Medi-Cal Expansion Under Health Care Reform: Peter Winston Executive Vice President

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1 Medi-Cal Expansion Under Health Care Reform: A Provider Perspective Peter Winston Executive Vice President

2 Perceptions Medi-Cal was considered a different animal Ignored by mainstream medicine Medicaid id mills They scare away my paying patients Other perceptions of the Medicaid community The docs are of lesser quality

3 History Primary Care Case Management Program initiated in 1985 EHS was one of 13 original PCCMs The California version of PCCM was a capitated shared risk contract directly with the State EHS started with 4 clinics and 5,000 members in the San Gabriel Valley of LA County

4 By the early 1990s, California s PCCM model was so successful in holding costs down that the State decided to terminate the program PHP (Prepaid Health Plan) programs had also proliferated and were also very successful Included participation by such stalwarts as Blue Shield of California and PacifiCare (now United Healthcare) and some defunct plans such as Maxicare The State decided to terminate them too

5 The New Managed Care Paradigm In the mid-1990s, 3 new methods of organizing and delivering care County Organized Health System (COHS) Geographic Managed Care (GMC) Two-Plan Model Affected up to half of all Medi-Cal beneficiaries in the State In reality, this was the low-hanging fruit Pregnant moms; healthy kids; low pathology

6 Expansion Between 1997 and 2010, EHS expanded d from one county to seven Los Angeles (1997) Sacramento (2003) Fresno, Kings, Madera (2008) San Bernardino, Riverside (2010) Fully 80% of the business is Medi-Cal and Health Families (SCHIP)

7 SPDs In , Seniors and Persons with Disabilities (SPD) were added as a new mandatory population 380,000 in total statewide EHS alone added d 16,000 SPD members Continued network expansion in existing markets brings total EHS membership to 330,000 by close of 2012

8 Big Changes Coming Transition of SCHIP (Healthy Families) to Medi-Cal Expansion of Medi-Cal managed care into 26 rural counties Transition of the DUALS (Medi-Medi) Coordinated Care Initiative demonstration project in 8 counties Raising PCP professional fees from Medi-Cal to Medicare rates Cutting everybody else by 10% 2013/14 CA Budget Proposal

9 2014 Implementation of the Health Insurance Exchange Covered California The expansion of Medi-Cal

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11 Challenges Not knowing previous medical history Being able to absorb large numbers of new patients in a short period of time FQHCs and Community Clinics cannot be the only choice for these new beneficiaries They may already be seeing these patients in their uninsured pools Electronic health records are still a challenge Many community docs are still on paper!!!

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13 Addressing the Challenges You do so by ygiving gthe traditional providers who already take care of this community the additional tools to make change happen And you do it with technology Even if you have to drag the provider kicking and screaming into the 21 st century

14 CONNECT Provider and Member Ecosystem Key Features and Benefits 1. Interconnected Virtual Platform 2. User Friendly with 2.0 User Interface 3. Greater Efficiency / Eliminate Paper 4. Increased Coding and Reporting Efficiency 5. Smart Rules with Evidenced-Based d d Criteria 6. Improved Workflow 7. Member Portal 8. Plan Portal 9. HIE Connected

15 CONSULT Curbside Consult Key Features and Benefits 1. Secure Communication 2. Improved Patient Access 3. Greater Access to Specialty Care 4. Better Treatment Times 5. Continuing Education 6. Increased Patient Satisfaction 7. Advanced Clinical Technology 8. Greater Patient Retention 9. Currently closing 100+ each month

16 PLAN Key Features and Benefits 1. Cut admin costs with real time access to claims & auth details 2. Better care coordination between IPA and health plan staff 3. Greater transparency by having access to IPA s own database 4. No more demand letters. View claims and payments in real time 5. Secure access any time and anywhere. 6. Current in beta testing

17 Works in Progress Member Portal Caregiver Portal Hospital Portal Hospitalist Portal ER Portal SNF Portal

18 STORE Group Purchasing Organization Services Supplies Equipment Insurance Real Estate

19 Passport to Better Health Bringing HEDIS, P4P and 5-Star Quality Measures to the Medi-Cal Community

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22 Oncology Palliative Care End of Life Hospice CM DM Pain Clinic MA Enhanced Generalist M.D. SW Psychiatry Pulmonary NP Chronic Complex Homeless (Street Team) Neuro-rehab

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24 shie SynerMed Health Information Exchange Plus Core HIE services via IEHIE ( Metrics/Analytics via PIPE (Pacific Independent Physician Exchange) Connecting the virtual medical community

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26 Population Health Population Health requires that the medical community treat the ENTIRE population and not just portions of it But the negative perceptions of Medicaid id continues to be felt to this day, resulting in cherry picking and bifurcation based on line of business Until perceptions change, we will continue to have a tiered health care delivery system Not necessarily between the haves and have nots, but between the haves and the have something differents

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28 Peter Winston Executive Vice President