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PARTNERSHIP HEALTHPLAN OF CALIFORNIA PHYSICIAN ADVISORY COMMITTEE ~ MEETING NOTICE

Members: Khuram Arif, M.D. – pending resignation Jeffrey Bosworth, M.D. Shandi Fuller, M.D. *alternates Jeffrey Gaborko, M.D. (Chair) Michael Ginsberg, M.D. - excused Steve Gwiazdowski, M.D.

Michele Herman, M.D. Willard Hunter, M.D. Melissa Marshall, M.D. Antoinette Martinez, M.D. – pending resignation Mills Matheson, M.D.

Danielle Oryn, D.O. Thomas Paukert, M.D. Mitesh Popat, M.D. Michael Stacey, M.D. *alternates Colleen Townsend, M.D. - pending resignation Lisa Ward, M.D.

PHC Staff: Liz Gibboney, Chief Executive Officer Robert Moore, MD, MPH, Chief Medical Officer Wendi West, Northern Executive Director Peggy Hoover, RN, Senior Director, Health Services Patti McFarland, Chief Financial Officer Mary Kerlin, Senior Dir., Provider Relations (PR) Dept. Marshall Kubota, MD, Regional Medical Director Mark Netherda, MD, Regional Medical Director Michael Vovakes, MD, Northern Regional Med. Dir. Jeffrey Ribordy, MD, Regional Medical Director Colleen Townsend, MD, Regional Medical Director Debra McAllister, RN, Director of Utilization Mgmt. Stan Leung, Pharm.D., Director, Pharmacy Services Ad Hoc PHC Sonja Bjork, Chief Operating Officer Kevin Spencer, Director of Member Services Members: Kirt Kemp, Chief Information Officer Bettina Spiller, MD, Associate Medical Director Lynn Scuri, Regional Director Mark Glickstein, MD, Associate Medical Director Kelley Sewell, N. Region Mbr Services & PR Director David Katz, MD, Associate Medical Director Carolyn Stewart, Senior Director of Financial Analysis Diane Wong, Pharm.D., Senior Clinical Pharmacist Jennifer Chancellor, Northern Regional Manager Nancy Steffen, Assoc. Dir. of Quality Improvement (N) Carly Fronefield, RN, N. Region, Health Services Dir. Ledra Guillory, Senior Prov. Relations Rep. Manager Rebecca Boyd Anderson, RN, Director, Care Coord. Margarita Garcia-Hernandez, Manager, Health Analytics Robin Krohn, N. Region Manager, Care Coordination Margaret Kisliuk, Behavioral Health Administrator Karen Stephen, Ph.D., Mental Health Clinical Director Rachael French, Sr. Mgr. of Quality Compliance & Accreditation cc: PHC Commission Chair Harris Levin, MD Gabriel Samuel Chua, MD Gregory Baldwin, MD Kali Stanger, MD Voltaire Velarde, MD Richard Fogg Jerry Douglas, MD Amy Brom, Psy.D.

FROM: Linda Largent DATE: May 2, 2018 SUBJECT: PHYSICIAN ADVISORY COMMITTEE MEETING The Physician Advisory Committee will meet as follows and will continue to meet the second Wednesday of every month (exception / July and December.) Please review the Meeting Agenda and attached packet, as discussion time is limited.

DATE: Wednesday, May 9, 2018 TIME: 7:30 a.m. – 9:00 a.m.

LOCATIONS:

________Via Video Conference________ ____________________________Access Via Teleconference____________________________

Partnership HealthPlan of CA 4665 Business Center Drive (Please Park in Front of Bldg.) Fairfield, CA

PHC – Sonoma Office 495 Tesconi Circle Santa Rosa

Baechtel Creek Medical 1245 S. Main Street Willits

Marin Community Clinic9 Commercial Blvd., Suite100 Novato

Shasta Community Health Centers 1035 Placer Street Redding

CommuniCare Health 2051 John Jones Road Davis

PHC - Eureka Office 1036 5th Street, Suite E Eureka

PHC – Redding Office 2525 Airpark Drive Redding

Redwood Community Health Coalition 1310 Redwood Way, #135 Petaluma

Please contact me at (707) 863-4228, or e-mail [email protected] if you are unable to attend.

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REGULAR MEETING OF PARTNERSHIP HEALTHPLAN OF CALIFORNIA’S PHYSICIAN ADVISORY COMMITTEE - MEETING AGENDA

Date: May 9, 2018 Time: 7:30 – 9:00 a.m. Location: PHC

PUBLIC COMMENTS Speaker 2 minutes

Speaker 2 minutes

Welcome / Introductions I. Approval of Minutes – Chair

April 11, 2018 March 14, 2018

5 – 16 17 - 27

7:30

II. Standing Agenda Items Lead Pg # Time

A. Status Update Administration Medical / Health Services Report Regional Medical Director Reports

- Napa County- Southeast Counties- Southwest Counties- Northwest Counties- Northeast Counties

Ms. Gibboney Dr. Moore

Dr. Townsend Dr. Netherda Dr. Kubota Dr. Ribordy Dr. Vovakes

7:40 7:50

7:55 7:58 8:01 8:04 8:07

A1. Update from County Public Health Departments Available Representative(s)

8:10

A2. Committee Member Highlight Dr. Matheson 8:13

B. Quality / Utilization Advisory Committee (Q/UAC) Activities Report with attachments – Consent Review Activities & Minutes of the March 21 & April 18, 2018 meetings: - Minutes – Internal Quality Improvement 02/13/18 & 03/13/18 (attached)

*Policies &Procedures: March & April Reviewed for May PAC

* See Pages 44-45 & 82-83**Note – only pages with significant changes are included for policies

April (Pages 28-64) - Quality Improvement Update - April - Assisting Providers with Missed Appointments (MP301) - Peer Review Committee (MPQP1053) - Technology Assessment (MCUP3042) - Grievance Report

March (Pages 65-119) - Quality Improvement Update - March - Waiver Programs Policy (MCUP3106) - Excerpts -PHC TAR Requirements & Medical Necessity Criteria for Pain Management Procedures (vs. review of MCUP3049) - Inter-Rater Reliability, TARs and Timeliness Data - 2016/2017 Primary Care Provider (PCP) Quality Improvement Program (QIP) Evaluation

Dr. Moore 28 - 119

8:18

C. Pharmacy &Therapeutics (P&T) Committee / Consent Review Minutes & Formulary Recommendations of the April 5, 2018 meeting (attached) ** - Pharmacy TAR Procedure (MCRO4018) - Pharmacy & Therapeutics (P&T) Committee (MPRP4001) - Brand Name Drug Requests MPRP4033) - 340B Compliance Program (MCRP4060) - Drug Wastage Payments (MPRP4062)

Dr. Leung / Dr. Moore

120 - 190

8:18

D. Provider Advisory Group (PAG) Report – Consent Review No Meeting in April

Ms. Kerlin / Ms. Sewell

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E. Credentialing Committee Meeting Summary – Committee approved Summary of the February 14 & March 14, 2018 meetings (attached)

Dr. Kubota 191 - 216

8:19

F. Recommended Committee Appointments / Resignations

Physician Advisory Committee - Colleen Townsend, MD, Ole Health – Resignation

(New Medical Director for the HealthPlan)

Dr. Moore 217 8:19

Continued

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- Khuram Arif, MD, Dignity Health, Woodland Clinic - Resignation

- Antoinette Martinez, MD – Resignation (no longer with United Indian Health)

Credentialing Committee - Michele Herman, MD, La Clinica Vallejo – Appointment

III. Old Business Lead Pg # Time

A. Hospital Quality Improvement Program (QIP) 2018/2019 Measures – Approval Required

Ms. Lasher 218 - 225

8:20

IV. New Business

A. Physician Advisory Committee Policy (MPQP1003) Dr. Moore 226 - 230

8:35

B. Discussion Topic: Controlling the Swing of the Opioid Pendulum Dr. Moore 231 - 233

8:40

VI. Adjournment 8:55

This agenda contains a brief description of each item to be considered. Except as provided by law, no action shall be taken on any item not appearing on the agenda. Government Code §54957.5 requires that public records related to items on the open session agenda for a regular committee meeting be made available for public inspection. Records distributed less than 72 hours prior to the meeting are available for public inspection at the same time they are distributed to all members, or a majority of the members of the committee. The committee has designated the Administrative Assistant to the Chief Medical Officer as the contact for Partnership HealthPlan of California located at 4665 Business Center Drive, Fairfield, CA 94534, for the purpose of making those public records available for inspection. The Physician Advisory Committee Agenda and supporting documentation is available for review from 8:00 AM to 5:00 PM, Monday through Friday at all PHC regional offices (see locations under the Meeting Notice). It can also be found online at www.partnershiphp.org. In compliance with the Americans with Disabilities Act, PHC meeting rooms are accessible to people with disabilities. Individuals who need special assistance or a disability-related modification or accommodation (including auxiliary aids or services) to participate in this meeting, or who have a disability and wish to request an alternative format for the agenda, meeting notice, agenda packet or other writings that may be distributed at the meeting, should contact the Administrative Assistant to the Chief Medical Officer at least two (2) working days before the meeting at (707) 863-4228 or by email at [email protected]. Notification in advance of the meeting will enable PHC to make reasonable arrangements to ensure accessibility to this meeting and to materials related to it.

Meeting Notes – Physician Advisory Committee – 05/09/2018

Action Items Assigned To:

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PARTNERSHIP HEALTHPLAN OF CALIFORNIA MEETING MINUTES

PAGE 1 OF 12 Committee: Physician Advisory Committee Date / Time: April 11, 2018 - 7:34 to 9:02 am

Members Present:

Jeffrey Bosworth, MD - TC Jeffrey Gaborko, MD (Chair)

Michael Ginsberg, MD Steven Gwiazdowski, MD

Michele Herman, MD Mills Matheson, MD - TC

Danielle Oryn, DO - TC Colleen Townsend, MD

Members Excused:

Shandi Fuller, MD Melissa Marshall, MD

Lisa Ward, MD

Members Absent:

Khuram Arif, MD Antoinette Martinez, MD

Mitesh Popat, MD

Michael Stacey,MD

Participated via Teleconference, but not included in Quorum based on Brown Act regulations.

Willard Hunter, MD

Thomas Paukert, MD

Visitors: Elisabeth Chicoine, RN On behalf of Lisa Ward, MD

Brittany Speer, Lilly Consultant Note: via Video Conf. (VC) via Teleconference (TC)

PHC Staff Present:

Liz Gibboney, Chief Executive Officer Patti McFarland, Chief Financial Officer Sonja Bjork, Chief Operating Officer - VC Kirt Kemp, Chief Information Officer Margaret Kisliuk, Behavioral Health Admin. Lynn Scuri, Regional Director - VC Jennifer Chancellor, N. Regional Mgr.- VC

Robert Moore, MD, Chief Medical Officer Peggy Hoover, RN, Senior Director, Health Services Stan Leung, Pharm.D., Pharmacy Director Jessica Thacher, Dir., Quality & Perf. Improvement Debra McAllister, RN, Dir. Utilization Management Mary Kerlin, Sr. Director, Provider Relations Ledra Guillory, Sr. Prov. Relations Rep. Mgr.

Marshall Kubota, MD, Regional Medical Director - VC Michael Vovakes, MD, Northern Regional Med. Dir. -VC Jeff Ribordy, MD, NW Regional Medical Director - VC Bettina Spiller, MD, N. Associate Medical Director - VC Ro Summers, Quality Improvement Prgrm, Project Mgr. Amy Lasher, Quality Project Manager QI Yao, Quality Improvement Analyst

AGENDA

ITEM DISCUSSION / CONCLUSIONS RECOMMENDATIONS /

ACTION TARGET

DATE DATE

RESOLVED

Public Comments Quorum I. Approval of March Minutes II.A. Status Update Administration

Committee Chairman, Dr. Gaborko, asked for public comments. None were presented. During the course of the meeting, Committee members were reminded that those calling in cannot be counted in the Quroum, unless they are calling in from a designated access site, due to Brown Act Requirements. The HealthPlan’s Chief Executive Officer (CEO) provided the following report on Partnership HealthPlan of California (PHC) activities. - Federal Budget – An official budget is in place. The overall spending package is

$1.3 trillion, which goes through at the end of September. There is an additional $10 billion over 2017 funds for Health and Human Services, allowing for additional

N/A Committee quorum requirements not met. There were no Motions on Action Items during the meeting. Deferred For information only, no formal action required.

05/09/18

N/A

N/A

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Physician Advisory Committee Minutes – 04/11/18 - Page 2 of 12

AGENDA ITEM

DISCUSSION / CONCLUSIONS RECOMMENDATIONS / ACTION

DATE RESOLVED

II.A. Status Update Admin., Continued

opioid research and treatment, added behavioral health workforce, medication assisted treatment (MAT), and more flexibility on prescribing for nurse practitioners and physician assistants. The House Energy and Commerce Committee will be releasing a Bill on opioid funding, and the Senate has a Hearing on their version of the Bill today.

- National Committee for Quality Assurance (NCQA) Accreditation – The Plan is progressing and is

approximately 65% complete on standards that should be met by the end of June to allow for Accreditation next year. A significant part of the Plan’s readiness this year is establishing its Member Portal, which allows members to interact with the HealthPlan over its website (check their eligibility, order new Identification cards, change their primary care provider [PCP], access some limited laboratory [lab] results, review prescriptions and see drug to drug interactions, etc.) The Portal will go live late June on a limited basis, and more widely in July.

- State Budget – A number of Hearings are scheduled at the State, some of which will begin to address the increased interest around Single Payer / Universal Coverage / Public Option. Assemblyman, Jim Wood, from Santa Rosa has introduced a number of Bills related to these various topics, since he chairs the Assembly Health Committee. One of the Bills would require health plans, like PHC, to participate in the Exchange, as well as looking into creating a Public Option. Another Bill would make Medi-Cal coverage available to undocumented citizens, following the same income requirements, and setting aside documentation status. Some of these proposals may gain some traction, or they may linger, waiting for a new Governor to come in.

- HealthPlan Budget – Next year’s fiscal budget, which starts July 1, is in the process of being developed. Preliminary rates for the new fiscal year are expected from the State next month, which is earlier than anticipated. There are several new initiatives being worked on, which include the California Children Services (CCS) Redesign and Drug Medi-Cal. With the Housing Initiative, the Plan is in the process of contracting with a variety of organizations that submitted applications. Some entities are further along than others. It will take a number of months for the roll-out. Some applicants are also contenders with the State’s “No Place Like Home” housing funds, which is currently tied up in a lawsuit.

- Other Major HealthPlan Initiatives -

CCS Redesign – Plan staff is working with all of its counties to determine the arrangements it will have on a county by county basis, come January 2019. Most counties are opting for the Plan to manage the Utilization Management (UM) and Care Coordination functions. Some are interested in contracting back those functions to the county for a period of time. Draft rates have been received from the State, which look good at this point.

For information only, no formal action required. For information only, no formal action required. For information only, no formal action required. For information only, no formal action required.

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DATE RESOLVED

II.A. Status Update Administration, Continued II.A. Status Update Medical

Health Homes Program (HHP) – Many providers are participating in the Plan’s Intensive Outpatient Case Management (IOPCM) programs, and are interested in what the State is doing with Health Homes. Partnership will not be going forward with HHP this July, as originally scheduled, due to concerns with rates and the programmatic structure changes. The HealthPlan has given the State its recommendations for changes, but is not confident that those changes will be made.

Drug Medi-Cal Program – This program is set to go live this July. Plan staff continues to negotiate with the State on a county by county basis, going through actuarial projections and showing how the Plan utilizes county funds and how Partnership will subsidize that benefit. This is in addition to the standard new benefit processes (establishing the network, configuring the Plan’s system, etc.)

Dr. Gwiazdowski asked if the HealthPlan was familiar with Assembly Bill (AB) 3087 (“price control” Bill), which is opposed by the California Medical Association (CMA). Partnership’s CEO noted that staff had not been following that proposed Bill, but will look into it.

The HealthPlan’s Chief Medical Officer (CMO presented an overview of some Health Services activities. - Health Information Exchange (HIE) – There was an HIE serving community-based organizations in the

counties of Napa, Sonoma, Solano and parts of Yolo, called ConnectHealthcare. Their vendor was Inland Empire HIE, which used a product called Orion. That HIE was acquired by Cal INDEX, which is largely controlled by Blue Cross & Blue Shield. The reestablished HIE did not share in the same vision that PHC’s local providers had, so the vendor association was discontinued. Over the past several months, the providers have been assessing various options. This month, the majority of providers (NorthBay Hospital, St. Joseph and Adventist Health Systems, as well as the Redwood Community Health Coalition) have agreed to join the HIE that serves Northeast California called Sac Valley Med Share (SVMS). Partnership was already contracted with SVMS for five of its Northern counties. SVMS uses a vendor called Informatics Corporation of America (ICA), which is now owned by The SSI Group (SSI), a privately held company. SSI has a large stake in the claims processing area, and acquiring ICA allows them to get into the health information sector. SSI is very stable financially, so it should meet the needs of the growing local organization. There will be several board seats that SVMS will be adding to accommodate the new providers in this area of the state.

- Credentialing Committee – The Plan is looking for physician members for the Credentialing Committee, which meets immediately prior to the Physician Advisory Committee (PAC) at 7am. It is not a Brown Act committee, so members are not restricted with their call-in locations. There are a couple members who do not participate on the PAC, so that is not a requirement. It is also a good leadership opportunity for other physicians within provider organizations. Discussions at the committee also include important issues. Dr. Gwiazdowski offered his thought, that strong organizations take effort. Being on the Credentialing Committee himself, he can attest to the mindfulness used when reviewing the landscape of all the providers within the Partnership. It is rewarding to know that much of the work being done at the committee is geared toward providing the best possible conduit by which Plan members are getting their care.

For information only, no formal action required.

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AGENDA ITEM


DATE RESOLVED

II.A. Status Update Medical, Continued

- Hepatitis C Medications – Hepatitis C (Hep C) is a fairly prevalent condition. When a new generation of medications became available, new standards in high costs of medication therapy were set. In the past 6 months, Plan staff has seen a significant drop in costs, largely due to the newest medication (MAVYRET), which is half the cost of the other medication and can be used for a shorter time period. PHC’s standards are available under its website, and additional links will be included in the upcoming Medical Director Newsletter(to be distributed soon). Providers are encouraged to develop a robust program for detecting patients who would qualify for Hep C treatment, and screening appropriately. PHC’s Chief Financial Officer advised that the HealthPlan is anticipating costs associated with Hep C utilization to be included in its rates by 2020. Currently, the Plan is somewhat insulated from a large downside risk. With that in mind, it would be financially prudent for members needing treatment to do so within the next fiscal year.

- PHC Staff Changes – Dr. Scott Endsley is no longer working with Partnership, but staff is looking forward to Dr. Colleen Townsend coming on board. Dr. Townsend has been a member of this Committee for a number of years, and has agreed to join PHC as one of the Associate Medical Directors. Thereafter, there will be some shuffling of responsibilities. Dr. Townsend will be assuming the Regional Medical Director role for Napa, Solano, and Yolo counties, with an overlap of time while Dr. Cotter and she transition his current responsibilities for Napa County. Dr. Netherda will be introducing Dr. Townsend to the various providers in Solano and Yolo counties, before his transition to the role of Associate Medical Director for Quality. Though sad for the HealthPlan, staff wishes Jessica Thacher, Director of Quality and Performance Improvement, all the best as she moves onto her new position as Senior Learning and Impact Officer for the California Health Care Foundation (CHCF). Ms. Thacher has left a very positive imprint on the Quality department, and her contributions to the Partnership and this Committee are appreciated. This will be her last meeting with the PAC.

- Palliative Care Benefit Implementation – Though moving out of the Regional Medical Director’s position for Napa County, Dr. Cotter will continue to focus on care coordination support for programs he is currently involved in (i.e. IOPCM and Palliative Care). But, being retired, he would like to reduce his hours at PHC. The Implementation of the Palliative Care Benefit is proceeding, in terms of enrollment of patients. Partnership would like to ensure that primary care specialists and hospitals are aware that this benefit is available. All HealthPlan counties are covered with at least one provider (details available under PHC’s website). Marketing materials are being developed, and palliative care providers have been asked to reach out to their area providers. Of note, Medicare does not yet have an intensive outpatient palliative care benefit, but has started to look at the possibility. The HealthPlan has been contacted by the Centers for Medicare and Medicaid Services (CMS) regarding its IOPCM program.

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DATE RESOLVED


PHC’s Regional Medical Director for Napa County was not available for a brief overview. PHC’s Regional Medical Director for the Southeastern (SE) counties presented a brief overview. - Opioid Coalition – The Plan’s Fairfield office hosted a large meeting, sponsored by Solano County Drug

Courts, for the development of a Solano Opioid Coalition. Representatives included those from the Drug Courts, Federally Qualified Health Centers (FQHCs), Solano County Health & Human Services and the Health Department, staff from treatment programs, Supervisor Skip Thompson, the Medical Society, along with one judge. There continues to be much interest in establishing a coalition, though funding has not been determined. The three hour meeting contained a lot of active discussions, and went very well.

- Access – Elica Health Centers opened a new medical office in Yolo County, and Winters Healthcare has not yet broken ground on their new site (targeted to open this year).

PHC’s Regional Medical Director for the Southwestern (SW) counties presented a brief overview. - Cervical Cancer Screening Media Campaign – A media campaign in Lake and Mendocino counties is

underway, with funding support from the HealthPlan. This campaign was successfully run in the Humboldt and Del Norte counties, and was completed under budget. Those excess funds are now being put to use. This is in conjunction with the health centers, to increase the cervical cancer screening rate, which is low. The campaign will run May through July and includes radio, bus advertisements, handouts and flyers, and social media.

- Health Officers – As mentioned in previous meetings, there have been changes with health officers in several counties. Dr. Sara Goldgraben is now the Health Office in Lake County, filling the vacancy left when Dr. Tait retired. Dr. Gary Pace is now the Health Officer in Mendocino County. And, Dr. Milman resigned her position in Sonoma County, which has yet to be filled.

- Behavioral Health – There is turmoil in Sonoma County Mental Health, which is running a multi-million dollar deficit. This has resulted in a change of leadership. Health Action is developing a mental health segment and subcommittee to help address the issues and budget deficit.

- Whole Person Care (Post-Meeting Clarification – State grant program to several counties, which varies in details, county by county) – This program has been put on hold in Sonoma County, but is moving forward in Marin and Mendocino counties.

PHC’s Regional Medical Director for the Northwestern (NW) counties presented a brief overview. - Opioid Town Hall – A second Town Hall on opioids was held at the end of March, hosted by

Senator McGuire’s office and Supervisor Virginia Bass. There was less attendance at this forum than the previous meeting, but outreach efforts did not appear to be as robust. There was an impressive lineup of speakers along with a presentation. It is unknown if another Town Hall will be scheduled, but Del Norte’s Opioid Committee has an interest in hosting a similar forum.

- Access – It has been fairly stable in the region, with regards to provider movement. As noted during the Committee’s roll call, Dr. Hunter is at Open Door’s Willow Creek clinic covering for the only staff physician, who is out on medical leave.

N/A For information only, no formal action required. For information only, no formal action required. For information only, no formal action required.

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AGENDA ITEM


DATE RESOLVED

II.A. Status Update Medical, Continued II.A1. Update - County Public Health II.A.2. Committee Member Highlight

- Residency Program (Program) – Dr. Hunter reported that the Program had its Accreditation Council for Graduate Medical Education (ACGME) review, and should be hearing at the end of this month / early next month, regarding their certification. Once certified, the Residency Program will participate in the “match”, and start July 2019.

The HealthPlan’s Northern Regional Medical Director presented a brief overview on activities for the Northeastern (NE) counties. - HealthPlan Staffing – With the upcoming Drug Medi-Cal and CCS Redesign programs, both the

Northern and Southern regions will require additional staffing. The Eureka and Redding offices will be holding a Hiring Fair in early May, to help fill positions specific to those programs.

- Access – There has not been much shifting of providers, but there are a few name changes. McCloud and Dunsmuir (previously known as McCloud Health Care Clinic), is changing its name to the Shasta Cascade Health Centers. Mountain Valley (in Shasta and Siskiyou counties), acquired Weed Health Center and Mount Shasta Health Center, both of which had direct patient ties to Shasta Regional Medical Center in Redding.

- “Week of the Young Child” – Shasta County is in the midst of its “Week of the Young Child”. As part of the commemoration, PHC’s Redding office lobby is decorated with a number of paper dolls, created by local grade school children to encourage support for young children and their families.

- Medication Assisted Therapy (MAT) – Between 6pm and 7pm on April 30th, in collaboration with Dr. Stockton, the HealthPlan, and Aegis Treatment Center, the Redding Library will host a community Narcan Education Distribution event. A pharmacist will be on site to address how the nasal Narcan should be used, and will distribute 100 doses to any of those attending from the public who wants one. This event is an extension of the area’s opioid coalition.

Dr. Stacey was not available to present a brief epidemiology update to the Committee. The Committee’s Chair noted that Dr. Ginsberg offered to share some highlights on himself, as the group continues to learn more about its members. Dr. Ginsberg advised that he is a pediatrician and site leader for NorthBay Center for Primary Care in Fairfield. He is originally from the Detroit area, and came to the Bay Area for the first time in 1996 to attend Stanford University. He obtained his Bachelor’s and Master’s degrees in biology, then returned to Michigan for medical school, University of Michigan. He moved to the Bronx in New York City for his Residency at an all-city hospital that served Medicaid patients, called Jacobi Medical Center. Since Dr. Ginsberg is bilingual with English and Spanish, he found that he loved working with that population, and also learned that this patient group was underserved. Non-English speaking parents found it extremely helpful having a pediatrician they could have complex medical discussions with about their children.

For information only, no formal action required. N/A

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AGENDA ITEM


TARGET DATE

DATE RESOLVED

II.A.2. Committee Member Highlight, Continued II.B. Quality/ Utiliz. Advisory, & II.E. Credentialing committees IV.A. Hospital Quality Improvement Program

Dr. Ginsberg started a Fellowship in adolescent medicine at the University of California (UC) San Francisco (SF), but left after approximately 7 months, due to a number of reasons. His job search brought him to NorthBay, where he had the opportunity to work with a similar patient population as he had during his residency. Though he thoroughly enjoyed the work, he assumed he would only stay with the organization a couple years and find employment closer to his home in Oakland. Eight years later, he remains at NorthBay. He became a member of this Committee in 2013, and has enjoyed that participation. In various capacities, Dr. Ginsberg takes part in a number of committees at NorthBay, along with Partnership, all of which are opportunities to meet colleagues he would otherwise not have a chance to meet. The meetings also allow him to speak for NorthBay, where PHC policies are concerned. For all these reasons, he has enjoyed his time on this Committee. Due to lack of quorum, approval of the consent calendar was deferred. The Plan’s CMO advised that the hospital pay-for-performance program has been in existence approximately four years, starting with just a few contracted hospitals. After an extensive internal process, recommended changes to the Hospital Quality Improvement Program (HQIP) measurement set is brought to this Committee for approval. Partnership’s HQIP Project Coordinator (Project Coordinator) noted that the program has grown to include 26 hospitals. The Hospital QIP is divided into two measurement sets, one is for large hospitals, the other for small hospitals. Large hospitals are defined as those with at least 50 licensed general acute beds. Proposed measures for the 2018/2019 Hospital QIP were highlighted. Large Hospitals / Requirements and Rationale Health Information Exchange (HIE) Requirement – For the current measurement year

(2017/2018), the measurement is stratified by the year the hospital joined the QIP. New participants are asked to complete their interface with a community HIE by the end of the measurement year. The HealthPlan is setting uniform standards, based on the status of HIE in the state. Existing participants are asked to maintain their Admission, Discharge and Transfer (ADT) interface, and also join the Emergency Department Interface Exchange (EDIE). EDIE is a software that allows for health care providers, health plans, and health care organizations to collaborate for complex care management.

For information only, no formal action required. Agenda item deferred.

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AGENDA ITEM

DISCUSSION / CONCLUSIONS

IV.A. Hospital Quality Improvement Program, Continued

For the next measurement year (2018/2019), the Plan is proposing the same requirement for all hospitals (new or existing), to be live with EDIE by the end of the measurement year, and to continue their ADT interface with a community HIE. The distinction between HIE and EDIE is that EDIE allows for the complex care management.

Delegation Requirement (New) – Since the HealthPlan is seeking NCQA Accreditation, it is important that Utilization Management requirements

are met by all of Partnership’s capitated hospitals in the network. Hospitals will need to submit a written Utilization Program Description to PHC, and submit timely reports. Specifications on the timeliness are still being worked on, but the proposed impact of not meeting the requirement is a 5% or 10% payment reduction.

Large Hospitals Measurements and Rationale 1) All-Cause Adult Readmission Rate – Currently, there is a back-up measure (follow-up visit within four calendar days of discharge). The proposal

is to remove the back-up measure, with the rationale that the Plan wants the focus on the readmissions rate. Of note, the back-up measurement has not been used by the hospitals participating in the QIP.

2) Palliative Care Capacity with two options. Under Option 1, it is recommended to change the requirement to one or the other, when referring to a Licensed Clinical Social Worker or a Licensed Registered Nurse (RN), Nurse Practitioner (NP), or Physician Assistant (PA), so that the measure is more achievable for hospitals. It is also recommended to remove the exclusion of hospitals with fewer than 20 beds. Plan staff were notified by smaller hospitals that the measurement would be achievable for them.

The next three measurements pertain to maternity care. The Plan has asked hospitals to participate in the California Maternal Quality Care Collaborative (CMQCC). Data submitted by hospitals is trended by CMQCC, and reviewed in terms of the State’s performance. Currently, the following three measures are reported by the hospitals to the HealthPlan. The Plan wants that information reported to CMQCC. The benefit is two-fold, it encourages more participation with CMQCC, and decreases the chance of errors by submitting the data to various sources before submission to PHC. 3) Elective Delivery before 39 weeks 4) Exclusive Breast Milk Feeding 5) Nulliparous, Term, Shingleton, Vertex (NTSV) Cesarean Birth Rate 6) Timely Participation in California Perinatal Quality Care Collaborative Data Reporting – There is a minor recommended change for deliverable

deadlines to this measurement. The preference is to align the deadlines to that of the hospital’s, for a more meaningful interaction with the program.

10- Timely Participation in CMQCC Data Reporting – Remove this measure, due to the recommended change to the three maternity care measures. Of note, the detailed specifications are not included in this presentation, due to the amount of information and this Committee’s available review time. There are no recommended changes to the following three measures: 7) Venous thromboembolism (VTE)-6 Hospital Acquired Potentially-Preventable VTE 8) California Hospital Patient Safety Organization (CHPSO) Patient Safety Organization Participation 9) Quality Improvement (QI) Capacity

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IV.A. Hospital Quality Improvement Program, Continued

New Proposed Measures PHC’s Project Coordinator presented the proposed measures. 10) Median Time from Emergency Department (ED Arrival to ED Departure for Discharged ED Patients [Large Hospitals]) – To ensure the measurements

are comprehensive, an outpatient measure was added. Access to treatment and quality of care for patients can be improved by reducing the time they remain in the ED. Twelve out of thirteen of PHC’s large hospitals are currently reporting on this measure. Review of current participants’ data shows a minimum time of 96 minutes with a maximum of 208 minutes, reflecting an opportunity for improvement for some.

11) California Immunization Registry (CAIR) Utilization Measure – The HealthPlan is required by the Department of Health Care Services (DHCS) to have all contracted entities report to CAIR, which does not cost the provider to use. There are currently 12 out of 13 large hospitals and 8 out of 13 small hospitals registered with the CAIR system. Out of these, eight large and five small hospitals have submitted data within the past four months. Since there is insufficient data on participation, the proposal includes a pay-for-performance measure for the first year.

The Plan’s CMO advised that the DHCS requirement (for all PHC’s providers) is new, and was just recently received by way of an All Plan Letter from the State. This is for adult and pediatric immunizations. The measure has statewide implications. Dr. Ginsberg noted that his organization used the CAIR system a few years ago, finding it to be problematic, due to the workload and the need to manually submit the information twice. It is understood that CAIR has been working on their interface to improve the system, but Dr. Ginsberg hopes that Partnership will advocate on the providers’ behalf to ensure they have the tools they need to meet this requirement. NorthBay Center for Primary Care ascertained that a full-time employee would need to be devoted to immunizations for the work involved. PHC’s CMO shared that Plan staff are in regular contact with the CAIR staff, who are working very hard on improving the interface function. If any organization is having difficulty with responsiveness, they can send specific examples to the HealthPlan. Plan staff will relay those issues directly to the physician in charge of the CAIR program. It was noted that the provider’s HIE vendor needs to cooperate with the interfaces as well.

Dr. Bosworth addressed a concern regarding Measurement 10, and the median time for a patient’s arrival versus discharge at an ED. A few years back, the Redding area had some hospital measures intended to address this. He saw a lot of unintended consequences as EDs attempted to shorten the time. These included staff going through the emergency waiting room and ordering tests without a full evaluation of the patient. Providers were left to make a decision on one quick visit, based on data that they had not requested. They then needed to determine if the patient should be admitted or discharged, without taking the appropriate time to assess the patient. With this in mind, there may need to be other measures in place to ensure this type of system manipulation does not occur. PHC’s CMO appreciated the insight, and noted that the Plan’s CEO directed staff to find an outpatient measure suitable for the Hospital QIP. This measure was the only one not completely unworkable, though there were concerns raised by Plan staff. Since non-standard measures create a lot more work for the hospitals and for PHC staff, standard measures are used. Dr. Gwiazdowski concurred with Dr. Bosworth’s concern, suggesting a balance performance measure (i.e. – returning to the ED within 48 hours). Partnership’s SE Regional Medical Director shared that, when reviewing utilization management (UM), some patient admissions could have been handled through ED observation. Even a small number of those cases can skew a hospital’s rate. This then leads to the concern that hospitals will admit a patient, instead of utilizing the 23-hour observation available through the ED, but the admission will then be denied by Plan staff as unnecessary. There seems to be a conflict in the message Partnership is giving hospitals. PHC’s Director of UM brought up the “ED jumpers”, patients who do not get the answer they want at one ED, and then go down the road to another ED. PHC UM staff see this patient maneuver a lot.

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IV.A. Hospital Quality Improvement Program, Continued IV.B. Demonstration of Partnership Quality Dashboard (PQD)

The Committee’s Chair asked for an informal consensus of who was opposed to Measurement 10. There were no attending members in favor of the measure. Dr. Gwiazdowski advised that more information should be made available before he could make a determination on the measure. Dr. Ginsberg shared that it would be really unfortunate if all the hospitals were penalized because of another influenza (flu) season similar to the one this year. The Committee’s Chair offered his concern of “is a shorter stay a quality stay”. Dr. Gwiazdowski asked if the raw scores could be converted into percentile ranks, taking into account circumstances like a flu season. That is not necessarily standard, but it may just be a cross-calculation to convert into a percentile rank. It may also behoove the Plan to schedule an impromptu discussion with some ED medical directors to get their input on unintended consequences. Partnership’s CMO noted that the conversion process would be doable, but may not address the other concerns. Small Hospital Measurement Sets (less than 50 licensed general acute beds) PHC’s Project Manager advised that most of the measurement changes for small hospitals are the same as the large hospitals, with the exception of the maternity care measures. Measurements 5 through 7 (Elective Delivery before 39 weeks, Exclusive Breast Milk Feeding, and the NTSV Cesarean Birth Rate) had not been included in the small hospital set before. It was determined that 7 out of 13 small hospitals offer maternity services, so those measures have been added to the set. If the hospital does not offer maternity care, they will be excluded. The addition of these measures is the only change made for small hospitals. Partnership’s CMO advised that the Hospital QIP will be returned to the Committee in May, though a full review should not be necessary. The Plan’s CMO reported that Partnership is excited to introduce the Partnership Quality Dashboard (PQD), which has been two years in the making and part of the Plan’s Strategic Use of Reserves (SUR). The dashboard was presented to quality providers (by way of a webinar), a couple weeks ago. Partnership’s Director of Quality shared that the tool was built to help create real time visibility into both PHC’s and its providers’ networks performance on key quality metrics, and to increase the ability to analyze that data. The PQD was developed in-house in collaboration with Quality and Information Technology (IT) staff. The project was far more complicated than the Plan envisioned, so many thanks to those who worked on and developed the tool. The data included in the PQD is not new, but was historically housed in difficult to access areas, and required a lot of Excel manipulation. The PQD allows the Plan and providers direct

Due to lack of quorum, approval of the Hospital Quality Improvement Program was deferred to May’s meeting.

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IV.B. Demonstration of Partnership Quality Dashboard (PQD), Continued

access to the information. There are three sources of data that are built, or in the process of being built, in the PQD. The first two are related to the Primary Care Provider (PCP) Quality Improvement Program (QIP). The first are the non-clinical measures (readmissions, utilization, and currently building in the eReports data). The second source is from the Healthcare Effectiveness Data and Information Set (HEDIS) data, which allows Plan staff to delve more thoroughly and conduct comparative analytics. The HEDIS tool has not been released to providers, as the QIP portion has. The Non-Clinical Measures and the HEDIS data modules are complete, with the eReports module in progress. Those wanting more detailed information regarding the QIP portion can contact the Plans’s QIP team. PHC’s Quality Improvement Analyst (QI Analyst) presented a high level demonstration on the Non-Clinical Measures for the Provider Dashboard. Practices with more than one site can review data from all its sites. Independent practice sites will only show that one site’s information. Data includes historical and current data. The PQD is updated on a monthly basis, so providers will be able to view the most current data the HealthPlan has. Details under the PQD include points earned for each measure, the provider’s ranking as compared to all other participating providers, each measurement score showing the target for the provider, county (or sub-region) averages, trending of any particular measure, along with demographics. The demographics portion allows the provider to populate the outcome of a measure by a specific age group, gender, language, or ethnicity. Drilldown is also available for office visits, admissions, avoidable ED and readmissions, including specific member level details (i.e. admission and discharge dates, identification, hospital name, etc.) Aggregate data is available for an organization as a whole, which can also be compared to measurement benchmarks. The Plan’s QI Analyst demonstrated the HEDIS module, which will be opened up to providers in the future. Drilldown for HEDIS measures include data by measure, specific timeframes, and rates by county. This can be extended by a number of filters, including region, sub-region, specific organization, demographics, member compliance, and provider level. Along with monthly data, there is a yearly dashboard showing the final performance for each measurement year, allowing comparisons between measurement years. Though there are only two years currently available, the cross-reference is very beneficial in reviewing trends. Dr. Gwiazdowski acknowledged the amazing amount of work put into the PQD, and asked about the access to providers. The Plan’s Quality Director advised that the HealthPlan needs the amount of detail to determine driving forces of a measure, as that drilldown has previously been time consuming for staff to extract. The Non-Clinical module is currently available to providers. Thought is being given as to what pieces of the HEDIS module should be released, as many measures are a sampling, and may not be representative to a provider’s actual performance. If disseminated to providers, Dr. Gwiazdowski asked if the Partnership intended on having them agree to not using the data as a marketing tool to promote their practice. The Plan’s CMO advised that there has not been any qualms with providers bragging about their high rates, which is believed to help incentivize other practices. There is a value of social pressure for providers to strive for better results. Taking that position, Dr. Gwiazdowski sees this as an opportunity for providers doing well to share their best practices with those who may not be reaching their target levels. The Plan’s Quality Director noted that there is intent on disseminating best practice information, and connecting high and low performers.

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IV.B. Demonstration of Partnership Quality Dashboard (PQD), Continued VI. Adjournment

Dr. Herman questioned if the HealthPlan used a national consensus for measuring avoidable ED visits, and if not, then how does it measure those visits. PHC’s CMO advised that there is no national benchmark. The Plan uses the lowest bar, made up of non-emergent diagnosis codes. These are conditions that could have been held to the following day when the patient’s PCP could be contacted (i.e. coughs, colds, ear infections). The list was developed several years ago by the State. The Committee’s Chair asked if the age/gender grouping of HEDIS rates could be shared with Kaiser, as their leadership follows Medi-Cal statistics. He will talk off-line with the PHC’s Quality Director, as she needs to give thought on how that may be shared, since Kaiser does not participate in the PCP QIP. Referring to the PQD, Dr. Gaborko shared that Kaiser Permanente physicians have benefited from this level of report detail, which assists them in fulfilling their Maintenance of Certification (MOC) requirements. Dr. Bosworth asked if the specifications (specs) on each measure will be accessible from the PQD site. The Plan’s Quality Project Manager advised that this information is available through the eReports portal. There are links to specs for the entire measurement set. The specifications are also available through Partnership’s main web page. It was noted that providers can hover over a measure under the PQD, which reflects the threshold of the measurement. The Committee adjourned at 8:58 AM Respectfully submitted: Linda Largent

For demonstration and information only, no formal action required.

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The foregoing minutes were APPROVED AS PRESENTED on: ___________________________ ____________________________________ Date Jeffrey Gaborko, M.D., Committee Chairman The foregoing minutes were APPROVED WITH MODIFICATION on: ___________________________ ____________________________________ Date Jeffrey Gaborko, M.D., Committee Chairman

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PAGE 1 OF 11 Committee: Physician Advisory Committee Date / Time: March 14, 2018 - 7:35 to 9:02 am

Members Present:

Jeffrey Bosworth, MD - TC Jeffrey Gaborko, MD (Chair)

Michael Ginsberg, MD Steven Gwiazdowski, MD

Willard Hunter, MD - VC Melissa Marshall, MD - TC Mills Matheson, MD - TC

Colleen Townsend, MD Lisa Ward, MD - VC

Members Excused:

Shandi Fuller, MD Michele Herman, MD

Mitesh Popat, MD

Members Absent:

Khuram Arif, MD Antoinette Martinez, MD

Danielle Oryn, DO Michael Stacey, MD

Participated via Teleconference, but not included in Quorum based on Brown Act regulations.

Thomas Paukert, MD

Visitors: Touro Rotation Student, Leah Benner Note: via Video Conf. (VC) via Teleconference (TC)

PHC Staff Present:

Liz Gibboney, Chief Executive Officer Patti McFarland, Chief Financial Officer Sonja Bjork, Chief Operating Officer - VC Kirt Kemp, Chief Information Officer Wendi West, Northern Executive Director- VC Margaret Kisliuk, Behavioral Health Admin. Lynn Scuri, Regional Director - VC Jennifer Chancellor, N. Regional Mgr.- VC

Robert Moore, MD, Chief Medical Officer Peggy Hoover, RN, Senior Director, Health Services James Cotter, MD, Regional Medical Director Stan Leung, Pharm.D., Pharmacy Director Jessica Thacher, Dir., Quality & Perf. Improvement Debra McAllister, RN, Dir. Utilization Management Mary Kerlin, Sr. Director, Provider Relations Ledra Guillory, Sr. Prov. Relations Rep. Mgr. Robin Krohn, Care Coord. Team Manager (North)-VC

Marshall Kubota, MD, Regional Medical Director - VC Michael Vovakes, MD, Northern Regional Med. Dir. -VC Jeff Ribordy, MD, NW Regional Medical Director - VC Bettina Spiller, MD, N. Associate Medical Director - VC Carly Fronefield, RN, Northern, Health Services Dir.- VC Ro Summers, Quality Improvement Prgrm, Project Mgr. Amy Lasher, Quality Project Manager Cody West, Senior Quality Improvement Analyst - North Tara Fogliasso, Quality Project Manager - North

AGENDA

ITEM DISCUSSION / CONCLUSIONS RECOMMENDATIONS / ACTION TARGET

DATE DATE

RESOLVED

Public Comments Quorum I. Approval of Minutes II.A. Status Update Administration

Committee Chairman, Dr. Gaborko, asked for public comments. None were presented. The Committee’s Chair presented the February 2018 meeting minutes for approval. The HealthPlan’s Chief Executive Officer (CEO) provided the following report on Partnership HealthPlan of California (PHC) activities. Recognition – There is sad news to report. Herrmann Spetzler, Chief Executive Officer (CEO) of Open Door Community Health Centers (ODCHC) in Humboldt and Del Norte counties, has passed away

N/A Committee quorum requirements met. MOTION: Dr. Gwiazdowski moved to approve Agenda Item [I.] as presented, seconded by Dr. Ginsberg. ACTION SUMMARY: [9] yes, [0] no, [0] abstentions. Motion carried. For information only, no formal action required.

N/A

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II.A. Status Update Admin., Continued

unexpectedly. Mr. Spetzler has been with Open Door for forty years. He and his wife have been instrumental in the expansion and growth of the health center. They have been visionary leaders with telehealth, provider recruitment, and adopting electronic health records. Mr. Spetzler has been a member of the HealthPlan’s Board since its expansion into the Northern Region in 2013. His passing is a tremendous loss to the community, and touches the 500 staff employed at Open Door, many of whom have worked with him for years. Open Door’s Chief Operating Officer (COO), Mrs. Cheyenne Spetzler, has been named the Interim CEO, which should ease the transition. Dr. Hunter, Chief Medical Officer (CMO) for Open Door reflected on Mr. Spetzler’s huge presence in Humboldt County, along with the state and the Partnership HealthPlan. His advocacy for health services in the rural areas extended to a national level. Open Door is now a main player in the county for primary care. He was instrumental in starting and expanding what is now ODCHC, though it had its non-supporters in the startup years. Mr. Spetzler has been a tireless advocate for the underserved populations (and staff), having mortgaged his home to meet payroll demands a couple of times in the early years. He spearheaded the initiative of increasing the minimum wage to $15 an hour for all the employees, and made sure they also had the benefit of a retirement fund. As a personal friend, Mr. Spetzler was appreciated for his inquisitive mind and wide-ranging interests. Open Door has a transition plan in place. At their meeting last evening, the Board scheduled a strategy session for replacing Mr. Spetzler’s position. As of now, a date for a Celebration of Life has not been selected. Everyone’s support has been very appreciated during this time of loss. - Federal Budget and Medicaid – There has been a lot of waiver activity with the new Centers for Medicare &

Medicaid Services (CMS) Administrator, in terms of approving waivers nationwide, particularly from more conservative states. Those waivers include the allowance of work requirements to receive Medicaid benefits, as well as a heightened interest in capping Medicaid benefits over the course of the member’s lifetime. PHC is monitoring how those waivers roll out, and if CMS will use waivers to manipulate some states.

- HealthPlan Budget – Next year’s fiscal budget (starting July 1) is in the process of being developed. Preliminary rates for the new fiscal year are expected from the State next month, which is earlier than anticipated. There are several new initiatives being worked on that will start up in the new fiscal year, which include the California Children Services (CCS) Redesign, and Drug Medi-Cal. With the Housing Initiative, the Plan is in the process of contracting with a variety of organizations that submitted applications. Some entities are further along than others. It will take a number of months for the roll-out. Some applicants are also contenders with the State’s “No Place Like Home” housing funds, which is currently tied up in a lawsuit.

- California Future Health Workforce Commission – Partnership’s CEO continues to participate, with focus on the behavioral health portion. The Commission is expected to wrap-up in October. Some of the emerging themes include:

For information only, no formal action required. For information only, no formal action required. For information only, no formal action required.

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II.A. Status Update Administration, Continued II.A. Status Update Medical

A lot of interest in regulatory easing related to peer support providers, especially in the substance use area Interest in expanding California’s recognition of psychiatric nurses’ ability to practice. Other states are

much less restrictive than California. Push to restore significant funding for training at the state level, which sunsets this year.

- National Committee for Quality Assurance (NCQA) Accreditation – The HealthPlan is approximately 54% in

compliance with standards, with a target of being 100% compliant by this June. The next level of Accreditation is already being worked on, which will come after this initial set.

- Major Initiatives with the State –

CCS Redesign – The Redesign is still scheduled to go forwrd next January 2019. Staff is talking with each of its counties regarding the model they want to pursue - Partnership taking over the Utilization Management (UM) and Care Coordination of CCS services, or the HealthPlan may subcontract back to some of the counties for a period of time. The caveat to the second option is that the county meets NCQA Accreditation standards.

Drug Medi-Cal Program – PHC is in active discussions with the Department of Health Care Services (DHCS) regarding its financial model, showing its data, and developing final rates. The State asked for innovation, and it is believed the Plan’s model meets that requirement. However, the State is unsure how to proceed with the Regional Model.

Health Homes Program (HHP) – The draft rates received from the State were determined to be insufficient, in addition to some other programmatic changes that DHCS wanted to make. The HealthPlan provided feedback regarding the rates and other changes, and recently discussed its continued concerns with DHCS. A final decision has still not been made.

Prospective Payment System (PPS) Redesign – DHCS has advised health plans that it is no longer actively working with CMS on this potential pilot. So, Partnership is looking internally for a Plan B, and potentially partner with one interested Federally Qualified Health Center (FQHC) to redesign how payments are structured. The HealthPlan is committed to this redesign, as it will go a long way toward delivering better outcomes and continuity for all of its members, but the lift is heavy.

The HealthPlan’s Chief Medical Officer (CMO presented an overview of some Health Services activities. - Spring Quality Conference – This Plan-sponsored event is scheduled for next Monday, and there is still room

for some reservations. The conference will be available at all four PHC locations via video (Eureka held at the Sequoia Conference Center). Details were included in the Clinical Newsletter distributed a few days ago.

- Regional Medical Director Meetings – The round of regional meetings have been completed, and all were well attended. There was even representation from the Plan’s most remote site in Cedarville.

- Confidential Screening/Billing Report (PM 160) Form Followup – In followup to the discrepancy of information received this past year, the State has confirmed that the Child Health and Disability Prevention (CHDP) services form (PM 160) will no longer be required. Providers will not be required to submit these forms to PHC, since it will no longer submit to the State. However, there is information included on

For information only, no formal action required. For information only, no formal action required. For information only, no formal action required.

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the form relevant to CHDP providers, that is of benefit to their county. Information on children under the Gateway or State Medi-Cal programs requiring a referral needs to be directed to the county. Providers are encouraged to contact their county to see what is required for these cases. Each county may require something different.

- Cologuard for Colon Cancer Screening – This test is good for up to three years, and is recognized by the NCQA. DHCS has approved Cologuard as a Medi-Cal benefit, and the Partnership has an active contract with the company for the test. Though DHCS’ benefit indicates yearly, the HealthPlan has limited the screening to every two years, which is well under the three year interval recommended by the US Preventive Services Task Force (USPSTF).

- 340B Program – The State released suggested “Trailer Bill Language”, though the Legislature has not yet accepted the language. In essence, the language attempts to dismantle the 340B Program as much as possible. There is a lot of ongoing advocacy to stop this effort. The Plan is not a viable advocate, as that is better represented by benefit recipients.

- Drug Medi-Cal – There are a number of activities around this program. The Plan’s Behavioral Health Administrator advised that there are two major areas identified for clinical policies, which are: 1) detoxification (detox) withdrawal management services, and developing more guidelines on Medication Assisted Treatment (MAT), and 2) residential care, and how utilization is monitored.

PHC’s Regional Medical Director for Napa County presented a brief overview. - Ole Health – Management has been in the process of recruiting a new CMO. David Gorchoff, MD, has accepted

that position. - Medical Reserve Corps (MRC) – There has been ongoing work with Napa County for the MRC. MRC is where

physicians sign up to be volunteers for cases of emergency. Signups are done through the State, and counties have a list of those physicians. Napa has had three major disasters in the past ten years, and it is expected that another will befall the area. As it turns out, MRC’s list includes deceased and retired physicians, along with some unknown in the area. Napa Medical Society is working with the County toward creating a robust list. Other counties are encouraged to do something similar.

- Palliative Care Benefit – There have been over 250 members (nearing their end of life) to participate in the in-home care program. The Plan’s current focus is to ensure that primary care providers (PCPs) and communities are aware of this benefit. A presentation was made to the Plan’s Consumer Advisory Committee (CAC) last week. The program has been well received, though not everyone is aware of the benefit.

- Introduction and Community Health Initiative – Leah Benner, student with Touro University’s Masters in Public Health and Physician Assistant program, was introduced to the Committee. Ms. Benner is on her last rotation and will be graduating in a couple of weeks. She has been working with the Regional Medical Director on the Children’s Health Initiative (now the Community Health Initiative) in Napa. The Initiative has improved the number of children who are medically insured (now at 98%), those who have a PCP (up to 98%), and those who have had a well-child visit within the first ten months of joining (85%). The outreach is extending their focus to adults and seniors. Napa’s County Health Officer participates on the Initiative’s Evaluation Committee, along with the County’s Administrator in charge of Medi-Cal applications.

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The application process from the County, to the State, and ultimately to PHC can take three months or longer. The Initiative’s Evaluation Committee is striving to speed up the process at the county level, since there are individuals not receiving the care they need during the gaps of time. Ms. Benner is assisting the Regional Medical Director with the program evaluation process, which is out of date.

PHC’s Regional Medical Director for the Southeastern (SE) counties was not available for an overview. PHC’s Regional Medical Director for the Southwestern (SW) counties presented a brief overview. - Health Officers – There have been several changes with Health Officers in the SW counties. In

Mendocino, Dr. Gary Pace has assumed that role. Dr. Pace has been in the area for 30 years. Lake County also has a new Health Officer, Dr. Sara Goldgraben. Sonoma County continues to recruit to fill the void left by Dr. Karen Milman’s resignation.

- New Health Center – Dr. Ward advised that the Santa Rosa Community Health Centers (SRCHC) opened a 24 exam room facility with 14 full-time equivalent (FTE) providers. The location also houses a Complimentary and Alternative Medicine (CAM) suite, as well as the Intellectual and Developmental Disabilities Program for community dwelling adults needing primary and some specialty services care, who formerly lived at the Sonoma Developmental Center. It is expected that this facility will eventually take care of 8,000 patients. The expansion also includes a dental wing, allowing for sedation dental services and teledentistry in the home, so it can accommodate some of the complexity of dental care required by individuals with developmental disabilities. As a whole, it is a complex program housed in a stunning clinic, which has been planned for years. Of note, teledentistry is handled by staff in the home (or institutional home), avoiding the need of general anesthesia or physical restraints. The object is to give patients with complex mental illness or neurodevelopmental disorders the most care, with the least amount of intervention. Services include screenings, some diagnostic treatments, portable x-rays, etc. This past Monday, a second clinic was opened called the Airway Campus. That site is a temporary, year-long clinic located in the Sutter Ambulatory Care building. It includes another 24 exam rooms, and is housing SRCHC’s 36 Family Medicine Residents and 10 faculty members. The site is used for SRCHC’s internal specialty care referral network, residency training, and specialty care services. In a two week timeframe, SRCHC expanded by 50 exam rooms.

- Sonoma West – This surgical site is targeted to open next week, which is good news for the area. The

facility’s surgical unit has been closed for sterilization cleanup, due to findings of mold by inspectors. PHC’s Regional Medical Director for the Northwestern (NW) counties presented a brief overview. - Regional Medical Directors’ Meeting – As previously noted, the forum was well attended. And, as with

other regions, providers are attending for the purpose of Plan updates, versus using it as an opportunity to express complaints and concerns. Unfortunately, some providers were not able to attend, due to poor weather conditions.

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II.A. Status Update Medical, Continued II.A1. Update - County Public Health II.A.2. Committee Member Highlight

- Access – There has not been a lot of movement with providers in the area. There is one pediatrician at Open Door who will be leaving, since her husband is being transferred. St. Joseph’s (St. Joe’s) Hospital has hired a new Ear, Nose and Throat (ENT) specialist, which is a big help for the area. And, it is understood that they have been having difficulty retaining emergency room (ER) and hospitalist physicians. Team Health is currently handling both placements. St. Joe’s has changed contracts several times over the past five years, which lends to the inconsistency. The latest rumor is that St. Joe’s will go in-house to create their own hospitalist and ER section.

- Residency Program (Program) – Dr. Hunter advised that the Program had a site review by the Accreditation Council for Graduate Medical Education (ACGME), and the reviewer was very pleased and impressed by the medical staff and the administrative portion. Somehow, the Program was added to the ACGME’s docket for their April meeting. Staff should know sometime in April on the status of the Program’s Accreditation. If that is the case, they will be able to start recruiting candidates for the first cohort of residents for the summer of 2019. There is great hope that the Residency Program will help stabilize the area’s access to medical care.

The HealthPlan’s Northern Regional Medical Director presented a brief overview on activities for the Northeastern (NE) counties. - Regional Medical Directors’ Meeting – Last week’s forum in Redding had around 30 attendees, and

included representation from all the NE counties. - Access – There has not been any major shifts in providers for the area. Of good news, Canby Clinic

has been without a physician for quite a long time. Dr. Matthew Edmonds, previously with the clinic, has moved back to the area and has rejoined the staff. Coming this spring is a mobile mammography pilot for Modoc and Trinity counties. The details of this program are still being worked out. It is hoped that this will begin in April, as both counties do not have these services currently.

Dr. Stacey was not available to present a brief epidemiology update to the Committee. Continuing with the ongoing effort to be more familiar with members of the Committee, Dr. Townsend shared some highlights about herself. Raised in Minnesota, she grew up around the Twin Cities area and attended a small Liberal Arts college in Central Wisconsin. During college, she took some time off to live abroad in England, completing the non-science portions of pre-medical requirements. Since London was so enjoyable, she stayed another couple years and worked as a nanny for a couple with one child. She has maintained that friendship over the years. The University of Minnesota was selected for her medical school, which really emphasizes primary care in their curriculum, and consistently has one of the largest graduating primary care classes. The college

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DISCUSSION / CONCLUSIONS RECOMMENDATIONS / ACTION DATE RESOLVED

II.A.2. Committee Member Highlight, Continued II.B. Quality/ Utiliz. Advisory, II.D. Provider Adv., & II.E. Credentialing committees II.F. Committee Membership

placed a lot of emphasis on primary care for rural communities when she attended, since the state is largely rural. At that time, Dr. Townsend did not want to live in a rural community, though she wanted to pursue primary care. Through research, she found that some challenges for primary care were specific to urban areas. Along with other interested medical students, they developed a rotation that focused on serving underserved communities in the urban areas (currently known as social determinants of health). The group started a program in which medical students could spend 2 to 3 months working in community health centers for their primary care rotation. This was a progression for Dr. Townsend’s love of primary care, having interfaced with the National Health Service in England. That allowed her to see community medicine and the single payer system. Residency in Family Practice was done at the University of California, San Francisco (San Francisco General at that time). That program was chosen because of its focus on community medicine and addressing systems for better care within underserved communities in urban areas. Dr. Robert Moore recruited her to join Ole Health’s physician team in 2001. Her intent was to fulfill a three-year commitment for the National Health Service, but she found something in Ole Health that has kept her there. Over the past sixteen years, she has been able to grow clinically, and serve the community and organization by participating in leadership and management, and help build programs that serve the communities. Though Dr. Townsend has had many roles at Ole Health, her current position is Senior Director of Community and Specialty Partnerships, allowing her to help cultivate and maintain the relationships with organizations and specialists to better serve Ole Health’s patients. On a personal note, she is married with two children, who are active in athletics. She had learned to love baseball through Little League, but the interest has shifted to La Cross, requiring her avid attention to follow the fast pace of the sport. Other interests include hiking and traveling, and spending time with friends in the area. There were no items pulled for additional review by the Committee. The Plan’s CMO advised that Dr. Rod Manalo, a member of the Quality / Utilization Advisory Committee (Q/UAC) from its inception in 1994, who retired from Kaiser several years ago, has decided to move out of the area. He is no longer able to participate on the committee. Dr. Manalo has been a quality champion. With reluctance, his resignation is recommended.

MOTION: Dr. Townsend moved to approve Agenda Items [II.B., II.D., & II.E.] as presented, seconded by Dr. Gwiazdowski. ACTION SUMMARY: [9] yes, [0] no, [0] abstentions. Motion carried. MOTION: Dr. Townsend moved to approve Agenda Item II.F., as presented, seconded by Dr. Ginsberg. ACTION SUMMARY: [9] yes, [0] no, [0] abstentions. Motion carried.

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AGENDA ITEM

DISCUSSION / CONCLUSIONS RECOMMENDATIONS / ACTION DATE RESOLVED

IV.A. Lactation Clinical Practice Guideline (CPG) (MPXG5008) IV.B. CPG: Pain Mgmt., Chronic Pain Mgmt., & Safe Opioid Prescribing (MPXG5009) IV.C. eReports System (& the new Partnership Quality Dashboard System – Deferred)

PHC’s CMO noted that the Lactation CPG was pulled from consent, as these are reviewed by the Committee. There were a couple of minor changes, mainly with the language around the Plan’s current program, in which, staff calls members regarding their postpartum visits, and to inquire if there are any issues. The Plan’s CMO advised that language was updated in the CPG to include the importance of the patient’s primary care provider’s (PCP’s) role in the pain management, prior to being referred to a pain management specialist. Non-opioid options to treating pain were also added to the guideline. Partnership’s CMO reported that the Plan is pleased to share electronic tools relating to its pay for performance program (Quality Improvement Program [QIP]). Today’s agenda reflects both the eReports System and the Partnership Quality Dashboard (PQD), but the latter is being deferred to next month for presentation to the Committee. The Plan’s Quality Director shared that the eReports system supports the clinical measures of PHC’s PCP QIP. The non-clinical measurements are not encompassed under eReports. The system allows providers to see their denominator list, and the numerator status, as well as understand how many members they are away from meeting their target. Aside from creating some transparency regarding the population that the provider’s payment will be based upon, it allows providers to upload data to the HealthPlan, when that information is not available. Of note, the PQD, which will be demonstrated next month, has similar information as eReports, but it is more of an analytics tool. The Plan’s Senior Quality Improvement (QI) Analyst (QI Analyst) and Quality Project Manager (Project Manager) from the Northern Region were introduced to the group. PHC’s Project Manager highlighted the QIP eReports system for those not familiar with it. The on-line system tracks all of the QIP clinical measures, and was developed in-house by the Plan’s Web Applications team. The QIP team is available to provide assistance to PCPs for utilization of the tool. The database gives providers the ability to track their clinical performance in real time and download patient reports for all clinical measures tracked, along with the ability to upload any supplemental data not being received by the HealthPlan through other administrative sources. Feedback from providers is taken into account when exploring the feasibility of enhancing the system.

MOTION: Dr. Gwiazdowski moved to approve Agenda Item IV.A. as presented, seconded by Dr. Townsend. ACTION SUMMARY: [9] yes, [0] no, [0] abstentions. Motion carried. MOTION: Dr. Ginsberg moved to approve Agenda Item IV.B. as presented, seconded by Dr. Gwiazdowski. ACTION SUMMARY: [9] yes, [0] no, [0] abstentions. Motion carried.

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AGENDA ITEM


IV.C. eReports System, Continued (Partnership Quality Dashboard System – Deferred)

The first major enhancement made is Single Sign-On. It allows the provider to log onto the system with one user name and password. Some practice sites had multiple user names and passwords. All previous user names and passwords to the QIP eReports system have been deactivated. Providers are required to complete a brief survey to designate an eReports administrative user, and access their Secret Key. The administrative user will also be the internal owner of the Secret Key, and the one who designates the appropriate permissions within their organization. One primary point of contact is required for the entity, and more than one is fine. The second major enhancement is the provider’s ability to Drill Down to Site Level Data. The initial log-in gets the user to the site’s parent organization level. The user can then drilldown to the various sites (if applicable). The dropdown feature is available under the Threshold Report. The Plan’s QI Analyst reviewed the new clinical measures added to QIP eReports for 2018. All measures are shown by their practice type (Family, Internal, and Pediatric), so that each site will list the measures assigned to them. Data for eReports is acquired through claims (i.e. immunizations from care, lab results, pharmacy data), as well as the supplemental data providers upload. This information is used for calculations of denominators and numerators. In the past, eReports was refreshing nightly. This year, those refreshes will occur once per end of week (Friday eve), to allow for capture of data from the noted sources. Measurements added for 2018 are included in the system for the appropriate practice type. Breast cancer screening reviews the number of continuously enrolled Medi-Cal women ages 50 to 74 years, who have had a mammogram. This measurement takes into account the full Healthcare Effectiveness Data and Information Set (HEDIS) specification, and staff is looking at enrollment criteria prior to the measurement year (enrolled in the HealthPlan) for fairness to providers. The childhood immunization Combination 3 measure reviews children two years of age, who need to satisfy a series of seven vaccinations (providers should review the QIP Specifications [Specs] Manual for details). This measure is undergoing further development in eReports, due to its complexity. Staff continues to work on a way to meaningfully display gaps in care and what vaccinations may be missing. The timeline of this additional information is sometime between June and December. The addition of supplemental data is not yet available for this measure, pending the ability to display gaps in care. The asthma medication ratio reviews members 5 to 18 years of age, who have been identified as having persistent asthma and have a ratio of controller medications to total asthma medications of 0.5 or greater, during the measurement year. This is only being added to measurements for pediatric practices. Immunizations for adolescents is not a new measure, but it is a new combination. The Human Papillomaviruses (HPV) vaccine has been added for patients between the ages of 9 and 13. eReports enhancements include the ability for providers to capture numerators through administrative services for diabetic retinal eye exams. Again, providers should refer to the QIP Specs for details. Partnership’s Project Manager demonstrated the system live for the benefit of the Committee. The QIP eReports can be accessed under the Plan’s website, then drilling down by hovering over “Providers” then clicking the link to the PCP QIP under Quality. This leads the user to the QIP website, and ultimately to the measurements by practice type. eReports can be accessed under the “Tools” option. Once there, providers are encouraged to bookmark the location, for ease in future access. Providers will always be reminded of the “Terms and Conditions”, and required to accept, due to the Protected Health Information (PHI) included under the site. Using the cervical cancer screening as a sample, the Plan’s Project Manager demonstrated how the provider can review their targets, the additional number of patients required to meet that target, the denominator (number of eligible members), and the numerator (number of women who have completed the screening), resulting in the provider’s current rate. The system further breaks this information down, showing the targets for the 75th and 90th percentile levels. New measurements for the current year will reflect the 50th percentile level.

