University of California, Office of the President

CALIFORNIA PROGRAM POLICY RESEARCH O N ACCESS CENTER T O CARE Califor nia California Policy Program Resear on Access c h to Center Care University California University of California, Office of the President POLICY BRIEFING C O O R D INA T I N G M EDI - C A L C ARE FOR V U L N E R A B L E P O P U L ATI O N S : B LIND, D I S A B L E D, ELDERLY A N D PERSONS LIVIN G WITH HIV Wednesday, April 26, 2006 1:00 p.m. to 4:00 p.m. California Secretary of State-Multi-Purpose Room 1500 11 th Street, Sacramento A G E N D A 1:00 p.m. INTRODUCTIONS BY CO-CONVENERS: CPAC AND UARP Gilbert Ojeda, Director, CPAC, UC Office of the President George Lemp, Dr. PH, Director, Universitywide AIDS Research Program, UC Office of the President PRESENTATION PANEL (20 minute presentations followed by 5 minute Q&A sessions) Moderator: Albert Lowey-Ball, MS, MA, Medi-Cal Advisor to CPAC 1:10 p.m. Access to Medicaid and its Impact on Insurance Coverage and Treatment of HIV+ Individuals" Arleen Leibowitz, PhD, Professor, Public Policy, School of Public Affairs, UC Los Angeles Neeraj Sood, PhD, Associate Professor and Economist RAND Corporation 1:35 p.m. The Impact of Medi-Cal Restructuring on Care of Beneficiaries with HIV/AIDS David Zingmond, MD, PhD, Associate Professor, Department of Medicine, UC Los Angeles 2:00 p.m. How Health Plans Coordinate Care to Vulnerable Medi-Cal Populations David Meadows, Vice President, State Health Programs, Health Net of California Janice Milligan, RN, Director of Strategy and Business Development, State Health Programs, Health Net of California 2:25 p.m. Medi-Cal Issues in Chronic Care Management Andrew Bindman, MD, Professor, School of Medicine, UC San Francisco 2:50 p.m. DISCUSSION PANEL (10 minutes each) Stan Rosenstein, Deputy Director, Medical Care Services, California Department of Health Services Bryon McDonald, Project Manager, World Institute of Disability, Berkeley Donald Lyman, MD, Chief, Division of Chronic Disease and Injury Prevention, California Department of Health Services

Access to Medicaid and its Impact on Insurance Coverage and Treatment of HIV+ Individuals Neeraj Sood (With Arleen Leibowitz & Arkadipta Ghosh) April 26, 2006

Medicaid is a Large and Growing Component of State Expenditure Second largest program in most states general fund budgets - accounts for 15-17% of state spending (Kaiser Commission, 2005) Also, the fastest growing state expenditure category - Grew at 13% in FY 2002 (Hoadley et al., 2004) - Moderated, but still growing at 7.5% in FY 2005 (Smith et al., 2005) 2

States have enacted several measures to reduce Medicaid costs Common cost containment policies: cutting or freezing provider payments, trimming benefits and premiums restricting eligibility In FY 2005 - - Provider payment rate changes were enforced in all states (except MA) and DC - 7 states reduced benefits (ID, LA, ME, NM, NC, OR, SC) - 8 introduced eligibility cuts (DE, ME, MS, MO, NM, OR, PA, TN) (Source: Kaiser Commission on Medicaid and the Uninsured, 2005) 3

Effect of Cost-containment on Insurance Coverage & Health Status Some evidence that charging premiums increases both disenrollment and the number of uninsured (Artiga & O Malley; 2005) Effects of more stringent income eligibility criteria on insurance coverage & treatment less clear -- for particularly vulnerable populations like the PLH 4

Research Questions How would changes in Medicaid eligibility affect insurance coverage of PLH? Replace with private insurance? Or become uninsured? What is the impact of changes in Medicaid eligibility on the use of antiretroviral therapy (HAART)? Are the disabled differentially affected? 5

Data HCSUS baseline data merged with database on states Medicaid eligibility rules Nationally representative sample of HIV+ persons in care in 1996 Detailed information on demographics, health, treatment and insurance coverage Also included state level data on unemployment and uninsurance rates 6

Methods: Medicaid Eligibility, Insurance & HAART Use Estimate how insurance coverage (None, Private, Medicaid, Medicare) and HAART use relate statistically to: State Medicaid eligibility, measured by Medically- Needy Threshold Individual health and demographics State unemployment and uninsurance rates Census region 7

Restricting Eligibility Increases Uninsurance & has No Effect on Private Coverage 0.6 0.50 0.48 0.46 0.44 0.42 0.39 0.4 0.29 0.29 0.29 0.30 0.30 0.30 0.17 0.18 0.19 0.20 0.21 0.23 0.2 100 80 60 40 20 Medically Needy Threshold None Private Medicaid 0 8 0

