2.01 TRINITY COUNTY. County Contract No. Department Health & Human Services. Board Item Request Form Phone

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1 County Contract No. Department Health & Human Services TRINITY COUNTY 2.01 Board Item Request Form Contact Letty Garza Phone Requested Agenda Location Presentations AM Requested Board Action: Receive a presentation from Partnership Health Plan regarding Medi-Cal Managed Care. Fiscal Impact: No fiscal impact. Motion: Second Roll Call: Ayes: Nays: Tabled To: Action: Notes:

2 STAFF REPORT Subject: Receive a presentation from Partnership Health Plan about the conversion to Managed Medi-Cal. Date: September 10, 2013 ISSUE: Marta McKenzie of Partnership Health Plan to address the Board regarding the upcoming conversion to Managed Medi-Cal. ALTERNATIVES INCLUDING FINANCIAL IMPLICATIONS: 1) Informative presentation only RECOMMENDATION: Informative presentation only. Letty Garza, Deputy Director CAO RECOMMENDATION: Concur: Yes No Comments:

3 Partnership HealthPlan of California Medi Cal Managed Care Trinity County Board of Supervisors September 10, 2013 Presented by Marta McKenzie, RD, MPH, Interim Northern Region Executive Director

4 Today Brief introduction: Medi cal Managed Care Partnership HealthPlan Medical Home Payment Restructure Quality Improvement Enhanced Member and Provider Supports

5 The Change from Fee for Service (FFS) to Managed Medi Cal Governor Brown s February 2012 Budget intent that ALL 28 Counties with FFS (fee for service) Medi Cal would become Managed Medi Cal Not part of the Affordable Care Act Result: 18 counties to contract with Blue Cross and Centene (Health and Wellness California) Eight northern California counties to work with Partnership HealthPlan: Del Norte, Humboldt, Lake, Lassen, Modoc, Shasta, Siskiyou, Trinity Go live date for 8 counties: September 1, remaining now postponed to November 1, 2013

6 Statewide Expansion of Managed Medi Cal Three Models of Managed Medi Cal in California Geographic Managed Care (Sacramento, San Diego) Two Plan Model (LA, Central Valley, Bay Area and 20 new rural expansion counties) County Organized Health Systems Partnership HealthPlan of California (Solano, Napa, Yolo, Sonoma, Marin, Mendocino, Lake, Humboldt, Del Norte, Trinity, Shasta, Lassen, Siskiyou & Modoc) Cal Optima (Orange County) Central California Alliance (Santa Cruz, Monterey and Merced) CenCal (Santa Barbara, San Luis Obispo and San Benito) Gold Coast (Ventura) Health Plan of San Mateo (San Mateo)

7 What is Managed Care? Establishes contracted networks of care Greater emphasis on primary and preventive care Coordinated delivery of health services Primary Care Provider (PCP) and Healthplan collaboration, particularly for more difficult and complex members

8 Goals of Managed Health Care Deliver quality care in environment that manages and control costs Health care delivered is medically necessary and appropriate for the member s condition Care rendered by most appropriate provider and in leastrestrictive setting (largely driven by medical home/primary Care Provider)

9 Benefits of Managed Care Medical Home Case management Coordination of care Emphasis on prevention and wellness Health plans can offer more resources/quality Nurse advice lines Transportation assistance Help getting appointments with specialists Health Education opportunities Quality Improvement Programs Grievance systems Continuous Healthcare Effectiveness Data and Information Set (HEDIS) measurements Member and Provider support

10 County Organized Health System (COHS) Model of Managed Care Locally approved & operated managed care organization County Board of Supervisors approve model and provider, and appoint Governing Board members Capitated arrangements and full risk contracts Enrollment is mandatory all Medi cal members are under one model for most medical care (not dental, AOD, SMI)

11 Fundamental Difference FFS to Managed Care Model of Care Preventive Care Referral to Specialty Care Primary Care Health Home Health Education to promote Healthy Lifestyles Medical Care for Acute Chronic Illness 90% of Members Have a Selected or Assigned Primary Care Provider Site 10% Special Members

