REGULAR MEETING OF THE GOVERNING BOARD OF THE

Transcription

REGULAR MEETING OF THE GOVERNING BOARD
OF THE
INLAND EMPIRE HEALTH PLAN
August 08, 2016
Board Report #259
San Bernardino County Government Center
385 N. Arrowhead Ave, First Floor
San Bernardino, CA 92335
If disability-related accommodations are needed to participate in this meeting, please contact Annette Taylor, Secretary to the
IEHP Governing Board at (909) 296-3584 during regular business hours of IEHP (M-F 8:00 a.m. – 5:00 p.m.)
PUBLIC COMMENT AT INLAND EMPIRE HEALTH PLAN GOVERNING BOARD MEETINGS:
The meeting of the Inland Empire Health Plan Governing Board is open to the public. A member of the public may address
the Board on any item on the agenda and on any matter that is within the Board’s jurisdiction. Requests to address the Board
must be submitted in person to the Secretary of the Governing Board prior to the start of the meeting and indicate any
contributions in excess of $250.00 made by them or their organization in the past twelve (12) months to any IEHP Governing
Board member as well as the name of the Governing Board member who received contribution. The Board may limit the
public input on any item, based on the number of people requesting to speak and the business of the Board.
All public record documents for matters on the open session of this agenda can be viewed at the meeting location listed
above, IEHP main offices at 10801 6th Street, Suite 120, Rancho Cucamonga, CA 91730 and online at http://www.iehp.org.
AGENDA
I.
Call to Order
II.
Board Secretary: Any changes to the agenda packet including the “Information Relative To The
Possible Conflict of Interest” Form
III.
COMMENTS FROM THE PUBLIC ON MATTERS ON THE AGENDA
IV.
Conflict of Interest Disclosure:
V.
Adopt and Approve the Meeting Minutes from the July 11, 2016 Regular Meeting of the
Governing Board of the Inland Empire Health Plan
VI.
CONSENT AGENDA
ADMINISTRATION (Bradley P. Gilbert, M.D.)
1.
Update on Additional Authorized Staffing Positions Under Board Approved Guidelines
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Submittals to Inland Empire Health Plan Governing Board
Staff Reports and Recommendations #259
August 08, 2016
FINANCE DEPARTMENT
No Items
INFORMATION TECHNOLOGY DEPARTMENT (Michael Deering)
No Items
MARKETING DEPARTMENT (Susan Arcidiacono)
No Items
MEDICAL SERVICES DEPARTMENT (Jennifer N. Sayles, M.D./Marcia Anderson)
No Items
OPERATIONS DEPARTMENT (Rohan Reid)
2.
Approve the Fourth Amendment to the Multi-Tenant Office Lease with 15000 7th Street,
LLC Suite 208-E
PROVIDER NETWORK DEPARTMENT (Kurt Hubler)
3.
Ratify and Approve the Second Amendment to the Per Diem Hospital Agreement with
Prime Healthcare Services III, LLC DBA Montclair Hospital Medical Center
4.
Ratify and Approve the Third Amendment to the Hospitalists Agreement with HNI
Medical Services of California, P.C.
5.
Ratify and Approve the Second Amendment to the Health-Plan Provider Agreement with
San Bernardino County Fire Protection District
6.
Ratify and Approve the New Participating Privider Agreenment with IE Health and
Wellness Management, Inc., A Texas Corporation
7.
Approval of the Standard Templates to the Following Master Agreements and
Attachments, and Authorization for the Chief Executive Officer of IEHP to Sign the
Agreements and Attachments:
1) Autism – Master Agreement
2) Behavioral Health Master Agreement (Excluding Medicare)
3) Behavioral Health Master Agreement (All Lines of Business)
4) Community Based Adult Services Provider Agreement (All Lines of Business)
5) Exhibit K-1 Autism – Master Agreement
6) Master Admitter Hospitalist Agreement (No Medicare)
7) Master Admitter Hospitalist Agreement (All Lines of Business)
8) Master Agreement (Excluding Medicare)
9) Master Agreement (Medicare Only)
10) Master Agreement (All Lines of Business)
11) Master Capitated Hospital Agreement
12) Master Per Diem Hospital Agreement
13) Master Per Diem Hospital Agreement for Behavioral Health Services
14) Master Hospitalist Template
15) Master IPA Agreement (All Lines of Business)
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16) Master IPA Agreement (Excluding Medicare)
17) Master IPA Agreement (Medicare Only)
18) Master Letter of Agreement Appeal Reviewer – Blanket Evergreen
19) Master Letter of Agreement – Autism Blanket – Evergreen
20) Master Letter of Agreement – Blanket – PCP – SPD
21) Master Letter of Agreement – Long Term Sub Acute SNF – Evergreen
22) Master Letter of Agreement – Member Specific
23) Master Letter of Agreement – Member Specific - Out of Network Autism
Providers
24) Master Letter of Agreement – Mental Health Provider (LCSW – MFT –
Psychologist – Psychiatrist)
25) Master Letter of Agreement – Mental Health Provider (LCSW – MFT)
26) Master Letter of Agreement – Mental Health Provider (Psychiatrist)
27) Master Letter of Agreement – Mental Health Provider (Psychologist)
28) Master Participating Provider Agreement – Vision
29) Master Participating Provider Agreement – Vision (Exam Only)
30) Master Skilled Nursing Facility Provider Agreement (Excluding Medicare)
31) Master Skilled Nursing Facility Provider Agreement (All Lines of Business)
32) Master SNFist Agreement Template
33) Master Transportation Template
34) Home Health – Attachment B
35) Home Health – Hospice – Attachment B
8.
Approval of Evergreen Contracts:
a) Ancillary Provider Agreement with Ajeet R. Singhvi, M.D. – Effective
September 1, 2016, additional five (5) year term.
b) Ancillary Provider Agreement with Cindy Wiemann dba Omni Medical –
Effective October 1, 2016, additional five (5) year term.
c) Ancillary Provider Agreement with Golden Valley Medical & Oxygen Service –
Effective September 1, 2016, additional five (5) year term.
d) Ancillary Provider Agreement with Inland Valley Hospice Care, Inc. – Effective
e) Ancillary Provider Agreement with Neogenomics Laboratories Inc. – Effective
October 1, 2016, additional five (5) year term.
f) Ancillary Provider Agreement with Option Care Enterprises Inc dba Walgreens
Infusion Services – Effective September 1, 2016, additional five (5) year term.
g) Ancillary Provider Agreement with Serenity Hospice LLC – Effective
h) Capitated Agreement with Heritage Provider Network – Effective September 1,
2016, additional one (1) year term.
i) Open Access Provider Agreement (Excluding Medicare) with Corona Pediatrics,
Inc. dba Corona Pediatrics – Effective September 1, 2016, additional five (5)
year term.
j) Open Access Provider Agreement (Excluding Medicare) with Juan M Acosta
dba Clinica Medica Del Valle – Effective September 1, 2016, additional five (5)
year term.
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k) Fee-For-Service Primary Care Provider Agreement (All Lines of Business) with
Neelam Gupta MD dba Ramona Medical Clinic – Effective September 1, 2016,
additional five (5) year term.
l) Fee-For-Service Primary Care Provider Agreement with Rene Salhab M.D. –
m) Fee-For-Service Primary Care Provider Agreement (Excluding Medicare) with
Loma View Pediatric Medical Clinic Inc – Effective September 1, 2016,
n) Participating Provider Agreement with Comprehensive Primary Medical
Associates – Effective September 1, 2016, additional five (5) year term.
o) Participating Provider Agreement with Desert Heart Rhythm Consultants –
p) Participating Provider Agreement with Ifeanyi Ugochuku dba Inland Surgical
Group, Inc. – Effective September 1, 2016, additional five (5) year term.
q) Participating Provider Agreement with Indermohan S Luthra MD – Effective
r) Participating Provider Agreement with Micha Rettenmaier Brown Lacey
Partnership dba Gynecologic Oncology Associates – Effective September 1,
2016, additional five (5) year term.
s) Participating Provider Agreement with Radiation Oncology Physicians Inc –
t) Participating Provider Agreement with Riverside Medical Clinic Inc. – Effective
September 1, 2016, additional two (2) year term.
u) Participating Provider Agreement with Rodolfo R Batarse dba Rodolfo R Batarse
MD – Effective September 1, 2016, additional five (5) year term.
v) Participating Provider Agreement with Serendipity Hearing Inc dba Sonus
SF0010 – Effective September 1, 2016, additional one (1) year term.
w) Participating Provider Agreement with Shadi A Qasqas MD Inc – Effective
x) Participating Provider Agreement with William D Suval MD Inc – Effective
y) Participating Provider Agreement (Medicare Only) with San Bernardino Medical
Group, Inc. – Effective September 1, 2016, additional five (5) year term.
VII.
POLICY AGENDA AND STATUS REPORT ON AGENCY OPERATIONS:
ADMINISTRATION (Bradley P. Gilbert, M.D.)
9.
Review of the Monthly Membership Report
10.
Approve the Fiscal Year 2016/2017 Risk Sharing Funds Measurement and Distribution for
the Medi-Cal Expansion Population
11.
2016 Second Quarter Review of the IEHP Compliance Program
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FINANCE DEPARTMENT
12.
Review of the Monthly Financials
13.
Ratify and Approve the Fourth Amendment to the Professional Services Agreement with
Varis, LLC.
INFORMATION TECHNOLOGY DEPARTMENT (Michael Deering)
No Items
MARKETING DEPARTMENT (Susan Arcidiacono)
No Items
MEDICAL SERVICES DEPARTMENT (Jennifer N. Sayles, M.D./Marcia Anderson)
14.
Overview of the Medi-Cal and Medicare Healthcare Effectiveness Data and Information
Set Results for HEDIS 2016.
OPERATIONS DEPARTMENT (Rohan Reid)
No Items
PROVIDER NETWORK DEPARTMENT (Kurt Hubler)
15.
Review of the 2015 Provider Network Status Study
MAIN OBJECTIVES FOR THE NEXT 90 DAYS AND SUMMARY COMMENTS
(Bradley P. Gilbert, M.D.)
16.
Main Objectives for the Next 90 Days and Summary Comments
VIII.
COMMENTS FROM THE PUBLIC ON MATTERS NOT ON THE AGENDA
IX.
Recess Into The IEHP Health Access Meeting
X.
Reconvene From The IEHP Health Access Meeting Back Into The IEHP Meeting
XI.
ADJOURNMENT
The next meeting of the IEHP Governing Board will be held on September 12, 2016 at the Riverside
County Government Center.
