ALAMEDA ALLIANCE FOR HEALTH BOARD OF GOVERNORS REGULAR MEETING. June 8, :00 pm 2:00 pm 1240 South Loop Road, Alameda, CA SUMMARY OF PROCEEDINGS

Transcription

1 ALAMEDA ALLIANCE FOR HEALTH BOARD OF GOVERNORS REGULAR MEETING June 8, :00 pm 2:00 pm 1240 Suth Lp Rad, Alameda, CA SUMMARY OF PROCEEDINGS Bard Members Present: Marty Lynch (Chair), Sctt Cffin, Feda Almaliti, Rebecca Gebhart, Nichlas Perain, Dr. Nha Abelata, Will Sctt, David Vliet, Delvecchi Finley, Aarndeep Basrai, Dr. Rllingtn Fergusn, Wilma Chan, Dr. Bertram Lubin, Dr. Michael Marchian, Travis Stein Excused: Dr. Evan Seevak (Vice Chair) Alliance Staff Present: Sctt Cffin, Gil Rijas, Matt Wdruff, Dr. Steve O Brien, Anastacia Swift, Diana Sekhn, Sasi Karaiyan, Nancy Pun, Carl VanOsterwijk AGENDA 1. CALL TO ORDER M. Lynch The regular bard meeting was called t rder by M. Lynch at 12:03 PM. A bard qurum was established by a simple majrity fr the meeting. 2. INTRODUCTIONS M. Lynch Intrductins were made fr thse present. Nne Nne 3. AGENDA APPROVAL OR MODIFICATIONS M. Lynch There were n mdificatins t the agenda. Nne Nne Nne Nne 4. CONSENT CALENDAR M. Lynch M. Lynch requested a mtin t apprve the Cnsent Calendar: Apprval f Minutes May 11, 2018 Bard f Gvernrs Meeting W. Sctt mved t apprve the Cnsent Calendar. The mtin was secnded by Nick P. The mtin passed unanimusly. 5. a. BOARD MEMBER REPORT COMPLIANCE ADVISORY GROUP R. Gebhart R. Gebhart reprted the Cmpliance Advisry Cmmittee met this mrning. The purpse f the Cmpliance Advisry Cmmittee is t reprt Mtin: W. Sctt Secnd: N. Perain Mtin passed unanimusly. Nne Nne Nne

2 n the prgress n findings and crrective actin plans (CAPs). R. Gebhart prvided the fllwing Cmpliance dashbard updates: 2A- Financial Audit: One (1) deficiency was clsed; late claims prcessing due t incrrect data input; CAP was issued, cmpleted and accepted by DHCS n May 29 th ; will cntinue t mnitr internally. 2B- Medical Services Audit: audit (19) findings; all CAPs cmpleted and clsed n May 22 nd ; will cntinue t internally mnitr methdlgy fr prviders related t timely access. 2C-Medical Services Audit: (Octber 2017) Six (6) findings; fur (4) cmpleted; tw (2) pen Ptential Quality Issues (PQI) identificatin, educatin and backlg reslved. Access and availability CAP in prgress Utilizatin management CAP repened fr behaviral health ut-f-netwrk referrals. 2D- Mental Health Parity: Sutter cntract amendment in prgress t determine mental health parity n admissins. 2E- Encunter Data: All three (3) findings have been cmpleted fr encunters which were denied and nt resubmitted; nging mnitring fr internal cmpliance. 2F- Cmplex Case Management: All CAPs cmpleted; created prcesses, P&Ps, hiring and training f staff; dubled number f members in prgram. Multidisciplinary teams have been frmed which includes case managers, scial wrkers and health navigatrs. Practively lking at ppulatin, utilizing referrals frm prviders and cmmunity partners t evaluate and identify members fr the prgram. 2G- DMHC Audit: (April) Audit results are expected within mnths. Pssible findings were identified in (14) areas including: Ptential Quality Issues (PQI) backlg has been reslved Utilizatin management- review and dcumentatin f denials; plans fr interventins; prcess fr peer-t-peer AAH BOG 6/8/ f 10

