Contra Costa County Sustainability Audit Health Management Associates October 11, 2011

Overview Study Purpose Report Contents Barriers to Sustainability October 11, 2011 Overview Study Purpose Report Contents Barriers to Sustainability System Strengths Additional Findings/Discussion Alternative Governance Structures Questions/Discussions/Feedback

October 11, 2011 Study Purpose Review the County health care system in order to “…secure the fiscal sustainability…and to ensure the most efficient and effective delivery of medical services to County residents that are consistent with the implementation of health care reform.” (HMA Contract with Contra Costa County) Important to note that the report is grounded in the assumption that ACA will be implemented as currently enacted

Report Contents Stage 1: Information Memorandum October 11, 2011 Report Contents Stage 1: Information Memorandum Medi-Cal and uninsured: demographics and projections Current and future service capacity, needs Basic Health Care Program Data/performance indicators This report is largely descriptive

Projected Population Growth October 11, 2011 Projected Population Growth Source: State of California Department of Finance

October 11, 2011 Medicaid Enrollment Source: CA DHCS

Reports (cont.) Stage 2: Preliminary Report October 11, 2011 Reports (cont.) Stage 2: Preliminary Report Preliminary strategic analysis Potential alternative models Human resources/staffing analysis Maximizing federal reimbursement Impact of Low Income Health Program (LIHP) Primary care medical home (PCMH): preliminary steps

Reports (cont.) Stage 3: Final Report PCMH work plan Management review October 11, 2011 Reports (cont.) Stage 3: Final Report PCMH work plan Management review Alternative governance structures Local labor market Organizational changes Performance measurement and monitoring options

Barriers to Sustainability October 11, 2011 Barriers to Sustainability Workforce: Recruitment Compensation Flexibility in work rules (i.e. need more ability to respond to changing demands) Departmental control over HR, purchasing process Organizational: Succession planning Transparency Accountability

October 11, 2011 System Strengths The County operates a well-integrated health care system and is taking steps to meet the future challenges presented by health care reform The Health Services Department has done an excellent job in maximizing federal reimbursement for the system

Additional Discussion October 11, 2011 Additional Discussion PCMH: The County has made a good start down this path; next steps include performing detailed self-assessment, formulating plan Instituting an observation unit at CCRMC would address the high percentage of short-stay patients Length of stay should be addressed Improving ER utilization with additional urgent capacity is recommended

Additional Discussion (cont.) October 11, 2011 Additional Discussion (cont.) HSD should also: Enhance specialty care capacity Improve the appointment scheduling process Establish a public performance dashboard Select and track quality measures that are specific to health centers Track ambulatory care sensitive hospitalizations

Additional Discussion (cont.) October 11, 2011 Additional Discussion (cont.) HSD and the County should also: Conduct an annual formal market survey related to compensation Implement electronic timekeeping and attendance system Ensure wider distribution of user-friendly monthly financial reports Measures of financial performance should include all revenue sources and be delineated by care setting

Alternative Governance Structures October 11, 2011 Alternative Governance Structures Model Type 1: Retain Current Structure Model Type 2: “Arm’s Length” Arrangement Model Type 3: Divestiture No Governance Change Public Ownership/Private Management Separate Non-Profit Entity Privatization Health Authority/District

Alternative Structures (cont.) October 11, 2011 Alternative Structures (cont.) Key Points: There is no “magic bullet” Any substantive change is a lengthy process requiring buy-in from a variety of stakeholders Recommended changes to system, services should proceed irrespective of governance discussion Costs and benefits need to be weighed (e.g., more capital revenue vs. cutting off public financing opportunities) Doctors Medical Center situation should be in the mix in any conversation

October 11, 2011 Conclusion Questions Discussion Feedback