12 Who is a Special Member? (unassigned to a PCP) Share of Cost members 1 st month eligible (if they have not picked a PCP, and all members for Sept 2013 in the 7/8 new counties, and all new Medi Cal enrollees in the future) Long Term Care patients Members that do not live in County (out of county adults) Foster care placements Specific Medical conditions (dialysis, HIV/AIDS, CCS kids, etc.) Members with commercial health insurance coverage

13 How the Money Works State HealthPlan Contracts with the State Paid Per Member Per Month (PMPM) Capitation Rate HealthPlan HealthPlan Establishes Contracted Provider Network Includes all willing providers Providers PCP Capitation for assigned members for well and sick care Some visits generate additional fees for the PCP (hospital visit, vaccination) Many other services (pharmacy, labs, medical equipment, hospital care) paid per contracts

14 Who is Partnership HealthPlan Not for Profit Organization Began Operations in Solano County in 1994 Board Representation from participating counties $1.4 Billion Annual Budget Administrative costs < 5% 500 Employees (recruiting addl positions for expansion) Main Office Fairfield Regional Offices: Santa Rosa Eureka Redding

15 Our Goals Create a local system of care for Medi Cal members Improve access to care Focus on primary and preventive care Reduce use of Emergency Room for routine care Improve the quality of care Increase provider reimbursement Increase scope of services to the member Run a locally responsive organization

16 Mission Driven

17 Governance Board of Directors 24 members, appointed by county BOS to 32/34 (2014) Mix of providers, consumers, advocates and county officials Committees Finance Committee Physician Advisory Committee Quality, Credentialing, Peer Review, Pharmacy Physician Advisory Committee Provider Advisory Group

18 Who is impacted? Managed Medi Cal Expansion Trinity County Healthy Families 212 Rural Medi Cal Expansion 2,532 CMSP/LIHP 382 Newly Eligible for Medi Cal 253 Total PHC Members 3,379 Readiness: Challenges: Infrastructure Provider Capacity Hiring additional staff Specialty Access Enrollment Strategy Larger geography Expanded Case Management Quality and Efficiency One in four residents will have Medi Cal Coverage (25% of Total Population)

19 Medi Cal Covered Services PHC Covered Benefits Primary Care Specialty Care Lab and Diagnostic Imaging Hospital Services Pharmacy Long Term Care Maternity Care CHDP CPSP Benefits Paid by State/County Mental Health Dental Care HIV/AIDS Medications AODS CCS Psychotropic Medications

20 Enhanced Services Benefits Pulmonary Rehab Podiatry (for diabetics) AODS Supplemental Services Nutrition Counseling Weight Management Transportation Clinical Support Care Coordination Care Transitions Complex Case Management Growing Together Perinatal Program 24/7 Advice Nurse Program Provider & Member Support Member Services Department Local Provider Relations Staff Claims Customer Service Quality Improvement Program Committee Structure Local Governance

21 Quality Improvement Program Only for Primary Care 20 % 30% PCP Reimbursement from Quality Outcomes Used to promote positive behavior change in both quality, efficiency & patient experience (Triple Aim) $20 $15 $10 $5 $ 30% $60% Primary Care Payment PMPM 100% QIP Other FFS CHDP Primary Care Cap

22 Clinical Domain (20 Points) First Year QIP Family Medicine and Internal MedicineSites: Cervical Cancer Screening (women aged years of age) Pediatric Medicine Sites: Childhood Immunization DTaP( members 2 years of age) Appropriate Use of Resources (40 Points) AllSites: Pharmacy Utilization following formulary/generic Access and Operations 40 points; 10 points for each measure) AllSites: PCP Office Visits Avoidable ED Visits (2.2 ayear members plan overall average) Practice open to PHC members Submit data on Third Next Available Appointment (3NA), No Show Rate, Call Abandonment Rate, Provider continuity (2 quarters of data) Targets set at 90% percentile all Medicaid Plans with provision for relative improvement

