Partnership HealthPlan of California Napa County Board of Supervisors Report

Transcription

1 Partnership HealthPlan of California Napa County Board of Supervisors Report Mission: To help our members, and the communities we serve, be healthy Vision: To be the most highly regarded managed care plan in California

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3 Contents Partnership HealthPlan of California Overview... 2 History Origin and Growth... 2 PHC is a County Organized Health System (COHS) Plan... 3 Membership... 4 PHC Demographics... 5 Revenue... 6 Programs... 6 Napa County... 8 Membership... 8 Providers... 8 Demographics... 8 PartnershipAdvantage Managing Pain Safely Quality Improvement Conclusion Page 1 of 11

4 Partnership HealthPlan of California Overview Partnership HealthPlan of California (PHC) is a non-profit community based health care organization that contracts with the State of California and local counties to administer Medi-Cal health care benefits through local care providers. With four regional offices in Eureka, Fairfield, Redding, and Santa Rosa, PHC provides quality health care to 500,000 1 members Figure 1: PHC Service Area - Regional Offices Eureka Fairfield Redding Santa Rosa (See Figure 1). History Origin and Growth PHC was formed from a broad base of community organizations focused on health care issues in Solano County. This coalition comprised the Solano Coalition for Better Health (SCBH). In 1988, SCBH set out to address the problem of health care access for Solano County's growing number of medically uninsured and underserved; at the time Solano County s three hospital emergency room facilities were used as the primary source of care for the counties Medi-Cal residents. Originally named Solano Partnership HealthPlan, we provided services to 44,000 Medi-Cal members in our first year. Shortly after beginning to provide care in Solano County, Napa County approached PHC to discuss expanding into the neighboring county. In 1998, Solano Partnership HealthPlan became Partnership HealthPlan of California as we began providing services in Napa County. Since that time four additional expansions occurred in which Del Norte, Humboldt, Lake, Lassen, Marin, Mendocino, Modoc, Shasta, Siskiyou, Sonoma, Trinity, and Yolo counties Figure 2: PHC Expansion Timeline Operations began in Solano County Future 1 Note All enrollment figures cited in this report are as of Nov. 1, 2014 Page 2 of 11

5 became partners with PHC (See Figure 2). Today, PHC is the largest (geographically) public plan in California. PHC is a County Organized Health System (COHS) Plan The COHS managed care model ensures Medi-Cal recipients have access to comprehensive, cost-effective health care. Each COHS plan is sanctioned by the County Board of Supervisors and governed by an independent commission (See Figure 3). As PHC is one of six COHS plans, there are many benefits afforded to members, providers, counties, the State of California, and other community organizations. With the COHS model, PHC is able to save California about 10 percent compared to traditional Medi-Cal, while providing improved access and quality of care. The COHS structure allows us to work in connection with safety net providers and invest more into the health of our members and communities. As a comprehensive managed care plan, PHC is able to coordinate with public health programs within a county to improve care. Working with each county PHC is able to facilitate voluntary intergovernmental transfers (IGT) to bring in additional Medi-Cal funds. An IGT allows a local governmental entity to contribute funds towards Medi-Cal services in their community and in turn receive matching funds from the Federal Government. In over $316 million of new Federal funds were given to California as a result of IGTs. Each county also has at least one member on our Board of Commissioners. For providers, PHC has a higher payment than fee-forservice Medi-Cal as well as performance based incentives. Additionally, our fully staffed claims department allows providers to directly bill PHC for services and receive payment in about 30 days. In comparison, providers that submit claims to the state may have to wait up-to 90 days to receive payment. As a result of a higher reimbursement rate to providers, PHC is able to provide better access to care for members. We are committed to ensuring that members receive the care and assistance they need, we employ care coordinators to help members navigate the care that includes appointments with specialists, transportation, etc. Additionally, our call center is open Monday-Friday from 8 a.m. to 5 p.m. Lastly, members are also given the opportunity to participate in various work groups so that we are able to better understand the needs of the community. Page 3 of 11

