Chief Medical Officer
Resume:
EMILY R. FONDA, MD, MMM, CHCQM
Diplomate of the American Board of Internal Medicine
Master of Medical Management
Diplomate of the American Board of Qual i ty Assurance & Uti l i zation Review Physicians
(9 4 9) 9 3 9 - 2 8 8 5 emil adpp91@r.postjobfree.com
EXPERIENCE
CALOPTIMA CHIEF MEDICAL OFFICER
ORANGE, CA DEPARTMENT OF MEDICAL MANAGEMENT
Dec. 2013 – present March 2021-present
Interim Chief Medical Officer
DEPARTMENT OF MEDICAL MANAGEMENT
December 2020 – March 2021
• Ensures the CalOptima mission: to provide members with access to quality health care services delivered in a cost-effective and compassionate manner.
• Supervises functional areas including Utilization Management, Quality Management, Case Management, Disease Management, Long-Term Services and Supports, Pharmacy, Behavioral Health, Health Education, Credentialing, and PACE COVID-related activities for members and staff with 12 direct reports.
• Oversees the Orange County Nursing Home COVID Infection Prevention Program that provides training for healthcare staff to protect themselves and long-term care members along with environmental staff during the pandemic in conjunction with the OCHCA and a UC Irvine Epidemiology team beginning May 2020 in anticipation of the COVID resurgence and funded by a one-year $630,000 grant.
• Directs the expansion and extension of the OC Nursing Home COVID Infection Prevention program funded with $1.2 million by the CalOptima BOD January 2021 to overcome vaccine hesitancy among nursing home staff and promote vaccine confidence among CalOptima nursing home residents.
• Champions non-monetary gift certificate incentives for CalOptima COVID vaccine recipients with $35 million in funding approved by the Board.
• Administers a non-monetary gift certificate as a COVID vaccine incentive for the CalOptima homeless population to be distributed by mobile Clinical Field Teams at shelters, recuperative care sites and hot spots with $400,00 funding.
• Directs continuation and expansion of the Post-Acute Infection Prevention Quality Initiative among 27 nursing homes started October 2019 to combat Multi-Drug Resistant Organisms (such as MRSA) in OC Nursing Homes by subsidizing and incentivizing the substitution of regular liquid soap with Chlorhexidine soap with Page 2 of 8
Board approval of a total of $5.7 million in funding. Data analysis presented at ID Week showed that nursing homes participating in either the intensive COVID-19 prevention training program or the PIPQI program experienced 42% fewer cases of COVID in nursing home staff and 54% fewer cases of COVID in nursing home patients compared to control nursing homes.
• Winner of the mPulse mobile Achieving Health Equity Award at Activate 2021 for the CalOptima COVID Vaccination Campaign- October 2021
• Acknowledged by California Assemblywoman Petri Norris with an Assembly Resolution for the CalOptima PACE contribution to Orange County Seniors over the last 8 years – October 2021
• CMS audit score from July 2021 of 0.59, which was in the top 25% across 52 health plans in the published audit scores among comparable lines of business from 2018 and 2019.
• Winner of the DHCS Managed Care Quality Conference Member Satisfaction Award 2021 for Adults in a large scale plan.
• Prepares materials for and participate in public meetings including Board of Directors, Quality Assurance Committee, Provider Advisory Committee, Member Advisory Committees in addition to participation in committees reporting up to the Board.
• Maintains and improves CalOptima’s National Committee on Quality Assurance (NCQA) accreditation scores (100% July 2021) and Centers for Medicare & Medicaid Services
(CMS) ratings.
• 2021-Named by NCQA as one of the top Medi-Cal Plans in California for the 7th consecutive year.
• Ensures Medical Affairs is fully prepared for all regulatory and NCQA routine audits.
• Recruits, develops, and retains a strong management team within Medical Affairs.
• Works effectively and collaboratively with the CalOptima senior leadership team.
• Represents CalOptima to state and federal regulators, accreditation organizations and other local and national health care professional organizations, associations, and partnerships.
• Provides COVID-19 updates and vaccine hesitancy presentations for the OC Register newspaper, Channel 7, Channel 4, Angel’s Radio and informational videos. DEPUTY CHIEF MEDICAL OFFICER
DEPARTMENT OF MEDICAL MANAGEMENT
October 2019 – December 2020
• Ensures delivery of quality healthcare to CalOptima members, including the development and implementation of programs, policies and procedures and strategic planning for the County Organized Health Plan of Orange County responsible for approximately 800,000 lives.
