5. Improving Member Experience
5.5. Action Series: Provider Communication Training
For the Provider-Patient Communication Action Series, a master trainer from the Institute for Healthcare Communication gave two day-long training sessions for providers on how to improve communication and patient centeredness while using an Electronic Health Record. CME/CEU credits were offered to fifty-four providers who attended one of the trainings. 100% of participants rated the training as “effective” and were likely to
“recommend the training to colleagues.” Following the training, seven clinics implemented sustainability activities to reinforce the skills presented in the training, including peer coaching, discussing communication techniques in staff meetings, and implementing agenda setting forms to make visits more patient centered.
37 5.6. Providing Excellent Telephone Services
Our members find it easiest to reach us by telephone. Therefore, we are committed to ensuring that we provide excellent customer service over the phone. We monitor our performance in several ways and continue to work on improving our processes.
One way we do this is by using real time performance to track and monitor calls. Real time performance allows up-to-the-moment tracking and is displayed in the call center area so that Customer Service Representatives are aware of their performance as well as current call traffic. The electronic wallboard tracks the following metrics: 1) service level, 2) total call volume handled, 3) abandonment rate, 4) abandoned calls, 5) calls waiting in different language queues, and 6) number of agents available at each language queue.
SFHP’s Customer Service team members speak our four threshold languages: English, Chinese (Cantonese and Mandarin), Spanish, and Vietnamese, as well as Russian and Burmese. In 2012, we received 82,643 incoming calls through our telephone automated distribution system. We met or exceeded our performance standards on the following metrics:
Our service level, which measures efficiency and speed of service, was 95.3%, exceeding our goal of 90% by 5.3%. Our service level improved by 2% compared to last year.
The industry benchmark for call abandonment is 5%, whereas SFHP’s average
abandonment rate in 2012 was 0.94%; this rate improved by 33% compared to 2011.
5.7. Member Satisfaction with Customer Service
SFHP’s Customer Service Department conducted its eleventh annual member
satisfaction survey in the last quarter of 2012. The purpose of this survey is to assess the level of satisfaction with the services provided by the Customer Service Department and to improve our services based on feedback from members.
Methodology
The survey was conducted in English, Spanish, and Chinese. Members were asked to score SFHP performance in the following areas:
My call to SFHP Customer Service Call Center was answered quickly.
I received polite service from the Call Center Representative.
I received the information that I needed.
7,839 survey cards were sent to members who contacted Customer Service by phone during the months of October through December 2012. The response rate for the survey cards was 12%, with Chinese-speaking members having the highest response rate.
Survey Results
An average of 95.8% of our members reported overall satisfaction with the services provided by Customer Service team. 96.14% scored SFHP high for quick service, 97.09% for
38 polite service, and 94.3% for receiving needed information. The overall results were
consistent with those achieved in previous years. SFHP received excellent, useful results from this survey through the years. These positive responses indicate that they were highly satisfied with the services they received from the SFHP Customer Service team in 2012.
A new managed care platform called QNXT was implemented in 2012. Now, Customer Service staff can assist members with basic authorization and claims inquiries without transferring members to other departments. The information provided to members is more accurate and specific to the member. Additionally, Customer Service staff track calls and documents member activities more effectively. With this greater efficiency, Customer Service staff have the ability to resolve member issues quicker and easier.
Besides resolving member inquiries, Customer Service staff are also proactive to resolve issues before they occur. For example, they monitored PCP assignments for new SPD members to ensure members are assigned to their preferred doctors. Additionally, they help to monitor members’ eligibility and research potential problems.
5.8. Monitoring Member Grievances
In order to improve service to our members, SFHP monitors grievances each quarter to identify trends in member-identified challenges with the health system. To identify patterns and changes in our grievances, we report grievance rates by line of business, medical group, and grievance category.
