MINUTES OF THE MEETING OF THE SAN JOAQUIN COUNTY HEALTH COMMISSION December 9, 2015 Health Plan of San Joaquin Community Room

Transcription

1 MINUTES OF THE MEETING OF THE SAN JOAQUIN COUNTY HEALTH COMMISSION Health Plan of San Joaquin Community Room COMMISSION MEMBERS PRESENT: Greg Diederich, Chair Marvin Primack, MD, Vice Chair Rod Kawano Michael Kirkpatrick Mohsen Saadat, DO Brian Jensen Michael Herrera, DO Larry Ruhstaller Kathy Miller COMMISSION MEMBERS ABSENT: Gentry Vu, MD - Absent STAFF PRESENT: Amy Shin, Chief Executive Officer Cheron Vail, Chief Information Officer Marc Radner, VP, Human Resources Alejandra Clyde, Compliance Officer Michelle Tetreault, Chief Financial Officer Dr. Lakshmi Dhanvanthari, Chief Medical Officer David Hurst, VP of External Affairs Andrew Eshoo, County Counsel Sue Nakata, Executive Assistant I. Call to Order: Chair Diederich called the meeting to order at 5:00 p.m. and Roll Call was taken. Page 1

2 II. Approval of October 28, 2015 Meeting Minutes Chair Diederich presented for approval the October 28, 2015 meeting minutes with changes to Commissioner Kawano s title as Senior Deputy County Administrator. The motion was made, seconded and unanimous to approve the October 28, 2015 meeting minutes with suggested change (8/0). Commissioner Saadat joined the meeting at this time. III. Public Comments Gil Riojas, Deputy Director of DMHC introduced himself to the Commission. Mr. Rojas explained that unannounced attendance at board meetings of health plans, are part of DMHC oversight of the health plans. IV. Consent Items Chair Diederich presented four consent items for approval with minor changes to the Finance and Investment Committee minutes to reflect Commissioner Miller s absence on November 18, 2015: a. Human Resources (HR) Committee 10/30/2015 a. July 9, 2015 Meeting Minutes b. HPSJ Executive Team List c. CEO Salary Grade b. Human Resources Committee 11/18/2015 a. October 30, 2015 Meeting Minutes c. Finance and Investment ( F & I) Committee 11/18/2015 a. October 21, 2015 Meeting Minutes b. MGO Audit Corrective Action Plan d. Community Affairs Committee 11/19/2015 a. September 17, 2015 Meeting Minutes The motion was made, seconded and unanimous to approve the four Consent Items with changes to the F & I minutes (9/0). V. Commission Approval Items: Finance and Investment Committee (October 2015 Financial Report) 11/18/2015 Michelle Tetreault, CFO presented for approval the October 2015 financial report, highlighting the following: YTD Ending October 2015, Statement of Profit and Loss of All Business Units Page 2

3 o Net Income of $3.3M; $4.37M favorable to budget o Tangible Net Equity (TNE) was 386% o Total Membership is 14,574 favorable to budget; 6,012 in SJC and 9,041 in Stanislaus SJC Membership is favorable in both ACA and TANF populations Stanislaus ACA and dual populations are drivers of the favorable membership variance o Revenue Premium Revenue is $14.1M unfavorable to budget due to unbudgeted Contra Revenue of $17.7M relative to expansion groups in SJC and Stanislaus 10% rate reduction was budgeted for the expansion population in both counties, compared with actual rate reduction of 17% for SJC and 10.5% in Stanislaus; off-set by a favorable rate variance in TANF and SPD in SJC. Rates received for TANF and dual population in Stanislaus were lower than anticipated in the budget (off-setting more favorable expansion rate in this county) o Operating Expenses $4.4M favorable to budget o Medical Expenses $21.6M favorable to budget due to lower institutional costs in both counties and lower Professional and Pharmacy costs in SJC. The favorable variance is in part temporary due to the budget methodology. This will likely be off-set by unfavorable variances during the flu season and other higher utilization months Current overall MLR is at 92.1% o Balance Sheet Cash and Cash Equivalents increased by $96M due to the receipt of payments from the State reducing capitation receivables by $68.5M Upon review of the materials presented, Commissioner Saadat asked if management has a strategy to reduce claims backlog. Ms. Tetreault responded to the affirmative and noted that the process has already been implemented and should be complete by December 2015 month-end. Commissioner Saadat also asked for clarification on ACA and Contra Revenue. Ms. Tetreault noted that this is the first year HPSJ has had to record a liability for a minimum of 85% MLR for the Expansion populationas required by ACA. Utilization was lower than expected when rates were developed so most plans are experiencing lower than 85% MLR. Amy Shin, CEO also noted that the state developed rates based partially on LIHP population because there weren t any experiences to draw upon for the previously uninsured population. Chair Diederich asked if HPSJ is able to use excess funds to increase provider reimbursements. Ms.Tetreault noted that a provider incentive program is in place already. Ms. Shin also noted that the expansion population rate is anticipated to decrease so increasing provider reimbursement is not being considered. Commissioner Ruhstaller was very appreciative and acknowledged Ms. Tetreault on reformatting the reporting of the financials; information is clear and easy to follow. Page 3