• Provides leadership and operational oversight of the following medical divisions: Quality Improvement, Quality Analytics, Utilization Management, Long-term Services and Supports, Case Management, Behavioral Health Integration, Population Health, Page 3 of 8
Enterprise Analytics, Program of the All- Inclusive Care for the Elderly (PACE), Grievances and Appeals, Data Management, Pharmacy and other clinical programs.
• Maintains and improves community standards for participating providers.
• Provides clinical oversight for all contracted health networks.
• Acts as a liaison with community partners, such as Providers, County agencies, Regulators and Community Stakeholders.
• Prepares materials for and participate in public meetings including Board of Directors, Quality Assurance Committee, Financial Advisory Committee, Provider Advisory Committee, Member Advisory Committees and various Stakeholder meetings.
• Maintains oversight of 5 physician direct reports.
• Oversees concurrent, prior authorizations and retroactive reviews for Utilization Management.
• Assists the CalOptima Legal Department with medical issues and case reviews.
• Assures a collegial interaction with local hospitals, medical staffs and providers from delegated networks.
• Maintains and improves CalOptima’s National Committee on Quality Assurance (NCQA) accreditation scores and Centers for Medicare & Medicaid Services (CMS) ratings.
• Ensures Medical Affairs is fully prepared for all regulatory and NCQA routine audits.
• Reviews and testifies regarding case decisions during audits for CMS, DHCS and NCQA.
• Represents CalOptima to state and federal regulators, accreditation organizations and other local and national health care professional organizations, associations and partnerships.
• Reviews cases and participates in Peer Review.
MEDICAL DIRECTOR
DEPARTMENT OF MEDICAL MANAGEMENT
December 2013 – October 2019
• Chairperson Whole Child Model Clinical Advisory Committee 2019.
• Chairperson Long Term Services and Supports Quality Committee 2013-2019.
• Physician Champion in support of Project OC SHIELD since 6/18 conducted by UC Irvine Infectious Disease Professor, Dr. Susan Huang, that demonstrated a 25% reduction in colonization of Multi-Drug Resistant Organisms (MDROs) in 16 of CalOptima’s contracted skilled nursing facilities using a bathing protocol with Chlorhexidine wash and Iodophor nasal swabs to achieve infection prevention. To date, there is a significant decrease in inpatient hospitalizations for infection in our study group, and tremendous interest by the Center for Disease Control to follow Orange County progress. On 6/6/19, CalOptima’s Board of Directors approved $2.3 million to expand the project to include all 67 contracted skilled nursing facilities with a nursing staff trainer provided by the CDC.
• Participated in implementation of the Palliative Care Program for Medi-Cal per SB 1004, the Whole Child Model with upcoming CCS transition to CalOptima, the Whole Person Care Program, Health Homes Program, and LTSS work group to reduce readmissions, reporting Hemophilia processes to DHCS, Diabetes program to improve control for Page 4 of 8
patients with HgbA1c > 9, appeals training for GARS regarding SNF discharges, expert testimony for LTACH and hospital admissions.
• Conducts Interdisciplinary Care Meetings for OneCare Connect members and Seniors as well as occasional Persons with Disabilities (SPD) with Primary Care Physician participation and very positive member responses.
• Participates in attaining and maintaining CalOptima’s #1 Medi-Cal Health Plan rating in California for six years in a row per NCQA Medicaid Health Insurance Plan Ratings with a Commendable accreditation status.
• Responsible for daily cases in prior authorization, concurrent review, and retrospective reviews as well as Potential Quality Issues and Appeals cases; also responsible for all OneCare and OneCare Connect Administrative Law Judge hearings and some State Fair Hearings.
• Following a OneCare audit of November 2013, prior to my arrival, CMS imposed sanctions, consisting of a halt to new membership and delay in planned initiation of OneCare Connect Program (Cal MediConnect); subsequently assisted with reorganization and CMS resubmission of the OneCare Model of Care, including a new system of Personal Care Coordinators (PCCs) for each member and new Health Risk Assessment (HRA) in accordance with DHCS and NCQA requirements.
• Assisted with initial and ongoing training of PCCs.
• Developed a new OneCare Health Risk Assessment (HRA) and implemented newly required Interdisciplinary Care Team (ICT) meetings with Individual Care Plans for every OneCare member (17,000 in total).
• Developed an Initial Care Plan (iCP) with recommendations in line with NCQA, HEDIS, CMS, CDC, and USPSTF guidelines and derived from HRA responses.
• Responsible for all OneCare PCP and Physician Medical Group trainings (11 Groups) as well as Pharmacy trainings to utilize the Medication Review Tool.
• Additionally, developed an automated OneCare Initial Care Plan (iCP) based on HRA answers and supportive of HEDIS, CMS, and USPSTF measures.
• Assisted with successful completion of NCQA, CMS, and DHCS audits.
