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
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

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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)