96.1% 97.1% 94.3%
Quick Service Polite Service Information
Satisfaction Percentage
2012 Member Satisfaction Results
with Telephone Services
39 Line of Business
Looking at the comparison of SFHP annual rates below, Medi-Cal has the highest rate of grievances. The rate increased in 2012 from 2010, which is attributed largely to the
transition of SPD Medi-Cal recipients into managed care. Both Healthy Workers and Healthy Families saw a slight increase in their grievance rates, however there were no trending patterns identified. Healthy Kids rate saw a dramatic decrease of 75% compared to last year.
Grievance Rates by Line of Business, per 1,000 members
Line of Business 2010 Grievance Rates 2011 Grievance Rates 2012 Grievance Rates
Medi-Cal 0.16 0.23 0.38
Healthy Workers 0.21 0.19 0.30
Healthy Families 0.06 0.05 0.08
Healthy Kids 0.16 0.23 0.06
Medical Group
Little variation exists by medical group, with the exception of the Community Health Network. The Community Health Network is not actually a medical group, but rather a group of public health clinics and Federally Qualified Health Centers.
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 2012 0.14 0.23 0.36 0.37 0.34 0.48 0.46 0.23 0.47 0.30 0.33 0.30 2011 0.16 0.23 0.10 0.14 0.16 0.17 0.21 0.13 0.23 0.24 0.31 0.32 2010 0.26 0.09 0.14 0.22 0.19 0.12 0.13 0.18 0.10 0.13 0.15 0.16 0.00
0.10 0.20 0.30 0.40 0.50 0.60 0.70 0.80 0.90
Grievance Rate (per 1000 members)
Member Grievance Rates, 2010 - 2012
40 Grievance Rates by Medical Group, per 1,000 members
Grievance Category
The top categories across all lines of business were Denials/Refusals, Quality of Service, Access, and Quality of Medical Care. Denials/Refusals remained the top category and increased to 189 grievances in comparison to 64 grievances in 2011. Enrollment saw the biggest drop in 2012, as there was only one grievance in comparison to 13 grievances in 2011.
Grievances by Category
SFHP Grievance Response Time
In addition to looking for trends in our grievances, we also monitor the way we handle grievances for timeliness and regulatory compliance. Our goal is to provide excellent service and at a minimum, meet DMHC standards for responding to and resolving grievances (i.e.
Medical Groups
Community Health Network 0.16 0.25 0.17
UC San Francisco 0.40 0.48 0.09
Kaiser Permanente 1.93 0.06 0.03
North East Medical Services 0.08 0.05 0.03
Hill Physicians 0.21 0.35 0.02
Chinese Community Health Care 0.12 0.09 0.02
Brown & Toland Physicians N/A 0.47 0.01
41 resolution within 30 calendar days). Below is an overview of the grievances received in 2012 and key indicators showing compliance with regulatory standards:
333 member grievances were processed by SFHP and Kaiser Permanente (the one medical group in our network that is delegated for grievance processing and resolution).
304 of these grievances were non-delegated and therefore handled directly by SFHP.
Of these, only 4 grievances were not resolved within the 30-day period as mandated by DMHC.
Two grievances handled by SFHP had a Cultural and Linguistic Component.
42
6. Provider Relations
6.1. Provider Network Access Monitoring
SFHP closely monitors the adequacy of our provider network to ensure that our members have access to the care they need in a timely manner. We measure network access in a variety of ways to assess language capacity, wait times, and availability of specialists and PCPs. SFHP joined the ICE (Industry Collaboration Effort) Workgroup to develop a standard methodology and survey tool for monitoring appointment availability.