Restricting Eligibility Reduces HAART Use 0.3 0.27 0.26 0.24 0.22 0.2 0.2 0.1 100 80 60 40 20 0 Medically Needy Threshold HAART 9

What About the Disabled? Almost half the respondents in HCSUS are currently not working due to disability Frequency Percent Disabled 1,375 48.01 Non-disabled 1,489 51.99 Total 2,864 100.00 10

Hypothesis Restricting Medicaid eligibility will affect the disabled more because they lack private insurance options Employer based coverage Individual insurance policies 11

Restricting Eligibility Increases Uninsurance with a larger impact on the Disabled 0.78 0.50 0.74 0.48 0.70 0.46 0.66 0.44 0.61 0.42 0.56 0.39 0.8 0.6 0.4 0.21 0.23 0.19 0.20 0.17 0.18 0.17 0.14 0.12 0.08 0.10 0.06 100 80 60 40 Medically Needy Threshold 20 0 No Insurance (All) No Insurance (Disabled) Medicaid (All) Medicaid (Disabled) 12 0.2 0

Restricting Eligibility Reduces HAART Use with a larger impact on the Disabled 0.38 0.4 0.33 0.29 0.3 0.27 0.26 0.24 0.25 0.22 0.2 0.2 0.17 0.1 100 80 60 40 20 0 Medically Needy Threshold All Disabled 13

Results are Supported by Previous Findings Bhattacharya, Goldman, & Sood (2003): Both public and private insurance facilitates treatment and prevents premature death among the PLH 66% decline in one-year mortality with public insurance 79% decline in one-year mortality with private insurance.. Extending public insurance coverage to HIV+ patients in the early stage of the disease. might prevent a significant number of premature HIV related deaths. 14

Conclusion Lower Medicaid Eligibility thresholds are likely to raise uninsurance rates and reduce HAART use Lower eligibility thresholds reduce Medicaid coverage but have negligible effect on private coverage No crowd out effects for HIV+ population even though such effects might exist for other Medicaid populations Lower eligibility thresholds are likely to have a larger effect on uninsurance rates and HAART use among the disabled and unemployed 15

Impact of Medi-Cal managed care enrollment on persons with AIDS: implications for Medi-Cal restructuring David Zingmond MD, PhD, Thomas Rice PhD, and William Cunningham MD, MPH UCLA Schools of Medicine and Public Health

Background Medi-Cal is a major provider for Californians living with HIV/AIDS. Between 1/4 and 1/3 of Californians with AIDS are enrolled in Medi-Cal. Monthly census is > 24,000 enrollees living with HIV or AIDS Medi-Cal pays for more than half of all AIDS hospitalizations in CA each year.

Background In Medi-Cal, fee-for-service (FFS) is the traditional model, but voluntary and mandatory enrollment in managed care (MCP) programs has been implemented. ~15% of enrollees with AIDS are in MCPs Half have mandatory MCP enrollment.

Medi-Cal Managed Care Implementation Two-Plan Model - 2 not-for-profit Managed Care Plans voluntary enrollment GMC - 6 or more Managed Care Plans voluntary enrollment COHS - 1 county-operated Managed Care Plan mandatory enrollment Other limited provider plan participation Fee-For-Service - Rural counties

Background Mandatory MCP enrollment for all aged, blind, and disabled enrollees has been proposed to save money and improve the efficiency of care in Medi-Cal. The impact of mandatory MCP enrollment on the care and outcomes of Medi-Cal enrollees with AIDS is not well known.

Study Objectives 1. Determine characteristics of Medi-Cal FFS/ Managed Care Plan (MCP) enrollees. 2. Examine the impact of FFS/MCP enrollment on clinical outcomes. 3. Identify the impact of FFS/MCP enrollment on plan switching and disenrollment. 4. Compare current MCP capitation rates to estimated costs of care. 5. Examine PCP vs. specialist visits and ARV use as indicators of MD readiness for MCP participation.

