% Not sig. Not sig.

Discussing Cessation Strategies 40 57.5% 46.6% 43.3% Not sig. Not sig.

* Summary Rates are defined by NCQA in its HEDIS 2017 CAHPS® 5.0H guidelines and generally represent the most favorable response percentages.

** The 2017 SPH Analytics Book of Business consists of 43 commercial adult (Non-PPO) samples that conducted surveys with SPH Analytics in 2017 and submitted data to NCQA. The 2016 Public Report benchmark is derived from NCQA's Quality Compass® benchmark and calculated by SPH Analytics . The benchmark is the mean of 201 plan-specific samples (Non-PPO) that submitted to NCQA in 2016. See Glossary of Terms for more information.

*** Significance Testing - All significance testing is performed at the 95% significance level. "—" indicates "Unable to Test" due to a combination of low valid n and/or extreme Summary Rate. Significance testing of composites should be used with caution as a rough guideline, since the test procedure is approximate.

Note 1: Members who responded "No" to Q37 are included in "Always" of Q38, per NCQA HEDIS 2017 Volume 3 guidelines.

Note 2: Please note that the rolling average methodology is not used to calculate the Flu Vaccinations (Adults 18-64) measure.

Commercial Adult CAHPS // BenchmarksFlorida Health Care Plan, Inc.

Composites, Ratings, and Key Questions2017 2016

Valid n Contract Score* Valid n Contract Score*

DOMAIN: Member Experience with Health Plan

Getting Needed Care 85.7 86.0 Q10 Getting care, tests, or treatments necessary 384 87.1 214 86.8 Q29 Ease of getting appointment with a specialist 291 84.4 202 85.1 Getting Care Quickly 81.3 78.1 Q4 Obtaining needed care right away 130 88.2 113 87.3 Q6 Obtaining care when needed, not when needed right away 322 90.2 268 85.3 Q8 Saw person came to see within 15 minutes of appointment time 342 65.4 289 61.7 Health Plan Customer Service 92.8 89.4 Q34 Getting information/help from customer service 148 87.4 102 80.7 Q35 Treated with courtesy and respect by customer service staff 147 95.2 102 92.8 Q37 Health plan forms easy to fill out 369 95.8 342 94.7 Care Coordination** 87.8 86.6 Q20 Personal doctor's office followed up to give you test results 306 87.8 275 87.5 Q21 Got test results as soon as you needed 308 87.6 267 88.0 Combined Item - Test Results 307 87.7 271 87.8 Q18 Doctor had medical records or other information about your care 331 95.4 297 96.1 Q23 Doctor talked about prescription medicines 320 81.7 277 84.2 Q26 Got help managing care 72 93.8 61 86.9 Q32 Doctor informed and up-to-date about specialty care 253 80.5 193 78.1Rating of Health Plan (Q38) 382 90.6 350 88.6Rating of Health Care (Q9) 392 88.1 360 88.5

DOMAIN: Member Experience with the Drug Plan

Getting Needed Prescription Drugs*** 93.5 92.7 Q42 Ease of using health plan to get prescribed medicines 365 93.2 329 92.7 Combined Local Pharmacy and Mail 272 93.8 236 92.7 Q44 Ease of using health plan to fill prescriptions at local pharmacy 190 94.2 136 90.7 Q46 Ease of using health plan to fill prescriptions by mail 147 92.7 146 92.9Rating of Drug Plan (Q47) 371 88.9 339 87.8

DOMAIN: Staying Healthy - Screenings, Tests, and Vaccines

Annual Flu Vaccine (Q57) 383 69.7% 352 73.0%

OTHER MEASURES

Doctors Who Communicate Well 92.3 92.1 Q13 Doctors explaining things in an understandable way 335 91.7 296 91.4 Q14 Doctors listening carefully to you 335 91.7 298 91.7 Q15 Doctors showing respect for what you had to say 334 94.0 299 94.3 Q16 Doctors spending enough time with you 334 91.8 296 91.0Rating of Personal Doctor (Q17) 333 92.6 297 91.5Rating of Specialist (Q31) 282 88.9 216 88.8