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AGENDA ITEM


IV.C. eReports System, Continued (Partnership Quality Dashboard System – Deferred)

This gives the provider the opportunity to prepare for the next measurement year. The data can also be exported to an Excel table. Organizations with multiple sites (or practice types) can drilldown to show specific data by site or practice type. Users wanting a list of members within each measure can do so through a hyperlink under the Denominator or the Numerator caption. Specific examples were highlighted with the group, showing compliance by member. Additionally, the system will reflect all the data sources used to bring the member into the practice site’s measure, along with the applicable procedure code. The patient list for a measure can also be downloaded into Excel. There are multiple ways to access the patient list. One of the newer enhancements was derived from provider feedback. Whereas, providers wanted the ability of downloading their entire member denominator list for all measurements. This is now available through a single click, call the QIP Member Report, and can be filtered as the provider prefers. Member Search was another enhancement added. Sites have requested a way to determine if a member is included under more than one measurement. This is achieved by entering the member’s Client Identification Number (CIN), or any of the search criteria listed under the site page, then hit search. A detailed link will populate, allowing the provider to view this information. If the member has been excluded from a measurement (i.e. not under cervical cancer screening if received a hysterectomy), that has also been identified. Uploading QIP data into the system was demonstrated. Elements for numerator compliance, which the HealthPlan requires for a measurement, is also listed for the provider’s reference. Areas addressed by the Committee included: - Dr. Gwiazdowski complimented the program, which is a powerful tool for providers. He asked if there was a way to project the nominator (patients still

requiring the screening). – The Plan’s Quality Director advised that, for the purpose of the QIP, members are included under the numerator portion when they become compliant. The denominator reflects those not compliant. Secondly, how is the data set populated into the database? – PHC’s QI Analyst shared that the value sets are derived from the HEDIS information and the sources previously highlighted.

- Dr. Ward asked about the timeframe from service to claims, as many of the metrics are driven by claims data. What is the general time before claims data is part of the weekly upload? - PHC’s QI Analyst advised that staff has also been challenged to answer this, in terms of how much time should be allowed before the provider should upload supplemental data. Ultimately, this is dependent on each organization’s timeframe of billing. Data uploaded and refreshed can occur within one to two weeks, and is based on received (not paid) claims. Consequently, providers are encouraged to go to the “details” section of eReports to determine if the system has captured the information. There is also a grace period allowed at the end of the year for providers to add data not captured. In terms of physicians who split their time between sites, Dr. Ward wondered if there was a mechanism to reflect a PCP at more than one site simultaneously. If not, how are affiliations communicated so that the information is most reflective of where PCPs are practicing? – The Plan’s Quality Director advised that the eReports system is by site, and not drilled down to the clinician level (based on member assignment).

- Dr. Gwiazdowski questioned how duplication of data uploads are handled, and how the data’s integrity is preserved, when there is self-reporting involved.

– PHC’s QI Analyst advised that the system is set up to capture all the data, but will filter so that it is counted only once. The duplication will simply be shown as additional information. Data integrity is determined through the end-of-year audit process, and reconciled by Plan staff.

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AGENDA ITEM


DATE RESOLVED

IV.C. eReports System, Continued IV.D. 2016/2017 Hospital QIP Evaluation Adjournment

Provider feedback on the eReports system has been very favorable, and reported to be on the cutting edge when comparing programs similar health plans have available. The Plan’s QIP Project Coordinator (Project Coordinator) reported that the Hospital QIP was started in 2012. There are currently 37 eligible hospitals in PHC’s 14 counties, with 26 hospitals participating. The purpose of the program is to improve health outcomes of Plan members, and to assist hospitals in assessing the quality of care they are providing. There were nine measures included in the 2016/2017 measurement set, and large hospitals (at least 50 general acute beds) reported on all nine measures. Small hospitals (less than 50 acute beds) reported on two of those measures. The Hospital QIP Evaluation is to assess the performance of the measures, and to identify areas needing improvement. As the information is reviewed, there are some considerations to note. In 2012, there were six hospitals participating. In 2017, the program started with 26 participants. Performance statistics revealed stable or increased improvements overall, with the exception of the exclusive breast milk feeding (EBMF) rates. The Plan’s rate for EBMF was 75%, and shows a slight decrease from the previous year, but the statewide average is at 65%. Quality staff is working with hospitals to determine the discrepancy for the vaginal birth after cesarean (VBAC) rate. But, overall, there was improvement. The last measure to point out is elective delivery (before 39 weeks gestation). Due to a correction submitted by a hospital a few days ago, that percentage should now reflect 2.98%, not 3.98%. Though there is one outlier hospital, the balance of hospitals have a low elective delivery rate overall. In summary, at least 70% of the Plan’s hospitals earned whole points for 8 out of 9 measurements. These measures use targets that are based on national trends and thresholds. Going forward, staff will focus on retrieving maternal data from the California Maternal Quality Care Collaborative (CMQCC), which should help reduce errors. Provider engagements will be continued, along with the Quality Symposium sponsored by the HealthPlan, and monthly newsletter updates. The Plan’s CMO reminded the Committee that the Evaluation was based on the measurement set at that time, which was changed for this year. Next month, proposed changes for the coming year will be brought to the Committee for review and approval. The Committee adjourned at 9:02 AM Respectfully submitted: Linda Largent

For information only, no formal action required. For information only, no formal action required.

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The foregoing minutes were APPROVED AS PRESENTED on: ___________________________ ____________________________________ Date Jeffrey Gaborko, M.D., Committee Chairman The foregoing minutes were APPROVED WITH MODIFICATION on: ___________________________ ____________________________________ Date Jeffrey Gaborko, M.D., Committee Chairman

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Committee: Quality and Utilization Advisory Committee (Q/UAC) Meeting

Date/Time: Wednesday, April 18, 2018 / 7:30 AM – 9:00 AM Napa/Solano Room, 1st Floor

Members Present: Gwiazdowski, Steven, M.D., FAAP Murphy, John, M.D. Namihas, Steven, M.D. Quon, Robert, M.D.

Thomas, Randolph, M.D. Threlfall, Alexander, M.D. Wilson, Jennifer, M.D.

Members Absent: Borde, Madhusudan, M.D. Choudhry, Sara, M.D. Montenegro, Brian, M.D.

Paukert, Thomas, M.D. Strain, Michael, PHC Consumer Member Swales, Chris, M.D.

PHC Members Present: Becerra, Eric, Grievance and Appeals Resolution Manager Cotter, James, MD, Associate Medical Director French, Rachael, Senior Manager, Quality Compliance and Accreditation Glickstein, Mark, Associate Medical Director Guillory, Ledra, Senior Provider Relations Representative Manager Hoover, Peggy, RN, Health Services Senior Director Katz, David, MD, Associate Medical Director Kubota, Marshall, MD, Regional Medical Director

McAllister, Debra, RN, Utilization Management Director Moore, Robert, MD, MPH, MBA Chief Medical Officer – Chairman Netherda, Mark, MD, Regional Medical Director Ribordy, Jeff, Northern Region Medical Director Scuri, Lynn, Administration Regional Director Spiller, Bettina, M.D. Northern Region Associate Medical Director Vovakes, Michael, MD, Northern Region Medical Director

PHC Members Absent: Boyd Anderson, Rebecca, Care Coordination Director Fronefield, Carly, Northern Region Health Services Director Leung, Stan, Pharmacy Services Director

Steffen, Nancy, Northern Region Associate Director Quality, Analytics and Project Management Thacher, Jessica, MPH, Director Quality, Performance Improvement

Guests: Enos, Mary Associate Director of Enrollment Garnick, Karen, Member Services Administrative Assistant King, Latonya, Associate Director of Utilization Management Leslie, Liz, Program Manager

Patel, Vic, Clinical Pharmacist Santos, Rosemenia, Manager of Quality Assurance/Patient Safety Stevenson, Lauri, Northern Region Manager of Clinical Quality and Patient Safety

AGENDA ITEM DISCUSSION RECOMMENDATIONS / ACTION DATE RESOLVED

I. Call to Order Approval of Minutes

Dr. Robert Moore called the meeting to order at 7:30 a.m. Internal Quality Improvement Minutes from March 13, 2018 and Quality and Utilization Advisory Committee Minutes from March 21, 2018 were reviewed and accepted. A request for public comment was made by Dr. Moore.

Motion for IQI Minute acceptance: Dr. Quon Second for Minute acceptance: Dr. Gwiazdowski Motion for QUAC Minute acceptance: Dr. Quon Second for Minute acceptance: Dr. Gwiazdowski

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II. Standing Agenda Items 1. Status of Open

Action Items None

2. QI Department Update

Rachael French gave the Quality Improvement update found on page 20. The Partnership Quality Dashboard (PQD) Module 1 (non-clinical PCP QIP measures) is

now live and data is available through October 2017. All PCPs have access to this module. The Kick-Off webinar was held March 22nd; many attendees expressed their enthusiasm towards the value and utility of the portal.

We are in the final stages of our HEDIS medical record collection projects; we are approximately 85% complete. We have already submitted our preliminary rates to our auditor but that will shift in the next few weeks. We should have our final HEDIS data reported out by early July, which is about a month ahead due to the new Partnership Quality Dashboard tool takes away some of the manual work.

The last ADVANCE training session was held on March 22-23. Teams spent time reviewing the content learned, sharing successes and talking about spread and sustainability. Evaluation results are being worked on and will be presented in the fall.

In regards to NCQA accreditation, we are currently about 65% compliant in interim. The NCQA team presented a readiness assessment to the steering committee made up of executive members at PHC and received a green light to go forward with interim and first survey. Although we have some focus areas of attention, we feel confident we can get there.

The Director of Quality and Performance Improvement, Jess Thacher, is leaving PHC; her last day is April 26th. We are in the active recruiting stages so if the committee knows of anyone, please reach out to Dr. Moore. Additionally, we are still recruiting for the Manager of Quality Incentive Program that is still open.

Dr. Gwiazdowski asked if there is a flyer with the job description or qualifications that can be sent to the committee members. Dr. Moore confirmed that there is and Rachael will send out to the committee.

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3. HealthPlan Update

Dr. Moore gave the HealthPlan update. We have a new Medical Director joining PHC, Dr. Colleen Townsend from OLE Health. She

will be the Regional Medical Director for Napa, Solano and Yolo counties. Following the transition period, Dr. Cotter will be focusing his work on Palliative Care and supporting the Care Coordination team in the Intensive Outpatient Care Management Program. Dr. Netherda will be transitioning to the roll of Associate Medical Director for Quality.

The implementation of the Regional Substance Use Disorder benefit has been delayed. It was targeted for July 1st but the state is having a challenging time figuring out the financial model. We do know there is a commitment to the benefit, but it’s just moving slow. We estimate that it will not be in place until January or July 2019. PHC is still gearing up for it but not at the pace we were before. PHC is close to finalizing a new Senior Clinical Medical Director of Behavioral Health that will be oversee both the substance use and the mental health benefit. In the interim, we are still promoting what primary care is able to do, which is medication-assisted therapy and to promote voluntary inpatient detox in an inpatient setting. Dr. Moore has asked the state how many times they have received claims for inpatient detox, and it was very low. The state determined they had a configuration error that will be fixed, there are two specific codes that need to be included on the claims. They will be sending out notes to all the

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denials they’ve done in the past based on not having the right codes and asking for them to be resubmitted.

The state has officially announced that PHC’s new target date for health homes for patients with complex needs is July 1, 2019. The only county going live in July 2018 is San Francisco, and only Inland Empire agreed to live the following January.

The Whole Child Care initiative (CCS transition) is proceeding with a more firm deadline of January 1, 2019. We are on track to take the responsibility for the care coordination pretty much exclusively in-house and PHC will be hiring nurses to support this effort.

DHCS is at an impasse with CMS on the Alternative Payment Methodology and it cannot be resolved, so it’s off the table for a while. PHC is exploring a potential Plan B, but that is still in the discussion stages.

Our next big training is our Maternal and Child Health Conference: Stepping Stones from Infancy to Adolescence. The conference will be hosted in our Redding office, but PHC will have video conferencing from Fairfield. Dr. Moore sent out the registration information to those included in his Medical Directors mailing list, and it will also be sent to the committee members.

Hepatitis C costs have plummeted in the last six month due to a combination of three factors. 1) The cost of the new drug is about half the price, 2) A person only needs to take the medicine for eight weeks, and 3) PHC has already had a peak of people treated. The state is likely to loosen up on the criteria so that anybody can be treated now that price is coming down. This is expected to happen in the near future, which will cause another bump in requests.

III. Old Business There was no old business discussed. IV. New Business (Committee Members as Applicable)Consent Calendar Delegation Reports - Credentialing / Re-Credentialing

Quality Improvement: MPQP1002 – Quality/Utilization Advisory Committee MPQP1004 – Internal Quality Improvement Committee Utilization Management/Care Coordination: MCUG3007 – Authorization of Ambulatory Procedures and Services MCUP3047 – Tuberculosis Related Treatment (prev. Directly Observed Therapy) MCUP3115 – Community Based Adult Services MCUP3135 – Hysterectomy Review Policy MPUP3006 – Appropriate Service & Coverage (Over/Under Utilization) MPUP3048 – Dental Services (including Dental Anesthesia) MPUP3059 – Negative Pressure Wound Therapy (NPWT) Discussion on policy MPQP1002: Section VI, Item A.1.b Dr. Glickstein suggested to change NR/SR Medical Director and Associate Medical Director of Quality as there are actually more than two Regional Medical Directors and more than one Assistant Medical Director. Rachael advised that the feedback that we received from Internal Quality Improvement Committee was that not all regional medical directors would be able to attend and so we have attempted to state that a representative from each region would attend. Dr. Moore advised that with the exception of the Associate Medical Director for Quality it’s very repetitive for them to attend both meetings. The committee agreed to list these positions as “Regional Medical Director(s)” and “Associate Medical Director(s)”.

The following policies were extracted from the Consent Calendar for discussion: MPQP1002 and MCUG3007 Motion to approve: Dr. Gwiazdowski Second: Dr. Quon The remaining policies were approved without changes Motion to approve MCQP1002: Dr. Gwiazdowski Second: Dr. Quon MPQP1002 Approved with change to reflect: Regional Medical Director(s) and Associate Medical Director(s) Motion to approve MCUG3007: Dr. Gwiazdowski Second: Dr. Quon MCUG3007 was approved without changes

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Discussion on MCUG3007: Section VI, Item C, Dr. Gwiazdowski asked if state and federal law, such as Title 22, are referenced anywhere. Dr. Moore advised that Medi-Cal is pretty good about reflecting state and federal law in their criteria, so by stating Medi-Cal Criteria, it encompasses it all.

1. MCQG1005

Dr. Moore pulled policy MCQG1005-Adult Preventive Health Guidelines from the agenda as additional updates are needed. This will come back to the committee in May. Dr. Moore commented that this policy is one that DHCS is really looking at with their audits so will look to get a consultant who is an expert in preventive care to review the policy annually. Dr. Moore asked for feedback from the committee so that any other needed changes could be incorporated and the following questions were asked: On page 77 of Attachment A, Dr. Murphy commented that it states that required interventions are italicized, but there is nothing in italics. Dr. Moore commented that we believe the italics were lost in the revisions and will be looked at with the current changes being made. On page 79 Dr. Katz commented that the wording around unintended pregnancy screening could be better. Dr. Moore advised that is one that he will be revising to reflect the current standard screening question.

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2. MPQP1053

Rose Santos reported on MPQP1053 found on page 84. On page 84, Section V, clarified that the purpose remained the same, the only change was to

add the acronym “PRC”. On page 85, Section VI, Item A.1.b, updated the policy to reflect the current position/title. On page 85, Section VI, Item A.3, updated the frequency of the meeting. On page 86, Section VI, Item B.5, added information regarding subcommittees and their

ability to review peer review issues as needed now that the meeting is held quarterly. Dr. Moore confirmed that the subcommittees would provide expert opinion but this committee is the approving body.

Dr. Glickstein commented in regards to Section V, the policy states that the Peer Review Committee (PRC) reviews the care provided by contracted providers and asked what would happen if PHC has approved for our member to see a non-contracted provider and there was a problem with the care received, does the PRC have any oversight over that? Dr. Moore confirmed that if we get something in regards to a non-contracted provider we do investigate it on the PQI side, but because they are non-contracted we can’t penalize them, all we can do is report it. In the past, we have had a few cases where it’s a non-contracted provider and we bring it to the committee for input on what to do. Dr. Murphy asked if Policy MPCR #9A was available to the public. Rachael confirmed that is a public policy and available on the website under the Providers section, under Provider Manual.

Motion to approve: Dr. Quon Second: Dr. Gwiazdowski Approved without changes

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3. MP301

Mary Enos reported on MP301 found on page 88. On page 88, Section VI, Item B was updated and Item C was removed to reflect the current

process in Member Services (MS). MS will contact the member to advise them of their missed appointments and how it affects their health and try to determine if there are any barriers to care they can assist with. If they can’t reach the member by phone, a letter is sent.

Motion to approve: Dr. Gwiazdowski Second: Dr. Quon Approved with change Change to be made: Section I, Item A, add the title of the policy

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On page 90, Attachment A was updated, eliminating the choice between letter 66 and 67 as MS only uses letter 66.

Rachael requested to add the title of policy MP316 in Section I.

4. MCUP3042

Debbie McAllister reported on MCUP3042 found on page 91. On page 92 Sections V and VI, added language for clarification. On pages 93-94 Section VI, changes reflect suggestions made in the IQI meeting. Better

descriptions were added and language was standardize throughout. The state uses the term “relevant specialist” so we incorporated that language into the policy.

Dr. Gwiazdowski asked if the yellow highlights mean anything. Dr. Netherda confirmed that it was a residual of the change process and they should be removed.

Motion to approve: Dr. Quon Second: Dr. Wilson Approved with change Change to be made: Remove yellow highlights

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5. MCUP3125

Peggy Hoover reported on MCUP3125 found on page 99. On page 101, Section VI, Item C.2.g.6 added verbiage around Rhinoplasty; PHC will require

photographs of the person’s nose in order to determine if it’s for cosmetic reasons or an actual need.

Dr. Gwiazdowski commented that this seems like it’s very subjective. Dr. Kubota advised that there is scientific data that states noses are inherited; they are not gender based. PHC was taken to a hearing on this and the judge stated that PHC could not use the scientific data across the board, so we now use photos. Dr. Moore confirmed that the photos are used by the Medical Directors to make the judgement. Dr. Quon commented that we are not specialist in this area and asked if plastic surgeons should be involved. Dr. Moore advised that plastic surgeons have an inherent conflict of interest and are not the best person to make the decision. Dr. Katz commented that it seems that our current process is hard to discuss on an appeal; can we standardize some way of describing it so that it would be more convincing? Dr. Kubota has suggested a standard language that can be used when making determinations. Dr. Moore advised it’s a good internal discussion topic but not part of this policy.

Motion to approve: Dr. Gwiazdowski Second: Dr. Quon Approved without changes

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6. MCUP3131 Dr. Moore reported on MCUP3131 found on page 103. The policy has been updated to reflect changes from the state. The majority of the changes are to add new tests to Attachment A. In addition to new tests, the following changes were made: Page 109, with the BRCA testing there is potential for a TAR override. The language around

this was added to every BRCA test in the document. Page 119, the QT syndrome analysis has been removed and replaced with new tests that are

included in the document. Page 128, removed a section that is now a separate test that is included in the document. Page 135, removed a section that is now a separate test that is included in the document. Page 137 a generic expression regarding having a family variant has been added. Attachment B was also updated to reflect the current form from Quest Diagnostics.

Motion to approve: Dr. Murphy Second: Dr. Quon Approved without changes

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7. MCUP3138

Debbie McAllister reported on MCUP3138 found on page 166. This is a new policy created to meet NCQA standards. It identifies the definition of Independent Medical Review and describes the process used by PHC to provide a comprehensive and fair evaluation of health service


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requests. Debbie confirmed that this is a new policy and that the redline changes are the changes recommended from IQI committee.

V. Presentations 1. Grievance

Report

Eric Becerra presented the Q4 2017 Grievance Report found on page 170 which included: The Grievance Volume Report, which is an NCQA reporting standard. Five categories were

included and overall the numbers were fairly low compared to Q3. The Grievance Review showed that appeals were up in Q4, which is attributed to the new

policy with final rule where members have to exhaust their appeal rights before they move on to a state hearing. This bumped up the appeals numbers, and dropped our state hearings numbers in the 4th quarter.

The volume of Standard Grievances remained fairly steady between Q3 and Q4 in the four categories included.

The volume of Exempt Grievances had a decrease in Q4 in the three categories included. The appeal volume included three categories. Withdrawn was down in Q4 however

Overturned and Upheld were both up. Overall about half of the appeals that come in are upheld by the medical directors.

The numbers for State Hearings are significantly down, as members are exhausting their appeal rights before getting to a state hearing.

Dr. Thomas asked if opioids are the only medication included under the denial of medication. Eric confirmed that it was listed as an example as it’s the medication they get the most grievances for. Dr. Vovakes asked if we know our numbers compared to other health plans. Eric advised that he doesn’t have that information but he would reach out to other plans and add it for the next report. Dr. Gwiazdowski suggested to include several quarters and not just two if we are trying to trend the data. Eric advised that for the first two quarters of 2017 we weren’t really tracking the numbers as accurately as we were in the last two so it would not have been a true assessment. Dr. Quon asked if from a staff and time cost, if having more appeals was a positive improvement versus going to a state hearing. Eric advised that his staff prefers the appeals as there is more that goes into state hearings. Dr. Kubota did comment that these appeals also include the transportation appeals.

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VI. Additional Business Discussion Topic Dr. Moore led a discussion with committee members on Improving Diagnostics. Dr. Moore

included an article in his recent newsletter about this, and a summary of an article from the National Academy of Scientists is found on page 174. The summary includes a model of the diagnostic process and things that can impact it. The

stages of the model include an information gathering stage, followed by information integration and interpretation by the health care worker, and then a working diagnosis, which is refined with further questioning. The diagnosis and treatment are then communicated and outcomes are measured at the end of the process.

There are a number of factors you can look at to try to evaluate errors in diagnoses including systematic checks as well as evaluations done by more experienced clinicians.

Studies show that diagnostic errors range from 5-50%; depending on the type of patient/problem. Most studies though can hone down the error range to about 10-20%.

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There are two types of thinking: fast, intuitive thinking and slow, rational thinking. It’s key for physicians to be able to toggle between slow and fast thinking.

Some suggestions for reducing diagnostic errors include more effective teamwork, education and training, and technology solutions.

Open discussion with the committee included: Dr. Wilson asked if the studies he quoted about diagnostic errors separate by type of licensures. Dr. Moore confirmed he didn’t see any studies on that. Dr. Katz commented that a patient could be diagnosed with one thing, but can deteriorate over the next few days, and if they go to an emergency room, they have created a situation where a study would reflect this as a wrong diagnosis. However, if they were to contact him it would allow him to correct the treatment plan based on new information and avoid a wrong diagnosis. Dr. Quon commented that the patient component seems to be missing from this process. A very aggressive patient will be persistent but a very compliant patient will go along with what’s being told to them. Clinicians need to be able to recognize body language, and encourage open dialog with patients to determine the best treatment plan. Dr. Moore agreed the patient component is missing and being able to read the non-verbal communication is critical. Dr. G Gwiazdowski commented that electronic medical records (EMRs) lend to a big data solution as testing, diagnoses, and codings are entered and you can begin to look do comparisons. He asked if there are consulting groups that PHC can leverage to look at what we are doing with our TARS or other information to start looking at these things. Dr. Moore agreed it’s a good thought but fundamentally our data is much more incomplete than what might exist in the electronic health record that that someone like Kaiser may have. Dr. Moore asked Dr. Quon if Kaiser is doing this at all to try to uncover any tendencies. Dr. Quon stated to a degree, yes, but not necessarily all the way down to an individual patient. The advantage that Kaiser has as a fully integrated system is that the prescription, the diagnosis, the tests, the labs are all under one house and can cross correlate it all now that they have an EMR. Dr. Murphy commented that we need to be aware that there is potential harms in really trying hard to get a diagnosis and there can be some harms in excess screening in an effort to make a diagnosis. He advised there this is a very informative 30 minute video by Larry Weed that has very poignant thoughts about how our information systems have helped, or not helped, and the potential that is there. He also commented that we need to consider what the role of the payer is in helping the clinicians improve their diagnostic skills. A provider may sense that patient could benefit from a specific test but knows that the payer isn’t going to cover it. That is a diagnostic opportunity missed because of this barrier. There is also a barrier with specialists in the more rural areas, if you can’t get the patient to the right specialist who can make the most informed diagnosis, the payer can have purvey. Dr. Katz added that it is important to consider data analysis in health services processes such as continuity of care. If patients see a variety of providers over time, each one of them get one chance at making a diagnosis and sometimes without the benefit of the history of the previous provider’s work up. So we want to use the data that not only looks at medical decision errors but

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also at trying to separate out system issues from individual medical diagnostic processes and treatment decision. Dr. Threlfall, commented that in behavioral health diagnostic accuracy is a constant problem and many times treatment becomes medication focused rather than psychotherapy, supportive counseling and skill building focused. People need to be educated about having more accurately diagnosed mental health conditions, especially bipolar and schizophrenia. They have to take the time to get to know the patient and understand their background, which can be a difficult process to undertake when you are inundated with a lot of patients and acute needs. He feels that any support around training and getting this message out around our networks would go a long way. Dr. Moore agreed that education would be helpful. Dr. Spiller commented that we have seen that a lot of our high risk patients are the ones that have the high turnover with physicians. We can identify that they have a high number of medications and also at the highest risk for diagnostic errors. In terms of prevention education of the EMR hygiene can prevent some errors and can help to ensure that diagnostic results don’t get lost and follow up is done when needed. Dr. Moore agreed that EMR hygiene by itself will help. Dr. Quon commented that it seems like it would be hard to collect the data as the article mentions most of the mistakes in diagnoses are minor and get better on their own anyway. In pediatrics, kids have been diagnosed with bronchitis and really just had colds and would have gotten better anyway. In this case, there is a missed diagnosis but there’s no adverse outcome to it. Dr. Moore commented that it goes back to the idea of toggling between slow and quick thinking. Rachael provided a patient perspective to the value of hearing the parent or patient. When you ignore the patient you silence them and they begin to feel like they are over reacting and that they need to adjust the way they think and not react and they end up not being the advocate that they really should be. Dr. Moore asked Dr. Quon if the training that he gives at Kaiser about the importance of catching the non-verbal communication and how not to push back would it lend itself to a one-hour webinar that we could give to our providers? Dr. Quon advised that he’s never done it in an hour before but we could start that conversation. He commented that as a clinician he’s also coached patients to own their part of the process and how to be able to communicate with their physician, as it’s really is a discussion that goes both ways.

Respectfully submitted by: Karen Garnick, Project Coordinator Signature of Approval: ________________________________________________ Date: ____________________________ Robert Moore, MD, MPH, MBA Chairman

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Committee: Internal Quality Improvement (IQI) Meeting

Date/Time: Tuesday, March, 13, 2018 / 1:30 PM – 3:30 PM Board Room, 3rd Floor

Members Present: Bjork, Sonja, JD, Chief Operating Officer Boyd-Anderson, Rebecca, RN, Director of Care Coordination Cabrera, Maria, Member Services Lead Representative Supervisor Chancellor, Jennifer, Northern Region Administration, Regional Manager French, Rachael, Senior Manager Quality Compliance and Accreditation Garcia-Hernandez, Margarita, Senior Manager of Health Analytics Gibboney, Elizabeth, MA, Chief Executive Officer Hoover, Peggy, RN, Senior Director, Health Services Kerlin, Mary, Senior Director of Provider Relations Kubota, Marshall, MD, Regional Medical Director

Leung, Stan, PharmD, Pharmacy Services Director McAllister, Debra, RN, Director of Utilization Management Moore, Robert, MD, Chief Medical Officer Rosel, Melissa, Team Manager, Utilization Management Russell, Joan, Senior Manager of Provider Education Santos, Rose, Manager of Quality Assurance and Patient Safety Scuri, Lynn, Regional Director Thacher, Jessica, MPH, Director, QI/PI

Guests: Cook, Dawn, Pharmacy Services Program Manager Garnick, Karen, Administrative Assistant Hoerber, Ely, Program Manager Hoffman-Spector, Sharon, Team Manager, UM King, Latonya, Associate Director of Utilization Management Lasher, Amy, Project Coordinator

Thomas, Andrea, Communications Coordinator Villasenor, Edna, Associate Director of Call Center Vovakes, Michael, MD, Regional Medical Director Yao, Qi, QI Analyst

Members Absent: Barresi, Katherine, RN, Associate Director of Care Coordination Becerra, Eric, Grievance and Appeals Resolution Manager Cotter, James, MD, Associate Medical Director Cuellar, Dina, CPhT, Director Regulatory Affairs Frederickson, Paula, Senior Claims Director Fronefield, Carly, RN, Northern Region Health Services Director Glickstein, Mark, MD, Associate Medical Director Guillory, Ledra, Senior Director Provider Relations Rep Manager

Netherda, Mark, MD, Regional Medical Director Ribordy, Jeff, MD, MPH, Regional Medical Director Sewell, Kelley, Northern Region Director of MS & PR Sibilsky, Susanna, Northern Region Health Educator Smith, Lyle, Director of Operations Excellence & PMO Steffen, Nancy, Northern Region Associate Director of Quality Improvement Turnipseed, Amy, Senior Director of External and Regulatory Affairs

AGENDA ITEM DISCUSSION RECOMMENDATIONS / ACTION DATE

RESOLVED I. Call to Order

Approval of Minutes

Dr. Robert Moore called the meeting to order at 1:30 p.m. Minutes from the 02/13/2018 IQI meeting were reviewed.

Motion to Approve: Debbie McAllister Second: Joan Russell Approved without changes.

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Action Items None


Jess Thacher gave the Quality Improvement updated found on page 13. 03/13/18

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The 2018 eReports launched on March 1, and the Partnership Quality Dashboard will be launching on March 22 for the PCP network. We are working on measure development for the Hospital Quality Improvement Program (QIP), and looking to potentially integrate delegation oversight as a measurement on the Hospital QIP.

We are working on a perinatal service QIP pilot for Comprehensive Perinatal Services Program (CPSP) providers; deadline for providers to sign up is March 31. PHC hosted a webinar for CPSP providers to learn more about the program and is hosting an in-person meetings as well.

HEDIS medical record collection is underway and we are on track to complete on time. Our ADVANCE program is wrapping up this month. Our final 2-day in-person learning

session will focus on how to develop a sustainability and spread plan. We will host the Better Health through Better Partnerships: How Health Centers Integrate Their Knowledge of the Community with the Delivery System next week. This is one of four regional teleconference opportunities.

In regards to HEDIS score improvement, QI is helping with the cervical cancer screening media campaign in Lake and Mendocino Counties. The CCS media campaign is anticipated to launch in April and run through June 2018. We are working on improving the rate of breast cancer screening and piloting outreach in Marin County. Currently looking to see what the best outreach effort might be.

One of PHC’s Strategic Use of Reserves (SUR) projects will fund the start up for four new Advance Care Planning (ACP) coalitions that will work on promoting Advance Care Planning in our network. These coalitions will also receive technical assistance from the Coalition for Compassionate Care of California.

The Northern Region did a birthday club pilot at Shasta Community Health Center to improve the rate of Well Child visits for 3-6 year olds. They targeted 222 children, 130 were successfully reached and 80 of the 222 children completed their well child exam and received gift cards.

Budget time is upon us; our team is thinking a lot about NCQA accreditation and potential resources there, if any support is needed is this area reach out to the QI NCQA Project Management Team.

Question was asked if ADVANCE will be continuing next year? Jess confirmed that we are building it into our budget and will do an evaluation of the past three years, so it may change a bit but it will run again


Utilization Management/Care Coordination: MCUP3017 - Health Services Review of Non-admission In-hospital Obstetrical Evaluations MCUG3023 - Infant Monitor Guidelines MCUP3052 - Medical Nutrition Services MCUG3058 - Utilization Review Guidelines ICF/DD, ICF/DD-H, ICF/DD-N Facilities MCUP3119 - Sterilization Consent Protocol MPUP3129 - Podiatry Services Provider Relations:

Policy MCQP1053 was pulled and will be presented next month. IQI Consent Calendar Motion to approve: Debbie McAllister Second: Rebecca Boyd-Anderson The remaining policies were approved without changes

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MPPRPLCR401 - Credentials Document Collection, Review, and Verification MPCR13A - Credentialing of Hospice and Palliative Care Medicine Specialist Quality: MPQP1053 - Peer Review Committee

1. MCUP3106

Debbie McAllister reported on MCUP3106 found on page 73. On page 73, Section VI, Item A, added four additional Home and Community Based Services

(HCBS) Waiver programs. On pages 74-76, Section VI, Item C, updated the referral information for the original three

programs and added information on the four added programs. On page 77, Section VII, updated the references. What is a waiver program? Debbie confirmed it’s where there are state allocations for specific programs for a specific population of people and waives Medicaid program requirements under HCBS Waivers. In addition, Dr. Moore stated that the Pediatric Palliative Care Waiver Program expired last year and got a one year extension. We are still not sure what they will do with it. This does not change the policy, it remains in the policy as it’s currently still in place.

Motion to approve: Peggy Hoover Second: Jess Thacher Approved without changes

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2. MCUP3131

Dr. Moore reported on MCUP3131 found on page 78. On page 78, Section IV, Attachment B has changed. On page 79, Section VI, Item C, added language about TAR overrides. On Attachment A, beginning on page 82, there are many changes due to new tests, and new

Medi-Cal rules. Dr. Moore discussed a few specific changes: o On page 84 regarding BRCA, included information about the ability to override the once

in a lifetime frequency. Specific language the state put out regarding this was added on pages 84-85.

o On page 103, test 81528, states once per year, however a new standard was just discovered that was not included in the revised policy. The new standard is now every three years; therefore, change will be made to the frequency limit to state no more than once every two years.

Motion to approve: Peggy Hoover Second: Debbie McAllister Approved with change On Attachment A, update the frequency limit on test 81528.

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3. MCUG3118

Rebecca Boyd-Anderson reported on MCUG3118 found on page 141. This policy started through committee in January but there were questions if the policy was referencing the most current version of the American College Obstetricians & Gynecologists (ACOG) perinatal guidelines. On page 143 all of the graphs that attempted to reproduce the guidelines were taken out and

stated for providers to follow the guidelines.

Motion to approve: Debbie McAllister Second: Rachael French Approved without changes

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4. MCUP3049

Debbie McAllister and Dr. Moore reported on MCUP3049 found on page 150. On page 153 on we changed Attachment A to state when the cumulative cost of items

exceeds $100 in a calendar month and that providers may refer to the DME billing codes and billing sections to determine if items are related within a group.

On page 154 Attachment A was updated to reflect $50 within a 15-month period, previously it stated $50 a month.

On page 161 Attachment B there was a change for codes 64490 to 64495. Previously, it was not clear between initial injection and repeat injection. The first section is now initial injection and the second for repeat injections. Specifically the log has to show the previous injection had at least a 50% reduction in pain.

Motion to approve: Dr. Moore Second: Debbie McAllister Approved without changes

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5. MCCD2012

Rebecca Boyd-Anderson reported on MCCD2012 found on page 163. Requesting approval to archive the Chronic Kidney Disease Program policy as we have

added it the Complex Case Management Program policy MCCP2007. Change is on page 173 that added the “CKD” acronym specifically as it was implied in the version that went through committee and approved in February. Approval today is to archive MCCD2012 and accept the CKD change in policy MCCP2007, keeping same approval date of 2/14/18.

Motion to approve to archive: Rebecca Boyd-Anderson Second: Debbie McAllister Approved without changes

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6. MCRO4018

Stan Leung reported on MCRO4018 found on page 179. Many of the changes made were to meet NCQA requirements. On page 179, Section III, added definitions regarding what is considered an administrative or

operational TAR vs. a therapeutic TAR. On page 179, Section IV, added a sample TAR form with detailed instructions on the process. On page 179-183, Section VI, added definitions for different TAR scenarios and provided

language on the utilization restrictions.

Motion to approve: Stan Leung Second: Jess Thacher Approved without changes

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7. MCRP4060

Dawn Cook reported on MCRP4060 found on 186. On page 186-187, Section III, updated definitions:

o Office of Pharmacy Affairs Information System, updated name and link. o Provider In-House Dispensing added some information regarding forms. o Added definition for UD Modifier.

On page 187-188, Section IV, added updated attachments. On page 188-190, Section VI,

o Clarified information regarding the list we maintain for covered entities. o Included information about what the invitation process is for our program. o Added a citations in regards to the requirements of the Welfare & Institutions Code. o Clarified the physicians’ dispensed drugs and the onus being on the 340B covered entity

to ensure that it is flagged appropriately and to follow the procedures in the PHC provider manual for any changes needed; also added the link to the manual.

o Updated the timeframe for notification of file format changes and added format type. On page 190, Section VII, updated the link. Changes to Attachment A include:

o The agreement was updated to reflect the same information updated in the policy. o On page 195, added that in order to receive the file format used for submission of claims

from Clearinghouse they now need to sign a non-disclosure agreement. o On page 206, the fee schedule was updated to match what is outlined in the provider

manual. Changes to Attachment B include:

o Page 222 added information that a decision was handed down and the permanent injunction was vacated in a case that had been holding up a lot of decisions in California.

Motion to approve: Dawn Cook Second: Debbie McAllister Approved without changes

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8. MPRP4001

Stan Leung reported on MPRP4001 found on page 227. Changes were made to meet Final Rule and NCQA requirements. On page 227-234, Section VI:

o Clarified the responsibilities of the reviewing committee members adding definitions for the various formulary edits.

o Added information regarding how the formulary information is distributed to the providers and members.

Motion to approve: Stan Leung Second: Debbie McAllister Approved with change Minor update to be made on page 227, section VI where we say Physician Advisory committee,

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o Added information on the implementation of certain criteria used for the review process. o Updated how requests for formulary considerations can be submitted. o Added information on how a provider can request a topic for discussion. o Added information on how we meet the requirement to review every drug class.

will add “(PAC)” as we reference PAC throughout the document.

9. MPRP4033

Stan Leung reported on MPRP4033 found on page 238. On page 240, section VI, added language to support our denial process for when single-

source and multisource brand name products exceeds the 30-day limit. Added criteria to be met when prescriber asks to approve a 60-day supply. Change is to support our denial process as we have to provide the policy as well as the reason for denial.

Dr. Kubota asked if single source brand name is still only approved for 30 days. Stan confirmed that yes, unless the doctor feels there is an issue and can provide justification for the patient to receive a 60 day supply with a TAR. Right now the policy has no language to support denial for a 2 or 3 month supply.

Motion to approve: Stan Leung Second: Debbie McAllister Approved without changes

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10. MPRP4062

Stan Leung reported on MPRP4062 found on page 245. On page 245, Section IV, updated the drug list (Attachment A). On page 246, Section VI, updated the explanation of the drug list as being a list that is not

exclusive and will undergo review/updates throughout the year. Added what considerations are made for drug waste requests that are not on the attachment.

Motion to approve: Stan Leung Second: Debbie McAllister Approved with change Add a comment to Attachment A, drug list, to state that if the drug is not listed to reference the policy.

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V. Presentations 1. Inter Rater-

Reliability/TAR Timeliness

Debbie McAllister presented the Inter Rater-Reliability, TARs and Timeliness Data found on page 250. Page 250 is the physician review data. Had one dip, where one physician didn’t agree with

the other, but ultimately this is reviewed by Dr. Moore and it was signed off. Page 251 is the inpatient data. July, August and September were deferred due to the

implementation of Essette. Ratings are all above the 90th percentile across the board. Page 252 is the outpatient data. We were within our threshold of >90%, ranging from 96%-

100%. Page 253 is the RAF volume, manual vs. electronic. We received over 100,000 referrals

between July and December, the majority of them electronic. Page 254 is denied TARs by region. Total denied was 6,780. We are looking at the

breakdown and doing some random checks on denials to ensure they are within standards and to ensure physicians are on all denials.

Page 255 is all TARs completed, we had a total of 99,275 combined inpatient and outpatient.

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2. 2016-17 Hospital Quality Incentive Program Evaluation

Amy Lasher provided a presentation on the 2016-17 Hospital QIP Evaluation found on page 256. The goal of the Hospital QIP is to assess the performance of our hospitals and also to identify

areas of improvement. There are 26 hospitals participating, out of 37 in our network and this is our 5th year of the

Hospital QIP. The purpose is to improve the health outcomes of our members and to help participating

hospitals assess the quality of care provided to their patients. Large hospitals are measured on all nine measures, small hospitals on just two.

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Considerations to keep in mind is that our participants have changed and grown over theyears, starting with six participants in 2012-12 and 26 participants in 2017-18.

Performance graphs are on pages 263 and 264 and data shows that performance has eitherimproved or remained stable over the years. Once exception is Exclusive Breast MilkFeeding (EBMF), we saw a slight dip due to new participants added; however, we are stillabove the California average. There also appears to be a spike in Elective Delivery, but this isattributed to incorrect data being submitted. After drilling down on the data, the actualincrease is attributed to one hospital that had high elective deliveries.

In conclusion at least 70% of the hospitals met full point targets for 8 out of 9 of themeasures.

We will focus on improving the quality of data collected, will work with our partners to getdata directly from them to improve our data.

We will work to increase engagement and guide hospitals in the QI efforts.3. 2016-17

Primary CareProviderQualityIncentiveProgramEvaluation

Qi Yao provided a presentation on the 2016-17 PCP QIP Evaluation found on page 288. The PCP QIP offers financial incentives, data resources and technical assistance to PCPs who

serve our members so that we can we can make significant improvements. For the review period, July 1, 2016 to June 30, 2017 we had 222 providers participating, with

30 measures and paid $36 million, and average points of 65.5. There showed a stability in the percent of providers meeting the 90th percentile target. There

was a modest increase in the percent of providers meeting the 75th percentile target. Large practice size and family practice correlate with better program performance/higher Per

Member Per Month (PMPM). The average point earnings is consistent year over year. Northern Region showed

improvement over 15-16 and performed slightly better than the Southern Region. Based on our findings we do believe that the PCP QIP does improve care. Many measures

show improvement over time. We also look at provider experience and 95% of the participants agreed that QIP does

improve patient care, and 100% are satisfied with the program. Significant program changes were made effective 1/1/18 which are supported by 16-17

program year results, and no measures are ready for retirement based on high performance. We will consider slow changes to the patient experience which includes the CAHPS survey

findings and also the readmissions and admissions targets in the future.

Dr. Moore asked about the Controlling High Blood pressure measure. Qi reviewed the slide on page 300. The addition of CBP to the family practice measurement set correlated with improved HEDIS rate. The CBP performance in QIP increased in 2016-17. Dr. Moore commented that the state had noticed the increase in our 2017 HEDIS Reporting Year, we believe this is attributed to the CBP measure added to the family practice measurement set.

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VI. Additional BusinessThere was no additional business discussed.

Respectfully submitted by: Karen Garnick, Project Coordinator

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QI Department Update

April 2018 Prepared by Jess Thacher, Director of Quality and Performance Improvement

Quality Improvement Programs (QIPs) • The 2018 PCP QIP eReports Demo Webinar was held on 3/14 with 55 attendees. The webinar

highlighted new enhancements such as Single Sign On, eReports Admin User, and the addition of new clinical measures in the portal.

• Partnership Quality Dashboard (PQD) Module 1 (non-clinical PCP QIP measures) is live on eReports with data available through 10/17. All primary care providers have access to PQD Module 1. The PQD Kick-Off webinar was held on 3/22. Many attendees expressed their enthusiasm towards the potential value and utility of the portal.

• The Perinatal QIP - Extended Pilot 2018 Kick-Off Webinar was held on 2/28 with 38 attendees. PHC also hosted in-person Meet-and-Greet sessions on 3/20 in Fairfield and 3/21 in Redding.

Healthcare Effectiveness Data Information Set (HEDIS) • As of 3/16, our HEDIS vendors have collected 5,803 of 14,218 records and completed over 5,400

medical record reviews. Retrieval is complete at our three largest sites: Open Door Community Health Centers, Shasta Community Health Center, and Santa Rosa Community Health Centers. We are on track to complete the medical record retrieval and review project by the 5/9 NCQA audit deadline.

• On 3/30, the following documentation was submitted to HSAG: o Convenience Sample - This is an opportunity to send a sample of numerator positive reviews to

ensure our interpretation of measure compliance aligns with the specifications. o Preliminary Abstractor Accuracy Report - This report ensures the inter-rater reliability for each

nurse reviewer from PHC and KDJ meets our 96% accuracy standard. o Preliminary Medical Record Procurement Report - This report is a new NCQA requirement,

detailing the percentages of retrieval and reviews conducted throughout the HEDIS Medical Record project by measure.

• On 4/13, we will submit preliminary HEDIS rates to HSAG per the NCQA audit timeline. Quality Improvement Trainings • An ABCs of Quality Improvement training was held in Santa Rosa on 3/7. Of the 33 participants, 93%

said they would recommend the training to a colleague. Most participants reported they understood the basic components of the Model for Improvement, including how to write an aim statement, use data for quality improvement, and test changes. Additional trainings will be held in Redding on 5/3 and in American Canyon in the fall.

• The last ADVANCE training session was held on 3/22-23 in American Canyon. Teams spent time reviewing content learned the last 12 months, sharing project successes, and learning about spread and sustainability. Evaluation results will be presented fall of 2018.

• On 3/19 the “Better Health through Better Partnerships: How Health Centers Can Integrate their Knowledge of the Community into the Delivery System” conference was held at PHC offices. Speakers and panelists from Southcentral Foundation and PHC network providers shared best practices for understanding patient and community needs and redefining models of care to meet those needs.

HEDIS Score Improvement – Highlights • The Performance Improvement team continues to help plan the Cervical Cancer Screening

Campaign in Lake and Mendocino Counties. The team has engaged partner organizations from within both counties to participant in the campaign due to launch 5/18. The campaign will include a bus advertisement, postcards, posters, and web ads and banners.

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Quality Compliance and Accreditation • As of 3/21, PHC is 57.14% compliant with Interim Survey Requirements. • The Program Management Team will share a plan-wide readiness assessment in April. The report

will provide a summary of where PHC stands relative to Interim Survey Compliance and will be reviewed by the NCQA Steering Committee. Formal interim application is scheduled for June 2018.

• A new internal workgroup was formed to drive improvements in Initial Health Assessment (IHA) compliance. The group reviewed current strategies and brainstormed new potential interventions. Their first meeting was 3/22.

Patient Safety (2/27 – 3/20) • 21 Potential Quality Issue (PQI) referrals received; 12 PQI cases processed and closed; 65 open PQI

cases. • 11 Facility Site Reviews (FSR); 6 Medical Record Reviews (MRR); and 4 Physical Accessibility Reviews

(PAR) conducted. • 4 Facility Site Review (FSR) Corrective Action Plans (CAP); 1 FSR Critical Element (CE); and 1 MRR CAP

issued. • New sites opened this period: 5. Personnel The Director of Quality and Performance Improvement, Jess Thacher, will be leaving her position at PHC, effective 4/26. PHC is recruiting to fill this position, in addition to a manager-level role within the QI department.

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Policy/Procedures/Guidelines Old Number

New Assigned Number

Comments Provider Manual

Reminder - Effective January 2018, Approval Date reflects that of the Physician Advisory Committee’s meeting date.

Health Services – Quality – Reviewed by the Physician Advisory Committee in May

Physician Advisory Committee MPQP1003 Regular review; policy updated per National Committee for Quality Assurance (NCQA) requirements – section added regarding Technology Review, which may require input from an appropriate specialist who has expertise in the technology field under review

X

The following documents were reviewed by the Quality / Utilization Advisory Committee in April

Member Services

Assisting Providers with Miss Appointments

MP301 Regular review; updated to reflect current processes and for clarification

X

Health Services - Quality

Quality / Utilization Advisory Committee MPQP1002 Regular review; clarifications added - section on PHC staff members updated and restructured; verbiage added that committee does not meet in July and December; section added regarding review & recommendations relative to member satisfaction

X

Internal Quality Improvement Committee MPQP1004 Regular review; clarifications added – reference to following NCQA standards added; section on standing members reorganized;

X

Peer Review Committee MPQP1053 Regular review; updated for clarification and to reflect current processes and staff; section added regarding subcommittees that report to the Peer Review Committee

X

Health Services – Utilization Management

Authorization of Ambulatory Procedures & Services Attachments: A. B. C.

MCUG3007 Regular review; language added that the ordering physician should initiate the authorization process

X

Tuberculosis Related Treatment MCUP3047 Regular review; minor verbiage change X

Community Based Adult Services MCUP3115 Regular review; minor verbiage clarification

X

Hysterectomy Review Policy MCUP3135 Regular review; no changes to policy content

X

PHCSystem Updates

May 2018

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New Assigned Number


Appropriate Service & Coverage Policy MPUP3006 Regular review; section regarding

decisions made on medical appropriateness updated for clarity

X

Dental Services (including Dental Anesthesia)

MPUP3048 Regular review; website link added for the American Society of Anesthesiologists; References updated to include Department of Health Care Services (DHCS) All Plan Letter (APL)

X

Negative Pressure Wound Therapy (NPWT) Device Pump

MPUP3059 Regular review; minor language corrections

X

Technology Assessment MCUP3042 Regular review; updated to reflect NCQA criteria, to better explain how investigational services will be evaluated and approved

X

Gender Dysphoria / Surgical Treatment MCUP3125 Regular review; section added regarding rhinoplasty, which may be considered following the guidelines noted in the policy

X

Genetic Testing Attachments: A updated per State requirements, B replaced

A. Genetic Testing Requirements B. Quest Diagnostics TM Hereditary

Cancer Patient & Family Clinical History Form

MCUP3131 Regular review; language clarifications added; reference to BRCAvantage replaced with TM Hereditary Cancer; references updated

X

External Independent Medical Review Attachment A & B: removed

MCUP3138 Regular review; language clarifications added; references updated to include NCQA guidelines

X

Health Services - Pharmacy

Pharmacy TAR Procedure Attachment: A. PHC TAR form

MCRO4018 Regular review; sections added for better compliance with Final Rule and NCQA

X

Pharmacy & Therapeutics (P&T) Committee Attachment: A. Provider Formulary Addition Request

Form

MPRP4001 Regular review; sections added for better compliance with Final Rule and NCQA

X

Brand Name Drug Requests Attachment: A. Med Watch Form

MPRP4033 Regular review; language clarifications added; section added on requirements for single-source & multisource brand name products

X

340B Compliance Program Attachments: updated to comply with HRSA requirements

A. 340B Compliance Program Agreement

B. PHC 340B Compliance Program White Paper

MCRP4060 Regular review; Definitions updated; policy revised to reflect current processes and requirements under Health Resources and Services Administration (HRSA)

X

Drug Wastage Payments Attachment: updated

A. Allowable Waste Drug List

MPRP4062 Regular review; section added and references regarding the Allowable Waste Drug List updated

X

45 of 233

PARTNERSHIP HEALTHPLAN OF CALIFORNIA

POLICY / PROCEDURE

Page 1 of 2

Policy/Procedure Number: MP301 Lead Department: Member Services

Policy/Procedure Title: Assisting Providers with Missed Appointments

External Policy Internal Policy

Original Date: 01/22/1999 Next Review Date: 03/15/201805/09/2019 Last Review Date: 03/15/201705/09/2018

Applies to: Medi-Cal Employees

Reviewing Entities:

IQI P & T QUAC

OPERATIONS EXECUTIVE COMPLIANCE DEPARTMENT

Approving Entities:

BOARD COMPLIANCE FINANCE PAC

CEO COO CREDENTIALING DEPT. DIRECTOR/OFFICER

Approval Signature: Kevin Spencer \ Kelley Sewell Approval Date: 03/15/201705/09/2018

I. RELATED POLICES:

A. MP316 – Provider Request to Discharge Member & Assistance with Inappropriate Member Behavior II. IMPACTED DEPTS: N/A III. DEFINITIONS: N/A

IV. ATTACHMENTS: N/A A. Missed appointments notification form #29

A. V. PURPOSE:

To preserve the physician/patient relationship, assist physicians with patient compliance and educate the member about the importance of keeping scheduled appointments.

VI. POLICY / PROCEDURE:

Members who miss two (2) or more consecutive appointments within the previous three (3) month period, are contacted by PHC staff, upon request of the member’s provider. If the request is initiated by a specialist, the specialist is expected to notify the member’s PCP of the missed appointments. A. Routing the Missed Appointment Notification Form

1. Providers request PHC's intervention by faxing the Missed Appointment Notification Form (attachment A) to the PHC Member Services (MS) Department.

B. Processing the Missed Appointment Notification Form

1. Designated Member Service’s (MS) staff informs the member of the importance of keeping scheduled appointments and possible discharge from the practice as outlined below:

a. a. MS staff attempts to contact the member by phone (or sends letter #66A with the

Non-Discrimination and Language inserts) . to determine if the member has had any barriers to care, if they are in treatment or have any scheduled tests. Staff advises the member of the importance of keeping their appointments and if they continue to miss appointments, the PCP can request to discharge the member from their practice.

b. If the member cannot be contacted by phone, a letter is sent within five (5) business days of

receipt.

46 of 233



☒External Policy ☐Internal Policy


Applies to: ☒ Medi-Cal ☐ Employees

Page 2 of 2

b. The provider is notified of actions taken by MS staff. c. If the member or provider identifies a medical condition requiring PHC intervention,

designated MS staff refers the case is referred to PHC’s Care Coordination (CC) Department.

cd. The MS staff completes the “PHC Use Only” section of the Missed Appointment

Notification Form (attachment A) notates the actions taken on the Missed Appointment Form and faxes it back to the physician’s office.

d. All actions are noted in the member’s record and completed within five (5) business days. The MS staff will notate which letter was sent and the date the letter was sent on the member’s

record in the Call Center System.

C. Members that Continue to Miss Appointments 1. If a provider requests PHC’s assistance a second time:

a. Designated MS staff contacts the member to determine if the member has had any barriers to care, if they are in treatment or have any scheduled tests. Staff A MS staff also aadvises the member; of the importance of keeping their appointments, and if they continue to miss appointments, the PCP can request to discharge the member from their practice.

If the member is in the middle of care or has treatment or tests scheduled, the case is referred to the MS staff forwards the completed Care Coordinationthe CC Department. Referral Form (Form #5), noting previous action taken to the PHC Care Coordination Help Desk

All actions are notated in the for follow-up with the member and updates the member’s record in the Call Center System to reflect actionsand completed within five (5) business days.

VII. REFERENCES: N/A

VIII. DISTRIBUTION:

A. SharePoint B. Provider Manual

IX. POSITION RESPONSIBLE FOR IMPLEMENTING PROCEDURE: Director of Member Services. X. REVISION DATES:

01/22/1999; 01/10/2001; 01/16/2003; 07/22/2003; 08/10/2004; 08/10/2005; 06/16/2006; 12/09/2008; 02/01/2010; 04/21/2010; 03/12/2013; 01/30/2015; 04/12/2016; 03/15/2017; *05/09/2018 *Through 2017, Approval Date reflective of the Quality Utilization Advisory Committee meeting date. Effective January 2018, Approval Date reflects that of the Physician Advisory Committee’s meeting date. PREVIOUSLY APPLIED TO: Healthy Kids 11/01/2005 to 12/31/2016

47 of 233


POLICY / PROCEDURE

Page 1 of 2




Original Date: 01/22/1999 Next Review Date: 05/09/2019 Last Review Date: 05/09/2018


Reviewing Entities:

IQI P & T QUAC


Approving Entities:



Approval Signature: Kevin Spencer Approval Date: 05/09/2018

I. RELATED POLICES:

A. MP316 – Provider Request to Discharge Member & Assistance with Inappropriate Member Behavior II. IMPACTED DEPTS: N/A III. DEFINITIONS: N/A

IV. ATTACHMENTS:

A. Missed appointments notification form #29 V. PURPOSE:

To preserve the physician/patient relationship, assist physicians with patient compliance and educate the member about the importance of keeping scheduled appointments.


Members who miss two (2) or more consecutive appointments within the previous three (3) month period are contacted by PHC staff, upon request of the member’s provider. If the request is initiated by a specialist, the specialist is expected to notify the member’s PCP of the missed appointments. A. Routing the Missed Appointment Notification Form

1. Providers request PHC's intervention by faxing the Missed Appointment Notification Form (attachment A) to the PHC Member Services (MS) Department.

B. Processing the Missed Appointment Notification Form

1. Designated MS staff informs the member of the importance of keeping scheduled appointments and possible discharge from the practice as outlined below: a. MS staff attempts to contact the member by phone (or sends letter #66A with the Non-

Discrimination and Language inserts) to determine if the member has had any barriers to care, if they are in treatment or have any scheduled tests. Staff advises the member of the importance of keeping their appointments and if they continue to miss appointments, the PCP can request to discharge the member from their practice.

b. If the member or provider identifies a medical condition requiring PHC intervention, the case is referred to PHC’s Care Coordination (CC) Department.

c. The MS staff completes the “PHC Use Only” section of the Missed Appointment Notification Form (attachment A) and faxes it back to the physician’s office.

d. All actions are noted in the member’s record and completed within five (5) business days.

48 of 233



☒External Policy ☐Internal Policy



Page 2 of 2


VIII. DISTRIBUTION: A. SharePoint B. Provider Manual

IX. POSITION RESPONSIBLE FOR IMPLEMENTING PROCEDURE: Director of Member Services. X. REVISION DATES:

01/22/1999; 01/10/2001; 01/16/2003; 07/22/2003; 08/10/2004; 08/10/2005; 06/16/2006; 12/09/2008; 02/01/2010; 04/21/2010; 03/12/2013; 01/30/2015; 04/12/2016; 03/15/2017; *05/09/2018 *Through 2017, Approval Date reflective of the Quality Utilization Advisory Committee meeting date. Effective January 2018, Approval Date reflects that of the Physician Advisory Committee’s meeting date. PREVIOUSLY APPLIED TO: Healthy Kids 11/01/2005 to 12/31/2016

49 of 233


POLICY/ PROCEDURE

Page 1 of 4

Policy/Procedure Number: MPQP1053 Lead Department: Health Services

Policy/Procedure Title: Peer Review Committee ☒External Policy

☐ Internal Policy

Original Date: 09/17/2014 Next Review Date: 03/15/201804/11/201905/09/2019

Last Review Date: 03/15/201704/11/201805/09/2018

Applies to: ☒ Medi-Cal ☒ ☐ Employees

Reviewing

Entities:

☒ IQI ☐ P & T ☒ QUAC

☐ OPERATIONS ☐ EXECUTIVE ☐ COMPLIANCE ☐ DEPARTMENT

Approving

Entities:

☐ BOARD ☐ COMPLIANCE ☐ FINANCE ☒ PAC

☐ CEO ☐ COO ☐ CREDENTIALING ☐ DEPT. DIRECTOR/OFFICER

Approval Signature: Robert Moore, M.D., MPHRobert

Moore, MD, MPH, MBA Approval Date:

03/15/201704/11/201805/09/2018

I. RELATED POLICIES:

A. CMP10 – Confidentiality

B. MPQP1008 - Conflict of Interest

C. MPQP1016 - Potential Quality Issue Investigation and Resolution

D. MPCR #9A - Reporting to the Medical Board of California and the National Practitioner Data Bank

D.

II. IMPACTED DEPTS:

N/A

III. DEFINITIONS:

N/A

IV. ATTACHMENTS:

A. N/A

V. PURPOSE: The Peer Review Committee investigates patient or practitioner complaints about the quality of clinical care

provided by Partnership HealthPlan of California’s (PHC) contracted providers and make recommendations

for corrective action. The Committee also reviews sentinel conditions identified as having quality concerns.

The Committee discussions and documents are protected by federal and state laws providing confidentiality

of health care peer review activities which are conducted in good faith.The Peer Review Committee (PRC)

investigates patient or practitioner complaints about the quality of clinical care provided by Partnership

HealthPlan of California’s (PHC) contracted providers and make recommendations for corrective action.

The Committee also reviews sentinel conditions identified as having quality concerns. The Committee

discussions and documents are protected by federal and state laws providing confidentiality of health care

peer review activities which are conducted in good faith.


A. Committee Structure

1. Membership

a. External Physician Members: The PRC is comprised of one or more representatives from

primary practice specialties (e.g., Family Medicine, Internal Medicine and Pediatrics), one or

more specialist physicians (e.g. OB/GYN, General Surgery). These members represent licensed

providers for hospitals, medical groups, and practice sites in geographic sections of PHC’s

50 of 233


Policy/Procedure Title: Peer Review Committee ☒ External Policy

☐ Internal Policy


Last Review Date: 03/15/201704/11/201805/09/2018


Page 2 of 4

service area. There will be a minimum of 3 external Physician members on the PRC. There is

no upper limit to the number of standing members on the PRC.

b. PHC staff members of the PRC include the Chief Medical Officer, Associate Medical Director

of Quality, Regional and Associate Medical Directors, the Health Services Director, the Director

of Quality and Performance Improvement, the Manager of Quality Assurance & Patient Safety,

Registered Nurse Peer Review Lead, the Performance Improvement Clinical Specialists from

the Northern and Southern Regions and the Peer Review Coordinator.

c. Members serve open terms and may elect to resign at any time by formally advising the chair.

d. Members with annual attendance of < 50% may be barred from future participation in the PRC.

2. Chair: The Chief Medical Officer (CMO) chairs the PRCeer Review Committee. When the CMO is

unavailable, the Associate Director of Quality is the designated chair. The Regional or Associate

Medical Directors act as the temporary chair when needed. The role of the Chair is to assure that all

quality matters and concerns are evaluated thoroughly, that there is adequate input to the discussion,

that a reasonable effort is made to obtain the facts of the matter, and that matters are fully

investigated and any actions are completed. The Chair must assure that the process follows protocol

is fair and unbiased at all times that a provider under scrutiny has had adequate notice and an

opportunity to defend him or herself and has had due process.

3. Meetings: The PRC meets nine (9) times a year orquarterly orand on an as needed basis but no less

than quarterly.

4. Compensation: Physician members who are not PHC staff are eligible to receive a financial stipend

for each meeting attended.

5. Voting: Internal and External Physician members constitute the voting membership, with the

committee chair serving in a tie breaking capacity as necessary. The PRC’s quorum is comprised of

50% of the voting membership. The Chair may not be counted for purposes of a quorum. A

quorum is not required for a meeting to occur, except where a formal action needs to take place or in

instances where the Chair determines that a quorum is necessary.

6. Confidentiality: To preserve an atmosphere promoting free and open discussion between and among

committee members, each committee member signs an annual Confidentiality Statement prepared by

PHC. This statement signifies the intent to protect individuals against misuse of information and to

ensure that all information, medical or otherwise, regarding patients, practitioners and providers is

handled in a confidential manner.

7. Conflict of Interest: The integrity of the Peer Review process requires prevention of input and

decision making where a conflict of interest exists. All non-PHC staff physicians taking part in the

peer review process, including those on the PRC are required to adhere to PHC’s policy on Conflict

of Interest (MPQP 1008). PHC staff is governed by similar Conflict of Interest policies.

B. Committee Responsibilities

1. The PRC will carefully review the clinical care in all situations in which a quality concern has been

raised and forwarded for Committee review. See MPQP 1016 Potential Quality Issue Investigation

and Resolution for details of this process.