Methods

Data Sources 1 Linked patient level data - Medi-Cal Eligibility files - Medi-Cal FFS claims - California AIDS Registry - California (OSHPD) hospital discharge records - California Death Statistical Master File Mean capitation rates for TPM MCPs

Data Sources 2 Linked provider level data - Medi-Cal provider file - Medi-Cal FFS claims - American Academy of HIV Medicine - membership - ABIM I.D. board certification

Cohort Enrollment and Outcome analyses Medi-Cal enrollment Jan 2000 to Dec 2003 Living in TPM and GMC counties AIDS verified by the AIDS Registry > 20 years old Cost and physician readiness analyses Medi-Cal Enrollment - 2002 (MD) or 2003 (cost) Not enrolled in Medicare Living in TPM and GMC counties AIDS verified by the AIDS Registry > 20 years old

Dependent Measures Clinical outcomes time to death, time to hospitalization Enrollment time to disenrollment, time to plan change Cost estimated non-arv costs (vs. cap. Rates) MD Readiness PCP visit, specialist visit, use of ARV

Independent Measures Demographics - age, race, sex, residence location, time enrolled in Medi-Cal, dual Medicare enrollment Disease measures - exposure route, time with AIDS, Severity Classification of AIDS Hospitalizations (SCAH) Other severity measures - hospitalization in past two years

Analytic Methods Bivariate comparisons of independent and dependent variables by MCP/FFS enrollment Chi square and t-tests Time to event analyses Unadjusted comparisons (KM curves) Cox multivariate regressions Cost analyses GEE with gamma model and log-link function MD Readiness Multivariate logistic regressions

Results

1. Determine characteristics of Medi- Cal FFS/ Managed Care Plan (MCP) enrollees. 2. Examine the impact of FFS/MCP enrollment on clinical outcomes. 3. Identify the impact of FFS/MCP enrollment on plan switching and disenrollment. 4. Compare current MCP capitation rates to estimated costs of care. 5. Examine PCP vs. specialist visits and ARV use as indicators of MD readiness for MCP participation.

Demographics Variable N Male (%) Age (mean; years) Race (%) White Black FFS MCP 11,004 1,937 85 72 ** 42 41 45 42 28 27 Latino 24 27 Asian 2 3 Other/Unknown 1 1 Time enrolled (median; mths) 54 63 ** *

Case-Mix Severity Variable FFS MCP HIV Exposure Risk Factors (%) ** MSM-IVDU 16 10 MSM 52 43 IVDU 18 22 Blood Product 0 0 Heterosexual exposure 8 16 Other/Unknown 7 8 Time with AIDS (mean; years) 5 5 Severity of AIDS (SCAH; %) ** 0 29 35 1 38 36 2 19 18 3 14 11 Hospitalization in the past 2 yrs (%) 48 41 **

1. Determine characteristics of Medi-Cal FFS/ Managed Care Plan (MCP) enrollees. 2. Examine the impact of FFS/MCP enrollment on clinical outcomes. 3. Identify the impact of FFS/MCP enrollment on plan switching and disenrollment. 4. Compare current MCP capitation rates to estimated costs of care. 5. Examine PCP vs. specialist visits and ARV use as indicators of MD readiness for MCP participation.

Mortality P = 0.020

Hospitalization P < 0.001

Disenrollment from Medi-Cal P = 0.034

Medi-Cal Plan Change P < 0.001

Multivariate Results: Clinical Outcomes and Enrollment HR 95% CI Clinical Outcomes Mortality 0.97 0.84 1.12 Hospitalization 0.91 0.81 1.03 Enrollment Disenrollment 0.97 0.81 1.17 Plan Change 3.29 2.15 5.02 Multivariate Cox regression analyses controlling for age, race, sex, risk factor exposure, time AIDS, SCAH, Charlson Index, hospitalization in past two years, time enrolled in Medi-Cal, with clustering for county of residence.

1. Determine characteristics of Medi-Cal FFS/ Managed Care Plan (MCP) enrollees. 2. Examine the impact of FFS/MCP enrollment on clinical outcomes. 3. Identify the impact of FFS/MCP enrollment on plan switching and disenrollment. 4. Compare current MCP capitation rates to estimated costs of care. 5. Examine PCP vs. specialist visits and ARV use as indicators of MD readiness for MCP participation.

Average Monthly FFS Costs non-er ambulatory visit $24 ER visit $4 Hospital $134 Total Mental Health $61 Other Medications $641 Other Tests / Treatments $277 Anti-Retroviral Treatment Costs $784 Sub-total: non-arv Costs $1,142 Total $1,926 Patients enrolled only in FFS Medi-Cal only in TPM/GMC counties in 2003. N = 6,376

Estimated non-arv Costs vs. TPM Capitation Rates Estimated non- ARV Costs Average TPM Capitation Rates $974 $1,308 N = 499; TPM MCP Enrollees in the 11 TPM Counties in 2003 Dual Medicare enrollees excluded.

1. Determine characteristics of Medi-Cal FFS/ Managed Care Plan (MCP) enrollees. 2. Examine the impact of FFS/MCP enrollment on clinical outcomes. 3. Identify the impact of FFS/MCP enrollment on plan switching and disenrollment. 4. Compare current MCP capitation rates to estimated costs of care. 5. Examine PCP vs. specialist visits and ARV use as indicators of MD readiness for MCP participation.