3 discussin. Pharmacy dcumentatin f denials Grievance & Appeals Timely access Care crdinatin need dcumented plan fr crdinatin f mental health services. Quality management - crss department referrals and training; dcumentatin fr rt cause analysis; prcess fr interventin and reslutin; nt identified in cmmittee meeting minutes. D. Sekhn added that DHCS will be nsite fr the Annual Medical Survey Audit n June M. Lynch inquired abut the prcess fr integrating the mental health services in the management f high cst utilizatin. S. O Brien respnded the prcess ensures that Beacn is participating in case management and building pathways with the cunty fr the severely mental ill members. D. Sekhn added that the auditrs will be lking fr the dcumentatin f these wrkflws and prcesses. M. Lynch acknwledged R. Gebhart and ther bard members fr their wrk n the cmmittee and inquired if there is specific areas that need the bard s attentin. R. Gebhart respnded that encunter data shuld be clsely mnitred with new changes at the state level requiring encunter data fr additinal prgrams. The quality f the encunter data will drive the reimbursement t the prviders. M. Marchian inquired if there are plans t partner with any addictin clinics. S. O Brien respnded that a Drug MediCal Waiver is part f the cuntry systems which we plan t partner with, which deals with substance abuse treatments. The Alliance is als participating in high level executive case management with the cunty n issues including husing, substance abuse, and behaviral health. W. Sctt cmmented that husing is critical especially when yu can t find the peple wh need the case management. S O Brien agreed that hmelessness is a huge rt cause fr a lt f the high utilizing AAH BOG 6/8/ f 10

4 members inability t btain services. 5. b. BOARD MEMBER REPORT FINANCE COMMITTEE R. Fergusn R. Fergusn reprted frm the Finance Cmmittee meeting n June 5 th. TNE and MLR are stable at 620% and 95% respectively. The preliminary budget initially had a prjected lss f $50M which has been adjusted t $38M. The majr lss is due t net cntracting csts f $20M in additin t medical expense. Pssible savings include avidable admissins, readmissins and pharmacy csts. Outpatient radilgy remains a significant prblem frm which we need t achieve savings. Prpsitin 56 payments t prviders are expected t begin in July. 6. a. BOARD BUSINESS FINANCIAL REPORT - APRIL G. Rijas G. Rijas prvided the fllwing financial updates fr April: Enrllment decreased by 294 members since March; primarily in the child and adult categries f aid which cntinues t trend dwnward. The MCE ppulatin is n lnger reprting net incme; SPD cntinue t cntribute a lss. Net incme $181K; $4.8M YTD; favrable variance due t lwer administrative expenses and higher than anticipated ther incme. Revenue $82.6M; related t $6.4M received fr Prp 56 fr July 2017 t April 2018 perid; ffset by crrespnding increase in medical expense. M. Lynch nticed a typ in the Executive Dashbard regarding Net Incme that will be crrected. Incurred But Nt Paid claims estimate (IBNP) was relatively flat with n changes. Outpatient expense verage is largely driven by behaviral health and lab and radilgy trends. Administrative expense is $43M; budgeted $50M; due t higher than expected vacancy rate and lwer than expected cst fr prgrams and cnsulting fees; administrative expenses represent 5.4% f revenue and 5.8% YTD. Investment incme YTD $4.7M; average yield f 2.1% Claims interest expense $2.1M Nne Nne Nne AAH BOG 6/8/ f 10