2. The PRC will evaluate the quality concern related to the clinical care and make a determination as to

whether there is sufficient evidence that the involved practitioner failed to provide care within

generally accepted standards.

3. Minutes are recorded at all meetings. Minutes are maintained according to the Confidentiality

policy CMP10.

4. External Peer Review

a. Circumstances that require external review:

1) The need for specialty review when there are no medical staff members within the PRC of

the same or similar specialty;

2) The PRC cannot make a determination and requests external review;

51 of 233


Policy/Procedure Title: Peer Review Committee ☒ External Policy

☐ Internal Policy


Last Review Date: 03/15/201704/11/201805/09/2018


Page 3 of 4

3) The individual whose case is under review requests external peer review;

4) When dealing with potential litigation that might affect a provider’s contracted status;

5) When dealing with ambiguous or conflicting recommendations from internal reviewers, or

when there does not appear to be a strong consensus for a particular recommendation.

5. Subcommittees: Complex or specialized peer review issues may be reviewed by a subcommittee of

the Peer Review Committee. These subcommittees meet on an ad hoc basis when cases are

identified through the peer review process that require specialized peer review. A minimum of 3

clinicians are assigned to any peer review subcommittee. A minimum of 50% of subcommittee

members must be present on the committee to take action. The notes, findings and

recommendations of peer review subcommittee are presented to the next regular peer review

meeting for deliberation. The principles of evaluation, confidentiality and recommended rating are

the same as for the Peer Review Committee as a whole. There are two standing subcommittees.

Other ad hoc subcommittees may be created at the discretion of the Chief Medical Officer or the

Peer Review Committee.

a. Medication Safety Subcommittee: This subcommittee evaluates potential quality issues referred

by the Quality Department related to appropriate use of opioid medications in patients with a

diagnosis of chronic pain. Members of this subcommittee will include at least one specialist

board certified in pain management and one behavioral health provider.

5)b. Substance Use Services Subcommittee: This subcommittee evaluates potential quality issues

referred by the Quality Department related to the provision of services related to the treatment of

Substance Use Disorder. The subcommittee will be chaired by the behavioral health medical

director, and include at least one outside specialist experienced in addiction treatment or in

addiction medicine.

C. Confidentiality

1. As specified in State statute, Peer Review activities are not subject to Discovery. The members of

the PRC and the records associated with its reviews and actions shall be afforded all of the

immunity, protection and privileges under California law. A practitioner under review shall be

afforded all rights and protections under California law. The PRC and the CMO shall take all

reasonable steps to protect the confidentiality of the committee’s deliberations, reviews and actions

including all information obtained at all stages of the investigation, review and decision making

process. Any confidential health information obtained during the course of peer review

investigations shall be protected from loss, tampering, alteration and unauthorized or inadvertent

disclosure of information.

D. Indemnification

1. PHC will indemnify, defend and hold harmless the members of the PRC from and against losses and

expenses (including attorneys’ fees, judgments, settlement and other costs, direct or indirect)

incurred or suffered by reason or based upon any threatened, pending or completed action, suit,

proceeding, investigation or other dispute relating or pertaining to any alleged act or failure to act

within the scope or quality assessment activities as a member of the PRC. PHC will retain the

responsibility for the sole management and defense of any such claims, suits, investigations or other

disputes against PRC members, including, but not limited to, selection of legal counsel to defend

against any such actions. The indemnity set forth herein is expressly conditioned on the PRC

member’s good -faith belief that his or her actions and/or communications are reasonable and

warranted and in furtherance of PHC’s peer review, quality assessment, or quality improvement

responsibilities, in accordance with the purposes of PHC’s peer review. In no event will PHC indemnify a member for acts of omissions taken in bad faith or in pursuit of the member’s private

economic interests.

E. Oversight

1. The PRC is accountable to the PHC Board of Commissioners on Medical Care.

52 of 233


POLICY/ PROCEDURE

Page 1 of 4


Policy/Procedure Title: Peer Review Committee ☒External Policy ☐ Internal Policy



Reviewing Entities:



Approving Entities:



Approval Signature: Robert Moore, MD, MPH, MBA Approval Date: 05/09/2018


A. CMP10 – Confidentiality B. MPQP1008 - Conflict of Interest C. MPQP1016 - Potential Quality Issue Investigation and Resolution D. MPCR #9A - Reporting to the Medical Board of California and the National Practitioner Data Bank

II. IMPACTED DEPTS: N/A

III. DEFINITIONS: N/A

IV. ATTACHMENTS: A. N/A

V. PURPOSE: The Peer Review Committee (PRC) investigates patient or practitioner complaints about the quality of clinical care provided by Partnership HealthPlan of California’s (PHC) contracted providers and make recommendations for corrective action. The Committee also reviews sentinel conditions identified as having quality concerns. The Committee discussions and documents are protected by federal and state laws providing confidentiality of health care peer review activities which are conducted in good faith.


A. Committee Structure 1. Membership

a. External Physician Members: The PRC is comprised of one or more representatives from primary practice specialties (e.g., Family Medicine, Internal Medicine and Pediatrics), one or more specialist physicians (e.g. OB/GYN, General Surgery). These members represent licensed providers for hospitals, medical groups, and practice sites in geographic sections of PHC’s service area. There will be a minimum of 3 external Physician members on the PRC. There is no upper limit to the number of standing members on the PRC.

b. PHC staff members of the PRC include the Chief Medical Officer, Associate Medical Director of Quality, Regional and Associate Medical Directors, the Health Services Director, the Director of Quality and Performance Improvement, the Manager of Quality Assurance & Patient Safety, the Performance Improvement Clinical Specialists from the Northern and Southern Regions and

53 of 233


Policy/Procedure Title: Peer Review Committee ☒ External Policy ☐ Internal Policy



Page 2 of 4

the Peer Review Coordinator. c. Members serve open terms and may elect to resign at any time by formally advising the chair. d. Members with annual attendance of < 50% may be barred from future participation in the PRC.

2. Chair: The Chief Medical Officer (CMO) chairs the PRC. When the CMO is unavailable, the Associate Director of Quality is the designated chair. The Regional or Associate Medical Directors act as the temporary chair when needed. The role of the Chair is to assure that all quality matters and concerns are evaluated thoroughly, that there is adequate input to the discussion, that a reasonable effort is made to obtain the facts of the matter, and that matters are fully investigated and any actions are completed. The Chair must assure that the process follows protocol is fair and unbiased at all times that a provider under scrutiny has had adequate notice and an opportunity to defend him or herself and has had due process.

3. Meetings: The PRC meets quarterly and on an as needed basis. 4. Compensation: Physician members who are not PHC staff are eligible to receive a financial stipend

for each meeting attended. 5. Voting: Internal and External Physician members constitute the voting membership, with the

committee chair serving in a tie breaking capacity as necessary. The PRC’s quorum is comprised of 50% of the voting membership. The Chair may not be counted for purposes of a quorum. A quorum is not required for a meeting to occur, except where a formal action needs to take place or in instances where the Chair determines that a quorum is necessary.

6. Confidentiality: To preserve an atmosphere promoting free and open discussion between and among committee members, each committee member signs an annual Confidentiality Statement prepared by PHC. This statement signifies the intent to protect individuals against misuse of information and to ensure that all information, medical or otherwise, regarding patients, practitioners and providers is handled in a confidential manner.

7. Conflict of Interest: The integrity of the Peer Review process requires prevention of input and decision making where a conflict of interest exists. All non-PHC staff physicians taking part in the peer review process, including those on the PRC are required to adhere to PHC’s policy on Conflict of Interest (MPQP 1008). PHC staff is governed by similar Conflict of Interest policies.

B. Committee Responsibilities 1. The PRC will carefully review the clinical care in all situations in which a quality concern has been

raised and forwarded for Committee review. See MPQP 1016 Potential Quality Issue Investigation and Resolution for details of this process.

2. The PRC will evaluate the quality concern related to the clinical care and make a determination as to whether there is sufficient evidence that the involved practitioner failed to provide care within generally accepted standards.

3. Minutes are recorded at all meetings. Minutes are maintained according to the Confidentiality policy CMP10.

4. External Peer Review a. Circumstances that require external review:

1) The need for specialty review when there are no medical staff members within the PRC of the same or similar specialty;

2) The PRC cannot make a determination and requests external review; 3) The individual whose case is under review requests external peer review; 4) When dealing with potential litigation that might affect a provider’s contracted status; 5) When dealing with ambiguous or conflicting recommendations from internal reviewers, or

when there does not appear to be a strong consensus for a particular recommendation. 5. Subcommittees: Complex or specialized peer review issues may be reviewed by a subcommittee of

the Peer Review Committee. These subcommittees meet on an ad hoc basis when cases are identified through the peer review process that require specialized peer review. A minimum of 3

54 of 233


Policy/Procedure Title: Peer Review Committee ☒ External Policy ☐ Internal Policy



Page 3 of 4

clinicians are assigned to any peer review subcommittee. A minimum of 50% of subcommittee members must be present on the committee to take action. The notes, findings and recommendations of peer review subcommittee are presented to the next regular peer review meeting for deliberation. The principles of evaluation, confidentiality and recommended rating are the same as for the Peer Review Committee as a whole. There are two standing subcommittees. Other ad hoc subcommittees may be created at the discretion of the Chief Medical Officer or the Peer Review Committee. a. Medication Safety Subcommittee: This subcommittee evaluates potential quality issues referred

by the Quality Department related to appropriate use of opioid medications in patients with a diagnosis of chronic pain. Members of this subcommittee will include at least one specialist board certified in pain management and one behavioral health provider.

b. Substance Use Services Subcommittee: This subcommittee evaluates potential quality issues referred by the Quality Department related to the provision of services related to the treatment of Substance Use Disorder. The subcommittee will be chaired by the behavioral health medical director, and include at least one outside specialist experienced in addiction treatment or in addiction medicine.

C. Confidentiality 1. As specified in State statute, Peer Review activities are not subject to Discovery. The members of

the PRC and the records associated with its reviews and actions shall be afforded all of the immunity, protection and privileges under California law. A practitioner under review shall be afforded all rights and protections under California law. The PRC and the CMO shall take all reasonable steps to protect the confidentiality of the committee’s deliberations, reviews and actions including all information obtained at all stages of the investigation, review and decision making process. Any confidential health information obtained during the course of peer review investigations shall be protected from loss, tampering, alteration and unauthorized or inadvertent disclosure of information.

D. Indemnification 1. PHC will indemnify, defend and hold harmless the members of the PRC from and against losses and

expenses (including attorneys’ fees, judgments, settlement and other costs, direct or indirect) incurred or suffered by reason or based upon any threatened, pending or completed action, suit, proceeding, investigation or other dispute relating or pertaining to any alleged act or failure to act within the scope or quality assessment activities as a member of the PRC. PHC will retain the responsibility for the sole management and defense of any such claims, suits, investigations or other disputes against PRC members, including, but not limited to, selection of legal counsel to defend against any such actions. The indemnity set forth herein is expressly conditioned on the PRC member’s good -faith belief that his or her actions and/or communications are reasonable and warranted and in furtherance of PHC’s peer review, quality assessment, or quality improvement responsibilities, in accordance with the purposes of PHC’s peer review. In no event will PHC indemnify a member for acts of omissions taken in bad faith or in pursuit of the member’s private economic interests.

E. Oversight 1. The PRC is accountable to the PHC Board of Commissioners on Medical Care.

VII. REFERENCES:

N/A VIII. DISTRIBUTION:

PHC Provider Manual

55 of 233


POLICY / PROCEDURE

Page 1 of 5

Policy/Procedure Number: MCUP3042 (previously UP100342) Lead Department: Health Services

Policy/Procedure Title: Technology Assessment ☒External Policy

☐ Internal Policy

Original Date: 04/14/1999 Next Review Date: 10/18/201805/09/2019

Last Review Date: 10/18/201705/09/2018


Reviewing

Entities:



Approving

Entities:



Approval Signature: Robert Moore, MD, MPH, MBA Approval Date: 10/18/201705/09/2018


A. MCUP3041 - TAR Review Process

B. MPRP4001 - Pharmacy and Therapeutics (P&T) Committee

B.C. MCUP3138 – External Independent Medical Review

II. IMPACTED DEPTS:

A. Health Services

B. Claims

C. Member Services

III. DEFINITIONS:

The following definitions apply to entirely new technologies or new applications of existing technologies

INTERVENTION Lab or

animal

studies

completed

Human

studies

completed

FDA or

regulatory

approval

State

Medi-Cal

benefit

PHC benefit

Experimental

(preclinical trials)

No No No No No

Investigational

(clinical trials in

progress)

Yes No No No If all 6

criteria are

met

New technology

(clinical trial

results available)

Yes Yes Yes or No No Case-by case

review

OR

Consider

addition as a

PHC benefit

New benefit

Yes Yes Yes Yes Yes

IV. ATTACHMENTS:

56 of 233


Policy/Procedure Title: Technology Assessment ☒ External Policy

☐ Internal Policy


Last Review Date: 10/18/201705/09/2018


Page 2 of 5

A. Review of New Medical Technology Form

V. PURPOSE: To define the process utilized by Partnership HealthPlan of California (PHC) to evaluate new

technologies/investigational services and interventions including medical and behavioral health procedures,

pharmaceuticals and devices as well as changes in the application of existing technologies or adding new

benefits for members.


A. Investigational Iinterventions:

1. Department of Health Care Services (DHCS) policy [Title 22, California Code of Regulations

(CCR) Section 51303] for approval of investigational services (interventions) states that all six of the

following criteria must be fully met:

a. Conventional therapy will not adequately treat the intended patient’s condition.

b. Conventional therapy will not prevent progressive disability or premature death.

c. The provider of the proposed service has a record of safety and success with it, equivalent or

superior to that of other providers of the investigational service.

d. The investigational service is the lowest cost item or service that meets the patient’s medical

needs and is less costly than all conventional alternatives.

e. The service is not being performed as part of research study protocol.

f. There is a reasonable expectation that the investigational service will significantly prolong the

intended patient’s life or will maintain or restore a range of physical and social function suited

to the activities of daily living.

2. After collection of all materials necessary to evaluate whether these criteria are met, the Chief

Medical Officer (CMO) or Physician Designee will review the request. If all criteria are judged to

be met, the investigational service will be approved.

3. If criteria are not met, the case may be sent for independent medical review by a case matched

relevant specialist in the area of the intervention. If, in the opinion of the specialist, criteria have

been met, the procedure will be approved.

B. Coverage for Cancer Clinical Trials follows Department of Health Care Services (DHCS) Policy

Statement 2001 06, which states that PHC covers routine patient care costs for eligible members who are

in any one of the four clinical trial phases as long as the following are met:

1. The treating physician recommends participation in the trial

2. Participation in the trial MUST have meaningful potential to benefit the member

3. The trial must NOT exclusively be to test toxicity, but must have a therapeutic intent

4. Will NOT occur in the inpatient setting if there is no indication for acute care treatment

5. Trials that qualify for approval include:

a. Those involving a drug exempt under federal regulation from a new drug application.

b. Those approved by the National Institute of Health and The Food and Drug Administration in

the form of an investigational new drug application, the United States Department of Defense,

or The United States Veterans Health ’ Administration.

C. New technologies physician request and authorization process

1. Case-by-case review: If PHC receives a physician’s request to provide benefits of a new intervention

for a specific member the process is as follows:

a. A Treatment Authorization Request (TAR) must be submitted to PHC describing the intervention and containing medical justification for its use. Pertinent patient medical records

must be included.

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http://eshare/sites/PoliciesnProcedures/_layouts/15/WopiFrame.aspx?sourcedoc=/sites/PoliciesnProcedures/Utilization%20Management/MCUP3042%20Attachments/MCUP3042-A.docx&action=default



☐ Internal Policy


Last Review Date: 10/18/201705/09/2018


Page 3 of 5

b. The Chief Medical OfficerCMO or physician designee will ask the provider for background

information including copies of clinical studies regarding the intervention. PHC staff also will

perform a literature search for peer reviewed studies or recommendations from professional

societies regarding the use, efficacy, and safety of the proposed service.intervention and may,

Iin addition, PHC will consider determinations of regulatory authorities (e.g. Centers for

Medicare and Medicaid Services [CMS] or US Food and Drug Administration [FDA])

concerning the intervention. , use the services of a technology assessment organization such as

Emergency Care Research Institute (ECRI) or Organizationothers.

c. The Chief Medical OfficerCMO or physician designee may request input from the a appropriate

relevant specialist prior to presenting the request to the various committees such as the

Pharmacy and Therapeutics (P &T) Committee or Physician Advisory Committee (PAC). This

specialist must have expertise in the technology under review. d. All behavioral health technologies will include input from an appropriate behavioral health

specialist. c.e. When clinically indicated, a case may be sent for external review to a contracted independent

medical review organization. (See policy MCUG3138 External Independent Medical Review.) d.f. Based on recommendations ofinput from the Utilization Management Department, P &T

Committee, PAC and or relevant consultantsspecialist, the decision will be made by the Chief

Medical Officer (CMO) or Physician Designee renders a determination.

e.g. All records concerning the review are retained by PHC’sThe Health Services department. will

retain all records.

f.h. Determination criteria that will be used by both the relevant sspecialist, P& T or Ccommittee ,

Physician Advisory CommitteeAC, and the Chief Medical OfficerCMO or physician designee

will include:

1) Sufficient objective information regarding the safety, efficacy, and indications for the

intervention is available and supports the use of the intervention in this case.which support

its use.

2) The proposed intervention is likely to lead to a better outcome than conventional

interventions that are currently available.

3) The provider of the proposed service has a record of safety and success with the proposed

service which ist equivalent or superior to that of other providers of the intervention.

4) The practitioner who proposinges to provide the intervention is willing to accept thea

payment rate offered by PHC.

5) The intervention is not being provided as part of a funded research protocol.

g.i. Evaluations of new and existing medications is done are managed by the process described in

the Pharmacy and Therapeutics (P&T) Committee policy MPRP4001.

D. Consideration Addition of addition of a new benefit:

1. A request to add a new PHC benefit may be submitted by a provider, a member, or PHC staff. that a

new technology intervention be added as a PHC benefit. In such instancethis case, the following

steps will occur:

a. The request should be is sent to the Chief Medical OfficerCMO or physician designee and

should containwhich includes a statement explaining why the proposed requested service would

should be added as a PHC benefit, identification of the PHC member to benefit from the

services and all pertinent supporting clinical background information.

b. PHC staff also will perform a literature search regarding the use, efficacy and safety of the intervention, and may in additionalso use the services of a technology assessment organization

such as ECRI Institute or others.

c. The materials collected relating to the request will beare forwarded by the Chief Medical

OfficerCMO or physician designee to an appropriate physician relevant specialist (or to an ad-

58 of 233



☐ Internal Policy


Last Review Date: 10/18/201705/09/2018


Page 4 of 5

hoc physician committee) to review the material and to advise PHC regarding the use of the new

technology. The reviewer or review committee will beis asked to recommend whether the

intervention should be added as a PHC benefit, and if so, to delineate criteria used to evaluate

for the use of the new technology.

d. The report recommendation of from the relevant physician reviewerspecialist or ad hoc review

committee is reviewed by PHC staff, and a recommendation formulated by the Internal Quality

Improvement (IQI) Committee (IQI) and PHC staff, and a. This recommendation is formulated.

d.e. then This recommendation is forwarded to the Quality / Utilization Advisory Committee

(Q/UAC) for preliminary approval, and then to the Physician Advisory Committee (PAC), and

if necessary, the Finance Committee, if necessary, for their consideration. If the

recommendation by the PAC is to addition of the new technology intervention, is recommended

by the PAC, the request will be is forwarded to the PHC Commission for their review and final

determination.

2. Notification of New Benefit Addition: Once approved by the PHC Commission, information

regarding the new benefit will beis disseminated in the following manner:

a. All Primary Care Providers (PCPs) and appropriate relevant specialists will be are notified by

mail.

b. Internal notification is sent to PHC Department Heads and the Health Services Department staff

so that policies and procedures may be created and the information gathered to can be used in

making inform utilization management determinations, benefit interpretations, care coordination

decisions, and the design of health educational materials.

c. PHC Members are nNotifiedcation of the benefit addition will be included invia the next

Member Newsletter. scheduled for next release.

VII. REFERENCES: A. Title 22, California Code of Regulations (CCR) Section 51303

B. Operating Instruction Letter (OIL) 026-02 conveying DHCS Policy Statement 2001 06

B.C. National Committee for Quality Assurance (NCQA) Guidelines (Effective July 1, 2018) UM 10

Evaluation of New Technology Elements A & B

VIII. DISTRIBUTION:

A. PHC Department Directors

B. PHC Provider Manual

C. Health Services Department Heads and Staff

IX. POSITION RESPONSIBLE FOR IMPLEMENTING PROCEDURE: Senior Director, Health Services

X. REVISION DATES: 06/21/00; 12/19/01; 10/16/02, 10/20/04; 10/19/05; 10/18/06; 10/17/07; 05/21/08;

07/15/09; 05/18/11; 02/20/13: 01/20/16; 10/19/16; 10/18/17; *05/09/18

*Through 2017, dates reflective of the Quality/Utilization Advisory Committee meeting date. Effective

January 2018, Approval Date reflects that of the Physician Advisory Committee’s meeting date.

PREVIOUSLY APPLIED TO: N/A

***********************************

In accordance with the California Health and Safety Code, Section 1363.5, this policy was developed with

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POLICY / PROCEDURE

Page 1 of 4


Policy/Procedure Title: Technology Assessment ☒External Policy ☐ Internal Policy



Reviewing Entities:



Approving Entities:





A. MCUP3041 - TAR Review Process B. MPRP4001 - Pharmacy and Therapeutics (P&T) Committee C. MCUP3138 – External Independent Medical Review

II. IMPACTED DEPTS:

A. Health Services B. Claims C. Member Services

III. DEFINITIONS:

The following definitions apply to entirely new technologies or new applications of existing technologies

INTERVENTION Lab or animal studies

completed

Human studies

completed

FDA or regulatory approval

State Medi-Cal

benefit

PHC benefit

Experimental (preclinical trials)

No No No No No

Investigational (clinical trials in progress)

Yes No No No If all 6 criteria are met

New technology (clinical trial results available)

Yes Yes Yes or No No Case-by case review OR Consider addition as a PHC benefit

New benefit

Yes Yes Yes Yes Yes

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Policy/Procedure Title: Technology Assessment ☒ External Policy ☐ Internal Policy



Page 2 of 4

IV. ATTACHMENTS:

A. Review of New Medical Technology Form

V. PURPOSE: To define the process utilized by Partnership HealthPlan of California (PHC) to evaluate new technologies/investigational services and interventions including medical and behavioral health procedures, pharmaceuticals and devices as well as changes in the application of existing technologies or adding new benefits for members.


A. Investigational Interventions: 1. Department of Health Care Services (DHCS) policy [Title 22, California Code of Regulations

(CCR) Section 51303] for approval of investigational services (interventions) states that all six of the following criteria must be fully met: a. Conventional therapy will not adequately treat the intended patient’s condition. b. Conventional therapy will not prevent progressive disability or premature death. c. The provider of the proposed service has a record of safety and success with it, equivalent or

superior to that of other providers of the investigational service. d. The investigational service is the lowest cost item or service that meets the patient’s medical

needs and is less costly than all conventional alternatives. e. The service is not being performed as part of research study protocol. f. There is a reasonable expectation that the investigational service will significantly prolong the

intended patient’s life or will maintain or restore a range of physical and social function suited to the activities of daily living.

2. After collection of all materials necessary to evaluate whether these criteria are met, the Chief Medical Officer (CMO) or Physician Designee will review the request. If all criteria are judged to be met, the investigational service will be approved.

3. If criteria are not met, the case may be sent for independent medical review by a relevant specialist in the area of the intervention. If, in the opinion of the specialist, criteria have been met, the procedure will be approved.

B. Coverage for Cancer Clinical Trials follows Department of Health Care Services (DHCS) Policy Statement 2001 06, which states that PHC covers routine patient care costs for eligible members who are in any one of the four clinical trial phases as long as the following are met: 1. The treating physician recommends participation in the trial 2. Participation in the trial MUST have meaningful potential to benefit the member 3. The trial must NOT exclusively be to test toxicity, but must have a therapeutic intent 4. Will NOT occur in the inpatient setting if there is no indication for acute care treatment 5. Trials that qualify for approval include:

a. Those involving a drug exempt under federal regulation from a new drug application. b. Those approved by the National Institute of Health and The Food and Drug Administration in

the form of an investigational new drug application, the United States Department of Defense, or The United States Veterans Health Administration.

C. New technologies physician request and authorization process 1. Case-by-case review: If PHC receives a physician’s request to provide benefits of a new intervention

for a specific member the process is as follows: a. A Treatment Authorization Request (TAR) must be submitted to PHC describing the

intervention and containing medical justification for its use. Pertinent patient medical records must be included.

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Page 3 of 4

b. The CMO or physician designee will ask the provider for background information including copies of clinical studies regarding the intervention. PHC staff will perform a literature search for peer reviewed studies or recommendations from professional societies regarding the use, efficacy, and safety of the proposed service. In addition, PHC will consider determinations of regulatory authorities (e.g. Centers for Medicare and Medicaid Services [CMS] or US Food and Drug Administration [FDA]) concerning the intervention.

c. The CMO or physician designee may request input from a relevant specialist prior to presenting the request to the various committees such as the Pharmacy and Therapeutics (P &T) Committee or Physician Advisory Committee (PAC). This specialist must have expertise in the technology under review.

d. All behavioral health technologies will include input from an appropriate behavioral health specialist.

e. When clinically indicated, a case may be sent for external review to a contracted independent medical review organization. (See policy MCUG3138 External Independent Medical Review.)

f. Based on input from the Utilization Management Department, P &T Committee, PAC or relevant specialist, the CMO or Physician Designee renders a determination.

g. All records concerning the review are retained by PHC’s Health Services department. h. Determination criteria used by the relevant specialist, P& T Committee, PAC, and the CMO or

physician designee will include: 1) Sufficient objective information regarding the safety, efficacy, and indications for the

intervention which support its use. 2) The proposed intervention is likely to lead to a better outcome than conventional

interventions currently available. 3) The provider has a record of safety and success with the proposed service which is

equivalent or superior to that of other providers of the intervention. 4) The practitioner proposing to provide the intervention is willing to accept the payment rate

offered by PHC. 5) The intervention is not provided as part of a funded research protocol.

i. Evaluations of new and existing medications are managed by the process described in the Pharmacy and Therapeutics (P&T) Committee policy MPRP4001.

D. Addition of a new benefit: 1. A request to add a new PHC benefit may be submitted by a provider, member or PHC staff. In such

instance the following steps occur: a. The request is sent to the CMO or physician designee which includes a statement explaining

why the requested service should be added as a PHC benefit, identification of the PHC member to benefit from the service and all pertinent supporting clinical information.

b. PHC will perform a literature search regarding the use, efficacy and safety of the intervention and may also use the services of a technology assessment organization such as ECRI Institute or others.

c. The materials collected relating to the request are forwarded by the CMO or physician designee to an appropriate relevant specialist (or to an ad-hoc physician committee) to review the material and to advise PHC regarding the use of the new technology. The reviewer or review committee is asked to recommend whether the intervention be added as a PHC benefit and to delineate criteria used to evaluate the use of the new technology.

d. The recommendation from the relevant specialist or ad hoc committee is reviewed by the Internal Quality Improvement Committee (IQI) and PHC staff, and a recommendation is formulated.

e. This recommendation is forwarded to the Quality/Utilization Advisory Committee (Q/UAC) for preliminary approval, the PAC, and the Finance Committee, if necessary, for their consideration.

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Page 4 of 4

If the recommendation by the PAC is to add the new technology intervention, the request is forwarded to the PHC Commission for their review and final determination.

2. Notification of New Benefit Addition: Once approved by the PHC Commission, information regarding the new benefit is disseminated in the following manner: a. All Primary Care Providers (PCPs) and relevant specialists are notified by mail. b. Internal notification is sent to PHC Department Heads and the Health Services Department so

that policies and procedures may be created and information gathered to inform utilization management determinations, benefit interpretations, care coordination decisions, and the design of health educational materials.

c. PHC Members are notified of the benefit addition via the Member Newsletter scheduled for next release.

VII. REFERENCES:

A. Title 22, California Code of Regulations (CCR) Section 51303 B. Operating Instruction Letter (OIL) 026-02 conveying DHCS Policy Statement 2001 06 C. National Committee for Quality Assurance (NCQA) Guidelines (Effective July 1, 2018) UM 10

Evaluation of New Technology Elements A & B VIII. DISTRIBUTION:

A. PHC Department Directors B. PHC Provider Manual C. Health Services Department Heads and Staff


X. REVISION DATES: 06/21/00; 12/19/01; 10/16/02, 10/20/04; 10/19/05; 10/18/06; 10/17/07; 05/21/08;

07/15/09; 05/18/11; 02/20/13: 01/20/16; 10/19/16; 10/18/17; *05/09/18

*Through 2017, dates reflective of the Quality/Utilization Advisory Committee meeting date. Effective January 2018, Approval Date reflects that of the Physician Advisory Committee’s meeting date. PREVIOUSLY APPLIED TO: N/A

*********************************** In accordance with the California Health and Safety Code, Section 1363.5, this policy was developed with involvement from actively practicing health care providers and meets these provisions:

Consistent with sound clinical principles and processes

Evaluated and updated at least annually

If used as the basis of a decision to modify, delay or deny services in a specific case, the criteria will be disclosed to the provider and/or enrollee upon request

The materials provided are guidelines used by PHC to authorize, modify or deny services for persons with similar illnesses or conditions. Specific care and treatment may vary depending on individual need and the benefits covered under PHC.

PHC’s authorization requirements comply with the requirements for parity in mental health and substance use disorder benefits in 42 CFR 438.910.

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Grievance & Appeals Department

Internal Quality Improvement Committee

Grievance presentation April 10, 2018

Grievance Volume Report (NCQA reporting based on total members)*

Category Quarter 3 Quarter 3

Complaints Per

1,000 Members

Quarter 4 Quarter 4

Complaints Per

1,000 Members

Quality of Care 103 0.20 94 0.19

Access 77 0.15 67 0.13

Attitude/Service 144 0.29 152 0.30

Billing/Financial 31 0.06 10 0.02

Quality of Provider Site 22 0.04 8 0.02

Total/Number per 1,000 377 0.74 331 0.66

* Not including Kaiser, as they are delegated to handle their own grievances.

Grievance Review for Q4 2017

The grand total of all grievance types for the 4th quarter was 1072. In comparison to the 3rd quarter, the

total numbers were down 83 grievances. Below is the breakdown of the 2 quarters.

Standard Grievance

A standard grievance is an expression of dissatisfaction that cannot be resolved by the end of the

following business day. These grievances are handled by the grievance staff and require a written

acknowledgement and a written resolution. The standard grievances remained steady for the both

quarters.

Standard Grievance Trends Dissatisfied with treatment plan

Dissatisfied with the provider

Dissatisfied with MTM

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Committee: Quality and Utilization Advisory Committee (Q/UAC) Meeting

Date/Time: Wednesday, March, 21, 2018 / 7:30 AM – 9:00 AM Napa/Solano Room, 1st Floor Members Present: Choudhry, Sara, M.D. Gwiazdowski, Steven, M.D., FAAP Montenegro, Brian, M.D. Murphy, John, M.D.

Namihas, Steven, M.D. Quon, Robert, M.D. Swales, Chris, M.D. Thomas, Randolph, M.D. Wilson, Jennifer, M.D.

Members Absent: Borde, Madhusudan, M.D. Paukert, Thomas, M.D.

Strain, Michael, PHC Consumer Member Threlfall, Alexander, M.D.

PHC Members Present: French, Rachael, Senior Manager, Quality Compliance and Accreditation Glickstein, Mark, Associate Medical Director Guillory, Ledra, Senior Provider Relations Representative Manager Hoover, Peggy, RN, Health Services Senior Director Kubota, Marshall, MD, Regional Medical Director McAllister, Debra, RN, Utilization Management Director Moore, Robert, MD, MPH, MBA Chief Medical Officer – Chairman

Netherda, Mark, MD, Regional Medical Director Ribordy, Jeff, Northern Region Medical Director Stevenson, Lauri, Northern Region Manager of Clinical Quality and Patient Safety Thacher, Jessica, MPH, Director Quality, Performance Improvement Vovakes, Michael, MD, Northern Region Medical Director

PHC Members Absent: Boyd Anderson, Rebecca, Care Coordination Director Chancellor, Jennifer, Regional Manager Cotter, James, MD, Associate Medical Director Cuellar, Dina, Director of Regulatory Affairs Fronefield, Carly, Northern Region Health Services Director Garcia-Hernandez, Margarita, Manager Health Analytics Jenkins, Shauncey, Member Services Supervisor Kerlin, Mary, Provider Relations Senior Director Kisliuk, Margaret, MPP, JD, Behavioral Health Administrator

Leung, Stan, Pharmacy Services Director Santos, Rosemenia, Manager of Quality Assurance/Patient Safety Scuri, Lynn, Administration Regional Director Sewell, Kelley, Northern Region Director of Member Services & Provider Relations Sibilsky, Susanna, Northern Region Health Educator Spiller, Bettina, M.D. Northern Region Associate Medical Director Steffen, Nancy, Northern Region Associate Director Quality, Analytics and Project Management Stephen, Karen, PhD, Health Services Mental Health Director West, Wendi, Northern Region Executive Director

Guests: Beavers, Mitchell, Relypsa Pharma. Inc. Garnick, Karen, Member Services Administrative Assistant Hoffman-Spector, Sharon, UM Team Manager

Lasher, Amy, Project Coordinator Nopwaskey, Sara, Performance Improvement Clinical Specialist Thomas, Andrea, Quality Improvement Communications Coordinator Yao, Qi, QI Analyst



Dr. Robert Moore called the meeting to order at 7:30 a.m. Internal Quality Improvement Minutes from 2.13.18 and Quality and Utilization Advisory Committee Minutes from 2.21.18

Motion for IQI Minute acceptance: Dr. Quon Second for Minute acceptance: Dr. Gwiazdowski Accepted with no changes

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A request for public comment was made by Dr. Moore.

Motion for QUAC Minute acceptance: Dr. Gwiazdowski Second for Minute acceptance: Dr. Quon Approved with no changes


Action Items None


Jess Thacher gave the Quality Improvement update found on page 25. We have a number of Quality Improvement Programs (QIP) on the annual calendar so there

is still activity around wrapping up last year’s program, which includes finalizing scores and calculating payments so we can send checks out. We then will kick off the current year and will host webinars to get the providers up to speed on the measurement set and any changes to the program for this year.

Hospital QIP is not on the annual year, it’s on the fiscal year from July-June. We are finalizing the measurement set and the goal is to bring it to PAC in April for approval.

Today’s meeting will include presentations on two of the QIPs; the 16-17 PCP QIP evaluation and the 16-17 Hospital QIP evaluation. This will be the last year we are evaluating the PCP QIP on the fiscal year, since we are now transitioning to the calendar year.

The Partnership Quality Dashboard has gone live and we will be hosting a webinar to officially launch the first module for the Provider Network. We have been working on this for a couple of years and this is the first piece that is being released externally for the provider network. Module 1 shows the non-clinical measures for the QIP. Historically the data has been shared via PDF reports that are emailed every other month. This will be a huge improvement for providers to access data real-time, in a web-based platform. It will also allow them to drill down to patient level detail that wasn’t readily available on the non-clinical measures before.

The HEDIS 2018 On-Site Audit was completed in February. The HEDIS medical record retrieval project is underway; we are currently about 40%

complete with procurement and chart reviews.. We have received and gone through a little over 5,500 medical charts as of March 16. We are on track to complete the project by NCQA’s completion date of May 9th.

Our ADVANCE program is wrapping up this month. Our final 2-day in-person learning session will focus on how to develop a sustainability and spread plan.

PHC hosted the Better Health through Better Partnerships: How Health Centers Integrate Their Knowledge of the Community with the Delivery System symposium earlier this week.

In regards to HEDIS score improvement, QI is helping with the cervical cancer screening media campaign in Lake and Mendocino Counties.

We have four new Advance Care Planning (ACP) coalitions that PHC has awarded grant funding to and have arranged for technical assistance to be provided by the Coalition for Compassionate Care of California. The new ACP coalitions are in Humboldt, Lake, Siskiyou and Yolo counties.

There has been a lot of work on the annual monitoring for patients on persistent medications (MPM) measure. We have done a few different PDSAs that have really demonstrated the efficacy of live calls to our members on this measure so we are talking about how we can spread that a little more to do health plan based live calls to encourage members to go in for their screenings.

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The Northern Region did a birthday club pilot at Shasta Community Health Center to improve the rate of Well Child visits. The data is promising in regards to direct member outreach and an incentive for children to get their well-check visits.

We are about 54% compliant with our interim NCQA survey requirements. Our goal is to be at 100% by the end of the fiscal year. Big focus items include delegation oversight and NCQA analytic requirements. There are also new NCQA standards on population health management strategy that we are working on.

Statistics on the Patient Safety volume in terms of Potential Quality Issue (PQI) and site review are included in the written report.

3. HealthPlan Update

Dr. Moore gave the HealthPlan update. From our board meeting in February, after the Affordable Care Act (ACA) there was a

confluence of factors plus the geographic expansion that led to a time of revenue exceeding expenses by quite a bit which is why we had our Strategic Use of Reserves (SUR) for several years. Currently, PHC is in the part of the cycle where you go below the breakeven line and we will be spending some of the reserves for regular operations this year. Our goal is to incorporate some of the increased expenses into our rates which will hopefully make us whole in approximately two years from now. The big dependency is how the state actuaries and what the assumptions will be in their calculations, as just a 1 or 2 % change in their assumptions could have a large impact on a big budget. We hope to get our rates in April and that will tell us if it’s a tolerable use of reserves or more worrisome rapid use. PHC does have enough reserves built up to last for a couple of years but we’d rather not use them all. PHC will continue with projects we are currently working on and will not be doing any major new spends or initiatives at this time.

Question was asked, what drives the cyclical nature of that and do we share historical data with them? Dr. Moore advised that part of the SUR were expenses that are being continued to expend and those will eventually be built into the rates, but it takes two years to build it in. Once they are built in, the revenue side will match. He also confirmed that yes, we do look at trends and share with the state. The California Children’s Services (CCS) Carve In, or the Whole Child Care program, is

scheduled to go live in January. This is the program that will carve in CCS in the 11 counties that are currently carved out. Should be seamless to front line providers but to PHC will be increase in staff and training to take on the roles.

Dr. Moore completed his series of four regional director meetings. One thing that came up in the Northern Region (NR) is the status of the CHDP PM 160 form. This was included in medical director’s newsletter, and basically for non-Partnership providers there is still a requirement for some type of documentation and every county is supposed to determine what that is and communicate it to the providers.

The state drafted the rates structure and regulations for Health Homes for patients with complex needs but they are not acceptable to PHC so we have pushed back with an explanation as to why they won’t work. There was conversation with the state but because of CCS and the drug Medi-Cal program and some other priorities, we can’t do them all at the same time. The earliest we would go live with Health Homes is July 2019. We remain committed to our extensive outpatient care management program and continue to support that and encourage its growth.

There was an impasse between CMS and DHCS on some key aspects of the alternate payment methodology which was passed into legislation a few years ago that could not be

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resolved. PHC received a message stating it’s unresolvable and the state will not move forward with it. PHC and some other plans are looking at an alternate way to test out that model of care using Healthplan funds but that will have increased expense. Conversations are taking place, and it appears that the pilot will not be as large of scale that the state was thinking about.

Comment from Ledra that an important notice dated 3/13/18 just went out regarding CHDP, and providers should be getting that in the mail soon. Dr. Moore asked if it a CHDP provider notice and Ledra confirmed that yes it was.


Utilization Management/Care Coordination: MCUP3017 - Health Services Review of Non-admission In-hospital Obstetrical Evaluations MCUG3023 - Infant Monitor Guidelines MCUP3052 - Medical Nutrition Services MCUG3058 - Utilization Review Guidelines ICF/DD, ICF/DD-H, ICF/DD-N Facilities MCUP3119 - Sterilization Consent Protocol MPUP3129 - Podiatry Services Discussion on policy MCUP3052: On page 36, the language about Obesity and Overweight is not easy to understand. Currently it reads: Greater than the 85th percentile weight for height OR BMI (>2 y.o.) using the appropriate growth chart for age (NCHS). This should be changed to reflect: Below age 2 use weight to height and Over age 2, greater than the 85th percentile of BMI.

The following policy was extracted from the Consent Calendar for discussion: MCUP3052. Motion to approve: Dr. Gwiazdowski Second: Dr. Quon The remaining polices were approved without changes. Motion to approve MCUP3052: Dr. Thomas Second: Dr. Murphy Approved with change to reflect: Below age 2 use weight to height and Over age 2, greater than the 85th percentile of BMI.

03/21/18

1. MCUP3106

Debbie McAllister reported on MCUP3106 found on page 55. On page 55, Section VI, Item A, added four additional Home and Community Based Services

(HCBS) Waiver programs. Most of these are limited and we don’t have members in them but we needed to add them to the policy per state guidelines.

On pages 57-58, Section VI, Item C, updated the referral information for the original three programs and added information on the four added programs.

On page 59, Section VII, updated the references.

What is a waiver program? Peggy confirmed it’s where there are state allocations for specific programs for a specific population of people and waives Medicaid program requirements under HCBS Waivers. In addition, Dr. Moore stated that the Pediatric Palliative Care Waiver Program expired last year and got a one year extension. We are still not sure what they will do with it. This does not change the policy, it remains in the policy as it’s currently still in place. What is the Assisted Living Waiver? Debbie confirmed that for PHC it is only in Sonoma County where there is special funding that can go to keep a patient housed there for up to a year without paying a copay. However, there are many rigid rules and as far as we know there are two beds in Sonoma County that allow the waiver program.

Motion to approve: Dr. Wilson Second: Dr. Quon Approved without changes

03/21/18

2. MCUP3131

Dr. Moore reported on MCUP3131 found on page 60. On page 60, Section IV, Attachment B has changed.

Motion to approve: Dr. Gwiazdowski Second: Dr. Quon

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On page 61, Section VI, Item C, added language about TAR overrides. On Attachment A, beginning on page 64, there are many changes due to new tests, and new

Medi-Cal rules. Dr. Moore discussed a few specific changes: o On page 65 regarding test 81162, included information about the ability to override the

once in a lifetime frequency. Specific language the state put out regarding this was added on pages 66-67.

o On page 71, a duplicate was removed for test 81211. o On page 78, 81280 and 81281 were removed and replaced with 81413 and 81414 found

on page 113. o On page 94, two items removed from test 81403. These were moved as they got their

own codes and are now on page 64. o On page 85, test 81528, the new standard is now every three years; therefore, the

frequency limit changed to state no more than once every two years. Is there any kind of requirement to prove that tests have not been done before? Dr. Moore confirmed that if the TAR is put in by the lab, and they are using the same lab it should come up. Debbie confirmed that if it requires a TAR, we do check in our system to see if it’s been done but we are limited to just the time they have been a PHC member. Post Meeting Note: Per Dr. Moore, MCUP3131 was pulled from the April PAC meeting as there were new updates per Operating Instruction Letter (OIL) and also changes in the Medi-Cal guidelines. Policy will be further updated and sent back to IQI and Q/UAC in April.

Approved without changes

3. MCUG3118

Peggy Hoover reported on MCUG3118 found on page 123. This policy started through committee in January but there were questions if the policy was referencing the most current version of the American College Obstetricians & Gynecologists (ACOG) perinatal guidelines. On page 125 all of the graphs that attempted to reproduce the guidelines were taken out and

stated for providers to follow the guidelines. Should the policy state that we are really saying we are basing it on the guidelines as of this moment? Dr. Moore advised that the policy is worded so that if the guidelines change, we don’t have to change the policy; Peggy confirmed this is the intent. Comment was made that it’s up to the providers to stay up-to-date on the guidelines.

Motion to approve: Dr. Montenegro Second: Dr. Gwiazdowski Approved without changes

03/21/18

4. MCUP3049

Debbie McAllister and Dr. Moore reported on MCUP3049 found on page 132. We updated the TAR request requirements to be consistent with our current one. On page 135 we changed Attachment A to state when the cumulative cost of items exceeds

$100 in a calendar. On page 143 Attachment B there was a change for codes 64490 to 64495. Previously, it was

not clear between initial injection and repeat injection. The first section is now initial injection and the second for repeat injections.


03/21/18

5. MCCD2012

Peggy Hoover reported on MCCD2012 found on page 145. Requesting approval to archive the Chronic Kidney Disease Program policy as we have

added it the Complex Case Management Program policy MCCP2007. Approval today is to archive MCCD2012. Policy MCCP2007 was provided as a reference to show that CKD was added there.

Motion to approve to archive: Dr. Quon Second: Dr. Swales Approved without changes

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V. Presentations 1. Inter Rater-

Reliability/TAR Timeliness

Debbie McAllister presented the Inter Rater-Reliability, TARs and Timeliness Data found on page 161. Page 161 is the physician review data and we have a 90% target range of passing and we had

one case that dropped to the 80th percentile that was reviewed by Dr. Moore. Page 162 is the inpatient data. July, August and September were deferred due to the

implementation of Essette. Ratings are all above the 90th percentile across the board. Page 163 is the outpatient data. Also deferred July, August and September due to Essette. We

were within our threshold of >90%, ranging from 96%-100%. Page 164 is the referral (RAF) volume, manual vs. electronic. We received over 100,000

referrals between July and December, the majority of them electronic. Page 165 is denied TARs by region. In the Northern Region, there was a total of 3,416 denied

with 1,174 being denied for medical reason, 1,162 being outpatient. Due to the high number we drilled down and looked at reports and found that about 77% were from one provider sending in for scans, CTs and MRIs that did not meet criteria. Will refer this to over/under utilization so that we can drill down more. In the Southern Region is was pretty benign. For both North and South we have TARS denied needing CCS authorization. Come January we may not see this as we will be CCS authorization and denying it doesn’t mean it didn’t get paid.

Page 166 is all TARs completed, we had a total of 99,275 combined inpatient and outpatient. Dr. Thomas asked if there is any kind of follow up to see what happened to those patients with the TARS denied due to scans, etc. Debbie confirmed she is working with Carly in the north to research this and are trying to determine if they could be repeat requests.

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2. 2016-17 Hospital Quality Incentive Program Evaluation

Amy Lasher provided a presentation on the 2016-17 Hospital QIP Evaluation found on page 183. The goal of the Hospital QIP is to assess the performance of our hospitals and also to identify

areas of improvement. There are 26 hospitals participating, out of 37 in our network and this is our 5th year of the

Hospital QIP. The purpose is to improve the health outcomes of our members and to help participating

hospitals assess the quality of care provided to their patients. There were nine measures in the program. Large hospitals are measured on all nine measures,

small hospitals on just two. Considerations to keep in mind is that our participants have changed and grown over the

years, starting with six participants in 2012-12 and 26 participants in 2017-18. Any changes in performance that are in this evaluation could be due to the additional hospitals alone rather than a change in performance year to year.

Performance graphs are on pages 190 and 191 and data shows that performance has either improved or remained stable over the years. Once exception is Exclusive Breast Milk Feeding (EBMF), we saw a slight dip due to new participants added; however, we are still above the California average. There also appears to be a spike in Elective Delivery, but this is attributed to incorrect data being submitted. After drilling down on the data, we reached out to two hospitals that had most of the elective deliveries and one hospital submitted a correction, which lowered our aggregate. There still was a slight increase, but this increase is attributed to the increase in the number of hospitals participating.

At least 70% of the hospitals met full point targets for 8 out of 9 of the measures.

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On page 194 we did some performance by hospital characteristics. There is some disparity between small and large hospitals. Small hospitals are performing a little less that large hospitals and we are trying to mitigate that by creating separate measurement sets and adjusting our measures based on the differences we have seen.

We will focus on improving the quality of data collected, will work with our partners to get data directly from them to improve our data.

We will work to increase engagement and guide hospitals in the QI efforts. Dr. Quon asked why our hospital QIP is so maternal/child health heavy. Dr. Moore confirmed that about 40% of our members are children and our number one admission is childbirth. The other factor is just finding good adult measures and many times with the adult measures they have tiny denominators and it’s hard for us to make those measures especially in the smaller hospitals. He also advised that when we introduce our measurement set recommendations a few outpatient measures have been added to help provide balance, and next year there are some additional non-clinical measures. Jessica Thacher, Director of QI/PI added that we are working on measure development and we are always thinking about next year’s measures and asked if anyone has ideas about measures that they feel would be appropriate to please let us know. Dr. Quon advised that they have looked at the standardized infection ratio. Amy advised we did look at sepsis rates and although it’s publicly reported we had a challenge in establishing a baseline as the publicly available data had a two year lag, and we didn’t think it was appropriate to hold hospitals to a baseline established with two year old data. Dr. Katz commented about the classification of the hospitals, and that the physical size of the hospital makes sense but from Partnership’s point of view as a payer, should we classify hospitals by how much service they provide to our members as this may help focus incentive directives. Dr. Moore confirmed that they have to be a hospital in our region to be considered for the QIP. Dr. Murphy commented that potentially a measure could come off if it doesn’t continue to be a meaningful measure, such as advance care planning that has a 99.3% rating. Dr Moore confirmed that it did come off for the current year and clarified that the numbers in this presentation were for the prior year. Dr. Gwiazdowski commented that there are measures that fold into star ratings that hospitals are actually measuring. Is it worth considering some of these? Amy captured the suggestions and confirmed that both Dr. Quon and Dr. Gwiazdowski are available to have offline conversations regarding their suggestions.

3. 2016-17 Primary Care Provider Quality Incentive Program Evaluation

Qi Yao provided a presentation on the 2016-17 PCP QIP Evaluation found on page 199. The PCP QIP offers financial incentives, data resources and technical assistance to PCPs who

serve our members so that we can we can make significant improvements. For the review period, July 1, 2016 to June 30, 2017 we had 222 providers participating, with

30 measures and paid $36 million, and average points of 65.5. There showed a stability in the percent of providers meeting the 90th percentile target. There

was a modest increase in the percent of providers meeting the 75th percentile target. Large practice size and family practice correlate with better program performance/higher Per

Member Per Month (PMPM).

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The average point earnings is consistent year over year. Northern Region showed improvement over 15-16 and performed slightly better than the Southern Region.

Based on our findings we do believe that the PCP QIP does improve care. Many measures show improvement over time.

We also look at provider experience and 95% of the participants agreed that QIP does improve patient care, and 100% are satisfied with the program.

Significant program changes were made effective 1/1/18 which are supported by 16-17 program year results, and no measures are ready for retirement based on high performance.

We will consider slow changes to the patient experience which includes the CAHPS survey findings and also the readmissions and admissions targets in the future.

Dr. Moore discussed the slide on page 211 about the measure for Controlling High Blood (CBP) Pressure. The addition of CBP to the family practice measurement set correlated with improved HEDIS rate. The CBP performance in QIP increased in 2016-17. Dr. Moore commented that the state had noticed the increase in our 2017 HEDIS Reporting Year, we believe this is attributed to the CBP measure added to the family practice measurement set. Do we know what contributed to the drop in the northwest rating? Dr. Moore advised it could

be due to fact that this was a sampling of charts and the majority was from one provider. Rachael confirmed we are watching this measurement closely this year.

Is there some effort to gather the best practices that successful practices use and look at those that did not get high percentiles? Rachael confirmed they were and that we were surprised to see those rates considering the active engagement and the work the NR was involved with. Dr. Moore advised that there multiple ways that we do share/highlight high performers including regional directors meetings and newsletters. Rachael confirm that we did review the charts and it wasn’t that the members weren’t being seen, it was just that the most recent blood pressure taken was out of control as HEDIS looks at only the most recent taken and not the historical data in the chart.

Does this take into account home blood pressure readings? Dr. Moore confirmed that NCQA standard does not allow home blood pressure readings.

Are we able to make phone calls to members to remind them to take or pick up their medications? Dr. Moore confirmed that we do have something set up in our pharmacy system for it a patient is not picking up their medication on time it will generate an automated phone call to remind them. This is not a live nurse call; the live nurse calls were for people who specifically needed lab tests.

Dr. Quon suggested that the charts on page 202, which represent the providers that meet either the 90th or 75th percentile, would be better represented as a bar graph. This may be visually easier and could combine the slides into one. Dr. Swales asked how does PHC measures the nutrition and physical activity counseling listed on page 209? Rachael confirmed PHC uses documentation in the chart, such as handouts about physical activity or safety, and also that this is just for well-child; it does not apply to adults.

VI. Additional Business The discussion topic was deferred to the April meeting due to time constraints.

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Committee: Internal Quality Improvement (IQI) Meeting

Date/Time: Tuesday, February 13, 2018| 1:30 PM - 3:30 PM Board Room, 3rd Floor

AGENDA ITEM DISCUSSION / CONCLUSIONS RECOMMENDATIONS / ACTION

TARGET DATE

DATE RESOLVED


Dr. Robert Moore called the meeting to order at 1:30 p.m. Minutes from the 01/09/2018 IQI meeting were reviewed.

Motion: Mary Kerlin Second: Peggy Hoover Approved without changes.

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II. Standing Agenda Items

1. Status of Open Action Items

Rachael French responded to the timeline concerning the interim Group Needs Assessment (GNA). DHCS requires PHC to conduct a GNA every five years. Per NCQA, we have identified the need for an interim GNA. The Network Adequacy Team goal and the Cultural and Linguistics Workgroup are actively working on this. Once a timeline is established, it will be

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Members Present: Becerra, Eric, Grievance and Appeals Resolution Manager Bjork, Sonja, JD, Chief Operating Officer Boyd-Anderson, Rebecca, Director of Care Coordination Cabrera, Maria, Member Services Lead Representative Chancellor, Jennifer, Northern Region Administration, Regional Manager Endsley, Scott, MD, Associate Medical Director French, Rachael, Senior Manager Quality Compliance and Accreditation Hoover, Peggy, RN, Senior Director, Health Services Kerlin, Mary, Senior Director of Provider Relations

Kubota, Marshall, MD, Regional Medical Director Leung, Stan, Pharmacy Services Director McAllister, Debra, RN, Director of Utilization Management Moore, Robert, MD, Chief Medical Officer Russell, Joan, Senior Manager of Provider Education Santos, Rose, Manager, Quality and Patient Safety Scuri, Lynn, Regional Director Siblisky, Susanna, Northern Region Health Educator Steffen, Nancy, Northern Region Associate Director of QI, Analytics, PMO Thacher, Jessica, MPH, Director, QI/PI Turnipseed, Amy, Senior Director of External and Regulatory Affairs

Guests: Enos, Mary, Associate Director of Enrollment Garnick, Karen, Administrative Assistant Hoerber, Ely, Program Manager Hoffman-Spector, Sharon, Team Manager, UM Kaufer, Jennifer, Manager of Performance Improvement

Leslie, Liz, Program Manager Robinson, Gary, Compliance Oversight Manager Stevenson, Lauri, Manager of QI Performance Improvement Thomas, Andrea, Communications Coordinator Wurden, Meredith, Associate Director of Finance Policy

Members Absent: Cotter, James, MD, Associate Medical Director Cuellar, Dina, Director Regulatory Affairs Frederickson, Paula, Senior Claims Director Fronefield, Carly, Northern Region Health Services Director Garcia-Hernandez, Margarita, Manager of Health Analytics Gibboney, Elizabeth, MA, Chief Executive Officer Glickstein, Mark, MD, Associate Medical Director

Guillory, Ledra, Senior Director Provider Relations Gutierrez, Araceli, Member Services Supervisor Netherda, Mark, MD, Regional Medical Director Ribordy, Jeff, MD, Regional Medical Director Rosel, Melissa, Team Manager, Utilization Management Sewell, Kelley, Director, Member Services, Provider Relations

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communicated to the Committee. This is a first survey requirement so there is time to establish due dates.


Jess Thacher gave the Quality Improvement update found on page 14. There were many recent changes to the Primary Care Provider Quality Improvement

Program (QIP). One major highlight includes systems build to support QIP. Our Northern Region QI team leads the production of our eReport system in partnership with IT. There is a concentrated effort in this area to get this program up and running with the 2018 Measurement Specifications. It is scheduled to launch 3/1/18.

The Partnership Quality Dashboard (PQD) is starting Module 4, which is the integration of the eReports data (the QIP clinical measures into the dashboard). Essentially, by integrating this data into the dashboard, it will allow us to do analytics on our eReports data.

The HEDIS audit is scheduled for 2/15/18 and the HEDIS medical record retrieval project is underway.

We are wrapping up our second cohort of our internal Performance Improvement Training called QI-Ex. Presentations will be given on 2/14/18 from the teams working on HEDIS related measures. This program was expanded to included Northern Region QI staff as well as Pharmacy personnel.

In terms of external opportunities, Better Health through Better Partnerships: How Health Centers Integrate Their Knowledge of the Community with the Delivery System will be hosted on 3/19. This symposium will showcase health centers who have shaped their medical practice and organizational structure around their community and community needs. On 3/7, the ABCs of Quality Improvement training will be held in Santa Rosa.

There is a lot of work centered around NCQA Accreditation. In the spring, an assessment of point earnings for interim accreditation will be conducted. In April, we will make a recommendation to the NCQA Steering Committee as to whether PHC would like to apply for interim accreditation.

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III. Old Business

There was no old business discussed.

IV. New Business (Committee Members as Applicable)

Consent Calendar Delegation Reports Credentialing/ Re-Credentialing

MCUP3013 (previously UP100313) - DME Authorization MCUP3104 - Major Organ Transplants MPUG3112 - Breast Magnetic Resonance Imaging (MRI) Guidelines MCUP3111 (previously MPUP3111) - Pulmonary Rehabilitation MPUP3018 (previously UP100318) - Health Services Review of Observation Code Billing MCUP3103 - Coordination of Care for Members in Foster Care MCCP2020 (previously MCUP3009; MPUG3009; UG100309) - Lactation Policy and Guidelines (formerly Breastfeeding Guidelines) MCCP2021 (previously MCUP3100) - Women, Infants and Children (WIC) Supplemental Food Program MC340 - Continuation of Insurance Premium (CIP) MPCR6A - Initial Credentialing Requirements for Non-Physician (Allied Health) Practitioners MPCR13 - Credentialing of Pain Management Specialist MPCR16 - Lactation Consultant Credentialing Policy MPPRPLCR401A - Initial Credentialing Document Collection, Review, and Verification for

Policy MCQP1021 was extracted from the Consent Calendar for further discussion by Lauri Stevenson. IQI Consent Calendar Motion to approve: Peggy Hoover Second: Debbie McAllister The remaining policies were approved without changes. In policy MCQP1021, an additional attachment needs to be added under Section IV. Attachments, Item C, to

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Behavioral Health Practitioners MCQP1021 (previously QP100121) - Initial Health Assessment and Behavioral Risk Assessment MCQP1052 - Physical Accessibility Review Survey - SR Part C MPQP1055 (previously CMP36) - Provider Preventable Condition (PPC) Reporting CGA024 (previously CGA-003; Health Services [HS] MCQP1034; Member Services [MS] policy #300) - Medi-Cal Member Grievance System

represent the threshold language of Tagalog. Motion to approve: Debbie McAllister Second: Peggy Hoover Approved with change.

1. MPXG5009 Rebecca Boyd Anderson presented on policy MPXG5009 found on page 178. The changes in the policy clarify timelines.

Motion to approve: Debbie McAllister Second: Peggy Hoover Approved without changes.

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2. ADM38 Dr. Moore presented on policy ADM38 found on page 189. This is an administrative policy on the development structure of policy and procedures. All

Administrative Assistants and those involved in policy writing should review. Attachment B features a template for policies outlining detailed instructions when creating a

policy. It also outlines a numbering system for policies and procedures by department and spacing guidelines.

Attachment C outlines how policies flow through Committees. Attachment D indicates the DHCS approval process. Attachment E outlines the retention duration of policies. Attachment F is the Synopsis of Changes form for Discussion Policies. Rachael French added the following points: Desktop procedures should not be part of attachments when sending an external policy

through for review. In the reference section, the Practioner’s Manual has now been changed to Provider Manual. If there are links within a policy, it is important to validate the links and then update the

accessibility date accordingly.

No voting required. 2/13/18

3. MPUP3026 Debbie McAllister reported on policy MPUP3026 found on page 231. This policy was revised to meet NCQA standards. On page 231, language was revised to reflect the percentages and numbers of how many

inter-rater reliabilities are conducted and how often they occur. UM Nurse Coordinator was changed to Nurse Coordinator.

On page 232, Section VI, Item B-3b, language was revised to reflect each selected TAR will be audited by a clinical staff member who is a licensed employee in a non-supervisory role.

Motion to approve: Peggy Hoover Second: Rebecca Boyd Anderson Approved without changes.

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4. MPHP8001 Susanna Sibilsky reported on MPHP8001 found on page 239. On page 240, Section VI, Item B-6, language was added to include national origin, disability and sex as components of the demographics description. On page 240, Section VI, Item B-8, language was added to reflect health education materials are available in other languages upon the request of the member. On page 241, Section VI, Item B-9, language was added to reflect the finding from the GNA as well as other internal and external data sources are utilized to guide the development and implementation of health education interventions. On page 242, Section VI, Item B-20, reflects the change of MMCD to the Managed Care Quality and Monitoring Division (MCQMD) of DHCS. On page 242, Section VII, Item A, Policy Letter 10-012 was updated to Policy Letter 17-002. This will need to be modified again from Policy Letter 17-002 to All Plan Letter.

Motion to approve: Peggy Hoover Second: Dr. Kubota Approved with change.

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5. MPHD8002 Susanna Sibilsky reported on MPHD8002 found on page 304. On page 305, the first paragraph now includes PHC’s member portal as a component of

health education program. On page 306 and 307, in the Goals section, references were added to reflect the Interim PHC

GNA that is conducted in between the state mandated GNA occurring every five years. On page 307, language was added to the Referral to Health Education Program section so it

includes the Member Portal and includes a link to the Health Education page on PHC’s website.

On page 310, under the Program Review and Evaluation section, the change was made from DHCS MMCD to the Managed Care Quality and Monitoring Division (MCQMD) of DHCS and the due date of the C&LHE work plan was changed from May 30 to December 31.

Dr. Moore suggested the following changes: On page 309, under Oversight, Provider Advisory Committee should be changed to

Physician Advisory Committee (PAC). On page 306, under Goals, an internal comment needs to be deleted. Rachael French commented on the following: On page 310, under Oversight, should Program Evaluation be added as part of the review

process? The Committee agreed the Program Evaluation should be reviewed semi-annually at CLHEC, IQI, and Q/UAC.

Jennifer Kaufer commented on the following: It appears the committee is being referenced differently throughout the policy, CLHEC and

C&LHE. A global search will be conducted to align terms.

Motion to approve: Joan Russell Second: Mary Enos Approved with changes.

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6. MPXG5008 Dr. Moore reported on policy MPXG5008 found on page 311. On page 312, language was modified to recognize the services and responsibilities of

Primary Care Providers (PCP), pain management specialists, and other specialists caring for members with chronic pain. The PCP is ultimately responsible for coordinating the services.

On page 313, the Opioid Prescribing Guidelines for Physicians were revised to offer non-opioid medications.

Motion to approve: Dr. Scott Endsley Second: Peggy Hoover Approved with no changes.

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7. CGA022 Eric Becerra reported on policy CGA022 found on page 347. On page 347, Section III, language was added describing the Adverse Benefit

Determination. Some of these definitions were updated to align with the Member Grievance policy for consistency. The Grievance Supervisor definition was added and the Lead Grievance Coordinator definition was updated.

On page 348, Section V, Item A, the word “language” was added with regard to discrimination.

On page 349, Section VI, Item B, language was added to identify the Grievance Supervisor as the designee.

On page 349, Section VI, Item D, language was changed from grievances must be submitted within 60 days to grievances can be submitted at any time.

On page 349, Section VI, Item E, language was modified to state grievances can now be made by calling Member Services in addition to written submissions.

On page 349, Section VI, Item K, 180 days was inadvertently deleted. It will be placed back in the policy.

Motion to approve: Debbie McAllister Second: Peggy Hoover Approved with change.

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8. MPQP1023

Jess Thacher reported on policy MPQP1023 found on page 353. The changes to this policy relate to NCQA standards and the DHCS APL on network certification. On page 353, Section III, Item A, the High-Impact Specialist definition now includes

oncology/hematology as a high-impact specialty type every year. On page 353, Section III, Item B, High-Volume Behavioral HealthCare Practitioner now

outlines how we identify our High-Volume Practitioner type. On pages 353 and 354, Section III, Items D, E and F, we now include DHCS’ definition for

rural, suburban or small, and urban or medium counties and outline the counties we serve within each definition.