Physician Availability Spec non- Spec Total # Doctors 101 3,534 3,635 # enrollees / MD 63 1.8 1.7 Ave # visits / MD 83 21 N = 6,316 Medi-Cal only FFS enrollees with AIDS in TPM/GMC counties Providers / ambulatory care visits in 2002-2003 in TPM/GMC counties Specialty Doctors HIV Society membership or I.D. specialist Visits to doctors in 2002-2003

Outpatient Visits for Patients Variable % mean # visits / Pt with visit median # visits / Pt with visit Any outpatient visit 51 8.7 5 Any primary care visit 38 8.1 5 MD was an HIV-MD 11 - - Any ER visit 53 4.0 2 Any hospitalization 45 - Death in '02 or '03 9 - N=6,316; Visit characteristics from 2002-2003 for FFS Medi-Cal only enrollees with AIDS living in TPM/GMC counties

Multivariate Predictors of PMD Visit OR 95% CI Latino 1 0.60 0.51 0.71 ** 40-49 years 2 1.22 1.05 1.41 * 50-59 years 2 1.34 1.11 1.61 ** Risky sexual exposure 3 0.73 0.57 0.93 * SCAH = 3 4 1.37 1.11 1.70 ** Months in Medi-Cal 1.01 1.01 1.01 ** P Multivariate logistic regression, FFS Medi-Cal only enrollees with AIDS living in TPM/GMC counties in 2002-2003, N = 6,316 1 vs. non-latino Whites; 2 vs. 20-29 years old; 3 vs. MSM; 4 vs. SCAH = 0

Impact of Having an HIV Provider Use of ARV HAART Use (%) Any ARV Usage (%) Provider Type (%) ** ** HIV Provider 4 42 72 Other Provider 33 29 56 No Provider 63 27 54 ARV Any Antiretroviral Therapy; HAART Highly Active Antiretroviral Therapy HAART or ARV in the last month of enrollment for persons with AIDS in 2002-2003

Impact of Having an HIV Provider Use of ARV Any HAART Any ARV OR 95% CI P OR 95% CI P Provider Type (%) HIV Provider 1.56 1.18 2.08 0.00 1.64 1.21 2.22 0.00 Other Provider 0.99 0.86 1.14 0.86 1.01 0.89 1.15 0.85 No Provider 1.00 - - - 1.00 - - - ARV Any Antiretroviral Therapy; HAART Highly Active Antiretroviral Therapy HAART or ARV in the last month of enrollment for persons with AIDS in 2002-2003 Multivariate logistic regression accounting for age, gender, race, exposure, SCAH, hospitalization, time w/aids, time in MCD, distance to the closest high volume provider.

Discussion Clinical Outcomes Although MCP patients appear healthier, riskadjusted outcomes do not differ between MCP and FFS enrollees. - Prior work in the study of MCPs suggests patient selection is an important factor in unadjusted differences in outcomes and utilization. - Patients who voluntarily enroll in managed care are likely to be healthier, thus requiring lesser amounts of care.

Discussion - Enrollment MCP enrollees are more likely to change to FFS enrollment than those in FFS to MCP. - Switching from MCP to traditional FFS Medi-Cal may be a marker for patient dissatisfaction or access issues. - Together, these raise important questions regarding the appropriateness of current managed care implementations for chronically ill populations.

Discussion Capitation Rates Lower predicted costs of care among MCP enrollees suggest overly generous payments for care. - This indicates potentially inefficient use of resources. - It undercuts the argument of cost-savings among MCP enrollees. - May represent information asymmetry between MCPs and Medi-Cal. - MCPs may be offering additional care.

Discussion MD Readiness A large number of providers are seeing HIV-infected patients at this time. However, relatively few providers are seeing the large majority of cases. The highest volume providers tend to be institutional providers, but some individuals do see a large number of cases. There are high volume providers in all counties.

Discussion MD Readiness Identifiable HIV specialists are different. They tend to have many more encounters than non-specialists. HIV providers appear to deliver better care (as measured by patient ARV usage).

Discussion Identifiable use of ambulatory care by patients appears to low. < 40% of MCD FFS patients had a PMD visit. Only 11% of persons with a PMD had an HIV specialist as a PMD. Latinos & persons with high risk sexual exposure are less likely to get PMD, but overall rates are just too low.

Limitations Retrospective observational study. Results and conclusions may not be generalizable to other regions, MCP arrangements, or other ill populations. MD readiness results limited to persons with AIDS in MCD-only in TPM/GMC counties. MCR enrollees appear to have underreporting of physician encounters. MCP enrollees do not have reliable claims. Analyses likely undercount HIV specialists.