6 Membership As mentioned previously, in 1994 PHC had 44,000 members in its first year of operation in Solano County. With each additional expansion our membership has progressively increased. The largest increase in membership has occurred over the past year as PHC expanded into California s northern most counties in As seen in Chart 1, this latest expansion saw our membership grow from 232,187 in August to 343,520 in October. The largest growth in membership began in January as the State of California s Medi-Cal expansion as part of the Patient Protection and Affordable Care Act (ACA) went into effect. Since January 1, 2014, the number of PHC members in the 14 counties we serve has swelled from almost 376,000 to over 502,700. Additionally, the state last reported a backlog of 171,000 Medi-Cal applications statewide that are still being processed. Once this backlog is cleared we expect to have more than 500,000 Medi-Cal members enrolled in PHC. Chart 1: PHC Membership Year # of Members Year # of Members Year # of Members , ,195 Aug , , ,409 Oct , , ,748 Current 502, , ,881 PHC members consist of some of the most vulnerable populations that include but is not limited to: low income members in rural counties; children (42 percent of members are under the age of 19); those with disabilities physical, alcohol and drug dependency; mental illnesses; and elderly (9.3 percent of members are over the age of 65). With the wide range of health needs from our members it is imperative that we partner with community safety net organizations to ensure our members and communities are healthy. Page 4 of 11

7 120,000 PHC Demographics PHC Demographics Membership Per County 104, ,000 98,796 80,000 60,000 56,662 47,641 40,000 41,590 32,885 32,082 24,979 25,841 20,000-14,744 10,221 6,389 2,696 4,093 Del Norte Humboldt Lake Lassen Marin Mendocino Modoc Napa Shasta Siskiyou Solano Sonoma Trinity Yolo Age Gender 20% 23% 9% 2% 7% 7% 15% 8% 9% % 53% Female Male 4% Language 1% Ethnicity 17% English Spanish 13% 7% African American Caucasion 78% Tagalog Other 26% 8% 46% Filipino Hispanic Other Page 5 of 11

8 Revenue Our primary focus over the years is ensuring that we are good stewards of our revenue, as members place a large amount of trust in our ability to deliver services. With each expansion PHC has completed the appropriate analyses to determine the viability of adding each county without impacting the care provided to current members. In Fiscal Year (FY) 2013/2014 PHC s revenue reached $1.6 billion (See Chart 2); in FY 2014/2015 PHC is anticipating revenue to reach about $2.3 billion. Chart 2: PHC Revenue (in thousands) 2,000,000 1,500,000 1,000, ,000 - Year Revenue Year Revenue Year Revenue 1994 $ 94, $ 269, $ 913, $ 106, $ 327, $ 1,600, $ 102, $ 607,016 FY $ 2,300, $ 155, $ 907,771 Programs PHC currently provides care to individuals through three programs Medi-Cal, Healthy Kids, and PartnershipAdvantage. The Healthy Kids program, which began in 2005, is a joint partnership between PHC and Napa, Solano, Sonoma, and Yolo Counties to offer healthcare coverage for uninsured children under the age of 19 who are not eligible for full scope Medi-Cal. Note that, in Sonoma County children must be under the age of 6 to be eligible. This program provides care to nearly 1,300 children. Beginning in the fall of 2006, PHC contracted with the Centers for Medicare and Medicaid Services (CMS) to offer PartnershipAdvantage in Napa, Solano, and Yolo Counties. This program is designed to serve low income seniors and persons with disabilities by combining Medicare, Medi-Cal, and prescription drug coverage into a single comprehensive healthcare package. In 2013, PartnershipAdvantage was recognized by CMS as a 4-star plan, which made Page 6 of 11

9 the PartnershipAdvantage plan the only 4-star plan in California. Currently, there are over 8,000 individuals who are enrolled in the program. Note: With the expansion of Medi-Cal in January of 2014, the State of California ended the Healthy Families program that PHC began offering in All of those individuals that qualified for Medi-Cal were automatically enrolled into Medi-Cal. Page 7 of 11

10 # of Members Napa County This year, 2014, marks the sixteenth year that PHC has provided Medi-Cal managed care in Napa County. It is no secret that our success over nearly two decades in the county has been directly dependent on our many community partners that include hospitals, clinics, safety net organizations, providers, local officials, and many more. These partnerships will remain critical as we continue to improve the health of our members in Napa County. Membership There are over 25,841 PHC members in Napa County: 24,767 Medi-Cal 2 o ACA Expansion in Napa County Prior 17,750 3 After 19, ,074 PartnershipAdvantage Providers There are approximately 324 providers contracted with PHC to provide care in Napa County: Mid-Level 65 PCP 37 Specialty 222 Demographics The majority of our members in Napa County, 46 percent, are under the age of 20 (See Chart 3). This trend holds true for each of the other 13 counties. The next highest age group in Napa County is at 18 percent. As the majority of our members are adolescents we have a greater responsibility to ensure that they have access to the care that they need to have healthy lives now and as adults. Chart 3: Napa County PHC Member Ages ,266 4,361 4,658 1,966 2,482 2,629 3,248 1, As of Nov. 1, As of Dec. 1, As of March 1, 2014 Page 8 of 11