4 The motion was made, seconded and unanimous to approve the October 2015 financial as presented (9/0). Finance and Investment Committee (Provider Incentive Program) 11/18/2015 Ms. Tetreault and Dr. Lakshmi Dhanvanthari, CMO presented for approval the Provider Incentive Program for FY 2016, noting that the program is consistent to previous years; targeting certain HEDIS initiatives, quality measures and access. Dr. Lakshmi presented the details of the program to the Commission, highlighting: Improve access initiative Measurements were made based on utilization and quality measures with emphasis on quality Dental/Fluoride varnish HEDIS (in the previous years all HEDIS measures were incentivised annually, in FY 2016, the payout for some of the event driven measures will be more timely-monthly or quarterly) Avoidable ER visits are based on certain diagnosis; state provides the criteria and bimonthly reports are submitted to providers from HPSJ All capitated and non-capitated are eligible under the program (the total incentive pool is the same amount of $15M as last years; part of MLR) Hospitals in Stanislaus are not included in the program just as in the previous years. In San Joaquin the APR-DRG hospitals are not included in the incentive program since they are already incentiviced to manage their utilization and quality based on the contract No incentive program for specialists due to the challenges in administering the program Upon review of the materials presented, Commissioner Saadat asked how data were compiled for the program. Dr. Lakshmi advised that data were compiled mostly through the company s claims and encounter data. Chair Diederich asked how much does HPSJ pay out for each visit and how incentive payment will be processed (under claims payment). Dr. Lakshmi responded that the company pays an extra $25 for each health exam visits and that incentives will be processed separately under incentive payment. Chair Diederich asked how the incentive plan was developed. Dr. Lakshmi responded the incentive plans were developed based on state monitoring data, measures of where the company is not doing well on HEDIS, and by using NCQA required HEDIS measures. It is required that the company do well on some of these measures both from an NCQA accreditation perspective and the state monitoring. Commissioner Saadat asked how providers will be monitored under the program. Dr. Lakshmi noted, throughout the year (every other month) report cards will be sent to providers based on the rates (gaps in care). This will allow providers the opportunity review their data compared to HPSJ s reports. The motion was made, seconded and unanimous to approve the FY 2016 Provider Incentive Program as presented (9/0). Page 4

5 Human Resources Committee (Commissioner Position Responsibilities) 10/30//2015 Marc Radner, VP of Human Resources reported the draft of the Commission Chair and Commissioner position responsibilities were presented to the HR Committee for review on October 30, 2015 and that the final draft, with recommended changes from that committee, are being presented to Commission for approval. The Health Commission s Chair and Commissioner Position Responsibilities was put together to meet the latest DHMC filing requirement and to outline the governance and fiduciary responsibilities common to most boards. Chair Diederich noted based on the recommended changes, he agrees with the purpose and for the adoption of best practices on commission roles and responsibilities. Commissioner Jensen agreed to the affirmative and also noted that the job description quantifies what the Commission is doing and that this is not out of the ordinary. Commissioner Primack stated it would be best to hold a training to review Commissioners roles. Ms. Shin agreed to the affirmative and noted based on her report a few meetings back, management has found a consultant firm to hold governance training that will be held before an upcoming commission meeting (2 hour training session). The motion was made, seconded and unanimous to approve the Chair and Commissioner s Position Responsibilities as presented (9/0). QMUM Committee Meeting 11/18/2015 Dr. Lakshmi Dhanvanthari, CMO announced new leadership team members in Medical Management: Dr. Robert Castillo, Medical Director Cathy Flanagan, Director of Quality Tamara Foster, HEDIS and Accreditation Manager Dr. Lakshmi then presented for approval the QMUM Committee meeting report for November 18, 2015, highlighting the following committee meetings and policies that were reviewed and approved: Behavioral Health/Medical Coordination Committee - 10/26/2015 o HPSJ referred 142 high risk members with a behavioral health diagnosis to Beacon over the past 2 months Delegation Oversight Committee 10/26/2015 o Beacon s Annual Delegation Oversight Audit with no corrective action plan (CAP) o For September 2015, Beacon did not meet their abandonment rate metric and a CAP was issued o Carenet s protocols were reviewed and approved o Monthly reports from Kaiser for UM, QM and Customer Service was reviewed and approved Page 5

