PHYSICIANS ADVISORY GROUP AGENDA
DATE: Thursday, June 5, 2014 TIME: 12:00 PM - 1:30 PM
PLACE: Video Conference at Alliance Offices (Scotts Valley, Merced, Salinas)
Members: John Jameson, MD, Jennifer Hastings, MD, James Rabago, MD, Robert Streeter, MD, Brian Moore, MD, Cristina Mercado, MD, Amy McEntee, MD, Nathan Atkinson, MD, John Silva, MD, Kevin Coldwater, MD, Maximiliano Cuevas, MD, Mike Molesky Alliance Staff: Dale Bishop, MD, Julio Porro, MD, Kathy Neal, RN, Ann Kern, Jennifer Mockus, RN,
Michelle Stott, RN, Mary Brusuelas, RN, Karen Black, Cathy Elliott, RN, Lilia Chagolla
A. Call to Order and Welcome 5 min Dr. Bishop 12:00
B. Introductions / Roll Call 5 min Dr. Bishop 12:05
C. Oral Communications
Members of the public may address the PAG Committee on items not listed on today’s Agenda, which are within the jurisdiction of the PAG Committee. Presentations must not exceed five minutes in length and individuals may speak only once during Oral Communications.
If any member of the public wishes to address the PAG Committee on any item that is listed on today’s agenda, they may do so when that item is called.
5 min Public 12:10
D. Consent Agenda
Minutes for PAG Meeting, March 6, 2014 (attached)
Follow-up items:
- Beacon - SBIRT
- CBI Improvement 2015
5 min 10 min
Dr. Bishop Dr. Bishop
12:15 12:20
E. New Business – Updates
New Members
Medicaid Expansion & PCP Access
Pain Management
10 min 20 min 20 min
Dr. Bishop Bishop/Ann K.
Dr. Bishop
12:30 12:40 1:00
March 6, 2014
Physicians Advisory Group (PAG) Meeting Minutes
Thursday, March 6, 2014 12:00-1:30 PM
Members in Attendance: Nathan Atkinson, MD, Jennifer Hastings, MD, Kevin Coldwater, MD, Larry deGhetaldi, MD, Mike Molesky,
Members Absent: Cristina Mercado, MD, John Jameson, MD, Rob Streeter, MD, Amy McEntee, MD, Brian Moore, MD, James Rabago, MD, John Silva, MD
Alliance Staff: Dale Bishop, MD, Julio Porro, MD, Cathy Elliott, RN, Kathy Neal, RN, Liza Warren, RN, Michelle Stott, RN, Lilia Chagolla, Jennifer Mockus, RN, Ann Kern, Christine Gerbo, RN, Karen Black, Mary Brusuelas, RN
Community Attendees: Deborah Albert
ITEM DISCUSSION ACTION
A. Call to Order, Roll Call, Oral Communications B. Consent Agenda
PAG Minutes
Decision: Minutes approved.
Follow up items: Avoidance of Antibiotics - the Alliance fell below MPL in Merced county in 2012 (17.8%), improvement opportunities were identified and targeted education conducted. Results from 2013 HEDIS indicate that results are above MPL in Merced (18.5%) and almost 28% in Monterey and Santa Cruz county. Efforts made by staff have helped a great deal and education efforts are continuing. Outreach continues to members, providers, ED and hospitalists. Dr. deGhetaldi noted the importance of keeping the Avoidance of Antibiotics measure consistent across all health plans and with IHA measures.
There has been a positive response to PCMH and Coleman. The Board approved additional clinics and learning sessions are taking place at the Steinbeck Center. Dr.
Coldwater noted that Sauld completed Coleman with a positive response and follow- up from Coleman was good. Some changes made included huddles but reminder training would be beneficial.
ITEM DISCUSSION ACTION C. New Business:
New Medi-Cal Mental Health Benefits Update
Discussion: Dr. Bishop presented on Behavioral Health Benefits.
Criteria for the Alliance benefits are mild to moderate individuals and defined by DSM.
County to treat moderate to severe individuals. The Alliance chose Beacon Health Strategies to administer the mental health benefit. Most plans in California that contract use Beacon as they have best practices and a good track record. Services include:
• Individual and group mental health treatment (psychotherapy)
• Psychological testing to evaluate a mental health condition
• Outpatient services to monitor drug therapy
• Psychiatric consultation
Other areas covered by Beacon are network, claims, screening and referral, utilization management, quality management and improvement, county integration, care
coordination and PCP support. Beacon care management will be brought onsite to the Alliance in the future.
PCP responsibilities include directing care for members with mild to moderate mental health challenges, and referral to mental health providers when appropriate. Alcohol use screening is now a part of the standard preventative and wellness services. Dr. Bishop shared hand-outs for the Behavioral Health Screening Tool and Referrals and the Behavioral Health Screening form which is currently in draft form. The Alliance is
receiving input from the counties regarding the forms and they are still being developed.