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Staff Reports and Reports and Recommendations #259
August 8, 2016
CONSENT CALENDAR
ADMINISTRATION
1. UPDATE ON ADDITIONAL AUTHORIZED STAFFING POSITIONS UNDER BOARD
APPROVED GUIDELINES
Recommended Action:
Update On Additional Authorized Staffing Positions Under Board Approved Guidelines
Contact:
Bradley P. Gilbert, M.D., Chief Executive Officer
Background:
At the June 13, 2016 Governing Board Meeting, under Resolution 16-88, the Governing Board
approved the proposal authorizing the CEO to approve additional staffing under the following
guidelines:
1) Maintaining IEHP’s General and Administrative (G&A) Expenses percentage at 5% or less.
2) Authorization only includes approval of additional staffing in IEHP’s current position
classifications. Approval of newly created positions will require Board approval; this does not
include position title changes that do not have any significant financial impact.
3) Monthly reports to the Board under the Consent Agenda outlining any additional authorized
positions with brief description of justification and related budget information.
4) This authority authorized for one year, through June 30, 2017.
This process will allow for flexibility to match staffing to operational needs and will maintain high
levels of service to our members and providers while concurrently maintaining accountability on a
monthly basis to the Governing Board.
Discussion:
The following positions have been approved:
CEO
APPROVAL
DATE
POSITION TITLE
SUPERVISOR
SALARY RANGE
$51,300
1
2
06/17/16
06/30/16
State Program Analyst
Director of Behavioral Health
Rebecca Mayer
Marcia Anderson
$140,185
3
07/07/16
Behavioral Health Specialist
Diana Gonzalez
$41,440
4
5
6
07/11/16
07/12/16
07/15/16
Queenie Flores
Tamara Gutierrez
Kathryn Gray
$33,000
$71,000
$98,456
7
07/15/16
8
07/15/16
Administrative Assistant EPMO
LTC Nurse
UM QA Training Manager
Manager of Data Science
Systems
Healthcare Informatics
Supervisor
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Michael Deering
Michael Deering
$110,764
$84,195
August 8, 2016
CONSENT CALENDAR
CEO
APPROVAL
DATE
9
10
07/15/16
07/15/16
11
07/20/16
12
07/20/16
POSITION TITLE
Informatics Architect
Project Coordinator x 2
Member Services
Representatives x 40
Behavioral Health Coordinator
Strategic Priorities:
Quality of Care
Human Development
SUPERVISOR
SALARY RANGE
Michael Deering
Paulo Salazar
Vanessa
Hernandez
Dr. Sarah
Wilkinson
$85,320
$37,750
$37,750
$37,750
Access to Care
Practice Transformation
Technology
Not Applicable
Fiscal Impact:
Included in FY 16/17 Budget
Approximately $3,204,302 annually (estimated salary and benefit impact).
Attachments:
None
Reviewed by Counsel:
N/A
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CONSENT CALENDAR
OPERATIONS DEPARTMENT
2.
APPROVE THE FOURTH AMENDMENT TO THE MULTI-TENANT OFFICE LEASE
WITH 15000 7TH STREET, LLC SUITE 208-E
Recommended Action:
That the Governing Board of the Inland Empire Health Plan (IEHP) approve the Fourth
Amendment to the Lease Agreement with 15000 7th Street, LLC Suite 208-E, for the office space
used to house the IEHP Health Navigators Program located in Victorville, California. The term of
this agreement is for one (1) year, cost not to exceed $3,700.
Contact:
Rohan Reid, Chief Operations Officer
Background:
In August 2012 under Minute Order 09-98, the Governing Board approved the lease agreement
with 15000 7th Street for an office in Victorville, California to support IEHP’s Health Navigator
staff. The lease agreement was fully executed in September, 2012
In September 2013 under Minute Order 13-49, the Chief Executive Officer approved the First
Amendment to the Multi-Tenant lease space with 15000 7th Street, LLC that renewed lease for an
additional one (1) year.
In September 2014 under Minute Order 13-49, the Chief Executive Officer approved the Second
In September 2015 under Minute Order 15-194, the Governing Board approved the Third
Discussion:
In November 2011, the IEHP Marketing department expanded their Health Navigator program
efforts to the High Desert area. This required leasing office space to run a satellite office for staff
to handle home visits in the High Desert area. The current leased space accommodates staff,
supplies, and equipment needs. IEHP has opted to continue to occupy this space.
Quality of Care
Human Development
Access to Care
Technology
Not Applicable
Fiscal Impact:
New Expenditure
The total compensation payable under this Agreement shall not exceed $3,700 per contract year.
Attachments:
A copy of the Fourth Amendment is attached
Yes
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Submittals to the Inland Empire Health Plan Governing Board
August 8, 2016
CONSENT CALENDAR
PROVIDER NETWORK DEPARTMENT
3.
RATIFY AND APPROVE THE SECOND AMENDMENT TO THE PER DIEM
HOSPITAL AGREEMENT WITH PRIME HEALTHCARE SERVICES III, LLC DBA
MONTCLAIR HOSPITAL MEDICAL CENTER
Recommended Action:
That the Governing Board of the Inland Empire Health Plan (IEHP) ratify and approve the Inland
Empire Health Plan Per Diem Hospital Agreement with Prime Healthcare Services III, LLC dba
Montclair Hospital Medical Center
Contact:
Kurt Hubler, Chief Network Officer
Background:
Prime Healthcare Services III, LLC dba Montclair Hospital Medical Center is currently a
contracted Provider in the IEHP Provider Network.
Discussion:
This Amendment extends the Agreement term for three years, beginning July 1, 2016 through June
30, 2019 and the Attachment C1, Compensation Rates reflects Inpatient Hospital Services APRDRG rates.
All other items and conditions of the Agreement remain in full force and effect.
Quality of Care
Human Development
Access to Care
Technology
Not Applicable
Fiscal Impact:
Attachments:
Copy of the Inland Empire Health Plan Per Diem Agreement is attached to the Minute Orders.
Yes
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CONSENT CALENDAR
4.
RATIFY AND APPROVE THE THIRD AMENDMENT TO THE HOSPITALISTS
AGREEMENT WITH HNI MEDICAL SERVICES OF CALIFORNIA, P.C.
Recommended Action:
That the Governing Board of the Inland Empire Health Plan (IEHP) ratify and approve the
Hospitalists Agreement with HNI Medical Services of California, P.C. as assignee and delegee of
the Hospitalist Agreement by and between Inland Empire Health Plan and Srinivas Vuthoori MD
A Professional Corporation dba Cambridge Hospitalists, effective June 15, 2016.
Contact:
Background:
HNI Medical Services of California, P.C. as assignee and delegee of the Hospitalist Agreement by
and between Inland Empire Health Plan and Srinivas Vuthoori MD A Professional Corporation
dba Cambridge Hospitalists is currently a contracted Provider in the IEHP Provider Network.
Discussion:
This Amendment includes a monthly stipend for the period of three (3) months from the date of
this amendment, ending on September 15, 2016.
All other items and conditions of the Agreement remain in full force and effect.
Quality of Care
Human Development
Access to Care
Technology
Not Applicable
Fiscal Impact:
Attachments:
Copy of the Hospitalists Agreement is attached is attached to the Minute Orders.
Yes
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CONSENT CALENDAR
5.
RATIFY AND APPROVE THE SECOND AMENDMENT TO THE HEALTH-PLAN
PROVIDER AGREEMENT WITH SAN BERNARDINO COUNTY FIRE PROTECTION
DISTRICT
Recommended Action:
That the Governing Board of the Inland Empire Health Plan (IEHP) ratify and approve the Health
Plan-Provider Agreement with San Bernardino County Fire Protection District effective July 1,
2014.
Contact:
Background:
Health Plan-Provider Agreement is currently a contracted Provider in the IEHP Provider Network.
Discussion:
This Second Amendment allows San Bernardino County Fire Protection District to participate in
the intergovernmental transfer revenues allowed by the California Department of Health Care
Services to maintain the availability of Medi-Cal health services to Medi-Cal beneficiaries.
The term of this Agreement is July 1, 2014, and shall terminate on September 30, 2017.
Quality of Care
Human Development
Access to Care
Technology
Not Applicable
Fiscal Impact:
Attachments:
Copy of the Health Plan-Provider Agreement is attached to the Minute Order.
N/A
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CONSENT CALENDAR
6.
RATIFY AND APPROVE THE NEW PARTICIPATING PROVIDER AGREEMENT
WITH IE HEALTH AND WELLNESS MANAGEMENT, INC., A TEXAS
CORPORATION
Recommended Action:
That the Governing Board of the Inland Empire Health Plan (IEHP) ratify and approve the
Participating Provider Agreement with IE Health and Wellness Management, Inc., A Texas
Corporation (“IEHWM”), effective July 12, 2016.
Contact:
Background:
IE Health and Wellness Management, Inc., A Texas Corporation (“IEHWM”) has agreed to
participate in the IEHP network.
Discussion:
This Agreement was tailored to reflect the Annual Health Assessments services offered by IE
Health and Wellness Management, Inc., A Texas Corporation (“IEHWM”).
Quality of Care
Human Development
Access to Care
Technology
Not Applicable
Fiscal Impact:
Attachments:
Copy of the Participating Provider Agreement is attached to the Minute Order.
Yes
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CONSENT CALENDAR
7.
APPROVE THE STANDARD TEMPLATES TO THE FOLLOWING MASTER
AGREEMENTS AND ATTACHMENTS, AND AUTHORIZATION FOR THE CHIEF
EXECUTIVE OFFICER OF IEHP TO SIGN THE AGREEMENTS AND ATTACHMENTS
Recommended Action:
That the Governing Board of the Inland Empire Health (IEHP) approve the IEHP Standard
Template Agreements, referenced below in section (d), and authorize the Chief Executive Officer
or his designee to execute the template, wherein the body of the document remains unchanged
except for the identifying information of the individual provider and non-material changes per
individual provider requirements.
Contact:
Background:
IEHP contracts with physicians and other providers using Governing Board approved Standard