6 HEDIS o Measurement Year 2015 = Reporting Year 2016 HEDIS Kick-Off Meeting was held on 11/17/15 with a cross-functional team Member and Provider Interventions to improve HEDIS rate was discussed Provider Report Cards for current year and upcoming 2016 MY was discussed extensively HPSJ s Oral Health Initiative Oral health for Children Starts at Birth o Goal of the program is to improve the well-being of children by monitoring good dental health o HPSJ will improve the provision of fluoride to children age 0-6 by promoting application of fluoride varnish and/or the provision of fluoride drops/tablets o Educate parents and children about good oral health and hygiene through multi-channel social marketing campaign Reviewed and Approved Disease Management Program o Asthma Management Program Description FY o Congestive Heart Failure Program Description FY o Diabetes Management Program Description FY Reviewed and Approved Quality Management and Utilization Management Evaluation for FY 2015 Upon review of the materials presented, Chair Diederich asked what are Public Health s involvement with these committees. Dr. Lakshmi noted that there is no specific public health involvement in these meetings but there are certain venues that Public Health does interface with. Public Health is participating on dental health initiative. Commissioner Ruhstaller asked if there are enough dental providers to cover HPSJ s membership. Dr. Lakshmi noted that it has been a challenge through Denti-Cal but Medical Management and Marketing team staff are providing lists of Denti-Cal providers to pediatricians and family physicians. Due to Denti-Cal s reimbursement being very low, providers are opting out on accepting Denti-Cal members. Discussions were also held on the carve out of mental health and how HPSJ is working with Beacon on referrals. The motion was made, seconded and unanimous to approve the QMUM Committee meeting report as presented (9/0). VI DHCS Audit Final Report Alejandra Clyde, Compliance Officer provided an update on the 2014 DHCS Audit Final Report, highlighting the following: Review period from April 1, 2013 to March 31, 2014 On-Site Survey/Audit from June 23, 2014 to July 23, 2014 Final Audit Report was received on May 13, 2015 Submitted initial CAP responses on June 13, 2015 Page 6

7 Management received DHCS CAP Closure Letter on October 27, 2015 noting that all deficiencies have been reviewed and 5 of the 49 have been provisionally closed and 1 finding was waived. Even though the CAP has been closed, DHCS will continue to monitor and follow up on the remaining 5 provisionally closed deficiencies, which are: 1. Provide a summary report detailing quantitative and qualitative analysis of authorization denials, appeals and referrals (deliverables submitted 11/30/15) 2. Submit results of HEDIS review scheduled for January thru 5. Submit the results of Appointment Availability survey when they become available after March VII. Internal Audit Update Alejandra Clyde, Compliance Officer provided a report on HPSJ s first Internal Audit. The internal audit was conducted from May 4, 2015 to June 5, 2015, which included the review of HPSJ s policies for new vendor contract procurement and renewal and policy effectiveness. The purpose of the internal audit was to ascertain the vendor contract procurement process to comply with HPSJ s internal policy and procedures, company by-laws, and Plan contract with DHCS. The audit methodology used was selecting random vendors for review. The file was chosen from a list of vendors and amounts paid and received by finance. An exit conference was held on July 2, 2015, with the Executive Team to review preliminary findings. The Executive Team was allowed until July 24, 2015 to provide supplemental information addressing the draft internal audit report findings. Report was finalized August The audit evaluated five categories of performance: 1. Overall New Vendor Procurement Process 2. Contract Review Form 3. State of Work 4. Internal Review 5. Termination Some of the deficiencies identified were: Lack of staff training on current policies and procedures within policies ADM01 and ADM02 (will be revised for clarity) Lack of defined responsibility of tracking and trending expenses accrued by vendors Processes for contract procurement was not being enforced Lack of staff training on budgetary limits where certain individuals are permitted to approve without CFO/CEO approval Manual processes for tracking of contract renewals or extensions Policies and procedures contained vague and undefined terms and parameters After the audit report was finalized, Executive Team worked to developed corrective actions. Ms. Clyde distributed the corrective action documentation that will guide HPSJ to bring HPSJ into compliance with all deficiencies found. Ms. Shin also noted that the internal audit function was created due to the activities that occurred in Page 7

8 VIII. HPSJ Employee Concerns Marc Radner, VP of Human Resources provided an update on one HPSJ employee allegations on inappropriate and illegal practices at the company. Allegations have been addressed to the Commission Chair and County Counsel. Some of the actions taken are: Preliminary investigations completed and no illegal activities nor malficience were found to have occurred Engaged with external investigator to ensure internal investigations were proper Final report from the external investigator should be complete and received by HPSJ by December 21 IX. CEO Report Amy Shin, CEO highlighted on few sections of the October 2015 Dashboard report. X. Chairman Report Chair Diederich provided an update on Ms. Shin s to Commissioners on November 10, 2015 regarding HPSJ s non-participation on the RFP for SJHA TPA. Extensive discussions were held on the reasons for HPSJ s non-participation, identity of TPA vs. Medi-Cal members, the affect of Cadillac Tax and provider network. The due date for the RFP was on 11/30/15 and HPSJ did not submit a response. XI. Commissioner Comments No comments were forthcoming. XII. Closed Session At this time, the Health Commission adjourned to Closed Session at 6:35 P.M. Closed Session for Conference with Labor Negotiator California Government Code Section HPSJ Chief Negotiator: Reanette Fillmer Closed Session to Consider Trade Secrets Welfare and Institutions Code Section Title: Strategic Plan Closed Session - Public Employee Performance Evaluation Government Code Section Title: Chief Executive Officer Page 8

9 The Commission came out of Closed Session at 7:59 PM and a report will be provided at the January 2016 meeting. XI. Adjournment Chair Diederich adjourned the meeting at 7:59 PM. The next regular meeting of the Health Commission is scheduled for Wednesday, January 27, Page 9