lessons learned from medi-cal managed care experience “what you don’t know could help you”...
TRANSCRIPT
LESSONS LEARNED FROM
MEDI-CAL MANAGED CARE EXPERIENCE
“WHAT YOU DON’T KNOW COULD HELP YOU”
Mary Szecsey – Executive Directorwww.wchealth.org
• Clinical Sites:– Primary Care – Occidental, Guerneville, Sebastopol– Dental and Mental Health Services – Guerneville– Teen Clinic – Forestville– Graton Labor Center Outreach – Forestville Wellness Center
• Staff and Providers– 125 employees in seven locations; 107 FTEs– 17 medical providers, 2 dentists, 7 mental health counselors
and including .6 FTE psychiatrist
• Patients• 12,306 individuals, 85 % under 200% of poverty level
• 2012 Budget• $10.4 million• 70% patient fees, 30% grants, contracts, fundraising
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5. Sonoma County Indian Health Project 6. Sonoma Valley Community Health Center7. West County Community Health Centers
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1. Alexander Valley Regional Medical Center
2. Alliance Medical Center 3. Petaluma Health Center4. Santa Rosa Community Health Centers
Background 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 Funding was withdrawn for unknown reasons.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 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 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
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: 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
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
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 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
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
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 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
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
Complex Case Management Project Patient Centered Medical Home Payment
Enhancements 340B program Shared savings -ACO Exchange Plan CHC representation on PHP Board
