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

What

Who is included in

managed care

What Services are included or

excluded

HowPrimary 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

CommitteesFinance 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 Families1,500 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 QuestionsContact Us At:

Lynn Scuri, MPHAssociate Regional Director(707) 863-4146lscuri@partnershiphp.org

Bob Moore, MD, MPHChief Medical Officer(707) 863-4228rmoore@partnershiphp.org

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