On page 354, Section VI, Item A-1, language was added to indicate we will maintain an overall ratio of one physician to every 1,200 members.

On page 355, regarding the table entitled Geographic Distribution of Practitioners, Primary Care, the addition of Obstetrics/Gynecology was added as required by the APL.

On page 356, Item C, language was added stating PHC monitors geographic availability for additional specialty types defined by DHCS as Core Specialists.

On page 357, Item E, the featured table identifies the geographic distribution for specialty care. All of the specialty types are listed and the geographic distribution standard. It is also noted to indicate if the provider is high-volume specialty type or high-impact specialty type.

On page 359, standards for pharmacy and hospital access were added as required by the APL.

On page 360, performance goals were added around appointment wait times as NCQA requires analyses indicating performance level relative to goal.

On page 360, Item C, language was added to specify office hours and telephone access standards for primary care practitioners.

One page 361, Item D, language was added to include requests for utilization of out-of-network services.

Mary Enos commented on the following: On page 355, the second column of the table entitled Geographic Distribution of

Practitioners, Primary Care, lists “1 within 10 miles or 30 minutes from the member’s residence” for PCP’s and “1 within 30 miles or 60 minutes from the members’ residence” for Family Medicine/General Practitioner. It seems conflicting.

Jess Thacher responded DHCS has the overall Primary Care standard, which is reflective of the 1 within 10 miles or 30 minutes from the member’s residence. NCQA requires us to set standards for sub-specialty (family medicine, pediatrics, and internists). As an example, a member could be within 10 miles of a family practice provider but the member is within 30 miles of a pediatrician. We look at how close a member is to a primary care overall and then we look at how close a member is to a sub-specialist of primary care.

It was decided this table should include a disclaimer explaining the difference between the DHCS standard and that of NCQA.

Rachael French commented: On page 362, Section VII, Item B, “PHC Provider” should be removed. Item C,

“Practitioner Manuals” should be changed to “Provider Manuals”. On page 353, Section I, Item B, the Delegation Oversight Policy is referenced. This is still

being drafted so should not be listed.

Motion to approve: Mary Enos Second: Peggy Hoover Approved with changes.

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Stan Leung commented: On page 360, 5. Access to Pharmacy, language should be changed from, “the greater of 24

hours or one business day response,” to “within 24 hours.” 9. MPQP1006 Dr. Moore reported on policy MPQP1006 found on page 373.

The only change to this policy was the removal of the reference to NCQA requirements as NCQA removed the clinical practice guidelines criteria in 2018.

Motion to approve: Dr. Kubota Second: Mary Enos Approved with no changes.

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10. Facility Site Review

Lauri Stevenson presented the Facility Site Review found on page 377. Facility Site Reviews (FSR) are conducted as part of credentialing and re-credentialing

purposes. It is a state mandate sites are able to show they meet safety and access standards. There are two components: FSR and Medical Record Reviews (MRR). The FSR portion

looks at areas ranging from Access and Safety to Infection Control with an overall passing score of 80%. For the MRR, a random sample of members’ records are selected. The sample can range from 10 to 30 records depending on the number of PCPs at the site. An 80% overall score is required to pass. If any of the domains fall below 80%, a Corrective Action Plan (CAP) is required for the entire review.

Results from the period 7/1/17 - 12/31/17 for FSRs were as follows: SE - Slight decrease in infection control domain. SW - No significant changes were noted across all domains. NE - Some improvement was noted in personnel domain. NW - No significant changes were noted across all domains.

Results from the period 7/1/17 - 12/31/17 for MRRs were as follows: SE - No significant change noted in MRR. SW - No significant change noted in MRR. NE - Noted increase in pediatric preventive screening, as well as adult preventive

screening. NW - Significant increase in documentation domain.

Nurses conducting reviews agree there is a need to continue to educate on the IHA and the SHA. Adult immunizations are often lacking, as well as pap smears. Advanced Healthcare Directives continue to be low scoring, especially in young adults. Preventive health is one of the most discussed subjects on reviews and cause the majority of CAPs.

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11. Physical Accessibility Review Survey (PARS)

Lauri Stevenson presented the Physical Accessibility Review Survey (PARS) found on page 381. The purpose of the PARS is to assess the physical accessibility of provider sites using a set

of standards approved by DHCS. There were a total of 104 Part C surveys conducted during the time period 1/1/17 to

12/31/17. There are two levels upon which a provider’s site will be identified as, which include basic and limited access, in addition to medical equipment access. Of the 104 surveys, the following scores were derived: Basic Access: 35; Limited Access: 69; Medical Equipment: 18. The accessible weight scale was the main item that caused most providers to be assessed at the Limited Access Level. Other common findings included adjustable exam table and restroom fixtures in older buildings.

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12. 2016 Beacon Audit Report

Gary Robinson presented the 2016 Beacon Audit Report found on page 383. The delegation oversight audit for Beacon Health Systems was conducted in accordance

with the NCQA 2017 standards as well as DHCS contractual standards and covered the period of 1/1/16 through 12/31/16.

Motion: Debbie McAllister Second: Peggy Hoover Approved with changes.

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The audit was an evaluation of eight primary elements of performance: (1) Grievances and Appeals; (2) Member Services; (3) Care Coordination; (4) Utilization Management; (5) Quality Improvement; (6) Credentialing; (7) Health Education and Linguistic Services; and (8) Claims. A CAP was recommended for each element with a rating that fell below 95%.

Element 1 - Grievance and Appeals. This element received a rating of 100%. Element 2 - Member Services. This element resulted in a rating of 38%. A CAP was issued

but upon further documentation provided by Beacon, it was resolved and removed. Element 3 - Care Coordination. Element 3 received a rating of 88%. A CAP was issued but

upon further documentation provided by Beacon, it was resolved and removed. Element 4 - Utilization Management. This element covered 13 subcategories and two

deficiencies were found: Timeliness of Utilization Decisions. However, the overall performance rating for this element was 94% and a CAP was not recommended. This area will continue to be monitored and will be reviewed again during the next audit period.

Element 5 - Quality Improvement. This element received a rating of 100%. Element 6 - Credentialing. This element received a rating of 100%. Element 7 - Health Education and Linguistic Services. This element received a rating of

100%. Element 8 - Claims. This element received a rating of 50%. A CAP was issued but upon

further documentation provided by Beacon, it was resolved and removed. Mary Kerlin commented: Access and availability needs to be added to this audit. Rachael French commented: On page 386, in the first sentence under Scope, “and DHCS” needs to be added after NCQA

standards. VII. Additional Business

Respectfully submitted by Andrea Thomas, Quality Improvement Communications Coordinator Signature of Approval: ____________________________________ Date: ______________________________ Robert Moore, MD, MPH, MBA Chairman

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QI Department Update

March 2018 Prepared by Jess Thacher, Director of Quality and Performance Improvement

Quality Improvement Programs (QIPs) • The 2018 PCP QIP Measurement Set webinar was held on 2/6. There were 38 attendees. • 2018 eReports launched on 3/1 and will offer a demo webinar on 3/14. All eReports usernames and

secret keys are being re-set in order to eliminate separate log-in credentials for provider organizations with multiple sites.

• Partnership Quality Dashboard Module 1 (non-clinical QIP measures) is in the process of loading 2017 Transition Period data to the dashboard. The development team is evaluating data against the Business Requirement Document for Module 4 (eReports/QIP clinical data). A PQD Module 1 Kick-Off webinar is scheduled for 3/22. Following this webinar, providers will be able to access their non-clinical QIP data through PQD.

• The 2018 Palliative Care QIP webinar was held on 2/21. Seven of eight palliative care provider sites attended the webinar.

• Based on 2016-17 evaluation findings, the Hospital QIP team is exploring an opportunity to streamline maternal quality data collection by working directly with the California Maternal Quality Care Collaborative to retrieve data.

• The 2018 LTC QIP Kick-Off webinar was held on 2/14 with about 30 participants. Four additional long-term care facilities have agreed to participate in the 2018 LTC QIP, bringing the total to 68 sites out of 74 contracted with PHC.

• Comprehensive Perinatal Service Providers (CPSP) have until 3/31 to sign up to participate in the Perinatal QIP. The Kick-Off webinar was held on 2/28. PHC will host an in-person meet-and-greet sessions on 3/20 in Fairfield and 3/21 in Redding for sites to learn more about the program.

Healthcare Effectiveness Data Information Set (HEDIS) • The HEDIS 2018 On-Site Audit was completed on 2/15. The On-site Audit is a required HEDIS activity

conducted by our HSAG auditor to validate the accuracy and completeness of our data. Overall, the auditor was pleased at the progress made over the last year.

• The medical record retrieval project is underway. Approximately 1,865 of 14,058 records have been retrieved and reviewed. We are on track to complete the Medical Record project by the NCQA audit deadline of 5/9.

Quality Improvement Trainings • ADVANCE teams will meet in March for the final in-person session to learn about what it means to

be an improvement advisor and how to develop a sustainability and spread plan. • An ABCs of Quality Improvement training will be held on 3/7 in Santa Rosa and on 5/3 in Redding. • In February, QI-EX teams, comprised of PHC QI and Pharmacy staff, presented their test projects

focusing on specific HEDIS measures. Pilot projects included: o Plan-led member outreach to improve MPM rates o Member incentives to improve childhood and adolescent immunization rates o Supplying data and education to select provider sites to improve AMR rates The PI team is in the process of evaluating the program and developing recommendations for next steps. Early learnings included – high efficacy of live calls to improve MPM rates; low member knowledge of importance of lab monitoring tests when taking ACE/ARBs or diuretics, significant impact from updating PHC member contact information with more accurate records from local pharmacy.

• PHC will host a conference on 3/19, Better Health through Better Partnerships: How Health Centers Integrate Their Knowledge of the Community with the Delivery System. This symposium will showcase health centers who have shaped their medical practice and organizational structure around their community and community needs.

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HEDIS Score Improvement – Highlights • The PI team is assisting with two HEDIS improvement projects in the Southwest region focused on

member outreach, including a cervical cancer screening (CCS) media campaign in Lake and Mendocino Counties and a breast cancer screening (BCS) outreach pilot in Marin County. The CCS media campaign is anticipated to launch in April and run through June 2018. The BCS member outreach effort is under development with our clinic partner.

• Four new, local Advance Care Planning (ACP) coalitions were selected to receive grant funding from PHC. Coalition for Compassionate Care of California was engaged as a contractor to provide training and technical assistance to the new coalitions. The selected ACP grantees will receive 18 months of financial, leadership, educational, mentorship, and logistical support to enhance and expand advance care planning in their communities. The new coalitions include: o Humboldt County Advance Care Planning Coalition (HumACP) o My Life. My Way, Lake County Coalition for Advance Care Planning o Siskiyou ACP Coalition “Let’s Talk” o Yolo Coalition to Honor Choices (YCHC)

• Monitoring Patients on Persistent Medications (MPM) PDSA Cycle II for Santa Rosa Community Health Center was submitted to DHCS on 2/16. This highlighted two PDSAs testing patient outreach from 10/1/17-2/16/18. The outreach efforts included live phone calls and mailers, and the interventions were very successful. For the final PDSA cycle (February - June 2018), the clinic will continue to test outreach with an expanded sample size.

• PHC coordinated a Humboldt County Immunization focus group meeting on 3/2. The goal of the meeting was to gather perspective, barriers, and experiences to further improve activities in the Northwest region.

• The Birthday Club pilot at Shasta Community Health Center (SCHC) to improve the rate of Well Child Visits for 3-6 year olds recently concluded. The total number of children targeted was 222. Of the 222 children targeted, 130 were successfully reached. From October through December 2017, a total of 80 members (36.04%) completed exams and received gift cards. Based on these results, Shasta Community was just 1.04% short of hitting the SMART objective goal of a 15% improvement. PHC and SCHC met in February to adopt and expand this pilot across all SCHC sites for April through June 2018. At the same time, PHC and SCHC initiated brainstorming and planning meetings to apply lessons learned for a new intervention targeting the Childhood Immunization (CIS-3) measure. This measure is below MPL in the Northeast.

• With PHC strategic use of reserves funding, Shasta Family YMCA is providing a yearlong Diabetes Prevention Program to decrease the percentage of new Type 2 Diabetes diagnoses. This program will run September 2018 through August 2019. This effort serves as a precursor to the anticipated Diabetes Prevention Program Medi-Cal benefit in 2019.

Quality Compliance and Accreditation • As of 2/22, PHC is 54% compliant with Interim NCQA Survey Requirements. • The Program Management Team will share a plan-wide readiness assessment in April. The purpose

of this is to evaluate where PHC stands relative to Interim Survey Compliance and obtain Executive approval to move forward with our application process.

• Grand Analysis discussion will be presented at the upcoming PRB in March to obtain priority within the organization and assign resources to it.

Patient Safety (1/25 – 2/26) • 30 Potential Quality Issue (PQI) referrals received; 13 PQI cases processed and closed; and 53 open

PQI cases. • 5 Facility Site Reviews (FSR) conducted and 6 Medical Record Reviews (MRR) conducted. • 1 FSR Corrective Action Plan (CAP) issued and 2 MRR CAPs issued.

81 of 233


New Assigned Number


Reminder - Effective January 2018, Approval Date reflects that of the Physician Advisory Committee’s meeting date.

Health Services – Care Coordination

Chronic Kidney Disease (CKD) Program Description

Archived

MCCD2012 Archived – Information included in MCCP2007

X

Health Services – Utilization Management

Health Services Review of Non-admission In-hospital Obstetrical Evaluations (Solano County)

MCUP3017 Regular review; no changes to policy content

X

Infant Monitor Guidelines MCUG3023 Regular review; no changes to guideline content

X

Medical Nutrition Services Attachments: no changes

A. Referral Guidelines for Children/ Adolescents

B. Referral Guidelines for Adults C. Adult Body Mass Index


X

Utilization Review Guidelines ICF/DD, ICF/DD-H, ICF/DD-N Facilities Attachment: unchanged

A. Bed hold/TAR Process

MCUG3058 Regular review; language corrections added for clarity (specification of calendar or business days)

X

Sterilization Consent Protocol Attachment: no to policy

A. DHCS Form PM 330 – Consent Form

MCUP3119 Regular review; language corrections added for clarity (specification of calendar or business days)

X

Podiatry Services MPUP3129 Regular review; no changes to policy content

X

Waiver Programs MCUP3106 Regular review: Extensive updates vs. DHCS contractual obligations – addition of 4 descriptions - HCBS Waiver Programs, referral information updated; Federal citation removed (not the HealthPlan’s obligation); References updated

X

Prenatal & Perinatal Care MCUG3118 Regular review; language clarifications added; references regarding provider referrals of pregnant women to PHC’s Growing Together Perinatal Program updated to PHC’s Care Coordination Dept. for ongoing support; section qualifying Requirements removed – Amer. College of Obstetricians & Gynecologists (ACOG) and Comprehensive Perinatal Services Program (CPSP) Program Guidelines should be followed

X

PHCSystem Updates

April2018

Approval Date / May 2018

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New Assigned Number


Pain Management Specialty Services Attachments: updated

A. PHC Treatment Auth. Request Requirements

B. PHC Medical Necessity Criteria for Pain Management Procedures


Attachments A & B updated

X

83 of 233


POLICY / PROCEDURE

Page 1 of 5

Policy/Procedure Number: MCUP3106 Lead Department: Health Services

Policy/Procedure Title: Waiver Programs ☒External Policy

☐ Internal Policy


Last Review Date: 11/16/201604/11/2018

Applies to: ☒ Medi-Cal ☐ Healthy Kids ☐ Employees

Reviewing

Entities:



Approving

Entities:





A. County specific Regional Center MOUsMemoranda of Understanding (MOUs) for specific geographical

areas

II. IMPACTED DEPTS:

A. Health Services

B. Claims

C. Member Services

III. DEFINITIONS:

A. HCBS: Home and Community Based Services

B. DHCS: Department of Health Care Services

C. IHO: In-Home Operations Waiver

A.D. DDS: Department of Developmental Services N/A

IV. ATTACHMENTS:

A. N/A

V. PURPOSE: State and Federal Waiver Programs ensure members who may benefit from Medi-Cal Home and Community

Based Services (HCBS) Waiver Programs are identified and referred for medical care coordination and care

management.


A. The Department of Health Care Services (DHCS) administers a number of HCBS Waiver Programs.

These waiver programs include:

1. In-Home Operations Waiver (IHO)

2. Human Immunodeficiency Virus/Acquired Immune Deficiency Syndrome (HIV/AIDS) Home and

Community Based Services Medi-Cal Waiver Program

3. Home and Community Based Services Waiver for the Developmentally Disabled

4. Assisted Living Waiver (ALW)

5. Home and Community-Based Alternatives (HCB Alternatives) Waiver (previously titled Nursing Facility/Acute Hospital Waiver

6. Multipurpose Senior Services Program (MSSP) Waiver

3.7. Partners for Children (PFC) Pediatric Palliative Care (PPC) Waiver Program

Partnership HealthPlan of California (PHC)’s providers and/or its Utilization Management (UM)/Care

84 of 233


Policy/Procedure Title: Waiver Programs ☒ External Policy

☐ Internal Policy


Last Review Date: 11/16/201604/11/2018


Page 2 of 5

Coordination staff identify and refer members who are eligible for Waiver Programs. Members are not

disenrolled from PHC when enrolled in a waiver program.

B. Criteria Used For Identification

1. The Primary Care Provider (PCP), Specialist, and/or PHC Care Coordination/ Utilization

Management Departments refer members to Waiver Programs.

2. Persons with developmental disabilities are identified through coordination with the regional centers

and in the course of utilization and case management services. Members with developmental

disabilities who may meet the requirements for participation in this waiver are referred to the HCBS

administered by the State Department of Developmental Services (DDS).

C. Referrals

1. The PCP requests prior authorization for services from the appropriate State Waiver Program and

provides all appropriate medical information. The PCP may request assistance from the Care

Coordination department for the following:

a. Facilitating authorization from appropriate Waiver Program(s)

b. Completion of the Waiver Program application

c. Follow up on status of acceptance to appropriate Waiver Program(s)

d. Medical care coordination of member while awaiting acceptance and/or placement into a

Waiver Program

Note: No member may be enrolled in more than one HCBS Waiver Program at a time.

PHC maintains the responsibility to provide comprehensive care management and authorize all

medically necessary covered services for members including those accepted into the Waiver

Programs. The PCP will continue to treat and coordinate treatment for the member.

2. Referrals for the In-Home Waiver Program are made via telephone or mail:

In-Home Operations SectionBranch

1501 Capitol Avenue

MS 4502

P.O. Box 942732, 97437Mail Stop 4502

Sacramento, CA 95899-74374234-7320

(916) 552-9105 in Sacramento

(213) 897-6774 in Los Angeles

Fax: (916) 552-91459149

3. Referrals toFor the HIV/AIDS Home and Community Based ServicesMedi-Cal Waiver Program

(MCWP)m, patients should be referred to a MCWP Provider in their county (or if their county does

not have an MCWP are made by requesting a HIV/AIDS Waiver Program Application

from:provider, they may be referred to a nearby county that participates in the MCWP). A list of

MCWP Providers can be found here: https://www.cdph.ca.gov/Programs/CID/DOA/CDPH%20Document%20Library/MCWPProviderList.pdf

Information for the AIDS Medi-Cal Waiver Program is posted on this website:

https://www.cdph.ca.gov/Programs/CID/DOA/Pages/OA_care_mcwp.aspx

Through this waiver program, local agencies provide home and community based services as an alternative to nursing

facility care or hospitalization. The agencies are under contract with the

California Department of Health ServicesCalifornia Department of Public Health

Office of AIDS

Community-Based Care Section

MS 7700

P.O. Box 997426

Sacramento, CA 95899-7426

(916) 449-5900

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https://www.cdph.ca.gov/Programs/CID/DOA/CDPH%20Document%20Library/MCWPProviderList.pdf

https://www.cdph.ca.gov/Programs/CID/DOA/Pages/OA_care_mcwp.aspx



☐ Internal Policy


Last Review Date: 11/16/201604/11/2018


Page 3 of 5

4. Referrals Members who may qualify for services through to the Persons withthe Home and

Community Based Services Waiver for the Developmentally Disabledilities who may qualify for

services are referred to the Regional Center responsible for their geographic area as followsor to:

a. Alta California Regional Center (provides services in Yolo county)

2241 Harvard Street, Suite 100

Sacramento, CA 95815

(916) 978-6400

b. Far Northern Regional Center (provides services in Lassen, Modoc, Shasta, Siskiyou and

Trinity counties)

1900 Churn Creek Road

Redding, CA 96002

(530) 222-4791

c. Golden Gate Regional Center (provides services in Marin county)

4000 Civic Center Drive, Suite 310

San Rafael, CA 94903

(415) 446-3000

d. North Bay Regional Center (provides services in Solano, Napa, and Sonoma counties)

Solano/ Napa Sonoma

610 Airpark Road 2351 Mendocino Avenue

Napa, CA 94558 Santa Rosa, CA 95403

(707) 256-1100 (707) 569-2000

e. Redwood Coast Regional Center (provides services in Del Norte, Humboldt, Lake, and

Mendocino counties)

Del Norte Humboldt

1301-A Northcrest Drive 525 2nd Street, Suite 300

Crescent City, CA 95531 Eureka, CA 95501

(707) 464-7488 (707) 445-0893

Lake Mendocino

180 3rd Street 270 Chestnut Street, Suite A

Lakeport, CA 95453 Fort Bragg, CA 95437

(707) 262-0470 (707) 964-6387

Contact information for the State agency is as follows:

California Department of Developmental Services (DDS)

1600 9th Street

Sacramento, CA 95814

Mailing Address:

P. O. Box 944202


Info: (916) 654-1690

TTY: (916) 654-2054

5. The Assisted Living Waiver (ALW) program is only offered in certain counties. Sonoma County is

currently the only county which PHC serves that provides ALW services. A list of all participating

facilities can be found at this webpage:

http://www.dhcs.ca.gov/services/ltc/Documents/ListofRCFEfacilities.pdf

Additional downloadable forms related to the ALW program can be found at this website:

http://www.dhcs.ca.gov/services/ltc/Pages/Assisted-Living-Waiver-Provider-Resources.aspx

How to enroll: Medi-Cal members do not submit applications. Medi-Cal members are enrolled

through Care Coordination Agencies, which are providers within the ALW program. Full scope

86 of 233

http://www.dhcs.ca.gov/services/ltc/Documents/ListofRCFEfacilities.pdf

http://www.dhcs.ca.gov/services/ltc/Pages/Assisted-Living-Waiver-Provider-Resources.aspx



☐ Internal Policy


Last Review Date: 11/16/201604/11/2018


Page 4 of 5

Medi-Cal members must contact a Care Coordination Agency, which determines each individual's

care needs. Assessments are done by registered nurses employed by a Care Coordination Agency

(CCA). A list of these agencies by county can be found on this webpage:

http://www.dhcs.ca.gov/services/ltc/Documents/CareCoordinationAgencies2017.pdf

NorCal Care Coordinator Agency (Alameda, Contra Costa, Sacramento, San Francisco, San

Joaquin, San Mateo, Santa Clara and Sonoma Counties):

6060 Sunrise Drive, Suite 3350 Citrus Heights, CA 95610-7099

Debbie Brooke (916) 385-2784

Yolanda Nixon (925) 519-6100 FAX (916) 512-3473

Debbie Brooke and Yolanda Nixon, Owners [email protected] [email protected]

Assisted Living Waiver Program

Department of Health Care Services

Long-Term Care Division

1501 Capitol Avenue, MS 4503

PO Box 997437


ALW Hotline (916) 552-9322

6. The Home and Community-Based Alternatives (HCB Alternatives) Waiver (previously titled

Nursing Facility/Acute Hospital Waiver) provides care management services at home to Medi-Cal

beneficiaries with high level needs who would otherwise receive care in a facility. Some of the

services that may be provided to support Waiver participants in the community include, but are not

limited to: in-home nursing services, waiver personal care services, family/caregiver training, home

or facility respite, habilitation services, community transition services, environmental accessibility

adaptation, medical equipment operating expenses, personal Emergency Response System (PERS)

installation, testing, and operation. The application for the program can be found here:

http://www.dhcs.ca.gov/services/ltc/Documents/HCBA_Application.pdf

When complete, mail this application to the following address:

Integrated Systems of Care Division

HCBS Programs Eligibility/Intake Unit

311 South Spring Street, Ste. 800

Los Angeles, CA 90013

Or submit the application by FAX: (213) 620-4448

7. Referrals for the Multipurpose Senior Services Program (MSSP) Waiver program are made by

sending the Medi-Cal Member (who is 65 years or older) to a local MSSP site in the county

where the Member resides. MSSP site staff will make a certification determination based upon

Medi-Cal criteria. A list of MSSP sites can be found here:

https://www.aging.ca.gov/ProgramsProviders/MSSP/Contacts/

8. The Partners for Children (PFC) Pediatric Palliative Care (PPC) Waiver Program is offered in

participating counties as noted on this webpage:

http://www.dhcs.ca.gov/services/ppc/Pages/CCSProgram.aspx

Marin and Sonoma County are currently the only counties which PHC serves that participate. The

program offers supportive services for eligible children with life-limiting or life-threatening illnesses

and their families. These services are provided by local participating hospice and home health agencies. General information about PPC Waiver Program can be found on this web page:

http://www.dhcs.ca.gov/services/ppc/Pages/default.aspx

Members whose family may benefit from this program should talk to their PCP. The child’s doctor

will provide information about the child’s medical condition to the County CCS office. The CCS

87 of 233

http://www.dhcs.ca.gov/services/ltc/Documents/CareCoordinationAgencies2017.pdf

mailto:[email protected]

http://www.dhcs.ca.gov/services/ltc/Documents/HCBA_Application.pdf

https://www.aging.ca.gov/ProgramsProviders/MSSP/Contacts/

http://www.dhcs.ca.gov/services/ppc/Pages/CCSProgram.aspx

http://www.dhcs.ca.gov/services/ppc/Pages/default.aspx



☐ Internal Policy


Last Review Date: 11/16/201604/11/2018


Page 5 of 5

office will determine if the child is eligible and contact the family with more details and to set up a

meeting to talk about enrollment.

VII. REFERENCES: Regulatory: Title 22 California Code of Regulations (CCR) Section 1915 (c)

DHCS Contract: Exhibit A, Attachment 11, Provisions 11.C. and 15.A. and B. aAttachment 18, Provision

11.U and Exhibit A, Attachment 18, Provisions 11.M, S, and X.Attachment 11, Provision 9.C

VIII. DISTRIBUTION:

A. PHC Department Directors

B. PHC Provider Manual


X. REVISION DATES: 11/28/12; 01/20/16; 11/16/16; *04/11/18

*Through 2017, Approval Date reflective of the Quality/Utilization Advisory Committee meeting

date. Effective January 2018, Approval Date reflects that of the Physician Advisory Committee’s meeting

date.


*********************************

In accordance with the California Health and Safety Code, Section 1363.5, this policy was developed with

involvement from actively practicing health care providers and meets these provisions:

Consistent with sound clinical principles and processes

Evaluated and updated at least annually

If used as the basis of a decision to modify, delay or deny services in a specific case, the criteria will be

disclosed to the provider and/or enrollee upon request

The materials provided are guidelines used by PHC to authorize, modify or deny services for persons with similar

illnesses or conditions. Specific care and treatment may vary depending on individual need and the benefits

covered under PHC.

PHC’s authorization requirements comply with the requirements for parity in mental health and substance use

disorder benefits in 42 CFR 438.910.

88 of 233


POLICY / PROCEDURE

Page 1 of 5


Policy/Procedure Title: Waiver Programs ☒External Policy ☐ Internal Policy



Reviewing Entities:



Approving Entities:





Regional Center Memoranda of Understanding (MOUs) for specific geographical areas

II. IMPACTED DEPTS: A. Health Services B. Claims C. Member Services

III. DEFINITIONS:

A. HCBS: Home and Community Based Services B. DHCS: Department of Health Care Services C. IHO: In-Home Operations Waiver D. DDS: Department of Developmental Services

IV. ATTACHMENTS: A. N/A

V. PURPOSE: State and Federal Waiver Programs ensure members who may benefit from Medi-Cal Home and Community Based Services (HCBS) Waiver Programs are identified and referred for medical care coordination and care management.


A. The Department of Health Care Services (DHCS) administers a number of HCBS Waiver Programs. These waiver programs include: 1. In-Home Operations Waiver (IHO) 2. Acquired Immune Deficiency Syndrome (AIDS) Medi-Cal Waiver Program 3. Home and Community Based Services Waiver for the Developmentally Disabled 4. Assisted Living Waiver (ALW) 5. Home and Community-Based Alternatives (HCB Alternatives) Waiver (previously titled Nursing

Facility/Acute Hospital Waiver 6. Multipurpose Senior Services Program (MSSP) Waiver 7. Partners for Children (PFC) Pediatric Palliative Care (PPC) Waiver Program Partnership HealthPlan of California (PHC)’s providers and/or its Utilization Management (UM)/Care Coordination staff identify and refer members who are eligible for Waiver Programs. Members are not disenrolled from PHC when enrolled in a waiver program.

89 of 233


Policy/Procedure Title: Waiver Programs ☒ External Policy ☐ Internal Policy



Page 2 of 5

B. Criteria Used For Identification 1. The Primary Care Provider (PCP), Specialist, and/or PHC Care Coordination/ Utilization

Management Departments refer members to Waiver Programs. 2. Persons with developmental disabilities are identified through coordination with the regional centers

and in the course of utilization and case management services. Members with developmental disabilities who may meet the requirements for participation in this waiver are referred to the HCBS administered by the State Department of Developmental Services (DDS).

C. Referrals 1. The PCP requests prior authorization for services from the appropriate State Waiver Program and

provides all appropriate medical information. The PCP may request assistance from the Care Coordination department for the following: a. Facilitating authorization from appropriate Waiver Program(s) b. Completion of the Waiver Program application c. Follow up on status of acceptance to appropriate Waiver Program(s) d. Medical care coordination of member while awaiting acceptance and/or placement into a

Waiver Program Note: No member may be enrolled in more than one HCBS Waiver Program at a time. PHC maintains the responsibility to provide comprehensive care management and authorize all medically necessary covered services for members including those accepted into the Waiver Programs. The PCP will continue to treat and coordinate treatment for the member.

2. Referrals for the In-Home Waiver Program are made via telephone or mail: In-Home Operations Branch 1501 Capitol Avenue MS 4502 P.O. Box 997437 Sacramento, CA 95899-7437 (916) 552-9105 in Sacramento (213) 897-6774 in Los Angeles Fax: (916) 552-9149

3. For the AIDS Medi-Cal Waiver Program (MCWP), patients should be referred to a MCWP Provider in their county (or if their county does not have an MCWP provider, they may be referred to a nearby county that participates in the MCWP). A list of MCWP Providers can be found here: https://www.cdph.ca.gov/Programs/CID/DOA/CDPH%20Document%20Library/MCWPProviderList.pdf Information for the AIDS Medi-Cal Waiver Program is posted on this website: https://www.cdph.ca.gov/Programs/CID/DOA/Pages/OA_care_mcwp.aspx Through this waiver program, local agencies provide home and community based services as an alternative to nursing facility care or hospitalization. The agencies are under contract with the

California Department of Public Health Office of AIDS

(916) 449-5900 4. Members who may qualify for services through the Home and Community Based Services Waiver

for the Developmentally Disabled are referred to the Regional Center responsible for their geographic area as follows: a. Alta California Regional Center (provides services in Yolo county)

2241 Harvard Street, Suite 100 Sacramento, CA 95815 (916) 978-6400

90 of 233





Page 3 of 5

b. Far Northern Regional Center (provides services in Lassen, Modoc, Shasta, Siskiyou and Trinity counties)

1900 Churn Creek Road Redding, CA 96002 (530) 222-4791

c. Golden Gate Regional Center (provides services in Marin county) 4000 Civic Center Drive, Suite 310 San Rafael, CA 94903 (415) 446-3000

d. North Bay Regional Center (provides services in Solano, Napa, and Sonoma counties) Solano/ Napa Sonoma 610 Airpark Road 2351 Mendocino Avenue Napa, CA 94558 Santa Rosa, CA 95403 (707) 256-1100 (707) 569-2000

e. Redwood Coast Regional Center (provides services in Del Norte, Humboldt, Lake, and Mendocino counties) Del Norte Humboldt 1301-A Northcrest Drive 525 2nd Street, Suite 300 Crescent City, CA 95531 Eureka, CA 95501 (707) 464-7488 (707) 445-0893

Lake Mendocino 180 3rd Street 270 Chestnut Street, Suite A Lakeport, CA 95453 Fort Bragg, CA 95437 (707) 262-0470 (707) 964-6387

Contact information for the State agency is as follows: California Department of Developmental Services (DDS) 1600 9th Street Sacramento, CA 95814 Mailing Address: P. O. Box 944202 Sacramento, CA 94244-2020 Info: (916) 654-1690 TTY: (916) 654-2054

5. The Assisted Living Waiver (ALW) program is only offered in certain counties. Sonoma County is currently the only county which PHC serves that provides ALW services. A list of all participating facilities can be found at this webpage: http://www.dhcs.ca.gov/services/ltc/Documents/ListofRCFEfacilities.pdf Additional downloadable forms related to the ALW program can be found at this website: http://www.dhcs.ca.gov/services/ltc/Pages/Assisted-Living-Waiver-Provider-Resources.aspx How to enroll: Medi-Cal members do not submit applications. Medi-Cal members are enrolled through Care Coordination Agencies, which are providers within the ALW program. Full scope Medi-Cal members must contact a Care Coordination Agency, which determines each individual's care needs. Assessments are done by registered nurses employed by a Care Coordination Agency (CCA). A list of these agencies by county can be found on this webpage: http://www.dhcs.ca.gov/services/ltc/Documents/CareCoordinationAgencies2017.pdf

NorCal Care Coordinator Agency (Alameda, Contra Costa, Sacramento, San Francisco, San Joaquin, San Mateo, Santa Clara and Sonoma Counties): 6060 Sunrise Drive, Suite 3350 Citrus Heights, CA 95610-7099

91 of 233





Page 4 of 5

Debbie Brooke (916) 385-2784 Yolanda Nixon (925) 519-6100 FAX (916) 512-3473 Debbie Brooke and Yolanda Nixon, Owners [email protected] [email protected]

Assisted Living Waiver Program Department of Health Care Services Long-Term Care Division 1501 Capitol Avenue, MS 4503 PO Box 997437 Sacramento, CA 95899-7413 ALW Hotline (916) 552-9322

6. The Home and Community-Based Alternatives (HCB Alternatives) Waiver (previously titled Nursing Facility/Acute Hospital Waiver) provides care management services at home to Medi-Cal beneficiaries with high level needs who would otherwise receive care in a facility. Some of the services that may be provided to support Waiver participants in the community include, but are not limited to: in-home nursing services, waiver personal care services, family/caregiver training, home or facility respite, habilitation services, community transition services, environmental accessibility adaptation, medical equipment operating expenses, personal Emergency Response System (PERS) installation, testing, and operation. The application for the program can be found here: http://www.dhcs.ca.gov/services/ltc/Documents/HCBA_Application.pdf When complete, mail this application to the following address: Integrated Systems of Care Division HCBS Programs Eligibility/Intake Unit 311 South Spring Street, Ste. 800 Los Angeles, CA 90013 Or submit the application by FAX: (213) 620-4448

7. Referrals for the Multipurpose Senior Services Program (MSSP) Waiver program are made by sending the Medi-Cal Member (who is 65 years or older) to a local MSSP site in the county where the Member resides. MSSP site staff will make a certification determination based upon Medi-Cal criteria. A list of MSSP sites can be found here: https://www.aging.ca.gov/ProgramsProviders/MSSP/Contacts/

8. The Partners for Children (PFC) Pediatric Palliative Care (PPC) Waiver Program is offered in participating counties as noted on this webpage: http://www.dhcs.ca.gov/services/ppc/Pages/CCSProgram.aspx Marin and Sonoma County are currently the only counties which PHC serves that participate. The program offers supportive services for eligible children with life-limiting or life-threatening illnesses and their families. These services are provided by local participating hospice and home health agencies. General information about PPC Waiver Program can be found on this web page: http://www.dhcs.ca.gov/services/ppc/Pages/default.aspx Members whose family may benefit from this program should talk to their PCP. The child’s doctor will provide information about the child’s medical condition to the County CCS office. The CCS office will determine if the child is eligible and contact the family with more details and to set up a meeting to talk about enrollment.

VII. REFERENCES:

DHCS Contract: Exhibit A, Attachment 11, Provisions 11.C. and 15.A. and B. and Exhibit A, Attachment 18, Provisions 11.M, S, and X.

92 of 233

Attachment A - MCUP3041 Attachment A - MCUP3049 Attachment B - MCUG3007

(TAR to be submitted by the provider performing the service) Revised 08/16/201704/11/2018

Page 1 of 8

PHC TAR REQUIREMENTS

A. Hospitalization 1. The hospital must notify PHC of any admission within 24 hours of the admission. 2. Authorization for elective admission must be requested by the admitting physician prior to the admission.

B. Long Term Care

The LTC facilities must notify PHC of any admissions, transfer, bed hold/ leave of absence, or change in payor status within one working day. (Examples include Medicare non-coverage or exhaustion of benefits / hospice election.)

C. Outpatient Surgical Procedures – see CPTs Requiring TAR list

D. Pain Management – see CPTs Requiring TAR list

E. Outpatient Hemo / Peritoneal Dialysis

(Note: initial authorization will be limited to 90 days and a lifetime TAR will be granted only after submission of Medicare determination.)

F. Drugs and Pharmaceuticals – A TAR is required for all prescription drugs, over-the-counter drugs and injectable drugs (including drugs compounded for IV infusion therapy) not on the PHC formulary.

PLEASE REFER TO PHC FORMULARY

G. Diagnostic Studies

♦ CT Scans (Except 76497) ♦ MRI (Except 76494, 76380, 76506) ♦ Cardiac MRI - 75561 only (effective 08/01/2017) ♦ MRA ♦ PET scan ♦ Transcranial Doppler ♦ Sleep Studies / Polysomnography

H. Ancillary / Support Services

RAF authorizes one visit only. Requests for additional visits require the ancillary service provider to submit copies of initial evaluation and treatment plan attached to TAR. TAR must include total visits requested including initial visit.

♦ Acupuncturist Speech Therapy ♦ Chiropractor Occupational Therapy ♦ Faith Healer Home Infusion Therapy (Nursing Component Only) ♦ Physical Therapy Home Health Care

I. Hospice Care (Inpatient Only)

93 of 233

lblacks

Text Box

Excerpt - Pages 4 - 8 removed from Attachment (no changes)



Page 2 of 8


J. Pulmonary Rehabilitation K. Hyperbaric Oxygen Pressurization

L. Non-Emergency Medical Transportation

M. EPSDT (Early and Periodic Screening, Diagnosis and Treatment) Supplemental Services

N. Phototherapy for dermatological condition

O. Dental Anesthesia

P. CCS/GHPP - Authorization for services related to eligible condition(s) must be requested from

CCS or GHPP office(s). Q. Supplies / Equipment

♦ Orthotics – Cumulative costs for repair/maintenance or purchase exceeds $250 / item ♦ Prosthetics – Cumulative costs for repair / maintenance or purchase exceeds $500 / item

And any unlisted / miscellaneous code including: - L0999 Addition to spinal orthosis, not otherwise specified - L1499 Spinal orthosis, not otherwise specified - L2999 Lower extremity orthosis, not otherwise specified - L3649 Orthotic shoe, modification, addition or transfer, not otherwise specified - L3999 Upper limb orthosis, not otherwise specified - L5999 Lower extremity prosthesis, not otherwise specified - L7499 Upper extremity prosthesis, not otherwise specified - L8039 Breast prosthesis, not otherwise specified - L8499 Unlisted procedure for miscellaneous prosthetic services - L8699 Prosthetic implant, not otherwise specified ANY CUSTOM MADE ITEM THAT DOES NOT HAVE A MEDI-CAL RATE (BY-REPORT OR BY-INVOICE)

♦ Ostomy Supplies – If monthly cumulative cost for all related supplies exceeds $150 ♦ Hearing Aid – All purchases, rentals or repairs exceeding $50 / item

(Batteries are non-covered except some CCS / EPSDT cases, in which case TAR is required)

♦ Oxygen and related supplies ♦ Diabetic Supplies are to be provided by Pharmacies ONLY ♦ Nebulizers – When the billed price including tax is $100 or more ♦ Medical Supplies – (If dispensed by PHARMACY, please refer to formulary) ♦ DME – (If dispensed by PHARMACY, please refer to formulary)

- Repairs or maintenance over $250.00 / item (Out of guarantee repairs are to be guaranteed for at LEAST three (3) months from the date of repair. Reimbursement will NOT be allowed for parts or labor during a guarantee period if due to a defect in material or workmanship)

- Purchase items when the cumulative cost of items within a group exceeds over $100.00 within the calendar month. / item Providers may refer to the Durable Medical Equipment (DME): Billing Codes and Reimbursement Rates section in the Medi-Cal manual to determine if items are related within a group. Items grouped together under specific headings, such as “Hospital Beds” or “Bathroom Equipment,” are considered within the same group. (Vendor to guarantee for a MINIMUM of six (6) months from the date of purchase)

- Rental items when the cumulative cost of rental for items within the group exceeds over

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Page 3 of 8


$50.00 / month / itemwithin a 15-month period. This includes any daily amount that an individual item, or a combination of a similar group of DME items, exceeds the $50 threshold. The 15-month period begins on the date the first item is rented. (Rental rate includes equipment related supplies.)

- Any unlisted or miscellaneous code - Purchase of any wheelchairs for Medi-Medi members

♦ Incontinence Supplies

- Incontinence supplies if monthly cumulative cost for all related supplies exceeds $125.00 - Washes and creams for members with incontinence will only be authorized if the physician

justifies medical necessity ♦ Nutritional Supplements (Submit TAR to Pharmacy) ♦ AND any unlisted or miscellaneous code

R. Genetic Testing – A TAR is required for certain genetic testing as outlined in Attachment A of the Genetic Testing policy MCUP3131.

S. Gender Dysphoria– A TAR is required for all procedures related to gender dysphoria. T. Fecal Microbiota Transplant (FMT)

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Medical Necessity Criteria for Pain Management Procedures MCUG3007 Authorization of Ambulatory Procedures and Services - Attachment C MCUP3049 Pain Management Specialty Services – Attachment B 03/15/201704/11/2018

Page 2 of 3

63650 thru 63688 Insertion, revision, or removal of spinal neurostimulator

Covered for the following conditions after a temporary stimulator in the epidural space demonstrates at least 50% relief of pain documented by a pain log for a minimum 48 hour trial: 1. Failed back syndrome with low back pain and significant

radicular pain; 2. Complex regional pain syndrome 3. Last resort treatment for severe chronic neuropathic pain

resulting from actual damage to peripheral nerves, lumbosacral arachnoiditis and radiculopathies, phantom limb/stump pain, peripheral neuropathy, or incomplete spinal cord injury that is refractory to 12 or more months of standard therapy.

64479 to 64484 Transforaminal epidural injection

Same as InterQual except: remove requirement for documentation of trial of NSAIDS; 1. Progress note must document a history of radicular symptoms

and imaging must document nerve root impingement. If MRI shows spinal stenosis with no significant impingement, epidural injection is not medically indicated.

2. A minimum of 30 days conservative treatment before eligible for epidural steroid injection.

3. For repeat injections, a minimum of 50% improvement in pain symptoms lasting 8 weeks from the prior epidural injection is required.

4. Maximum of 2 levels of transforaminal epidural injections of the spine per 3 months. This may be 2 levels on the same side or 1 level bilaterally.

5. The interval between injections must be no more frequently than every 2 months, and the maximum number of injections per site is 3 per year.

64490 to 64495 Paravertebral facet injections and medial branch blocks

Initial injection: Same as InterQual criteria, except documentation of physical therapy for 6 weeks and NSAIDs are not needed. 1. Patient must have a minimum of 12 weeks of symptoms

consistent with facet joint pain. 2. The progress note should document a physical examination of

the back, including pain elicited with movement. 3. No more than 3 levels will be approved, either 3 levels

unilaterally or 3 levels bilaterally. 4. Maximum of 2 MBB per level per year.

For Repeat Injections:, Aa pain log must be submitted showing that the pain relief from the previous injection was consistent with the anesthetic agent used, with documentation of at least 50% reduction in pain. For example, for a pure bupivacaine block, this is about 2‐3 hours; bupivacaine plus minimal dose steroid block could be up to 3‐4 days for medial branch blocks versus a month to several months for facet joint block.

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UTILIZATION MANAGEMENT - PHYSICIAN REVIEW

#Inter-Rater Physician

Review 07/2017 -

12/2017Total

TARs

Process

Errors

No

Process

Errors

%Could not

determine

Inter-Rater

Physician

Review

07/2017 -

12/2017Total

TARs

Criteria

Did not

Agree

Criteria

Agreed

%Could not

determine

1 5 0 5 100.0% 0 1 5 0 5 100.0% 0

2 5 0 5 100.0% 0 2 5 0 5 100.0% 0

3 5 0 5 100.0% 0 3 5 0 5 100.0% 0

4 5 0 5 100.0% 0 4 5 1 4 80.0% 0

5 5 0 5 100.0% 0 5 5 0 5 100.0% 0

6 5 0 5 100.0% 0 6 5 0 5 100.0% 0

7 5 0 5 100.0% 0 7 5 0 5 100.0% 0

8 5 1 4 80.0% 0 8 5 0 5 100.0% 0

Process Compliance 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 80.0%

Criteria Compliance 100.0% 100.0% 100.0% 80.0% 100.0% 100.0% 100.0% 100.0%

Target Compliance Rate 90% 90% 90% 90% 90% 90% 90% 90%

0.0%

20.0%

40.0%

60.0%

80.0%

100.0%

120.0%

1 2 3 4 5 6 7

PROCESS/CRITERIA/TARGET COMPLIANCE RATE

Process Compliance Criteria Compliance Target Compliance Rate

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UTILIZATION MANAGEMENT - INPATIENT INTER - RATER RELIABILITY -JULY THRU DECEMBER 2017

Month Total TARs Eligibility TimelinessCouldn't

Determine

Free from

Error% Total TARs

Criteria

Did not

Agree

Criteria

Agreed %

Couldn't

Determine

* Jul #DIV/0! #DIV/0!

* Aug #DIV/0! #DIV/0!

* Sep #DIV/0! #DIV/0!

Oct 50 1 0 0 49 98.0% 50 3 47 94.0% 0

Nov 50 0 2 0 48 96.0% 50 4 46 92.0% 0

Dec 60 2 0 0 58 96.7% 60 5 55 91.7% 0

Month Jul Aug Sep Oct Nov Dec

Process

Compliance #DIV/0! #DIV/0! #DIV/0! 98.0% 96.0% 96.7%

Criteria

Compliance#DIV/0! #DIV/0! #DIV/0! 94.0% 92.0% 91.7%

Target

Compliance

Rate

90% 90% 90% 90% 90% 90%

**DUE TO IMPLEMENTATION OF ESSETTE MANAGEMENT DEFERRED THE IRRS UNTIL OCTOBER 2017

0.0%

20.0%

40.0%

60.0%

80.0%

100.0%

120.0%

Jul Aug Sep Oct Nov Dec

Process Compliance/Criteria Compliance/Target Compliance


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UTILIZATION MANAGEMENT - OUTPATIENT INTER - RATER RELIABILITY -JULY THRU DECEMBER 2017

Month Total TARs Eligibility TimelinessCouldn't

Determine

Free from

Error% Total TARs

Criteria

Did not

Agree

Criteria

Agreed %

Couldn't

Determine

* Jul #DIV/0! #DIV/0!

* Aug #DIV/0! #DIV/0!

* Sep #DIV/0! #DIV/0!

Oct 30 0 1 0 29 96.7% 30 1 29 96.7% 0

Nov 30 0 1 0 29 96.7% 30 0 30 100.0% 0

Dec 30 0 1 0 29 96.7% 30 1 29 96.7% 0

Month Jul Aug Sep Oct Nov Dec

Process

Compliance #DIV/0! #DIV/0! #DIV/0! 96.7% 96.7% 96.7%

Criteria

Compliance#DIV/0! #DIV/0! #DIV/0! 96.7% 100.0% 96.7%

Target

Compliance

Rate

90% 90% 90% 90% 90% 90%

**DUE TO IMPLEMENTATION OF ESSETTE MANAGEMENT DEFERRED THE IRRS UNTIL OCTOBER 2017

0.0%

20.0%

40.0%

60.0%

80.0%

100.0%

120.0%

Jul Aug Sep Oct Nov Dec

Process Compliance/Criteria Compliance/Target Compliance


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Report Title: RAF Volume - Manual vs Electronic (Summary)

Region Input Source Count Auths Percentage

Northern Region Electronic 30,142 98.52%

Manual (Amisys) 453 1.48%

Northern Region Region Total: 30,595 30.31%

Region Input Source Count Auths Percentage

Southern Region Electronic 69,810 99.24%

Manual (Amisys) 532 0.76%

Southern Region Region Total: 70,342 69.69%

Grand Total: 100,937 100.00%

Entered Between: 7/1/17 - 12/30/17

Report Name/Date: Manual vs Electronic - RAF Volume - 2/7/18

Outpatient RAF Statistics:

Total Outpatient RAF Volume: 100,937

Total Manual (Amisys) RAFs: 985

Total Electronic RAFs: 99,952

Percent of Manual (Amisys) RAFs: 0.98%

Percent of Electronic RAFs: 99.02%

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kryan

Highlight

kryan

Highlight

UTILIZATION MANAGEMENT - DENIED TARS BY REGION 07-01-17_12-31-17

NORTHSTATUS DESCRIPTION INPATIENT OUTPATIENT

DENIED - PER MEDICAL REVIEW 12 1162 1174

Needs CCS authorization 249 112 361

Adminstrative Denials (No TAR Required, Not a Benefit, Not Accepted, Not Timely, Other Ins., Req. Info Not Recvd.)397 1484 1881

TOTAL TARS 658 2758 3416

SOUTHSTATUS DESCRIPTION INPATIENT OUTPATIENT

DENIED - PER MEDICAL REVIEW 44 527 571

Needs CCS authorization 349 261 610

Adminstrative Denials (No TAR Required, Not a Benefit, Not Accepted, Not Timely, Other Ins., Req. Info Not Recvd.)1073 4526 5599

TOTAL TARS 1466 5314 6780

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CLASS Jul Aug Sep Oct Nov Dec Total:

MediCal: INPATIENT 4167 4498 4089 4816 4221 3975 25766

OUTPATIENT 12015 13604 12013 12256 12051 11570 73509

Subtotal: 16182 18102 16102 17072 16272 15545 99275

UTILIZATION MANAGEMENT - ALL COMPLETED TARS 7/1/2017 thru 12/31/2017

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PCP QIP 2016-2017 Program Evaluation Summary

The Primary Care Provider Quality Improvement Program (PCP QIP) offers substantial financial incentives, data resources, and technical assistance to PCPs who serve our capitated members so that significant improvements can be made across a variety of care domains.

Significant program changes were made, effective 1/1/2018. This evaluation is an analysis of the July 1, 2016 – June 30, 2017 program year, and therefore does not analyze the impact of our most recent changes.

Program Performance

Overall performance was consistent with prior year

Stability in % of providers meeting 90th percentile

target; modest increase in % of providers meeting

75th percentile target

Large practice size and Family Practice correlated

with better program performance/higher PMPM

Consistent year-over-year average point earnings;

NR improvement compared to last year

Provider Experience

100% satisfaction with the program

More providers actively participated in the program

based on Unit of Service measure submission and

eReports utilization

Opportunity to improve ease and usefulness of eReports

and the non-clinical reports

Does the PCP QIP Improve Care?

Tentatively yes, but difficult to conclude definitively without more robust research methods

Modest improvement over time seen in population-level rates

95% of surveyed participants agreed that the QIP improves patient care

QIP performance tracks with HEDIS performance; impacting the former should impact the latter

Want to accelerate improvement/program impact 2018 program changes

30%40%50%60%70%80%90%

Population Level Rates for Clinical Measures Plan Wide

2014-2015 2015-2016 2016-2017 HEDIS 2017 (MY2016)

222 providers 30 measures $36 million

Average points 65.5

Program Improvements

We made significant program changes effective

1/1/18; those changes are supported by 16-17

program year results

No measures ready for retirement based on high

performance

Consider slow changes to CAHPS, Readmissions

and Admissions targets in future years

63

64

65

66

67

68

2013-2014 2014-2015 2015-2016 2016-2017

Average Points Earnings By Region, Trended

South North All

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2016‐2017 PCP QIP Evaluation

March 2, 2018By Qi Yao

ContentsContents

‐ Overview‐ Summary of 16‐17 QIP program performance‐ Provider engagement with the QIP‐ Does QIP improve care?‐ Re‐assessing 2018 program changes‐ For consideration: Future improvements to QIP program

‐ Conclusion

PHC Internal Use Only

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OverviewOverview

‐ 222 providers participated in the 2016‐2017 PCP QIP

‐ In 2016‐2017, the base rate committed on a per member per month basis was $5.00.

‐ The total pay‐out was $36 million (15‐16: $34 million)

‐ Fixed Pool*: ‐ 14 Clinical measures (Child BMI retired)‐ 8 Non‐Clinical Measures

‐ Unit of Service:‐ 8 Measures (Health Information Exchange added)

*Not all practice types report on all measures


Summary of 16‐17 QIP Program PerformanceSummary of 16‐17 QIP Program Performance

‐ Providers meeting full/partial target – Clinical Domain

‐ Providers meeting full target – Non‐Clinical Domain

‐ Points earnings breakdown

‐ Points earnings by practice type and size

‐ Absolute change in adjusted points earned

‐ PMPM distribution by practice size

‐ PMPM distribution by practice type

‐ Patient experience


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Providers Meeting Full Targets – Clinical DomainProviders Meeting Full Targets – Clinical Domain


*Demonstrates statistically significant improvement (p<.05) using the fisher’s exact test.

Proportion of sites meeting the 90th percentile target

• Low: 12.08% (DTap); Median: 27.49% (MPM, Hba1c); High: 66.67% (Asthma Care)• Overall limited change over time in % of providers meeting 90th percentile target. • The percentage meeting target rose for five measures (1 statistically significant), and

declined for six (0 statistically significant).

Measure 2011‐2012 2012‐2013 2013‐2014 2014‐2015 2015‐2016 2016‐2017

Asthma Care ‐ ‐ ‐ ‐ ‐ 66.67%

Nephropathy Screenings ‐ ‐ 62.90% 62.36% 58.29% 41.45%

Nutrition Counseling ‐ ‐ ‐ 26.32% 33.33% 36.84%

Controlling High Blood Pressure ‐ ‐ ‐ 16.67% 16.13% 33.69%

Childhood Immunization MMR ‐ ‐ ‐ ‐ ‐ 33.33%

Physical Activity Counseling ‐ ‐ ‐ 36.84% 27.78% 31.58%

HbA1C Good Control 24.70% 41.10% 56.20% 19.66% 34.76% 28.50%

MPM ‐ ‐ ‐ 34.48% 40.00% 26.47%

Adolescent Immunization 40.00% 31.30% 25.00% 47.37% 38.89% 26.32%

Retinal Eye Exams ‐ ‐ 11.20% 19.10% 11.76% 17.10%

Well‐Child Visits 17.60% 44.40% 30.10% 20.13% 20.63% 16.88%

Colorectal Cancer Screening ‐ ‐ ‐ ‐ ‐ 15.15%

Cervical Cancer Screening 1.00% 15.20% 23.20% 5.29% 6.09% 12.50%*

DTaP ‐ ‐ ‐ 21.05% 13.91% 12.08%

Providers Meeting Partial Targets – Clinical DomainProviders Meeting Partial Targets – Clinical Domain


*Demonstrates statistically significant improvement (p<.05) using the fisher’s exact test.

Proportion of sites meeting the 75th percentile target

• Low: 16.11% (DTap); Median: 42.45% (CBP, IMA); High: 66.67% (Asthma Care)• Overall positive change• The percentage in all but three measures (HbA1C Good Control, MPM and DTaP) rose

with Cervical Cancer Screening being significant.

Measure 2011‐2012 2012‐2013 2013‐2014 2014‐2015 2015‐2016 2016‐2017

Asthma Care ‐ ‐ ‐ ‐ ‐ 66.67%

Nephropathy Screenings ‐ ‐ 71.90% 64.60% 58.29% 63.21%

Nutrition Counseling ‐ ‐ ‐ 46.70% 44.44% 52.63%

Physical Activity Counseling ‐ ‐ ‐ 33.30% 27.78% 47.37%

Childhood Immunization MMR ‐ ‐ ‐ ‐ ‐ 44.44%

HbA1C Good Control 36.40% 55.60% 67.40% 20.80% 44.39% 43.52%

Controlling High Blood Pressure ‐ ‐ ‐ 21.70% 19.35% 42.78%

Adolescent Immunization 46.70% 43.80% 31.30% 53.30% 38.89% 42.11%

Colorectal Cancer Screening ‐ ‐ ‐ ‐ ‐ 33.84%

MPM ‐ ‐ ‐ 36.40% 43.33% 32.35%

Well‐Child Visits 29.40% 61.10% 38.60% 37.80% 25.00% 29.38%

Retinal Eye Exams ‐ ‐ 16.90% 30.20% 16.58% 21.76%

Cervical Cancer Screening 5.80% 22.20% 35.40% 16.50% 10.66% 19.00%*

DTaP ‐ ‐ ‐ 40.00% 55.56% 16.11%

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Providers Meeting Full Targets – Non‐clinical DomainProviders Meeting Full Targets – Non‐clinical Domain


0.0%

20.0%

40.0%

60.0%

80.0%

100.0%

Pharmacy Readmissions Admissions/1000 Opioid Safety

% of Sites Meeting Targets for Appropriate Use of Resource Measures

2011‐2012 2012‐2013 2013‐2014 2014‐2015 2015‐2016 2016‐2017

• Consistently high percentage of sites meeting targets for Appropriate Use of Resource measures, and steadily increasing in Avoidable ED measure.

• Pharmacy and Opioid Safety measures retired.

0.0%

20.0%

40.0%

60.0%

80.0%

100.0%

Avoidable ED PCP Office Visits Open Practice

% of Sites Meeting Targets for AccessMeasures Plan Wide

2011‐2012 2012‐2013 2013‐2014 2014‐2015 2015‐2016 2016‐2017

Patient ExperiencePatient Experience


0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

2016 CAHPS (n=68) 2015‐2016 Survey/Training(n=151)

2015‐2016 PatientExperience (n=219)

2017 CAHPS (n=94) 2016‐2017 Survey/Training(n=128)

2016‐2017 PatientExperience (n=222)

Patient Experience Provider Point Distribution

Full Points Partial Points No Points

• While the proportion of sites earning points from the Survey/Training option has remained steady, many more sites earned points from the CAHPS survey.

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Points Earnings BreakdownPoints Earnings Breakdown


Region Southern Northern Plan‐wide

Year2013‐

2014

2014‐

2015

2015‐

2016

2016‐

2017

2013‐

2014

2014‐

2015

2015‐

2016

2016‐

2017

2013‐

2014

2014‐

2015

2015‐

2016

2016‐

2017

Average 66.7 66.5 65.8 65.3 65.8 67.6 63.2 65.8 66.3 65.9 64.7 65.5

Median 66.1 65.8 68.4 64.4 70.3 64 63.6 66.1 66.8 65.0 65.0 65.5

Lowest 20.0 30.0 25.0 25.0 20.0 28.0 26.8 37.9 20.0 28.0 25.0 25.0

Highest 100.0 95.0 100.0 100.0 100.0 95.0 100.0 100.0 100.0 95.0 100.0 100.0

• The plan‐wide increase from 2015‐2016 to 2016‐2017 is mainly driven by Northern Region providers with their improvement on DTaP and Colorectal Cancer Screening.

Average Point Earnings by Practice Type and SizeAverage Point Earnings by Practice Type and Size


Size Adult Family Pediatric Total

1‐49 48.28 (n=16) 59.62 (n=14) N/A (n=0) 53.57 (n=30)

50‐199 46.91 (n=8) 56.32 (n=16) 51.41 (n=5) 52.88 (n=29)

200‐749 65.89 (n=10) 65.88 (n=40) 66.16 (n=7) 65.91 (n=57)

750‐1649 85.83 (n=3) 67.14 (n=34) 82.19 (n=4) 69.67 (n=41)

1650+ N/A (n=0) 73.51 (n=61) 71.25 (n=3) 73.41 (n=64)

Total 55.72 (n=35) 67.54 (n=165) 65.70 (n=22)

• On the whole, larger practices/Family earned more points on the PCP QIP.

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Absolute Change in Adjusted Points EarnedAbsolute Change in Adjusted Points Earned


Points Change Number of Sites Percent to Total (n=211*)

<‐20 13 6.16%

>=‐20, <‐10 28 13.27%

>=‐10, <0 57 27.01%

>=0, <10 53 25.12%

>=10, <20 37 17.54%

>=20 23 10.90%

• The number of sites that experienced a positive change in points exceeded the number of sites that had a negative change which indicates overall improvement this year.

• Only the same 211 sites participated in both 2015‐2016 and 2016‐2017 measurement years.

PMPM Distribution by Practice SizePMPM Distribution by Practice Size


0

2

4

6

8

10

12

>5000 1000‐5000 <1000

PMPM Distribution by Practice Size

• The large sites had a higher average and narrower range of PMPM amount.

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PMPM Distribution by Practice TypePMPM Distribution by Practice Type


• Family Practice had a higher average of PMPM amount.• Pediatric had a narrower range of PMPM amount.

0

2

4

6

8

10

12

Family Adult Pediatric

PMPM by Practice Type

Provider Engagement with the QIPProvider Engagement with the QIP

‐ Provider engagement survey

‐ Webinar attendance

‐ eReports utilization

‐ Pay‐for‐Reporting measures performance


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Provider Engagement SurveyProvider Engagement Survey


• Overall, 95% of the respondents believed that the QIP led to improved patient care at their respective provider sites.

• Ongoing concern with ease and usefulness of eReports and the non‐clinical reports.

• 0% strongly agreed that the annual QIP results are a good reflection of the care provided.

Survey Questions Strongly

Agree

Agree Disagree Strongly

Disagree

I am satisfied with the program. 25% 75% 0% 0%

The annual QIP results are a good reflection of the care provided. 0% 71% 14% 14%

Staff and providers in my organization are aware of the QIP. 50% 40% 5% 5%

My opinions are heard in various QIP processes, including measure

development.

21% 53% 16% 10%

I understand what the requirements are in order to perform well in

the QIP.

50% 45% 5% 0%

In monitoring clinical measures, eReports is useful and easy to use. 32% 37% 15.5% 15.5%

In monitoring non‐clinical measures, the quarterly non‐clinical reports

are useful and easy to use.

11% 52% 21% 16%

I am aware of the pre‐payment validation processes, including the

eReports grace period and Preliminary Reports.

35% 50% 0% 15%

The QIP measures are actionable. 15% 80% 0% 5%

The QIP leads to improved patient care at my provider site. 30% 65% 0% 5%

The QIP drives our quality improvement agenda. 40% 55% 0% 5%

The QIP team responds to my questions and concerns in a timely

manner.

53% 37% 5% 5%

The QIP team’s response to my questions and concerns is helpful. 63% 32% 0% 5%

Important program updates to the QIP are communicated effectively. 50% 45% 0 5%

Webinar AttendanceWebinar Attendance


Webinar Date No. of Participants % rating of good and/or

excellent

Kick‐Off Webinar (Advanced) July 26, 2016 24 100.0% (13/13)

Kick‐Off Webinar (Beginner) July 27, 2016 6 100.0% (2/2)

MPM Webinar October 3, 2016 56 93.8% (30/32)

eReports Demo Webinar October 5, 2016 48 86.7% (26/30)

Measurement Year Transition & 2018 Measure

Development

January 30, 2017 48 96.8% (30/31)

2016‐2017 QIP Wrap‐Up and 2015‐2016 Evaluation June 13, 2017 43 100.0% (26/26)

• An overall 86.7%‐100% approval rating where the respondents rated the webinar they attended as good or excellent, improved dramatically from last year’s Kick Off Advanced ratings (15‐16 Advanced:29.4% 5/17 mainly due to technical difficulties).