Conclusions There are no compelling benefits for the currently proposed mandatory enrollment of the Medi-Cal AIDS population into MCPs. 1. MCP pts are healthier than FFS pts. 2. MCP & FFS pts have similar outcomes. 3. MCP enrollees are more likely to leave MCPs they may have lower satisfaction. 4. Current TPM reimbursements appear overly generous vs. estimated FFS costs.

Conclusions Access to providers already appears limited. - Care for pts is concentrated in a small number of providers. - Pts do not appear to have adequate numbers of office visits to PMDs. - MCPs will have to focus on identifying and retaining specialty providers.

Stage of Disease Overall County Type County AIDS Unknown COHS Monterey 93 100 193 Napa 28 28 56 Orange 488 384 872 San Mateo 160 205 365 Santa Barbara 59 80 139 Santa Cruz 94 86 180 Solano 116 134 250 Subtotal 1,038 1,017 2,055 GMC Sacramento 495 614 1,109 San Diego 1,336 1,125 2,461 Subtotal 1,831 1,739 3,570 TPM Alameda 753 924 1,677 Contra Costa 294 363 657 Fresno 228 438 666 Kern 137 249 386 Los Angeles 4,762 6,534 11,296 Riverside 681 405 1,086 San Bernardino 401 706 1,107 San Francisco 2,212 1,698 3,910 San Joaquin 185 312 497 Santa Clara 267 333 600 Stanislaus 114 168 282 Tulare 38 133 171 Subtotal 10,072 12,263 22,335 Rural 1,006 1,416 2,422 Total 13,947 16,435 30,382

AIDS Patients by County FFS No MCR MCR MCP Total Alameda 447 346 73 866 Contra Costa 167 116 49 332 Fresno 115 118 33 266 Kern 87 76 23 186 Los Angeles 2,606 2,108 1,094 5,808 Riverside 311 520 37 868 Sacramento 242 280 69 591 San Bernardino 255 214 31 500 San Diego 581 858 68 1,507 San Francisco 1,190 1,239 73 2,502 San Joaquin 103 88 23 214 Santa Clara 132 170 20 322 Stanislaus 54 78 12 144 Tulare 26 27 7 60 Total 6,316 6,238 1,612 14,166 Enrollees with Verified AIDS in TPM / GMC Counties, 2002

Cost Estimates by County County Name Obs Est. Monthly Costs ($) SE ($) Ave Monthly Cap. Rate ($) Alameda 40 931 890 1,396 ** Contra Costa 30 949 431 1,225 ** Fresno 28 601 158 1,298 ** Kern 20 1,453 2,687 1,263 Los Angeles 264 1,040 511 1,307 ** Riverside 22 655 198 1,226 ** San Bernardino 21 661 273 1,283 ** San Francisco 34 1,072 409 1,400 ** San Joaquin 17 991 391 1,226 * Santa Clara 12 871 302 1,458 ** Stanislaus 3 1,152 108 1,180 Tulare 8 539 132 1,305 ** Overall 499 974 737 1,308 ** AIDS Health Care Foundation 345 1,245 757 - -

Number of Doctors by County non- HIV HIV Total Alameda 157 8 165 Contra Costa 56 2 58 Fresno 116 2 118 Kern 73 2 75 Los Angeles 1,845 44 1,889 Riverside 199 3 202 Sacramento 134 4 138 San Bernardino 254 4 258 San Diego 296 9 305 San Francisco 150 16 166 San Joaquin 72 1 73 Santa Clara 87 5 92 Stanislaus 68 1 69 Tulare 27 0 27 Total 3,534 101 3,635 Providers who saw patients for ambulatory care in 2002-2003 HIV Doctors Society membership, board certification, or ID reported services by Medi-Cal claims.

Number of Patients to Doctors non- HIV HIV Total Alameda 5.1 99 4.8 Contra Costa 5.1 142 4.9 Fresno 2.0 117 2.0 Kern 2.2 82 2.2 Los Angeles 2.6 107 2.5 Riverside 4.2 277 4.1 Sacramento 3.9 131 3.8 San Bernardino 1.8 117 1.8 San Diego 4.9 160 4.7 San Francisco 16.2 152 14.6 San Joaquin 2.7 191 2.6 Santa Clara 3.5 60 3.3 Stanislaus 1.9 132 1.9 Tulare 2.0-2.0 Total 3.6 124 3.5 Ratio of FFS AIDS Pts to Providers who saw patients for ambulatory care in 2002-2003 HIV Doctors Society membership, board certification, or ID reported services by Medi-Cal claims.