Template Agreements. On a periodic basis IEHP reviews the IEHP & IEHP Direct Standard
Templates and updates are made to the templates, as necessary. The Governing Board has
authorized the Chief Executive Officer to sign the Agreement in lieu of having the Chair of the
Governing Board execute the documents.
Discussion:
The following standard templates are being presented to the Governing Board for the approval:
1. Autism – Master Agreement
2. Behavioral Health Master Agreement (Excluding Medicare)
3. Behavioral Health Master Agreement (All Lines of Business)
4. Community Based Adult Services Provider Agreement (All Lines of Business)
5. Exhibit K-1 Autism – Master Agreement
6. Master Admitter Hospitalist Agreement (No Medicare)
7. Master Admitter Hospitalist Agreement (All Lines of Business)
8. Master Agreement (Excluding Medicare)
9. Master Agreement (Medicare Only)
10. Master Agreement (All Lines of Business)
11. Master Capitated Hospital Agreement
12. Master Per Diem Hospital Agreement
13. Master Per Diem Hospital Agreement for Behavioral Health Services
14. Master Hospitalist Template
15. Master IPA Agreement (All Lines of Business)
16. Master IPA Agreement (Excluding Medicare)
17. Master IPA Agreement (Medicare Only)
18. Master Letter of Agreement Appeal Reviewer – Blanket Evergreen
19. Master Letter of Agreement – Autism Blanket – Evergreen
20. Master Letter of Agreement – Blanket – PCP – SPD
21. Master Letter of Agreement – Long Term Sub Acute SNF – Evergreen
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CONSENT CALENDAR
22. Master Letter of Agreement – Member Specific
23. Master Letter of Agreement – Member Specific - Out of Network Autism Providers
24. Master Letter of Agreement – Mental Health Provider (LCSW – MFT – Psychologist –
Psychiatrist)
25. Master Letter of Agreement – Mental Health Provider (LCSW – MFT)
26. Master Letter of Agreement – Mental Health Provider (Psychiatrist)
27. Master Letter of Agreement – Mental Health Provider (Psychologist)
28. Master Participating Provider Agreement – Vision
29. Master Participating Provider Agreement – Vision (Exam Only)
30. Master Skilled Nursing Facility Provider Agreement (Excluding Medicare)
31. Master Skilled Nursing Facility Provider Agreement (All Lines of Business)
32. Master SNFist Agreement Template
33. Master Transportation Template
34. Home Health – Attachment B
35. Home Health – Hospice – Attachment B
Quality of Care
Human Development
Access to Care
Technology
Not Applicable
Fiscal Impact:
Attachments:
Copies of the above referenced Standard Templates are attached to the Minute Order.
Yes
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CONSENT CALENDAR
8.
APPROVAL OF EVERGREEN CONTRACTS
Recommended Action:
That the Governing Board of the Inland Empire Health Plan (IEHP) approve the listed Evergreen
Contract for an additional one (1) to five (5) year term.
Contact:
Background:
Evergreen Contract – A Contract that automatically renews on the same terms and subject to the
same conditions as the original agreement, upon the approval of Governing Boards of Inland
Empire Health Plan and IEHP Health Access, unless sooner terminated in accordance with the
terms and conditions.
Discussion:
Renewal Under The Evergreen Clause Of The Following Agreements:
a) Ancillary Provider Agreement with Ajeet R. Singhvi, M.D. – Effective September 1, 2016,
b) Ancillary Provider Agreement with Cindy Wiemann dba Omni Medical – Effective October 1,
c) Ancillary Provider Agreement with Golden Valley Medical & Oxygen Service – Effective
d) Ancillary Provider Agreement with Inland Valley Hospice Care, Inc. – Effective September 1,
e) Ancillary Provider Agreement with Neogenomics Laboratories Inc. – Effective October 1,
f) Ancillary Provider Agreement with Option Care Enterprises Inc dba Walgreens Infusion
Services – Effective September 1, 2016, additional five (5) year term.
g) Ancillary Provider Agreement with Serenity Hospice LLC – Effective September 1, 2016,
h) Capitated Agreement with Heritage Provider Network – Effective September 1, 2016,
additional one (1) year term.
i) Open Access Provider Agreement (Excluding Medicare) with Corona Pediatrics, Inc. dba
Corona Pediatrics – Effective September 1, 2016, additional five (5) year term.
j) Open Access Provider Agreement (Excluding Medicare) with Juan M Acosta dba Clinica
Medica Del Valle – Effective September 1, 2016, additional five (5) year term.
k) Fee-For-Service Primary Care Provider Agreement (All Lines of Business) with Neelam Gupta
MD dba Ramona Medical Clinic – Effective September 1, 2016, additional five (5) year term.
l) Fee-For-Service Primary Care Provider Agreement with Rene Salhab M.D. – Effective
m) Fee-For-Service Primary Care Provider Agreement (Excluding Medicare) with Loma View
Pediatric Medical Clinic Inc – Effective September 1, 2016, additional five (5) year term.
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n) Participating Provider Agreement with Comprehensive Primary Medical Associates – Effective
o) Participating Provider Agreement with Desert Heart Rhythm Consultants – Effective
p) Participating Provider Agreement with Ifeanyi Ugochuku dba Inalnd Surgical Group, Inc. –
q) Participating Provider Agreement with Indermohan S Luthra MD – Effective September 1,
r) Participating Provider Agreement with Micha Rettenmaier Brown Lacey Partnership dba
Gynecologic Oncology Associates – Effective September 1, 2016, additional five (5) year
term.
s) Participating Provider Agreement with Radiation Oncology Physicians Inc – Effective
t) Participating Provider Agreement with Riverside Medical Clinic Inc. – Effective September 1,
2016, additional two (2) year term.
u) Participating Provider Agreement with Rodolfo R Batarse dba Rodolfo R Batarse MD –
v) Participating Provider Agreement with Serendipity Hearing Inc dba Sonus SF0010 – Effective
September 1, 2016, additional one (1) year term.
w) Participating Provider Agreement with Shadi A Qasqas MD Inc – Effective September 1, 2016,
x) Participating Provider Agreement with William D Suval MD Inc – Effective September 1,
y) Participating Provider Agreement (Medicare Only) with San Bernardino Medical Group, Inc.
Quality of Care
Human Development
Access to Care
Technology
Not Applicable
Fiscal Impact:
Attachments:
A copy of the original Agreements are attached to the Minute Order and are maintained in IEHP’s
permanent file cabinets.
N/A
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POLICY CALENDAR
ADMINISTRATION
9.
REVIEW OF THE MONTHLY MEMBERSHIP REPORT
Recommended Action:
Review and File
Contact:
Background:
This report reflects IEHP’s actual membership versus the membership projections in the IEHP
budget
Discussion:
Base Membership growth has been increasing; it remains predominately Medi-Cal Expansion
Members, with some growth in “regular” Medi-Cal Membership as well. No other trends noted
for June.
Fiscal
Year
Forecast
Membership
Actual
Membership
+ or –
Forecast
+ or –
Last Month
Month
FY 14/15
June, 2015
1,084,447
1,092,651
8,204
(93)
FY 15/16
July, 2015
1,089,574
1,099,841
10,267
7,190
August, 2015
1,096,298
1,112,437
16,139
12,596
September, 2015
1,102,974
1,124,395
21,421
11,958
October, 2015
1,109,225
1,122,182
12,957
(2,213)
November, 2015
1,115,436
1,124,726
9,290
2,544
December, 2015
1,122,604
1,127,581
4,977
2,855
January, 2016
1,129,730
1,134,643
4,913
7,062
February, 2016
1,136,814
1,143,302
6,488
8,659
March, 2016
1,143,858
1,148,179
4,321
4,877
April, 2016
1,150,863
1,153,720
2,857
5,541
May, 2016
1,154,830
1,162,082
7,252
8,362
June, 2016
1,158,760
1,172,959
14,199
10,877
Quality of Care
Human Development
Access to Care
Technology
Not Applicable
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POLICY CALENDAR
Fiscal Impact:
None
Attachments:
None
N/A
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POLICY CALENDAR
ADMINISTRATION
10.
APPROVE THE FISCAL YEAR 2016/2017 RISK SHARING FUNDS MEASUREMENT
AND DISTRIBUTION FOR THE MEDI-CAL EXPANSION POPULATION
Recommended Action:
That the Governing Board of the Inland Empire Health Plan (IEHP) approve the Fiscal Year
2016/2017 Risk Sharing Funds Measurement and Distribution for the Medi-Cal Expansion
Population.
Contact:
Background:
In 2014, California implemented the Medicaid (Medi-Cal) Expansion (MCE) eligibility change
based on federal guidelines from the Affordable Care Act (ACA). The ACA significantly
increased the eligibility for Medi-Cal both in terms of the upper income limit (now 133% of the
Federal Poverty Level) and by allowing childless adults who meet the income guidelines to be
eligible. The MCE population is a major expansion of Medi-Cal eligibility for a population that
has generally not had access to any health care coverage. As of July 2016, the MCE enrollment
was 316,087.
Discussion:
As an update to the December 8, 2014 and July 13, 2015 Governing Board Items on the same
subject, the distribution approved for calendar year 2014 and the first nine months of 2015 totaled
$381.7 million that was awarded to Hospitals, IPAs, PCPs, and Specialists.
As in prior fiscal years, the Risk Pool for Fiscal Year 2016/2017 will be based on a combination of
quarterly utilization measures and quality metrics. The metrics for the measurements will be based
upon MCE experience from October 1st through December 31st, 2015 and calendar year 2016.
Due to the lag in receiving claims from providers, there is a nine month delay in processing
payments for these periods. The Risk Pool funds for the fourth quarter of 2015 will be allocated
into two primary pools; 60% to Hospitals and 40% to IPAs and physicians. The 2016 quarterly risk
pool funds will be split 70% to Hospitals and 30% to IPAs and physicians.
Hospital Metrics:
Each Hospital’s pool will be determined by the number of MCE bed days in their facility. The
pool for the fourth quarter of 2015 will be awarded based upon the following metrics at 25%
each:

Readmission rates at or below 18% will be awarded a share of the pool based upon relative
utilization.

Physician/Specialist follow-up within seven calendar days of an inpatient hospital discharge
will be distributed to hospitals that meet or exceed 22.1% based on relative utilization.
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
Progressing toward full participation in the IEHIE with pre-established milestones to
complete.

Connecting electronically and submitting electronic face sheets for patient submissions.
The Hospital pool for calendar year 2016 will be awarded based on the following metrics at 25%
each:

Readmission rates, (excluding obstetrical days) at or below 16.9 % will be awarded a share of
the pool based upon relative utilization.

Physician/Specialist Follow-up within seven calendar days of an inpatient hospital discharge,
(excluding obstetrical days) will be distributed based on two levels of achievement: Level 1=
21.2% threshold for 50% reimbursement. Level 2= 25% threshold for 100% reimbursement.

Continue progressing towards full IEHIE participation.

Electronic transmission of hospital lab results to IEHP.
IPA Metrics:
The IPA for the fourth quarter 2015 will be distributed based upon relative enrollment for the
MCE population and awarded based upon the following metrics at 25% each;

Readmission rates at or below 18.7% will be awarded a share of the pool based upon relative
utilization.

Physician//Specialist Follow-up within seven calendar days of an inpatient hospital discharge
will be distributed to IPAs that meet or exceed 21.5% based on relative utilization.

Member Satisfaction results from CAHPS and CAHPS like surveys; IPAs in the 75%
percentile will receive 100%. IPA’s with results in the 50% to 74% quartile will receive 75%.

Eligibility file connectivity with the IEHIE by November 1, 2016.
The IPA Pool for calendar year 2016 will be awarded based on the following metrics at 25%
each:

Readmission rates, (excluding obstetrical days) at or below 16.9 % will be awarded a share of
the pool based upon relative utilization.

Physician/Specialist Follow-up within seven calendar days of an inpatient hospital discharge,
(excluding obstetrical days) will be distributed based on two levels of achievement: Level 1=
20.8% threshold for 50% reimbursement. Level 2= 25% threshold for 100% reimbursement.

Continue progressing towards full IEHIE participation

Member Satisfaction results from CAHPS or CAHPS like surveys. IPA’s in the 75% quartile
will receive 100%. IPA’s with results in the 50% to 74% quartile will receive 75%.
IEHP Direct Network Physician Metrics:
IPA funds allocated to IEHP Direct will be distributed 70% to contracted Specialists based upon
encounter data for the fourth quarter 2015 and calendar year 2016.
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Thirty percent will be distributed to Primary Care Physicians for the fourth quarter 2015 based
upon the following metrics at 50% each:

Physician/Specialist Follow-up within seven calendar days of an inpatient hospital discharge
will be distributed to hospitals that meet or exceed 21.5% based on relative utilization.

Emergency Department Visit at or below 662 per thousand.
For calendar year 2016, the IEHP Direct Primary Care Physicians metrics valued at 50% each
shall be the following:

Post inpatient acute discharge follow-up for MCE members within 7 days at 19.7%, excluding
OB discharges.

