Partnership HealthPlan of CaliforniaMediCal Managed Care
OverviewHealth Alliance of Northern California
Peer Network Day
May 11, 2012Presented by Lynn Scuri, MPHAssociate Regional Director
Today
WhoCounty
Organized Health System
Partnership HealthPlan
WhatWho is
included in managed care
What Services are included or excluded
How
Primary Care Model
Care Management
Payment Structures
WhyBenefits to Members
Benefits to Providers & Community
Med-iCal Managed Care - Three ModelsGeographic Managed Care (Sacramento, San Diego)
Two Plan Model (LA, Central Valley, Bay Area)
County Organized Health Systems
CenCal (Santa Barbara, San Luis Obispo – 105,000)
Health Plan of San Mateo – 80,000
Partnership HealthPlan of California (Solano, Napa, Yolo, Sonoma- Marin, Mendocino - 200,000)
CalOptima (Orange – 440,000)
Central California Alliance (Santa Cruz, Monterey, Merced – 220,000)
Gold Coast – Ventura - 115,000
Our Mission
• In every aspect of the HealthPlan’s operations, from day to day activities to the strategic planning for our future, our mission is to help our members and the communities we serve be healthy
Our GoalsCreate 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
PHC History1988 – Private/public discussion to address overall health of community; funding from Kaiser, NorthBay, Sutter, cities and other1992 – State Contract approved and Commission formed1994 – Solano Operations began! 1998 – Expansion to Napa2001 – Expansion to Yolo2002 – County Medical Services Program (CMSP) Pilot 2006 – Healthy Kids2007 – Medicare/Medi-Cal Partnership Advantage Product2009 – Medi-Cal Expansion to Sonoma County2010 – Healthy Families Provider2011 – Medi-Cal Expansion to Marin and Mendocino
More About PHCOne of 6 County Organized Health Systems (COHS) in California covering six counties
Not for Profit Organization
Full range of aid codes including SPD and LTC
31% of enrollment is Seniors & Persons with Disabilities (SPD)
300 Employees
$900 million Annual Budget
Administrative costs < 5%
Jack Horn, Chief Executive Officer, Partnership HealthPlan of California
Shasta Region Medi-Cal Members
Total Eligible for Medi-Cal
PHC Members
PHC Model
• 62,000 Medi-Cal Eligibles in Five County Region
• 1:5 Eligible for Medi-Cal
• Most but not all Medi-Cal Aid Codes
• Limited Scope Medi-Cal and other aid codes retained by State
• 70% Assigned to a PCP Site/Medical Home
• 30% Special Case Managed Members
100%
90%
Modoc, Lassen, Shasta, Siskiyou and Trinity Counties
Excluded Benefits
•Mental Health•Dental Care•HIV/AIDS Medications•AODS•CCS•Psychotropic Medications
Medi-Cal Covered Benefit•Primary Care•Specialty Care•Lab and Diagnostic Imaging•Hospital Services•Pharmacy•Long Term Care•Maternity Care•CHDP•CPSP
PHC Covered Services
Enhanced Services
Benefits•Pulmonary Rehab•Podiatry (for diabetics)•AODS Supplemental Services•Nutrition Counseling•Weight Management•Over the counter drugs•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
We Answer the Phone!
Model of Care
Primary Care
Health Home
Preventative Care
Health Education
and Healthy Lifestyles
Medical Care for Acute Chronic Illness
Referral to Specialty
Care
PCP Assignment
70% Assigned to PCP Site/ 30% Unassigned (Special Case Managed Members
Goal 80% selections complete prior to “Go Live”
Outreach to members: by Plan and Providers (phone, mail & fax)
Auto assignment based on: Claims history - Family association - Zip code map
Referrals & Authorizations
PCP initiates referral to:PHC contracted specialist or Medi-Cal certified provider
Specialist performs initial consult
Referral faxed to specialist by PHC
Specialty office requests Treatment
Authorization* (TAR) from PHC (if needed)
PHC reviews TAR & makes determination(3 – 5 day turnaround)
Specialist provides care/service/supplies
Communication
* Only select procedures/equipment/supplies require a TAR
$$ Claims Payment $$Claims Submitted Electronically to
PHC
Weekly Check Run to Providers
90% of Clean Claims Paid within
30 Days
Payment Structure
State
•PHC Contracts with the State
•Paid PMPM Cap Rate (Aid Code Adjusted)
PHC
•PHC Establishes Contracted Provider Network
•Includes all willing providers
Providers
•Primary Care Capitation – submit encounter data
•Fee-for-service claims submitted to PHC
Hospitals
Capitation
Fee-for-Service/Per Diem Rate
Specialty Physicians
Fee-for-Service
(enhanced rate)
Capitation
Primary Care
Providers
Capitation
Fee-for-Service
CPSPCHDP
Quality Improve-
ment Program
Ancillary Providers
Fee-for-Services
LTC
Fee-for-Service/Per Diem Rate
Pharmacy
Contract through
Pharmacy Benefit
Manager(MedImpact)
Payment Options
Working with a COHS PlanLocal Governance & Administration:
Access for community to policy making and managementBoard meetings are open and transparent to the public
Community Involvement:Advisory boards that participate in collective decision making regarding the direction of the plan
Board meetings are open and transparent to the public
GovernanceBoard of Directors
22 members
Mix of providers, consumers, advocates and county officials
Committees
Finance Committee
Physician Advisory Committee Quality, Credentialing, Peer Review, Pharmacy
Consumer Advisory Committee
Provider Advisory Group
Our ProgramsMediCal:
200,000 low-income members
Healthy Kids800 low-income, MediCal ineligible kids
Medicare Special Needs Plan7,500 low-income, senior/disabled members
Healthy Families
1,500 kids
Benefits for MembersMember Services – PHC receives and services 1,000 calls per day helping patients (wait time < 1 min.)
Enhanced benefits
Care Coordination programs
Higher quality of care, improved HEDIS scores
Improved access to physician services
We Answer the Phone!
Member Satisfaction2010 Survey Results
Overall satisfaction with:Partnership HealthPlan: 98%
Personal doctor: 90%
Easy or usually easy to receive specialty care: 80%
Always got help they needed from Member Services Department: 87%
Satisfaction scores based on a 8-10 of a 10 point scale.
Benefits to ProvidersHealth Care Centers / Primary Care Physicians
Rates enhancedQuicker payQuality Improvement Incentive ProgramPHC pays when State freezes payments
Specialty Care130% of FFS MediCal payment/80% of MedicareQuicker pay – less than 14 days on clean claimsHigh quality referralsProvider services and supportPHC pays when State freezes payments
All Other ProvidersPayment at Medi-Cal rateLTC enhanced rates for higher acuity patients. One week turn around, better cash flow
We Answer the Phone!
Provider SatisfactionQuestion
Overall satisfaction with PHC The Plan processes my claim s
w/in 30 days I am satisfied with the Plan’s
referral auth process (RAF). Practices that use the PHC e-
eligibility system Rating the consistency of
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%
Why Managed Medi-Cal?A Better System of Care
Coordination
Value
Quality
Builds on strong Primary Care Foundation
Questions, and More Questions
Contact Us At:
Lynn Scuri, MPHAssociate Regional Director(707) [email protected]
Bob Moore, MD, MPHChief Medical Officer(707) [email protected]
MilestonesResponse from the State
Assemble Planning Team
State Contract & Rates
Network Development
Revised PPS Rate from State
And More MilestonesCommunity Education & Outreach
Member Education and PCP Site Selection
Provider Education – Referrals, TARs, Claims, Formulary
Go Live!!!!!
Formulary Transition
More Training, more education AND more training