Access to Primary Care Providers
Our stable network of PCPs is more than adequate to care for our approximately 79,000 members. Regulatory requirements set forth in our Knox-Keene license guide our
accessibility standards. State regulations require that a primary care physician panel should contain no more than 2,000 patients. While our ratio of members to PCPs falls well within those standards, we cannot accurately measure true PCP panel size because our PCPs see patients from several different payors as well as care for the uninsured. Below is a table that shows a snapshot of our PCP and member counts:
Medical
BTP 1,370 38 1,368 51
CCHCA 4,396 32 4,822 48
UCSF 3,458 42 2,980 60
NEMS 8,324 45 8,567 56
HILL 3,022 30 1,862 26
CHN 10,641 164 25,217 206
Note: PCPs caring for children include physician and mid-level PCPs designated as
adolescent medicine, family medicine, family practice, general practice, pediatric adolescent medicine, or pediatrics. PCPs caring for adults include physician and mid-level PCPs
designated as family medicine, family practice, general practice, geriatric medicine, internal medicine, or Ob/Gyn.
Access to Specialists
We regularly monitor the number of physicians in our network in specialty areas that our members access the most. UCSF provides the bulk of specialty care even for members assigned to other medical groups. The table below shows that each of our medical groups had at least one specialist in every key specialty in 2012:
43
Specialty BTP CCHCA CHN NEMS HILL UCSF Total
Cardiology 24 11 23 4 7 37 106
Endocrinology 10 1 9 1 4 19 44
Gastroenterology 19 11 12 6 2 18 68
Ob/Gyn 22 14 28 12 9 61 146
Ophthalmology 5 11 30 8 8 66 128
Pulmonary Disease 1 1 14 2 1 19 38
Radiology 7 4 13 14 6 44 88
Total 88 53 129 47 37 264 618
PCP Language Concordance
SFHP works to ensure that our members have access to either a primary care provider who speaks their language or have access to professional interpreter services. We monitor the number of PCPs who speak Chinese, Spanish, Vietnamese and Russian because they are the most common non-English languages spoken by our members. Members are
encouraged to choose a PCP when they enroll, but if they do not choose a PCP, our systems help optimize the number of members who are assigned to a PCP who speaks their
language. The table below shows the number of PCPs who speak one of the predominant SFHP threshold languages at the end of 2012:
Medical Group
Chinese-Speaking PCPs
Spanish- speaking PCPs
Vietnamese- speaking PCPs
Russian- speaking PCPs
BTP 18 23 4 4
CCHCA 59 5 4 0
CHN 25 135 9 1
NEMS 62 16 6 2
HILL 6 22 1 3
UCSF 6 27 2 1
Total 176 228 26 11
6.2. Clinical Quality Monitoring
San Francisco Health Plan (SFHP) has a Memorandum of Understanding with Anthem Blue Cross of California to review all jointly contracted primary care providers and sites, in order to comply with California Department of Health Care Services (DHCS) policies. SFHP delegates and oversees the full scope reviews (Facility Site and Medical Record), Facility Site Review-Attachment C (FSR-C), and Interim Monitoring for its medical groups.
44 Full Scope Reviews include on-site inspection and interviews with site personnel.
Reviewers use reasonable evidence available during the review to determine if practices and systems on site meet survey criteria. Compliance levels include:
Exempted Pass: 90% or above without deficiencies in Critical Elements, Pharmaceutical, or Infection Control
Conditional Pass: An overall score of: 80-89%; or a score above 90% but with deficiencies in either Critical Elements, Pharmaceutical or Infection Control Not Pass: below 80%
Compliance rates are based on 150 total possible points. The number of points is adjusted if there are items that do not apply to a specific provider. The medical record review portion evaluates 32 criteria in the areas of chart format, documentation, continuity and coordination of care, and preventive care. A corrective action plan is required for a total score less than 90%, or if there are any deficiencies in items under Critical Elements,
Pharmaceutical Services, or Infection Control regardless of score.
Interim Monitoring is an FSR that occurs between full scope reviews and is conducted approximately 18 months following the last Facility Site Review. Twelve were completed in 2012. For a new primary care provider to open a SFHP panel, they must pass a FSR. PCPs that do not pass the 18-month Interim Monitoring are closed to seeing new members and must complete an extensive Corrective Action Plan with a nurse reviewer.
