20-621 Medi-Cal 2019 Provider Appointment Availability and After-Hours Access Survey Results

Date: 08/14/20

This information applies to Physicians, Participating Physician Groups (PPGs) and Ancillary providers.

This information applies to Medi-Cal in Fresno, Kings and Madera counties.

SUMMARY UPDATE

See how results compared to the previous year

The Department of Managed Health Care (DMHC) and Department of Health Care Services (DHCS) have requirements to ensure health care services are provided to patients in a timely manner appropriate for the nature of the patients’ conditions and consistent with good professional practice. The surveys measure how well providers comply with DMHC and DHCS availability and access requirements.

The complete provider update 20-621, Medi-Cal 2019 Provider Appointment Availability and After-Hours Access Survey Results covers the below content in detail:

• Corrective action plan (CAP) when timely access to care standards are not met.
• Tips to help maintain appointment access standards and after-hours messaging.
• Resources to help comply with appointment availability and after-hours access standards.
• Complete 2019 annual Provider Appointment Availability Survey (PAAS) and Provider After-Hours Access Survey (PAHAS) results (overall and by county).

The complete update is available below. Providers may also request a print copy of update 20-621 by contacting the Provider Communications Department by email at provider.communications@healthnet.com.

Areas for improvement

Based on 2019 survey results, the below DMHC metrics did not meet the 90% performance goal:

• Urgent care appointment with PCP within 48 hours.
• Urgent care appointment with specialist that requires prior authorization within 96 hours.
• Non-urgent appointment with PCP within 10 business days.
• Non-urgent appointment with specialist within 15 business days.
• Preventive health or well-child appointment with PCP within 10 business days.
• Physical exam/wellness check appointment with PCP within 30 calendar days.
• Initial prenatal appointment with PCP within two weeks.

If you have questions about the information in this update, contact CalViva Health at 1-888-893-1569.

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COMPLETE UPDATE

See how results compared to the previous year

The 2019 annual Provider Appointment Availability Survey (PAAS) and Provider After-Hours Access Survey (PAHAS) results are in. The results are from a random sample of participating primary care physicians (PCPs), specialty care providers (SCPs), ancillary providers, and non-physician mental health providers (NPMH) surveyed from August 2019 through December 2019.

The surveys comply with the Department of Managed Health Care (DMHC) and the Department of Health Care Services (DHCS) access requirements. The survey results are used to monitor provider compliance with timely access and after-hours regulations, and evaluate the effectiveness of the network to meet the needs and preferences of CalViva Health members.

Failure to meet one or more timely appointment and after-hours access standards, as indicated, will result in a corrective action plan (CAP).

2019 Provider Appointment Availability Survey results

Availability and access requirements are designed to ensure that health care appointments are provided to patients in a timely manner appropriate for the nature of the patient’s condition and consistent with good professional practice.

The results of the 2019 PAAS survey for DMHC and DHCS appointment access standards reflect a need for improvement in several areas. The following DMHC appointment access metrics did not meet the performance goal of 90%:

• Urgent care appointment with PCP within 48 hours.
• Urgent care appointment with specialist that requires prior authorization within 96 hours.
• Non-urgent appointment with PCP within 10 business days.
• Non-urgent appointment with specialist within 15 business days.
• Preventive health or well-child appointment with PCP within 10 business days.
• Physical exam/wellness check appointment with PCP within 30 calendar days.
• Initial prenatal appointment with PCP within two weeks.

Refer to tables on pages 2–4 for the appointment availability results overall and by county.

Measurement year (MY) 2019 and MY 2018 Medi-Cal provider appointment availability results – overall

Access measure	Appointment standard (wait time)	Performance goal	MY2019 rate (%)	MY2018 rate (%)
PCPs and specialists
Urgent care appointment with PCP	48 hours of request	90%	70.9^	71.4
Urgent care appointment with specialist that requires prior authorization	96 hours of request		52.2^	62.8
Non-urgent appointment with PCP	10 business days of request		84.7	82.1
Non-urgent appointment with specialist	15 business days of request		75.4	68.1
Preventive or well-child appointment with PCP	10 business days		76.9	73.6
Physical exam/wellness check appointment with PCP	30 calendar days		87.8	88.5
Initial prenatal appointment with PCP	2 weeks		88.4	90.3
Initial prenatal appointment with specialist	2 weeks		91.2	88.9
Non-urgent ancillary appointment for magnetic resonance imaging (MRI), mammogram, physical therapy	15 business days of request		93.3	66.7*
Urgent and non-urgent PCP and specialists combined
Urgent care appointment with PCP or Specialist	48 or 96 hours of request	90%	60.3	N/A
Non-urgent appointment with PCP or Specialist	10 or 15 business days of request		78.7	N/A
Initial prenatal appointment with PCP or Specialist	2 weeks		90.1	N/A
Behavioral health providers
Urgent care appointment with psychiatrist	96 hours of request	90%	52.9	75.0*
Non-urgent appointment with psychiatrist	15 business days of request		77.8	80.0*
Urgent care appointment with non-physician mental health provider (NPMH)	96 hours of request		75.3	65.9
Non-urgent appointment with NPMH provider	10 business days of request		91.1	86.3

_{*Denominator less than 10. Rates should be interpreted with caution due to the small denominator.}

_{^Rate for MY 2019 cannot be compared to MY 2018 due to change in the sampling methodology.}