Average Pt Visits to Doctor HIV MD non-hiv MD N Mean N Mean Alameda 8 196 157 33 Contra Costa 2 3 56 7 Fresno 2 43 116 29 Kern 2 10 73 10 Los Angeles 44 79 1,845 22 Riverside 3 106 199 11 Sacramento 4 168 134 13 San Bernardino 4 84 254 13 San Diego 9 81 296 28 San Francisco 16 62 150 30 San Joaquin 1 11 72 15 Santa Clara 5 39 87 14 Stanislaus 1 8 68 11 Tulare 0 27 13 Overall 101 83 3,534 21 Providers who saw HIV/AIDS patients for ambulatory care in 2002-2003 HIV Doctors Society membership, board certification, or ID reported services by Medi-Cal claims. Average # MCD-only visits to doctors in 2002-2003

Case Volume: # of Pts Seen Quintile # MDs Pts / Range MD Min Max 1 20 222 106 687 2 75 58 36 101 3 231 18 11 36 4 768 5 3 10 5 2,541 2 1 3 Overall 3,635 6 1 687 Results stratified by equal # s of total patients seen per quintile

Case Volume: # of Visits Quintile # MDs Visits Range / MD Min Max 1 9 1,826 860 3,824 2 39 404 234 859 3 126 130 79 230 4 433 39 23 78 5 3,028 5 1 23 Overall 3,635 22 1 3,824 Results stratified by equal # s of total pt visits per quintile

Who Are the High Volume Providers? 24 / 48 providers by # of visits are individuals The top five providers by # of visits were all group / institutional providers

Patient Characteristics Associated with a PMD Visit N=6,316 Had a PMD Visit Yes No N 2,378 3,938 Male (%) 77 79 Race (%) White 35 33 Black 41 34 Latino 20 29 Asian 3 3 Other 1 1 Age (%) < 20 years 3 2 20-29 years 3 5 30-39 years 26 32 40-49 years 44 41 50-59 years 21 17 60+ years 3 3 ** **

Patient Characteristics Associated with a PMD Visit N=6,316 Had a PMD Visit Yes No N 2,378 3,938 Risk Exposure (%) MSM-IVDU 15 14 MSM 41 40 IVDU 26 24 Transfusion 0 0 Risky sexual exposure 10 12 Other or Unknown 9 10 SCAH (%) ** 0 32 37 1 40 37 2 16 16 3 12 11 Charlson (%) ** No hospitalization 32 37 0 29 32 1 to 2 19 15 3 to 4 15 13 5 to 6 4 3 > 6 1 1

Patient Characteristics Associated with a PMD Visit Had a PMD Visit Yes No N 2,378 3,938 Hospitalization, past 2 yrs (%) 30 27 * Years with AIDS (mean) 4.9 4.5 ** Months in Medi-Cal (mean) 68 61 ** Miles to HVP (mean) 3.1 6.0 Miles to HVP (90% ptile) 3.2 3.0 PMD is an HIV MD (%) 11 - N=6,316

Multivariate Predictors of PMD Visit OR 95% CI P Race (%) White 1.00 - - - Black 1.09 0.94 1.27 0.25 Latino 0.60 0.51 0.71 0.00 Asian 1.08 0.74 1.57 0.69 Other 0.85 0.47 1.55 0.61 Age (%) 20-29 years 0.84 0.60 1.19 0.33 30-39 years 1.00 - - - 40-49 years 1.22 1.05 1.41 0.01 50-59 years 1.34 1.11 1.61 0.00 60+ years 1.33 0.94 1.89 0.10

Multivariate Predictors of PMD Visit OR 95% CI P Risk Exposure (%) MSM-IVDU 1.26 1.04 1.53 0.02 MSM 1.00 - - - IVDU 0.95 0.79 1.14 0.58 Transfusion 1.02 0.40 2.60 0.97 Risky sexual exposure 0.73 0.57 0.93 0.01 Other or Unknown 0.81 0.63 1.04 0.10 SCAH (%) 0 1.00 - - - 1 1.16 0.99 1.36 0.07 2 1.14 0.94 1.38 0.18 3 1.37 1.11 1.70 0.00 Months in Medi-Cal (mean) 1.01 1.01 1.01 0.00 Not significant: male, past hospitalization, yrs w/aids, & distance

Coordinating Care to Vulnerable Medi-Cal Populations Dave Meadows Vice President, State Health Programs Health Net of California Jennifer Nuovo, MD Regional Medical Director, State Health Programs Health Net of California April 26, 2006

Overview Health Net is one of the largest health plans in California Health Net has: More than 2.5 million members in California Nearly 700,000 Medi-Cal, Healthy Families, AIM, and Healthy Kids members Nationally, more than 5.3 million members in 14 states including Medicaid in Connecticut and New Jersey More than 48,000 doctors 750 physician group locations 4,600 pharmacies