The Alliance is working with the county and Beacon for warm handoffs of members to ensure they get the quality care. Dr. Bishop shared the workflow regarding how to access services beginning with FQHC, PCP or RHC either referring the member to Beacon or by internally conducting a screening. Beacon will assist in facilitating communication among PCPs and Outpatient Behavioral Health Providers. Kathy Neal reported 63 providers have been contracted in all 3 counties and 48 contracts are pending and the network is growing. It was noted 8% of members incur 75% of cost and
ITEM DISCUSSION ACTION Misuse (SBIRT) screening, brief behavioral counseling interventions and referral to treatment. Screening
is for risky and hazardous drinking which includes:
Men 18-64 >7 drinks/week > 3 in one day
Women and Men >65 > 7 drinks/week > 3 in one day.
Currently there is one screen per year but the Alliance is considering more than one screen. Lilia Chagolla noted that the State is considering whether to allow for more than one screening per year but she has not received any further information at this time.
DHCS recommends beginning with SHA (USPSTF Question) or other approved
screening tool. Intervention techniques include: evaluate stage of readiness for change, motivational interviewing, and cognitive behavioral techniques. If members’ do not respond to treatment, they can be referred to the county alcohol and drug program.
Treatment must be rendered by a licensed provider:
• At least 4 hours of SBIRT training is encouraged but not required unless supervising others.
Staff (health educator, certified addiction counselor, health coach, medical assistant, non-licensed behavioral assistant) under supervision of licensed physician, PA, NP or Psychologist may render SBIRT provided the following:
• One licensed supervisor per practice must complete 4 hours of SBIRT training by the first 12 months after starting.
• Staff is supervised by licensed provider.
• Complete a minimum of 60 documented hours of professional experience within their field.
• Complete a minimum of 30 additional face to face client contacts in their field in addition to 60 hours above.
• Complete a minimum of 4 hours of SBIRT or SBIRT related training.
• Staff and supervisor attest they have completed the training within 12 months.
Dr. Coldwater and Dr. Hastings had questions regarding billing for SBIRT benefit and requested further clarification. DHCS statewide SBIRT informational training is available to providers. Dr. Bishop asked for input from group regarding training. Group stated they felt online training would be beneficial and further information regarding billing would be appreciated. Ann Kern stated that work is being done on the codes and information will be shared with providers.
ITEM DISCUSSION ACTION
Care Based Incentive Recommendations
Discussion: Dr. Bishop discussed analysis of recommendations for Care Based Incentives. The goal of the program is to improve quality, efficiency, access and incentives for care management. Potential unintended consequences include; large payment for “business as usual,” potential to have overall performance static or decrease, bottom half of performers are not incentivized to improve. Analysis was conducted internally and with providers. Several measures were considered with the possibility of adding an obstetric CBI. Another suggestion is to create an improvement category with use of objective criteria (benchmarks) for improvement. Option to provide incentive for improvement of quality of care measure by 5% or more. The quality of care measures include well child and adolescent visits, BMI, Cervical Screening, Diabetes and Asthma. Other incentives include: Avoidable ED, Ambulatory Care Sensitive Admission and Readmissions.
Dr. Bishop shared 2013 data from the State as well as the Alliance on the well child visits, diabetes care and other HEIDS parameters.
Dr. deGhetaldi inquired whether specific populations were being considered in the measures such as disabled women in regard to cervical cancer screening. Dr. Hastings noted challenges exist with the developmentally disabled and obtaining cervical
screens; she is interested in alternatives for screening for this population. It was noted current issues exist around the HPV vaccine and the group agreed there is an
opportunity for public education in this area.
The Alliance is working to become NCQA accredited by 2016. To become accredited, the Alliance will have to consider additional measures beyond DHCS recommendations.
Dr. Bishop shared last year’s data, in new NCQA Medicaid measures where the Alliance was below MPL. Dr. Bishop discussed the possibility of adding testing for children with pharyngitis and spirometer testing in COPD to CBI measures.