Facility Site Review and Medical Record Review Summary
There were 80 Facility Site Reviews and 59 Medical Record Reviews completed by San Francisco Health Plan and its delegated medical groups in calendar year 2012. 28 initial reviews were conducted in clinics that had not been in our network previously.
95% of the Facility Site Reviews (FSR) scored over 90%; 3 scored “Not pass” and were reported to providers’ participating medical groups
61% of the medical record reviews (MRR) scored 90% or better; 4 scored “Not pass”
and were reported to the providers participating medical groups
With the exception of a provider that terminated with San Francisco Health Plan, the three primary care providers that scored below 80% were reviewed at SFHP’s February 14, 2013 Physician Advisory/Peer Review Committee meeting.
A new PCP with Chinese Community Health Care Association and Brown and Toland (FSR score of 73% and MRR score of 63%) underwent extensive nurse intervention and earned approval for the Corrective Action Plan on 5/25/2012.
A PCP with Chinese Community Health Care Association who scored 75% on his Medical Record Review was closed to new members during his CAP and review process. The Corrective Action Plan (CAP) was approved on 12/13/12.
A PCP with Hill Physicians Medical Group received a 79% on his MRR and 98% on his FSR. SFHP closed the PCP to new members during the CAP and review process. The nurse reviewer assisted with CAP implementation and the CAP was approved on 10/11/12.
45 Summary of Facility Site Reviews
Summary of Medical Record Reviews Medical Group # Sites Reviewed
BTP 1
Facility Site Review Attachment C
Per DHCS policy, plans are required to use FSR Attachment C to assess the physical accessibility of primary care provider sites, including specialist and ancillary service providers that serve a high volume of seniors and persons with disabilities (SPDs).
As of December 31, 2012, San Francisco Health Plan (SFHP) completed a total of 161 FSR-Cs for primary care sites. SFHP placed highest priority on reviewing primary care
Medical
46 providers to make access information available to members, especially the population of Seniors and Persons with Disabilities (SPD) mandated into managed care plans.
The results of these surveys have been shared in the following ways:
Posted on SFHP website where they are searchable by members, providers, and staff Included in the SFHP Medi-Cal Provider Directory
Shared with SFHP Member Advisory and Quality Improvement Committees Summary of FSR-Cs
Changes with regards to the Facility Site Reviews occurred in 2012. DHCS released new facility site and medical record review tools and guidelines in January 2012. In response to the new tools and guidance, SFHP executed the following activities:
Distributed electronic FSR and MRR tools that calculate scores
Created a new 2012 FSR Work Plan on an external SharePoint site in order for
medical groups and Anthem Blue Cross to access site review scores, dates/deadlines, and site IDs
Created personalized work flow procedures for each medical group on how to use the external SharePoint site, including on-site education on effective uses of the site Uploaded 2012 site reviews to external SharePoint site, available to medical groups and Anthem Blue Cross
6.3. Medical Group Oversight Audits Medical Group Delegation Structure
SFHP contracts with medical groups to provide health care services to plan members.
SFHP delegates certain functions and activities to these medical groups. SFHP further delineates the functions delegated to the medical groups in an annual Responsibilities and Reporting Requirement (R3) Agreement. SFHP monitors medical groups’ compliance with their Delegation Agreement through an annual oversight audit. In addition, medical groups submit weekly, monthly, quarterly, biannual, and annual reports, which are reviewed by SFHP staff. SFHP staff meet with the medical group in a Joint Administrative Meeting (JAM) to discuss any issues as needed. These meetings generally occur twice a year.
It is SFHP’s policy to conduct a full-scope review and audits of a medical group that is planning to enter into a delegation agreement. The medical group must implement
corrective actions if any deficiencies are determined. Under SFHP’s Delegation Agreement, medical groups have the authority to carry out a specific function on SFHP’s behalf. SFHP
47 retains the responsibility for ensuring that the delegated functions are performed according to Federal and State standards.