Emergency Department visits for all MCE members at or below 662/1000.
Funds for this Risk Sharing Program were included in the Fiscal Year 2016/2017 budget as part of
overall expenses for the MCE Members.
Quality of Care
Access to Care
Human Development
Technology
Not Applicable
Fiscal Impact:
Included in the FY16/17 Budget
Attachments:
None
N/A
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ADMINISTRATION
11.
2016 SECOND QUARTER REVIEW OF THE IEHP COMPLIANCE PROGRAM
Recommended Action:
Review and File
Contact:
Rohit Gupta, Director of Compliance / Compliance Officer
Background:
IEHP is required to implement an effective compliance program that meets the regulatory
requirements set forth in 42 C.F.R. § §422.503(b)(4)(vi) and 423.504(b)(4)(vi). The principles
outlined in the regulatory guidelines are applicable to all IEHP relevant decisions, situations,
communications and developments. The Governing Board is required to exercise reasonable
oversight with respect to the implementation and effectiveness of the program.
This report provides an update on the IEHP Compliance Program and activities during Second
Quarter 2016.
Discussion:
Centers for Medicare and Medicaid Services (CMS) Audits:
Part D Transition Monitoring Program Analysis CY 2016
On May 24, 2016, IEHP submitted 30 selected rejected claims for the 2016 Transition Monitoring
Program (TMPA) for Part D. As previously reported, the purpose of the TMPA is to evaluate
point-of-sale (POS) rejected claims to ensure that Part D sponsors adequately administering
Medicare Part D formulary transition requirements. For each reject claims, IEHP provided an
explanation as to why the rejection was Appropriate or Inappropriate.
All files were successfully submitted on time and accepted. CMS has not provided results and
there is no indication that results will be provided to plans. The Compliance Department considers
this audit as closed and will provide updates to the Governing Board should CMS communicate
updates.
State Program Audits:
2015 Compliance and Medical Survey (DMHC and DHCS)
On July 16, 2015, IEHP received notification from the Department of Health Care Services
(DHCS) of the medical audit and survey that will be conducted in coordination with the
Department of Managed Health Care (DMHC). DHCS conducted a routine medical audit and
DMHC conducted an 1115 Waiver Seniors and Persons with Disabilities (SPD) survey, a Cal
MediConnect survey and a routine Knox-Keene Act Survey. The review period is October 1, 2014
through September 30, 2015. Per the Inter-Agency Agreements between DHCS and DMHC,
medical surveys shall be conducted once every three years and will assess the Plan’s overall
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performance in meeting the health care needs of its members. In addition, the Cal MediConnect
medical survey assesses the Plan’s provision of Medicaid based services.
The joint audit was conducted on-site October 5, 2015 through October 16, 2015. The audit
focused on the outcomes of our activities and processes, including our P&Ps, job aids, and process
workflows.
On February 9, 2016, IEHP held an on-site Exit Conference with DHCS to discuss the preliminary
findings of the DHCS Medical Audit component of the DMHC-DHCS Joint Audit. The Plan was
provided 15 working days to submit relevant information concerning the draft reports and findings.
On April 5, 2016, IEHP received the findings and Corrective Action Plan (CAP) requests for the
DMHC CMC Survey and the DMHC 1115 Waiver SPD Survey. The CAPs were due to DHCS by
May 5, 2016. On April 8, 2016, IEHP received the findings and CAP requests for the DHCS
Medical Audit. The CAPS were due to DHCS by May 6, 2016. On April 26, 2016, IEHP received
the findings and CAP request for the DMHC KKA Survey. The CAPs were due to DMHC on June
9, 2016. The Compliance Department received CAP approval and closing letters from DHCS and
DMHC on July 25, 2016 for the on-site Medical Audit and 1115 Waiver SPD Survey. The
Compliance Department is pending CAP approval and a Closing Letter from DHCS for the CMC
Survey. The Compliance Department will continue to update the Governing Board as updates
become available.
First Five San Bernardino Audit
The Children and Families Commissions for Riverside and San Bernardino Counties promote,
support, and enhance the health and early development of children prenatal through age five (5)
through funding from the California Children and Families Act (Proposition 10).
The First 5 San Bernardino County Program Audit took place on December 17, 2015. The review
period is July 2015 to December 2015. The Compliance department is awaiting the results of the
audit and the closing letter.
The first half of the First 5 San Bernardino County Program Fiscal Audit took place on January 19,
2016. The review period is July 2015 to January 2016. The Compliance Department anticipates the
results of the audit and the closing letter.
The Compliance Department is awaiting confirmation of the audit date for the second half of the
First 5 San Bernardino County Program Fiscal Audit. At this time, The Compliance Department
considers the audit as closed as no additional information has been requested from the Agency.
First Five Riverside Administrative Compliance Audit
The Children and Families Commissions for Riverside and San Bernardino Counties promote,
support, and enhance the health and early development of children prenatal through age five (5)
through funding from the California Children and Families Act (Proposition 10).
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The First 5 Riverside County Fiscal Audit on March 10, 2015 was conducted off-site as a desk
review by the auditor. The Compliance Department is currently awaiting a status update on the
audit from the auditors.
The First 5 Administrative Compliance Audit took place on March 22, 2016. The review period is
October 1, 2015 through December 31, 2015. The Compliance Department is awaiting the results
of the audit and the closing letter. At this time, The Compliance department considers the audit as
closed as no additional information has been requested from the Agency.
Office of Inspector General Medical Loss Ratio
On August 13, 2015, IEHP received notification from the Department of Health and Human
Services, Office of Inspector General of the audit of California’s implementation of medical loss
ratio (MLR) standards for Medicaid managed-care plans. The objective of the audit is to determine
potential Medicaid program savings if the California Department of Health Care Services required
its Medicaid managed-care plans to meet the MLR standards established by the Patient Protection
and Affordable Care Act (ACA).
The DHS OIG MLR audit was conducted on-site September 14, 2015 and September 15, 2015.
The audit is ongoing and we are awaiting the results of the audit. At this time, The Compliance
Department considers the audit as closed as no additional information has been requested from the
Agency.
Medical Loss Ratio (MLR) Audit and Administrative Expense Evaluation
On February 3, 2016, IEHP received notification from the Department of Managed Healthcare
(DMHC) of the medical loss ratio (MLR) audit and administrative expense evaluation that will be
conducted in coordination with the Department of Health Care Services (DHCS). The purpose of
the evaluation is to assess the Plan’s financial condition and the accuracy of previously reported
financial information. The review period is July 1, 2014 through June 30, 2015. IEHP submitted
documents to DMHC on April 4, 2016 and on April 29, 2016.
Since the April 29, 2016 submission, DMHC has issued eight (8) Information Document Requests
(IDR) requesting additional information and clarification of the data submitted. However, The
Compliance Department has not received a Final Report, and the audit remains on-going. The
Compliance Department will continue to provide updates to the Governing Board as updates
become available.
Special Investigation Unit (SIU) Case Report
The Compliance Department experienced a 60% increase in investigations related to privacy
incidents from the Second quarter of 2015 (Q2-2015) to the Second quarter of 2016 (Q2-2016).
The number of cases reported to the State increased from 2 cases in Q2-2015 to 8 cases reported in
Q2-2016. One of the privacy cases reported to the State involved a breach caused by Kaiser
Permanente. The breach occurred as a result of the theft of a mail delivery service vehicle and
affected 2,452 IEHP Members. Kaiser Permanente provided Member notification and media notice
as required.
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The number of fraud cases investigated in Q2-2015 compared to the number of cases for Q2-2016
shows a 31.9% increase. Of those cases, 39 were reported to State/Federal agencies in Q2-2015
compared to 22 cases reported in Q2-2016 (a 43.6% decrease of reported cases). The decrease in
reported fraud cases is a result of additional guidance from the State as to the type of fraud cases
which should be reported.
The increase in overall cases reflects the steady growth of IEHP Membership in Q2-2016. Trends
continue to show that the increase in cases closely follows the increase in IEHP Membership.
Number of Cases
SIU Cases Compared to Membership Growth:
2nd Quarter 2015 / 2nd Quarter 2016
50
1,160,000
40
1,140,000
30
1,120,000
20
1,100,000
10
1,080,000
0
FWA Cases
Privacy Cases
Membership (all LOBs)
April
2015
29
May
2015
28
June
2015
34
April
2016
44
May
2016
30
June
2016
46
1,060,000
27
23
30
39
40
49
1,069,862 1,101,939 1,096,204 1,143,889 1,150,956 1,162,557
Director of Compliance / Compliance Officer Update:
Effective August 8, 2016, Steve Sohn, Managing Counsel, will act as interim Compliance Officer
for IEHP. Rohit Gupta will be leaving IEHP in early August to pursue other opportunities. Rohit
has played a significant role in the expansion and development of the IEHP Compliance
Department, navigating IEHP through the CMS Program Audit in 2014, and further developed the
IEHP Compliance Program to ensure compliance with regulatory, contractual and legislative
requirements. Dr. Bradley Gilbert and the Compliance Department will inform the Governing
Board as updates are available.
Quality of Care
Human Development
Access to Care
Technology
Not Applicable
Fiscal Impact:
None
Attachments:
None
Yes
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FINANCE DEPARTMENT
12.
REVIEW OF THE MONTHLY FINANCIALS
Recommended Action:
Review and File
Contact:
Background:
This report is presented monthly and is a Summary of the Financial Statements.
Discussion:
Summary Income Statement for the Month Ended June 30, 2016.
Highlights:
Enrollment of approximately 1.17 million generated a favorable actual result compared to budget
of $6.6 million for the month ended June 30, 2016:

Enrollment of approximately 1.17 million generated a favorable actual result compared to
budget of $6.6 million for the month ended June 30, 2016:

Increase of $36.9 million due to DHCS settlement of a Notice of Dispute for previous years
SPD rates periods.

Decrease of $36.2 million due to Reserve for CCI rate decrease due to significant delays in
rate adjustments by the State.

Increase of $17.6 million due to CMS Risk Factor reimbursement due to increased HCC
scores with supplemental data submissions.

Total operating expenses just under $1.0 million less than budget.
Quality of Care
Human Development
Access to Care
Technology
Not Applicable
Fiscal Impact:
Attachments:
Summary Income Statement for the Month Ended June 30, 2016 (next page)
N/A
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Inland Empire Health Plan
Summary Income Statement for the Month Ended June 30, 2016
Actual
Budget
Variance $
Operating Revenue
Medi-Cal
Healthy Kids
Medicare
Net Revenue
312,208,202
130,509
60,736,643
373,075,354
334,656,867
120,663
30,898,473
365,676,003
(22,448,665)
9,846
29,838,170
7,399,352
Medical Costs
Total Medi-Cal Costs
Total Healthy Kids Costs
Total Medicare Costs
Total Medical Costs
287,093,875
212,447
47,258,205
334,564,528
303,895,373
150,239
29,233,280
333,278,891
(16,801,498)
62,209
18,024,926
1,285,637
Gross Margin
38,510,827
32,397,112
6,113,715
Operating Expenses
Total Operating Expenses
12,340,868
13,330,263
(989,396)
Operating Surplus (Deficit)
26,169,959
19,066,849
7,103,110
238,350
(203,702)
-
47,132
(264,610)
20,000
191,218
60,909
(20,000)
348,273
500,000
25,364,582
125,000
12,500
18,731,870
223,273
(12,500)
500,000
6,632,711
Other Income (Expense)
Property Management Income (Expense)
Third Party Agreement (TPA)
Behavioral Health Clinic
ED Navigator Project
Hospital Community Fund
Net Surplus (Deficit)
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FINANCE DEPARTMENT
12.
REVIEW OF THE MONTHLY FINANCIAL REPORTS (continued…..)
Recommended Action
Review and File
Contact
Background
Discussion
Summary Income Statement on a Year-To-Date basis for period ended
June 30, 2016.
Highlights:
Enrollment of approximately 13.62 million generated a favorable actual result compared to
budget of $86.7 million for the year ended June 30, 2016:

Increase of $36.9 million due to DHCS settlement of a Notice of Dispute.

Decrease of $49.1 million due to Reserve for CCI rate decrease as noted for June.

Increase of $30.6 million due to Medicare Part-D subsidies.

Increase of $17.6 million due to CMS Risk Factor reimbursement as noted for June.

Increase of $11.7 million due to P4P Pharmacy adjustment.

Total operating expenses for the year just under $18 million less than budget primarily
due to position vacancies.
Fiscal Impact
Attachments
Summary Income Statement for the Twelve Months Ended June 30, 2016 (next page)
Reviewed by Counsel
N/A
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POLICY CALENDAR
Year-To-Date Summary Income Statement for the Twelve Months Ended June 30, 2016.
Actual
Budget
Variance $
Operating Revenue
Medi-Cal
Healthy Kids
Medicare
Net Revenue
3,677,981,074
1,536,951
376,113,188
4,055,631,212
3,863,636,920
1,447,959
362,618,567
4,227,703,446
(185,655,847)
88,991
13,494,621
(172,072,234)
Medical Costs
Total Medi-Cal Costs
Total Healthy Kids Costs
Total Medicare Costs
Total Medical Costs
3,305,958,309
1,503,399
375,525,354
3,682,953,674
3,581,129,239
1,816,446
342,430,030
3,925,375,715
(275,170,929)
(313,048)
33,095,324
(242,422,040)
Gross Margin
372,677,538
302,327,731
70,349,806
Operating Expenses
Total Operating Expenses
138,917,136
156,809,964
(17,892,828)
Operating Surplus (Deficit)
233,760,401
145,517,767
88,242,634
1,396,801
(3,830,187)
-
558,818
(2,971,017)
40,000
837,983
(859,170)
(40,000)
2,053,483
30,000
750,000
228,201,603
1,500,000
150,000
141,495,568
553,483
(120,000)
750,000
86,706,035
Other Income (Expense)
Property Management Income (Expense)
Third Party Agreement (TPA)
Behavioral Health Clinic
ED Navigator Project
Hospital Community Fund
Net Surplus (Deficit)
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FINANCE DEPARTMENT
12.
REVIEW OF THE MONTHLY FINANCIAL REPORTS (continued…..)
Recommended Action
Review and File
Contact
Background
Discussion
Balance Sheet as of June 30, 2016.
Balance Sheet Highlights:

Decrease in cash and increase in DHCS Accounts Receivable are due to delay in
payment.