Meeting Adjourned: 1:30 PM
Behavioral Health Benefits Update
Physicians Advisory Group
June 5, 2014
Provider Network Development
Mental Health Utilization 1
Legend
1
01/01/2014 – 05/02/2014 time period
2
Screenings done by Beacon; does not include County, FQHC, or other screenings
* Monterey County clinic utilization pending
Screening, Brief Intervention, and Referral to treatment for Alcohol Misuse (SBIRT)
Physicians Advisory Group
June 5, 2014
SBIRT Services
• Screening
• Brief behavioral counseling Interventions
• Referral to Treatment (SBIRT)
Alcohol Misuse Screening by PCP
• USPSTF Grade B Recommendation as of May 2013 for alcohol misuse
• Risky and hazardous drinking:
• 21% of adults engage in risky or hazardous drinking
• Hazardous drinking
• Men age 18‐64, >14 drinks/week, >4 in one day
• Women and men> 65, >7 drinks/week, > 3 in one day
• Prevalence of current alcohol dependence ‐ 4%
Screening Parameters
• Members age 18 and over
• 1 screen/client per year
• Use validated screening tool
Care Based Incentives Update for 2015
Physicians Advisory Group
June 5, 2014
Improvement Incentive for 2015
• Use objective criteria (benchmarks) not relative scoring for improvement
― Quality of Care Measures (NCQA‐5% improvement is significant)
― Apply 5% improvement criteria to Care Coordination measures
‾ Rate of readmission (reduce)
‾ Preventable ED (reduce)
‾ Ambulatory Care Sensitive Admissions (reduce)
― Give improvement credit for achievement of High
Performance Level (> 90 th percentile nationwide
standards for Quality of Care) or achievement of
plan goals for Care Coordination
Improvement Incentive Scoring Process
• Use one CBI pool
• Total potential 10 points for improvement measure
• Quality of Care Measures as applicable to PCP category
⁻ Well Child Visit 3‐5
⁻ Well Adolescent Visit
⁻ Asthma Medication Ratio
⁻ Cervical Cancer Screening
⁻ Diabetes LDL‐C Screening
⁻ Diabetes HbAIC Screening
⁻ Diabetes Nephropathy
• Care Coordination Measures
⁻ Ambulatory Care Sensitive Admissions
Quality of Care Measure Changes recommendations
• Rationale
⁻ HEDIS Measure below Medicaid 25 th percentile (MPL) in need of attention:
• Avoidance of Antibiotics in Adults with Acute Bronchitis
⁻ Measures required for NCQA accreditation that are below MPL:
• Appropriate testing for Children with Pharyngitis
• Use of Spirometer testing in assessment and diagnosis of COPD
• Plan
⁻ Add 3 new measures above, to current 8
⁻ remove BMI (note it is still incentivized through CBI fee‐for‐
service)
⁻ Total of 10 measures (30 points)
Post‐Partum Care Incentive
• Pilot Post‐Partum care incentive for existing CBI participating practices
• Alliance currently 25‐50 th percentile in DHCS HEDIS measures
• Measure proposal:
• Incent post partum visit 21‐56 days after delivery
• Fee‐for‐service payment ($25) using Existing member CBI Post Partum Care Form
• Providers holding a PCP contract with a CBI
addendum will be eligible
Keys to CBI Success = PCMH models
• Quality of Care Measures and Fee‐for–Service Measures
• Activate patient interest
• Consider every visit as an opportunity
• Identify gaps in care
• Provider portal functionality (quality and FFS)
• Disease registry functionality in EMR
• Patient education/group visits (FFS)
• Dedicated staff?
• Care Coordination Measures
• Provide Access
• Provider care coordination
• Staff outreach
• Consultation from Alliance care management
PAG Committee Membership
• Selection of Members: Members are recruited several ways including, but not limited to:
• Personal request by Chief Medical Officer
• Volunteer by individual physician
• Request by Chief Medical Officer to identifiable constituency groups for a delegate, or volunteer from same group
• Physicians with specific expertise may be invited to assist with the group's work.
• Term: PAG members serve a one‐year term, renewable by The Commission. Physicians unable to attend at least half of meetings will be encouraged to yield their seats to
others with more compliant schedules.
Medicaid Expansion
Pain Management
Physicians Advisory Group
June 5, 2014
Acupuncture Pilot
• Members with chronic pain on high and/or
escalating doses of narcotic pain medications may benefit from Acupuncture.
• Offer Acupuncture program as resource to PCPs in all three Alliance Counties for top 200 Alliance
members (adults) stratified by prescription narcotic dose.
• Measure morphine equivalent usage (and costs) in same patients before and after acupuncture
program.
• Evaluate member pain perception and functioning before and after initial 10 week course and at 6
and 12 months of treatment.
Plan
• Primary Care Providers with “Top 200”
members will receive communication describing program list of qualified members and authorization process
• 20 sessions will be authorized at a time
Other Considerations
• Provider Education
1. Conferences, e.g. large medical group, best practices, recorded video?
2. Scope of pain 3. Other?
• Resource Development
1. Uncontrolled pain, specialists, alternative modalities
2. Opioid use disorder (DSM 5), evaluate and treatment – to be developed
3. Addiction – county and state, AOD – to be developed
• Plan limits on medication?
Questions?
PHYSICIANS ADVISORY GROUP MEETING CALENDAR FOR 2014
Thursday, March 6 12:00 PM to 1:30 PM Thursday, June 5 12:00 PM to 1:30 PM Thursday, September 11 12:00 PM to 1:30 PM Thursday, December 11 12:00 PM to 1:30 PM
All meetings will be held via video conference at the Alliance offices listed below:
Alliance Main Office: 1600 Green Hills Road, Suite 101, Scotts Valley, CA 95066
*Alliance Salinas Office: 950 East Blanco Road, Suite 101, Salinas, CA 93901
Alliance Merced Office: 530 West 16
thStreet, Suite B, Merced, CA 95340
*New location
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