Recent Program Additions Medicare: Special Needs Plan in Los Angeles, Kern and Orange counties Healthy Kids: Children s Health Initiatives -- health plans for kids not eligible for Medi-Cal or Healthy Families Kern, Tulare, Fresno, Sacramento, Colusa, Yuba and El Dorado counties

Medi-Cal MCH Experience Majority of Medi-Cal Managed Care members are children and their mothers Improved outcomes are a result of an integrated health care delivery system designed to meet the needs of vulnerable populations Rather than recreate the wheel, Health Net sought out and contracted traditional and safety net providers Developed coordination of care agreements with over 20 maternal and child health programs

Medi-Cal MCH Experience (cont.) Adopted Comprehensive Perinatal Services Program (CPSP) provider standards Adopted Child Health and Disability Prevention (CHDP) Program provider standards and procedures Implemented the Children with Special Health Care Needs (CSHCN) best practices for screening and coordinating care, including coordination with California Children s Services (CCS), schools, Early Start and Regional Centers

SPD Enrollment Growth Cumulative SPD Enrollment Growth Rate Compared to Overall Enrollment 9.0% 8.5% 8.0% 7.5% 7.0% 6.5% 6.0% 5.5% 5.0% 4.5% 4.0% 3.5% 3.0% 2.5% 2.0% 1.5% 1.0% 0.5% 0.0% -0.5% -1.0% -1.5% -2.0% -2.5% Jan-05 Feb-05 Mar-05 Apr-05 May-05 Jun-05 Jul-05 Aug-05 Sep-05 Oct-05 Nov-05 Dec-05 Jan-06 Feb-06 Mar-06 Apr-06 HN SPD Cumulative Growth Rate HN Overall Cumulative Growth Rate Total Managed Care Cumulative Growth Rate

Medi-Cal Managed Care Expansion January 2005, Governor proposes to expand the Medi-Cal Managed Care program to include seniors and persons with disabilities (SPDs) Health Net has retained consultants from the Centers for Disabilities at Western University to conduct an internal readiness assessment to facilitate the physical and communication pathways needed for the SPD population to access services, including: development of enhanced delivery system development of policies and procedures that outline Health Net s enhanced program to facilitate effective health care services for SPD membership

Access Access means Ability to get timely needed services Availability of services Awareness that services exist and how to obtain them Access elements Physical and equipment Communication and attitude Competent services and programs June Isaacson Kales, MSW, LCSW

SPD Expansion Health Net s objectives: Create corporate culture that can meet the needs of persons with disabilities Increase understanding of health care access issues for people with disabilities Increase understanding of how providers can better serve people with disabilities Expand our health care network to include specialty providers and programs June Isaacson Kales, MSW, LCSW

SPD Expansion Health Net s training and site certification activities: Participated in OPA disability survey Enhanced primary care facility site review launched in Los Angeles County Developed alternative format health plan materials Enhanced line staff disability training

Medi-Cal Managed Care Health Care Coordination Challenges to current system: Existing State adult case management programs aren t well integrated in health plans Focus has been on preventive care for well populations State s Quality Improvement Programs focus on well populations and/or children Narrow scope of disease state management programs

Meeting the Challenges Opportunities: Create a community-model case management program in conjunction with existing agencies Develop primary case management coordination model Expand disease state management programs with an emphasis on dual diagnoses

Core Program Components Develop adult initial comprehensive health assessment system Enhance member service outreach to include scheduling appointments and arranging transportation Develop primary care case management provider credentialing system Link to appropriate primary care case management provider based on condition and access

Care Management Plan Development Case conference Anticipate health needs Rate acuity Assign delivery network Quarterly case management plan evaluation Contract Formal collaboration/coordination with community-based organizations

Integrated Health Plan Case Management Week 1: Initial health screens coordinated by the health plan Member Relations Department, PCP visit scheduled Week 2: Primary care assessment complete Week 3: In-house medical management team case management plan completed and acuity assigned Field Case Managers Health Net employees with provider site case management privileges Onsite with plan electronic management access Responsible for case management plan revision and acuity update

Health Plan Case Management Resource Sharing: develop agreements with provider system to augment availability and capacity via grants Examples: equipment, personnel, MD contracts, skilled nursing, wrap-arounds Case management system Examples: case management, plan integration, medical management staff Carve-out program resource integration

Health Plan Case Management Choreworker Primary Care Nursing Care DME Member Home Health Meals on Wheels Home Modification Community Based Programs Coordination of Care Program Provider System Prescriptions Physical Therapy Medical Alert System Laboratory Personal Care

Chronic Care Management in Medi-Cal Andrew B. Bindman, MD University of California San Francisco April 26, 2006 Work in part supported by the California HealthCare Foundation and California Program on Access to Care

