Medi-Cal and HPSJ Briefing - Health Plan of San Joaquin
Transcription
Medi-Cal and HPSJ Briefing - Health Plan of San Joaquin
Medi-Cal and HPSJ Briefing California’s Medicaid Program by the Numbers Medi-Cal - largest Medicaid program in the U.S. Covers approx. 30% of all Californians, and more than 50% of CA children Surpassed 11 million as of Sept 20141 Projected to be 12.2 million in 2015-162 The 2015-16 projected spending of $95.4 billion for Medi-Cal2 Medi-Cal Delivery Medi-Cal Managed Care vs. Fee-For-Service (FFS) Medi-Cal Managed Care Transition and Expansion 2010/11 – Seniors and Persons with Disabilities (SPD) 2013 – Healthy Families Program Managed Care 79% (8.8 million) enrolled in managed care3 Now in all 58 counties Different models by county 1MEDS Database Proposed Budget 3DHCS 11/2014 22015-16 Medi-Cal Managed Care Models County Organized Health System (COHS) Geographic Managed Care (GMC) Locally developed and county sponsored; publicly accountable DHCS contracts with multiple commercial plans which compete for enrollment No plan selection for Medi-Cal recipients—all in COHS No local oversight or involvement Newest (1993) and most commonly used model Early model of managed care delivery (1983) Pilot effort (1993) in Sacramento and San Diego Allows choice and public engagement Expansion is limited by Federal Regulations DHCS to allow new plans to enter in 2015 5.7 million enrollees in 14 counties LIs cover 71% of two-plan market 10 LI plans 1.9 million enrollees in 22 counties 6 COHS plans No fee-for-service 920,000 enrollees in 2 counties 6 GMC plans Two-Plan Model Local Initiative (LI) competes with Commercial Plan (CP) Local Initiative is locally developed, county sponsored, and accountable to the public DHCS 11/2014 Medi-Cal Funding State Medi-Cal Budget – by Source Total spending: $91 billion (FY 14-15) Federal 65% State GF 19% Other/Local 15% Federal Financial Participation FMAP varies by state and program Local Sources MCO Tax 1115 Waiver How Medi-Cal Managed Care Plans are Paid DHCS pays plans a prospective capitated rate (per member per month) based on enrollment Federal law requires states pay rates that are “actuarially sound” DHCS/Mercer rates require federal CMS approval Rates vary by population category, managed care model, and plan HPSJ OVERVIEW • Established in 1995 by State statute and County ordinance • Coverage in San Joaquin and Stanislaus Counties • Serving nearly 300,000 members: Medi-Cal, AIM and TPA • Employer of choice with more than 250 employees • 40,000+ square foot Headquarters in French Camp • Office in Stanislaus County-Downtown Modesto PRODUCT LINES Medi-Cal Managed Care 1996 – San Joaquin 2013 – Stanislaus San Joaquin Health Administrators (Third Party Administrator) 1998 Feb 2015 ❖ Over 290,000 health plan members ❖ Market Share: 89.3% in San Joaquin & 56.4% in Stanislaus ❖ Health Net is HPSJ’s competitor in both counties Administration of multiple San Joaquin County Employee self-funded plans Over 4,000 participants and dependents County employees can also choose Kaiser Administer non-risk programs: Claims, Customer Service, Utilization Management, Case Management ENROLLMENT SNAPSHOT March 2015 Medi-Cal Managed Care 1996 – San Joaquin County 2013 – Stanislaus County San Joaquin Health Administrators 1998 – Third-Party Administrator Nearly 300,000 Medi-Cal members Market Share: 89.2% (San Joaquin) & 56.8% (Stanislaus) Health Net is HPSJ’s competitor in both counties Over 4,000 participants Administration of multiple San Joaquin County Employee self-funded plans Non-risk programs: Claims, Customer Service, Utilization Management, Case Management LICENSING & COMPLIANCE Knox-Keene License (DMHC) Stanislaus County in 2006 San Joaquin County in 1996 Contractual Partnership with: Department of Health Care Services (DHCS) Regulated by: Department of Managed Health Care (DMHC) HMO Operations TPA License: Department of Insurance Governance and Leadership Locally Based, Locally Governed SAN JOAQUIN COUNTY HEALTH COMMISSION 11 Member Commission ❖ Chair - Director of SJC Healthcare Services (1 - ex officio) ❖ Greg Diederich ❖ Local Physicians (4) ❖ Michael Herrera, MD, Marvin Primack, MD, Mohsen Saadat, DO, & Gentry Vu, MD ❖ Hospital Representative (1) ❖ Brian Jensen, Hospital Council of Cen/Nor CA ❖ Community Representatives (2) ❖ Mike Kirkpatrick & Harvey Williams ❖ Board of Supervisors (2 - ex officio) ❖ Steve Bestolarides & Kathy Miller ❖ County Administrative Officer (1 - ex officio) ❖ Chris Rose, Senior Deputy Administrator GOVERNANCE STRUCTURE San Joaquin County Health Commission Subject to the Brown Act *Ad hoc committees when appropriate Finance and Investment Committee Chair, Chris Rose Human Resources Committee Reviews and recommends issues of a financial matter. Typical items are the review of the annual