23 Clinical Domain Second Year QIP Focus Well Child Visits (3 6 years) Childhood Immunization HepB Adolescent Immunization Child BMI (3 17 yrs) Nutrition Counseling (3 17 yrs) Physical Activity Counseling (3 17 yrs) Cervical Cancer Screening Diabetes Management (18 75 yrs) (Select 4 out of 7) LDL control, LDL testing, HbA1C testing, HbA1C control, Retinal eye exam, Nephropathy, Blood pressure control Monitoring for Patients on Persistent Medications Controlling High Blood Pressure

24 Second Year QIP Focus Appropriate Use of Resources Acute bed days/1000 OR Follow up post discharge Readmission Rate OR Follow up post discharge* Pharmacy Utilization Specialist Referral Management (Total number of specialty office visits only) *Follow up post discharge can be the back up measure for either acute bed days/1000 or readmission rate, but not both. Specialist Referral Management (Total number of specialty office visits only)

25 Access & Operations Avoidable ED Visits Practice open to PHC members PCP Office Visits (6 pts) Second Year QIP Focus Submit data on 3NA, No Show Rate, Call Abandonment Rate, Provider continuity (4 out of 4 quarters) Patient Experience Survey Option: Implement a survey Training Option: Participate in an external patient experience learning collaborative or program that is approved by PHC

26 Second Year QIP Focus Unit of Service/Ala Carte Menu Advance Care Planning attestations PCMH Certification Access/Extended Office Hours Peer led self management support groups (both new and existing) Registration & Utilization of the California Immunization Registry (CAIR)

27 Other Benefits Member Services Call Center General information about medical benefits Select or change the primary care doctor or medical group Check eligibility Problems getting appointments Schedule transportation Order new ID card Solve Billing/Claims problems Referral to specialist problems Problems or complaints regarding medical care Monday Friday 8:00 am 5:00 pm #

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29 Provider Network What Providers will be included in the PHC provider network? PHC expects that most all providers currently seeing Medi Cal patients will be included in PHC s provider network. PHC s goal is to increase the number of providers willing to see Medi Cal recipients. We have achieved that goal in all counties in which we serve.

30 Partnership HealthPlan of California Medi Cal Managed Care Program Trinity Provider Directory Hayfork: Hayfork Community Health Clinic Mad River: Southern Trinity Health Services Weaverville: Trinity Community Health Clinic Trinity Hospital (Hospital Provider) Specialists can be found in specialist directory on website:

31 Provider Satisfaction Question Overall satisfaction with PHC The Plan processes my claims w/in 30 days I am satisfied with the Plan s referral auth process (RAF). Practices that use PHC e eligibility system Rating the consistency/ knowledge of Plan staff Rating the responsiveness of phone calls Rating the helpfulness of the Plan s staff PCP 97% 91% 94% 86% 95% 98% 97% Specialist 97% 80% 80% 84% 89% 98% 99%

32 Provider Services Available to Assist Providers with contracting, claims, other Kelley Sewell, Northern Director of Provider Relations/Member Services (707) Mary Kerlin, Director of Provider Relations Darryl Crowder, Provider Contracts Manager

33 Commitment to Excellence 2012 HEDIS scores (Healthcare Quality measures): In all counties, none of the measures scored Low Many of the measures scored Outstanding (better than 90% of Health Plans nationwide) Star Ratings (Medicare Plan): Rated a Four Star Plan by CMS (In the top 13 percent of plans nationwide) Received 2013 DHCS Best Plan Award Tops Among 21 California Health Plans Employee Satisfaction Survey Not less than 79% satisfaction on any measure. Average score for all measures: 91%

34 Questions? Contact Us At: Marta McKenzie, RD, MPH Interim Executive Regional Director (707) Mike Vovakes, MD Northern Region Medical Director (707) Jack Horn, Partnership HealthPlan CEO, Mt Whitney