Medi-Cal Managed Care Managed care requires beneficiaries to have a regular primary care provider A regular source of care may improve access to care and coordination of services Opportunities for population-based care management to improve quality

California Health Interview Survey: Medi-Cal Beneficiaries Reported Access to Care Delivery Model Access/Utilization Measures n Fee-forservice Managed Care p- value Percentage Has usual source of care 7922 81.1 89.9 <0.001 Physician visit prior 12 mos 7922 85.9 89.9 0.001 Cervical cancer screening 4977 88.6 92.1 0.004 Breast cancer screening 1485 74.3 82.3 0.01 Colon cancer screening 2323 40.8 45.8 0.07

Annual Hospitalization Rate for Ambulatory Care Sensitive Conditions in Medi-Cal FFS and Managed Care Hospitalization Rate per 1000 Person Years 70 60 50 40 30 20 10 0 48 Voluntary Managed Care 58 Mandatory Managed Care 66 Fee-For- Service Source: Office of Statewide Health Planning and Development/Department of Health Services 1994-2002

Medi-Cal Managed Care Most of the experience is with TANF population SPD population has substantially greater chronic care needs than TANF population

Percentage of Medi-Cal Beneficiaries < 65 Years in Managed Care: 1996-2002 90 80 70 60 50 40 30 20 10 0 All Beneficiaries TANF SPD 1996 1997 1998 1999 2000 2001 2002

SPD Beneficiaries Annual Admission Rates in Fee- For-Service (FFS), Mandatory Managed Care (MMC), and Voluntary Managed Care (VMC) for Diabetes Rate per 1000 Person Years 10 9.1 9 7.8 8 7.4 7 6 FFS 5 MMC 4 VMC 3 2 1 0 Diabetes

Effect of Managed Care on the SPD Hospitalization Rates for Ambulatory Care Sensitive Conditions Over Time 5.8 5.6 5.4 5.2 5.0 4.8 4.6 4.4 4.2 1994 1995 1996 1997 1998 1999 2000 2001 2002 Year Observed ACS rates with managed care increase Expected ACS rates without managed care increase

How Can Medi-Cal Improve Chronic Care Quality? Organizational structure that rewards chronic care quality Physician decision support Patient self-management support Delivery system re-design Linkages with community resources

Rewarding Chronic Care Quality Assignment of default patients to higher quality plans is an innovative first step Pay for performance can be tied more specifically to quality of chronic care Need to remove dis-incentive for caring for high cost patients through risk adjustment

Medi-Cal Care Management Practices for Asthma/Diabetes Medical Directors Report 2/3 provide guideline training 1/2 have registries, patient reminders, and self management support 1/3 use physician reminders Care management practices associated with penetration of Medi-Cal managed care Rittenhouse, Medical Care, 2006

Integrating Chronic Care Management Practices Quality improvement is more likely to occur in settings in which multiple care management tools (>4) are coordinated and focused on a clinical problem This is more often done in integrated delivery systems, group practices, and clinics but is seen in some IPA networks as well

Tailor Chronic Care to Medi-Cal Population Characteristics Medi-Cal population has a greater representation of minorities than California population as a whole Medi-Cal population at increased risk for limited health literacy Average reading level = 5th grade Spanish speakers, African Americans, elderly, women more likely to have limited health literacy Limited health literacy impacts knowledge of chronic conditions and ability to do self-care

Automated Telephone Disease Management (ATDM) Nurse Diabetes Care Manager ATDM: Weekly Monitoring and Health Education Primary Care Physician Patient Interactive touch tone response technology Weekly surveillance & health education In patients preferred language (English, Spanish or Cantonese) Generates weekly reports of out of range responses Live phone follow-up through a bilingual nurse

Computerized Visual Medication Schedule

Delivery System Re-Design

Group Medical Visits Monthly Group Medical Visits -Primary Care Provider -Health Educator -Pharmacist English- Speaking Groups Spanish- Speaking Groups Cantonese- Speaking Groups 6-10 patients in monthly group meetings In patients preferred language (English, Spanish, or Cantonese) Facilitated by a bilingual health educator and a primary care provider A pharmacist present at end of each group visit Encourage patients to become active in self-care through participatory learning and peer education

Computer kiosk Patient answers questions about physical environment, exercise preferences, and transportation needs. Database Program searches for high-quality, easily-accessible resources for physical activity. Exercise Prescription Do you like to swim? yes Prints out a physical activity prescription, which includes suggestions for community resources to use and directions for how to access those resources. no I don t know

Medi-Cal s Opportunities to Improve Chronic Care Quality Provide explicit guidance on standard of care Invest in the development and dissemination of successful care management practices and patient self management approaches Encourage practice re-design and engagement of community resources Evaluate provider performance - process and outcomes Learn from variation Link payment to performance