Transcript lessons learned from medi-cal managed care experience “what you

LESSONS LEARNED FROM
MEDI-CAL MANAGED CARE EXPERIENCE
“WHAT YOU DON’T KNOW COULD HELP YOU”
Mary Szecsey – Executive Director
www.wchealth.org
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Clinical Sites:
– Primary Care – Occidental, Guerneville, Sebastopol
– Dental and Mental Health Services – Guerneville
– Teen Clinic – Forestville
– Graton Labor Center Outreach
– Forestville Wellness Center
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Staff and Providers
– 125 employees in seven locations; 107 FTEs
– 17 medical providers, 2 dentists, 7 mental health counselors
and including .6 FTE psychiatrist
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Patients
12,306 individuals, 85 % under 200% of poverty level
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2012 Budget
$10.4 million
70% patient fees, 30% grants, contracts, fundraising
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Alexander Valley Regional Medical Center
Alliance Medical Center
Petaluma Health Center
Santa Rosa Community Health Centers
5. Sonoma County Indian Health Project
6. Sonoma Valley Community Health Center
7. West County Community Health Centers
Background
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Sonoma County has had several experiences with
Medi-Cal Managed Care including a Fee-for Service
Pilot Project back in the 1990’s
The FFS Program included all of the health centers
and was successful both in terms financial benefits to
the county and terms of coordinating care for
patients. Funding was withdrawn for unknown reasons.
Sonoma County health officials wanted to create a
County Organized Health System but the State would
not allow any new COHS.
Background - continued
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January 2005: Medi-Cal redesign plan called for
expansion of COHS model to Sonoma County
February 2006: Sonoma County formed a Managed
Medi-Cal Planning Group consisting of 23 people
from county government, health care providers
(hospitals, health centers, specialty care, skilled
nursing) and consumers.
Planning group was chaired by the Health Officer and
met monthly for ten months. Reviewed various options
and alternatives for program including creating a new
COHS and joining Partnership Health Plan
Criteria for Improved Medi-Cal System
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Access to Care – improve supply, benefits, timeliness
High Quality Care – compassionate, culturally
competent, prevention-focused and client-centered
Provider Reimbursement – fair reimbursement that
preserves safety-net
Operations – Efficient, cost effective and responsive
to providers and beneficiaries
Governance – locally accountable and locally
directed
Partnership Health Plan
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December 2006: Committee found that PHP substantially met
all of the established criteria and made a recommendation to
BOS to pursue relationship with PHP contingent on resolution of
following issues:
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Development of local/regional office and appropriate services in
Sonoma county;
Agreement on policies for assignment of members to medical homes and
on provisions for continuity of care during the transition along with other
operational issues;
Appropriate representation on the PHC Governing Board and
committees. Board and committee representation should reflect the
proportional size of the Counties participating in the Plan; and,
A governance structure that provides Sonoma county provider and
community members the on-going opportunity to address local issues
and be actively involved in the decision making process.
Partnership Health Plan
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2007/08: Local implementation group met with
Partnership Health Plan staff to discuss implementation
issues.
Delay in rate-setting at State caused implementation to
be pushed out to October 2009
During pre-implementation phase, PHC contracted with
providers, notified patients and developed its internal
infrastructure to double number of covered lives.
Health centers in RCHC decided to contract as a
group.
Pre-Implementation
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Joint contract developed with PHP
Code 19 applications submitted for wrap-around
payment
Patient notification – County, PHP, health centers
PHP Board and committee involvement – clinician
committee, strategic planning, board, quality
improvement program
Staff training – front office, billing, referrals
Experience to Date - Enrollment
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Roughly 53,000 Medi-Cal lives in Sonoma County
One-third are “special members”, not capitated or
assigned. Includes AIDS, foster children, medi-medi
Of the assigned lives, 80% are assigned to a health
center, 18% are assigned to Kaiser and only 2%
are assigned to private physicians
RCHC has an organized “retention” initiative to
send letters and make calls to clients when their
Medi-Cal is expiring
Services
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Some specialties are still hard to access but has
improved considerably
Quest lab contract was initially an issue, side
agreement that they also provide free services for
our uninsured
All six hospitals are contracted, has not impacted
historical practice patterns
Use Medi-Cal formulary for medications
Data and Quality
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Strong focus on data and reporting, both financial
and quality measures, HEDIS
Quality Incentive Bonus system jointly developed
with providers.
Technical assistance on data analysis from RCHN
and PHP
Not getting as much data was we would like in
terms of detail and timeliness
Quality Incentive Program Measures
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IP Days/1,000
Readmission rate
Generic rate
Formulary use
Specialty cost
Avoidable ED visits
PCP visits
# quarters practice is open
Electronic claims submission
Member satisfaction
HEDIS measures
Billing and Finances
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Good turnaround on clean claims.
Regular reports on denials and training for billing
staff.
Some impact initially on cash flow, important to
negotiate reasonable Code 18 rates.
Additional income from Quality Incentives, both at
Partnership and coalition level. Does not impact on
PPS rate.
Future Opportunities
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Complex Case Management Project
Patient Centered Medical Home Payment
Enhancements
340B program
Shared savings -ACO
Exchange Plan
CHC representation on PHP Board
QUESTIONS?
[email protected]