Decrease in Accrued Medical Expenses of $53.1 million primarily due to the
disbursements of pass-through payments to providers.

Increase in Due to DHCS of $62.4 million primarily due to DHCS revenue rate
adjustments for Medi-Cal Expansion program.
Board approved liquidity analysis is compliant at 84.20%.
Total Assets:
$ 1.5 billion
Total Liabilities:
$ 804.0 million
Net Assets:
$ 700.2 million
Fiscal Impact
FY 15/16 Budget
Attachments
Balance Sheet as of June 30, 2016 (next page)
Reviewed by Counsel
N/A
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Balance Sheet as of June 30, 2016
Jun FY1516
May FY1516
Jun FY1415
ASSETS
CURRENT ASSETS
Cash
Restricted Fund
Funds Held in Trust
DHCS Receivable
Other Receivables
Prepaid Expenses
TOTAL CURRENT ASSETS
871,209,583
300,000
461,208,594
57,332,338
9,395,968
1,399,446,483
1,276,614,836
300,000
37,832,173
50,015,564
6,816,603
1,371,579,176
816,643,157
300,000
408,432
381,048,479
52,045,683
67,342,881
1,317,788,631
FIXED
ASSETS
Building,
Office Furniture &
Equipment
Accumulated Depreciation
NET FIXED ASSETS
DEFERRED
OUTFLOWS OF
RESOURCES
NET OTHER ASSETS
TOTAL ASSETS
130,455,727
(31,571,612)
98,884,115
5,620,234
325,755
1,504,276,587
120,208,860
(30,891,845)
89,317,015
7,250,010
480,796
1,468,626,997
100,425,454
(23,670,031)
76,755,423
7,250,010
480,796
1,402,274,860
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POLICY CALENDAR
LIABILITIES AND NET ASSETS
CURRENT LIABILITIES
MEDICAL
Incurred But Not Reported
(IBNR)
Accrued Medical Expenses
Capitation Payable
Deferred Revenue
271,208,742
158,627,997
652,009
-
269,291,666
211,751,565
476,282
(27,202)
265,120,766
406,540,848
115,241
6,819,161
324,072,064
18,298,273
-
261,653,418
17,739,890
415,225
-
180,273,623
26,659,599
415,225
(68,913)
ADMINISTRATIVE
Accounts Payable
Accrued Operating Expenses
Accrued Salaries and Benefits
Tenant Refundable Deposits
Current Portion of LTD
TOTAL CURRENT LIABILITIES
3,394,248
14,388,385
9,547,340
110,330
511,832
800,811,220
851,245
15,569,363
8,878,063
110,330
366,387
787,076,233
424,792
3,885,887
8,797,371
147,472
1,780,612
900,911,684
LONG TERM LIABILITIES
Lease Payable
Note Payable
Less Current Portion of LTD
TOTAL LONG TERM LIABILITIES
994,628
(511,832)
482,797
1,040,184
(366,387)
673,798
1,531,018
23,572,825
(1,780,612)
23,323,232
DEFERRED INFLOWS OF RESOURCES
2,777,361
6,036,339
6,036,339
804,071,378
793,786,370
930,271,254
228,201,603
124,387,355
400,000
347,216,251
700,205,209
1,504,276,587
202,837,021
122,626,719
400,000
348,976,887
674,840,627
1,468,626,997
317,349,170
112,112,127
400,000
42,142,310
472,003,606
1,402,274,860
OTHER
Due to
Due to
Due to
Due to
DHCS
BOE
CMS
DOI
TOTAL LIABILITIES
Increase (Decrease) in Net Assets
TNE Requirement
Reserve for FQHC
Residual Fund Balance
NET ASSETS
TOTAL
LIABILITIES AND NET
ASSETS
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FINANCE DEPARTMENT
13.
RATIFY AND APPROVE THE FOURTH AMENDMENT TO THE PROFESSIONAL
SERVICES AGREEMENT WITH VARIS, LLC.
Recommended Action:
That the Governing Board of IEHP ratify and approve the Fourth Amendment to the Professional
Services Agreement (PSA) with Varis, LLC for the provision of DRG Overpayment Identification
Services for a total cost not to exceed $1.0 million annually effective July 1, 2016 through June 30,
2018.
Contact:
Background:
IEHP primarily pays inpatient hospital claims for Medicare members using CMS’s reimbursement
method, referred to as “inpatient prospective payment system” or “Medicare DRG payments”.
Additionally, a small amount of Medi-Cal for certain claims types are also contracted at these
rates. This payment method categorizes inpatient cases in to diagnosis-related groups, referred to
as “DRG”.
IEHP uses third party software to price inpatient Medicare claims based on data elements
contained in the hospital claim. IEHP is limited in its ability to detect erroneously billed DRG
claims including coding, processing, calculations, regardless of source. As a result, overpayment of
hospital billing errors can go undetected.
Varis, LLC possesses the required expertise to screen inappropriately billed hospital claims,
correspond with hospitals and review medical records to substantiate accurate DRG billing and
payment. Varis’s reimbursement rate model is 25% commission of successful claims recovered.
Fiscal year to date Varis has recovered $1,660,788 on behalf of IEHP.
The original agreement was approved by the Governing Board in June 2011 under Resolution 11173. In July 2012 under Resolution 12-210, the First Amendment was approved which renewed
the original agreement. In July 2013 under Minute Order 13-225, a Second Amendment was
approved. In July 2015 under Minute Order 15-171, a Third Amendment was approved.
Discussion:
This Fourth Amendment extends the Agreement term for an additional two (2) years beginning
July 1, 2016 through June 30, 2018 for an additional amount of $1.0 million. All other items and
conditions of the Agreement remain in full force and effect. All costs for this Agreement are
covered by recovered payments from providers.
Quality of Care
Human Development
Access to Care
Technology
Not Applicable
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Fiscal Impact:
The total compensation payable under this Amendment shall not exceed $1.0 million per year.
All costs for this Agreement are covered by recovered payments from providers.
Attachments:
Copy of the Fourth Amendment is attached.
Yes
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MEDICAL SERVICES DEPARTMENT - CLINICAL
14.
OVERVIEW OF THE MEDI-CAL AND MEDICARE HEALTHCARE EFFECTIVENESS
DATA AND INFORMATION SET RESULTS FOR HEDIS 2016.
Recommended Action:
Review and File
Contact:
Jennifer N. Sayles, M.D., Chief Medical Officer
Background:
HEDIS® was developed and is maintained by the National Committee for Quality Assurance
(NCQA). HEDIS® is a “standardized set of health plan performance measures” that measures the
quantity, timeliness and in certain cases, outcome of specific medical services delivered to health
plan members. These “measures” allow purchasers, such as employers and state governments, to
evaluate one health plan against another by comparing the HEDIS® performance results of each
health plan.
HEDIS® measures are important because they:

are required for NCQA (50% of accreditation score)

are required by Department of Health Care Services (DHCS) and used in the DHCS default
membership assignment process

are used by CMS as a large part of the Quality Withhold Program for Cal MediConnect

are publically reported

identify areas of improvement for IEHP

assist IEHP in maintaining quality oversight of the care provided to Members

allow IEHP to benchmark its results and put plans into place to improve these results
Discussion:
Medi-Cal Results:
A total of 35 HEDIS® measures were submitted to DHCS and NCQA for Medi-Cal performance in
measurement year 2015. Overall performance reveals the following trends:

20 measures had stable performance to prior year (2014)

7 measures improved over prior year (2014)

8 measures declined from prior year (2014)
In 2014, IEHP grew by over 320,000 Members, in large part, due to the Medi-Cal Expansion
(MCE). This is a population primarily consists of adults with chronic health conditions and poor
access to medical care and preventive health screenings. 2015 was the first year the MCE
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Members were eligible for measurement in HEDIS®. The HEDIS® denominators for adult
measures increased on average by 46% due to the MCE population.
The grid that follows displays IEHP’s HEDIS® Medi-Cal results over the last four years. The
percentile rankings displayed are based on current NCQA standard scoring adjustments:
NCQA Accreditation
Measures
Diabetes Care
HbA1c Testing
HbA1c Adequate Control (<8)
HbA1c Control (≤9)
Eye Exams
Monitoring for Diabetic
Nephropathy
Blood Pressure Control (<140/90)
Pediatric Health
Weight Assessment and Counseling
for Nutrition and Physical Activity
for Children/Adolescents
BMI Screening
Counseling on Nutrition
Counseling on Physical
Activity
Childhood Immunizations Combo 2
Childhood Immunizations Combo
10
Immunizations for Adolescents
Combo 1
HPV for Female Adolescents
Cardiovascular Conditions
Controlling High Blood Pressure
Behavioral Health Conditions
Antidepressant Medication
Management
Effective Acute Phase
Treatment
Effective Continuation
Phase
Follow-Up for Children Prescribed
ADHD Medication
Initiation Phase
Cont. and Maint. Phase
Respiratory Conditions
Medication Management for People
with Asthma – 75% of time
HEDIS HEDIS HEDIS HEDIS Score
2013
2014
2015
2016
Change
85.6%
Percentile
Ranking1
63.8%
59.4%
84.7%
46.9%
60.6%
51.7%
86.1%
50.2%
63.4%
57.4%
86.8%
51.0%
61.3%
55.7%
--