_{N/A – not applicable for the measurement year.}

2019 Medi-Cal provider appointment availability results – by county

Access measure	Appointment standard (wait time)	Performance goal	Fresno		Kings		Madera
			MY2019 rate (%)	MY2018 rate (%)	MY2019 rate (%)	MY2018 rate (%)	MY2019 rate (%)	MY2018 rate (%)
PCPs and specialists
Urgent care appointment with PCP	Appointment within 48 hours of request	90%	71.9^	74.2	67.3^	59.3	70.3^	81.3
Urgent care appointment with specialist that requires prior authorization	Appointment within 96 hours of request		53.8^	68.0	42.3^	44.4	50.9^	53.2^
Non-urgent appointment with PCP	Appointment within 10 business days of request		85.5^	85.7	84.9^	85.2	79.5^	62.5^
Non-urgent appointment with specialist	Appointment within 15 business days of request		77.1^	72.2	64.3^	73.7	74.2^	43.1^
Preventive health or well-child appointment with PCP	Appointment within 10 business days		77.5^	69.8	79.6^	85.2	70.3^	68.8^
Physical exam/wellness check appointment with PCP	Appointment within 30 calendar days		88.1^	85.2	91.5^	92.6	81.6^	93.8^
Initial prenatal appointment with PCP	Appointment within 2 weeks		90.0^	94.4	91.3^	90.0	70.0^	66.7*^
Initial prenatal appointment with specialist	Appointment within 2 weeks		90.3^	87.5	100*^	100*	NR	100*^
Non-urgent ancillary appointment for MRI, mammogram and physical therapy.	Appointment within 15 business days of request		90.9	60.0*	100*	100*	100*	NR
Behavioral health services
Urgent care appointment with psychiatrist	Within 96 hours of request	90%	46.7	75.0*	100*	NR	NR	NR
Non-urgent appointment with psychiatrist	Within 15 business days of request		75.0	75.0*	100*	100*	NR	NR
Urgent care appointment with NPMH	Within 96 hours of request		74.6	66.7	66.7*	40.0*	100*	100
Non-urgent appointment with NPMH provider	Within 10 business days of request		91.3	83.7	83.3*	100*	100*	100

_{NR – no reportable data}

_{*Denominator less than 10. Rates should be interpreted with caution due to the small denominator.}

_{^Rate for MY 2019 cannot be compared to MY 2018 due to change in the sampling methodology}

2019 After-hours access survey results

A new survey vendor was used for the 2019 PAHAS. Performance guidelines require 90% compliance for after-hours access. Overall results for 2019 PAHAS indicate both metrics were met. The following tables display the after-hours results overall and by county. The results indicate there is a statistically significant increase in the performance score compared to previous year for both measures.

MY 2019–MY 2018 Medi-Cal provider after- hours availability results – overall
Access measure	Standards	Performance goal	MY2019 Rate (%)	MY2018 Rate (%)
After-hours emergency instructions	Appropriate instructions for emergency issues	90%	97.9	93.9
Contact on-call physician after hours (for urgent issues)	Callback within 30 minutes		99.4­	82.0

 

MY 2019 – MY 2018 Medi-Cal provider after-hours availability results – by county
Access measure	Standards	Performance goal	Fresno		Kings		Madera
			MY2019 Rate (%)	MY2018 Rate (%)	MY2019 Rate (%)	MY2018 Rate (%)	MY2019 Rate (%)	MY2018 Rate (%)
After-hours emergency instructions	Appropriate instructions for emergency issues	90%	97.9­	95.2	99.0	95.0	96.1­	80.5
Ability to contact on-call physician after hours	Callback within 30 minutes	90%	99.4­	82.3	99.0­	77.8	100­	85.0

­_{¯ Statistically significant difference between MY2019 vs MY2018, p<0.05}           

Corrective Action Plan (CAP)

DMHC regulations (CCR T28 §1300.67.2.2(d)(3)) require that health plans investigate and request corrective action when timely access to care standards are not met. To comply with these requirements and meet the plan’s compliance requirements, as delineated by CalViva Health’s Accessibility of Providers and Practitioners policy, a CAP will be issued to contracted PPGs and provider offices who fail any of the urgent or non-urgent metrics.

PPGs and providers who receive a CAP are required to:

• Submit a written improvement plan (IP) within 30 calendar days, including the actions taken to correct each deficiency.
• Attend an online provider training webinar, hosted online by Health Net*, as part of their IP.

Providers with questions or concerns regarding their ability to meet these standards may contact Health Net, on behalf of CalViva Health, via email.

Maintaining access standards

Providers should review current office scheduling practices and after-hours protocol periodically to ensure they are accurate and meet current guidelines. Orientation for new staff, office staff and answering service staff should include the appointment access standards and after-hours procedures and scripts. Providers can test their own appointment scheduling and after-hours practices by scheduling self-audits or secret shopper calls. This allows provider offices to verify appointment standards are being met and after-hours outbound messaging is appropriate and take steps to correct any issues identified. The goal of reasonable access to care is essential for member safety and is monitored annually. After-hours script templates can be found online (see Resources) and are available in English, Spanish and Hmong.

Resources

Research shows that high patient satisfaction is linked to better health outcomes. For help in complying with appointment access standards, refer to the resources online in the Provider Library.

Included with the CAP packets is the Improve Health Outcomes: A Guide for Providers toolkit for participating Medi-Cal providers. The toolkit includes information, support tools and resources that focus on drivers of patient satisfaction:

• Health Care Performance Measurement Systems
• QI Activities
• Timely Appointment Access
• Advance Access

Implementing just one practice intervention can make a big difference to an organization and a patient’s experience. The brochure is available electronically through the QI Corner at provider.healthnet.com > Working with Health Net > Quality. Under Provider Resources, select Improve Health Outcomes: A Guide for Providers.pdf

Additional information

Providers are encouraged to access the provider portal online at provider.healthnet.com for real-time information, including eligibility verification, claims status, prior authorization status, plan summaries, and more.

If you have questions regarding the information contained in this update, you may contact the Access and Availability Unit via email or CalViva Health at 1-888-893-1569.