The QIHEC is led by Health Net’s Chief Medical Directory and Chief Health Equity Officer and is overseen by Health Net’s Governing Board. The QIHEC meets quarterly. External practitioners (Network Providers, including but not limited to hospitals, clinics, county partners, physicians, subcontractors, downstream subcontractors.

Subcontractors, downstream subcontractors, and network providers must be representative of the composition of the HNCS’ provider network and include, at a minimum, network providers who deliver health care services to members affected by health disparities, limited English proficiency (LEP), children with special health care needs (CSHCN), seniors and persons with disabilities (SPDs) and persons with chronic conditions participate on this committee along with representatives from Behavioral Health, Pharmacy Department, Network Management, Medical Affairs, Customer Service Operations, Credentialing, Peer Review, and Population Health & Clinical Operations (PHCO) which includes Utilization Management (UM) and Care Management.

QIHEC functions include the following:

• Annually assess UM, QI, and Health Equity activities, including areas of success and needed improvements in services rendered within the QI and Health Equity program at the regional and/or county level; Conduct a quality review of all services rendered, the results of required performance measure reporting, and the results of efforts to reduce health disparities;
  • Address activities and priorities related to the Quality Improvement and Health Equity Transformation Program (QIHETP)
  • Analyze and evaluate the results of QI and Health Equity activities including annual review of the results of performance measures, utilization data, consumer satisfaction surveys;
  • Institute actions to address performance deficiencies, including policy recommendations;
  • Ensure follow-up of identified performance deficiencies or gaps in care;
• Support efforts to align resources, strategies, and partners by place in order to reduce identified inequities (e.g., via use of Health Equity Improvement Zones);
• Identify differences in quality of care and utilization of physical and behavioral health care services for members directly managed and delegated to providers;
• Ensure that all interventions to address differences in quality of care and utilization have an equity focus, including addressing underlying factors such as SDoH;
• Review performance measure results and address deficiencies, including results and deficiencies of all fully delegated subcontractors;
• Review progress summaries from Joint Operating Meetings
• Ensure connectedness to the findings, recommendations and actions from the Quality Improvement Committee, Community Advisory Committees (CAC), and Public Policy Committee to drive universal decisions and programming;
• Ensure member confidentiality is maintained in QI discussions and avoid conflict of interest among the QIHEC members;
• The QIHEC shall provide input and advice on the following non-exclusive list of topics:
  • Population Health Management;
  • Health Delivery Systems Reforms to improve health outcomes;
  • Coordination of Care;
  • Clinical quality of physical and behavioral health care;
  • Access to primary and specialty health care Providers and services;
  • Member experience with respect to clinical quality, access, and availability, culturally and linguistically competent health care and services, and continuity and coordination of care
  • Non-Specialty Mental Health Services (NSMHS) Member and PCP Outreach & Education Plan
• QIHEC is responsible for adequately addressing recommendations put forth by the CAC and providing feedback through a dashboard that outlines progress and decisions on recommendations
  • For recommendations that the QIHEC is unable to reasonably address, a CAC may opt to escalate their recommendation to the HNCS Board of Directors for further review and consideration.
• Form and delegate authority to subcommittees when appropriate; and
• Review and reassess the adequacy of the charter annually and recommend any proposed changes to the Board for approval. The Committee shall annually review its own performance.

Quality Management

• Review HNCS QI and QIHETP findings and required actions at the regional and/or county level;

• Review and approve the annual Health Equity Description, Work Plan, and Work Plan Evaluation;

• Monitor, support, and evaluate the activities for the QI and QIHETP programs, and make recommendations for improvements;

• Conduct an annual evaluation of the effectiveness of the language assistance services offered to support members with limited English proficiency and to mitigate potential cultural or linguistic barriers to accessing care in compliance with requirements from Centers for Medicare and Medicaid Services (CMS), Department of Health Care Services (DHCS), and Department of Managed Health Care (DMHC);

• Concentrate on eliminating identified health disparities including, structural racism and social risk, SDoH, and community needs; make recommendations to improve individual and community health outcomes.

• Review and provide status on formal recommendations presented by the HNCS CAC.

The Credentialing/Peer Review Committee verifies and reviews practitioners and organizational providers who contract to render professional services to Health Net members for training, licensure, competency, and qualifications that meet established standards for credentialing and recredentialing. The Credentialing Committee ensures Health Net's credentialing and recredentialing criteria for participation in the Health Net network are met and maintained for all lines of business, as defined by the regional health plans. The QIHEC delegates authority and responsibility for credentialing and recredentialing peer reviews to this committee. This committee is also responsible for peer review activities and decisions regarding quality improvement follow-up on service and clinical matters, including quality of care cases. The committee provides a forum for instituting corrective action as necessary and assesses the effectiveness of these interventions through systematic follow-up for all lines of business for both inpatient and outpatient care and services.

This committee reports quarterly to the QIHEC and provides a summary of activities to the Health Net board of directors. Membership includes practicing medical directors or practitioners (representing primary and specialty disciplines) from PPGs representing each region (northern, central and southern California).

The Pharmacy and Therapeutics (P&T) Committee ensures appropriate and cost-effective delivery of pharmaceutical agents to Health Net membership. Committee responsibilities include the review and approval of policies that outline pharmaceutical restrictions, preferences, management procedures, explanation of limits or quotas, the delineation of Recommended Drug List (RDL) exceptions, substitution and interchange, step-therapy protocols, and the adoption of prescription safety procedures.

The P&T Committee includes a Health Net medical director, practitioners from PPGs that represent primary care and specialty disciplines, and clinical pharmacists.

A Pharmacy and Therapeutics (P&T) Committee is comprised of actively practicing physicians, medical directors and clinical pharmacists who review the efficacy and safety data of medications using an evidence-based process in order to make clinically appropriate utilization management recommendations to health plans and pharmacy benefit managers. P&T Committee members also consider the potential for medication misuse or abuse, experimental or off-label use, and required level of laboratory or safety monitoring. P&T Committee utilization management tools include prior authorization criteria, quantity limits and step therapy.

Health Net may delegate responsibility for activities associated with utilization management (UM) and administrative services to its PPGs.

The Health Net Delegation Oversight Committee (DOC):

The Specialty Network Committee sets standards for the Health Net participating transplant performance centers and bariatric performance centers, guiding members to specialty network providers, monitoring performance, issuing requests for CAPs, and reporting to HNQIC. This committee meets at least six times per year and reports annually to HNQIC.