• Opportunity to improve participation

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eReports UtilizationeReports Utilization


0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

Uploaded Data Logged In

Percent of Provider Sites Utilizing eReports

2014‐15 2015‐16 2016‐2017

• Fewer sites (73%) logged in during 2016‐2017 compared to 79% during 2015‐2016, more sites uploaded data (61%) compared to 60% during 2015‐2016.

Pay‐for‐Reporting Measures PerformancePay‐for‐Reporting Measures Performance


0%

5%

10%

15%

20%

25%

30%

PCMH Recognition Peer‐Led Self ManagementSupport Group

Advance Care Planning SBIRT Buprenorphine

Proportion of Plan‐Wide Providers Participating in Manual Submission Measures

2013‐2014 2014‐2015 2015‐2016 2016‐2017

• More providers participated in four measures except a small decline in PCMH Recognition because it was designed to be a one‐time payment.

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Does QIP Improve Care?Does QIP Improve Care?

‐ Population‐level performance – Clinical Domain

‐ Population‐level performance – Non‐Clinical Domain

‐ Controlling High Blood Pressure measure impact on HEDIS


Population‐level Performance – Clinical DomainPopulation‐level Performance – Clinical Domain


Historical QIP Performance 16‐17 QIP Performance HEDIS 2017 Performance

(for comparison)

Measure 2014‐2015 2015‐2016 2016‐2017 HEDIS 2016

Percentile

HEDIS 2017

Rate

HEDIS 2017

Percentile

Cervical Cancer Screening 51.95% 52.48% 55.72%* 25th – 50th 56.73% 50th – 75th

Well‐Child Visits 70.00% 71.75% 72.95%* 50th – 75th 72.13% 50th – 75th

Adolescent Immunization ‐ 81.26% 83.08% 75th – 90th 69.46% 25th – 50th

HbA1C Good Control ‐ 62.43% 64.93%* 50th – 75th 62.18% 50th – 75th

Retinal Eye Exams ‐ 48.57% 54.03%* 25th – 50th 53.59% 50th – 75th

Nephropathy Screenings ‐ 86.20% 86.22% 75th – 90th 88.19% <25th

Controlling High Blood Pressure ‐ 58.53% 63.09%* 50th – 75th 59.70% 50th – 75th

MPM ‐ 81.37% 85.67%* 25th – 50th 85.39% <25th

Nutrition Counseling ‐ 65.01% 73.99%* 75th – 90th 69.16% 50th – 75th

Physical Activity Counseling ‐ 48.75% 58.78%* 50th – 75th 64.06% 75th – 90th

DTaP ‐ 71.77% 70.60% <25th 72.23% <25th

Colorectal Cancer Screening ‐ 33.00% 36.20%* 50th – 75th ‐ ‐

Asthma Care ‐ 62.14% 66.38% >90th 51.22% 25th – 50th

MMR ‐ 88.73% 81.90%# <25th 85.69% <25th

* Demonstrates statistically significant improvement (p<.05) from previous measurement year using the Chi‐Square Test.# Demonstrates statistically significant decline (p<.05) from previous measurement year using the Chi‐Square Test.

• Nine of the 14 measures showed statistically significant improvement.• DTaP and MMR were below MPL for both QIP and HEDIS 2017.

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Population‐level Performance – Clinical DomainPopulation‐level Performance – Clinical Domain



• The QIP and HEDIS rates aligned well for the most part, changes that impact QIP performance will impact HEDIS.

30%

40%

50%

60%

70%

80%

90%

Population Level Rates for Clinical Measures Plan Wide

2014‐2015 2015‐2016 2016‐2017 HEDIS 2017 (MY2016)

Population‐level Performance – Non‐clinical DomainPopulation‐level Performance – Non‐clinical Domain



Measure 2013‐2014 2014‐2015 2015‐2016 2016‐2017

Admissions/1000 ‐ ‐ 47.11 48.23#

Readmission Rate ‐ 14.22% 12.02% 13.54#

Generic Prescription Rate 92.22% 89.02% 89.01% 88.74%#

Formulary Prescription Rate 94.72% 98.33% 98.54% 98.27%#

Avoidable ED Visits 39.53 36.82 21.70 18.14*

PCP Office Visits ‐ 2.50 2.36 2.35#

Opioid Safety ‐ ‐ 61.70% 69.55%*

• Pharmacy‐related measures continue to have high performance (retired).• The two measures that saw significantly improvement were Avoidable ED

Visits and Opioid Safety.• Increase in Admissions/Readmissions

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Controlling High Blood Pressure Measure Impact on HEDISControlling High Blood Pressure Measure Impact on HEDIS

• CBP was to Internal Med in 2013‐14 and added to Family Practice in 2014‐15.• Addition of CBP to the measurement set correlated with improved HEDIS rate, though

not a perfectly linear relationship• The CBP population‐level performance in QIP increased from 58.53% in 2015‐16 to

63.09% in 2016‐17 which should be reflected in HEDIS 2018 (MY2017), indicating the improvement in the long term.

48.42%

54.74%

64.30%

47.45%

60.34%

48.10%

54.01%

65.53% 64.89%

56.72%58.52%

65.59%

61.70%

69.55% 69.79% 70.32% 70.55%

40.00%

45.00%

50.00%

55.00%

60.00%

65.00%

70.00%

75.00%

HEDIS 2014 (MY2013) HEDIS 2015 (MY2014) HEDIS 2016 (MY 2015) HEDIS 2017 (MY 2016)

CBP

NE NW SW SE HEDIS 90%ile

Internal med measure Family practice

measure

Re‐assessing 2018 Program ChangesRe‐assessing 2018 Program Changes

‐ Relative improvement change

‐ Continuous enrollment change

‐ Pharmacy measure removal

‐ CAHPS RI removal, consider target changes in future years


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Relative Improvement Change‐Point Earnings Distribution for Clinical Measures Plan‐Wide

Relative Improvement Change‐Point Earnings Distribution for Clinical Measures Plan‐Wide


0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Point Earnings Distribution for Clinical Measures Plan‐Wide

Full Points (Target) Full Points (Improvement) Partial Points (Target) Partial Points (Improvement) No Points

• While relatively few providers meet the target for many measures, a significantly higher proportion earned points as a result of improvement. It supports our finding in 2015‐16 evaluation and beginning in 2018, only significant improvement – defined as 15% relative improvement (and meeting MPL) – will be rewarded.

CE Change‐QIP Denominators Compared to HEDISCE Change‐QIP Denominators Compared to HEDIS

HEDIS denominators after exclusions applied

** Not reported for HEDIS 2017. Used internal HEDIS 2017 flowchart to extract data.


QIP Measure QIP Denominator HEDIS 2017

Population*

Percentage

Annual Monitoring of Patients on Persistent Medications 14,305 27,319 52.36%

Cervical Cancer Screenings 66,883 97,010 68.94%

Childhood Immunization ‐ DTaP 6,922 10,286 67.30%

Childhood Immunization – MMR 746 10,286 7.25%

DM – Retinal Eye Exams 11,593 15,975 72.57%

DM ‐ HbA1C Good Control 11,593 15,975 72.57%

DM ‐ Nephropathy Screenings 11,593 15,975 72.57%

Controlling High Blood Pressure 15,318 19,204 79.76%

Immunizations for Adolescents 721 9,668 7.46%

Medication Management for Asthma** (Asthma Care) 116 2,368 4.90%

Physical Activity Counseling 8,773 111,061 7.90%

Nutrition Counseling 8,773 111,061 7.90%

Well Child Visits 28,123 42,057 66.87%

Colorectal Cancer Screenings Not reported for HEDIS

• In 2016‐17, the population measured by the QIP is about 38% of the size of the HEDIS population. Beginning in 2018, the definition of continuous enrollment will change to meaning assigned to the same PCP parent organization for nine out of 12 months of the measurement period. This will allow the QIP to represent a better sample of the entire eligible population and to extend care to our members.

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Pharmacy Measure RemovalPharmacy Measure Removal


Measure 2013‐2014 2014‐2015 2015‐2016 2016‐2017

Generic Prescription Rate 92.22% 89.02% 89.01% 88.74%

Formulary Prescription Rate 94.72% 98.33% 98.54% 98.27%

75.0%

80.0%

85.0%

90.0%

95.0%

100.0%

Pharmacy

Percent of Sites Meeting Targets for Pharmacy Measure Plan Wide

2011‐2012 2012‐2013 2013‐2014 2014‐2015 2015‐2016 2016‐2017

Population‐Level Performance

• Performance on the Pharmacy measure continues to be high, supporting the measure removal starting in 2018.

CAHPS RI RemovalCAHPS RI Removal


• Points earned were based on hitting the targets instead of achieving improvement.• Final score is based on the higher of the two composite types.• Overall more sites earned full points this year.• RI calculation adds administrative burden.

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Adult Access Adult Comm Child Access Child Comm

CAHPS Points Earned Distrubution 2016‐2017

Full Points (Target) Full Points (RI) Partial Points (Target) Partial Points (RI) No Points

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For Consideration: Future Improvements to QIP ProgramFor Consideration: Future Improvements to QIP Program

‐ No measures ready for retirement based on 2016‐2017 performance; however, need to consider size of measurement set.

‐ The current CAHPS targets are 25th (partial) and 50th (full), consider potentially increase targets as almost all sites were earning points.

‐ High percentage of providers are meeting targets for Readmissions and Admissions measure; consider slow changes to these targets.


ConclusionsConclusions

‐ Modest positive change in population‐level rates and % of providers meeting targets and earning points.

‐ Significant improvement in Northern Region average points earned

‐ On the whole, larger sites/Family practices earned more points/received higher PMPM on the PCP QIP.

‐ High provider satisfaction with program administration‐ More providers actively participated in the program (UOS)‐ The QIP and HEDIS rates aligned well for the most part,

changes that impact QIP performance will impact HEDIS.‐ Based on QIP data, improvement priorities align with those

identified based on HEDIS results (IZ, CCS, MPM).‐ 2016‐17 data supports 2018 program changes.‐ No measure is ready for retirement, but consider increasing

CAHPS targets.PHC Internal Use Only

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Thank YouThank You


Questions?

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Minutes: P & T 4/12/2018

Partnership HealthPlan of California Meeting Minutes

COMMITTEE Pharmacy and Therapeutics Committee Meeting (P&T) DATE / TIME: Thursday, April 12, 2018 / 7:30am – 10:00am PT Members Present: Kristen Balano, Pharm.D.

Moje Moradi, Pharm.D. Thomas Paukert, MD

PHC Staff Present: Stan Leung, Pharm.D. Mark Glickstein, MD James Cotter, MD Michael Vovakes, MD Bettina Spiller, MD Marshall Kubota, MD Jeffery Ribordy, MD, MPH

Diane Wong, Pharm.D. Andrea O’Campo, Pharm.D. Jessica Huang, Pharm.D. Lynette Rey, Pharm.D. Jeannie Ngo, Pharm.D. Kim Fillette, Pharm.D. Marlana Ogawa, Pharm.D. Monika Brunkal, RPH Kathleen Vo, Pharm.D. Lisa Ooten, Pharm.D. Erin Montegary, Pharm.D. Vic Patel, Pharm.D. Ominder Mehta, Pharm.D. Tony Hightower, CPhT

Members Absent: Cristie Pellegrini, Pharm.D. David R. Gilliam, MD Robert Soper, MD Tom Bui, Pharm.D.

Visitors: Nirmal Mehton, MD

Members Excused: Jay Shubrook, DO PHC Staff Excused: Liz Gibboney, CEO, PHC Robert Moore, MD, MPH, MBA Mark Netherda, MD David Katz, MD

Karen Stephen, Ph.D. Peggy Hoover, RN Eva Lopez, CPhT Tony Sengdara, CPhT Danielle Biasotti, CPhT Jordan Sumodobila, Pharm.D.

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AGENDA ITEM

DISCUSSION / CONCLUSIONS RECOMMENDATIONS / ACTION TARGET DATE

DATE RESOLVED

I. Approval of minutes

II. Standing Agenda 1. PHC Update

Approved with minor typographical corrections (Quorum Reached) The cost of the Hepatitis C drugs costs are dropping and unless the state decides to change their criteria for treatment, we are looking at a savings of about 30% of our cumulative expense. We encourage our prescribers to change to Admelog from Novolog and Humalog, and our pharmacies need to keep that in mind. If you are a primary pharmacy or health center for our smaller communities you need to consider getting a standing order to substitute Admelog. Conversion is unit for unit and Admelog is available in similar styles of administration. As of January 1st, 2019 CCS will be a carved-in for all Partnership counties. It will be handled variably in each county, some will want to subcontract with us to preserve their CCS staff and it will affect prior authorization. We are still working on it, and there will be a lot of transitional activity to be ready for that. The governor is proposing to eliminate the 340B program for Medi-Cal, but is meeting vigorous opposition from both the hospitals and the FQHCs. There was a proposal in the governor’s budget to eliminate 340B, but it is not finalized. In May we will know further details with regard to the future of 340B. Last month we hosted a 340B webinar at the request of several health plans who wanted to learn more about the 340B program. We hosted the webinar to provide education as to how the 340B program works, and gave some details and features of our own 340B Compliance Program. One of the health centers reached out to us about the importance of the 340B program in their own health center as well as some of the programs that are supported and sustained because of the 340B program.

(Quorum reached after start of meeting). Presented by: Marshall Kubota, MD Regional Medical Director

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2. PHC

Formulary: Maintenance, Proposed Additions/ Changes, Prior Authorization Criteria

The 340B program is a vital source of financial support for health centers and entities that serve in areas where people are uninsured, underinsured, and underserved. Dr. Paukert has joined the committee. We know have a quorum, we can now go to the approval of the minutes. Corrections: •Pg 5: the word sero was spelled serial. •Pg 6: drug medical should be capitalized to Drug Medi-Cal. •Dr. Paukert, Kristen, Moje approved. (a) The following were presented as formulary

maintenance or informational items, no action needed by committee:

Insulin lispro (Admelog) Beclomethasone dipropionate HFA (QVAR

RediHaler) Fluorouracil (Adrucil) All repackaged NDCs Esomeprazole Mg 20mg (Nexium, Nexium 24) Cervical Cap (FemCap) J0943 Cabazitaxel 1mg J3262 Tocilizumab 1mg J3285 Treprostinil (Remodulin) J9226 Histrelin Acetate 50mg implant (Supprelin

LA) J9266 Pegaspargase (Oncaspar) J0588 IncobotulinumtoxinA (Xeomin)

(b) The following were presented for PHC formulary

review for the Medi-Cal Formulary: Sevelamer carbonate (Renvela) Mometasone (Nasonex) Fluocinolone otic oil 0.01% (DermOtic) Esomeprazole Mg 40mg (Nexium) Mesalamine 800mg DR (Asacol) Mesalamine 1.2g (Lialda)

Formulary Maintenance Items, Presented for Information Only (no objections):Drug Maintenance Action Insulin lispro No action, on formulary by

GPID already (shares same GPID as Humalog)

Beclomethasone dipropionate HFA

Added to formulary as line extension

Fluorouracil vials 10, 20, 50 & 100ml vials added to formulary as line extension.

Repackaged NDCs Reinstated block at benefit level. Not covered Medi-Cal

Esomeprazole Mg 20mg Removed preference for OTC NDCS, allowing both Rx and OTC NDCs within formulary GCN to be equal.

Cervical Cap Added to formulary per State OIL and per PHC contraceptive benefit.

J0943, J3262, J3285, J9226, J9266, J0588

PHC TAR requirement added to these PAD codes.

Added to Formulary: Drug Restrictions:

Sevelamer carbonate Limit 16/day, Step Edit: 90ds calcium acetate

Mometasone (Nasonex), Step edit: 2 preferred nasal ICS; 17ml/30ds

Fluocinolone oil 0.01% (DermOtic),

limit 20ml/7ds (14ds max)

N/A

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Desonide 0.05% lotion (DesOwen) Estradiol 0.075mg/24hr (Estring) Estradiol 0.1mg/24hr, 0.05mg/24hr (Femring) Rivaroxaban (Xarelto) 10mg Eszopiclone (Lunesta) Zolpidem ER (Ambien CR) Oseltamivir (Tamiflu) Dihydroergotamine 1mg/ml injection (DHE 45) Ergotamine-caffeine tablets (Cafergot) Ergotamine 2mg SL tabs (Ergomar) Ergotamine-Caffeine supp (Migergot) Insulin Lispro (Humalog) Insulin Aspart (Novolog) Insulin Glulisine (Apidra) Mesalamine 400mg DR caps (Delzicol) OTC Group:

o Thiamine o Cyanocobalamin o Cholecalciferol o Levocarnitine o Levocarnitine tartrate o Chlorhexidine 4% wash (Hibiclens, Betasept) o Zinc Oxide, topical paste, ointment, cream

(Desitin, Boudreaux’s, Triple Paste) o Menthol-Zinc Oxide (Calmoseptine) o Capsaicin cream (Zostrix, Zostrix HP) o Saline/Aloe Vera nasal gel (AYR gel) o Multivitamin (AquADEKS) o Folic Acid Derivatives (Deplin, Metanx,

Methylfolate) o Probiotics o Oral amino acids (L-Lysine, L-Tryptophan etc) o Lactase Enzyme o Oral N-acetylcysteine

Esomeprazole Mg 40mg (Nexium)

1/day

Mesalamine 800mg DR (Asacol)

6/day; age >/= 18

Mesalamine 1.2g (Lialda) 4/day; age >/= 18 Desonide 0.05% lotion (DesOwen)

limit 118 ml

Estradiol 0.075mg/24hr (Estring)

1 ring/90ds

Estradiol 0.1mg/24hr, 0.05mg/24hr (Femring)

1 ring/90ds

Thiamine 50, 100, 250 & 500mg tablets

Added with code 1 for px/tx of thiamine deficiency due to pregnancy, lactation, alcoholism, gastric surgery or severe liver disease.

B12 500, 1000, 1500, 2000, 2500, 3000, 5000 mcg immediate release tablets, capsules, chewables and SL tablets, SL lozenges. OTC strengths <500mcg and other dosage forms remain excluded.

Added to the formulary with Code 1 restriction: for prevention or treatment of B12 deficiency.

Cholecalciferol OTC (Vitamin D3), all strengths, forms

Added as line extensions

Levocarnitine 1 g/10 ml and 500mg tablets


Levocarnitine tartrate 330 mg and 500 mg tablets


AquADEKs 400 mcg/1 ml, 100-350 mcg chewable, 100-700 mcg capsules

Added to formulary with Code 1 restriction: Limited to members with CF, CCS, GHPP or EPSDT.

Chlorhexidine 4% wash (Hibiclens, Betasept)

Limit: 480ml

Zinc Oxide 40% paste & ointment, 16% ointment, 13% cream, 12.8$ ointment

Limit: 454g

Menthol-Zinc Oxide Limit: 230g Capsaicin cream 0.025%, 0.075%, 0.1%

Limit: 60g

Saline/Aloe Vera nasal gel Limit: 15g

7/1/18

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Changes made to formulary utilization edits: Drug Restriction Change:

Diclofenac 1% gel Removal of Step edit, increase QL to 300g/mo.

Rivaroxaban (Xarelto) 10mg Removal of 2 fills per year limit

Eszopiclone (Lunesta) Removal of step edit; 1/day; age >/= 18.

Zolpidem ER (Ambien CR 6.25 mg, 12.5 mg):

Removal of PA requirement; added step requirement of either eszopiclone or zolpidem IR. 1/day. Age >/= 18.

Oseltamivir (Tamiflu) Reinstated QL #10 caps, #180ml susp, 2 fills per year, and suspension </= age 12.

Dihydroergotamine 1mg/ml injection (DHE 45)

Added limit of 10ml/month

Ergotamine-caffeine tablets (Cafergot)

Added limit of 40 tablets/month

Removed from Formulary Drug Status

Ergotamine 2mg SL tabs (Ergomar)

See PA Criteria section

Ergotamine-Caffeine supp (Migergot)

Mesalamine 400mg DR caps (Delzicol)

Insulin Lispro (Humalog) Insulin Aspart (Novolog) Insulin Glulisine (Apidra)

Review of NON-BENEFIT status Dietary/Food supplement Informational

Folic Acid Derivatives (Deplin, Metanx, Methylfolate)

These are non-benefits per DHCS; P & T confirmed that

7/1/18 7/1/18 6/1/18

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(c ) The following were presented with new or revised clinical criteria for use: Dihydroergotamine Nasal Spray (Migranal) Ergotamine tartrate SL tabs (Ergomar) Ergotamine/Caffeine supp (Migergot) Budesonide nebulizer soln (Pulmicort Respules) Hydroxyprogesterone caproate (Makena) Albuterol HFA (ProAir HFA, Proventil HFA) Dupilumab (Dupixent) Crisaborole (Eucrisa) Insulin Lispro (Humalog) Insulin Aspart (Novolog, Fiasp) Insulin Glulisine (Apidra) Mesalamine 400 mg DR cap (Delzicol) Mesalamine 250 mg, 500 mg CR cap (Pentasa) Mesalamine 0.375 gm ER cap (Apriso) Fluticasone propionate nasal spray (Xhance) OnabotulinumtoxinA (Botox) IncobotulinumtoxinA (Xeomin) AbobotulinumtoxinA (Dysport) RimabotulinumtoxinB (Myobloc) Deutetrabenazine (Austedo) Tetrabenazine (Xenazine) Valbenazine (Ingrezza) Sevelamer HCl 800mg (Renagel)

Oral amino acids (L-Lysine, L-Tryptophan etc)

these products will also be non-benefits for PHC.

Lactase Enzyme Oral N-acetylcysteine Folic Acid Derivatives (Deplin, Metanx, Methylfolate) B-12 products other than those included in the formulary. Melatonin Generally a non-benefit but

exceptions may be made on a case-by-case basis only for CCS members and EPSDT requests based on medical necessity.

Probiotics (other than CCS)

Approved Criteria Drug or Drug Group Approval status Dihydroergotamine Nasal Spray (Migranal)

Approved as proposed, see PA Criteria section

Ergotamine tartrate SL tabs (Ergomar) Ergotamine/Caffeine supp (Migergot) Budesonide nebulizer soln (Pulmicort) Hydroxyprogesterone caproate (Makena) Albuterol HFA (ProAir HFA, Proventil HFA) Dupilumab (Dupixent) Crisaborole (Eucrisa) Insulin Lispro (Humalog) Insulin Aspart (Novolog, Fiasp) Insulin Glulisine (Apidra)


Mesalamine 400 mg DR cap (Delzicol) Mesalamine 250 mg, 500 mg CR cap (Pentasa) Mesalamine 0.375 gm ER cap (Apriso)

N/A 7/1/18

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Sevelamer Carbonate powder (Renvela packets) Lanthanum carbonate chewable tablets (Fosrenol)

Fluticasone propionate nasal spray (Xhance) OnabotulinumtoxinA (Botox) Approved as modified, see

PA Criteria section IncobotulinumtoxinA (Xeomin)


AbobotulinumtoxinA (Dysport)


RimabotulinumtoxinB (Myobloc) Deutetrabenazine (Austedo) Tetrabenazine (Xenazine) Valbenazine Oral (Ingrezza)

Approved as modified

Sevelamer HCl (Renagel)/Genzyme 800mg tabs


Sevelamer Carbonate powder packets (Renvela)/Various Lanthanum carbonate (Fosrenol), 500, 750 & 1000mg (ctab, powder)

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PHC TAR Criteria, as approved by P&T Committee, 4/12/18 Effective 7/1/18, unless otherwise specified

Ergotamine Migraine Products Dihydroergotamine Nasal Spray (Migranal) New criteria, approved as proposed

Covered Uses Exclusion Criteria Required Medical Documentation

Age Restriction

Prescriber Restriction

Coverage Duration Other

For the treatment of acute migraine headaches with or without aura

Coronary, cerebral, and peripheral vascular disease, pregnancy, renal or hepatic failure, uncontrolled HTN, basilar or hemiplegic migraine

TAR documentation of trial and failure to 2 formulary triptans AND dihydroergotamine injection (supported by either clinic notes OR claim history).

If prescription is provided by a generalist, TAR must include neurologist’s consult note.

18 years and older

Prescribed or recommended by a neurologist

12 months Limited to members with a confirmed diagnosis of migraine, with or without aura.

Approval requires that member be on a routinely dosed prophylactic regimen.

QL: 8mL (32mg) per 28 days.

Each package contains 8 nasal spray vials and 8 nasal sprayers, which can treat up to 8 attacks per month.

Dihydroergotamine tartrate sublingual tablets (Ergomar) New criteria, approved as proposed


Age Restriction





TAR documentation of trial and failure to 2 formulary triptans AND ergotamine/caffeine tabs (supported by either clinic notes OR claim history).


18 years and older




QL: 20 tablets per 28 days

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Dihydroergotamine-Caffeine suppositories (Migergot) New criteria, approved as proposed


Age Restriction





TAR documentation of trial and failure to 2 formulary triptans, ergotamine/caffeine tabs, AND preferred non-formulary ergotamine SL tabs (supported by either clinic notes OR claim history.


18 years and older




QL: 20 suppositories per 28 days

Inhaled Corticosteroids (nebulized) Budesonide nebulizer solution (Pulmicort Respules) Revised criteria, Approved as proposed

(proposed changes shown in blue)


Age Restrictions

Prescriber Restrictions


Budesonide Nebulizer: (1) For maintenance & prophylaxis of asthma in young children. (2) Treatment & prevention of recurrence of nasal polyps (off-label use; applies to the 0.25 mg/2 mL and 0.5 mg/2 mL strengths only)

Diagnosis other than asthma. Asthma: Age greater than 4 yrs old (1) Diagnoses other than asthma or nasal polyps (2) Nasal polyps: Requests for 1.0 mg/2 ml are not covered for nasal polyps due to lack of evidence showing any added benefit with concentrations over 0.5 mg/ml

(1) Asthma: Clinic notes documenting Documentation of patient trial and response to formulary inhaled corticosteroids with spacer (waived if recommended by specialist and diagnosis of asthma). (2) Nasal Polyps: Documentation of an adequate trial and response to nasal saline irrigation in conjunction with 1 formulary nasal corticosteroid.

Asthma: Less than or equal to age 4 Nasal polyps: Greater than or equal to age 18

Nasal polyps: Prescribed or recommended by ENT or Allergist

12 Months (1) Asthma: On recommendation of pulmonologist or allergist, OR following failure with formulary inhaled corticosteroid used in conjunction with a spacer (PHC may request a referral to a specialist). (2) Nasal polyps: Note that this is an off-label use, supported in the clinical literature and 2015 AAO-HNS Guidelines; however, neither the literature nor the guidelines indicate a preference for any one intranasal steroid over the other.

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PHC TAR Criteria, as approved by P&T Committee, 4/12/18 Effective 7/1/18, unless otherwise specified Pregnancy facilitating/maintaining agent, hormonal Hydroxyprogesterone caproate (Makena) Revised criteria, Approved as proposed



Age Restrictions



To reduce the risk of preterm birth in women with a singleton pregnancy (single fetus) who have a history of singleton spontaneous preterm birth.

Prior or current multiple gestational pregnancy is a contraindication.

Documented history of prior singleton spontaneous preterm birth (delivery at less than 37 weeks gestation). Treatment start date, treatment end date and the corresponding gestational week numbers.

Exact duration is dependent on start date. Will be extended up to & including gestational week 3736.

Member with a single fetus and documented history of spontaneous preterm delivery of singleton fetus. Treatment to start between 16 wks, 0 days and 20 weeks, 6 days, and continuing treatment through day 6 of week 36 or delivery, whichever occurs first.

Beta adrenergic agents, inhaled, short-acting

Albuterol HFA (Proventil HFA, ProAir HFA) New criteria, approved as proposed

Covered Uses Exclusion Criteria

Required Medical Documentation

Age Restrictions



Asthma COPD

None Documentation regarding reason(s) for failure to formulary alternatives along with symptom assessment while on preferred formulary products. PHC may request spirometry results.

None None 12 months Fill history to confirm prior use of BOTH Ventolin HFA and ProAir RespiClick along with spacer (+/- mask).

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PHC TAR Criteria, as approved by P&T Committee, 4/12/18 Effective 7/1/18, unless otherwise specified Eczema Agents, systemic, interleukin-4 receptor antagonist, monoclonal antibody

Dupilumab (Dupixent) 300mg/2ml, subcutaneous injection (self-administered packaging) New criteria, approved as proposed Covered Uses

Exclusion Criteria


Age Restriction

Prescriber Restriction Coverage Duration Other

Atopic Dermatitis

Specialists consult notes with diagnosis of moderate to severe atopic dermatitis, BSA affected, and details of all prior therapies tried and failed with duration of trials and nature of failure.

≥18 years Dermatologist, Allergist, or Immunologist

Initial approval: 16 weeks (due to clinical trial response period) Renewals: 12 months

New Starts: Diagnosis of moderate to severe atopic dermatitis and meeting the following criteria (both 1&2) 1.) Patient meets ONE of the following (a or b) a. .≥10% BSA affected with documented trial and failure of at least two medium to super-high potency topical corticosteroids applied daily for at least one month (14 day trial OK if using super-high potency TCS per prescribing information) & trial and failure of topical tacrolimus applied daily for at least one month. b. < 10% BSA involving sensitive areas that significantly affect quality of life (face, eyes, skin folds, genitalia) with documented trial and failure of topical tacrolimus ointment* applied daily for at least one month.

2.) Patient has tried and failed at least one of the following systemic agents within the previous 6 months: oral cyclosporine, azathioprine, methotrexate, mycophenolate.

*While there are two topical calcineurin inhibitors available, tacrolimus is indicated to treat moderate to severe AD while pimecrolimus is indicated to treat mild to moderate AD and therefore required prerequisite is for tacrolimus specifically.

Renewals: Documentation of positive response from dupilumab therapy submitted by the prescribing physician.

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PHC TAR Criteria, as approved by P&T Committee, 4/12/18 Effective 7/1/18, unless otherwise specified Topical anti-inflammatory, phosphodiesterase-4 (PDE4) inhibitor Crisaborole 2% ointment (Eucrisa) New criteria, approved as proposed Covered Uses

Exclusion Criteria


Age Restriction

Prescriber Restriction Coverage Duration Other

Atopic Dermatitis (eczema)

Specialist clinic notes documenting mild to moderate atopic dermatitis, BSA affected, and details of all prior therapies tried and failed with duration of trials and nature of failure.

Approved for use ≥ 2 years.

Dermatologist, Allergist, Immunologist

1 month initially. Renewal: 12 months with documentation of positive response to therapy.

Adults: Diagnosis of mild to moderate atopic dermatitis with documentation of trial and failure, or contraindication to, at least two medium to high-potency topical corticosteroids for a minimum of 14 days AND trial and failure of one topical calcineurin inhibitor (tacrolimus or pimecrolimus) for at least 1 month.

2-17 years: Diagnosis of mild to moderate atopic dermatitis with documentation of trial and failure, or contraindication to, at least one topical corticosteroid for a minimum of 14 days AND trial and failure of one topical calcineurin inhibitor (tacrolimus or pimecrolimus) for at least 1 month.

*Disease activity scales exists (e.g., the SCORAD index, the eczema area and severity index [EASI], and the patient-oriented eczema measure [POEM]) and patient QOL measurement scales have been tested and validated, however they are not commonly used in clinical practice.

Mild - Areas of dry skin, infrequent itching, +/- redness, little impact on ADL’s, sleep, psychosocial wellbeing.

Moderate-Areas of dry skin, frequent itching, redness, +/-excoriation and localized skin thickening, moderate impact on ADL’s and psychosocial wellbeing, frequently disturbed sleep.

Severe - Widespread areas of dry skin, incessant itching, redness (+/- excoriation, extensive skin thickening, bleeding, oozing, cracking, and alteration of pigmentation), severe limitation of ADL’s and psychosocial functioning, nightly loss of sleep

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PHC TAR Criteria, as approved by P&T Committee, 4/12/18 Effective 7/1/18, unless otherwise specified Endocrine Insulin Analogs – Rapid acting Effective 6/1/18 Insulin Lispro (Humalog 100 u/ml vial, cartridge, KwikPen, Jr KwikPen; 200 u/ml KwikPen) Insulin Aspart (Novolog 100 u/ml FlexPen, PenFill, vials; Fiasp 100 u/ml vial, FlexTouch pen) Insulin Glulisine (Apidra 100 u/ml vial and SoloStar) New criteria, approved as proposed



Age Limits



For the treatment of Diabetes mellitus type 1 and Diabetes mellitus type 2 to improve glycemic control

Clinic notes documenting dose adjustments made to Admelog based on pre and post meal blood glucose levels.

12 months New start: Documentation of trial and failure, or intolerance to Admelog is required. Request must provide clinic notes documenting: (1) minimum 3 month trial of Admelog with adequate dose adjustment to meet prandial blood glucose goals based on pre and post meal blood glucose levels. (2) Claim history must show member has adhered to insulin regimen.

For Humalog U-200 only: Criteria waived for board certified endocrinologists

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Respiratory Therapy Agents -- Nasal Corticosteroids Budesonide nebulizer solution (Pulmicort Respules) Revised criteria, Approved as proposed


Covered Uses Exclusion Criteria Required Medical Documentation Age Limits



Budesonide Nebulizer: (1) For maintenance & prophylaxis of asthma in young children. (2) Treatment & prevention of recurrence of nasal polyps (off-label use; applies to the 0.25 mg/2 mL and 0.5 mg/2 mL strengths only)

Diagnosis other than asthma. Asthma: Age greater than 4 yrs old (1) Diagnoses other than asthma or nasal polyps (2) Nasal polyps: Requests for 1.0 mg/2 ml are not covered for nasal polyps due to lack of evidence showing any added benefit with concentrations over 0.5 mg/ml

(1) Asthma: Clinic notes documenting Documentation of patient trial and response to formulary inhaled corticosteroids with spacer (waived if recommended by specialist and diagnosis of asthma). (2) Nasal Polyps: Documentation of an adequate trial and response to nasal saline irrigation in conjunction with 1 formulary nasal corticosteroid.

Asthma: Less than or equal to age 4 Nasal polyps: Greater than or equal to age 18

Nasal polyps: Prescribed or recommended by ENT or Allergist

12 Months (1) Asthma: On recommendation of pulmonologist or allergist, OR following failure with formulary inhaled corticosteroid used in conjunction with a spacer (PHC may request a referral to a specialist). (2) Nasal polyps: Note that this is an off-label use, supported in the clinical literature and 2015 AAO-HNS Guidelines; however, neither the literature nor the guidelines indicate a preference for any one intranasal steroid over the other.

Fluticasone propionate nasal spray, 93 mcg/actuation (Xhance) New criteria, approved as proposed

Covered Uses Exclusion Criteria Required Medical Documentation Age Limits



Treatment of nasal polyps

Documentation of intolerance to, or trial and failure of, 3 formulary nasal corticosteroids one of which must be mometasone (which requires step therapy).

>18 years

Prescribed or recommended by an ENT or allergist

Initial: 4 months Renewal: Documentation of efficacy and prescriber’s reasoning why member can’t be switched to other formulary nasal sprays.

Claim history must support the use of prerequisite therapy for adequate trial period of 4 weeks at recommended doses for treatment of nasal polyps. Requests are limited to 1 device (16 mL) per 30 days.

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Neuromuscular Blockers OnabotulinumtoxinA (Botox) Revised criteria, approved as

modified

Covered Uses Exclusion Criteria Required Medical Documentation Age Limits Prescriber Restrictions Coverage Duration

Cervical dystonia (CD), upper limb spasticity (ULS) in adults, severe primary axillary hyperhidrosis (SPAH), blepharospasm with dystonia (B-D), strabismus (STB), chronic migraine prophylaxis (CMP), lower limb spasticity (LLS), Overactive Bladder (OAB, non-neurogenic), Urinary Incontinence due to detrusor overactivity (neurogenic).

Clinic notes documenting responses to first/second line treatments tried and failed

Documentation (which may include office chart notes and lab results) supporting conditions for which the toxin will be used and that member has met all approval criteria. SPAH: Hyperhidrosis Disease Severity Scale (HDSS); indication to treat is score >/= 3. Renewals: Documentation of positive clinical response and return of clinical symptoms Requests exceeding 12 week frequency: additional documentation of medical necessity & justification for non-FDA approved dosing frequency.

See criteria 18 and older unless otherwise stated, per FDA labeling: CD: >/= 16 Blepharospasm, Strabismus: >/= 12

Specialist in the field, depending on diagnosis (dermatology, neurology, ophthalmology) CD. ULS, LLS: Prescribed by or in consultation with a neurologist or an orthopedist. Blepharospasm, Strabismus: Prescribed by a neurologist or ophthalmologist. Migraine: Prescribed by or in consultation with a neurologist or board certified headache medicine specialist. SPAH: prescribed by or in consultation with a neurologist or dermatologist. OAB, UI: Prescribed by or in consultation with a neurologist, urologist or uro-gynecologist.

TBD Up to 6 months

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Neuromuscular blocking agents, continued OnabotulinumtoxinA (Botox), continued Revised criteria, approved as

modified (proposed changes in bl e committee modifications in red)

Other (diagnosis-specific additional requirements)Treatment of: (1) Upper limb spasticity in adults, (2) Cervical dystonia in adults to reduce the severity of abnormal head position and neck pain, (3) Severe axillary hyperhidrosis, inadequately managed by topical agents, (4) Blepharospasm with dystonia in patients over 12 yrs of age, (5) Strabismus in patients over 12 yrs, (6) Prophylaxis of headaches in adults with chronic migraine (15 or more per mo. and lasting 4 hrs or more). In addition, HA treatment requires: (a) Request must be from neurology, (b) Trial and failure of at least 2 formulary agents: TCA, beta-blocker, valproate or calcium channel blocker. For all indications, doses and frequency are limited to the FDA approved dosing in the package labeling. Upper Limb Spasticity: Treatment of spasticity which interferes with mobility and restricts performance of ADLs, or spasticity due to stroke, brain injury, spinal cord injury, MS, cerebral palsy, brain or spinal cord tumors and other disorders of the CNS, and when such spasticity is refractory to oral medications: baclofen, tizanidine tablets and dantrolene. Lower limb spasticity: Treatment of spasticity which interferes with mobility and restricts performance of ADLs, or spasticity due to stroke, brain injury, spinal cord injury, MS, cerebral palsy, brain or spinal cord tumors and other disorders of the CNS, and when such spasticity is refractory to oral medications: baclofen, tizanidine tablets and dantrolene. Blepharospasm: Retreatment is every 12 weeks; earlier allowed with documentation of inadequate response evidenced by effect not lasting longer than 2 months. Chronic Migraine: Prophylaxis of headaches in adults with chronic migraine (15 or more days per month lasting 4 hrs or more) for at least 3 months AND Have had an adequate trial of a minimum 8 weeks each of 2 regimens for oral preventative therapy, representing at least 2 drug classes for migraine prophylaxis in the previous 6 months:

If member has not been on a prophylactic regimen in the past 6 months, documentation regarding reason why not is required. Severe Primary Axillary Hyperhidrosis: Documented condition that is inadequately managed by aluminum chloride (formulary Drysol 20% topical solution) for 2 months OR patient has medical complications from hyperhidrosis (i.e., skin maceration with secondary skin infections). Note: Treatment of hyperhidrosis in other body areas has not been established and will not be approved per criteria. Patients should be evaluated for potential causes of secondary hyperhidrosis (e.g., hyperthyroidism) to avoid symptomatic treatment of hyperhidrosis without the diagnosis and/or treatment of the underlying disease. OAB and UI/Detrusor overactivity: Documented moderate to severe symptoms AND documented trial of 2 months each at maximum tolerated dose (or documented intolerance) to 2 pharmacology classes: anticholinergic (i.e., oxybutynin, trospium, tolterodine) agents AND beta-3 agonist (Myrbetriq). Note: trospium and tolterodine require step therapy; Myrbetriq requires prior authorization. Non-FDA approved medical indications: Reviewed case-by-case. TAR must be submitted with supporting medical literature demonstrating safety and efficacy, along with previous treatments tried.

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PHC TAR Criteria, as approved by P&T Committee, 4/12/18 Effective 7/1/18, unless otherwise specified Neuromuscular blocking agents, continued IncobotulinumtoxinA (Xeomin) New criteria, approved as proposed



Age Limits



Cervical dystonia (CD), Upper limb spasticity (ULS), Blepharospasm

Documentation (which may include office chart notes and lab results) supporting conditions for which the toxin will be used and that member has met all approval criteria.

Requests exceeding 12 week frequency: additional documentation of medical necessity & justification for non-FDA approved dosing frequency.

>/= 18 CD. ULS: Prescribed by or in consultation with a neurologist or an orthopedist. Blepharospasm: Prescribed by a neurologist or ophthalmologist.

Up to 6 months For all indications, doses and frequency are limited to the FDA approved dosing in the package labeling. Upper Limb Spasticity: Treatment of spasticity which interferes with mobility and restricts performance of ADLs, or spasticity due to stroke, brain injury, spinal cord injury, MS, cerebral palsy, brain or spinal cord tumors and other disorders of the CNS, and when such spasticity is refractory to oral medications: baclofen, tizanidine tablets and dantrolene. Blepharospasm: Retreatment is every 12 weeks. Non-FDA approved medical indications: Reviewed case-by-case. TAR must be submitted with supporting medical literature demonstrating safety and efficacy, along with previous treatments tried.

AbobotulinumtoxinA (Dysport) New criteria, approved as proposed



Age Limits



Cervical dystonia (CD), Upper limb spasticity (ULS), Lower limb spasticity (LLS)



CD, ULS: >/= 18 LLS: >/= 2

Prescribed by or in consultation with a neurologist or an orthopedist.

Up to 6 months For all indications, doses and frequency are limited to the FDA approved dosing in the package labeling. Upper Limb Spasticity: Treatment of spasticity which interferes with mobility and restricts performance of ADLs, or spasticity due to stroke, brain injury, spinal cord injury, MS, cerebral palsy, brain or spinal cord tumors and other disorders of the CNS, and when such spasticity is refractory to oral medications: baclofen, tizanidine tablets and dantrolene. Lower limb spasticity: Treatment of spasticity which interferes with mobility and restricts performance of ADLs, or spasticity due to stroke, brain injury, spinal cord injury, MS, cerebral palsy, brain or spinal cord tumors and other disorders of the CNS, and when such spasticity is refractory to oral medications: baclofen, tizanidine tablets and dantrolene. Non-FDA approved medical indications: Reviewed case-by-case. TAR must be submitted with supporting medical literature demonstrating safety and efficacy, along with previous treatments tried.

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Neuromuscular blocking agents, continued

RimabotulinumtoxinB (Myobloc) New criteria, approved as d


Age Limits



Cervical dystonia (CD)



>/= 18 Prescribed by or in consultation with a neurologist or an orthopedist.

Up to 6 months Doses and frequency are limited to the FDA approved dosing in the package labeling: No more than 5,000 units within a 12 week period. Non-FDA approved medical indications: Reviewed case-by-case. TAR must be submitted with supporting medical literature demonstrating safety and efficacy, along with previous

i d

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PHC TAR Criteria, as approved by P&T Committee, 4/12/18 Effective 7/1/18, unless otherwise specified Neuromuscular Disease – CNS Movement Disorders

Deutetrabenazine (Austedo) Tetrabenazine (Xenazine) New criteria, approved as proposed



Age Limits



Tetrabenazine: Chorea associated with Huntington’s disease. Deutetrabenazine: Chorea associated with Huntington’s disease; Tardive Dyskinesia

Taken with other VMAT2 inhibitors, such as Ingrezza (valbenazine) or currently using monoamine oxidase inhibitor (MAOI). Contraindicated in patients who are suicidal, or with untreated/ inadequately treated depression (see black box warning in the package labeling).

Huntington’s Chorea (HC): Unified Huntington’s Disease Rating Scale (UHDRS) or equivalent (eg, Total Maximal Chorea Score (TMC), submitted with chart notes documenting chorea. Tardive Dyskinesia (TD): Baseline (initial requests) or current (renewal) abnormal Involuntary Movement Scale (AIMS) test score or equivalent test is submitted in chart notes documenting tardive dyskinesia. Either Diagnosis: Chart notes confirming that member does not have risk for suicidal or violent behavior and has stable psychiatric symptoms.

18 and older HC: Prescribed by or in consultation with a neurologist. TD: Prescribed by, or consultation with, a psychiatrist or neurologist.

HC: Initial is 3 months; renewal up to 12 months. TD: Initial is 2 months; renewal up to 12 months.

Tetrabenazine (generic for Xenazine): • Generic is required when available in the marketplace. Member’s with medical justification for brand: Brand Xenazine must be dispensed through PHC”s contracted limited distribution specialty pharmacy. • Limited to use in members with a diagnosis of Huntington’s Chorea documented in the medical record.

Deutetrabenazine (Austedo): • Failure/intolerance/contraindication (including, but not limited to, substance use disorder or concurrent opioids) clonazepam (Klonopin).

Recommendation: If tardive dyskinesia is related to drug use, and if appropriate for patient, the causative drug must be discontinued or tried at a lower dose. Renewal: Documentation of improvement in AIMS score from baseline and patient’s condition has stabilized/improved while on therapy. Dispensing Limits: Limited to a 15 day supply (#30) per fill for the first 2-3 months of treatment. Dose consolidation required, meaning: using the smallest number of tablets to achieve desired dose by using increasing strengths when available, rather than “doubling” up tablets.

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Neuromuscular Disease – CNS Movement Disorders, continued

Valbenazine (Ingrezza) New criteria, approved as modified (committee modifications in d)Covered

Uses Exclusion Criteria Required Medical Documentation

Age Limit

Prescriber Restrictio


Tardive dyskinesia

Use is not recommended in severe renal impairment (CrCl less than 30 mL/minute) and concomitant administration with MAOI’s (isocarboxazid phenelzine, selegiline), or a strong CYP3A4 inducer (carbamazepine, phenytoin rifampin, St. John's wort). Dual therapy with VMAT2 Inhibitor and Congenital long QT syndrome.

(1) Complete drug and problem lists, which include:

• A confirmed diagnosis of Tardive Dyskinesia • Abnormal Involuntary Movement Scale (AIMS)

(2) Documentation of trial and failure of, or contraindication* to clonazepam. *Contraindication may include (but is not limited to) avoidance of benzodiazepine due to a history of substance use disorder or concurrent opioid use.

18 years Neurology or Psychiatry

Initial: 2 months. Renewal: up to 12 months

Limited to members with documented diagnosis of Tardive Dyskinesia who have not benefited from first line treatment and for whom either a dose reduction or change in drug from the causative agent has been attempted or is not recommended. Approvals are limited to 1 tablet per day dosing and dose consolidation is required: new start prescriptions should be written as 2 separate Rx’s (40mg & 80mg) for titration/initiation rather than doubling up the 40mm to yield an 80mg dose. Recommendation: Discontinuation or reduction of causative agent such as anti-psychotic (neuroleptic) medication if clinically possible. Renewal: Documentation of reduction in TD symptoms evidenced by a reduction in the AIMS score. Approve for 12 months with documentation of response to treatment. Dispensing limits: Limited to a 15 day supply (#15 capsules) for the first 2-3 months of new start treatment. When member is dose-stable, requests may be approved for #30 (30 days) for maintenance treatment. Dose consolidation required, meaning: using the smallest number of tablets to achieve desired dose by using increasing strengths when available, rather than “doubling” up tablets.

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Electrolyte Regulation – Phosphate Binders Sevelamer HCl (Renagel) 800mg tablets Revised criteria, approved as

proposed L h b (F l) h bl bl ( d h i



Age Limits



Lanthanum carbonate chewable tablets (Fosrenol), Sevelamer HCL 800mg tablets (Renagel), Sevelamer Carbonate (Renvela): For the treatment of hyperphosphatemia in patients with end stage renal disease (ESRD), in dialysis

New & Renewal TARs: Current lab reports which include: serum Phosphate, Calcium, Creatinine, EGFR. Other: If calcium binders are contraindicated due to elevated calcium &/or the presence of vascular or soft tissue calcification, that information should be included with TAR.

Ages 20 years and younger are subject to CCS eligibility review and referral.

None 1 yr when adequate documentation is received which meets criteria for ongoing use

For control of hyperphosphatemia in dialysis members who are unresponsive to calcium based phosphate binder therapy (formulary calcium acetate or calcium carbonate) in amounts exceeding 1,500 mg total elemental calcium content 1500mg is provided by: PhosLo: 9 per day. Tums E-X 750mg: 5 per day New Starts: Limited to the use in members with CKD and on dialysis and (1) Are unable to achieve control of serum phosphate despite adequate trials of both a calcium product* (calcium acetate/PhosLo or calcium carbonate) AND maximum doses of sevelamer carbonate (Renvela) OR (2) Calcium-based binders are contraindicated due to elevated corrected calcium x Phos product (or other risks of soft tissue calcification) AND have tried and failed sevelamer carbonate (Renvela) due to either intolerable adverse reaction or inadequate response to maximum tolerated dose. (3) Member’s prescription claim history indicates member has been adherent to therapy as prescribed. *An adequate trial of calcium acetate or calcium carbonate would be a minimum of 1,500 mg total elemental calcium content. 1500mg is provided by: PhosLo: 9 per day. Tums E-X 750mg: 5 per day. Renewals and dose escalations: Most recent labs required. Member’s pharmacy claim history will be screened for potential adherence issues, and documentation that adherence has been addressed by the provider may be required in extreme cases prior to approval of dose escalation. Therapeutic Interchange: Note that Sevelamer HCl and Sevelamer Carbonate are generally considered to be therapeutically equivalent; therefore it is required that members able to swallow tablets use formulary Sevelamer Carbonate 800mg tablets, unless documentation clearly shows why a member requires the HCl form of sevelamer tablets (Renagel). Internal guidance: Members on Sevelamer HCl (Renagel), with TAR approval prior to 7/1/18: Upon TAR expiration, members will be allowed to continue via interim TAR authorizations until such time that the prescriber determines that the member can be safely transitioned to Sevelamer Carbonate (Renvela), per PHC Policy MCRP4064 Continuation of Prescription Drugs.

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Electrolyte Regulation – Phosphate Binders, continued Sevelamer carbonate powder packets (Renvela) Lanthanum carbonate powder packets (Fosrenol) New criteria, approved as proposed


Required Medical Documentation Age Limits

Prescriber Restrictions Coverage Duration Other

For the treatment of hyperphosphatemia in patients with end stage renal disease (ESRD), in dialysis, for members unable to take oral or chewable tablet dose forms.

New starts: Documentation of medical necessity for a non-solid dosage form, such as swallowing difficulty. New & Renewal TARs: Current lab reports which include: serum Phosphate, Calcium, Creatinine, EGFR. Other: If calcium binders are contraindicated due to elevated calcium &/or the presence of vascular or soft tissue calcification, that information should be included with TAR.

Ages 20 years and younger are subject to CCS eligibility review and referral.

None 1 yr when adequate documentation is received which meets criteria for ongoing use

New Starts: Limited to members on dialysis with hyperphosphatemia and difficulty taking solid dosage forms (tablets, capsules or chewable tablets). Renewals and dose escalations: Most recent labs required. Member’s pharmacy claim history will be screened for potential adherence issues, and documentation that adherence has been addressed by the provider may be required in extreme cases prior to approval of dose escalation. Internal guidance: Members on Sevelamer HCl (Renagel), with TAR approval prior to 7/1/18: Upon TAR expiration, members will be allowed to continue via interim TAR authorizations until such time that the prescriber determines that the member can be safely transitioned to an alternative product (eg, Velphoro chewable tablets or Phoslyra calcium acetate oral solution)

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POLICY / PROCEDURE

Page 1 of 6

Policy/Procedure Number: MCRO4018 (previously RO100418) Lead Department: Health Services

Policy/Procedure Title: Pharmacy TAR Procedure External Policy Internal Policy

Original Date: 04/25/1994 (Pharmacy Authorization)

Next Review Date: 11/17/201805/09/2019 Last Review Date: 11/17/201705/09/2018


Reviewing Entities:

IQI P & T QUAC


Approving Entities:



Approval Signature: Robert L. Moore, MD, MPH, MBA Approval Date: 11/17/201705/09/2018


A. MPRP4064 - Continuation of Prescription Drugs B. MPRP4003 – Brand Name Drug Requests C. MPRP4001 – Pharmacy and Therapeutics (P & T) CommitteCommittee

A. e

II. IMPACTED DEPTS: A. Pharmacy Department B. Member Services C. Grievances and Appeals

III. DEFINITIONS:

A. N/ATherapeutic TAR: A request which will be considered based on medical necessity, clinical prior authorization criteria &/or nationally recognized treatment guidelines (for example, but not limited to, NCCN, IDSA, ADA, AHA, NIH).

A.B. Operational TAR: A request for a prior authorization that is administrative in nature, such as early fills for lost medication and vacation supply requests.

IV. ATTACHMENTS:

A. N/APHC TAR Form V. PURPOSE:

To describe the guidelines for authorizing pharmacy Treatment Authorization Requests (TARs). VI. POLICY / PROCEDURE:

A. Prescriptions for the following, but not limited to, require a Treatment Authorization Request (TAR): 1. All non-formulary medications 2. Formulary drugs designated as Prior Authorization Required 3. Brand name drugs when an equivalent generic is available 4. Drugs not meeting the Code 1 restriction criteria 5. Drugs exceeding the member age, dosing limit, quantity, or duration of treatment, provider specialty

or other PBM dispensingclaim dispensing limits as determined by the P & T Committee. 6. Any prescription that costs $1000 or more unless indicated otherwise.the plan has implemented an

exception. 7. Brand name requests in excess of a 30 day supply (added 11/20/17, for post committee review prior

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Policy/Procedure Number: MCRO4018 (previously RO100418)

Lead Department: Health Services

Policy/Procedure Title: Pharmacy TAR Procedure ☒External Policy ☐Internal Policy




Page 2 of 6

to PAC)(see section VI.E.5-6). 8. Scheduled drug requests in excess of a 30 day supply (added 11/20/17, for post committee review

prior to PAC) (see section VI.E.6). 9. Requests for early refills when the pharmacy rejection POS message is “refill too soon’ yet member

does not have the medication (due to loss, theft or direction change) 10. Requests for early refills when the pharmacy rejection POS message is “refill too soon” due to

member needing a vacation supply. a. Vacation Supplies are allowed up to a 60 day supply when member’s eligibility is known to

extend into the next 60 days. 8.11. Drugs which are a medical benefit but are not on the pharmacy formulary due to

expectations that pharmacies generally do not dispense the medication directly to the member. B. The member’s health care providers (both pharmacist and prescriber) will be required to furnish

information for the TAR and include supplemental documents when needed to establish medical necessity (or as required by prior authorization criteria) for therapeutic/clinical TAR determinations. Operational TARs (such as for vacation overrides) can often be submitted with just the information the pharmacy has available and need not be supplied by the prescriber.

C. TAR review will be based on medical necessity along with prior authorization requirements as when criteria are available and nationally recognized treatment guidelines when HealthPlan criteria are not yet established. Medical necessity means is defined as: reasonable and necessary services to protect life, to prevent significant illness or significant disability, or to alleviate severe pain through the diagnosis or treatment of disease, illness or injury.

B.D. TARs may be requested by the pharmacy provider of service or by the prescriber by submitting an electronic TAR using the Plan’s electronic TAR submission portal (PARx) or by sending (preferably by FAX) a completed TAR form to Partnership HealthPlan of CA (PHC).

C. TARs must be requested by the provider of service by submitting an electronic TAR using the Plan’s electronic TAR submission portal (PARx) or by sending (preferably by FAX) a completed TAR form to Partnership HealthPlan of CA (PHC).

E. Documentation of Pharmacy TAR Information 1. The preferred process for submitting TARs and supporting documentation is through PHC’s online

electronic TAR applications, PARx. For those providers without access to PARx or ability to scan/upload additional supporting documents, requests may be faxed.

1. Pharmacy Provider personnel are expected to document that the information submitted on the TAR is true, accurate and complete and the requested service is medically indicated and necessary to the health of the patient.

2. Pharmacy provider personnel are expected to document that the information submitted on the TAR is true, accurate and complete, and that the requested service is medically indicated and necessary to the health of the patient.

2.3. The pharmacy is expected to maintain a record that verifies the information submitted on the TAR was provided by the prescriber or the prescriber’s representative.

3.4. Specifically, the pharmacy is expected to confirm a treatment failure with the formulary alternative prior to requesting a non-formulary medication because of a treatment failure with the formulary alternative. The pharmacy is expected to keep written documentation of this information.

Added 11/20/17, for post committee review prior to PAC: 5. Requests for brand name non-specialty drugs in excess of a 30 day supply should include reasons

why a monthly fill is a hardship for the member. When hardship exists, approval will be considered for non-scheduled drugs that are for maintenance of a chronic condition and claim history or notes submitted indicate member is dose-stable, and tolerating the current regimen and adherent to treatment.

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Page 3 of 6

6. Scheduled drugs (brand or generic): requests for greater than a 30 day supply will be reviewed on a case-by-case basis and will be considered for approval only for a one time fill when extenuating circumstances exist and allowing greater than a 30 day supply is medically necessary, as defined in VI.B C above.

F. The PHC Clinical Pharmacist, Pharmacy Technician, Pharmacy Director, or Registered Nurse HealthPlan staff will perform all initial TAR reviews. All reviews by the Pharmacy Technician adhere to PHC written criteria &/or internal desktop procedures and guidelines and are performed under supervision of a HealthPlan pharmacist.

G. References used to determine authorization decisions shall include, but are not be limited to: 1. Medical references which list FDA labeling information including current editions of the Physicians’

Desk Reference, Drug Facts & Comparisons, USP Drug Information for the Health Care Professional, and other references as available on the internet.

2. PHC prior authorization criteria. 3. PHC Clinical Practice Guidelines. 4. Consultation with the Medical Director and/or outside consultants.

H. The PHC Clinical Pharmacist, Pharmacy Technician, Pharmacy Director, or Registered Nurse HealthPlan staff reviewer may take the following TAR actions: 1. Approve: An approved TAR is a TAR approved for the requested drug, strength and quantity. If the

reviewer changes the units (# of fills) requested or date of service, this is still considered an approved TAR.

2. Approve as Modified (PHC Clinical Pharmacist and Pharmacy Director only): A modified TAR is a TAR that is approved with a total Rx quantity or a different daily dose quantity that differs from the requested quantity &/or day supply submitted by the provider. The reviewer may approve a TAR as Modified on the basis of their clinical judgment without consultation from the Medical Director.

3. Administrative Denials are based on the following administrative criteria: a. TAR not required. b. Carve-out drug. c. Member not eligible with PHC on date of service. d. Duplicate request. e. Member has other primary pharmacy insurance. f. TARs submitted not submitted on a timely basisfor a retroactive date of service and not

submitted within the required timeframe (see section VI.N). g. Insufficient information submitted on the TAR to further review (PHC Clinical Pharmacist and

Pharmacy Director only). I. The Chief Medical Officer (CMO) or Medical Director must be available, physically or by telephone,

during business hours to assist with the review of TARs. 1. CMO/Medical Director reviews may be requested by the Clinical Pharmacist in cases of potential

denial due to questionable medical necessity or inappropriate use of a drug. 2. The CMO/Medical Director may contact the prescribing physician and/or consultants for additional

information, as required, to assist him/her in rendering a decision about the case. 3. The CMO/Medical Director and Clinical Pharmacists can authorize denials based on medical criteria

or make any exceptions/changes to the established medical policy/criteria for pharmacy management.

4. The CMO/Medical Director and Clinical Pharmacists can authorize denials based on formulary limits and restrictions, when medical necessity for exception to the limit or restriction has not been established. Such limits include, but are not limited to: a. Quantity Limits b. Daily Dose Limit c. Fill Limit

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Page 4 of 6

d. Age limit e. Step therapy requirement f. Code 1 restriction g. Prescriber restriction a.h. Prior Authorization requirement

5. The CMO/Medical Director and Clnical Pharmacists can authorize denials when dose consolidation is available by changing to another marketed strength or concentration, which would result in the equivalent dose given as fewer units (tablets, capsules, pills, patches, mls), and is in accordance with the FDA approved package labeling regarding dosing and administration.

3.6. The CMO/Medical Director and Clinical Pharmacists can authorize denials for products which the HealthPlan and P & T Committee, in accordance with DHCS guidelines, has determined a product is not a covered benefit.

4.7. The CMO/Medical Director and Clinical Pharmacists can authorize denials based on DHCS issued instructions (OILs, APLs or Emails) that a product is not a covered benefit.

5.8. If the CMO/Medical Director is not available, he/she may designate another physician or Clinical Pharmacist to fulfill the requirements under H 1, 2, 3I 1-8.

J. Determination and provider notification by telephone, FAX or other telecommunication device of PHC determinations will be made within twenty-four (24) hours of receiving a completed TAR.

K. Determination and provider notification of PHC determinations for urgent TARs will be made within twenty-four (24) hours from the date and time the TAR is received. The Plan will make every effort to provide determination and both provider and member notification for urgent TARs, if the TAR is received by 3:00 PM on a Plan business day. All TARs received by PHC designated as urgent by the submitting provider are subject to review to determine if the TAR should be processed as urgent.

L. Determination and member notification of PHC determinations, which includes the reason for the denial, deferral, or modification and information about the appeals process, is made within one (1) working day of the following TAR actions: 1. A denied TAR that lacks medical justification for the intended use of the drug. 2. A denied TAR that lacks documentation of having met PHC criteria for use and lacks medical

justification for an approval outside of PHC criteria. 3. A denied TAR in which insufficient information was submitted on the TAR. 4. A denied TAR in which the requested drug is a Carve-out drug (member notification is

administrative and not a determination of medical necessity). 5. A denied TAR in which the member has other primary insurance (member notification is

administrative and not a determination of medical necessity). 6. A denied TAR in which the requested product is not a covered benefit 7. A modified TAR.

M. Emergency TARs outside of PHC’s normal business hours: 1. During PHC’s normal business hours (M-F 8 AM to 5 PM), pharmacies may call the PHC Pharmacy

Department for an emergency 5 day fill. The pharmacy department may authorize up to a 5-day supply of medication, pending further authorization by PHC if the Pharmacy Department is not able to determine the medical necessity of the full prescription.

2. Outside of PHC’s normal business hours PHC’s contracted Pharmacy Benefit Manager (PBM) is authorized to respond to emergency TARs outside of PHC’s normal business hours, including weekends and holidays. The PBM may authorize up to a 5-day supply of medication, pending further authorization by PHC.

3. When both PHC and the contracted PBM are unavailable, PHC will authorize a retroactive TAR allowing the pharmacy to dispense up to a 5 day supply of a non-formulary drug.

N. Retroactive TARs must be received by PHC within fifteen (15) business days of requested date of service or within 60 days of the date that a member’s retroactive eligibility is established with PHC.

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Retroactive TARs received after fifteen (15) business days of requested date of service may be submitted for consideration. Members do not have financial liability in this instance and may not be billed by the provider for services rendered. Consideration considered for review of a TAR received after fifteen (15) business days may be done under the following conditions: 1. When certification of the Medi-Cal beneficiary’s eligibility by the county welfare department was

delayed. 2. When other coverage (e.g., Medicare or other health insurance programs) denied payment of a claim

for services. 3. When a member does not identify himself/herself to the provider as a PHC member by deliberate

concealment or because of physical or mental incapacity to so identify himself/herself. 4. If a member has obtained retroactive eligibility, the TAR must be received by PHC within 60 days

of the members obtaining Medi-Cal eligibility. O. TAR approval will be granted for a member to continue the use of a non-formulary single source drug

which is part of a prescribed therapy in effect before enrollment with PHC until the therapy is no longer prescribed by the member’s doctor as described in Policy #MPRP4064 Continuation of Prescription Drugs.

VII. REFERENCES:


A. PHC Department Directors, B. PHC Provider Manual C. Policies & Procedures SharePoint site

IX. POSITION RESPONSIBLE FOR IMPLEMENTING PROCEDURE:

Associate Director of Pharmacy Operations X. REVISION DATES: 03/23/95; 10/10/97 (name change only); 05/28/99; 12/15/99, 10/17/01; 04/17/02;

11/20/02; 11/19/03; 04/21/04; 04/3/08; 01/27/11; 08/18/11; 01/17/13; 01/16/14; 10/1/15; 10/6/16; 04/06/17, 11/17/2017; 05/09/2018 *Through 2017, Approval Date reflective of the Pharmacy and Therapeutics Committee meeting date. Effective January 2018, Approval Date reflects that of the Physician Advisory Committee’s meeting date.