50th
50th
50th
50th
84.5%
82.1%
84.5%
92.6%

90th
71.0%
62.9%
64.4%
59.2%

25th
78.9%
74.5%
79.9%
73.8%
78.0%
76.4%
79.6%
80.1%


75th
90th
47.7%
53.0%
65.1%
65.7%
--
75th
81.3%
78.7%
77.1%
72.7%

25th
28.2%
33.3%
30.1%

25th
70.6%
70.6%
76.2%

50th
28.5%
28.7%
--
75th
72%
62.9%
67.6%
69.3%
58.9%

50th
47.5%
44.6%
48.4%
55.3%

75th
32.4%
30.8%
33.1%
40.5%

75th
21.0%
17.4%
21.8%
19.7%
24.8%
22.8%
26.1%
29.6%


<25th
<25th
29.5%
27.2%
34.9%

50th
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NCQA Accreditation
Measures
HEDIS HEDIS HEDIS HEDIS Score
2013
2014
2015
2016
Change
Percentile
Ranking1
Asthma Medication Ratio
44.4%
49.9%

<25th
Respiratory Conditions (cont.)
Appropriate Treatment for Children
with Upper Respiratory Infection
Avoidance of Antibiotic Treatment
in Adults with Acute Bronchitis
Appropriate Treatment for Children
with Pharyngitis
Use of Spirometry in the
Assessment and Diagnosis of
COPD
Pharmacotherapy Management of
COPD Exacerbation
Systemic Corticosteroids
Bronchodilators
Musculoskeletal Condition
Use of Imaging Studies for Low
Back Pain (avoiding unnecessary
studies)
Adult Health
Adult BMI Assessment
Women’s Health
Breast Cancer Screening
Cervical Cancer Screening
Chlamydia Screening in Women
Timeliness of Prenatal Care
Frequency of Ongoing Prenatal
Care
Postpartum Care
88.6%
89.4%
89.3%
90.7%

50th
22.5%
21.5%
21.8%
23.1%

25th
23.3%
25.9%
35.7%
35.3%
--
<25th
12.4%
10.9%
12.3%
14.2%

<25th
67.4%
86.2%
69.6%
86.1%
66.9%
83.8%


50th
25th
75.1%
75.4%
74%

25th
80.3%
88.2%
90.3%

90th
60.4%
70.5%
57.6%
86.4%
59.3%
68%
57.8%
86.4%
57.6%
54.1%
59.2%
83.7%




25th
25th
50th
25th
56.3%
59.9%

50th
61%
59.7%
--
25th
77.5%
54.4%
72.5%
60.4%
88.4%
59.6%
59.0%
Top performing measures include measures in the 90th percentile:

Adult BMI Assessment

Weight Assessment and Counseling for Nutrition and Physical Activity for
Children/Adolescents – Nutritional Counseling Rate

Monitoring for Diabetic Nephropathy
Low performing measures include measures that fell below the 25th percentile:

Follow-Up for Children Prescribed ADHD Medication (both rates)

Asthma Medication Ratio

Appropriate Treatment for Children with Pharyngitis
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
Use of Spirometry in the Assessment and Diagnosis of COPD
Measures with the greatest improvements (>5% increase from last year):

Monitoring for Diabetic Nephropathy (+8.1%)

Medication Management for People with Asthma – 75% of time (+7.7%)

Antidepressant Medication Management - Continuation Phase Treatment (+7.4%)

Antidepressant Medication Management - Effective Acute Phase Treatment (+6.9%)

Follow-Up for Children Prescribed ADHD Medication - Cont. and Maint. Phase (+6.8%)

Immunizations for Adolescents - Combo 1 (+5.6%)

Asthma Medication Ratio (+5.5%)
Cal MediConnect - Medicare Results:
A total of 26 HEDIS® measures were submitted to CMS and NCQA for Cal MediConnect
performance in measurement year 2015. Overall performance reveals the following trends:

6 measures had stable performance to prior year (DSNP 2014)

8 measures improved over prior year (DSNP 2014)

12 measures declined from prior year (DSNP 2014)
HEDIS® 2016 is the first year for the Cal MediConnect (CMC) population public reports.
Effective January 2015, most DualChoice Special Needs Plan (DSNP) membership rolled into the
Cal MediConnect population. Therefore they are included in the CMC HEDIS® 2016 reporting
population. Since this is the first year of CMC reporting, the DSNP HEDIS® rates are used for
trending. In addition, no Medicare-Medicaid Plan (MMP) population benchmarks are available for
HEDIS® since this is the first year of public reporting for all MMP plans and no SNP benchmarks
are available for comparison. All benchmark comparisons are based on Medicare Advantage
populations.
The table that follows displays IEHP’s Medicare Cal MediConnect for HEDIS® 2016, as well as
D-SNP HEDIS® results for HEDIS® 2013 – 2016. Also displayed are the percentile rankings based
on NCQA Medicare benchmarks:
Cal MediConnect HEDIS®
Performance Summary
NCQA Accreditation
Measures
Comprehensive Diabetes Care
HbA1c Testing
HbA1c Control (≤9)
HbA1c Adequate Control (<8)
Eye Exams
HEDIS
2013*
HEDIS
2014*
HEDIS HEDI Score
2015* S 2016 Change
87.5%
69.1%
58.3%
70.5%
90.3%
70.6%
62.3%
72.2%
89.8%
70.4%
58.3%
63%
38 of 47
90.7%
71.8%
58.3%
65.3%


-
Percentile
Ranking2
<25th
<25th
<25th
25th
August 8, 2016
POLICY CALENDAR
Performance Summary
NCQA Accreditation
Measures
Monitoring for Diabetic
Nephropathy
Blood Pressure Control
(<140/90)
Adult Health
Adult BMI Assessment (ABA)
Breast Cancer Screening
Colorectal Cancer Screening
Care For Older Adults
Advance Directives
Medication Review
Functional Status
Assessment
Care For Older Adults (cont.)
Pain Assessment
Plan All-Cause Readmissions
(lower is better) Ages 18+
Musculoskeletal Condition
Osteoporosis Management in
Women Who Had a Fracture
Rheumatoid Arthritis
Management
Medication Safety
Medication Reconciliation PostDischarge
Controlling High Blood
Pressure
Persistence of Beta-Blocker
After a Heart Attack
Behavioral Health Conditions
Antidepressant Medication
Management
Effective Acute Phase
Tx.
Effective Cont. Phase
Follow-Up After
Hospitalization for Mental
Illness
Within 7 Days
HEDIS
2013*
HEDIS
2014*
HEDIS HEDI Score
2015* S 2016 Change
90.5%
90.3%
90.7%
97%

90th
76.6%
67.6%
69.4%
66.4%

25th
89.6%
63.7%
63.3%
94.7%
69.1%
60.2%
96.5%
66.1%
58.6%
96.8%
65.4%
57.4%
-

50th
<25th
<25th
62%
74.3%
73.2%
96.1%
62.7%
82.2%
54.6%
81.5%

--
n/a
n/a
63.7%
70.8%
67.8%
63%

n/a
63%
72%
70.1%

n/a
14.7%
16.1%
21.1%
78.9%
20.39
%

n/a
13.3%
13.3%
23.6%

25th
71.6%
71.2%
73.3%
73.1%
--
25th
18.2%
12.3%
14.8%
21.2%

n/a
66.4%
63%
72.2%
62.3%

<25th
86.2%
83.8%
83.8%
--
<25th
57.7%
45.3%
60.2%
47.2%
57.3%
44.7%
65.1%
49.2%


25th
25th
26.9%
38%
53.8%
32.7%

50th
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Percentile
Ranking2
August 8, 2016
POLICY CALENDAR
Performance Summary
NCQA Accreditation
Measures
HEDIS
2013*
HEDIS
2014*
HEDIS HEDI Score
2015* S 2016 Change
Within 30 Days
Use of Spirometry in the
Assessment and Diagnosis of
COPD
(cont.)
Pharmacotherapy Management
of COPD Exacerbation
Systemic
Corticosteroids
Bronchodilators
44.5%
56.6%
68.2%
49.8%

25th
9.8%
9.2%
13.2%
15%

<25th
57.6%
62.5%
67.4%
65.4%
86.4%
85%
87.6%
80.1%


Percentile
Ranking2
<25th
<25th
KEY:
1
NCQA's accreditation measures ranking from the NCQA Benchmarks & Thresholds 2016
(Non-accreditation measures percentile ranking subject to change with the release of the NCQA’s 2016
Means, Percentiles and Ratios)
NCQA's Quality Compass - Means, Percentiles and Ratios from 2015 used for all Medicare measures.
Medicare Advantage population
Not available or not applicable
Raw Score percentage increased from prior year
Raw Score percentage decreased from prior year
Score ranking unchanged from prior year
Raw Score &/or percentile ranking increased
Raw Score &/or percentile ranking decreased
DSNP population rate
2
n/a