5 Medical Lss Rati 94.9%; 94% YTD Tangible Net Equity (TNE) 619% Cash and cash equivalents $640M Uncmmitted cash $213M Current rati 1.3% B. Lubin was surprised by the decrease in enrllment fr the children s categry. G. Rijas respnded the enrllment has trended dwn slightly. Based n their ethnicity, the children may nt be in the system because they are afraid f what may happen t them. G. Rijas directed attentin t analytics data related t trends regarding age, language and ethnicity. W. Chan inquired if the decrease in enrllment is within the nrmal range. G. Rijas respnded a 1% increase was budgeted, but the trend has been decreasing enrllment acrss varius cunties verall including cmmercial plans. N. Abelata inquired if there was a distinctin between members falling ff MediCal entirely r just nt being enrlled in the Alliance. G. Rijas referred t a discussin with DHCS which indicated that as the ecnmy des better there are less peple n MediCal. N. Abelata suggested a ptential area fr imprvement wuld be t get prviders invlved in being practive t renew MediCal members befre they are termed. S. Cffin added althugh there have been shifts in enrllment; the Alliance still has within 265,000 and 270,000 members. Outreach t Cunty Scial Services allws insight t trends, but data is nt available as t why peple leave the Medicaid system. A grwth strategy fr the next fiscal year is being develped. Dr. Abelata has vlunteered t help develp ideas n hw t engage prviders and ther cmmunity surces in the enrllment and retentin prcess. R. Fergusn added the imprtance f reviewing the trending f state data t predict where the members are ging. If we are lsing members, then strategies must be develped t reverse it. W. Chan inquired if the 8.2% decrease in the adult ppulatin is nrmal. G. Rijas respnded that it s cnsistently been decreasing since May AAH BOG 6/8/ f 10

6 2017. Previusly the adult enrllment was ver 40,000 and is nw at 37,500. N. Abelata inquired is there was a way t determine and predict the term dates t crrelate with enrllment. G. Rijas respnded that enrllment usually dips in January and then ramps up; hwever, there has nt been a ramp up in enrllment as in the past. M. Lynch inquired if data analytics culd prvide data and research n when members enter the prgram and their expected term dates. N. Pun respnded the state des prvide redeterminatin dates which are being included in the Health Hmes pilt eligibility files fr high utilizers. N. Abelata cmmented it is usually the lwer cst users that fall ff the prgram which we want t keep enrlled. M. Lynch inquired abut the inpatient barmeter fr actual days/thusand which is lwer than the target, and respectively, and yet the actual PMPM cst is way higher than the target. S. O Brien respnded there are mnth-t-mnth variatins fr days/thusand. Interventins have nt been started t mve this in a psitive directin. G. Rijas respnded research is needed t analyze the data. Retractive cntract activity will begin in June but nt fr April. N. Pun added the target infrmatin is based n average cst estimates whereas the actual is based n facility accepting admissins and cntract rates s the difference can depend n where the members are ging. R. Fergusn mved t accept the financial reprt. The mtin was secnded by R. Gebhart. The mtin passed unanimusly. Mtin: R. Fergusn Secnd: R. Gebhart Mtin passed unanimusly. 6. b. BOARD BUSINESS PRELIMINARY BUDGET FY G. Rijas G. Rijas reviewed the FY 2018 Frecast vs. Budget: Enrllment guides revenue and it was 1.6% less than budgeted. Medical expenses have increased significantly ver budget by $26M. Prjected net lss $2.9M Administrative expense rati 6%; budgeted 6.9% Medical Lss Rati (MLR) is abve prjectin at 94.8% Nne AAH BOG 6/8/ f 10

7 Tangible Net Equity (TNE) remains abve 600% The state recently ntified all the plans f the requirement fr a Medical Lss Rati f 85%. This may affect the financial statements fr FY17 and FY18. The Alliance was clse t the requirement. G. Rijas presented the FY 2019 Preliminary Budget: Prjected lss was adjusted frm $50M t $38M. This is based n estimates which d nt include the final rates. Administrative expense rati is estimated t be higher than FY18 as staff vacancies are expected t be filled. Medical Lss Rati (MLR) will be high at 98.4% which drives the net lss. Tangible Net Equity (TNE) is frecasted t be 472%. D. Vliet inquired if the FTE vacancies are in care crdinatin that affects the ROI. Is there a metric that is used t generate estimated cst savings by this class f staff? G. Rijas respnded the vacancies d cntribute t the case management prgram and the ROI. There may be mdels that can predict the cst savings but has nt been tried r relied upn. D. Vliet added it is imprtant t cnsider distinctins f staff psitins and hw they bring ROI and reduce cst. S. Cffin respnded ver the past tw years analysis has been dne t quantify prductivity. Results are nt tied t specific psitins; hwever, estimated savings have been prjected fr next year based n current capacity and regulatry requirements. Benchmarks will be develped and tracked internally. The hiring csts will be managed very carefully fr all backfill and net new psitins. W. Chan inquired what was changed in the budget t reduce the prjected lss t $38M. G. Rijas described the 2-phase budget prcess which included discussin with all the cst center managers. The targeted budget was $77M althugh the csts centers asked fr $85M. The budget was reviewed line by line and trimmed t $75M by scaling back n FTEs, cnsulting services, equipment, and cnferences. S. O Brien added the biggest areas f expense in Healthcare Services are in the inpatient csts, with a fcus n excess days, length f stay, AAH BOG 6/8/ f 10