XI. POLICY DISCLAIMER:

A. In accordance with the California Health and Safety Code, Section 1363.5, this policy was developed with involvement from actively practicing health care providers and meets these provisions: 1. Consistent with sound clinical principles and processes; 2. Evaluated and updated at least annually; 3. If used as the basis of a decision to modify, delay or deny services in a specific case, the criteria will

be disclosed to the provider and/or enrollee upon request. B. The materials provided are guidelines used by PHC to authorize, modify or deny services for persons

with similar illnesses or conditions. Specific care and treatment may vary depending on individual need and the benefits covered under PHC.

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POLICY / PROCEDURE

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Policy/Procedure Number: MCRO4018 (previously RO100418) Lead Department: Health Services

Policy/Procedure Title: Pharmacy TAR Procedure External Policy Internal Policy


Next Review Date: 05/09/2019 Last Review Date: 05/09/2018


Reviewing Entities:

IQI P & T QUAC


Approving Entities:





A. MPRP4064 - Continuation of Prescription Drugs B. MPRP4003 – Brand Name Drug Requests C. MPRP4001 – Pharmacy and Therapeutics (P & T) Committee

II. IMPACTED DEPTS:

A. Pharmacy Department B. Member Services C. Grievances and Appeals

III. DEFINITIONS:

A. Therapeutic TAR: A request which will be considered based on medical necessity, clinical prior authorization criteria &/or nationally recognized treatment guidelines (for example, but not limited to, NCCN, IDSA, ADA, AHA, NIH).

B. Operational TAR: A request for a prior authorization that is administrative in nature, such as early fills for lost medication and vacation supply requests.

IV. ATTACHMENTS:

A. PHC TAR Form V. PURPOSE:

To describe the guidelines for authorizing pharmacy Treatment Authorization Requests (TARs). VI. POLICY / PROCEDURE:

A. Prescriptions for the following, but not limited to, require a Treatment Authorization Request (TAR) 1. All non-formulary medications 2. Formulary drugs designated as Prior Authorization Required 3. Brand name drugs when an equivalent generic is available 4. Drugs not meeting the Code 1 restriction criteria 5. Drugs exceeding the member age, dosing limit, quantity, duration of treatment, provider specialty or

other PBM claim dispensing limits as determined by the P & T Committee. 6. Any prescription that costs $1000 or more unless the plan has implemented an exception. 7. Brand name requests in excess of a 30 day supply (see section VI.E.5-6). 8. Scheduled drug requests in excess of a 30 day supply (see section VI.E.6). 9. Requests for early refills when the pharmacy rejection POS message is “refill too soon’ yet member

does not have the medication (due to loss, theft or direction change)

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Next Review Date: 05/09/19 Last Review Date05/09/2018


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10. Requests for early refills when the pharmacy rejection POS message is “refill too soon” due to member needing a vacation supply. a. Vacation Supplies are allowed up to a 60 day supply when member’s eligibility is known to

extend into the next 60 days. 11. Drugs which are a medical benefit but are not on the pharmacy formulary due to expectations that

pharmacies generally do not dispense the medication directly to the member. B. The member’s health care providers (both pharmacist and prescriber) will be required to furnish

information for the TAR and include supplemental documents when needed to establish medical necessity (or as required by prior authorization criteria) for therapeutic/clinical TAR determinations. Operational TARs (such as for vacation overrides) can often be submitted with just the information the pharmacy has available and need not be supplied by the prescriber.

C. TAR review will be based on medical necessity along with prior authorization requirements as when criteria are available and nationally recognized treatment guidelines when HealthPlan criteria are not yet established. Medical necessity is defined as: reasonable and necessary services to protect life, to prevent significant illness or significant disability, or to alleviate severe pain through the diagnosis or treatment of disease, illness or injury.

D. TARs may be requested by the pharmacy provider of service or by the prescriber by submitting an electronic TAR using the Plan’s electronic TAR submission portal (PARx) or by sending (preferably by FAX) a completed TAR form to Partnership HealthPlan of CA (PHC).

E. Documentation of Pharmacy TAR Information 1. The preferred process for submitting TARs and supporting documentation is through PHC’s online

electronic TAR applications, PARx. For those providers without access to PARx or ability to scan/upload additional supporting documents, requests may be faxed.

2. Pharmacy provider personnel are expected to document that the information submitted on the TAR is true, accurate and complete, and that the requested service is medically indicated and necessary to the health of the patient.

3. The pharmacy is expected to maintain a record that verifies the information submitted on the TAR was provided by the prescriber or the prescriber’s representative.

4. Specifically, the pharmacy is expected to confirm a treatment failure with the formulary alternative prior to requesting a non-formulary medication because of a treatment failure with the formulary alternative. The pharmacy is expected to keep written documentation of this information.

5. Requests for brand name non-specialty drugs in excess of a 30 day supply should include reasons why a monthly fill is a hardship for the member. When hardship exists, approval will be considered for non-scheduled drugs that are for maintenance of a chronic condition and claim history or notes submitted indicate member is dose-stable, tolerating the current regimen and adherent to treatment.

6. Scheduled drugs (brand or generic): requests for greater than a 30 day supply will be reviewed on a case-by-case basis and will be considered for approval only for a one time fill when extenuating circumstances exist and allowing greater than a 30 day supply is medically necessary, as defined in VI.C above.

F. The PHC Clinical Pharmacist, Pharmacy Technician, Pharmacy Director, or Registered Nurse HealthPlan staff will perform all initial TAR reviews. All reviews by the Pharmacy Technician adhere to PHC written criteria &/or internal desktop procedures and guidelines and are performed under supervision of a HealthPlan pharmacist.

G. References used to determine authorization decisions shall include, but are not be limited to: 1. Medical references which list FDA labeling information including current editions of the Physicians’

Desk Reference, Drug Facts & Comparisons, USP Drug Information for the Health Care Professional, and other references as available on the internet.

2. PHC prior authorization criteria.

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3. PHC Clinical Practice Guidelines. 4. Consultation with the Medical Director and/or outside consultants.

H. The PHC Clinical Pharmacist, Pharmacy Technician, Pharmacy Director, or Registered Nurse HealthPlan staff reviewer may take the following TAR actions: 1. Approve: An approved TAR is a TAR approved for the requested drug, strength and quantity. If the

reviewer changes the units (# of fills) requested or date of service, this is still considered an approved TAR.

2. Approve as Modified (PHC Clinical Pharmacist and Pharmacy Director only): A modified TAR is a TAR that is approved with a total Rx quantity or a different daily dose quantity that differs from the requested quantity &/or day supply submitted by the provider. The reviewer may approve a TAR as Modified on the basis of their clinical judgment without consultation from the Medical Director.

3. Administrative Denials are based on the following administrative criteria: a. TAR not required. b. Carve-out drug. c. Member not eligible with PHC on date of service. d. Duplicate request. e. Member has other primary pharmacy insurance. f. TARs submitted for a retroactive date of service and not submitted within the required

timeframe (see section VI.N) g. Insufficient information submitted on the TAR to further review (PHC Clinical Pharmacist and

Pharmacy Director only). I. The Chief Medical Officer (CMO) or Medical Director must be available, physically or by telephone,

during business hours to assist with the review of TARs. 1. CMO/Medical Director reviews may be requested by the Clinical Pharmacist in cases of potential

denial due to questionable medical necessity or inappropriate use of a drug. 2. The CMO/Medical Director may contact the prescribing physician and/or consultants for additional

information, as required, to assist him/her in rendering a decision about the case. 3. The CMO/Medical Director and Clinical Pharmacists can authorize denials based on medical criteria

or make any exceptions/changes to the established medical policy/criteria for pharmacy management.

4. The CMO/Medical Director and Clinical Pharmacists can authorize denials based on formulary limits and restrictions, when medical necessity for exception to the limit or restriction has not been established. Such limits include, but are not limited to: a. Quantity Limits b. Daily Dose Limit c. Fill Limit d. Age limit e. Step therapy requirement f. Code 1 restriction g. Prescriber restriction h. Prior Authorization requirement

5. The CMO/Medical Director and Clnical Pharmacists can authorize denials when dose consolidation is available by changing to another marketed strength or concentration, which would result in the equivalent dose given as fewer units (tablets, capsules, pills, patches, mls), and is in accordance with the FDA approved package labeling regarding dosing and administration.

6. The CMO/Medical Director and Clinical Pharmacists can authorize denials for products which the HealthPlan and P & T Committee, in accordance with DHCS guidelines, has determined a product is not a covered benefit.

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7. The CMO/Medical Director and Clinical Pharmacists can authorize denials based on DHCS issued instructions (OILs, APLs or Emails) that a product is not a covered benefit.

8. If the CMO/Medical Director is not available, he/she may designate another physician or Clinical Pharmacist to fulfill the requirements under I 1-8.

J. Determination and provider notification by telephone, FAX or other telecommunication device of PHC determinations will be made within twenty-four (24) hours of receiving a completed TAR.

K. Determination and provider notification of PHC determinations for urgent TARs will be made within twenty-four (24) hours from the date and time the TAR is received. The Plan will make every effort to provide determination and both provider and member notification for urgent TARs, if the TAR is received by 3:00 PM on a Plan business day. All TARs received by PHC designated as urgent by the submitting provider are subject to review to determine if the TAR should be processed as urgent.

L. Determination and member notification of PHC determinations, which includes the reason for the denial, or modification and information about the appeals process, is made within one (1) working day of the following TAR actions: 1. A denied TAR that lacks medical justification for the intended use of the drug. 2. A denied TAR that lacks documentation of having met PHC criteria for use and lacks medical

justification for an approval outside of PHC criteria. 3. A denied TAR in which insufficient information was submitted on the TAR. 4. A denied TAR in which the requested drug is a Carve-out drug (member notification is

administrative and not a determination of medical necessity). 5. A denied TAR in which the member has other primary insurance (member notification is

administrative and not a determination of medical necessity). 6. A denied TAR in which the requested product is not a covered benefit 7. A modified TAR.

M. Emergency TARs outside of PHC’s normal business hours: 1. During PHC’s normal business hours (M-F 8 AM to 5 PM), pharmacies may call the PHC Pharmacy

Department for an emergency 5 day fill. The pharmacy department may authorize up to a 5-day supply of medication, pending further authorization by PHC if the Pharmacy Department is not able to determine the medical necessity of the full prescription.

2. Outside of PHC’s normal business hours PHC’s contracted Pharmacy Benefit Manager (PBM) is authorized to respond to emergency TARs outside of PHC’s normal business hours, including weekends and holidays. The PBM may authorize up to a 5-day supply of medication, pending further authorization by PHC.

3. When both PHC and the contracted PBM are unavailable, PHC will authorize a retroactive TAR allowing the pharmacy to dispense up to a 5 day supply of a non-formulary drug.

N. Retroactive TARs must be received by PHC within fifteen (15) business days of requested date of service or within 60 days of the date that a member’s retroactive eligibility is established with PHC. Retroactive TARs received after fifteen (15) business days of requested date of service may be submitted for consideration. Members do not have financial liability in this instance and may not be billed by the provider for services rendered. Consideration for review of a TAR received after fifteen (15) business days may be done under the following conditions: 1. When certification of the Medi-Cal beneficiary’s eligibility by the county welfare department was

delayed. 2. When other coverage (e.g., Medicare or other health insurance programs) denied payment of a claim

for services. 3. When a member does not identify himself/herself to the provider as a PHC member by deliberate

concealment or because of physical or mental incapacity to so identify himself/herself. 4. If a member has obtained retroactive eligibility, the TAR must be received by PHC within 60 days

of the members obtaining Medi-Cal eligibility.

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O. TAR approval will be granted for a member to continue the use of a non-formulary single source drug which is part of a prescribed therapy in effect before enrollment with PHC until the therapy is no longer prescribed by the member’s doctor as described in Policy #MPRP4064 Continuation of Prescription Drugs.

VII. REFERENCES:


A. PHC Department Directors, B. PHC Provider Manual C. Policies & Procedures SharePoint site


Associate Director of Pharmacy Operations X. REVISION DATES: 03/23/95; 10/10/97 (name change only); 05/28/99; 12/15/99, 10/17/01; 04/17/02;

11/20/02; 11/19/03; 04/21/04; 04/3/08; 01/27/11; 08/18/11; 01/17/13; 01/16/14; 10/1/15; 10/6/16; 04/06/17, 11/17/2017; 05/09/2018 *Through 2017, Approval Date reflective of the Pharmacy and Therapeutics Committee meeting date. Effective January 2018, Approval Date reflects that of the Physician Advisory Committee’s meeting date.






PHC’s authorization requirements comply with the requirements for parity in mental health and substance use disorder benefits in 42 CFR 438.910

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POLICY / PROCEDURE

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Policy/Procedure Number: MPRP4001 (previously RP100401) Lead Department: Health Services

Policy/Procedure Title: Pharmacy & Therapeutics (P&T) Committee External Policy Internal Policy

Original Date: : 05/28/1999 Next Review Date: 07/27/201805/09/2019 Last Review Date: 07/27/201705/09/2018

Applies to: Medi-Cal Healthy Kids Employees

Reviewing Entities:

IQI P & T QUAC


Approving Entities:



Approval Signature: Robert L. Moore, MD, MPH, MBA Approval Date: 04/06/201705/09/2018


A. N/AMCUP3042 Technology Assessment B. MCRO4018 Pharmacy TAR Procedure A.C. MPRP4001 Brand Name Drugs

II. IMPACTED DEPTS.:

N/A III. DEFINITIONS:

N/A IV. ATTACHMENTS:

A. Provider Formulary Addition Request Form V. PURPOSE:

To describe the organization, operation, function and scope of the Partnership HealthPlan of California (PHC) Pharmacy and Therapeutics (P&T) Committee.


A. The Pharmacy & Therapeutics Committee as created under the authority of PHC Chief Executive Officer (CEO) will make recommendations to the Physician Advisory Committee (PAC) regarding the content of the PHC Medi-Cal Formulary, which includes new drug evaluations, new technology related to pharmaceuticals, therapeutic class reviews, development of Prior Authorization Criteria and Code 1 Restrictions and other matters regarding the PHC drug benefit.

A.B. The P&T Committee shall develop, and review and update formularies for all Lines of Business (LOB) as follows: 1. The P&T Committee shall appropriately review the formularies to make recommendations regarding

revisions to adapt to both the number and types of drugs on the market. The P&T Committee shall review and approve the formulary on an annual basis, with the totality of

formulary review occurring over the course of the calendar year at quarterly P & T Committee meetings. approve inclusion or exclusion of drugs in the formularies on a quarterly basis.

2. The quarterly P & T Committee meetings will review items proposed by the plan, committee members and by providers for formulary addition, changes to formulary limits/restrictions, formulary removal, plan exclusions and prior authorization criteria for both formulary and non-formulary pharmaceuticals.

3. The P&T Committee shall consider whether or not the inclusion of a particular Covered Drug or

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http://eshare/sites/PoliciesnProcedures/Pharmacy/MPRP4001%20Attachments/MPRP4001-A.pdf


Policy/Procedure Title: Pharmacy & Therapeutics (P&T) Committee

☒ External Policy ☐ Internal Policy



Page 2 of 10

Pharmaceutical Class on the formularies formulary or on a particular formulary tier has any therapeutic advantages in safety and efficacy. The P&T Committee shall consider the therapeutic advantages in relation to the interaction of a drug therapy regimen and the use of other health care services, including non-pharmacologic treatments.

4. For the Medi-Cal formulary, theThe P&T Committee shall perform an initial review of drugs that are clinically effective. If two (2) or more drugs have the same therapeutic advantages in regard to safety and efficacy, the P&T Committee may consider total health care costs to achieve appropriate, safe, and cost effective drug therapy.

5. The P&T Committee shall review and update Plan policies that guide the Formulary Drug List, Exceptions, P & T, Pharmacy Programs and other utilization management processes including: a) Drug utilization review; b) MCRO4018 Pharmacy TAR Procedure c) MCRP4060 340B Compliance Program Policy d) MCRP4064 Continuation of Prescription Drugs e) MPRG4025 Palivizumab (Synagis) Guidelines f) MPRP4001 Pharmacy and Therapeutics (P & T) Committee g) MRPR4020 Restricted Status for Members Receiving Prescription Medications h) MpRP4033 Brand Name Drug Requests i) MPRP4034 Pharmaceutical Patient Safety a. MPRP4049 Chronic Opioid Therapy in Chronic Non-Cancer Pain j) MPRP4056 Pediatric Enteral Nutrition k) MPRP4059 Formulary Utilization Management for Managing Pain Safely l) MPRP4061 Enteral Nutrition Products m) MPRP4062 Drug Wastage Payments n) MPRP4063 Designated Specialty Drugs b. Quantity limits; c. Generic substitution; and d. Therapeutic interchange.

6. The P&T Committee shall evaluate and analyze treatment protocols and procedures related to the formularies formulary and non-formulary drug products at least annually, and consistent with policy guidelines and instructions from the Centers for Medicare & Medicaid Services (CMS).

2. Technology Review: The Chief Medical Officer or physician designee may request input from an

appropriate specialist within the community prior to presenting the request to the Pharmacy and Therapeutics (P&T) Committee, Quality/Utilization Advisory Committee (QUAC), Physician Advisory Committee (PAC). This specialist must have expertise in the technology under review. The decision to consult a specialist will depend on the nature of the technology being considered, and will be made on a case-by-case basis. (See New Technology Policy MCUP3042).

B. B.C. Partnership HealthPlan of California (PHC) shall remain accountable to CMS for the integrity,

expertise, and qualifications of the P&T Committee. C.D. PHC shall ensure that the P&T Committee uses appropriate scientific and economic criteria when

considering utilization management activities that affect access to drugs and drug classes such as: 1. Access to non-formulary drugs; process for submitting prior authorization requests for non-

formulary drugs is per policy MCRO4018; 2. Formulary restrictions and limits

a) Formulary restrictions and limits are implemented electronically at point of sale through the use of PBM Formulary Edits. Requests for exceptions to Edits may be requested through the prior authorization (TAR) process (see policy MCRO4018).

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a)b) Formulary Edits are defined and established by the Plan’s PBM and are selected by the Plan and submitted to P & T for the purpose of utilization management of formulary drugs based on safety, efficacy, FDA approved dose/duration or dose/durations as recommended by nationally recognized treatment guidelines or pharmaceutical compendia. The most commonly used edits are: 1) Prior authorization;: An item may be on formulary yet require clinical criteria to be

approved through the TAR process prior to use. 2) Step therapy: Previous paid claim(s) in the PBM data for a prerequisite treatment(s) which

is(are) to be used first before the claim will pay. ; 3) Code 1 restriction: A requirement placed on a drug which limits use based on diagnosis,

prescriber, clinical parameters, or other limits that cannot otherwise be implemented as specific edit. The prescriber is asked to list the qualifying diagnosis or other remark on the Rx; the pharmacy must verify the Code 1 usage with the office if not stated on the Rx. The Code 1 information as obtained from the prescriber (name, date) must be on the hardcopy Rx or in e-script notes and retrievable for audit purposes. The pharmacy is able to submit electronic override at point-of-sale (as attestation that Code 1 requirements are met), without having to submit prior authorization.

4) Quantity Limits: The number of units (tabs, mls, gms, etc) that may be either billed per Rx fill or per day supply.

5) Duration Limits: The number of days (consecutive or cumulative) a treatment may be limited to.

6) Fill Limits: The number of prescription fills a treatment may be limited to. 7) Age Limits: Determines age range for which claims will pay without prior authorization. 8) Grandfathering: Used when the committee opts to allow electronic claims’ verification of

continuation of care when a drug is removed from the formulary. 9) Prescriber Edits: used to allow Rx claims for certain specialist prescribers to pay regardless

of formulary status, Code 1, step edits or PA Criteria. 10) “Lookback Periods”: This is a PBM tool used by the plan to implement P & T approved

formulary edits when a specific period of time is needed for the claim adjudication process to take into account previous claim history. The Lookback periods will be determined by the plan in consultation with the PBM for optimal implementation of Step edits, Grandfathering, Fill limits and Duration limits. The P & T committee need not oversee /approve the lookback periods, but may be asked to advise.

3. 2.3. Generic substitution; : Generic substitution is required when an FDA approved generic is available

(see policy MPRP4033, Brand Name Drugs).and 3.4. Therapeutic interchange protocols: Defined through the use of formulary edits (Step therapy edits or

Code 1 restrictions) and Prior Authorization criteria when prerequisite prior therapy is required. E. The P&T Committee shall adhere to P&T guidelines that CMS shall, from time to time, promulgate with

regard to subject areas, including: 1. Membership; 2. Conflict of interest; 3. Meeting schedule; 4. Meeting minutes; 5. Therapeutic classes; 6. Drug review and inclusion; 7. Formulary management; 8. Utilization management and review; 9. Formulary exceptions; and

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10. Educational programs for Providers: a) For Pharmacy Providers: The Pharmacy Department conducts an annual survey of pharmacies

and reviews the results to get feedback during an annual focus group. b) For Prescribers: A PHC clinical pharmacist and/or PHC Medical Director meets annually with

selected provider sites during “academic detailing visits” at which time, any issues regarding continuity and coordination of pharmaceutical care from prescribers are addressed.

F. PHC shall adopt all P&T Committee recommendations regarding the drugs placed on the formulariesformulary when subsequently approved by the Physician Advisory Committee (PAC).

B. F.G. PHC shall consider recommendations from the P&T Committee in the following areas as advisory

and not binding: 1. Review of policies that guide utilization management; and 2. Evaluation and analysis of treatment protocols and procedures.

G.H. The P&T Committee shall maintain written documentation of decisions regarding formulary development and revision and utilization management activities.

H.I. GOALS: To assure continuing member access to a quality driven, cost-effective, rational drug benefit through the PHC Formulary and prescription drug preauthorization process.

I.J. Organization and Operation 1. Membership

a) The committee shall be comprised of the following members 1) PHC Chief Medical Officer 2) PHC Director of Pharmacy, who shall serve as secretary 3) PHC Clinical Pharmacist 4) PHC Medical Director 5) Practicing physician(s) representing primary care specialties including Family Practice,

Internal Medicine, and Pediatrics 6) Practicing physician(s) representing specialist groups such as OBGYN and medical

subspecialties 7) Practicing physician representing Psychiatry 8) Practicing community pharmacist(s) 9) Other representatives as determined appropriate by the Committee.

b) Membership of the P&T Committee shall include a majority of members who are practicing physicians or practicing pharmacists with: 1) At least one (1) practicing physician and at least one (1) practicing pharmacist who do not

have a conflict of interest with respect to PHC and pharmaceutical manufacturers; 2) At least one (I) practicing physician and at least one (1) practicing pharmacist who are

independent experts in the care of the elderly or disabled persons; and 3) Representation from various clinical specialties.

c) The PHC Chief Medical Officer shall serve as the Committee Chairman. d) Non-voting members.

1) PHC Director of Health Services Director 2) PHC Director of Provider Relations (ad hoc) 3) PHC Quality Assurance representative (ad hoc) 4) Other invited experts such as, consultant pharmacists or consultant physicians, etc.

e) The distribution of physician and pharmacist membership should represent the PHC member population.

2. A quorum defined by 1/3 of the practicing members must be present in order to conduct the P&T committee meeting. A consensus recommendation is made on formulary additions, changes, and deletions and drug/benefit policies. If no consensus is established, the issue is voted on with the

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decision determined by majority vote of the quorum. 3. The P&T Committee meets at least four times per year. If urgent matters pertaining to the selection

or utilization of drugs arise between meetings, a telephone meeting may be conducted with the members, or a poll of members by fax or email may be utilized. (See section VI.L.2.g)

4. An agenda and supplementary materials, including minutes of the previous meeting, are prepared and submitted to the committee members in sufficient time before the meeting to ensure proper review of the material. This is the responsibility of the secretary.

5. Minutes of the committee proceedings are prepared and signed and maintained in the permanent records of PHC.

6. All recommendations by the committee for additions, deletions or changes to the formulary are forwarded to the Physician Advisory Committee (PAC) for approval. Any additions, deletions or changes to the formulary or to prior authorization criteria will take effect no sooner than the first day of the month after the PAC meeting. This is to allow time to notify physicians, pharmacists and other providers and to change systems if needed.

7. Distribution of Pharmacy Formulary (Covered Drug List): Providers and members are notified of multiple times per calendar year on how to access the list of covered drugs (pharmacy drug formulary) which is maintained online on the Plan’s website. a) Providers are notified in the quarterly Provider Newsletter distributed by the Chief Medical

Officer. b) Members are notified in the written semi-annual newsletter by mail (distributed by PHC

Member Services). 8. Changes to the Pharmacy Drug Benefit are made available to members and providers.

a) Providers: PHC practitioners are notified by mail of all changes to the Plan’s policies and procedures for drug utilization management in the form of formulary additions, deletions and changes as well as new and revised prior authorization criteria, prior to the scheduled implementation date. This notification is accomplished by the following:

b) P & T Updates page on the PHC Website, updated quarterly prior to the effective date. 1) At least one previous calendar year’s updates will remain available, together with the

current calendar year. c) Pharmacy Updates page on the PHC Website, updated as needed, at least quarterly, will include

notification that there has been a formulary update and where to find the specific drug formulary changes.

d) A FAX-compatible version of the Pharmacy Updates will be faxed to pharmacy providers. e) The Plan’s Policies and Procedures are available to practitioners on the Plan’s website, which

includes Policies, Clinical Treatment Guidelines, the Provider Manual and the Pharmacy Procedure Manual.

f) Any of the above are available upon request to pharmacy and medical providers who do not have online or FAX access. A provider may contact the Pharmacy Department to have the most recent updates sent by mail:

Partnership HealthPlan of California, Pharmacy Services Department 4665 Business Center Drive Fairfield, CA 94534 (707) 863-4414

g) Members receive a written semi-annual newsletter (distributed by PHC Member Services) with information on drug benefit updates and instructions on how to access online (or obtain by mail) the current covered drug list; notification will also include how to access/obtain past and recent formulary change notifications found in PHC’s P & T Updates documents. Such formulary updates include, but are not limited to, the following:

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1) Formulary additions 2) Formulary removals 3) Changes in limits and restrictions to covered drugs

J.K. Functions: The functions and scope of this committee are designed to promote quality in the use of prescription drugs, to manage and control drug costs, and to continue to support the development of Treatment Guidelines and Clinical Practice Guidelines based on clinical efficacy and sound pharmacoeconomic principles.

K.L. Formularies 1. Maintain drug formularies, acceptable for use in the ambulatory care setting, which is updated on a

quarterly basis and reviewed annually.reviewed and updated on a quarterly basis. 2. Interim formulary updates may be made by PHC pharmacy department such as those immediately

necessary due market changes brought about by: a) New generics/line extension (same/similar entity already on formulary in another form or

strength) b) Market shortages of formulary preferred generic items. c) Changes in Pharmacy Benefit Manager (PBM) Maximum Allowable Cost (MAC) pricing. d) Removal of Generic from market, causing change of brand status to revert from Multi-

Sourced Brand (MSB) to Single Sourced Brand (SSB) (which would cause PBM to automatically place SSB on formulary if generic was on formulary prior to removal from market)

c)e) Moving drugs from non-formulary status to “formulary with prior authorization required” in order to meet business needs of the plan; no change to intent of criteria will be made, only such changes in wording regarding status as being on formulary instead of non-formulary. Reasons for doing so include: (a1) to meet requirements for supplemental rebates and (b2) to enable a “preferred” status among drugs in a class for which multiple alternatives exist and the plan wishes to prefer one over others for safety, cost &/or efficacy yet clinical criteria for use will remain in effect.

f) All changes/interim updates will be reviewed for consent (no action needed) by the P&T committee at next scheduled meeting as “formulary maintenance” items.

d)g) Drugs requiring implementation of interim prior authorization guidelines will be sent to the committee for comment and vote by email. The result will then be included in the next PAC meeting for approval and implemented at the first of the month following the PAC meeting. Such items will be included as addendum to the minutes in the next occurring P & T packet, not an item for further P & T action or consent.

3. Formulary addition or deletion requests must be submitted either by credentialed PHC clinicianscontracted clinicians, contracted pharmacistspharmacist ,providers, or PHC staff. All requests from non-PHC staff must be submitted on the Provider Formulary Addition Request Form (Attachment A) and sent to: 1)a) US Mail: Partnership HealthPlan of California

Director of Pharmacy 4665 Business Center Drive Fairfield, CA 94534

Or, b) FAX to Partnership HealthPlan of California: (707) 863-4330

Or, c) Email completed form to: [email protected]

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4. The P&T Committee shall base clinical decisions regarding utilization management on the strength of scientific evidence, and standards of practice, and safety and efficacy considerations. The P&T Committee may will use criteria for utilization management decisions which takes into account the following: to assist in decision-making. a) Pharmaceutical class – i.e., taking into account which drug classes are available as a PHC

benefit vs those that are either excluded or carved out to State fee-for-service Medi-Cal. b) Classes preferred or covered at any level c) Lists of preferred drugs d) Considerations for limiting drugs in certain classes

1) For example, Specialty Drugs (Policy MPRP4063) or 2) Opioid Analgesics (Policy MPXG5008, MPRP4049, MPRP4059)

e) Generic substitution, therapeutic interchange, step therapy or other utilization management methods described in section VI.D.2

f) Within each class of pharmaceuticals, the committee will consider: 1) those agents preferred or covered at any level 2) the criteria for prior authorization of any pharmaceutical 3) exceptions processes available to members 4) substitutions that will be allowed automatically or with permission from the prescribing

practitioner 5) evidence that preferred status agents can produce similar or better results for a majority of

the population than other pharmaceuticals in the same class; 2)6) other requirements, restrictions, limitations or incentives that apply to the use of certain

pharmaceuticals as described in section V1.D.2 4.5. The review process for formulary consideration of all drugs is based on clinical evidence which

includes the following: 1) Relevant findings of government agencies 2) Medical associations 3) National commissions 4) Peer-reviewed journals 5) Authoritative compendia 6) Confirmation that the drug has an approved indication by the Food and Drug Administration

(FDA) 7) Input from selected relevant specialists or professionals, if not represented on the P&T

Committee, who have expertise in the drug being reviewed 8) Randomized clinical trials; 9) Pharmacoeconomic studies; 10) Outcomes research data; and Other information as it determines appropriate. 11)

5.6. The committee uses the following criteria, documented by clinical studies and journal articles, when evaluating items to be added to the formulary: efficacy, safety, convenience, and cost.

7. The P&T Committee shall make reasonable effort to review a new chemical entity or new Food and Drug Administration (FDA) clinical indicator within ninety (90) calendar days after release into the market, and shall make a decision within one hundred eighty (180) calendar days after release into the market. a) . If the P&T Committee fails to meet timeframes set forth in Section III.J.1.g) of this policy,

PHC shall provide a clinical justification for such delay to CMS. a. b) PHC shall immediately remove from the formulary any drug removed from the market by the

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FDA or manufacturers for safety reasons. from the formulary 1) Pharmaceutical products that are no longer being manufactured for business reasons

alone and remain classified by the FDA as safe and effective may remain on the formulary for up to 2 years to allow pharmacies and wholesalers to utilize existing supply..

1) If the P&T Committee fails to meet timeframes set forth in Section III.J.1.g) of this policy, PHC shall provide a clinical justification for such delay to CMS.

b)c) The following types of products are not a benefit for PHC Medi-Cal members and are not subject to review by the P & T Committee and as such are not on the PHC Formulary or available by a Treatment Authorization Request, regardless of whether PHC is the secondary or primary payer: 1) Drugs not approved by the Food and Drug Administration (FDA) for the treatment or

diagnosis of any medical condition. This does not preclude those drugs with an approved FDA indication used with “off label” indications.

2) Products not evaluated by the FDA for safety, purity & efficacy. This includes herbal products, dietary/food supplements, medical foods and non-prescription treatments or products unless: a) Agent is listed in PHC’s formulary, or b) Agent is listed as a benefit in the State Medi-Cal Contract Drug List, or a)c) The need for dietary supplementation is medically necessary and meets the

requirements set forth in Policy MPRP4056 (Pediatric Enteral Nutrition) or MPRP4061 (Enteral Nutrition Products).

2)3) Any Products/Drugs when intended to be used used for the treatment of Erectile erectile Dysfunctiondysfunction, or infertility or other sexual dysfunction.

3)4) Drugs/Products used for cosmetic purposes in the absence of medical necessity 5) Common household items 6) Medical Cannabis 7) Drugs used for the purpose of enhancing athletic (including weight or muscle gain) or

mental performance in the absence of medical necessity 8) Drugs purchased in another country 9) FDA Schedule 1 controlled substances 10) OTC drinks/shakes/bars for assistance with weight loss 11) Enteral nutrition products used orally as a convenient alternative to preparing and/or

consuming regular solid or pureed foods 12) Infant formulas that are available through the WIC program 13) Individual drugs as instructed through DHCS Operational Instruction Letters as being a

non-benefit and the plan has not placed the drug on the formulary as a benefit enhancement over that which DHCS provides to Stated Fee-For-Service. Examples of such exclusions include, but are not limited to: Vitamin and mineral products (except for those exceptions on the formulary for pregnancy, renal disease and pediatric use), OTC products containing dextromethorphan, salicylic acid, benzoic acid, NSAIDs, carbamide peroxide, chlorophyll and dextrose/glucose supplements. Coverage for CCS and EPSDT beneficiaries may be exempt from non-coverage determination, depending on the instruction from state agencies for specific drugs.

2) c)d) PHC shall require all P&T Committee members to sign a conflict of interest statement that:

1) Reveals economic or other relationships with entities that may influence pharmaceutical decisions; and

2) Disclose such conflicts to other committee members.

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d)e) A committee member shall excuse himself or herself from any discussions or votes associated with a conflict of interest issue.

6.8. The committee reviews drug utilization patterns and establishes criteria, protocols, and procedures that help ensure high quality, cost-effective drug therapy.

7.9. The committee recommends, initiates, or directs drug utilization review (DUR) and quality assurance programs. This includes recommending target drugs, drug classes or disease states to review, approving use criteria before review, reviewing results when completed, and making recommendations to appropriate providers or other PHC committees.

8.10. Oversight: This committee is responsible to ensure that contracted emergency departments can provide drugs to members under emergency circumstances in sufficient quantities to last until the member can reasonably be expected to have a prescription filled. On a biannual basis, the committee reviews documentation from PHC contracted emergency departments that they have a policy on dispensing drugs under emergency circumstances.

VII. REFERENCES:

A. Applications from Medicare Advantage Prescription Drug Plans (MA-PD) Sponsors B. Title 42, Code of Federal Regulations, Section 423.120 (b)(l) C. Guidance: P&T Committee Integrity and Certification of Such by Part D Applicant Sponsor D. Federal Register, January 28, 2005, Vol. 70, No. 18 E. Medicare Modernization Act, Section 1860D-4(b)(3)(A)

VIII. DISTRIBUTION:

A. PHC Department Directors, B. PHC Provider, C. SharePoint


Pharmacy Services Director X. REVISION DATES:

Medi-Cal

07/06/00; 10/04/01; 04/18/02; 10/3/02; 01/15/04; 04/07/05; 01/18/07; 01/15/09; 09/7/10; 10/28/10; 08/02/12; 08/29/13; 10/1/15; 10/6/16; 04/06/17; 08/09/2017; 05/09/2018

*Through 2017, Approval Date reflective of the Pharmacy & Therapeutics Committee meeting date. Effective January 2018, Approval Date reflects that of the Physician Advisory Committee’s meeting date.

PREVIOUSLY APPLIED TO: PartnerSshipAdvantage: MPRP4001 - 01/18/2007 – 01/01/2015 Healthy Families: MPRP4001 - 10/28/10 to 03/01/2013 Healthy Kids 01/18/2007; 01/15/09; 09/7/10; 10/28/10; 08/02/12; 08/29/13; 10/1/15; 10/06/16 to 12/01/16 (Healthy Kids program ended 12/01/2016)

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POLICY / PROCEDURE

Page 1 of 9


Policy/Procedure Title: Pharmacy & Therapeutics (P&T) Committee External Policy Internal Policy


Applies to: Medi-Cal Healthy Kids Employees

Reviewing Entities:

IQI P & T QUAC


Approving Entities:





A. MCUP3042 Technology Assessment B. MCRO4018 Pharmacy TAR Procedure C. MPRP4001 Brand Name Drugs




A. Provider Formulary Addition Request Form V. PURPOSE:

To describe the organization, operation, function and scope of the Partnership HealthPlan of California (PHC) Pharmacy and Therapeutics (P&T) Committee.


A. The Pharmacy & Therapeutics Committee as created under the authority of PHC Chief Executive Officer (CEO) will make recommendations to the Physician Advisory Committee (PAC) regarding the content of the PHC Medi-Cal Formulary, which includes new drug evaluation, new technology related to pharmaceuticals therapeutic class reviews, development of Prior Authorization Criteria and Code 1 Restrictions and other matters regarding the PHC drug benefit.

B. The P&T Committee shall develop, review and update formularies for all Lines of Business (LOB) as follows: 1. The P&T Committee shall appropriately review the formularies to make recommendations regarding

revisions to adapt to both the number and types of drugs on the market. The P&T Committee shall review and approve the formulary on an annual basis, with the totality of formulary review occurring over the course of the calendar year at quarterly P & T Committee meetings.

2. The quarterly P & T Committee meetings will review items proposed by the plan, committee members and by providers for formulary addition, changes to formulary limits/restrictions, formulary removal, plan exclusions and prior authorization criteria for both formulary and non-formulary pharmaceuticals.

3. The P&T Committee shall consider whether or not the inclusion of a particular Covered Drug or Pharmaceutical Class on the formulary has any therapeutic advantages in safety and efficacy. The

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Original Date: 5/28/1999 Next Review Date05/09/2019 Last Review Date: 05/09/2018


Page 2 of 9

P&T Committee shall consider the therapeutic advantages in relation to the interaction of a drug therapy regimen and the use of other health care services, including non-pharmacologic treatments.

4. The P&T Committee shall perform an initial review of drugs that are clinically effective. If two (2) or more drugs have the same therapeutic advantages in regard to safety and efficacy, the P&T Committee may consider total health care costs to achieve appropriate, safe, and cost effective drug therapy.

5. The P&T Committee shall review and update Plan policies that guide the Formulary Drug List, Exceptions, P & T, Pharmacy Programs and other utilization management processes including: a) Drug utilization review; b) MCRO4018 Pharmacy TAR Procedure c) MCRP4060 340B Compliance Program Policy d) MCRP4064 Continuation of Prescription Drugs e) MPRG4025 Palivizumab (Synagis) Guidelines f) MPRP4001 Pharmacy and Therapeutics (P & T) Committee g) MRPR4020 Restricted Status for Members Receiving Prescription Medications h) MpRP4033 Brand Name Drug Requests i) MPRP4034 Pharmaceutical Patient Safety j) MPRP4049 Chronic Opioid Therapy in Chronic Non-Cancer PainMPRP4056 Pediatric Enteral

Nutrition k) MPRP4059 Formulary Utilization Management for Managing Pain Safely l) MPRP4061 Enteral Nutrition Products m) MPRP4062 Drug Wastage Payments n) MPRP4063 Designated Specialty Drugs

6. The P&T Committee shall evaluate and analyze treatment protocols and procedures related to the formulary and non-formulary drug products at least annually, and consistent with policy guidelines and instructions from the Centers for Medicare & Medicaid Services (CMS).

B. Technology Review: The Chief Medical Officer or physician designee may request input from an appropriate specialist within the community prior to presenting the request to the Pharmacy and Therapeutics (P&T) Committee, Quality/Utilization Advisory Committee (QUAC), Physician Advisory Committee (PAC). This specialist must have expertise in the technology under review. The decision to consult a specialist will depend on the nature of the technology being considered, and will be made on a case-by-case basis. (See New Technology Policy MCUP3042).

C. Partnership HealthPlan of California (PHC) shall remain accountable to CMS for the integrity, expertise, and qualifications of the P&T Committee.

D. PHC shall ensure that the P&T Committee uses appropriate scientific and economic criteria when considering utilization management activities that affect access to drugs and drug classes such as: 1. Access to non-formulary drugs; process for submitting prior authorization requests for non-

formulary drugs is per policy MCRO4018 2. Formulary restrictions and limits

a) Formulary restrictions and limits are implemented electronically at point of sale through the use of PBM Formulary Edits. Requests for exceptions to Edits may be requested through the prior authorization (TAR) process (see policy MCRO4018).

b) Formulary Edits are defined and established by the Plan’s PBM and are selected by the Plan and submitted to P & T for the purpose of utilization management of formulary drugs based on safety, efficacy, FDA approved dose/duration or dose/durations as recommended by nationally recognized treatment guidelines or pharmaceutical compendia. The most commonly used edits are: 1) Prior authorization: An item may be on formulary yet require clinical criteria to be

approved through the TAR process prior to use.

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2) Step therapy: Previous paid claim(s) in the PBM data for a prerequisite treatment(s) which is(are) to be used first before the claim will pay.

3) Code 1 restriction: A requirement placed on a drug which limits use based on diagnosis, prescriber, clinical parameters, or other limits that cannot otherwise be implemented as specific edit. The prescriber is asked to list the qualifying diagnosis or other remark on the Rx; the pharmacy must verify the Code 1 usage with the office if not stated on the Rx. The Code 1 information as obtained from the prescriber (name, date) must be on the hardcopy Rx or in e-script notes and retrievable for audit purposes. The pharmacy is able to submit electronic override at point-of-sale (as attestation that Code 1 requirements are met), without having to submit prior authorization.

4) Quantity Limits: The number of units (tabs, mls, gms, etc) that may be either billed per Rx fill or per day supply.

5) Duration Limits: The number of days (consecutive or cumulative) a treatment may be limited to.

6) Fill Limits: The number of prescription fills a treatment may be limited to. 7) Age Limits: Determines age range for which claims will pay without prior authorization. 8) Grandfathering: Used when the committee opts to allow electronic claims’ verification of

continuation of care when a drug is removed from the formulary. 9) Prescriber Edits: used to allow Rx claims for certain specialist prescribers to pay regardless

of formulary status, Code 1, step edits or PA Criteria. 10) “Lookback Periods”: This is a PBM tool used by the plan to implement P & T approved

formulary edits when a specific period of time is needed for the claim adjudication process to take into account previous claim history. The Lookback periods will be determined by the plan in consultation with the PBM for optimal implementation of Step edits, Grandfathering, Fill limits and Duration limits. The P & T committee need not oversee /approve the lookback periods, but may be asked to advise.

3. Generic substitution: Generic substitution is required when an FDA approved generic is available (see policy MPRP4033, Brand Name Drugs).

4. Therapeutic interchange protocols: Defined through the use of formulary edits (Step therapy edits or Code 1 restrictions) and Prior Authorization criteria when prerequisite prior therapy is required

E. The P&T Committee shall adhere to P&T guidelines that CMS shall, from time to time, promulgate with regard to subject areas, including: 1. Membership; 2. Conflict of interest; 3. Meeting schedule; 4. Meeting minutes; 5. Therapeutic classes; 6. Drug review and inclusion; 7. Formulary management; 8. Utilization management and review; 9. Formulary exceptions; and 10. Educational programs for Providers:

a) For Pharmacy Providers: The Pharmacy Department conducts an annual survey of pharmacies and reviews the results to get feedback during an annual focus group.

b) For Prescribers: A PHC clinical pharmacist and/or PHC Medical Director meets annually with selected provider sites during “academic detailing visits” at which time, any issues regarding continuity and coordination of pharmaceutical care from prescribers are addressed.

F. PHC shall adopt all P&T Committee recommendations regarding the drugs placed on the formulary when subsequently approved by the Physician Advisory Committee (PAC)

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G. PHC shall consider recommendations from the P&T Committee in the following areas as advisory and not binding: 1. Review of policies that guide utilization management; and 2. Evaluation and analysis of treatment protocols and procedures.

H. The P&T Committee shall maintain written documentation of decisions regarding formulary development and revision and utilization management activities.

I. GOALS: To assure continuing member access to a quality driven, cost-effective, rational drug benefit through the PHC Formulary and prescription drug preauthorization process.

J. Organization and Operation 1. Membership

a) The committee shall be comprised of the following members 1) PHC Chief Medical Officer 2) PHC Director of Pharmacy, who shall serve as secretary 3) PHC Clinical Pharmacist 4) PHC Medical Director 5) Practicing physician(s) representing primary care specialties including Family Practice,

Internal Medicine, and Pediatrics 6) Practicing physician(s) representing specialist groups such as OBGYN and medical

subspecialties 7) Practicing physician representing Psychiatry 8) Practicing community pharmacist(s) 9) Other representatives as determined appropriate by the Committee.

b) Membership of the P&T Committee shall include a majority of members who are practicing physicians or practicing pharmacists with: 1) At least one (1) practicing physician and at least one (1) practicing pharmacist who do not

have a conflict of interest with respect to PHC and pharmaceutical manufacturers; 2) At least one (I) practicing physician and at least one (1) practicing pharmacist who are

independent experts in the care of the elderly or disabled persons; and 3) Representation from various clinical specialties.

c) The PHC Chief Medical Officer shall serve as the Committee Chairman. d) Non-voting members.

1) PHC Director of Health Services Director 2) PHC Director of Provider Relations (ad hoc) 3) PHC Quality Assurance representative (ad hoc) 4) Other invited experts such as, consultant pharmacists or consultant physicians, etc.

e) The distribution of physician and pharmacist membership should represent the PHC member population.

2. A quorum defined by 1/3 of the practicing members must be present in order to conduct the P&T committee meeting. A consensus recommendation is made on formulary additions, changes, and deletions and drug/benefit policies. If no consensus is established, the issue is voted on with the decision determined by majority vote of the quorum.

3. The P&T Committee meets at least four times per year. If urgent matters pertaining to the selection or utilization of drugs arise between meetings, a telephone meeting may be conducted with the members, or a poll of members by fax or email may be utilized. (See section VI.L.2.g)

4. An agenda and supplementary materials, including minutes of the previous meeting, are prepared and submitted to the committee members in sufficient time before the meeting to ensure proper review of the material. This is the responsibility of the secretary.

5. Minutes of the committee proceedings are prepared and signed and maintained in the permanent records of PHC.

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6. All recommendations by the committee for additions, deletions or changes to the formulary are forwarded to the Physician Advisory Committee (PAC) for approval. Any additions, deletions or changes to the formulary or to prior authorization criteria will take effect no sooner than the first day of the month after the PAC meeting. This is to allow time to notify physicians, pharmacists and other providers and to change systems if needed.

7. Distribution of Pharmacy Formulary (Covered Drug List): Providers and members are notified of multiple times per calendar year on how to access the list of covered drugs (pharmacy drug formulary) which is maintained online on the Plan’s website. a) Providers are notified in the quarterly Provider Newsletter distributed by the Chief Medical

Officer. b) Members are notified in the written semi-annual newsletter by mail (distributed by PHC

Member Services). 8. Changes to the Pharmacy Drug Benefit are made available to members and providers.

a) Providers: PHC practitioners are notified of changes to the Plan’s policies and procedures for drug utilization management in the form of formulary additions, deletions and changes as well as new and revised prior authorization criteria, prior to the scheduled implementation date. This notification is accomplished by the following:

b) P & T Updates page on the PHC Website, updated quarterly prior to the effective date. 1) At least one previous calendar year’s updates will remain available, together with the

current calendar year. c) Pharmacy Updates page on the PHC Website, updated as needed, at least quarterly, will include

notification that there has been a formulary update and where to find the specific drug formulary changes.

d) A FAX-compatible version of the Pharmacy Updates will be faxed to pharmacy providers. e) The Plan’s Policies and Procedures are available to practitioners on the Plan’s website, which

includes Policies, Clinical Treatment Guidelines, the Provider Manual and the Pharmacy Procedure Manual.

f) Any of the above are available upon request to pharmacy and medical providers who do not have online or FAX access. A provider may contact the Pharmacy Department to have the most recent updates sent by mail:

Partnership HealthPlan of California, Pharmacy Services Department 4665 Business Center Drive Fairfield, CA 94534 (707) 863-4414

g) Members receive a written semi-annual newsletter (distributed by PHC Member Services) with information on drug benefit updates and instructions on how to access online (or obtain by mail) the current covered drug list; notification will also include how to access/obtain past and recent formulary change notifications found in PHC’s P & T Updates documents. Such formulary updates include, but are not limited to, the following: 1) Formulary additions 2) Formulary removal 3) Changes in limits and restrictions to covered drugs

K. Functions: The functions and scope of this committee are designed to promote quality in the use of prescription drugs, to manage and control drug costs, and to continue to support the development of Treatment Guidelines and Clinical Practice Guidelines based on clinical efficacy and sound pharmacoeconomic principles.

L. Formularies 1. Maintain drug formularies, acceptable for use in the ambulatory care setting, which is reviewed and

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updated on a quarterly basis. 2. Interim formulary updates may be made by PHC pharmacy department such as those immediately

necessary due market changes brought about by: a) New generics/line extension (same/similar entity already on formulary in another form or

strength) b) Market shortages of formulary preferred generic items. c) Changes in Pharmacy Benefit Manager (PBM) Maximum Allowable Cost (MAC) pricing. d) Removal of Generic from market, causing change of brand status to revert from Multi-

Sourced Brand (MSB) to Single Sourced Brand (SSB) (which would cause PBM to automatically place SSB on formulary if generic was on formulary prior to removal from market)

e) Moving drugs from non-formulary status to “formulary with prior authorization required” in order to meet business needs of the plan; no change to intent of criteria will be made, only such changes in wording regarding status as being on formulary instead of non-formulary. Reasons for doing so include: (1) to meet requirements for supplemental rebates and (2) to enable a “preferred” status among drugs in a class for which multiple alternatives exist and the plan wishes to prefer one over others for safety, cost &/or efficacy yet clinical criteria for use will remain in effect.

f) All changes/interim updates will be reviewed for consent (no action needed) by the P&T committee at next scheduled meeting as “formulary maintenance” items.

g) Drugs requiring implementation of interim prior authorization guidelines will be sent to the committee for comment and vote by email. The result will then be included in the next PAC meeting for approval and implemented at the first of the month following the PAC meeting. Such items will be included as addendum to the minutes in the next occurring P & T packet, not an item for further P & T action or consent.

3. Formulary addition or deletion requests must be submitted either by credentialed PHC contracted clinicians, pharmacist providers, or PHC staff. All requests from non-PHC staff must be submitted on the Provider Formulary Addition Request Form (Attachment A) and sent to: a) US Mail: Partnership HealthPlan of California

Director of Pharmacy 4665 Business Center Drive Fairfield, CA 94534

Or, b) FAX to Partnership HealthPlan of California: (707) 863-4330

Or, c) Email completed form to: [email protected]

4. The P&T Committee shall base clinical decisions regarding utilization management on the

strength of scientific evidence, standards of practice, and safety and efficacy considerations. The P&T Committee will use criteria for utilization management decisions which takes into account the following: a) Pharmaceutical class – i.e., taking into account which drug classes are available as a PHC

benefit vs those that are either excluded or carved out to State fee-for-service Medi-Cal. b) Classes preferred or covered at any level c) Lists of preferred drugs d) Considerations for limiting drugs in certain classes

1) For example, Specialty Drugs (Policy MPRP4063) or 2) Opioid Analgesics (Policy MPXG5008, MPRP4049, MPRP4059)

e) Generic substitution, therapeutic interchange, step therapy or other utilization management

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methods described in section VI.D.2 f) Within each class of pharmaceuticals, the committee will consider:

1) those agents preferred or covered at any level 2) the criteria for prior authorization of any pharmaceutical 3) exceptions processes available to members 4) substitutions that will be allowed automatically or with permission from the prescribing

practitioner 5) evidence that preferred status agents can produce similar or better results for a majority of

the population than other pharmaceuticals in the same class; 6) other requirements, restrictions, limitations or incentives that apply to the use of certain

pharmaceuticals as described in section V1.D.2 5. The review process for formulary consideration of all drugs is based on clinical evidence which

includes the following: 1) Relevant findings of government agencies 2) Medical associations 3) National commissions 4) Peer-reviewed journals 5) Authoritative compendia 6) Confirmation that the drug has an approved indication by the Food and Drug Administration

(FDA) 7) Input from selected relevant specialists or professionals, if not represented on the P&T

Committee, who have expertise in the drug being reviewed 8) Randomized clinical trials; 9) Pharmacoeconomic studies; 10) Outcomes research data; and 11) Other information as it determines appropriate.

6. The committee uses the following criteria, documented by clinical studies and journal articles, when evaluating items to be added to the formulary: efficacy, safety, convenience, and cost.

7. The P&T Committee shall make reasonable effort to review a new chemical entity or new Food and Drug Administration (FDA) clinical indicator within ninety (90) calendar days after release into the market, and shall make a decision within one hundred eighty (180) calendar days after release into the market. a) If the P&T Committee fails to meet timeframes set forth in Section III.J.1.g) of this policy,

PHC shall provide a clinical justification for such delay to CMS. b) PHC shall immediately remove from the formulary any drug removed from the market by the

FDA or manufacturers for safety reasons. 1) Pharmaceutical products that are no longer being manufactured for business reasons

alone and remain classified by the FDA as safe and effective may remain on the formulary for up to 2 years to allow pharmacies and wholesalers to utilize existing supply.

c) The following types of products are not a benefit for PHC Medi-Cal members and are not subject to review by the P & T Committee and as such are not on the PHC Formulary or available by a Treatment Authorization Request, regardless of whether PHC is the secondary or primary payer: 1) Drugs not approved by the Food and Drug Administration (FDA) for the treatment or

diagnosis of any medical condition. This does not preclude those drugs with an approved FDA indication used with “off label” indications.

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2) Products not evaluated by the FDA for safety, purity & efficacy. This includes herbal products, dietary/food supplements, medical foods and non-prescription treatments or products unless: a) Agent is listed in PHC’s formulary, or b) Agent is listed as a benefit in the State Medi-Cal Contract Drug List, or c) The need for dietary supplementation is medically necessary and meets the

requirements set forth in Policy MPRP4056 (Pediatric Enteral Nutrition) or MPRP4061 (Enteral Nutrition Products).

3) Any Products/Drugs when intended to be used for the treatment of erectile dysfunction, infertility or other sexual dysfunction.

4) Drugs/Products used for cosmetic purposes in the absence of medical necessity 5) Common household items 6) Medical Cannabis 7) Drugs used for the purpose of enhancing athletic (including weight or muscle gain) or

mental performance in the absence of medical necessity 8) Drugs purchased in another country 9) FDA Schedule 1 controlled substances 10) OTC drinks/shakes/bars for assistance with weight loss 11) Enteral nutrition products used orally as a convenient alternative to preparing and/or

consuming regular solid or pureed foods 12) Infant formulas that are available through the WIC program 13) Individual drugs as instructed through DHCS Operational Instruction Letters as being a

non-benefit and the plan has not placed the drug on the formulary as a benefit enhancement over that which DHCS provides to Stated Fee-For-Service. Examples of such exclusions include, but are not limited to: Vitamin and mineral products (except for those exceptions on the formulary for pregnancy, renal disease and pediatric use), OTC products containing dextromethorphan, salicylic acid, benzoic acid, NSAIDs, carbamide peroxide, chlorophyll and dextrose/glucose supplements. Coverage for CCS and EPSDT beneficiaries may be exempt from non-coverage determination, depending on the instruction from state agencies for specific drugs.

d) PHC shall require all P&T Committee members to sign a conflict of interest statement that: 1) Reveals economic or other relationships with entities that may influence pharmaceutical

decisions; and 2) Disclose such conflicts to other committee members.

e) A committee member shall excuse himself or herself from any discussions or votes associated with a conflict of interest issue.

8. The committee reviews drug utilization patterns and establishes criteria, protocols, and procedures that help ensure high quality, cost-effective drug therapy.

9. The committee recommends, initiates, or directs drug utilization review (DUR) and quality assurance programs. This includes recommending target drugs, drug classes or disease states to review, approving use criteria before review, reviewing results when completed, and making recommendations to appropriate providers or other PHC committees.

10. Oversight: This committee is responsible to ensure that contracted emergency departments can provide drugs to members under emergency circumstances in sufficient quantities to last until the member can reasonably be expected to have a prescription filled. On a biannual basis, the committee reviews documentation from PHC contracted emergency departments that they have a policy on dispensing drugs under emergency circumstances.

VII. REFERENCES:

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Page 9 of 9

A. Applications from Medicare Advantage Prescription Drug Plans (MA-PD) Sponsors B. Title 42, Code of Federal Regulations, Section 423.120 (b)(l) C. Guidance: P&T Committee Integrity and Certification of Such by Part D Applicant Sponsor D. Federal Register, January 28, 2005, Vol. 70, No. 18 E. Medicare Modernization Act, Section 1860D-4(b)(3)(A)

VIII. DISTRIBUTION:

A. PHC Department Directors, B. PHC Provider, C. SharePoint


Pharmacy Services Director X. REVISION DATES:

Medi-Cal

07/06/00; 10/04/01; 04/18/02; 10/3/02; 01/15/04; 04/07/05; 01/18/07; 01/15/09; 09/7/10; 10/28/10; 08/02/12; 08/29/13; 10/1/15; 10/6/16; 04/06/17; 08/09/2017; 05/09/2018

*Through 2017, Approval Date reflective of the Pharmacy & Therapeutics Committee meeting date. Effective January 2018, Approval Date reflects that of the Physician Advisory Committee’s meeting date.

PREVIOUSLY APPLIED TO: PartnerShipAdvantage: MPRP4001 - 01/18/2007 – 01/01/2015 Healthy Families: MPRP4001 - 10/28/10 to 03/01/2013 Healthy Kids 01/18/2007; 01/15/09; 09/7/10; 10/28/10; 08/02/12; 08/29/13; 10/1/15; 10/06/16 to 12/01/16 (Healthy Kids program ended 12/01/2016)


C. In accordance with the California Health and Safety Code, Section 1363.5, this policy was developed with involvement from actively practicing health care providers and meets these provisions: 1. Consistent with sound clinical principles and processes; 2. Evaluated and updated at least annually; 3. If used as the basis of a decision to modify, delay or deny services in a specific case, the criteria will

be disclosed to the provider and/or enrollee upon request. D. The materials provided are guidelines used by PHC to authorize, modify or deny services for persons


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POLICY / PROCEDURE

Page 1 of 4


Policy/Procedure Title: Brand Name Drug Requests External Policy Internal Policy

Original Date: 01/15/2004 – Medi-Cal 07/24/2008 - Healthy Kids



Reviewing Entities:

IQI P & T QUAC


Approving Entities:





A. MPRP4059: Formulary Management for Managing Pain Safely Program B. MCRO4018: Pharmacy TAR Procedure C. MPRP4001: Pharmacy & Therapeutics Committee




A. Med Watch form V. PURPOSE:

Partnership HealthPlan of California (PHC) requires generic substitution when an equivalent generic product is available. This policy & procedure describes the guidelines for authorizing pharmacy Treatment Authorization Requests (TARs) for brand name drugs when an equivalent generic product is available.


A. Title 22 Prior Authorization Adherence 1. PHC adheres to Title 22 of the California Code of Regulations 51003: Authorization may be granted

only for the lowest cost item or service covered by the program that meets the patient’s medical needs.

2. TITLE 22. Social Security, Division 3. Health Care Services, Subdivision 1. California Medical Assistance Program, Chapter 3. Health Care Services, Article 1.3. General Provisions, §51003. Prior Authorization.

B. Continuity of Care Legislation for Pharmacy 1. PHC’s policy of requiring a generic substitution when a member has previously received a brand

name product does not violate the Continuity of Care legislation for pharmacy. The Continuity of Care bill AB974 for those Health Plans who are Knox Keene licensed and under the jurisdiction of the Department of Managed Healthcare (DMHC) specifically states that it prohibits “construing the provision to prohibit generic drug substitutions, pursuant to specified existing law”

C. Maximum Allowable Cost (MAC) List 1. MAC pricing lists are reimbursement schedules currently developed by PHC’s Pharmacy Benefit

Manager (PBM) that determines both the ingredient cost used to calculate reimbursement to the

Deleted: 10/06/2017

Deleted: 10/06/2016

Deleted: Healthy Kids

Deleted: L.

Deleted: 10/06/2016

Deleted: N/A

Deleted: and added to the Maximum Allowable Cost (MAC) price list.

Deleted: is a

Deleted: reimbursement

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http://eshare/sites/PoliciesnProcedures/Pharmacy/MPRP4033%20Attachments/MPRP4033-A.pdf


Policy/Procedure Title: Brand Name Drug Requests ☒External Policy ☐Internal Policy




Page 2 of 4

Deleted: 10/06/2017

Deleted: 10/06/2016

Deleted: ☒ Healthy Kids

dispensing pharmacy and the rate PHC pays to the PBM for generic pharmaceutical products. The PBM enforces the following criteria for a drug to be added to the MAC list: a. The drug must be a Multi-Source product with a generic available b. The generic product must be manufactured by at least one nationally marketed company c. At least one of the generic manufacturers must have an “A” or “Z” rating d. A significant price spread must exist between the brand and the generic product e. A product must be approved for generic substitution by the PBM’s Pharmacy & Therapeutics

Committee. D. Food & Drug Administration (FDA) Ratings

1. The US FDA has rated all generic drugs “A” or “B” (www.fda.gov/cder/ob/default.htm). “A” rated drugs are considered bioequivalent to the brand-name original. They either have been demonstrated to be so by human bioavailability study (“AB”), or are considered inherently unlikely to have bioavailability problems (“AA”); “AA” drugs are usually oral solutions or oral drugs that dissolve readily in water. Other “A” designations (AN, AO, AP, AT) refer to non-oral formulations considered bioequivalent by the FDA. Only “A” rated products are interchangeable with their brand-name equivalents by the FDA.

2. “B” drugs have not been demonstrated to be bioequivalent by an in vivo test. These are generally older drugs that were approved by the FDA on the basis of chemistry, manufacturing controls and in vitro dissolution tests. Less than 3% of the marketed generic drugs have a “B” rating.

E. First Data Bank “Z” Rating 1. "Z" rating is not an official rating by the FDA but through First Data Bank who supports databases

for drugs. "Z" rating is generally used for entities that have been evaluated by the FDA for similar products, not a particular manufacturer's product, or that the reference product is no longer on the market and therefore equivalent designation could not be made. It may also be given this designation because the Orange Book does not have a therapeutic rating because the product did not go through any type of bioequivalency rating previously. Select drugs that are believed not to have therapeutic issues as long as they had the same active ingredient at the same drug concentration are “Z” rated and are added to the MAC list.

F. Therapeutic Equivalence 1. According to the October 14, 2002 Issues of the Medical Letter (Vol. 44, Issue 1141) on Generic

Drugs, product recalls for potency problems occur with both generics and brand-name products. No well-documented therapeutic differences between brand-name originals and FDA-approved generics have been reported. A more recent update review by The Medical Letter dated October 19, 2009 concluded: “the continuing claims of pharmaceutical manufacturers and others that generic drugs are inferior to brand-name originals still lack convincing documentation.”

G. TARs for use of a brand name product when a generic equivalent is available will be considered for review when the following information is provided: 1. Documentation from the member’s prescription profile or from the prescriber’s progress notes that

the member has had a previous adequate trial of at least two (2) of the requested generic equivalents within one hundred and eighty (180) days of the request.

2. Documentation from the member’s prescription profile or from the prescriber’s progress notes that the member has had a previous adequate trial of therapeutic alternatives within one hundred and eighty (180) days of the request

3. Medical justification why the member is unable to use the generic equivalent. 4. Medical justification why the member cannot use an alternative therapeutic equivalent. 5. If member is unable to use a generic equivalent due to an adverse event, a Med Watch form

(Attachment A) completed by the prescriber documenting the adverse event with the generic equivalent drug may be required.

H. Single-source and multisource brand name products are limited to a 30 day supply. Exceptions to this

Deleted: a

Deleted: a

171 of 233

http://www.fda.gov/cder/ob/default.htm






Page 3 of 4

Deleted: 10/06/2017

Deleted: 10/06/2016

Deleted: ☒ Healthy Kids

may be requested when monthly dispensing requirements are demonstrated to be an unnecessary burden to a member and filling less frequently is medically necessary to ensure optimum treatment response. Requests for exception to the 30 day limit should include patient-specific reasons why member is at risk with the 30 day requirement and: 1. Member must be on a stable dose 2. Member must be tolerating the treatment and not at risk of discontinuation due to ADRs 3. The product must be considered to be a maintenance medication for a chronic illness 4. The product cannot be one that is intended for short-term or PRN use 5. The member must have the ability and education to store the product in compliance with the

manufacturer’s storage recommendations 6. Reports of lost or stolen supplies larger than 30 day amounts will cause the approval of larger

quantities to be forfeited going forward. 7. Member must have expected continuation of eligibility beyond 30 days in the plan’s eligibility

information. 8. Exceptions to the 30 day limit will not be made for specialty drugs nor for Schedule II-V substances

(scheduled substances refer to policy MPRP4059)


VIII. DISTRIBUTION:

A. PHC Department Directors, B. Provider, C. Pharmacy Procedure Manual, D. SharePoint


A. Pharmacy Services Director X. REVISION DATES:

Medi-Cal 07/07/05; 07/24/08; 10/28/10; 04/04/13; 10/1/15; 10/6/16; 5/9/2018 *Through 2017, Approval Date reflective of the Pharmacy & Therapeutics Committee meeting date. Effective January 2018, Approval Date reflects that of the Physician Advisory Committee’s meeting date.