-Green
Red
*
Measures with the greatest improvements over prior year DSNP:

Osteoporosis Management in Women Who Had a Fracture measure (+10.3%)

Care for Older Adults: Pain Screening (+8.8%)

Antidepressant Medication Management: Effective Acute Treatment Phase (+7.8%)

Medication Reconciliation Post-Discharge measure (+6.4%)

Monitoring for Diabetic Nephropathy (+6.3%)

Antidepressant Medication Management: Effective Cont. Phase (+4.5%)
Measures with largest drops in performance over prior year DSNP:

Follow-up after Mental Health Admission – visit within 7 days rate (-21%)

Follow-up after Mental Health Admission – visit within 30 days rate (-18.4%)

Controlling High Blood Pressure (-9.9%)
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
Care for Older Adults: Advance Care Planning. (-8.1%)
Key Planned Activities for 2016 Improvement:
The following activities are planned for 2016 to improve HEDIS® performance:
1. Provider Incentive Programs:
a) IPA and PCP Global Quality P4P programs for targeted HEDIS® measures. Measures
include: Breast Cancer Screening, Cervical Cancer Screening, Childhood Immunizations,
Adolescent Well- Care Visits, Well-Child Visits in the 3-6 Years of Life, Comprehensive
Diabetes Care, Initial Health Assessments, Encounter Data Volume, and Member
Satisfaction
b) Physician incentive pay-for-performance program (P4P) to increase HEDIS® performance
on a per-event basis. These incentive programs pay physicians for providing the following
services: Well Child Visits, Childhood Immunizations, Cervical Cancer Screenings,
Diabetes Care, Asthma Controller Medication Prescriptions, Perinatal Care, and Annual
Adult Comprehensive Visit for CMC Members.
2. Provider Support Programs
a) Standing Orders Program: designed to facilitate PCP orders and follow-up of routine labs
and screenings for breast cancer screening (mammograms), diabetic lab tests, and
colorectal cancer screening (home test kits).
b) Vision Provider Member Outreach Program: IEHP matches Diabetic Members needing an
eye exam with Vision Providers in their neighborhoods. The office staff at the Vision
Provider offices outreach to Members schedule timely eye exam appointments.
c) Radiology Center Member Outreach Program: IEHP matches women needing a
mammogram with a contracted radiology center that is geographically close to the
Member’s home. The Radiology Center staff conducts outreach calls to schedule timely
mammograms by the year end. Results are sent to the Member’s assigned PCP.
d) OB/GYN Provider Member Outreach Program: IEHP matches women needing a Pap test
with OB/GYN and GYN providers in their neighborhoods. The office staff at the OB/GYN
conducts outreach to Members to schedule timely well-women exams including the Pap
test
e) Nurse Educator and Provider Service Representative Physician Office Education Visits:
Targeted PCP offices are visited and provided detailed physician education on key HEDIS®
measures. Topics include: physician performance data compared to goals, member gaps in
care roster reconciliation, physician incentive programs, and encounter data provider
performance data.
f) IEHP’s secure provider portal tools include: PCP Roster Lists that lists a PCP’s assigned
Members and indicates who is in needs key preventive services tied to HEDIS®. Member
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Gap in Care Alerts are seen on the Member Health History Page and include key
preventive care services that are past due.
3. Member Incentive Programs
Through IEHP’s focus group sessions, Members have reported that the Target, Stater Bros and
Wal-Mart gift cards are the preferred incentives. The Purchasing Department utilized an
informal bid process to determine which company could provide IEHP gift cards at the best
discount. Additionally, Purchasing performed research for governmental agencies that
conducted formal competitive bid awards for this service that allows utilization by other
political (public) entities. Through their research, the County of San Bernardino had issued a
formal solicitation and had selected the National Gift Card Registry (NGCR) as their awarded
vendor. San Bernardino’s established contract includes a “Use by Political Entities” clause
which allows other governmental agencies (i.e. IEHP) to use that agency’s contract.
San Bernardino’s awarded vendor, NGCR offers discounts based on volume buys. Based on
projected volume, the NGCR contract will allow us to get a discount of 3%. Their competitor,
SVM, offers a 1.5% discount based on volume buys
a) Members receive a $15 Target Gift Card when completing a needed preventive care service
by the year’s end.
b) Targeted measures include: Diabetic labs, Diabetic eye exams, Mammograms, Postpartum
Visits, Colorectal Cancer Screening, and Cervical Cancer Screening.
4. Member Support Programs
a) Member-specific Gap in Care Alerts in IEHP’s call center systems indicate what preventive
care services are due.
b) Outbound call campaigns to Members with gaps in care to educate Members on preventive
care services that are due and facilitate setting up PCP appointments.
c) New IEHP Maternal/Fetal (MF) Program. This program serves as a continuum of Care
Management including early Prenatal, High Risk and Postpartum OB Care. Key focus
areas that support HEDIS® include: Member Postpartum Visit scheduling and follow up,
and Member Incentive program awareness.
d) Targeted Member texting campaign for reminder to complete preventive care services.
5. Data Improvement Programs
a) Establish additional Lab Results Data Feed connections. Many HEDIS® measures rely on
complete lab data. Establishing more data connections to laboratory results, especially with
hospitals can improve HEDIS® results.
b) Establish supplemental data feeds with IPAs where gaps in data are identified and are
available in alternative data formats.
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c) Establish data feed with Planned Parenthood for well-woman tests including Pap and
Chlamydia testing.
Quality of Care
Human Development
Access to Care
Technology
Not Applicable
Fiscal Impact:
None
Attachments:
HEDIS 2016 Performance Update Presentation
N/A
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15.
REVIEW OF THE 2015 PROVIDER NETWORK STATUS STUDY
Recommended Action:
Review and File
Contact:
Background:
On an annual basis, IEHP reviews its overall network performance to ensure IEHP is compliant
with the Department of Health Care Services (DHCS), Department of Managed Health Care
(DMHC), and Centers for Medicare and Medicaid Services (CMS) regulatory standards for time,
distance, and Provider-to-Member ratios. Regulatory agencies establish these standards to ensure
sufficient network capacity to serve our growing Member population.
IEHP determines the specialties and facility types to include using the 2015 CMS Health Services
Delivery (HSD) reporting standards, DHCS network adequacy standards and IEHP Policy and
Procedure Manual Occupational and Speech Therapy are additional selected specialties added to
the study, however these are not identified as core specialties. For specialties and facility types
without industry standards for either time and distance or Provider-to-Member ratios, IEHP
determines standards using comparable specialties.
To be compliant with time and distance standards, at least 90% of the Members must have access
to at least one Provider for a given specialty, within the minimum time (minutes) or distance
(miles).
Discussion:
As part of its analysis, IEHP determines whether or not there are any deficiencies in the overall
Provider Network. IEHP is compliant with 90% of IEHP Medi-Cal and Medicare Members are
within the minimum time and distance standards for each specialty with exception of:

Long Term Care (LTC) not meeting (Medicare) and are close to not meeting (Medi-Cal) the
time and distance standards.

CBAS Facilities are close to not meeting the time and distance standards.
There are two facility types (Long-Term Care (LTC) and CBAS Facilities) not meeting or are
close to not meeting the time and distance standards. Since there are no regulatory standards for
these facility types, IEHP will re-examine the time and distance standards for future studies. IEHP
will also consider limiting the Membership population used for these metrics, such as limiting to
Members with a Seniors and Persons with Disabilities (SPD) aid code or adult Membership, who
would be more likely to utilize these facilities, instead of the entire Member population.
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IEHP will continue to monitor the standard for each specialty and facility type. Continuous
contracting efforts are being made to expand the LTC and CBAS Network in order to increase
access to specialty care and ensure coverage across the service area.
To date, the IEHP Network Expansion Fund Program has added 117 new Providers to practice in
the Inland Empire. IEHP will continue to accept applications to accommodate for the growing
population and to help improve Member access to care.
Quality of Care
Human Development
Access to Care
Technology
Not Applicable
Fiscal Impact:
None
Attachments:
Copy of the IEHP 2015 Provider Network Status Study Results
N/A
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16.
MAIN OBJECTIVES FOR THE NEXT 90 DAYS AND SUMMARY COMMENTS
(BRADLEY P. GILBERT, M.D.)
1.
Main Objectives for the Next 90 Days
a. Manage recent significant growth in Membership
b. Implement initiatives with Strategic Priorities areas
c. Hire new Chief Financial Officer and Director of Compliance
2.
Summary Comments
a. We have reached the 1.2 million Membership level; this suggests Inland Empire
economy is still challenged and makes it critical for IEHP to continue subsidizing
physician recruitment efforts with our provider entities.
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VIII. COMMENTS FROM THE PUBLIC ON MATTERS NOT ON THE AGENDA
IX. RECESS INTO THE IEHP HEALTH ACCESS MEETING
X.
RECONVENE FROM THE IEHP HEALTH ACCESS MEETING BACK INTO THE IEHP
MEETING
XI. ADJOURNMENT
1. The next meeting of the IEHP Governing Board will be held on September 12, 2016 at the
Riverside County Administrative Center.
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REGULAR MEETING OF THE GOVERNING BOARD OF THE

Transcription

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