• Physician champion of a Cognitive Health Program in conjunction with the Hoag OC Vital Aging Program – consisting of Minimal Cognitive Impairment Testing with the MCI Screen
(97% accuracy) – Contact: Dr. Rod Shankle.
• Assisted in the development of a Medication Review Tool with 5 automated HEDIS and CMS Quality Measures for cases of Polypharmacy (> 6 medications), viewed as “cutting edge” by CMS and championed its use for all members.
• The CMS re-audit of January 2015 exceeded all expectations for success.
• Instituted changes for the Medi-Cal Seniors and Persons with Disability Program (SPD) to align with OneCare, including a new HRA, iCPs, Personal Care Coordinators, and ICTs for high-risk members.
• Assisted with the development of the first Pediatric Health Risk Assessment accepted by the State of CA and assisted with developing an automated Initial Care Plan for Pediatrics.
• Medical Director in charge of developing a Home Health Program compliant with the Affordable Care Act.
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• Developed a Long-Term Care Program for OneCare Connect in which frequent visits and Treatment in Place were encouraged by Physician incentives and facility incentives by temporary transfer to Skilled Nursing Facility level of care; this was done due to high admission and readmission rates in accordance with 2016 HEDIS measure for Ambulatory Care Sensitive Conditions; the Treatment in Place (TIP) program was adopted.
ORTHONET (NATIONAL MANAGED CARE CONTRACTOR)
Long Beach, CA
REGIONAL MEDICAL DIRECTOR
October 2011– December 2013
• Responsible for Pre-Certification, Concurrent review, Retrospective reviews, Focused Claims Reviews, and Post-acute reviews at the Inpatient/Ambulatory Surgery/Observation levels to Long Term Acute Care, Acute Inpatient Rehabilitation, or Skilled Nursing facility level of care for twelve insurance contracts at 30-50 cases per day
(Total average 150-200 cases reviewed per day including focused claims reviews).
• Developed and delivered formal Inter-rater in-service Teaching programs with composition of quarterly Inter-rater reliability testing for nurse case managers as a Quality Improvement Project for URAC recertification.
• Developed, implemented, and presented a Quality Improvement Project (QIP) for Home Safety Evaluations for URAC recertification.
• Led the URAC company recertification for 3 years beginning in July 2013 with a 100% approval rating (without criticism) in the California office.
• Developed an official Policy & Procedure for Multi-specialty Medical Directors responsible for Focused Claim Reviews.
• Responsible for Dermatology Focused Claim Reviews for multiple contracts.
• Chairperson of the weekly, company-wide Utilization Management meetings involving post-acute care, continued case manager education, and case review.
• Daily interaction with case managers, providers, CMO’s, Physician Advisors, National Clinical, and Non-Clinical Managers of multiple commercial insurers.
• Devised an approach to Decision Making for Case Reviews as a tool for increasing inter- rater reliability between New York and California nurse case managers; this paper is still used as a basis for quarterly inter-rater case sample testing.
• Analyzed and improved contractual work-flow processes for the Long Beach office.
• Responsible for continuous employee oversight for approx. 70 total staff members, including nurse case managers, contract assistants, and physical therapists.
• Executed Physical Therapy retrospective reviews.
• Attended weekly national Humana upper management meetings and quarterly similar United Health Care meetings.
• Orchestrated weekly case management meetings with Oxford (UHC) covering post-acute transitions of care at all levels for the tri-state area of New York, New Jersey and Connecticut.
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• Responsible for increasing the rate of changing inpatient admissions to ambulatory surgery from 7% to 25% in 2013.
EXECUTIVE HEALTH RESOURCES (EHR) - OPTUM
Malvern, PA
SENIOR DIRECTOR: AUDIT, COMPLIANCE, & EDUCATION FOR EXECUTIVE March 2011– October 2011
• Nationwide travel to hospitals aimed at producing specific medical necessity audits, interpreting/presenting PEPPER reports, and providing Physician Education presentations regarding Recovery Audit Contractors/Medicare Administrative Contractors, Compliance, and Concordance for individual hospital medical staffs/UR Committees across the country.
EXECUTIVE HEALTH RESOURCES (EHR) – OPTUM
October 2008 – March 2011
• Physician Advisor performing concurrent inpatient reviews for 1500 contracted hospitals across the U.S. .
HOAG MEMORIAL HOSPITAL
Newport Beach, CA
INTERNAL MEDICINE PRIVATE PRACTICE
July 1982– October 2002
• Elected 1st female Chairperson of the Department of Medicine with 180 members; served from 1993 to 1995.
• Served as an active Medical Staff member in good standing at Hoag Memorial Hospital, Newport Beach, CA from 1982 to 2002.
