Quality And Compliance Committee

The Quality and Compliance Committee was created for the purpose of engaging PrimaryHealth providers and subcontractors in the service area to oversee the overall compliance and quality of services provided by PrimaryHealth and its subcontractors. For a complete overview of the QCC’s roles, responsibilities, membership and more, we invite you to download a copy of its charter below.

Committee Members

Shanna McGowan, PA-C Grants Pass Clinic

Dan McDonnell, Psych NP Siskiyou Community Health Center

Andy Luther, MD Grants Pass Clinic, Family Practice

Kevin Molteni, MD Grants Pass Clinic, Pediatrics

Marcel Wiggers, MD Grants Pass Clinic, Internal Medicine

Nina Laura, NP Associate Medical Director PrimaryHealth

Bill Kennon, R. Ph PrimaryHealth

Marcus Opel, MD Grants Pass Clinic, Internal Medicine

Tom Haddad, MD Grants Pass Clinic, Internal Medicine

Jennifer Johnstun, RN PrimaryHealth, Health Strategy Officer

Rick Jones, CADC II, NCAC II Choices, Executive Director

Ruth McBride, RN PrimaryHealth, Director Member Services

Susan Britton, PrimaryHealth, Compliance Officer

Quality and Compliance Committee Charter

PrimaryHealth Quality and Compliance Committee (QCC). The QCC is authorized and sponsored by the PrimaryHealth Governance Board.

I. Purpose of Quality and Compliance Committee
The QCC is created for the purpose of engaging PrimaryHealth providers and subcontractors in the service area to oversee the overall compliance and quality of services provided by PrimaryHealth and PrimaryHealth’s subcontractors.

II. Overall Roles and Responsibilities

  • Acting as quarterly Pharmacy and Therapeutics to review rationale for all decisions regarding the drug list development and revision
  • Assuring evidence based best practices and/or community standards are adopted and utilized by the CCO
  • Oversight of the Grievance System
    • Processing health plan appeals
    • Oversight of quarterly grievance reports
    • Issue and maintain performance improvement plans or other follow up items from grievance reporting
  • Analyzing utilization patterns, data and metrics, including identification of patterns from a quality perspective. When opportunities to improve clinical outcomes are noted, the QCC will work with the CAP to create strategies to address deficiencies and setting targets for ongoing performance.
  • Ensure compliance with terms of the Contract with the Oregon Health Authority
  • Oversee compliance of delegated entities
  • Oversee compliance with HIPAA
  • Oversee compliance with Fraud and Abuse/False Claims Act
  • Oversee CCO Policy and Procedures and Guidelines
  • Review compliance of health plan operations (timeliness of processing, etc)
  • Authorization and administration of flexible services program
  • Oversee complex referrals, complex medication reviews
  • Assure compliance with accessibility of health plan services covered under the Contract
  • Review outlier cases
  • Oversee compliance with OARs, CFRs
  • Review and approve annual Work Plan
  • Receive reports from delegated entities and partners (Options, Choices, 4 dental organizations, Translink) such as those pertaining to quality and outcomes
  • Monitoring the development of Patient Centered Primary Care Homes in the PrimaryHealth network and member access to primary care at PCPCH sites
  • Evaluation, with CAP, of case management and disease management programs provided by the CCO
  • Oversight of provider credentialing
  • With CAP, provide oversight of the CCO’s Quality Improvement Plan Effectiveness

III. Procedural Rules

a. Meetings
Meetings will be scheduled every first, third and fourth Tuesday of the month.

b. Minutes
Minutes of each meeting will be kept. The minutes of the meetings shall be kept on file in the QI Committee folder on the network drive. If requested, minutes may be reviewed by any QCC member.

c. Dismissal
Members who are absent without reasonable cause from three successive meetings may be considered to have resigned their seat. The QCC will move to fill the position.

d. Confidentiality
QCC members should be aware of Primary Health’s need for consumer confidentiality and discretion related to CCO Specific business. The QCC at times reviews member specific data. When possible, PrimaryHealth will attempt to de-identify member and provider specific information. In certain instances, certain information will not be de-identified, such as in review of grievance reports or provider credentialing. QCC Members shall not report member or provider specific information or opinions expressed in meetings outside the committee (other than to follow up on the member’s clinic specific business).

e. Decision making
The majority of members of the QCC will constitute a quorum. Consensus decision making processes will be used as much as possible. At the request of any QCC member a show of hands vote can be requested. When voting on appeals, only members with appropriate expertise in the area of the appeal may vote (usually MD, DO, NP, or PA).

f. Conflict of interest
It is recognized that QCC members and the organizations they represent may be personally, professionally, and financially impacted by the decision of the QCC. Transparency in sharing potential conflicts of interest is essential to ensure the integrity of the Panel’s decision making. QCC members are required to disclose any potential conflicts of interest by completing a conflict of interest declaration form, submitting it to the CCO staff and updating as necessary.

g. Subcommittees
The QCC will charter subcommittees or project teams as needed.

IV. Organizational Structure
The QCC is an advisory committee to the PrimaryHealth Governance Board and is sponsored by PrimaryHealth. Initial members of the QCC will be appointed by the Governance Board. When positions on the QCC are vacated, the QCC will recommend to the Board individuals to fill vacancies. The Board shall give final approval for all QCC positions. This is a standing and ongoing panel. At least one member of the Governance Board shall also serve on the QCC. The QCC is one of three advisory committees of the Board. The other two advisory entities include the:

  • Community Advisory Council (CAC): Comprised of at least 51% consumer members along with community representatives. The CAC will advise the CCO on issues such as member satisfaction, member engagement, and community health assessments. At least one member of the CAC shall also serve on the CAP.
  • Clinical Advisory Panel (CAP): The CAP engages providers in the PrimaryHealth service are to build networks that enhance the Triple Aim, Better experience of care, better population health and outcomes, and reduces costs. The CAP provides oversight and direction of the clinical initiatives driving care transformation and their associated metrics.

The PrimaryHealth QCC will provide CCO oversight as specified in section II above and will report regularly to the PrimaryHealth Governance Board.

V. Members
a. Composition
The QCC shall be comprised of a representative cross-section PrimaryHealth providers and sub-contractors. Total membership is not explicitly capped, however, it is recommended that membership not exceed 15 participants. The QCC shall identify a standing subcommittee of members

Representatives may include agencies such as:

  • Primary Care Providers (Pediatricians, FP or IM)
  • CCO Administration
  • Women’s Healthcare Providers
  • Emergency Department
  • FQHC
  • Dental
  • CMHP (crisis services, residential, clinical)
  • Community Pharmacy
  • Public Health
  • Chemical Dependency

The QCC shall be staffed with appropriate representatives with clinical expertise and knowledge necessary to carry out the functions in section II. At the discretion of the Chairperson, representatives of any participant may attend QCC meetings as observers. The QCC may extend temporary membership to individuals who bring particular expertise needed for their work.

b. Term
There is no specified term of membership.

c. Chair Person
The PrimaryHealth Board of Directors has appointed the PrimaryHealth Director of Quality and Member Services as the chairperson.

VI. Reports
Committee recommendations and reports requiring Board level oversight will be submitted either verbally or in writing to the PrimaryHealth Governance Board. Documents will reflect both suggested action and justification for suggestions. The board will respond to such recommendations/reports in minutes.

VII. Annual Goals
The QCC may provide an annual report to the Governance Board. This may include a summary of items in section II, and any resulting actions. It shall also include current goals, and evaluation of previous goals set by the QCC.

VIII. Date Chartered
May 21, 2013

Reviewed: 4/5/2016