Partnership HealthPlan of California MediCal Managed Care Overview Health Alliance of Northern California Peer Network Day May 11, 2012 Presented by Lynn Scuri, MPH Associate Regional Director

Today Who County Organized Health System Partnership HealthPlan What Who is included in managed care What Services are included or excluded How Primary Care Model Care Management Payment Structures Why Benefits to Members Benefits to Providers & Community

Med-iCal Managed Care - Three Models Geographic 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 Goals Create 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 History 1988 – Private/public discussion to address overall health of community; funding from Kaiser, NorthBay, Sutter, cities and other 1992 – State Contract approved and Commission formed 1994 – Solano Operations began! 1998 – Expansion to Napa 2001 – Expansion to Yolo 2002 – County Medical Services Program (CMSP) Pilot 2006 – Healthy Kids 2007 – Medicare/Medi-Cal Partnership Advantage Product 2009 – Medi-Cal Expansion to Sonoma County 2010 – Healthy Families Provider 2011 – Medi-Cal Expansion to Marin and Mendocino

More About PHC One 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 CPSP CHDP 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 Plan Local Governance & Administration: Access for community to policy making and management Board 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

Governance Board 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 Programs MediCal: 200,000 low-income members Healthy Kids 800 low-income, MediCal ineligible kids Medicare Special Needs Plan 7,500 low-income, senior/disabled members Healthy Families 1,500 kids

Benefitsfor Members Benefits for Members Member 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 Satisfaction 2010 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 Providers Health Care Centers / Primary Care Physicians Rates enhanced Quicker pay Quality Improvement Incentive Program PHC pays when State freezes payments Specialty Care 130% of FFS MediCal payment/80% of Medicare Quicker pay – less than 14 days on clean claims High quality referrals Provider services and support PHC pays when State freezes payments All Other Providers Payment at Medi-Cal rate LTC enhanced rates for higher acuity patients. One week turn around, better cash flow We Answer the Phone!

Provider Satisfaction Question 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% 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, MPH Associate Regional Director (707) Bob Moore, MD, MPH Chief Medical Officer (707)

Milestones Response from the StateAssemble Planning Team State Contract & RatesNetwork DevelopmentRevised PPS Rate from State

And More Milestones Community 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