• Expert witness experience including extensive chart review and deposition for malpractice questions from 1996 to 2000.
• Private practitioner of Internal Medicine with a solo practice in Newport Beach, CA from 1982 to 1998; responsibilities included managed patient care from 1995 to 1997 and locum tenens until 2002 with extensive experience in outpatient, inpatient management, extended care (including intensive care and emergency medicine), in addition to case management/utilization review of concurrent cases, retrospective cases, and insurance denials.
• Developed clinical pathways for pneumonia and stroke at Hoag Memorial Hospital in 1998.
• Widely experienced in credentialing and medical staff reappointment reviews from 1992 to 1996.
• Garnered lengthy expert testimony experience in 1993 at the California Appellate Court level on behalf of Hoag Hospital (>500 beds) regarding 50+ retrospective case management Page 7 of 8
issues dating back ten years as the only physician witness to protect Hoag Hospital from refunding over 10 million dollars in prior Medicaid reimbursements.
• Earned considerable expertise in utilization management, including concurrent and retrospective review with emphasis on quality assurance, risk management, and continuous quality improvement beginning in 1990 as the sole Hoag Hospital Physician Advisor to Utilization and Review.
• Worked closely with physicians, case managers, social workers, and hospital administrators for the benefit of patients with consideration for hospital solvency and compliance. PUBLICATIONS
• Barr, M.D., Ron, Valdes, Emily. Plastic Embedding of Cutaneous Specimens; An Important Diagnostic Aid in Mycosis Fungoides. Journal of Cutaneous Pathology, February 1982.
EDUCATION
• M.M.M. DEGREE: Master of Medical Management, Marshall School of Business, University of Southern California; Dean’s Scholar; completed in March 2010
• American College of Physician Executives Certification Part One; completed in August 2009
• American College of Physician Executives Peer Review Certification; completed in 2008
• UCLA Screenwriting Certificate; completed in 2008
• RESIDENCY INTERNAL MEDICINE: University of California, Irvine Medical Center, Orange, CA
• INTERNAL MEDICINE INTERNSHIP: Hospital of the Good Samaritan, Los Angeles, CA
• M.D. DEGREE: University of California Irvine School of Medicine
• B.S. DEGREE: Biological Sciences, University of Southern California ACCREDIDATIONS, LEADERSHIP, & AWARDS
• Proficient in Compliance and Education teamwork
• Quarterfinalist in the AAA Screenwriting competition (teleplay episode) in 2009 for the screenplay, HOUSE M.D.: SPELLBOUND
• Finalist in the Movibytes Screenwriting competition (mystery/thriller genre) in 2008 for the novel, OPEN HEART
• Member of the American College of Physician Executives
• From 2002 to 2008, actively participated in Premier League soccer teams, sailing teams, traveling club baseball, and national/international sailing competitions of both children
• Active Staff Member in good standing with Hoag Memorial Hospital (Newport Beach, CA; 1982-2002) with recognition
• Member of the Cancer Committee at Hoag Memorial Hospital from December 1995 to October 1996
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• Member of the Medical Care Improvement Committee at Hoag Memorial Hospital from October 1992 to October 1994
• Member of the Medical Executive Committee at Hoag Memorial Hospital from October 1992 to October 1994
• Chairperson of the Department of Internal Medicine Core Committee and Credentials and Discipline Board at Hoag Memorial Hospital from October 1992 to October 1994
• Member of the Medical Chart Review and Audit Committee at Hoag Memorial Hospital from October 1991 to October 1996
• Sole Physician Advisor for Hoag Memorial Hospital from September 1992 to October 1995
• Member of the Hoag Memorial Hospital Utilization Review Committee from October 1990 to October 1995
• Vice-Chairperson of the Department of Internal Medicine at Hoag Memorial Hospital from October 1994 to October 1996
• Chairperson of the Department of Internal Medicine at Hoag Memorial Hospital (170 Physician Members); elected as the Department of Medicine’s first female chairperson; served from October 1992 to October 1994
• Diplomate of the National Board of Medical Examiners
• United States Drug Enforcement Administration License—active and in good standing
• Medical Board of California Physician and Surgeon License—active and in good standing
• Diplomate of the American Board of Quality Assurance and Utilization Review Physicians 1995—current and in good standing
• Diplomate of the American Board of Internal Medicine—current and in good standing PERSONAL DATA
• Born in Baltimore, Maryland; raised in San Diego
• Maiden surname is Valdes; two children–one graduated from Cornell University and the Culinary Institute of America, while the other graduated from USC, earned a Master of Irregular Warfare from the Naval War College, and completed George Washington Law School while working as a Congressional Chief of Staff
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