PREVIOUSLY APPLIED TO: Healthy Families: MPRP4033 - 10/28/2010 to 03/01/2013 Healthy Kids 07/24/08; 10/28/10; 04/04/13; 10/1/15; 10/6/16


A. In accordance with the California Health and Safety Code, Section 1363.5, this policy was developed with involvement from actively practicing health care providers and meets these provisions: 1. Consistent with sound clinical principles and processes; 2. Evaluated and updated at least annually;

Deleted: e

Deleted:

Moved down [1]: Healthy Kids¶07/24/08; 10/28/10; 04/04/13; 10/1/15; 10/6/16¶

Formatted: Indent: Left: 0"

Moved (insertion) [1]

Deleted: ¶

172 of 233


POLICY / PROCEDURE

Page 1 of 4


Policy/Procedure Title: Brand Name Drug Requests External Policy Internal Policy




Reviewing Entities:

IQI P & T QUAC


Approving Entities:





A. MPRP4059: Formulary Management for Managing Pain Safely Program B. MCRO4018: Pharmacy TAR Procedure C. MPRP4001: Pharmacy & Therapeutics Committee




A. Med Watch form V. PURPOSE:

Partnership HealthPlan of California (PHC) requires generic substitution when an equivalent generic product is available. This policy & procedure describes the guidelines for authorizing pharmacy Treatment Authorization Requests (TARs) for brand name drugs when an equivalent generic product is available.


A. Title 22 Prior Authorization Adherence 1. PHC adheres to Title 22 of the California Code of Regulations 51003: Authorization may be granted

only for the lowest cost item or service covered by the program that meets the patient’s medical needs.

2. TITLE 22. Social Security, Division 3. Health Care Services, Subdivision 1. California Medical Assistance Program, Chapter 3. Health Care Services, Article 1.3. General Provisions, §51003. Prior Authorization.

B. Continuity of Care Legislation for Pharmacy 1. PHC’s policy of requiring a generic substitution when a member has previously received a brand

name product does not violate the Continuity of Care legislation for pharmacy. The Continuity of Care bill AB974 for those Health Plans who are Knox Keene licensed and under the jurisdiction of the Department of Managed Healthcare (DMHC) specifically states that it prohibits “construing the provision to prohibit generic drug substitutions, pursuant to specified existing law”

C. Maximum Allowable Cost (MAC) List 1. MAC pricing lists are reimbursement schedules currently developed by PHC’s Pharmacy Benefit

Manager (PBM) that determines both the ingredient cost used to calculate reimbursement to the

173 of 233






Page 2 of 4

dispensing pharmacy and the rate PHC pays to the PBM for generic pharmaceutical products. The PBM enforces the following criteria for a drug to be added to the MAC list: a. The drug must be a Multi-Source product with a generic available b. The generic product must be manufactured by at least one nationally marketed company c. At least one of the generic manufacturers must have an “A” or “Z” rating d. A significant price spread must exist between the brand and the generic product e. A product must be approved for generic substitution by the PBM’s Pharmacy & Therapeutics

Committee. D. Food & Drug Administration (FDA) Ratings

1. The US FDA has rated all generic drugs “A” or “B” (www.fda.gov/cder/ob/default.htm). “A” rated drugs are considered bioequivalent to the brand-name original. They either have been demonstrated to be so by human bioavailability study (“AB”), or are considered inherently unlikely to have bioavailability problems (“AA”); “AA” drugs are usually oral solutions or oral drugs that dissolve readily in water. Other “A” designations (AN, AO, AP, AT) refer to non-oral formulations considered bioequivalent by the FDA. Only “A” rated products are interchangeable with their brand-name equivalents by the FDA.

2. “B” drugs have not been demonstrated to be bioequivalent by an in vivo test. These are generally older drugs that were approved by the FDA on the basis of chemistry, manufacturing controls and in vitro dissolution tests. Less than 3% of the marketed generic drugs have a “B” rating.

E. First Data Bank “Z” Rating 1. "Z" rating is not an official rating by the FDA but through First Data Bank who supports databases

for drugs. "Z" rating is generally used for entities that have been evaluated by the FDA for similar products, not a particular manufacturer's product, or that the reference product is no longer on the market and therefore equivalent designation could not be made. It may also be given this designation because the Orange Book does not have a therapeutic rating because the product did not go through any type of bioequivalency rating previously. Select drugs that are believed not to have therapeutic issues as long as they had the same active ingredient at the same drug concentration are “Z” rated and are added to the MAC list.

F. Therapeutic Equivalence 1. According to the October 14, 2002 Issues of the Medical Letter (Vol. 44, Issue 1141) on Generic

Drugs, product recalls for potency problems occur with both generics and brand-name products. No well-documented therapeutic differences between brand-name originals and FDA-approved generics have been reported. A more recent update review by The Medical Letter dated October 19, 2009 concluded: “the continuing claims of pharmaceutical manufacturers and others that generic drugs are inferior to brand-name originals still lack convincing documentation.”

G. TARs for use of a brand name product when a generic equivalent is available will be considered for review when the following information is provided: 1. Documentation from the member’s prescription profile or from the prescriber’s progress notes that

the member has had a previous adequate trial of at least two (2) of the requested generic equivalents within one hundred and eighty (180) days of the request.

2. Documentation from the member’s prescription profile or from the prescriber’s progress notes that the member has had a previous adequate trial of therapeutic alternatives within one hundred and eighty (180) days of the request

3. Medical justification why the member is unable to use the generic equivalent. 4. Medical justification why the member cannot use an alternative therapeutic equivalent. 5. If member is unable to use a generic equivalent due to an adverse event, a Med Watch form

(Attachment A) completed by the prescriber documenting the adverse event with the generic equivalent drug may be required.

H. Single-source and multisource brand name products are limited to a 30 day supply. Exceptions to this

174 of 233






Page 3 of 4

may be requested when monthly dispensing requirements are demonstrated to be an unnecessary burden to a member and filling less frequently is medically necessary to ensure optimum treatment response. Requests for exception to the 30 day limit should include patient-specific reasons why member is at risk with the 30 day requirement and: 1. Member must be on a stable dose 2. Member must be tolerating the treatment and not at risk of discontinuation due to ADRs 3. The product must be considered to be a maintenance medication for a chronic illness 4. The product cannot be one that is intended for short-term or PRN use 5. The member must have the ability and education to store the product in compliance with the

manufacturer’s storage recommendations 6. Reports of lost or stolen supplies larger than 30 day amounts will cause the approval of larger

quantities to be forfeited going forward. 7. Member must have expected continuation of eligibility beyond 30 days in the plan’s eligibility

information. 8. Exceptions to the 30 day limit will not be made for specialty drugs nor for Schedule II-V substances

(scheduled substances refer to policy MPRP4059)


VIII. DISTRIBUTION:

A. PHC Department Directors, B. Provider, C. Pharmacy Procedure Manual, D. SharePoint


A. Pharmacy Services Director X. REVISION DATES:

Medi-Cal 07/07/05; 07/24/08; 10/28/10; 04/04/13; 10/1/15; 10/6/16; 5/9/2018 *Through 2017, Approval Date reflective of the Pharmacy & Therapeutics Committee meeting date. Effective January 2018, Approval Date reflects that of the Physician Advisory Committee’s meeting date.

PREVIOUSLY APPLIED TO: Healthy Families: MPRP4033 - 10/28/2010 to 03/01/2013 Healthy Kids 07/24/08; 10/28/10; 04/04/13; 10/1/15; 10/6/16


A. In accordance with the California Health and Safety Code, Section 1363.5, this policy was developed with involvement from actively practicing health care providers and meets these provisions: 1. Consistent with sound clinical principles and processes; 2. Evaluated and updated at least annually;

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POLICY / PROCEDURE

Page 1 of 5

Policy/Procedure Number: MCRP4060 Lead Department: Health Services

Policy/Procedure Title: 340B Compliance Program ☒External Policy ☐ Internal Policy



Reviewing Entities:

☒ IQI ☒ P & T ☐ QUAC

☒ OPERATIONS ☐ EXECUTIVE ☐ COMPLIANCE ☐ DEPARTMENT

Approving Entities:

☐ BOARD ☐ COMPLIANCE ☒ FINANCE ☒ PAC

☐ CEO ☐ COO ☐ CREDENTIALING ☒ DEPT. DIRECTOR/OFFICER



PHC 340B Policy for Primary Care Entities

II. IMPACTED DEPTS: A. Pharmacy B. Provider Relations C. Administration (Finance)

III. DEFINITIONS: A. 340B Program: The Veterans Health Care Act of 1992 established the 340B Program in section 340B of

the Public Health Service Act. The 340B Program requires drug manufacturers participating in Medicaid to provide discounted covered outpatient drugs to certain eligible health care entities, known as 340B Covered Entities (see definition below).

B. 340B Drug: Any covered outpatient drug purchased on a discounted basis under the 340B program, as defined by 42 U.S.C. § 256b and its implementing regulations, that is purchased via a qualified 340B Program distributor.

C. 340B Covered Entity: A healthcare provider registered with HRSA and approved to participate in the 340B Program.

D. 340B Participating Entity: A 340B Covered Entity that agrees to participate in PHC’s 340B Compliance Program and signs a 340B Compliance Program Agreement.

E. 340B Administrator: A subcontractor hired by a 340B Participating Entity to administer the 340B program, usually for a fee.

F. HRSA: United States Health Resources and Services Administration. G. DHCS: California Department of Health Care Services. H. Pharmacy Benefits Manager (PBM): A subcontractor of PHC that contracts with individual dispensing

pharmacies to create a network of pharmacies to provide the infrastructure for the pharmacy benefit of PHC.

I. 340B Office of Pharmacy Affairs Information System (“340B OPAIS”): A database overseen by OPA which includes detailed information related to all 340B Covered Entities, Contract Pharmacies, and Manufacturers all registered to participate in the 340B ProgramQuality Improvement Program (QIP): A

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Policy/Procedure Title: 340B Compliance Program ☒ External Policy ☐ Internal Policy

Original Date: 10/02/2014 Next Review Date: 10/06/201705/09/2018 Last Review Date: 10/06/20167


Page 2 of 5

quality incentive program used by PHC to incentivize quality. PHC has a Primary Care QIP applying to contract primary care providers.

J. 340BX Clearinghouse: The entity contracted with PHC to coordinate with various 340B players and perform data analysis and identification of 340B eligible pharmacy claims for the 340B Participating Entities.

K. PHC 340B Advisory Committee: A subcommittee of the PHC Board of Commissioners charged with overseeing PHC’s 340B Compliance Program, including review and approval of the 340B QIP program and related proposals.

L. Contract Pharmacy: A retail pharmacy dispensing 340B-purchased drugs on behalf of a 340B Covered Entity, based on a contract between the 340B Covered Entity and the pharmacy. A Contract Pharmacy operates with a mixed inventory of drugs (340B and non-340B Covered Outpatient Drugs). All eligible Contract Pharmacies are registered with HRSA and listed on the OPA 340B DatabaseOPAIS:

https://340bopais.hrsa.gov/homehttps://opanet.hrsa.gov/340B/Views/CoveredEntity/SearchDirectory.

M. In-House Pharmacy: A pharmacy in which the 340B Covered Entity owns the 340B drugs, pharmacy, and license. The 340B Covered Entity purchases the 340B drugs, which are dispensed to eligible patients, as defined by HRSA. The 340B Covered Entity is fiscally responsible for the pharmacy and pays the pharmacy staff. The pharmacy is (i) located on the premises of the 340B Covered Entity, (ii) provides services solely to the 340B Covered Entity’s patients, (iii) through the 340B Covered Entity’s providers, and (iv) dispenses only drugs and supplies purchased under the 340B Program to PHC beneficiaries. For the purposes of this Agreement, if all conditions, (i) through (iv), are not met, then the pharmacy would be considered a Contract Pharmacy, even though it might be physically located on the premises of the 340B Covered Entity. In-House Pharmacies are not registered with HRSA nor are they listed on the OPA 340B DatabaseOPAIS.

N. Provider/In-House Dispensing: The 340B Covered Entity owns drugs; employs or contracts with providers licensed in the state to dispense drugs on its behalf; holds a clinic dispensary license issued by the California Board of Pharmacy; and is fiscally responsible for the operation of the dispensary. These entities submit claims for 340B Covered Outpatient Drugs using the CMS-1500 format,or UB-04 format, or electronic 837 file format, which are not first processed by a PBM providing services under a direct contract with the 340B Participating Entity and on its behalf.

O. Physician-Administered Drug (“PAD”): Any covered outpatient drug provided or administered by the 340B Participating Entity to one of its patients, and billed by a provider other than a pharmacy. Such providers include, but are not limited to, physician offices, clinics, and hospitals. A covered outpatient drug is broadly defined as a drug that may be dispensed only upon prescription, and is approved for safety and effectiveness as a prescription drug under the Federal Food, Drug and Cosmetic Act. PADs include both injectable and non-injectable drugs. These drugs may sometimes be referred to as Physician-Dispensed Drugs.

P. 340BX Trust Account: A bank account in the name of NEC Networks, LLC (for Clearinghouse) at the Bank of San AntonioBBVA Compass Bank. This account will be utilized by Clearinghouse as a holding account to deposit 340B related funds paid by 340B Participating Entities, and also to transfer funds to PHC's bank account.

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Page 3 of 5

P.Q. UD Modifier: Approved modifier code for use in billing Medi-Cal. This modifier code is used by Section 340B providers to denote services provided or drugs purchased under the 340B Program

IV. ATTACHMENTS:

A. 340B Compliance Program Agreement B. PHC 340B Compliance Program White Paper

V. PURPOSE: The purpose of this policy is to outline the requirements for participation in PHC’s 340B Compliance Program, which is established to ensure 340B Participating Entities and PHC are complying with Federal and State 340B regulations. The data submission process outlined for the 340B Compliance Program is set-up so that 340B drugs prescribed by the 340B Participating Entities are identified to DHCS in a way that the State requires in order to ensure that no duplicate discounts are received and retained for the use of 340B drugs. This policy will be applied consistently across each class of 340B Covered Entity and set forth standards of accountability that are reasonable and meaningful.


A. Analysis of 340B Covered Entities as outlined by HRSA: 1. A master list of entities identified as eligible to participate in the 340B Program (340B Compliance

Program – 340B Covered Entity Master Tracking List) has been compiled by PHC using information from the OPA 340B Database OPAIS on HRSA’s website,

https://340bopais.hrsa.gov/homehttp://opanet.hrsa.gov/opa/CESearch.aspx. Those entities are referred to as 340B Covered Entities. a. On a quarterly basis, a report is run from the OPA 340B Database OPAIS to see if there are new

340B Covered Entities added to the 340B Program or if previously participating 340B Covered Entities have terminated their enrollment.

2. PHC sends an introduction letter to the new 340B Covered Entities describing PHC’s 340B Compliance Program and requirements for joining the programcompares the information from the quarterly report to the 340B Compliance Program – 340B Covered Entity Master Tracking List. The 340B Compliance Program – 340B Covered Entity Master Tracking List is updated based on the information in the report.

3. If a 340B Covered Entity indicates they would like to join the 340B Compliance Program, it is requested that they sign an Agreement with PHCEach quarter, PHC determines if additional 340B Covered Entities will be invited to join the 340B Compliance Program. Invitee determination is based on consideration by PHC of factors such as expressed interest from 340B Covered Entities, as well as input from PHC’s Chief Medical Officer (CMO) and Director of Pharmacy Services.

B. 340B Compliance Program Agreement: 1. There is a single 340B Compliance Program Agreement that covers all possible pharmacy

arrangements and 340B drug distribution methods (Attachment A). 2. Once an agreement is entered into between PHC and a 340B Covered Entity, the entity is referred to

as a 340B Participating Entity. 3. All 340B Participating Entities are tracked on a separate document, 340B Compliance Program –

Current 340B Participating Entities-Tracking Document.

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Page 4 of 5

a. When the quarterly report is run from the 340B OPAIS, PHC reviews the information and compares it to any Change Notification forms received from 340B Participating Entities to determine if any changes were not communicated to PHC.

C. Billing Rates: 1. Payments for 340B Covered Outpatient Drugs billed as claims to PHC will be paid at the network or

contracted rate negotiated between the 340B Participating Entity’s Contract or In-House Pharmacy and the PBM, subject to the requirements of Welfare & Institutions Code § 14087.325(d). PHC does not have access to information regarding rates established by the 340B Contract/In-House Pharmacies and the PBMPBM. This is applicable to all 340B drug claims for all of the following pharmacy inventory types: a. Dispense only 340B drugs b. Dispense both 340B drugs and non-340B drugs c. Listed on Medicaid Exclusion File and dispense only 340B drugs d. Listed on Medicaid Exclusion File and dispense both 340B drugs and non-340B drugs

D. Invoicing and Compliance Fees for 340B Participating Entities: 1. 340B prescription claims reclassified through 340BX Clearinghouse: There will be a 90 to 120 day

lag in the invoicing process for these claims. The invoices will come from 340BX Clearinghouse and reflect the 340BX Compliance Fees, as well as the PHC 340B Compliance Fees.

The 340B Participating Entity is the sole responsible party for the proper flagging of all 340B claims (including PAD claims, Physician-Dispended Drugs, and drug costs submitted as part of a fee-for-service, bundled, or capitated rate) submitted for 340B drugs requiring the use of the UD Modifier (refer to Attachment B). Clearinghouse is not involved with this type of flagging, as it is completed by the 340B Participating Entity, so there is no fee associated with the addition of the UD modifier. In the event the 340B Participating Entity requires assistance with flagging 340B claims missing the UD modifier, the 340B Participating Entity should follow the process outlined in the PHC Medi-Cal Provider Manual here: Section 3: Claims, PHC Medi-Cal Provider Appeal Process (CIF and Appeal Timelines), First Level Appeal – PHC Medi-Cal Claims Inquiry Form Process – 1. Electronic Claims Inquiry Form System (e-CIFclaims) filed for 340B drugs by the use of the UD Modifier (refer to Attachment B). In the event the 340B Participating Entity requires assistance with flagging 340B claims missing the UD modifier, they may submit a formal written request to PHC along with a file containing the needed claims information to identify each claim. By submitting the formal request to assist with flagging 340B claims with the UD modifier, the 340B Participating Entity acknowledges it will adhere to PHC’s process for correcting each claim and add the UD modifier for the fee outlined in the 340B Compliance Program Agreement (Attachment A). http://www.partnershiphp.org/Providers/Policies/Documents/Claims/Medi-Cal_Section%203.Subsection%20VIII.A.pdf 1.2.

E. Reporting of Changes to 340B Participating Entity’s 340B Program 1. It is the responsibility of the 340B Participating Entity to communicate any changes to its internal

340B Program that may affect any of the terms and/or conditions of the 340B Compliance Program Agreement.

2. A form is provided to the 340B Participating Entity to use when reporting changes to PHC. 3. Changes that should be reported to PHC are as follows:

a. New site for the 340B Participating Entity becomes eligible to participate in the 340B Program b. 340B Participating Entity site is terminated from the 340B Program

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Page 5 of 5

c. New Contract Pharmacy is added to the 340B Participating Entity’s Pharmacy Network d. Contract Pharmacy is removed from the 340B Participating Entity’s Pharmacy Network e. 340B Participating Entity opens an In-House Pharmacy f. 340B Participating Entity closed an In-House Pharmacy g. Any change to the contact information for the 340B Participating Entity on the OPA 340B

Database including Authorizing Official or Primary Contact F. Data Reporting Requirements:

1. Contract Pharmacy 340B Claims: a. For the exact language, please refer to the Agreement. The file format will be shared during the

340B Participating Entity’s on-boarding process with 340BX Clearinghouse. Any file format changes will be communicated to the 340B Participating Entity within thirty (30) calendar days before the changes become effectiveChanges in the file format will be communicated in advance.

2. In-House Pharmacy Claims: a. If an In-House Pharmacy processes 340B prescription claims at the POS, all claims for drugs

purchased through the 340B program and submitted through a PBM must have “20” entered into the Submission Clarification Code (DK-420) to indicate the claim was a 340B claim.

b. If an In-House Pharmacy submits claims directly to PHC, all claims must have a UD modifier listed after the HCPCS code for each and every 340B-purchased drug billed via paper or electronically using a CMS-1500 or format, UB-04 format, 837 format,m or related format.

3. PAD 340B Claims: a. The 340B Participating Entity is responsible for insuring that all PAD 340B claims are flagged

appropriately. b. All claims for drugs purchased through the 340B program and submitted as claims directly to

PHC must have a UD modifier listed after the HCPCS code for each and every 340B-purchased drug billed via paper or electronically using a CMS-1500 format, UB-04 format, 837 file format, or other related formatCMS-1500 or UB-04 form or related format.

VII. REFERENCES: VIII. https://340bopais.hrsa.gov/home http://www.hrsa.gov/opa/index.html

IX.VIII. DISTRIBUTION:

A. PHC Department Directors B. PHC Provider Manual

X.IX. POSITION RESPONSIBLE FOR IMPLEMENTING PROCEDURE: PHC Pharmacy Services

Department with 340B Advisory Committee oversight.

XI.X. REVISION DATES: 04/02/15; 10/06/16; 05/09/18 *Through 2017, Approval Date reflective of the Pharmacy and Therapeutics Committee meeting date. Effective January 2018, Approval Date reflects that of the Physician Advisory Committee’s meeting date. PREVIOUSLY APPLIED TO: N/A

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POLICY / PROCEDURE

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Policy/Procedure Title: 340B Compliance Program ☒External Policy ☐ Internal Policy



Reviewing Entities:


☒ OPERATIONS ☐ EXECUTIVE ☐ COMPLIANCE ☐ DEPARTMENT

Approving Entities:

☐ BOARD ☐ COMPLIANCE ☒ FINANCE ☒ PAC

☐ CEO ☐ COO ☐ CREDENTIALING ☒ DEPT. DIRECTOR/OFFICER



PHC 340B Policy for Primary Care Entities

II. IMPACTED DEPTS: A. Pharmacy B. Provider Relations C. Administration (Finance)

III. DEFINITIONS: A. 340B Program: The Veterans Health Care Act of 1992 established the 340B Program in section 340B of

the Public Health Service Act. The 340B Program requires drug manufacturers participating in Medicaid to provide discounted covered outpatient drugs to certain eligible health care entities, known as 340B Covered Entities (see definition below).

B. 340B Drug: Any covered outpatient drug purchased on a discounted basis under the 340B program, as defined by 42 U.S.C. § 256b and its implementing regulations, that is purchased via a qualified 340B Program distributor.

C. 340B Covered Entity: A healthcare provider registered with HRSA and approved to participate in the 340B Program.

D. 340B Participating Entity: A 340B Covered Entity that agrees to participate in PHC’s 340B Compliance Program and signs a 340B Compliance Program Agreement.

E. 340B Administrator: A subcontractor hired by a 340B Participating Entity to administer the 340B program, usually for a fee.

F. HRSA: United States Health Resources and Services Administration. G. DHCS: California Department of Health Care Services. H. Pharmacy Benefits Manager (PBM): A subcontractor of PHC that contracts with individual dispensing

pharmacies to create a network of pharmacies to provide the infrastructure for the pharmacy benefit of PHC.

I. 340B Office of Pharmacy Affairs Information System (“340B OPAIS”): A database overseen by OPA which includes detailed information related to all 340B Covered Entities, Contract Pharmacies, and Manufacturers all registered to participate in the 340B Program.

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J. 340BX Clearinghouse: The entity contracted with PHC to coordinate with various 340B players and perform data analysis and identification of 340B eligible pharmacy claims for the 340B Participating Entities.

K. PHC 340B Advisory Committee: A subcommittee of the PHC Board of Commissioners charged with overseeing PHC’s 340B Compliance Program, including review and approval of the 340B QIP program and related proposals.

L. Contract Pharmacy: A retail pharmacy dispensing 340B-purchased drugs on behalf of a 340B Covered Entity, based on a contract between the 340B Covered Entity and the pharmacy. A Contract Pharmacy operates with a mixed inventory of drugs (340B and non-340B Covered Outpatient Drugs). All eligible Contract Pharmacies are registered with HRSA and listed on the 340B OPAIS:

https://340bopais.hrsa.gov/home. M. In-House Pharmacy: A pharmacy in which the 340B Covered Entity owns the 340B drugs, pharmacy,

and license. The 340B Covered Entity purchases the 340B drugs, which are dispensed to eligible patients, as defined by HRSA. The 340B Covered Entity is fiscally responsible for the pharmacy and pays the pharmacy staff. The pharmacy is (i) located on the premises of the 340B Covered Entity, (ii) provides services solely to the 340B Covered Entity’s patients, (iii) through the 340B Covered Entity’s providers, and (iv) dispenses only drugs and supplies purchased under the 340B Program to PHC beneficiaries. For the purposes of this Agreement, if all conditions, (i) through (iv), are not met, then the pharmacy would be considered a Contract Pharmacy, even though it might be physically located on the premises of the 340B Covered Entity. In-House Pharmacies are not registered with HRSA nor are they listed on the 340B OPAIS.

N. Provider/In-House Dispensing: The 340B Covered Entity owns drugs; employs or contracts with providers licensed in the state to dispense drugs on its behalf; holds a clinic dispensary license issued by the California Board of Pharmacy; and is fiscally responsible for the operation of the dispensary. These entities submit claims for 340B Covered Outpatient Drugs using the CMS-1500 format, UB-04 format, or electronic 837 file format, which are not first processed by a PBM providing services under a direct contract with the 340B Participating Entity and on its behalf.

O. Physician-Administered Drug (“PAD”): Any covered outpatient drug provided or administered by the 340B Participating Entity to one of its patients, and billed by a provider other than a pharmacy. Such providers include, but are not limited to, physician offices, clinics, and hospitals. A covered outpatient drug is broadly defined as a drug that may be dispensed only upon prescription, and is approved for safety and effectiveness as a prescription drug under the Federal Food, Drug and Cosmetic Act. PADs include both injectable and non-injectable drugs. These drugs may sometimes be referred to as Physician-Dispensed Drugs.

P. 340BX Trust Account: A bank account in the name of NEC Networks, LLC (for Clearinghouse) at BBVA Compass Bank. This account will be utilized by Clearinghouse as a holding account to deposit 340B related funds paid by 340B Participating Entities, and also to transfer funds to PHC's bank account.

Q. UD Modifier: Approved modifier code for use in billing Medi-Cal. This modifier code is used by Section 340B providers to denote services provided or drugs purchased under the 340B Program

IV. ATTACHMENTS:

A. 340B Compliance Program Agreement B. PHC 340B Compliance Program White Paper

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V. PURPOSE:

The purpose of this policy is to outline the requirements for participation in PHC’s 340B Compliance Program, which is established to ensure 340B Participating Entities and PHC are complying with Federal and State 340B regulations. The data submission process outlined for the 340B Compliance Program is set-up so that 340B drugs prescribed by the 340B Participating Entities are identified to DHCS in a way that the State requires in order to ensure that no duplicate discounts are received and retained for the use of 340B drugs. This policy will be applied consistently across each class of 340B Covered Entity and set forth standards of accountability that are reasonable and meaningful.


A. Analysis of 340B Covered Entities as outlined by HRSA: 1. A master list of entities identified as eligible to participate in the 340B Program (340B Compliance

Program – 340B Covered Entity Master Tracking List) has been compiled by PHC using information

from the 340B OPAIS on HRSA’s website, https://340bopais.hrsa.gov/home. Those entities are referred to as 340B Covered Entities. a. On a quarterly basis, a report is run from the 340B OPAIS to see if there are new 340B Covered

Entities added to the 340B Program or if previously participating 340B Covered Entities have terminated their enrollment.

2. PHC compares the information from the quarterly report to the 340B Compliance Program – 340B Covered Entity Master Tracking List. The 340B Compliance Program – 340B Covered Entity Master Tracking List is updated based on the information in the report.

3. Each quarter, PHC determines if additional 340B Covered Entities will be invited to join the 340B Compliance Program. Invitee determination is based on consideration by PHC of factors such as expressed interest from 340B Covered Entities, as well as input from PHC’s Chief Medical Officer (CMO) and Director of Pharmacy Services.

B. 340B Compliance Program Agreement: 1. There is a single 340B Compliance Program Agreement that covers all possible pharmacy

arrangements and 340B drug distribution methods (Attachment A). 2. Once an agreement is entered into between PHC and a 340B Covered Entity, the entity is referred to

as a 340B Participating Entity. 3. All 340B Participating Entities are tracked on a separate document, 340B Compliance Program –

Current 340B Participating Entities-Tracking Document. a. When the quarterly report is run from the 340B OPAIS, PHC reviews the information and

compares it to any Change Notification forms received from 340B Participating Entities to determine if any changes were not communicated to PHC.

C. Billing Rates: 1. Payments for 340B Covered Outpatient Drugs billed as claims to PHC will be paid at the network or

contracted rate negotiated between the 340B Participating Entity’s Contract or In-House Pharmacy and the PBM, subject to the requirements of Welfare & Institutions Code § 14087.325(d). PHC does not have access to information regarding rates established by the 340B Contract/In-House Pharmacies and the PBM. This is applicable to all 340B drug claims for all of the following pharmacy inventory types:

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a. Dispense only 340B drugs b. Dispense both 340B drugs and non-340B drugs c. Listed on Medicaid Exclusion File and dispense only 340B drugs d. Listed on Medicaid Exclusion File and dispense both 340B drugs and non-340B drugs

D. Invoicing and Compliance Fees for 340B Participating Entities: 1. 340B prescription claims reclassified through 340BX Clearinghouse: There will be a 90 to 120 day

lag in the invoicing process for these claims. The invoices will come from 340BX Clearinghouse and reflect the 340BX Compliance Fees, as well as the PHC 340B Compliance Fees.

The 340B Participating Entity is the sole responsible party for the proper flagging of all 340B claims (including PAD claims, Physician-Dispended Drugs, and drug costs submitted as part of a fee-for-service, bundled, or capitated rate) submitted for 340B drugs requiring the use of the UD Modifier (refer to Attachment B). Clearinghouse is not involved with this type of flagging, as it is completed by the 340B Participating Entity, so there is no fee associated with the addition of the UD modifier. In the event the 340B Participating Entity requires assistance with flagging 340B claims missing the UD modifier, the 340B Participating Entity should follow the process outlined in the PHC Medi-Cal Provider Manual here: Section 3: Claims, PHC Medi-Cal Provider Appeal Process (CIF and Appeal Timelines), First Level Appeal – PHC Medi-Cal Claims Inquiry Form Process – 1. Electronic Claims Inquiry Form System (e-CIF). http://www.partnershiphp.org/Providers/Policies/Documents/Claims/Medi-Cal_Section%203.Subsection%20VIII.A.pdf 2.

E. Reporting of Changes to 340B Participating Entity’s 340B Program 1. It is the responsibility of the 340B Participating Entity to communicate any changes to its internal

340B Program that may affect any of the terms and/or conditions of the 340B Compliance Program Agreement.

2. A form is provided to the 340B Participating Entity to use when reporting changes to PHC. 3. Changes that should be reported to PHC are as follows:

a. New site for the 340B Participating Entity becomes eligible to participate in the 340B Program b. 340B Participating Entity site is terminated from the 340B Program c. New Contract Pharmacy is added to the 340B Participating Entity’s Pharmacy Network d. Contract Pharmacy is removed from the 340B Participating Entity’s Pharmacy Network e. 340B Participating Entity opens an In-House Pharmacy f. 340B Participating Entity closed an In-House Pharmacy g. Any change to the contact information for the 340B Participating Entity on the OPA 340B

Database including Authorizing Official or Primary Contact F. Data Reporting Requirements:

1. Contract Pharmacy 340B Claims: a. For the exact language, please refer to the Agreement. The file format will be shared during the

340B Participating Entity’s on-boarding process with 340BX Clearinghouse. Any file format changes will be communicated to the 340B Participating Entity within thirty (30) calendar days before the changes become effective.

2. In-House Pharmacy Claims: a. If an In-House Pharmacy processes 340B prescription claims at the POS, all claims for drugs

purchased through the 340B program and submitted through a PBM must have “20” entered into the Submission Clarification Code (DK-420) to indicate the claim was a 340B claim.

b. If an In-House Pharmacy submits claims directly to PHC, all claims must have a UD modifier listed after the HCPCS code for each and every 340B-purchased drug billed via paper or electronically using a CMS-1500 format, UB-04 format, 837 format, or related format.

3. PAD 340B Claims:

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a. The 340B Participating Entity is responsible for insuring that all PAD 340B claims are flagged appropriately.

b. All claims for drugs purchased through the 340B program and submitted as claims directly to PHC must have a UD modifier listed after the HCPCS code for each and every 340B-purchased drug billed via paper or electronically using a CMS-1500 format, UB-04 format, 837 file format, or other related format.

VII. REFERENCES:

https://340bopais.hrsa.gov/home VIII. DISTRIBUTION:


IX. POSITION RESPONSIBLE FOR IMPLEMENTING PROCEDURE: PHC Pharmacy Services

Department with 340B Advisory Committee oversight.

X. REVISION DATES: 04/02/15; 10/06/16; 05/09/18 *Through 2017, Approval Date reflective of the Pharmacy and Therapeutics Committee meeting date. Effective January 2018, Approval Date reflects that of the Physician Advisory Committee’s meeting date. PREVIOUSLY APPLIED TO: N/A

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POLICY/ PROCEDURE

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Policy/Procedure Number: MPRP4062 Lead Department: Health Services

Policy/Procedure Title: Drug Wastage Payments ☒External Policy ☐ Internal Policy



Reviewing Entities:



Approving Entities:



Approval Signature: Robert L. Moore, MD, MPHRobert Moore, MD, MPH, MBA Approval Date: 04/06/201705/09/2018


A. MCRO4018- Pharmacy TAR Procedure B. CMP09 – Fraud, Waste and Abuse Reporting

II. IMPACTED DEPTS:

A. Pharmacy B. Claims C. Provider Relations D. Compliance

III. DEFINITIONS: A. Drug Waste means the remainder of drug or biological that has been discarded from a single use

vial or other single use package after administering a dose/quantity of the drug or biological to a patient.

B. Fraud, Waste, and Abuse (FWA): 1. Fraud: In general, Medicaid fraud involves making a false statement or misrepresentation of material

facts to obtain a payment to which the provider is not otherwise entitled. The rules governing Medicaid define “fraud” as follows: “… an intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to himself or some other person. It includes any act that constitutes fraud under applicable Federal or State law.” An example of fraud is knowingly billing for services not furnished or supplies not provided.

2. Waste: Waste is not defined in the rules, but is “generally understood to encompass over-utilization or inappropriate utilization of services and misuse of resources, and typically is not a criminal or intentional act.” Examples of waste by a beneficiary could include making excessive office visits or accumulating more prescription medications than necessary for the treatment of specific conditions. Waste by a provider could include ordering excessive laboratory tests.

3. Abuse: Abuse is defined in the Medicaid rules as follows: “… provider practices that are inconsistent with sound fiscal, business, or medical practices, and result in an unnecessary cost to the Medicaid program, or in reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards for health care. It also includes beneficiary practices that result in unnecessary cost to the Medicaid program.”

IV. ATTACHMENTS:

A. Chemotherapy/BiologicalAllowable Waste Drug List

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http://eshare/sites/PoliciesnProcedures/_layouts/15/WopiFrame.aspx?sourcedoc=/sites/PoliciesnProcedures/Pharmacy/MPRP4062%20Attachments/MPRP4062-A.docx&action=default


Policy/Procedure Title: Drug Wastage Payments ☒ External Policy ☐ Internal Policy



Page 2 of 3

V. PURPOSE: To define the process on how to bill for discarded drugs and biologicals in an appropriate manner that falls within the guidelines of Healthcare Fraud, Waste, and Abuse and the Plan’s reporting of potential findings.

VI. POLICY / PROCEDURE:A. Policy:

1. Partnership HealthPlan of California (PHC) encourages physicians, hospitals, and other providers tocare for and administer to patients in such a way that they can use drugs or biologicals mostefficiently, in a clinically appropriate manner. Providers should administer medications in the mostcost-effective manner, utilizing the most cost-effective vial and/or combination of vial sizes in orderto minimize waste.

B. Procedure: 1. When a physician, hospital, or other provider must discard the remainder of a single use vial or other

single use package after administering a dose/quantity of a drug or biological, PHC will providepayment for the amount of the drug or biological discarded, as well as the dose administered listedon the Chemotherapy/BiologicalAllowable Waste Drug List (Attachment A), up to the amount of thedrug or biological as indicated on the vial or package label.

2. When submitting claims for drugs and biologicals, the JW modifier (drug amount discarded/notadministered to any patient) and National Drug Code (NDC) are required to identify unused drug orbiologicals from single use vials or single use packages that are appropriately discarded.a. The JW modifier is billed on a separate line and will provide payment for the amount of

discarded drug or biological.b. The NDC of the drug or biological used must be submitted in conjunction with the JW modifier.c. The JW modifier is only applied to the amount of the drug or biological that is discarded.d. The JW modifier is not permitted when the actual dose of the drug or biological administered is

less than the billing unit.The JW modifier is not permitted when the actual drug or biological is not listed on the Chemotherapy/Biological Drug List for billing waste (Attachment A).

3. The Allowable Waste Drug List (Attachment A) is not an exclusive list and will undergo review andrevision as needed throughout the year due to HCPCS code changes and market availability of single-dose vs multi-dose vials. e.a. When the JW modifier is used for a drug or biological which is not listed on the Allowable

Waste Drug List (Attachment A), a TAR must be submitted for consideration of approval of drug waste. pPharmacy department will review the request to determine if waste reimbursement is allowable based on the NDC submitted and waste considerations outlined in this policy.

3.4. PHC will not reimburse for discarded drugs or biologicals under the following situations: a. The drug or biological is administered from a multi-use vialb. The drug or biological is not administered to the patientc. An inappropriate vial size or combination of vials is used to deliver the administered dosed. The drug or biological is contaminated.

4.5. The patient’s medical record must document the following items: a. The physician’s order for the drug. If the order is written based on patient specific factors

(weight, body surface are, etc.), current measurement of those factors must also be documented.b. The date and time that the drug or biological was administered to the patientc. The amount of the drug or biological administered to the patientd. The route of administration of the drug or biological.e. The amount of the drug or biological that was discarded or wasted and the reason for wastage.f. The name and credentials of the person administering the drug

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POLICY/ PROCEDURE

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Policy/Procedure Title: Drug Wastage Payments ☒External Policy ☐ Internal Policy

Original Date: 01/21/2016 Next Review Date: 05/09/2019Last Review Date05/09/2018


Reviewing Entities:



Approving Entities:





A. MCRO4018- Pharmacy TAR Procedure B. CMP09 – Fraud, Waste and Abuse Reporting

II. IMPACTED DEPTS:

A. Pharmacy B. Claims C. Provider Relations D. Compliance

III. DEFINITIONS: A. Drug Waste means the remainder of drug or biological that has been discarded from a single use

vial or other single use package after administering a dose/quantity of the drug or biological to a patient.

B. Fraud, Waste, and Abuse (FWA): 1. Fraud: In general, Medicaid fraud involves making a false statement or misrepresentation of material

facts to obtain a payment to which the provider is not otherwise entitled. The rules governing Medicaid define “fraud” as follows: “… an intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to himself or some other person. It includes any act that constitutes fraud under applicable Federal or State law.” An example of fraud is knowingly billing for services not furnished or supplies not provided.

2. Waste: Waste is not defined in the rules, but is “generally understood to encompass over-utilization or inappropriate utilization of services and misuse of resources, and typically is not a criminal or intentional act.” Examples of waste by a beneficiary could include making excessive office visits or accumulating more prescription medications than necessary for the treatment of specific conditions. Waste by a provider could include ordering excessive laboratory tests.

3. Abuse: Abuse is defined in the Medicaid rules as follows: “… provider practices that are inconsistent with sound fiscal, business, or medical practices, and result in an unnecessary cost to the Medicaid program, or in reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards for health care. It also includes beneficiary practices that result in unnecessary cost to the Medicaid program.”

IV. ATTACHMENTS:

A. Allowable Waste Drug List

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V. PURPOSE: To define the process on how to bill for discarded drugs and biologicals in an appropriate manner that falls within the guidelines of Healthcare Fraud, Waste, and Abuse and the Plan’s reporting of potential findings.


A. Policy: 1. Partnership HealthPlan of California (PHC) encourages physicians, hospitals, and other providers to

care for and administer to patients in such a way that they can use drugs or biologicals most efficiently, in a clinically appropriate manner. Providers should administer medications in the most cost-effective manner, utilizing the most cost-effective vial and/or combination of vial sizes in order to minimize waste.

B. Procedure: 1. When a physician, hospital, or other provider must discard the remainder of a single use vial or other

single use package after administering a dose/quantity of a drug or biological, PHC will provide payment for the amount of the drug or biological discarded, as well as the dose administered listed on the Allowable Waste Drug List (Attachment A), up to the amount of the drug or biological as indicated on the vial or package label.

2. When submitting claims for drugs and biologicals, the JW modifier (drug amount discarded/not administered to any patient) and National Drug Code (NDC) are required to identify unused drug or biologicals from single use vials or single use packages that are appropriately discarded. a. The JW modifier is billed on a separate line and will provide payment for the amount of

discarded drug or biological. b. The NDC of the drug or biological used must be submitted in conjunction with the JW modifier. c. The JW modifier is only applied to the amount of the drug or biological that is discarded. d. The JW modifier is not permitted when the actual dose of the drug or biological administered is

less than the billing unit.

3. The Allowable Waste Drug List (Attachment A) is not an exclusive list and will undergo review and revision as needed throughout the year due to HCPCS code changes and market availability of single-dose vs multi-dose vials. a. When the JW modifier is used for a drug or biological which is not listed on the Allowable

Waste Drug List (Attachment A), a TAR must be submitted for consideration of approval of drug waste. Pharmacy department will review the request to determine if waste reimbursement is allowable based on the NDC submitted and waste considerations outlined in this policy.

4. PHC will not reimburse for discarded drugs or biologicals under the following situations: a. The drug or biological is administered from a multi-use vial b. The drug or biological is not administered to the patient c. An inappropriate vial size or combination of vials is used to deliver the administered dose d. The drug or biological is contaminated.

5. The patient’s medical record must document the following items: a. The physician’s order for the drug. If the order is written based on patient specific factors

(weight, body surface are, etc.), current measurement of those factors must also be documented. b. The date and time that the drug or biological was administered to the patient c. The amount of the drug or biological administered to the patient d. The route of administration of the drug or biological. e. The amount of the drug or biological that was discarded or wasted and the reason for wastage. f. The name and credentials of the person administering the drug

6. TAR requests for non-formulary drugs and biologicals should include the following information: a. The amount of drug or biological to be administered to the patient per treatment.

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b. The amount of drug or biological that will be wasted per treatment, listed separately. c. The NDC of the drug or biological that will be used.

C. Reporting: 1. Pharmacy Services Department clinical staff in conjunction with Claim department staff may

identify Claims after payment is rendered with billing errors as described above. 2. All claims identified by the Pharmacy Department staff for recovery of overpayment will be

reviewed quarterly for accuracy and reported annually to the Chief Compliance Officer via RAC_Inbox by the Pharmacy Services Director or his/her designee.

3. All potential FWA cases identified will be reported by the pharmacy Department Staff immediately via RAC_Reporting as described by Policy #CMP09.

VII. REFERENCES:

CMS. Medicare Claims Processing Manual, Chapter 17-Drugs and Biologicals, § 40. VIII. DISTRIBUTION:

A. PHC Provider Manual B. PHC Department Directors


Associate Director of Pharmacy Operations

X. REVISION DATES: 01/12/17; 04/06/17; 05/09/2018 *Through 2017, Approval Date reflective of the Pharmacy & Therapeutics Committee Meeting date. Effective January 2018, Approval Date reflects that of the Physician Advisory Committee’s meeting date.

PREVIOUSLY APPLIED TO:

Healthy Kids 01/21/2016 to 12/01/2016 (Healthy Kids Program ended 12/01/16) XI. POLICY DISCLAIMER:




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PHC (PARTNERSHIP HEALTHPLAN OF CALIFORNIA) PAC SUMMARY

Pg. 1 of 14 * =by phone conference

Committee: Credentialing Committee Date/Time: March 14, 2018 7:00 a.m. – 7:30 a.m. Members Present: Bradley Sandler, MD; Jeff Gaborko, MD; Steven Gwiazdowski, MD PHC Staff: Robert Moore, MD MPH MBA, PHC Chief Medical Officer; Marshall Kubota, MD*, PHC Regional Medical Director; Michael Vovakes, MD*,

PHC Northern Region Medical Director; Bettina Spiller, MD*, PHC Northern Region Medical Director; Mary Kerlin, Senior Director of Provider Relations; Heather Brandeburg, Director of Provider Relations; Jasmine Jones, Credentialing Specialist II; Skyler Bellmore ,Credentialing Specialist II

AGENDA ITEM DISCUSSION / CONCLUSIONS RECOMMENDATIONS / ACTION TARGET DATE

DATE RESOLVED

I. Meeting called to order

I. PHC Regional Medical Director Marshall Kubota, MD called the meeting to order.

3-14-2018

II. Review/Approval of previous minutes

II. A. The Credentialing Committee meeting minutes for February 14, 2018

II. Motion: Dr. Jeff Gaborko, MD. Second: Dr. Steven Gwiazdowski, MD. Meeting minutes approved without changes.

3-14-2018

III. Old Business A. Neurology, Shasta County Information Only: B. Family Practice Lassen County Information Only IV. New Business A. Review of Practitioner File B. University of California Davis Medical Group Pre-Delegation Assessment Report: Informational Only:

III. Committee voted to approve Administrative Suspension for lack of privileges without automatic reinstatement. III. B. Provider did not meet the criteria of PHC Policy MP CR #17- Standards for Contracted Primary Care Providers. IV. A. Please see approved list of Routine Providers on Pages 4-14 The Committee reviewed and discussed the list of fifteen (15) Physicians, eight (8) Non-Physician Medical Practitioners, six (6) Behavioral Health Analysts, one (1) Podiatrist, and one (1) Physical Therapist for Initial Credentialing, twenty six (26) Physicians, twelve (12) Non-Physician Medical Practitioners, and one (1) Podiatrist for Re-Credentialing. B. University of California Davis Medical Group Pre-Delegation Assessment Report: Informational Only: PHC staff conducted an assessment of this Medical Group’s credentialing activities and all requirements were met. PHC is entering into a Delegation Agreement for Credentialing effective March 1, 2018.

III.A. No discussion from Committee. III. B. No discussion from Committee. IV. A. Motion: Dr. Jeffrey Gaborko, MD. Second: Dr. Bradley Sandler, MD. Approved the list without changes of fifteen (15) Physicians, eight (8) Non-Physician Medical Practitioners, six (6) Behavioral Health Analysts, one (1) Podiatrist, and one (1) Physical Therapist for Initial Credentialing, twenty six (26) Physicians, twelve (12) Non-Physician Medical Practitioners, and one (1) Podiatrist for Re-Credentialing. IV. B. No discussion from Committee.

3-14-2018

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PHC Credentialing PAC Summary 3-14-18 Page 2 of 14 AGENDA ITEM DISCUSSION / CONCLUSIONS RECOMMENDATIONS / ACTION TARGET

DATE DATE

RESOLVED V. A. Doctors of Osteopathy: Information Only:

VI. A. Update of Ongoing Monitoring of Sanctions. One Provider Found: Family Practice, Mendocino County Information Only: VII. Consent Calendar Items. A. Report of Long Term Care Facility, Hospital, and Ancillary Prov. List. B. Review of Suboxone/ Buprenorphine credentialed primary care providers. C. 4th Quarter: Kaiser Santa Rafael: Credentialing/ Re- Credentialing Activities. D. 4th Quarter: Kaiser Santa Rosa: Credentialing/ Re- Credentialing Activities. E. 4th Quarter: Kaiser Vallejo: Credentialing/ Re- Credentialing Activities F. 4th Quarter: Kaiser Vacaville: Credentialing/ Re- Credentialing Activities.

V. A. OMT may be provided by a Primary Care Physician who is a DO as a treatment modality within their scope of primary care treatment. However, these practitioners do not meet PHC’s criteria for PCPs. VI.A. Effective March 29, 2018, the Medical Board of California (MBOC) order against respondent is terminated without imposition of discipline. II. A. Report of Long Term Care Facility, Hospital, and Ancillary provider list. B. Review of Suboxone/ Buprenorphine credentialed primary care providers. C. 4th Quarter: Kaiser Santa Rafael: Credentialing/ Re- Credentialing Activities D. 4th Quarter: Kaiser Santa Rosa: Credentialing/ Re- Credentialing Activities. E. 4th Quarter: Kaiser Vallejo: Credentialing/ Re- Credentialing Activities F. 4th Quarter: Kaiser Vacaville: Credentialing/ Re- Credentialing Activities.

V.A. The Committee briefly discussed the education and training for Doctors of Osteopathy. VI. A. No discussion from Committee.

VII.A. Motion: Dr. Jeff Gaborko, MD. Second: Dr. Steven Gwiazdowski, MD. Approved Consent Calendar Items without changes.

3-14-2018

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DATE DATE

RESOLVED VI. Consent Calendar Items (cont.) G. 3rd Sutter Pacific Medical Foundation, Sutter Medical Group of the Redwoods: Credentialing/ Re- Credentialing Activities. H. 4th Quarter BayChildren’s Physicians: Credentialing/ Re- Credentialing Activities. I. MPCR 13A (NO CHANGE): Credentialing of Hospice and Palliative Care Medicine Specialist J. MP PR PL CR 401 (NO CHANGE): Credentials Document Collection, Review, and Verification VIII. Meeting Adjourned

VI. Consent Calendar Items (cont.) G. 3rd Sutter Pacific Medical Foundation, Sutter Medical Group of the Redwoods: Credentialing/ Re- Credentialing Activities. H. 4th Quarter BayChildren’s Physicians: Credentialing/ Re- Credentialing Activities. I. MPCR 13A (NO CHANGE): Credentialing of Hospice and Palliative Care Medicine Specialist J. MP PR PL CR 401 (NO CHANGE): Credentials Document Collection, Review, and Verification With No further items for discussion, the meeting was adjourned Next Meeting Scheduled for April 11, 2018

3-14-2018

PAC Summary Meeting Minutes for March 14, 2018 respectfully prepared and submitted by Jasmine Jones - Credentialing Specialist II Chairman Signature of Approval __________________________________________ Date______________________________ Marshall Kubota M.D., PHC Credentialing Chairman

193 of 233

March 2018

AppType

Practitoner Name Provider Type Practice Name County Name Specialty Description Board Name

Board Certified

Hospital Name

Staff Category

Settlement Date

IAlbay, Diana T.,MD SPEC TeleMed2U Yolo Endocrinology None No

No Direct Patient Contact No Privileges

IAlbay, Diana T.,MD SPEC TeleMed2U Yolo Internal Medicine ABMS of Internal Medicine No


RAmbrosio, Joel P.,PA-C PCP

NBHG: Center for Primary Care-Green Valley, A NorthBay Affiliate Solano Physician Assistant Certified

National Commission on Certification of Physician Assistants Yes

RAmbrosio, Joel P.,PA-C PCP

NBHG: Center for Primary Care-Vacaville, A NorthBay Affiliate Solano Physician Assistant Certified


RAmster, Michael A.,MD SPEC

NBHG: NorthBay Center For Pain Solano Family Medicine ABMS of Family Medicine Yes

Hospitalist Coverage No Privileges

RAmster, Michael A.,MD SPEC

NBHG: NorthBay Center For Pain Solano Pain Medicine ABMS of Family Medicine Yes


IAncock, Benedict P.,MD SPEC

Marin HealthCare Dist: Cardiolvascular Assoc of Marin Marin Cardiovascular Disease ABMS of Internal Medicine Yes

Marin General Hospital

Provisional Active


Marin HealthCare Dist: Cardiovascular Assoc of Marin Marin Internal Medicine ABMS of Internal Medicine Yes


Provisional Active


Marin HealthCare Dist: Cardiovascular Assoc of Marin Marin

Public Health & General Preventive Medicine

ABMS of Preventive Medicine Yes


Provisional Active


Marin Healthcare Dist: Cardiovascular Assoc of Marin and SF Marin Cardiovascular Disease ABMS of Internal Medicine Yes


Provisional Active


Marin Healthcare Dist: Cardiovascular Assoc of Marin and SF Marin Internal Medicine ABMS of Internal Medicine Yes


Provisional Active


Marin Healthcare Dist: Cardiovascular Assoc of Marin and SF Marin




Provisional Active


Marin Healthcare District: Sonoma Cardiology Sonoma Cardiovascular Disease ABMS of Internal Medicine Yes


Provisional Active

194 of 233

March 2018

AppType


Board Certified

Hospital Name

Staff Category

Settlement Date


Marin Healthcare District: Sonoma Cardiology Sonoma Internal Medicine ABMS of Internal Medicine Yes


Provisional Active


Marin Healthcare District: Sonoma Cardiology Sonoma




Provisional Active

RAnderson, Ian C.,MD SPEC

Annadel Medical Group Sonoma Internal Medicine ABMS of Internal Medicine No

Santa Rosa Memorial Hospital Active

RAnderson, Ian C.,MD SPEC

Annadel Medical Group Sonoma Medical Oncology ABMS of Internal Medicine No


R

Ayeko, Christopher N.,FNP PCP

Mendocino Community Health Clinic: Hillside Health Center Mendocino Family Nurse Practitioner

American Academy of Nurse Practitioners Certification Board Yes

R

Ayeko, Christopher N.,FNP PCP

Mendocino Community Health Clinic: Lakeview Health Center Lake Family Nurse Practitioner


IBaier, Kelly BCBA BHP

Behavior Treatment & Analysis, Inc. Solano Behavioral Health

Behavior Analyst Certification Board Yes

IBernard, Leah S.,MD SPEC

Asante Physician Partners: Maternal Fetal Medicine Siskiyou Maternal and Fetal Medicine

ABMS of Obstetrics and Gynecology Yes

Rogue Regional Medical Center Active

IBernard, Leah S.,MD SPEC

Asante Physician Partners: Maternal Fetal Medicine Siskiyou Obstetrics and Gynecology


Rogue Regional Medical Center Active

RBorg, Bryson D.,MD SPEC

Solano Diagnostic Imaging Solano Diagnostic Radiology ABMS of Radiology Yes


RBorg, Bryson D.,MD SPEC

Solano Diagnostic Imaging Solano Neuroradiology ABMS of Radiology Yes


RBrittell, Barbara M.,PA-C PCP

Redwood Coast Medical Services Inc./Point Arena Community Health Clinic Mendocino Physician Assistant Certified


RBrittell, Barbara M.,PA-C PCP

Redwood Coast Medical Services, Inc./Gualala Medical Clinic Mendocino Physician Assistant Certified


195 of 233

March 2018

AppType


Board Certified

Hospital Name

Staff Category

Settlement Date

RBrown, Laurence J.,NP PCP

SR Comm Hlth Centers: Dutton Campus Sonoma Nurse Practitioner None No

RBrown, Laurence J.,NP PCP

SR Comm Hlth Centers: Vista Family Health Center Sonoma Nurse Practitioner None No

IBukowski, Dinah M.,MD PCP

PRIMA Medical Foundation Marin Critical Care Medicine ABMS of Internal Medicine Yes

Novato Community Hospital Associate


PRIMA Medical Foundation Marin Internal Medicine ABMS of Internal Medicine Yes



PRIMA Medical Foundation Marin Pulmonary Diseases ABMS of Internal Medicine Yes


RCrane, Stephen M.,MD PCP

Annadel Medical Group (Family Practice) Sonoma Family Medicine ABMS of Family Medicine No

Hospitalist Coverage No Privileges 12/21/2015

RCurley, Anjaly B.,MD SPEC

Health Diagnostics of California Marin Diagnostic Radiology ABMS of Radiology Yes


IDanan, Ilan J.,MD SPEC TeleMed2U Yolo Neurology

ABMS of Psychiatry & Neurology Yes


IEanes, Lori S.,DO PCP

Community Medical Centers, Inc. - Community Med Cntrs Vacaville Solano Family Medicine

Meets MPCR#17, Previously Board Certified in FM, IM, or PEDs No

Transfer Agreement No Privileges


Community Medical Centers, Inc. - Community Med Ctr - Esparto Yolo Family Medicine




Community Medical Centers, Inc. - Dixon Family Practice Solano Family Medicine



R

Edwards, Christina S.,DO PCP

Marin Healthcare District: North Marin Internal Medicine Marin Internal Medicine ABMS of Internal Medicine Yes

Novato Community Hospital Active

IFife, Jared K.,PA PCP

Hayfork Community Clinic Trinity Physician Assistant None No

IFife, Jared K.,PA PCP

Trinity Community Health Clinic Trinity Physician Assistant None No

196 of 233

March 2018

AppType


Board Certified

Hospital Name

Staff Category

Settlement Date

IGardner, Barbara A.,MD PCP

Adventist Health- Ukiah Valley Primary Care Medical Group Lake Pediatrics ABMS of Pediatrics Yes

Ukiah Valley Medical Center Provisional

IGardner, Mark L.,MD SPEC

Adventist Health: St. Helena Cardiology Lake Cardiovascular Medicine ABMS of Internal Medicine Yes


IGardner, Mark L.,MD SPEC

Adventist Health: St. Helena Cardiology Lake Internal Medicine ABMS of Internal Medicine Yes


RGillespie, Craig L.,MD PCP Craig Gillespie, M.D. Solano Family Medicine


Northbay Medical Center

Active Attending

I

Glugatch, Lindsay B.,BCBA BHP

Behavior Treatment & Analysis, Inc. Solano Behavioral Health


RGootnick, Susan A.,MD SPEC


No Direct Patient Contact Non-Applicable

IGundry, Cooper R.,MD SPEC



IHand, Carolyn NP PCP

Redwood Coast Medical Services, Inc./Gualala Medical Clinic Mendocino Nurse Practitioner None No

RHartung, Beth A.,MD PCP

Community Health Clinic Ole: DBA: Ole Health Napa Internal Medicine ABMS of Internal Medicine Yes

Queen of the Valley Active

RHartung, Beth A.,MD PCP

Community Health Clinic Ole: DBA: Ole Health Napa Internal Medicine ABMS of Internal Medicine Yes


IHason, Michael J.,MD PCP

Pit River Health Service, Inc. Shasta Buprenorphine/Suboxone None No

Admitting Agreement No Privileges


Pit River Health Service, Inc. Shasta Family Practice

Meets MPCR #17, Verified Residency on AMA No



Pit River Health Service, XL Clinic Modoc Buprenorphine/Suboxone None No


197 of 233

March 2018

AppType


Board Certified

Hospital Name

Staff Category

Settlement Date


Pit River Health Service, XL Clinic Modoc Family Practice



RHemmerlin, Staci L.,NP PCP Harvest Pediatrics Napa Nurse Practitioner None No

IHill, Sarah E.,PA-C PCP

Hayfork Community Clinic Trinity Physician Assistant Certified


IHill, Sarah E.,PA-C PCP

Trinity Community Health Clinic Trinity Physician Assistant Certified


RHughes, Marie B.,DO PCP

Napa Valley Family Medical Group Napa Family Medicine ABMS of Family Medicine Yes


I

Hurley, Jennifer M.,CNM SPEC

Santa Rosa Midwifery Center DBA Santa Rosa Birth Center Sonoma Certified Nurse Midwife

American Midwifery Certification Board Yes

IJesrani, Lena B.,FNP PCP

Lassen Medical Clinic - Cottonwood Shasta Family Nurse Practitioner

American Nurses Credentialing Center Yes

IJesrani, Lena B.,FNP PCP

Lassen Medical Clinic- Red Bluff Shasta Family Nurse Practitioner


RKal, Mark P.,MD PCP

Redwood Coast Medical Services Inc./Point Arena Community Health Clinic Mendocino Family Medicine ABMS of Family Medicine Yes


RKal, Mark P.,MD PCP

Redwood Coast Medical Services, Inc./Gualala Medical Clinic Mendocino Family Medicine ABMS of Family Medicine Yes


RKeiser, Leroy W.,MD SPEC

Annadel Medical Group Sonoma Internal Medicine ABMS of Internal Medicine Yes


198 of 233

March 2018

AppType


Board Certified

Hospital Name

Staff Category

Settlement Date

RKeiser, Leroy W.,MD SPEC

Annadel Medical Group Sonoma Medical Oncology ABMS of Internal Medicine Yes


RKruusmagi, Ellen B.,MD PCP

Sonoma County Indian Health Project, Inc. Sonoma Buprenorphine/Suboxone None No

Group Coverage No Privileges

RKruusmagi, Ellen B.,MD PCP

Sonoma County Indian Health Project, Inc. Sonoma Family Medicine ABMS of Family Medicine Yes

Group Coverage No Privileges

RLaurence, Jody B.,DPM SPEC

Jody B. Laurence, DPM Yolo Podiatry None No

No Hospital Privileges No Privileges

I

Le, Mae Jennifer G.,FNP SPEC Solano Kidney Care Solano Family Nurse Practitioner


RLeary, Michele F.,DO PCP

Solano County Health & Social Services/Pediatrics Solano Family Medicine AOB-Family Medicine Yes



Solano County Health & Social Services/Pediatrics Solano Neuromuscular Medicine

AOB of Neuromusculoskeletal Medicine Yes



Solano County Health & Social Services/Pediatrics Solano

Osteopathic Manipulative Medicine




Solano County Health & Social Services/Pediatrics Solano

Osteopathic Manipulative Therapy AOB-Family Medicine Yes



Solano County Health & Social Services: Adult Clinic Solano Family Medicine AOB-Family Medicine Yes



Solano County Health & Social Services: Adult Clinic Solano Neuromuscular Medicine



199 of 233

March 2018

AppType


Board Certified

Hospital Name

Staff Category

Settlement Date


Solano County Health & Social Services: Adult Clinic Solano

Osteopathic Manipulative Medicine




Solano County Health & Social Services: Adult Clinic Solano

Osteopathic Manipulative Therapy AOB-Family Medicine Yes


R

Lennon, Marlene P.,FNP SPEC

Annadel Medical Group: Breast Surgery Sonoma Family Nurse Practitioner


RLeVeque, Julie A.,FNP SPEC

Annadel Medical Group: After Hours Care Sonoma Family Nurse Practitioner


R Lim, Steve MD PCP

Concepcion & Lim M.D. Family Practice P.C. Solano Family Medicine ABMS of Family Medicine Yes

Sutter Solano Medical Center Active

R

Ludlow, Christopher C.,PA-C SPEC

Dignity Health: Foundation - North State - Airpark Dr Shasta Physician Assistant Certified


IMakhlouf, Tony MD SPEC TeleMed2U Yolo Internal Medicine ABMS of Internal Medicine Yes


IMakhlouf, Tony MD SPEC TeleMed2U Yolo Rheumatology ABMS of Internal Medicine Yes


RMartin, Grace T.,MD PCP

Annadel Medical Group Sonoma Pediatrics ABMS of Pediatrics Yes


200 of 233

March 2018

AppType


Board Certified

Hospital Name

Staff Category

Settlement Date

RMartin-Ko, Anne C.,MD PCP

Mendocino Community Health Clinic: Hillside Health Center Mendocino Pediatrics ABMS of Pediatrics Yes

Ukiah Valley Medical Center Active

R

Montemayor, Catherine S.,FNP PCP

Community Medical Centers, Inc. - Community Med Ctr - Esparto Yolo Family Nurse Practitioner


R

Montemayor, Catherine S.,FNP PCP

Community Medical Centers, Inc. - Dixon Family Practice Solano Family Nurse Practitioner


IMosca, Breanna BCBA BHP

Trumpet Behavioral Health-Arcata Humboldt Behavioral Health


R

Nagle, Elizabeth J.,FNP PCP

Redwood Coast Medical Services, Inc./Gualala Medical Clinic Mendocino Family Nurse Practitioner


INichols, Kacey BCBA BHP Best Behavior, LLC Shasta Behavioral Health


ROmura, Michelle C.,MD SPEC


No Direct Patient Contact Non-Applicable

RPapsco, Mary C.,FNP PCP

SR Comm Hlth Centers: Brookwood Health Center Sonoma Family Nurse Practitioner


IParson, Margolo FNP PCP

Winters Healthcare Clinic Yolo Family Nurse Practitioner


IPhillips, Colin C.,PT Allied

Sport Rehab Physical Therapy & Rehab Solano Physical Therapy

IPope, Jason E.,MD SPEC

Jason Edward Pope, MD Inc. Sonoma Anesthesiology ABMS of Anesthesiology Yes

Sonoma Valley Hospital

Provisional Active

201 of 233

March 2018

AppType


Board Certified

Hospital Name

Staff Category

Settlement Date

IPope, Jason E.,MD SPEC

Jason Edward Pope, MD Inc. Sonoma Pain Medicine ABMS of Anesthesiology Yes

Sonoma Valley Hospital

Provisional Active

RSakamoto, Brian S.,MD SPEC



I

Salas, Margaret A.,FNP BOTH

Sutter Coast Community Clinic Del Norte Family Nurse Practitioner


I

Salas, Margaret A.,FNP BOTH

Sutter Coast Community Walk-In Clinic Del Norte Family Nurse Practitioner


RScharfen, Cindy O.,MD SPEC

Annadel Medical Group Sonoma Radiation Oncology ABMS of Radiology Yes

Santa Rosa Memorial Hospital Active 11/17/2016

RSchindler, Lydia G.,MD PCP

West Marin Medical Center (Colin Hamblin, A Prof. Med. Corp) Marin Family Medicine ABMS of Family Medicine Yes


RSmith, Gregory B.,MD SPEC

Adventist Health California Med Grp- Oncology & Urology Lake Hematology ABMS of Internal Medicine Yes

St Helena Hospital Active


Adventist Health California Med Grp- Oncology & Urology Lake Internal Medicine ABMS of Internal Medicine Yes



Adventist Health California Med Grp- Oncology & Urology Lake Medical Oncology ABMS of Internal Medicine Yes


RSmith, Gregory B.,MD SPEC Adventist ST Helena Napa Hematology ABMS of Internal Medicine Yes


RSmith, Gregory B.,MD SPEC Adventist ST Helena Napa Internal Medicine ABMS of Internal Medicine Yes


RSmith, Gregory B.,MD SPEC Adventist ST Helena Napa Medical Oncology ABMS of Internal Medicine Yes


ISpence, Andrea BCBA BHP

Center for Autism and Related Disorders, LLC Yolo Behavioral Health


I

Spencer, Donavan D.,MD PCP

Mendocino Coast Pediatric Medical Group Mendocino Pediatrics ABMS of Pediatrics Yes


202 of 233

March 2018

AppType


Board Certified

Hospital Name

Staff Category

Settlement Date

RTamarisk, Ronald S.,FNP PCP

Community Health Clinic Ole: DBA: Ole Health Napa Family Nurse Practitioner



Community Health Clinic Ole: DBA: OLE Health Solano Family Nurse Practitioner



Community Health Clinic Ole: DBA: Ole Health Napa Family Nurse Practitioner


R

Teasdale, Robert D.,Jr., MD SPEC

Robert Teasdale, Jr. MD Marin Orthopaedic Surgery

ABMS of Orthopaedic Surgery Yes

Marin General Hospital Active

R

Teasdale, Robert D.,Jr., MD SPEC

Robert Teasdale, Jr. MD Marin Sports Medicine, Orthopaedic

ABMS of Orthopaedic Surgery No


RUppal, Indra MD SPEC Indra Uppal Shasta Gynecology


Banner Lassen Medical Center Active

RUppal, Indra MD SPEC Indra Uppal Shasta Obstetrics


Banner Lassen Medical Center Active

I

Vaerten, Katelyn T.,BCBA BHP

Center for Autism and Related Disorders, LLC Yolo Behavioral Health


IVenglarcik, Carey A.,MD PCP

SCHC: Shasta Community Health Center Shasta Pediatrics ABMS of Pediatrics Yes


IWerner, Diana A.,DPM SPEC

Petaluma Health Center Sonoma Podiatry None No


IWerner, Diana A.,DPM SPEC

Petaluma Health Center: Rohnert Park Health Center Sonoma Podiatry None No


R

Wheeler, Jonathan W.,MD PCP

Napa Valley Family Medical Group Napa Family Medicine ABMS of Family Medicine Yes


IWyborny, Tessa M.,MD PCP

Community Health Clinic Ole: DBA: Ole Health Napa Pediatrics ABMS of Pediatrics Yes

Queen of the Valley Provisional

203 of 233

March 2018

AppType


Board Certified

Hospital Name

Staff Category

Settlement Date

RZopfi, John P.,III, DO SPEC

NBHG: Center for Specialty Care, A NorthBay Affiliate Solano Surgery AOB of Surgery Yes


Active Attending

Medical Director/ Physician Approval of Routine List ___________________________________________ Marshall Kubota, M.D., PHC Credentialing Chairman

204 of 233

PHC (PARTNERSHIP HEALTHPLAN OF CALIFORNIA)

PAC SUMMARY

Pg. 1 of 12 * =by phone conference Committee: Credentialing Committee Date/Time: February 14, 2018 7:00 a.m. – 7:30 a.m. Members Present: M. Tracy Johnson, MD; Bradley Sandler, MD; Jeff Gaborko, MD; Steven Gwiazdowski, MD; Michael Stacey, MD*; Candy Stockton, MD* PHC Staff: Robert Moore, MD MPH MBA, PHC Chief Medical Officer; Marshall Kubota, MD*, PHC Regional Medical Director; Michael Vovakes, MD*,

PHC Northern Region Medical Director; Scott Endsley, MD, PHC Associate Medical Director of Quality; Mark Netherda, MD, PHC Regional Director, Bettina Spiller, MD*, PHC Northern Region Medical Director; Mary Kerlin, Senior Director of Provider Relations; Heidi Lee, Provider Systems Manager; Rose Rad, Credentialing Supervisor, Jasmine Jones, Credentialing Specialist II; Skyler Bellmore, Credentialing Specialist II; Carol Kriek, Credentialing Specialist II; Cathy Beltran, Credentialing Specialist

AGENDA ITEM DISCUSSION / CONCLUSIONS RECOMMENDATIONS / ACTION TARGET DATE

DATE RESOLVED

I. Meeting called to order

I. PHC Regional Medical Director Marshall Kubota, MD called the meeting to order.

2-14-2018

II. Review/Approval of previous minutes

II.A. The Credentialing Committee meeting minutes for January 10, 2018

II. Motion: Dr. Jeff Gaborko, MD. Second: Dr. Bradley Sandler, MD. Meeting minutes approved without changes.

2-14-2018

III. Old Business A. Siskiyou County B. Communication Process: Information Only IV. New Business A. Shasta County B. Review of Practitioner File

III. A. The Credentials Committee requested staff to provide a history of the providers credentialing at this meeting. III. B. Communication Process: Information Only: PHC will now include a list of providers that are monitored monthly and when Credentials Chair or CMO recommend a provider be monitored monthly it will be reported to Committee. IV: A. Dr. Moore gave the option of Summary Suspension or Administrative Actions. IV. B. Please see approved list of Routine Providers on Pages 4-12 The Committee reviewed and discussed the list of twenty five (25) Physicians, two (2) Non-Physician Medical Practitioners, fourteen (14) Behavioral Health Analysts, , and two (2) Chiropractors for Initial Credentialing, twenty five (25) Physicians, nine (9) Non-Physician Medical Practitioners, two (2) Podiatrists, and one (1) Chiropractor for Re-Credentialing.