* The contract score is the mean score converted to a 100-point scale, with the exception of the Annual Flu Vaccine, Delaying or Not Filling a Prescription, Pneumonia Vaccine, Contact: Filled or Refilled a Prescription, Contact: Taking Medications as Directed, Received Mail Order Medicines Not Requested, Health Plan offered to lower Co-pay Due to Health Condition, Health Plan Offered Extra Benefits Due to Health Condition, and Use Internet at Home questions. For these questions, the value is the percentage of members responding "Yes." Furthermore, Difficulty Walking or Climbing Stairs, Difficulty Dressing or Bathing, Difficulty Doing Errands Alone because of Physical, Mental or Emotional Condition reflect the proportion of members who responded "No." See Glossary of Terms for more information.** The Care Coordination composite is calculated by taking the average of those questions shaded in light blue. Furthermore, the 'Combined Item - Test Results' score is calculated by taking the average of 'Personal doctor's office followed up to give you test results' and 'Got test results as soon as you needed.' *** The Getting Needed Prescription Drugs composite is calculated by taking the average of the 'Ease of using health plan to get prescribed medicines' question and the weighted 'Combined Local Pharmacy and Mail' composite (those measures shaded light blue).Note 1: Significance Testing - Cells highlighted in red denote 2017 contract score is significantly lower when compared to trend data; Cells highlighted in green denote 2017 contract score is significantly higher when compared to trend data; No shading denotes that there was no significant difference between the scores or that there was insufficient sample size to conduct the statistical test. All significance testing is performed at the 95% significance level. Significance testing of composites should be used with caution as a rough guideline, since the test procedure is approximate.Note 2: "NA" represents results that have cell sizes of 10 or less. These results have been suppressed according to CMS rules. See Glossary of Terms for more information.Note 3: Results in SPH Analytics reporting do not represent CMS official results.Note 4: In 2016, Question 10 read, "In the last 6 months, how often was it easy to get the care, tests, or treatment you thought you needed through your health plan?"and Question 29 read, "In the last 6 months, how often was it easy to get appointments with specialists?" and had the response option "Someone else made my specialist appointments for me." Please use caution when making comparisons to trend data.

SPH Analytics 2017 At-A-Glance Report Chart 3-1

Medicare CAHPS MA-PD // Trend ComparisonsFlorida Health Care Plan, Inc.

Single-Items

Contact: Filled or refilled a prescription (Q41A) 365 24.7% 340 12.6%Contact: Taking medications as directed (Q41B) 336 18.5% 325 11.1%Delaying or Not Filling a Prescription (Q51) 379 11.3% 347 9.2%Received mail order medicines not requested (Q52) 381 NA 359 NAPneumonia Vaccine (Q58) 369 75.3% 347 79.3%

New Questions

Health plan offered to lower co-pay due to health condition (Q39) 308 4.9% NA NAHealth plan offered extra benefits due to health condition (Q40) 309 8.1% NA NADifficulty walking or climbing stairs (Q54) 383 69.7% NA NADifficulty dressing or bathing (Q55) 383 91.6% NA NADifficulty doing errands alone because of physical, mental, or emotional condition (Q56) 386 84.2% NA NAUse the internet at home (Q65) 380 69.5% NA NA

* The contract score is the mean score converted to a 100-point scale, with the exception of the Annual Flu Vaccine, Delaying or Not Filling a Prescription, Pneumonia Vaccine, Contact: Filled or Refilled a Prescription, Contact: Taking Medications as Directed, Received Mail Order Medicines Not Requested, Health Plan offered to lower Co-pay Due to Health Condition, Health Plan Offered Extra Benefits Due to Health Condition, and Use Internet at Home questions. For these questions, the value is the percentage of members responding "Yes." Furthermore, Difficulty Walking or Climbing Stairs, Difficulty Dressing or Bathing, Difficulty Doing Errands Alone because of Physical, Mental or Emotional Condition reflect the proportion of members who responded "No." See Glossary of Terms for more information.** The Care Coordination composite is calculated by taking the average of those questions shaded in light blue. Furthermore, the 'Combined Item - Test Results' score is calculated by taking the average of 'Personal doctor's office followed up to give you test results' and 'Got test results as soon as you needed.' *** The Getting Needed Prescription Drugs composite is calculated by taking the average of the 'Ease of using health plan to get prescribed medicines' question and the weighted 'Combined Local Pharmacy and Mail' composite (those measures shaded light blue).Note 1: Significance Testing - Cells highlighted in red denote 2017 contract score is significantly lower when compared to trend data; Cells highlighted in green denote 2017 contract score is significantly higher when compared to trend data; No shading denotes that there was no significant difference between the scores or that there was insufficient sample size to conduct the statistical test. All significance testing is performed at the 95% significance level. Significance testing of composites should be used with caution as a rough guideline, since the test procedure is approximate.Note 2: "NA" represents results that have cell sizes of 10 or less. These results have been suppressed according to CMS rules. See Glossary of Terms for more information.Note 3: Results in SPH Analytics reporting do not represent CMS official results.Note 4: In 2016, Question 10 read, "In the last 6 months, how often was it easy to get the care, tests, or treatment you thought you needed through your health plan?"and Question 29 read, "In the last 6 months, how often was it easy to get appointments with specialists?" and had the response option "Someone else made my specialist appointments for me." Please use caution when making comparisons to trend data.

SPH Analytics 2017 At-A-Glance Report Chart 3-2

Medicare CAHPS MA-PD // Trend ComparisonsFlorida Health Care Plan, Inc.

2017 florida health care plan quality improvement … · the fhcp quality improvement program...

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