budget, monthly financial statements and vendor contracts. Provides advice and recommendations on human resources related matters, including policies, compensation and benefits. Chair, Michael Kirkpatrick Quality Management and Utilization Management Committee Responsible for the implementation and ongoing monitoring of the Quality Management Program. Houses five subcommittees. Chair, Lakshmi Dhanvanthari, MD Community Affairs Committee Chair, Brenda Hagerman Represents the “voice of the customer” in our planning efforts. Makes recommendations for programs and services (quality, access, transportation, language, health education, member communications) and. Amy Y Shin Chief Executive Officer Sue Nakata Executive Assistant Jennifer Dinwoodie Chief Financial Officer OPEN (Jennifer Dinwoodie to transition) Chief Operations Officer Cheron Vail Victoria Hazen Chief Information Officer VP, Human Resources Dr. Lakshmi Dhanvanthari Chief Medical Officer David Hurst Alejandra Clyde VP, External Affairs Compliance Officer MISSION DRIVEN AND COMMUNITY FOCUSED Operational Overview MEDICAL MANAGEMENT Quality Improvement Quality Management Program Implementation Utilization Management NCQA (National Committee for Quality Assurance) Accreditation Applies Milliman Guidelines (evidenced based clinical guidelines) to provider authorizations and requests Improving HEDIS (Healthcare Effectiveness Data and Information Set) Scores Improve utilization metrics such as inappropriately high or low inpatient bed days Fraud and Abuse Prevention MEDICAL MANAGEMENT Care (Case & Disease) Management Prenatal Support and Child Obesity Resource Programs Programs for the Medi-Cal SPD population that have more chronic and difficult health conditions Disease Management (NCQA) Case Management and Complex Case Management (NCQA) Pharmacy Convenient panel of retail pharmacies in both counties Specialty pharmacy contract to obtain emerging high-cost medications at lower rates In-house formulary management affording tight management Generic medication use rate among highest in state at 88% Pharmacy Residency Program BUDGET – FY 15 ($ in Thousands) Medi-Cal Member Months TPA 3,108,752 AIM Consolidated 51,600 1,140 3,161,492 Revenue $ 737,708 $ 844 $ 1,460 $ 740,012 Health Care Expense $ 697,042 $ 436 $ 1,172 $ 698,650 Gross Margin $ 40,666 $ 408 $ 288 $ 41,362 Admin Expense $ 33,562 $ 406 $ 19 $ 33,987 Net Operating Margin $ 7,104 $ 2 $ 269 $ 7,375 $ 259 $ 7,634 Other Income Net Margin $ MLR/ALR (%) 94.49/4.55 7,104 $ 2 51.70/48.08 $ 269 80.26/1.30 94.38/4.59 PROVIDER NETWORK Provider Contracting and Relations are critical for: 1. Program viability 2. Member access to care 3. Cost management 370+ PCPs and over 3,000 specialists PCPs and Specialists Traditional and safety net PCPs Cross-county access All area hospitals Including expanded tertiary care (UCSF, Sutter, Children’s HospitalOakland, UC Davis, etc.) Ancillary providers lab, imaging, nursing facilities, etc. Innovative telemedicine EXTERNAL AFFAIRS Business Development Community Engagement Grants Administration Community Funding Program Health Career Scholarship Program Incoming Grants for Strategic Programs Targeted Outreach/Enrollment Public Relations /Community Events Health Promotion/Cultural Services HEDIS improvement efforts Member Education Community Health Collaborative Cultural Programs/Interpreter Services Legislative Affairs New Product Development Member Acquisition/Retention Program Enhancements Advertising/Branding Strategic Communications Marketing Communications Project Communications Member/Provider Communications Media Relations MEMBER & PROVIDER SUPPORT High-touch service Local employees familiar with local providers and facilities Bilingual staff (6 languages) Language line with over 170 languages 40,000 calls per month, on average Call center performance is at or above industry standards 24/7 Advice Nurse (RNs) INFORMATION TECHNOLOGY Claims System TriZetto QNXT DRE Home-grown solution for authorizations, care plans and case management (integrated with QNXT) Data Analytics Improving analytics capability –new data warehouse, dashboarding tools, and staff training. Disaster Modesto office as recovery site. Recovery Plan Mobile Provider search, lab results, prescription drug history, PCP change, ID Applications card order (for providers, members, and staff) HEALTH INFORMATION EXCHANGE (HIE) Innovation and Collaboration with Community Partners Care Coordination through sharing information between providers Ex: lab results, diagnostics, drug prescriptions, treatment plans HPSJ provides claims data (medical and pharmacy), member demographics, and collaborates on treatment plans. Founding Partners San Joaquin General Hospital (SJGH) Health Plan of San Joaquin (HPSJ) County Behavioral Health Services (BHS) Community Medical Centers (CMC)