III. A. Motion: Dr. Jeffrey Gaborko, MD. Second: Dr. Bradley Sandler, MD to continue to monthly monitor of sanctions. III. B. No discussion from Committee. IV.A. It was suggested that the Plan looked at a pathway of some form of suspension based on accusation and determine if these types of suspensions IV. B. Motion: Dr. Jeffrey Gaborko, MD. Second: Dr. Bradley Sandler, MD. Approved the list without changes of twenty five (25) Physicians, two (2) Non-Physician Medical Practitioners, fourteen (14) Behavioral Health Analysts, , and two (2) Chiropractors for Initial Credentialing, twenty five (25) Physicians, nine (9) Non-Physician Medical Practitioners, two (2) Podiatrists, and one (1) Chiropractor for Re-Credentialing.

2-14-2018

2-14-2018

2-14-2018

2-14-2018

205 of 233


DATE DATE

RESOLVED C. Lassen County

V. Update of Ongoing Monitoring of Sanctions. Information Only

VI. Consent Calendar Items. A. Report of Long Term Care Facility, Hospital, and Ancillary Prov. List. B. Review of Suboxone/ Buprenorphine credentialed primary care providers. C. 3rd Quarter: Mercy Medical Group: Credentialing/ Re- Credentialing Activities. D. 3rd Quarter: Sutter Pacific Medical Foundation- Physician Foundation Medical Associates and Marin Headlands: Credentialing/ Re- Credentialing Activities. E. MP CR 6A (No Changes): Initial Credentialing Requirements for Non-Physician (Allied Health)

IV. C. Chart review conducted for this physician because he did not meet the criteria of PHC Policy MP CR #17-Standards for Contracted Primary Care Providers. V. Information Only: A Medical Board of California License alert dated 1/17/2018 stated that this provider’s license was issued a Cease Practice Order effective 1/16/2018. This provider was termed from all PHC systems. VI. A. Report of Long Term Care Facility, Hospital, and Ancillary provider list.

IV. C. Motion: Candy Stockton, MD. Second: Dr. Jeffrey Gaborko, MD and Approved to place provider on 6 months’ probation, pending review of the results of a PACE assessment. V. No discussion from Committee.

VI. Motion: Dr. Jeff Gaborko, MD. Second: Dr. Candy Stockton, MD. Approved Consent Calendar Items without changes.

2-14-2018

2-14-2018

2-14-2018

206 of 233


DATE DATE

RESOLVED VI. Consent Calendar Items F. MP CR 13 (No Changes): Credentialing of Pain Management Specialist. G. MP PR 16 (No Changes): Lactation Consultant Credentialing Policy. H. MP PR PL CR 401A (No Changes): Initial Credentialing Document Collection, Review, and Verification for Behavioral Health Practitioners. VII. Meeting Adjourned

F. MP CR 13 (No Changes): Credentialing of Pain Management Specialist. G. MP PR 16 (No Changes): Lactation Consultant Credentialing Policy. H. MP PR PL CR 401A (No Changes): Initial Credentialing Document Collection, Review, and Verification for Behavioral Health Practitioners. With No further items for discussion, the meeting was adjourned Next Meeting Scheduled for March 14, 2018

2-14-2018

PAC Summary Meeting Minutes for February 14, 2018 respectfully prepared and submitted by Jasmine Jones - Credentialing Specialist II Chairman Signature of Approval __________________________________________ Date______________________________ Marshall Kubota M.D., PHC Credentialing Chairman

207 of 233

February 2018

AppType

Practitoner Name

Provider Type Practice Name County Name

Specialty Description Board Name

Board Certified Hospital Name

Staff Category

Settlement Date

RAdkins, Amanda C.,MD PCP

NBHG: Center for Primary Care-Fairfield, A NorthBay Affiliate Solano Internal Medicine

ABMS of Internal Medicine Yes

Hospitalist Coverage

No Privileges

I

Ahmad, Amenaghawon BCBA BHP

Maxim Healthcare Services Inc. Sacramento Behavioral Health


R Anand, Arun MD SPEC

An Anesthesia and Pain Management Medical Corp Solano Anesthesiology ABMS of Anesthesiology Yes



An Anesthesia and Pain Management Medical Corp Solano

Pain Management & Rehabilitation None No



An Anesthesia and Pain Management Medical Corp Solano Pediatrics ABMS of Pediatrics No


R

Anderson, Jacqueline E.,FNP PCP

Healdsburg Physician Group-PCP Sonoma

Family Nurse Practitioner


IAndrews, Laura FNP SPEC

NBHG: Heart and Vascular Center - Surgical. A NB Affiliate Solano



RAphailee, Victoria L.,CNM SPEC

Communicare Health Centers - Davis Community Clinic Yolo

Certified Nurse Midwife



Communicare Health Centers - Salud Clinic Yolo




Communicare Health Centers-Hansen Family Medical Center Yolo



RAtray, Naveen K.,MD SPEC

Capital Nephrology Medical Group Yolo Internal Medicine

ABMS of Internal Medicine No

Sutter Medical Center Sacramento Active 02/03/2015

RAtray, Naveen K.,MD SPEC

Capital Nephrology Medical Group Yolo Nephrology


Sutter Medical Center Sacramento Active

IAyanzen, Ron H.,MD SPEC

Health Diagnostics of California Marin

Diagnostic Radiology ABMS of Radiology Yes

No Direct Patient Contact

No Privileges

RBallenger, John R.,MD SPEC



Mercy General Hospital of Sacramento Active





208 of 233

February 2018

AppType

Practitoner Name




Staff Category

Settlement Date


Capital Nephrology Medical Group - Woodland Yolo Internal Medicine




Capital Nephrology Medical Group - Woodland Yolo Nephrology



RBarth, Gary P.,MD SPEC

Eye Care Institute, A Medical Corporation Sonoma Ophthalmology ABMS of Ophthalmology Yes

Sutter Santa Rosa Regional Hospital Courtesy

RBarylski, Chad R.,FNP BOTH Annadel Medical Group Sonoma Chiropractic None No

RBarylski, Chad R.,FNP BOTH Annadel Medical Group Sonoma



RBarylski, Chad R.,FNP BOTH

Annadel Medical Group (Family Practice) Sonoma Chiropractic None No


Annadel Medical Group (Family Practice) Sonoma




Annadel Medical Group: Orthopedic Surgery Sonoma Chiropractic None No


Annadel Medical Group: Orthopedic Surgery Sonoma



I Basu, Anjuli MD PCPPRIMA Medical Foundation Marin Internal Medicine



I Basu, Anjuli MD PCPPRIMA Medical Foundation Marin Pediatrics ABMS of Pediatrics Yes


RBirnbaum, Neal S.,MD SPEC

Adventist Health- Ukiah Valley Rural Health Mendocino Internal Medicine


Ukiah Valley Medical Center Consulting

RBirnbaum, Neal S.,MD SPEC

Adventist Health- Ukiah Valley Rural Health Mendocino Rheumatology


Ukiah Valley Medical Center Consulting

IBourne, Margaret E.,MD SPEC Hospice by the Bay Marin Family Medicine ABMS of Family Medicine Yes


No Privileges

IBourne, Margaret E.,MD SPEC Hospice by the Bay Marin

Hospice and Palliative Medicine ABMS of Family Medicine Yes


No Privileges

IBuechner, John P.,DC SPEC

Active Care Chiropractic, Fogg Professional Corporation Humboldt Chiropractic None No

IBurk, David R.,MD SPEC

Sutter Coast Community Clinic Del Norte

Orthopaedic Surgery None No


No Privileges

209 of 233

February 2018

AppType

Practitoner Name




Staff Category

Settlement Date

IByrnes, Rebecca R.,BCBA BHP

Gateway Learning Group Marin Behavioral Health


RChase, Karen G.,FNP SPEC

Sutter Coast Community Walk-In Clinic Del Norte



I Chen, Judy J.,MD SPEC

West Coast Retina Medical Group-Corte Madera Marin Ophthalmology None No Group Coverage

No Privileges

I Chen, Judy J.,MD SPEC

West Coast Retina Medical Group-San Francisco Marin Ophthalmology None No Group Coverage

No Privileges

IClark, Richard A.,MD SPEC

Sacramento Heart & Vascular Medical Associates Yolo

Cardiovascular Disease

ABMS of Internal Medicine Yes Group Coverage

No Privileges

IClark, Richard A.,MD SPEC

Sacramento Heart & Vascular Medical Associates Yolo Internal Medicine

ABMS of Internal Medicine Yes Group Coverage

No Privileges

ICrain, Sidney M.,MD SPEC

Dignity Health dba Mercy Regional Cancer Center Shasta Internal Medicine


Mercy Medical Center of Redding Courtesy

ICrain, Sidney M.,MD SPEC

Dignity Health dba Mercy Regional Cancer Center Shasta Oncology


Mercy Medical Center of Redding Courtesy

RDavid, Frederick C.,MD SPEC Annadel Medical Group Sonoma

Radiation Oncology ABMS of Radiology No


RDavid, Frederick C.,MD SPEC Annadel Medical Group Sonoma

Therapeutic Radiology ABMS of Radiology Yes


RDeck, Tatyana L.,PA-C PCP Elica Health Center Yolo

Physician Assistant Certified


RDeRose, David J.,MD PCP

Adventist Health Clear Lake Lake Internal Medicine



No Privileges

RDeRose, David J.,MD PCP

Adventist Health Clear Lake Lake




No Privileges

IDiPerna, Danielle A.,MD SPEC

Obstetrix Medical Group of Sacramento, PC Yolo

Maternal and Fetal Medicine None No Group Coverage

No Privileges 02/05/2015

IDiPerna, Danielle A.,MD SPEC

Obstetrix Medical Group of Sacramento, PC Yolo

Obstetrics and Gynecology

ABMS of Obstetrics and Gynecology Yes Group Coverage

No Privileges

210 of 233

February 2018

AppType

Practitoner Name




Staff Category

Settlement Date

IEckel, Gregory M.,MD SPEC

Harbor-UCLA Medical Foundation Trinity



No Privileges

REichner Blanusa, Lora K.,MD PCP Harvest Pediatrics Napa Pediatrics ABMS of Pediatrics Yes Group Coverage

No Privileges

IFamularo, Michael A.,MD SPEC

Adventist Health Feather River Shasta




No Privileges


Adventist Health Feather River Shasta Internal Medicine



No Privileges


Adventist Health Feather River Shasta

Interventional Cardiology



No Privileges

IFulton, William R.,DO SPEC

NBHG: Center for Specialty Care, A NorthBay Affiliate Solano General Surgery AOB of Surgery Yes


Active/Admitting

IGoodwin, Gregory T.,PA PCP

Karuk Health Center, Orleans Humboldt

Physician Assistant None No


Karuk Tribal Health Clinic, Happy Camp Siskiyou



Karuk Tribal Health Clinic, Yreka Siskiyou


RHanahan, Ralph B.,MD SPEC Annadel Medical Group Sonoma

Radiation Oncology None No

Santa Rosa Memorial Hospital Courtesy

RHanahan, Ralph B.,MD SPEC Annadel Medical Group Sonoma Radiology ABMS of Radiology Yes


RHanahan, Ralph B.,MD SPEC Annadel Medical Group Sonoma



IHolder, Pinella A.,DO SPEC

Humboldt Medical Specialists- Physical Medicine & Rehabilitation Humboldt

Physical Medicine & Rehabilitation

ABMS of Physical Medicine & Rehabilitation Yes Group Coverage

No Privileges

IHolder, Pinella A.,DO SPEC

Humboldt Medical Specialists- Physical Medicine & Rehabilitation Humboldt Sports Medicine

ABMS of Physical Medicine & Rehabilitation Yes Group Coverage

No Privileges

IJohnson, Troy R.,BCBA BHP

Learning Solutions Kids, Inc. Yolo Behavioral Health


RJoseph, Jay S.,MD SPEC Annadel Medical Group Mendocino

Radiation Oncology ABMS of Radiology Yes

Ukiah Valley Medical Center Active

RKashyap, Rohit MD SPEC



Sutter General Hospitals Active

RKashyap, Rohit MD SPEC



Sutter General Hospitals Active 02/03/2015

211 of 233

February 2018

AppType

Practitoner Name




Staff Category

Settlement Date

IKatana, John M.,MD PCP

Dignity Health - Mercy Mt. Shasta Comm Clinic Siskiyou Family Medicine ABMS of Family Medicine Yes

Mercy Medical Center Mt. Shasta Active

RKazak, Marat DPM SPEC

Sacramento Foot and Ankle Center, Inc. Yolo Podiatry None No

Mercy San Juan Hospital Active

I Khan, Akbar DO SPECNBHG: NorthBay Center For Pain Solano

Pain Management & Rehabilitation

ABMS of Physical Medicine & Rehabilitation Yes


No Privileges

R Khosla, Anil MD SPECSolano Diagnostic Imaging Solano



Non-Applicable

R Khosla, Anil MD SPECSolano Diagnostic Imaging Solano Neuroradiology ABMS of Radiology Yes


Non-Applicable

R Lee, Marge PA-C PCP

Communicare Health Centers-Hansen Family Medical Center Yolo

Physician Assistant Certified


ILeon, Federico G.,MD PCP Alliance Medical Center Sonoma Family Medicine ABMS of Family Medicine Yes


No Privileges

ILongchamp, Carla P.,MD PCP

SR Comm Hlth Centers: Southwest Comm Health Center Sonoma Family Medicine ABMS of Family Medicine Yes


No Privileges

IMantik, David W.,MD SPEC

Dignity Health- Redding Radiation Oncologists, PC: Mercy Regional Cancer Center Siskiyou


IMantik, David W.,MD SPEC

Redding Radiation Oncologists, PC: Redding Cancer Treatment Center Shasta


RManubens, Sergio M.,MD SPEC

QVMA: Queen of the Valley Medical Associates - Cardiology Napa





QVMA: Queen of the Valley Medical Associates - Cardiology Napa Internal Medicine




QVMA: Queen of the Valley Medical Associates - Cardiology Napa

Interventional Cardiology



R

McGovern, Catherine A.,CNM SPEC

Communicare Health Centers - Davis Community Clinic Yolo



212 of 233

February 2018

AppType

Practitoner Name




Staff Category

Settlement Date

R

McGovern, Catherine A.,CNM SPEC

Communicare Health Centers - Salud Clinic Yolo



IMeek, Emily BCBA BHP Learning ARTS Yolo Behavioral Health


IMey, Samantha BCBA BHP Learning ARTS Yolo Behavioral Health


RMiller, Terina M.,MD SPEC

East Bay Nephrology Medical Group Solano Internal Medicine

ABMS of Internal Medicine No

Alta Bates Summit Medical Center Active

RMiller, Terina M.,MD SPEC

East Bay Nephrology Medical Group Solano Nephrology



IMontano, Danette R.,BCBA BHP Starfish Hero Inc Humboldt Behavioral Health


INeedens, Brandon BCBA BHP Learning ARTS Yolo Behavioral Health


INejad, Michael L.,MD SPEC Hospice by the Bay Marin

Hospice and Palliative Medicine



No Privileges

INejad, Michael L.,MD SPEC Hospice by the Bay Marin Internal Medicine



No Privileges

RO'Brien, Michael W.,MD SPEC

Dignity Health: Foundation - North State - Airpark Dr Shasta Neurology


Mercy Medical Center of Redding Active

RO'Brien, Michael W.,MD SPEC

Dignity Health: Foundation - North State - Airpark Dr Shasta

Vascular Neurology


Mercy Medical Center of Redding Active

RO'Keefe, Galina BCBA BHP

Trumpet Behavioral Health-Dublin Solano Behavioral Health


ROdabaei, Golaun MD SPEC

East Bay Nephrology Medical Group Solano Internal Medicine



ROdabaei, Golaun MD SPEC

East Bay Nephrology Medical Group Solano Nephrology



IOrquiz, Chelsea D.,BCBA BHP

Center for Autism and Related Disorders, LLC Solano Behavioral Health


IPena, Shady A.,BCBA BHP Learning ARTS Yolo Behavioral Health


IPike, Deanna BCBA BHP

Autism Spectrum Therapies-Sacramento Yolo Behavioral Health


213 of 233

February 2018

AppType

Practitoner Name




Staff Category

Settlement Date

RPurrinson, Beth N.,NM SPEC Capital OB/GYN, Inc. Yolo


American Midwifery Certification Board No

RRagsdale, Richard A.,MD SPEC Greenville Rancheria Shasta Internal Medicine

ABMS of Internal Medicine Yes Group Coverage None

RRagsdale, Richard A.,MD SPEC Greenville Rancheria Shasta

Pulmonary Diseases

ABMS of Internal Medicine Yes Group Coverage None

I

Rezai, Mohammed T.,DO BOTH

Redding Rancheria: Churn Creek Healthcare- Shasta Family Medicine

Meets MPCR#17, verified residency by Residency Letter No


No Privileges

I


Redding Rancheria: Churn Creek Healthcare Shasta Urgent Care None No


No Privileges

I


SCHC: Shasta Community Health Center- Shasta Family Medicine

Meets MPCR#17, verified residency by Residency Letter No


No Privileges

I


SCHC: Shasta Community Health Center Shasta Urgent Care None No


No Privileges

RRobinson, Mark W.,NP PCP

Fairchild Medical Clinic (PCP Clinic) Siskiyou Nurse Practitioner None No

RRobinson, Mark W.,NP PCP Harold Budhram, MD Shasta Nurse Practitioner None No

ISafra, Jessica A.,MD SPEC Hospice by the Bay Marin

Hospice and Palliative Medicine



No Privileges

ISafra, Jessica A.,MD SPEC Hospice by the Bay Marin Internal Medicine



No Privileges

ISchaedler, Alisa E.,BCBA BHP



IScripko, Patricia D.,MD SPEC TeleMed2U Yolo Neurology



No Privileges

RSingh, Kabir J.,MD SPEC

Marin Healthcare Dist: Cardiovascular Assoc of Marin and SF Marin





Marin Healthcare Dist: Cardiovascular Assoc of Marin and SF Marin Internal Medicine




Marin HealthCare District: SF and Sirona Vascular Center Marin





Marin HealthCare District: SF and Sirona Vascular Center Marin Internal Medicine



RSnyder, Robert E.,MD PCP

Lassen Indian Health Center Lassen Family Practice None No


No Privileges

214 of 233

February 2018

AppType

Practitoner Name




Staff Category

Settlement Date

RStanton, Thomas S.,II, MD SPEC Annadel Medical Group Sonoma Hematology


Petaluma Valley Hospital Active

RStanton, Thomas S.,II, MD SPEC Annadel Medical Group Sonoma Internal Medicine



RStanton, Thomas S.,II, MD SPEC Annadel Medical Group Sonoma Medical Oncology



RStrange, Nicholas G.,DO BOTH Annadel Medical Group Sonoma Family Practice AOB of Family Physicians Yes


No Privileges

RStrange, Nicholas G.,DO BOTH Annadel Medical Group Sonoma

Osteopathic Manipulative Therapy AOB of Family Physicians Yes


No Privileges

RStrange, Nicholas G.,DO BOTH

Annadel Medical Group: Afters Hours Care Sonoma Family Practice AOB of Family Physicians Yes


No Privileges

RStrange, Nicholas G.,DO BOTH

Annadel Medical Group: Afters Hours Care Sonoma

Osteopathic Manipulative Therapy AOB of Family Physicians Yes


No Privileges

ISundberg, Kelsey BCBA BHP



RTan, Jessica C.,MD SPEC

Health Diagnostics of California Marin



No Privileges


Health Diagnostics of California Marin Neuroradiology ABMS of Radiology Yes


No Privileges


Marin Community Clinic: San Rafael Clinic Marin



No Privileges


Marin Community Clinic: San Rafael Clinic Marin Neuroradiology ABMS of Radiology Yes


No Privileges

RTovmassian, Gregory DPM SPEC

Sacramento Foot and Ankle Center, Inc. Yolo Podiatry None No

Mercy San Juan Hospital Active

IUkatu, Chidi J.,MD SPEC

Sutter Coast Community Clinic Del Norte General Surgery



No Privileges

RVeletto, Tony D.,MD PCP

Healdsburg Physician Group-PCP Sonoma Internal Medicine


Healdsburg District Hospital

Provisional Active

IWada, Hitomi BCBA BHP

Center for Autism and Related Disorders, LLC Solano Behavioral Health


IWallace, Sandra L.,MD SPEC

Marin Community Clinic: Campus Clinic Marin Infectious Disease


Transfer Agreement

No Privileges

IWallace, Sandra L.,MD SPEC

Marin Community Clinic: Campus Clinic Marin Internal Medicine


Transfer Agreement

No Privileges

RWeldon, Barbara J.,DC SPEC

Marin Community Clinic: Campus Clinic Marin Chiropractic None No

215 of 233

February 2018

AppType

Practitoner Name




Staff Category

Settlement Date


Marin Community Clinic: Larkspur Clinic Marin Chiropractic None No


Marin Community Clinic: Novato Clinic Marin Chiropractic None No


Marin Community Clinic: San Rafael Clinic Marin Chiropractic None No


Marin Community Clinic: South Novato Clinic Marin Chiropractic None No

IWilke, Allan J.,MD PCP

Humboldt Medical Specialists Humboldt Family Medicine ABMS of Family Medicine Yes Group Coverage

No Privileges

IWilke, Allan J.,MD PCP

Humboldt Medical Specialists Humboldt Geriatric Medicine ABMS of Family Medicine Yes Group Coverage

No Privileges

RWong, Kalane J.,MD SPEC

Eye Care Institute, A Medical Corporation Sonoma Ophthalmology ABMS of Ophthalmology Yes


IWright, Richard S.,DC SPEC

Active Care Chiropractic, Fogg Professional Corporation Humboldt Chiropractic None No

I Zeim, Sam MD SPECHarbor-UCLA Medical Foundation Trinity



No Privileges

Medical Director/Physician Approval of Routine List____________________________________________________

Marshall Kubota M.D., PHC Credentialing Chairman

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AGENDA ITEM: II.F. DATE: 05/09/2018


TO: Physician Advisory Committee FROM: Robert Moore, MD, MPH, Chief Medical Officer DATE: 05/09/2018 SUBJECT: PHC Committee Memberships

Physician Advisory Committee Resignations: Colleen Townsend, MD, Ole Health, has accepted a position at the HealthPlan. Her resignation from the Physician Advisory Committee is recommended and required. Khuram Arif, MD, Chief Medical Officer, Dignity Health, Woodland Clinic, has notified Partnership of his conflicting obligations and has requested resignation from the Physician Advisory Committee. His resignation is recommended. Antoinette Martinez, MD, is no longer with United Indian Health Services, so her membership to the Physician Advisory Committee is recommended.

Credentialing Committee Appointment: Michele Herman, MD, Associate Medical Director, La Clinica Vallejo, has expressed interest in participating on the Credentialing Committee. Her appointment is recommended. Dr. Herman is Board Certified in Family Medicine.

217 of 233

2018‐19 Hospital QIP (HQIP) Proposed Measurement Set: Large Hospitals

2017‐18 Large Hospital Measures Proposed 2018‐19 Large Hospital Measures Considerations Requirements

Health Information Exchange (HIE) Requirement New participants: Hospitals must complete

Admission, Discharge, and Transfer (ADT) interface with a community HIE by the end of the measurement year.

Existing participants: Hospitals complete Premanage/ED interface, and also maintain their existing ADT interface with their established HIE partner, by the end of the measurement year.

If not met, entire incentive amount will be withheld.

All hospitals: By the end of the measurement year, both of the following:

1. Live with Emergency Department Interface Exchange (EDIE) including a mechanism for the EDIE data to be pushed to ED physicians for patients who are seen.

2. ADT interface with a community HIE. If not met, entire incentive amount will be withheld.

Setting uniform standards given status of HIE in the state.

Delegation Requirement Hospitals must :

Submit to Partnership HealthPlan of California (PHC) a written Utilization Program Description

Submit timely reports. Exact timeliness is TBD, and will be based on the Reporting Schedule in each hospital’s delegation agreement.

Proposed impact of not meeting the entire requirement (TBD) is a 5% or 10% payment reduction

As PHC seeks National Committee for Quality Assurance (NCQA) Accreditation, it is important that NCQA UM requirements are met by all capitated hospitals in PHC’s network.

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2

Measures 1. All‐Cause Adult Readmission Rate Back‐up measure: Follow‐up visit within 4

calendar days of discharge Pay for Performance

1. All‐Cause Adult Readmission Rate Back‐up measure: Follow‐up visit within 4 calendar days of discharge Pay for Performance

May help concentrate the focus on readmissions. Furthermore, no hospital has ever used the Follow‐up option to meet this measure.

2. Palliative Care Capacity. Two options: ‐ Option 1: Dedicated inpatient palliative care

team (all hospitals): o One Physician Champion o One trained Licensed Clinical Social Worker o One trained Licensed RN, NP, or PA (Registered Nurse, Nurse Practitioner, or Physician Assistant)

o Availability of video or in‐person consult with a Palliative Care Physician

‐ Option 2: Inpatient palliative care capacity (small hospitals only):

o Two licensed staff: RN, NP, or PA o Availability of either video or in‐person consult with a Palliative Care Physician

Hospitals with fewer than 20 beds excluded. Pay for Process


team (all hospitals): o One Physician Champion o One trained Licensed Clinical Social Worker OR Licensed RN, NP, or PA





Changing option 1 to include one Physician and one RN/NP/PA would make the measure more achievable for hospitals, while still meeting our goal of having a dedicated PC team. Propose to remove the <20 bed exclusion after a hospital with fewer than 20 beds informed us that this is an achievable measure for them.

3. Elective Delivery before 39 weeks Pay for Performance

3. Elective Delivery before 39 weeks Hospitals will submit data to California Maternal Quality Care Collaborative (CMQCC), and PHC will work directly with CMQCC for reports. Pay for Performance

Change will decrease chance of data errors. Currently, hospitals submit numerator and denominator statement to PHC. Staff submitting data often aren’t close to this area, and errors sometimes occur in data transit. ‐ Will require chart abstraction

4. Exclusive Breast Milk Feeding

4. Exclusive Breast Milk Feeding Hospitals will submit data to CMQCC, and PHC will work directly with CMQCC for reports.

Change will decrease chance of data errors. Currently, hospitals submit numerator and denominator statement to PHC. Staff

219 of 233

3

Pay for Performance Pay for Performance submitting data often aren’t close to this area, and errors sometimes occur in data transit. ‐ Will require chart abstraction

5. Nulliparous, Term, Singleton, Vertex (NTSV) Cesarean Birth Rate

Pay for Performance

5. NTSV Cesarean Birth Rate Hospitals will submit data to CMQCC, and PHC will work directly with CMQCC for reports. Pay for Performance

Change will decrease chance of data errors. Currently, hospitals submit numerator and denominator statement to PHC. Staff submitting data often aren’t close to this area, and errors sometimes occur in data transit. ‐ No chart extraction required

6. Timely Participation in California Perinatal Quality Care Collaborative (CPQCC) Data Reporting

Pay for Reporting

Timely Participation in California Perinatal Quality Care Collaborative Data Reporting Reporting based on CPQCC deliverable deadlines Attend one CPQCC collaborative by end of measurement year. Change from April PAC: proposing measure removal

Change will ensure hospitals have a meaningful interaction with CPQCC. Propose removal because 5 out of 6 NICU hospitals have established participation with CPQCC, do not see need to continue measure.

7. Timely Participation in California Maternal Quality Care Collaborative Data Reporting

Pay for Reporting

Timely Participation in California Maternal Quality Care Collaborative Data Reporting Pay for Reporting

Removing because retrieving data from CMQCC for three maternal measures will ensure participation.

8. Venous thromboembolism (VTE)‐6 – Hospital‐Acquired Potentially‐Preventable VTE

Pay for Performance

6. No Change.

N/A

9. California Hospital Patient Safety Organization (CHPSO) Patient Safety Organization Participation

Pay for Reporting

7. No Change.

N/A

10. Quality Improvement (QI) Capacity Pay for Reporting

8. No Change.

N/A

220 of 233

4

OP‐18b: Median Time from Emergency Department (ED) Arrival to ED Departure for Discharged ED Patients

Pay for Performance Removed from consideration based on feedback at April PAC

PHC leadership requested outpatient measure. 12 out of 13 large hospitals and 1 out of 13 small hospitals are currently reporting HQIP average: 150 minutes CA average: 169.6 minutes HQIP Min: 96 minutes HQIP Max: 208 minutes

9. California Immunization Registry (CAIR) utilization measure

Pay for Reporting First Year

PHC is required by Department of Health Care Services (DHCS) to have all contracted entities report to CAIR. No cost to use CAIR. 12 out of 13 large and 8 out of 13 small hospitals are registered with a CAIR ID. Of these, 8 large and 5 small hospitals have submitted data within the last 4 months Average monthly entries Dec 2017 – Feb 2018 for 5 small HQIP hospitals: 35 Min: 15 Max: 87 Average monthly entries Dec 2017 – Feb 2018 for 8 large hospitals: 164 Min: 69 Max: 744

221 of 233

5

2018‐19 Hospital QIP Proposed Measurement Set: Small Hospitals

2016‐17 Small Hospital Measures 2017‐18 Small Hospitals Proposed Measures Change Rationale 1. All‐Cause Adult Readmission Rate Back‐up measure: Follow‐up visit within 4

calendar days of discharge Pay for Performance

1. All‐Cause Adult Readmission Rate Back‐up measure: Follow‐up visit within 4 calendar days of discharge Pay for Performance

May help concentrate the focus on readmissions. Furthermore, no hospital has ever used the Follow‐up option to meet this measure.

2. Palliative Care Capacity. Two options: ‐ Option 1: Dedicated inpatient palliative care team

(all hospitals): o One Physician Champion o One trained Licensed Clinical Social Worker o One trained Licensed RN, NP, or PA o Availability of video or in‐person consult with a Palliative Care Physician





team (all hospitals): o One Physician Champion o One trained Licensed Clinical Social Worker OR Licensed RN, NP, or PA





Changing option 1 to include one Physician and one RN/NP/PA would make the measure more achievable for hospitals, while still meeting our goal of having a dedicated PC team. Propose to remove the <20 bed exclusion after a hospital with fewer than 20 beds informed us that this is an achievable measure for them.

3. CHPSO Patient Safety Organization Participation Pay for Reporting

3. No Change. Pay for Reporting

N/A

4. QI Capacity Pay for Reporting

4. No Change. Pay for Reporting

N/A

5. Elective Delivery before 39 weeks Hospitals will submit data to CMQCC, and PHC will work directly with CMQCC for reports. Pay for Performance

7 out of 13 small hospitals offer maternity services ‐ Will require chart abstraction

222 of 233

6

6. Exclusive Breast Milk Feeding Hospitals will submit data to CMQCC, and PHC will work directly with CMQCC for reports. Pay for Performance

7 out of 13 small hospitals offer maternity services ‐ Will require chart abstraction

7. NTSV Cesarean Birth Rate Hospitals will submit data to CMQCC, and PHC will work directly with CMQCC for reports. Pay for Performance

7 out of 13 small hospitals offer maternity services ‐ No chart extraction required

8. CAIR utilization measure Pay for Reporting First Year

PHC is required by DHCS to have all contracted entities report to CAIR. No cost to use CAIR. 12 out of 13 large and 8 out of 13 small hospitals are registered with a CAIR ID. Of these, 8 large and 5 small hospitals have submitted data within the last 4 month Average monthly entries Dec 2017 – Feb 2018 for 5 small HQIP hospitals: 35 Min: 15 Max: 87 Average monthly entries Dec 2017 – Feb 2018 for 8 large hospitals: 164 Min: 69 Max: 744

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Proposed new measure: CAIR utilization measure (small and large hospitals) Recommendation: Add as pay for reporting measure for both small and large hospitals. Description Monitor the CAIR utilization of our contracted hospitals.

Rationale PHC is required by DHCS to have all contracted entities report to CAIR. Considerations 12 out of 13 large and 8 out of 13 small hospitals are registered with a CAIR ID. Of these, 9 large and 6 small hospitals have submitted data between December 2017 – Feb 2018: Small Hospital QIP Hospitals Large Hospital QIP Hospitals Monthly average 35 Entries 164 Entries Min 15 Entries 69 Entries Max 87 Entries 744 Entries Specifications Pay for reporting: Submit Policy/procedure and CAIR report by end of MY.

224 of 233

8

Measure considered but not recommended for inclusion: OP‐18b: Median Time from ED Arrival to ED Departure for Discharged ED Patients (large hospitals only) Recommendation: Add as pay for performance measure to large hospital measurement set only. Description Median time from emergency department arrival to time of departure from the emergency room for patients discharged from the emergency department. Rationale Reducing the time patients remain in the emergency department (ED) can improve access to treatment and increase quality of care. Specifications Pay for performance, baseline determined by 2016‐17 data. Report to PHC time (in minutes) from ED arrival to ED departure for patients discharged from the emergency department. Use Hospital OQR Specifications Manual v11.0a Considerations 12 out of 13 large hospitals and 1 out of 13 small hospitals are currently reporting

Hospital staff comment: We’ve been looking at comparative data on the CMS website for OP‐18b and find that other hospitals in the Bay area with similar EDs to ours (trauma centers, etc.) are having the same times and more often worse than ours using the National median, not the CA median or top decile. As long as patient flow remains a problem nationally and patients use EDs for primary care, I think the throughput measures will continue to be challenging. We’re actively working on this. Prefer OP‐22.”

HQIP average: 150 minutes CA average: 169.6 minutes HQIP Min: 96 minutes, HQIP Max: 208 minutes Size Hospital Name County Measure Score Sample Large MAD RIVER COMMUNITY HOSPITAL HUMBOLDT OP_18b 145 278Large MARIN GENERAL HOSPITAL MARIN OP_18b 149 381Large MERCY MEDICAL CENTER MT SHASTA SISKIYOU OP_18b 136 355Large MERCY MEDICAL CENTER REDDING SHASTA OP_18b 156 371Large NORTHBAY MEDICAL CENTER SOLANO OP_18b 173 1439Large PETALUMA VALLEY HOSPITAL SONOMA OP_18b 156 342Large QUEEN OF THE VALLEY MEDICAL CENTER NAPA OP_18b 148 386Large SANTA ROSA MEMORIAL HOSPITAL SONOMA OP_18b 192 343Small SONOMA VALLEY HOSPITAL SONOMA OP_18b 136 358Large ST HELENA HOSPITAL NAPA OP_18b 96 354Large ST JOSEPH HOSPITAL HUMBOLDT OP_18b 208 400Large UKIAH VALLEY MEDICAL CENTER MENDOCINO OP_18b 120 359Large WOODLAND MEMORIAL HOSPITAL YOLO OP_18b 130 374

225 of 233


POLICY / PROCEDURE

Page 1 of 3

Policy/Procedure Number: MPQP1003 (previously QP100103) Lead Department: Health Services Policy/Procedure Title: Physician Advisory Committee (PAC) Policy


Original Date: 07/19/1993 - Medi-Cal (Charter)



Reviewing Entities:

IQI P & T QUAC


Approving Entities:



Approval Signature: Jeffrey Gaborko, M.D. Approval Date: 06/14/201705/09/2018


MCUP 3042 Technology Assessment N/A



IV. ATTACHMENTS: A. NA

V. PURPOSE: The Physician Advisory Committee (PAC) is responsible for oversight and monitoring of the quality and cost-effectiveness of medical care provided to Partnership HealthPlan of California's members. The PAC reviews the activities of the Quality/Utilization Advisory Committee (Q/UAC), Provider Advisory Group (PAG), Pharmacy and Therapeutics Committee (P&T), the Quality Improvement Program Advisory Group, and the Credentials Committee, makes recommendations, and assists PHC in other ways as defined in this policy.


A. COMMITTEE STRUCTURE 1. Membership:

a. The PAC is comprised of the PHC CEO, Deputy Executive Director/Chief Operating Officer, Chief Medical Officer, Regional Medical Directors, Chief Financial Officer, Health Services Director, Provider Relations Director, Quality and Performance Improvement Director, Pharmacy Director, Member Services Director, and 15-25 other members that may include: 1) Participating physician representatives from primary and specialty care, including at least

one behavioral health provider. 2) Advanced practice clinicians such as certified nurse midwives, nurse practitioners or

physician assistants. 3) Members representing active medical staffs of hospitals, community-based practices, and

medical groups in the PHC service area. b. Members with annual attendance of <50% are evaluated for termination from the PAC. c. Other health plan staff may make special or periodic reports to the committee or may attend

selected meetings ex-officio.

226 of 233

Policy/Procedure Number: MPQP1003 (previously QP100103) Lead Department: Health Services

Policy/Procedure Title: Physician Advisory Committee ☒External Policy ☐Internal Policy




Page 2 of 3

2. Minutes: Minutes are recorded of all meetings and are maintained. 3. Chair: A PHC Physician on the Committee chairs the meeting and when unavailable, the Chief

Medical Officer chairs the Committee. 4. Meetings: The Committee meets at least nine (9) times a year, but does not convene in the months of

July or December, with the option to add additional meetings if needed. 5. Voting: Only committee members who are not PHC staff may vote. The Chief Medical Officer

serves in a tie breaking capacity as necessary. A quorum is that number of members present as described in the PHC by-laws which specifies 50% plus one of voting members.

B. COMMITTEE RESPONSIBILITIES 1. Reviews and makes recommendations for corrective action based upon other committee reports

including: a. Q/UAC b. P&T Committee c. Credentials Committee d. PAC

2. Annually review, recommend and approve the Quality Improvement Department Program Evaluation and the Quality Improvement Work plan. Performance in utilization management activities is included in the annual Quality Improvement Evaluation.

3. Provides medical opinion regarding technological advances in consideration of benefit enhancements, inclusions, and exclusions.

3.4. Technology Review: The Chief Medical Officer or physician designee may request input from an appropriate specialist within the community prior to presenting the request to the Pharmacy and Therapeutics (P&T) Committee, Quality/Utilization Advisory Committee (QUAC) Physician Advisory Committee (PAC). This specialist must have expertise in the technology under review. The decision to consult a specialist will depend on the nature of the technology being considered, and will be made on a case-by-case basis.

4.5. Makes recommendations for health plan policy and protocol changes based on guidelines and standards of practice, and select PHC policies that affect quality improvement, clinical care, or provider issues.

5.6. Oversight responsibility for utilization, quality, and other staff reports which monitor the utilization of services and outcomes of quality within the delivery system.

6.7. Reviews and approves Clinical Practice Guidelines adopted by PHC. 7.8. Provides oversight to the PCP and Hospital Quality Improvement Programs (QIPs) for providers and

hospitals, which includes: approval of the measures and payment methodologies; in addition to overseeing the implementation and evaluation of the QIP.

8.9. Advises and assists in the selection of Chief Medical Officer, as needed. C. COMMITTEE ACCOUNTABILITY

1. The Physician Advisory Committee has oversight responsibility for the above listed committees and is accountable to the PHC Board of Commissioners.

VII. REFERENCES:



IX. POSITION RESPONSIBLE FOR IMPLEMENTING PROCEDURE: Committee Chairman

227 of 233






Page 3 of 3

X. REVISION DATES: Medi-Cal 10/14/98; 06/14/00; 03/14/01; 06/12/02; 10/13/04; 02/8/06; 04/11/07; 05/14/08; 05/13/09; 06/09/10; 10/10/12; 10/09/13; 04/09/14; 05/13/15; 06/8/16; 06/14/17; *05/09/18 *Through 2017, Approval Date reflective of the Quality/Utilization Advisory Committee meeting date. Effective January 2018, Approval Date reflects that of the Physician Advisory Committee’s meeting date. PREVIOUSLY APPLIED TO: PartnershipAdvantage MPQP1003 - 04/11/2007 to 01/01/2015 Healthy Families MPQP1003 - 10/10/2012 to 03/01/2013 Healthy Kids 04/11/2007; 05/14/08; 05/13/09; 06/09/10; 10/10/12; 10/09/13; 04/09/14; 5/13/15; 5/11/16 to 12/01/16 (Healthy Kids program ended 12/01/2016)

228 of 233


POLICY / PROCEDURE

Page 1 of 3

Policy/Procedure Number: MPQP1003 (previously QP100103) Lead Department: Health Services Policy/Procedure Title: Physician Advisory Committee (PAC) Policy





Reviewing Entities:

IQI P & T QUAC


Approving Entities:



Approval Signature: Jeffrey Gaborko, M.D. Approval Date: 05/09/2018


MCUP3042 - Technology Assessment



IV. ATTACHMENTS: A. NA

V. PURPOSE: The Physician Advisory Committee (PAC) is responsible for oversight and monitoring of the quality and cost-effectiveness of medical care provided to Partnership HealthPlan of California's members. The PAC reviews the activities of the Quality/Utilization Advisory Committee (Q/UAC), Provider Advisory Group (PAG), Pharmacy and Therapeutics Committee (P&T), the Quality Improvement Program Advisory Group, and the Credentials Committee, makes recommendations, and assists PHC in other ways as defined in this policy.


A. COMMITTEE STRUCTURE 1. Membership:

a. The PAC is comprised of the PHC CEO, Deputy Executive Director/Chief Operating Officer, Chief Medical Officer, Regional Medical Directors, Chief Financial Officer, Health Services Director, Provider Relations Director, Quality and Performance Improvement Director, Pharmacy Director, Member Services Director, and 15-25 other members that may include: 1) Participating physician representatives from primary and specialty care, including at least

one behavioral health provider. 2) Advanced practice clinicians such as certified nurse midwives, nurse practitioners or

physician assistants. 3) Members representing active medical staffs of hospitals, community-based practices, and

medical groups in the PHC service area. b. Members with annual attendance of <50% are evaluated for termination from the PAC. c. Other health plan staff may make special or periodic reports to the committee or may attend

selected meetings ex-officio.

229 of 233






Page 2 of 3

2. Minutes: Minutes are recorded of all meetings and are maintained.3. Chair: A PHC Physician on the Committee chairs the meeting and when unavailable, the Chief

Medical Officer chairs the Committee.4. Meetings: The Committee meets at least nine (9) times a year, but does not convene in the months of

July or December, with the option to add additional meetings if needed.5. Voting: Only committee members who are not PHC staff may vote. The Chief Medical Officer

serves in a tie breaking capacity as necessary. A quorum is that number of members present asdescribed in the PHC by-laws which specifies 50% plus one of voting members.

B. COMMITTEE RESPONSIBILITIES 1. Reviews and makes recommendations for corrective action based upon other committee reports

including:a. Q/UACb. P&T Committeec. Credentials Committee

2. PACAnnually review, recommend and approve the Quality Improvement Department ProgramEvaluation and the Quality Improvement Work plan. Performance in utilization managementactivities is included in the annual Quality Improvement Evaluation.

3. Provides medical opinion regarding technological advances in consideration of benefitenhancements, inclusions, and exclusions.

4. Technology Review: The Chief Medical Officer or physician designee may request input from anappropriate specialist within the community prior to presenting the request to the Pharmacy andTherapeutics (P&T) Committee, Quality/Utilization Advisory Committee (QUAC) PhysicianAdvisory Committee (PAC). This specialist must have expertise in the technology underreview. The decision to consult a specialist will depend on the nature of the technology beingconsidered, and will be made on a case-by-case basis.

5. Makes recommendations for health plan policy and protocol changes based on guidelines andstandards of practice, and select PHC policies that affect quality improvement, clinical care, orprovider issues.

6. Oversight responsibility for utilization, quality, and other staff reports which monitor the utilizationof services and outcomes of quality within the delivery system.

7. Reviews and approves Clinical Practice Guidelines adopted by PHC.8. Provides oversight to the PCP and Hospital Quality Improvement Programs (QIPs) for providers and

hospitals, which includes: approval of the measures and payment methodologies; in addition tooverseeing the implementation and evaluation of the QIP.

9. Advises and assists in the selection of Chief Medical Officer, as needed.C. COMMITTEE ACCOUNTABILITY

1. The Physician Advisory Committee has oversight responsibility for the above listed committees andis accountable to the PHC Board of Commissioners.

VII. REFERENCES:N/A

VIII. DISTRIBUTION:A. PHC Department DirectorsB. PHC Provider Manual

IX. POSITION RESPONSIBLE FOR IMPLEMENTING PROCEDURE: Committee Chairman

X. REVISION DATES: See Redline for 3 of 3

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The Psychology of Clinical Decision Making

n engl j med 378;8 nejm.org February 22, 2018

to advance. Similar paradigm shifts have been more of a chal-lenge for policymakers, as reflect-ed in their difficulty in integrat-ing insights from economics and psychology into everyday applica-

tions. Medical prac-tice, as a hybrid of science and social science, could ben-

efit by learning from the work of the newest economics Nobelist and other behavioral researchers, even if this work seems remote from the sciences we’re accus-

tomed to studying. Understand-ing and addressing the unexpect-ed wrinkles and twists in human decision making could yield im-provements in care analogous to those based on understanding and addressing the unexpected wrinkles and twists in our pa-tients’ DNA.

Disclosure forms provided by the author are available at NEJM.org.

From Harvard Medical School and the Divi-sion of Pharmacoepidemiology and Phar-macoeconomics, Department of Medicine, Brigham and Women’s Hospital — both in Boston.

1. Kahneman D. Thinking, fast and slow. New York: Farrar, Straus, and Giroux, 2011.2. Avorn J. Academic detailing: “market-ing” the best evidence to clinicians. JAMA 2017; 317: 361-2.3. Thaler RH, Sunstein CR. Nudge: im-proving decisions about health, wealth, and happiness. New Haven, CT: Yale University Press, 2008.4. Choudhry NK, Avorn J, Glynn RJ, et al. Full coverage for preventive medications af-ter myocardial infarction. N Engl J Med 2011; 365: 2088-97.5. Cohen IG, Lynch HF, Robertson CT, eds. Nudging health: health law and behavioral economics. Baltimore: Johns Hopkins Uni-versity Press, 2016.

DOI: 10.1056/NEJMp1714987Copyright © 2018 Massachusetts Medical Society.The Psychology of Clinical Decision Making

An audio interview with Dr. Avorn is

available at NEJM.org

Controlling the Swing of the Opioid Pendulum

Controlling the Swing of the Opioid PendulumGeorge Comerci, Jr., M.D., Joanna Katzman, M.D., M.S.P.H., and Daniel Duhigg, D.O., M.B.A.

Mr. P. is a 34-year-old man who sees his primary care

physician regularly for chronic spine pain. Several years ago, he had a motorcycle accident that left him with a ruptured spleen, a shattered pelvis, and multiple thoracic vertebral fractures. After a prolonged hospital and rehab course, he was discharged with-out neurologic sequelae but with a severe chronic pain syndrome. The accident was a wake-up call for Mr. P. He stopped using alco-hol and drugs, got a job, and be-gan paying child support. His daily pain regimen consisted of 3600 mg of gabapentin, 60 mg of baclofen, 120 mg of oxycodone IR (a 180-mg morphine-equivalent dose), and nonsteroidal antiin-f lammatory drugs as needed.

Mr. P.’s condition had been sta-ble on this regimen for 2 years. His prescription-drug monitor-ing reports and urine toxicology screens were pristine. Unfortu-nately, his primary care physician announced that her practice had adopted a no-opioid policy. Mr. P.

was given a prescription for a month’s worth of oxycodone and advised to find another prescriber in the future. Not unexpectedly, six other physicians refused to pre-scribe him opioids, and he ended up in our pain clinic, sobbing in the exam room, terrified that he’d end up “back in my old life” if he had to buy his pain medica-tions on the street.

In the past year, our university-based interdisciplinary pain clin-ic has seen a f lood of cases like Mr. P.’s. The increase in opioid-related mortality fueled by injudi-cious prescribing and increasing illicit use of both prescription and illegal opioids has led some clinicians to simplify their lives by discontinuing prescribing of opioid analgesics. The fallout is a growing pool of patients who are forced to navigate their transition off prescribed opioids, often with little or no assistance or guid-ance, with the potential for dis-astrous results.

Well before the opioid crisis was recognized and attention was

directed to opioid-related deaths, clinicians cited issues related to opioids as a principal reason why they didn’t enjoy caring for pa-tients with chronic pain.1 Now, many physicians and advanced care practitioners (nurse practi-tioners and physician assistants) have decided that the risk associ-ated with prescribing opioids is too high. Some clinics, particu-larly in locations with high rates of opioid misuse, have established policies of not prescribing opioids at all.

The reasons for such policies are complex. Most clinicians have inadequate training in the mod-ern treatment of chronic pain and had learned that opioids were safe and effective for all forms of chronic pain. Lacking knowledge about nonopioid approaches to pain management, many of us have overprescribed opioids for patients with chronic pain and now feel guilt and misgivings about the monster we’ve created. With increasing legislation and scrutiny by medical boards, phar-

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Copyright © 2018 Massachusetts Medical Society. All rights reserved.

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macy boards, and federal agencies such as the Drug Enforcement Administration (DEA), many phy-sicians believe that the risk of incurring sanctions is too high for them to continue prescribing opioids.

Furthermore, it’s becoming more difficult for physicians to prescribe these drugs. Increasingly, prescription-drug plans are insti-tuting complicated and confusing opioid-prescribing rules. Often, limits are placed on dosage forms, quantities, or both without any evidence that such restrictions will ameliorate opioid overuse and misuse. Navigating these rules is time consuming for both clini-cians and pharmacists, who are increasingly dissatisfied with their work and unenthusiastic about caring for patients taking these medications. An even more un-settling phenomenon is drug-coverage plans’ discouragement of the use of safer opioids, such as buccal buprenorphine, in favor of less expensive but more dan-gerous alternatives such as mor-phine.

In our opinion, however, the most important contributor to a desire to stop prescribing opioids is the effect of opioid prescrib-ing on clinicians’ emotional well-being. We worry about the poten-tial unintended consequences of these medications even if they’re used appropriately. More imme-diately, it’s difficult to walk into an exam room knowing that we have to significantly reduce or stop a patient’s opioid treatment — and then deal with the lengthy, emotional, possibly con-frontational encounter that typi-cally ensues.

Inappropriate opioid prescrib-ing has certainly contributed to climbing rates of accidental death

from these drugs. The profession has responded by promulgating safer prescribing guidelines2 and rational pain-treatment guidelines. Yet an enormous number of pa-tients are currently using pre-scription opioids. Many of them will need to have their doses re-duced or be weaned off complete-ly, but many cannot achieve ade-quate pain control without their current doses. All these patients deserve compassionate and skilled pain management. We fear that an injudicious approach involv-ing blanket refusals to prescribe opioids and adoption of unrea-sonable prescribing and dispens-ing regulations will increase pa-tient suffering. Furthermore, the worst-case scenario is for patients to obtain prescription opioids il-legally and eventually transition to more dangerous drugs, such as heroin.3

Most patients with chronic pain are cared for by primary care clinicians; others are treated by specialists whose primary train-ing is not in chronic pain. There are too few U.S. pain clinics to care for all these patients, and referring them simply for opioid stewardship is both inappropriate and unrealistic. But some key steps can be taken.

First, all clinicians can improve their knowledge about evaluating and treating chronic pain. We be-lieve the opioid crisis is largely a crisis of inadequate treatment of chronic pain. With an estimated 100 million Americans with chron-ic pain, most specialties encoun-ter such patients. Increasingly, educational opportunities are be-coming available through profes-sional organizations such as the American College of Physicians and the American Academy of Family Medicine. Several national

organizations dedicated to chron-ic pain, such as the Academy of Integrative Pain Management and the American Academy of Pain Medicine, offer pain-management courses for clinicians of all back-grounds. In addition, Project ECHO (https:/ / echo . unm . edu/ pain-echo/ ) offers interactive, case-based tele-mentoring clinics throughout the United States and Canada that provide clinicians the opportu-nity to present cases on a video platform and learn pain- and opioid-management skills from peers and experts in real time.4

Second, clinicians can consider transitioning patients from risky opioid regimens to safer buprenor-phine treatment for chronic pain. We believe that every effort must be made to reduce the morphine-equivalent dose of opioid analge-sics to the safest dose achievable. Buprenorphine is a partial agonist–antagonist of the mu receptor with excellent pain-relieving properties and a much safer overdose pro-file. Many studies show that pa-tients taking high-dose mu-recep-tor agonists such as morphine or oxycodone can be successfully transitioned to this medication.5 Though not completely risk-free, it carries much less risk of respi-ratory depression than other opi-oids. Several buprenorphine prep-arations are approved by the Food and Drug Administration for chronic pain conditions. Any cli-nician with a DEA license can prescribe certain forms of bu-prenorphine for pain, though an “X” waiver (see below) is required to prescribe it for opioid use dis-order (OUD).

Third, clinicians can adopt risk-mitigation strategies for patients taking opioids. OUD is a com-mon, potentially devastating con-dition that may co-occur with



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other medical conditions involv-ing chronic pain. Physicians have an obligation to learn how to di-agnose it and develop strategies to address it. Risk-mitigation strategies such as periodic urine drug screening, scrutiny of pre-scription-monitoring reports, iden-tification of aberrant behaviors, and patient education in safe use and storage of opioid medica-tions are of paramount impor-tance for all patients taking opioid analgesics. Similarly, take-home or coprescription of naloxone for patients taking any opioids should be routine. This strategy could save not only the patient’s life but also that of a relative, friend, or bystander unlucky enough to suffer an opioid overdose.

Finally, physicians and ad-vanced care clinicians can under-go brief training (8 and 24 hours, respectively) to obtain an “X”

waiver on their DEA license so they can use buprenorphine to treat OUD. Increasing the avail-ability of such treatment could stem the tide of opioid misuse and improve the lives of patients with OUD.

Opioid analgesics are an im-portant part of our therapeutic armamentarium, but they have serious consequences when used improperly. As the pendulum swings from liberal opioid pre-scribing to a more rational, mea-sured, and safer approach, we can strive to ensure that it doesn’t swing too far, leaving patients suffering as the result of injudi-cious policies.

Disclosure forms provided by the authors are available at NEJM.org.

From the Pain Consultation and Treatment Center, Project ECHO Pain and Opioid Management Clinic (G.C., J.K.), the Depart-ment of Internal Medicine (G.C.), and the

Department of Neurosurgery ( J.K.), Univer-sity of New Mexico, and Department of Addiction Services, Psychiatry and Behav-ioral Health Clinical Program, Presbyterian Healthcare System (D.D.) — all in Albu-querque, NM.

1. Leverence RR, Williams RL, Potter M, et al. Chronic non-cancer pain: a siren for primary care — a report from the PRImary Care MultiEthnic Network (PRIME Net). J Am Board Fam Med 2011; 24: 551-61.2. Dowell D, Haegerich TM, Chou R. CDC guideline for prescribing opioids for chronic pain — United States, 2016. JAMA 2016; 315: 1624-45.3. Mars SG, Bourgois P, Karandinos G, Montero F, Ciccarone D. “Every ‘never’ I ever said came true”: transitions from opioid pills to heroin injecting. Int J Drug Policy 2014; 25: 257-66.4. Katzman JG, Comerci G Jr, Boyle JF, et al. Innovative telementoring for pain manage-ment: project ECHO pain. J Contin Educ Health Prof 2014; 34: 68-75.5. Daitch J, Frey ME, Silver D, Mitnick C, Daitch D, Pergolizzi J Jr Conversion of chronic pain patients from full-opioid ago-nists to sublingual buprenorphine. Pain Physician 2012; 15: Suppl: ES59-ES66.

DOI: 10.1056/NEJMp1713159

Copyright © 2018 Massachusetts Medical Society.Controlling the Swing of the Opioid Pendulum

Our Other Prescription Drug Problem

Our Other Prescription Drug ProblemAnna Lembke, M.D., Jennifer Papac, M.D., and Keith Humphreys, Ph.D.

The epidemic of opioid addic-tion and overdose has appro-

priately garnered national atten-tion and led to concerted efforts to reduce overprescribing of opi-oids, a major cause of today’s drug crisis. By contrast, there has been little effort to address in-appropriate prescribing of ben-zodiazepines — controlled sub-stances such as alprazolam, clonazepam, diazepam, and loraz-epam. The Food and Drug Ad-ministration (FDA) has approved benzodiazepines for a diverse set of clinical indications, including anxiety, insomnia, seizures, and acute alcohol withdrawal. These drugs are also prescribed off-

label for many other conditions, such as restless legs syndrome and depression.

Between 1996 and 2013, the number of adults who filled a benzodiazepine prescription in-creased by 67%, from 8.1 million to 13.5 million, and the quantity of benzodiazepines they obtained more than tripled during that period, from 1.1-kg to 3.6-kg lorazepam-equivalents per 100,000 adults.1 According to data from the National Institute on Drug Abuse, overdose deaths involving benzodiazepines increased from 1135 in 1999 to 8791 in 2015 (see graph). Despite this trend, the adverse effects of benzodiazepine

overuse, misuse, and addiction continue to go largely unnoticed. Three quarters of deaths involving benzodiazepines also involve an opioid,1 which may explain why, in the context of a widely recog-nized opioid problem, the harms associated with benzodiazepines have been overlooked.

In 2012, U.S. prescribers wrote 37.6 benzodiazepine prescriptions per 100 population. Alprazolam, clonazepam, and lorazepam are among the 10 most commonly prescribed psychotropic medica-tions in the United States. Medic-aid expenditures on benzodiaze-pines increased by nearly $40 million between 1991 and 2009,



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