8 readmissin rates and avidable admits especially fr ur high utilizers. Key areas in pharmacy include drugs fr nclgy and arthritis. Out f netwrk csts need t be minimized and bring services back int ur netwrk. W. Chan cmmented that initially the prjected lss was based n the uncertainty arund the rates frm the state; hwever, this discussin indicates there are peratinal csts that culd be reduced. G. Rijas referred t the cmpnents f the prjected lss which includes departmental expense, reinsurance, medical expense and net cntracting changes which are all majr drivers. R. Fergusn pinted ut the main drivers fr the lss is medical expenses and net cntracting changes. D. Finley inquired as t the actinable pprtunities. S. O Brien respnded high level targets were set t decrease length f stay t ¼ f a day and reduce readmissin rates by 1%. Pharmacy gals have nt yet been develped. N. Abelata inquired abut strategies t avid ut f netwrk services. S. O Brien respnded ne strategy is wrking clsely with cntracting t get prviders int ur netwrk. Plans als include educatin t prviders t refer within the netwrk. R. Fergusn inquired abut the net cntracting changes. S. Cffin respnded the MediCal 220 Waiver is a delivery system transfrmatin. The Public Hspital Redesign and Incentives fr MediCal (PRIME) is a statewide initiative and cmpnent f the waiver. The Alliance has been wrking with Alameda Health System (AHS) fr the past year and a half n this transfrmatin and wrking thrugh base rates. The majrity f the lss in net cntracting is a result f the negtiatins with AHS. The delivery transfrmatin (payment refrm) is wrking t ensure equity between the base rates and market rates. We are currently in the first year f a multi-year apprach. The majrity f the lss is ging back int ur safety net and partnership with AHS. AAH BOG 6/8/ f 10

9 D. Finley cnfirmed the current situatin. Alameda Health Systems has been able t survive n years f submarket rates. These substandard rates will likely impact supplemental dllars t AHS because the rates were depressed during the time n which these payment mechanisms were based. M. Lynch reminded the bard that details f rate negtiatins are nt fr discussin, but the bard cnsiders plicy issues. As a bard member, he is uncmfrtable passing a budget with the prjected lss, but understands this is a preliminary budget which will hpefully be better when the final budget is apprved. D. Finley inquired if the preliminary budget includes the expected rates. G. Rijas respnded the preliminary rates that were received by the state have been applied, but it is difficult t see where we will end up based n cuntywide averaging. We expect the final rates by late June r early July. D. Vliet mved t accept the interim preliminary budget. The mtin was secnded by N. Perain. The mtin passed unanimusly. 7. CEO UPDATE S. Cffin S. Cffin shared the fllwing pririties: Increased capacity fr care management and care crdinatin fr internal and cmmunity based prgrams. Advancement f prgrams started in 2016: Health Hmes Pilt, Whle Persn Care (AC3), and crss systems apprach. Cst cntrls Regulatry deficiencies Standards and structure fr all departments: P&P versight Data analytics and data management B. Lubin acknwledged the pririties as a strategic plan which shuld be included n the website. Mtin: D. Vliet Secnd: N. Perain Mtin passed unanimusly. Nne Nne 8. STAFF ADVISORIES ON BOARD BUSINESS FOR FUTURE MEETINGS M. Lynch There were n staff advisries fr future meetings. Nne Nne AAH BOG 6/8/ f 10

10 9. PUBLIC COMMENTS (NON-AGENDA S) M. Lynch There were n public cmments. Nne Nne 10. ADJOURNMENT TO CLOSED SESSION M. Lynch The meeting was adjurned t clsed sessin at 1:36 PM. Nne Nne Respectfully Submitted By: Lynda Fng, Cmpliance Crdinatr AAH BOG 6/8/ f 10