SFHP contracts with the following medical groups: Brown and Toland Physicians (BTP), Chinese Community Health Care Association (CCHCA), Hill Physicians Medical Group (HPMG), North East Medical Services (NEMS), and Kaiser Foundation Health Plan – San Francisco. All functions are fully delegated, except for grievances and member rights. As a Knox-Keene Licenses Health Plan, Kaiser is delegated grievances and member rights.
Medical Groups and Delegated Functions
In addition to medical groups, SFHP directly contracts with community clinics and public/private hospitals to provide primary care and hospitalization services to plan
members. These entities include San Francisco Department of Public Health, San Francisco General Hospital, and the University of California San Francisco Medical Center. SFHP delegates credentialing functions to these organizations, while SFHP performs other
functions such as utilization management, quality improvement, and claims. SFHP monitors clinic and hospital compliance with credentialing standards through an annual oversight audit.
Medical Group Audits Dates
The 2012 audit season took place between July and December. SFHP staff worked with the delegated network to review policies and procedures. Functions reviewed include Quality Improvement (QI), Utilization Management (UM), Case Management (CM), and Health Education, Cultural and Linguistic Services (HECLS). By conducting file reviews and staff interviews, SFHP identified areas that needed a corrective action plan that included specific recommendations for improvement. Below is a chart with the date and function of audits in 2012.
48 Summary of Oversight Audit Findings
The results from the annual audits are shared with SFHP’s Quality Improvement Committee. All audit deficiencies are followed up throughout the year until resolved, and are reviewed at the subsequent oversight audit. Below are general findings from the 2012 oversight audits; details of audit results by delegated entity are provided in Attachment 1.
Timely Access Regulations: Medical Groups informed their practitioners and staff about the regulations. During 2012, SFHP developed a Timely Access Regulation Training Manual for providers, which served as a review guide and a training tool for new providers and medical group staff. All medical groups were found compliant with this requirement.
Health Education and Cultural and Linguistic Services (HECLS): During the course of the audit we found some deficiencies in this area, including: absence of a training sign-in sheet (for which SFHP issued a CAP), and the need for health education materials to be written at a 6th grade reading level (resolved by adding a link to SFHP’s health education materials to the group’s website). The remaining groups were found compliant with this function.
49 Grievances (delegated only to Kaiser Permanente): Only one deficiency was found: in one out of 20 files reviewed, the Acknowledgement Letter was not sent in a timely manner.
A CAP was not issued since this occurred in September of 2011 and no other files presented this deficiency.
Dwell/Wait Time Studies: Two of SFHP’s newest medical groups are developing primary care provider dwell studies (the total amount of time a patient waits from their scheduled appointment time to the moment the provider enters the exam room to start the visit).
SFHP is helping the medical groups by sharing tools, reports, and processes. The remaining medical groups were found compliant with this requirement.
Credentialing: SFHP reviewed newly credentialed and re-credentialed practitioners files for all the delegates. Deficiencies were found at one medical group and one medical center audit, where new primary care practitioners did not sign the Summary of Key Information Attestation within 10 business days of initial credentialing approval date. A CAP was issued and submitted to DHCS for consideration and approval. The remaining medical groups were found compliant with requirements for this function.
Utilization Management: Minor deficiencies regarding Timeliness of UM Decision were found in two of the medical groups, where decisions were made past the five-day required timeframe. One medical group was deficient on the Provider Notification timeframe required for communicating member complaints (24-hours). In both cases, CAPs were
Utilization Management: Minor deficiencies regarding Timeliness of UM Decision were found in two of the medical groups, where decisions were made past the five-day required timeframe. One medical group was deficient on the Provider Notification timeframe required for communicating member complaints (24-hours). In both cases, CAPs were