11 In Napa County the three most prominent ethnicities are Hispanic (49.8 percent), Caucasian (32.2 percent) and Filipino (7.9 percent). Additionally, the three most prominent languages spoken by our members in Napa County are English, Spanish, and Tagalog (See Chart 4). Chart 4: Ethnicity and Language Ethnicity Language 1% 2% 10% Hispanic English 32% 50% Filipino Caucasion Other 39% 58% Spanish Tagalog Other 8% Page 9 of 11

12 Per Member Per Month PartnershipAdvantage We are proud to have been able to provide high quality health care services to our community through our PartnershipAdvantage (PA) program for more than seven years. In fact, PartnershipAdvantage is the only health plan in the state of California to have been awarded four stars by the Centers for Medicare & Medicaid Services (CMS), the Federal agency that oversees these programs. Although we have explored a number of options, unfortunately, reimbursement rates have not kept pace with the rise in health care costs, exhausting the federal funds that support the PA program (see chart 5). Although we would like to continue providing these services to our members, current California state law prevents us from using State funds (Medi-Cal) to support Federal programs (PartnershipAdvantage). Chart 5: PartnershipAdvantage Revenue and Total Expense $1,500 $1,400 $1,300 $1,200 $1,100 $1,000 Revenue Total Expense CY 2009 CY 2010 CY 2011 CY 2012 CY 2013 CY 2014 (proj) Beginning in October, members were notified by letter as to the ending of this program. The letter contained additional resources in each county were PA members can receive care. It is important to note that the ending of the PA program in no way affects members Medi-Cal benefits. Additionally, we are encouraging members to call us to get all their questions answered and provide them with the necessary information or resources to get access to the care they need. We are also actively working with the Health Insurance Counseling & Advocacy Program (HICAP) and Medicare to connect members to care options in their respective county. Lastly, we will be reaching out to those who are high users of various benefits to ensure that they have access to the resources they need to remain healthy. Page 10 of 11

13 Managing Pain Safely PHC began focusing on curbing the harmful effects of the high rate of misuse of pain medications in each of the 14 counties. This effort will not be a focus for a single month, but is a long term goal in helping our members become healthy. Figure 4: Opioid Use Why is this important? In the last decade, the death rate from opioid overdoses has quadrupled, making opioid overdose as common a cause of death as motor vehicle accidents. For every overdose death, there are 130 people who have a long-term dependence on opioids and 825 non-medical users of opioids (See Figure 4). *Source: CDC- As we are still in the process of finalizing our policy to reduce the dependency on pain medications, we plan on begin implementing the first phase in the fall of This first phase will focus on prescriptions for pain medications that are greater than 120mg, which most experts world-wide advocate as a maximum dose. This first phase simply is to ensure members are receiving appropriate dosages that do not negatively impact their health. It is important to note that PHC s Managing Pain Safely guidelines will not apply to patients with active cancer or who are near end of life. Quality Improvement The Quality and Performance Improvement Department aligns our key organization strategies with the Institute for Healthcare Improvement's Triple AIM: improved health outcomes, patient experience, and reduced healthcare costs. Key activities include measuring our performance in key quality indicators through the Healthcare Effectiveness Data Information Set (HEDIS), providing financial incentives to primary care providers, specialists, pharmacies and hospitals on a standard set of quality metrics; and offering capacity building programs to our providers to support patient centered medical home interventions. One program, the Coleman Collaborative, is a 10 month program aimed at improving appointment access and patient cycle time in primary care. We have six sites participating across our regions and preliminary results to date, show reduced no show rates and improved cycle time. Page 11 of 11

14 Conclusion This is an exciting time to be delivering health care. In the past year there have been many significant changes that have resulted in millions of more individuals obtaining healthcare coverage as a result of the ACA. At PHC we continue to feel the effects of the Medi-Cal expansion in January, fortunately we were able to plan in advance and we are in a position to handle the increase in membership. The strength of PHC in Napa County is our long partnerships with the community. It is due to these relationships that we are able to have a positive impact on the most vulnerable populations. For many newly insured it has been years since they have seen a doctor, and getting them connected with a primary care physician will significantly increase the health of the community. As part of our strategic plan, over the next three years we will focus on the following three areas; High Quality Health Care, Operational Excellence, and Fiscal Stewardship. By accomplishing the goals in these three areas will make us the most highly regarded managed care plan in California. Page 12 of 11

15 For additional information please contact: Robb Layne Director of Government and Public Affairs (707)