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Health Care Delivery Innovation in the Safety Net
John Baackes Chief Executive Officer October 5, 2016
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Geographic Managed Care GMC)
What is L.A. Care? Medi-Cal Managed Care Plan serving L.A. County since 1997 Created by California State enabling legislation and L.A. County resolution Three state created options that serve most counties participating in Medi-Cal Managed Care: L.A. County opted for Two-Plan model and L.A. Care was born as the Local Initiative, non-profit organization subject to public entity laws Stakeholder Board representing clinics, physicians, L.A. County, hospitals, and members County Organized Health Systems (COHS) Geographic Managed Care GMC) Two-Plan 2 counties 22 counties 14 counties
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California’s Two-Plan Model
CA Department of Health Care Services Commercial Plan Health Net Molina Local Initiative L.A. Care Health Plan L.A. Care Delegated Entities - 28 Anthem Blue Cross Care 1st Health Plan Kaiser Permanente Two-Plan Model Counties Alameda Contra Costa Fresno/Kings/Madera Kern Los Angeles Riverside/San Bernardino San Francisco San Joaquin Santa Clara Stanislaus Tulare
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L.A. Care Mission and Vision
Our Mission L.A. Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose. Our Vision A healthy community in which all have access to the health care they need.
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Medi-Cal Enrollment - Pre –ACA to Current
California* Los Angeles County** % of CA Medi-Cal Population Residing in LA County L.A. Care** % of L.A. Care Medi-Cal Membership out of Total LA County Medi-Cal Population Pre-ACA (2013) 7.8 million 2.26 million 29% 1.15 million 50% 2016 13.61 million 3.81 million 28% 1.97 million 48% % Increase 74% 41% 42% *Source: DHCS, Medi-Cal Monthly Enrollment Reports (MMCD) 2013 & 2016 **Source: L.A. Care, Internal Membership Trend Analysis 2013 & 2015
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L.A. Care Membership Product Line Enrollment (August 2016) Medi-Cal
1,939,606 Temporary Assistance for Needy Families (TANF) 1,055,061 Medi-Cal Expansion 557,258 Seniors and People with Disabilities 160,524 Coordinated Care Initiative 166,763 Cal MediConnect (duals pilot) 12,620 L.A. Care Covered (Covered CA) +Direct 10,998 PASC-SEIU 47,236 Healthy Kids 481 TOTAL 2,010,941
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L.A. Care Membership by Network of Providers
Membership Enrollment (August 2016) L.A. Care subcontracted Plan Partners 962,560 Kaiser 191,803 Anthem Blue Cross 460,581 Care 1st (Blue Shield of CA) 310,176 L.A. Care delegated entities - 28 LA County Department of Health Services ~193K Federally Qualified Health Centers ~280K IPAs -26 ~504K L.A. Care Directly Contracted Providers – Antelope Valley 367 (August 2016 Medi-Cal Only Figures) *Community Clinics include FQHCs, Lookalikes, Other Nonprofit
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Who Is Not Covered In LA County?
Remaining Uninsured Number Medi-Cal Eligible* 270,000 Exchange Eligible** 337,000 With subsidies 153,000 Without subsidies 184,000 My Health LA*** 145,000 Others** 601,000 TOTAL 1.3 million *Source: UCLA Center for Health Policy Research, AskCHIS 2014 **Source: Estimated using CalSIM data from UC Berkley Labor Center report, “Which Californians will Lack Health Insurance Under the Affordable Care Act?” ***Source: L.A. County Department of Health Services, My Health LA Program Key Demographics and Enrollment Summary
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Challenges for the Community
Access Need more physicians in Medi-Cal and Covered California Education Orient newly insured on how to use coverage Medi-Cal Covered California Holes in the safety net Poverty Homelessness Nutrition Immigration status Comprehensive Medi-Cal Funding Strategy ACA non-recurring funds
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Growing Pains for L.A. Care
Complexity of populations served and increased risk Tailored models of care for specific populations Focused shift from well care to complex care Organization structure Infrastructure and work processes need to catch up with growth Internal audit, enterprise risk assessment, and single source for data management and analytics Accountability unclear Inside Owners needed for accountability for population segment/product success Outside Delegated entities need to be held accountable to increased scrutiny
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Strategic Vision – Launched 9/2015
To address growth at L.A. Care Matrix structure Operating plan 4 attributes, 16 initiatives Technology New operating system Operational 8/15/16 Performance IPA report cards Direct network
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L.A. Care Executive Leadership Matrix
CEO Executive Director, Medi-Cal Plan Partners Executive Director, Medi-Cal TANF/ MCE Executive Director, Medi-Cal SPD/ CCI Executive Director, CMC & Medicare Ops Executive Director, Commercial Products CHIEF OPERATING OFFICER CHIEF MEDICAL OFFICER CHIEF FINANCIAL OFFICER GENERAL COUNSEL CHIEF OF ENTERPRISE INTEGRATION CHIEF COMPLIANCE OFFICER CHIEF OF STAFF
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Strategic Vision ( )
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IPA Scorecard Medi-Cal moving to value-based contracting
New CMS Medicaid Managed Care- Mega Rule L.A. Care quality performance consistency mediocre NCQA – Managed Care accreditation agency – score for L.A. Care dropping IPA scorecard ranks all 28 delegated entities Provides insight into opportunities for employment
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Access and Availability
IPA Scorecard Domain Score Weight Access and Availability 25 HEDIS Member Satisfaction 20 Utilization 15 Encounter Timeliness TOTAL 100
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Access & Availability: 25%
Available Data Sources Measures Medi-Cal Provider Appointment Availability Survey (PAAS) Reporting Year: 2014 Measurement Year: 2013 Methodology: Independent vendor survey of office site responses Measures with most data and best reflection of IPA Management Elements: After-Hours Survey: Overall Access Emergency Instructions Method to contact provider After-Hours Survey: Overall Timeliness Provider call-back within 30 min Appointment Availability Survey: Urgent 48 Hours (PCP)
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HEDIS (Medi-Cal only): 25%
Available Data Sources Measures HEDIS 17 Measure Composite Domain Score Reporting year: 2015, Measurement year: 2014 Methodology: Administrative data only (Not Hybrid) Same measures as L.A. Care Pay For Performance Program Elements: Childhood Immunization Status Well Child Visits in Third, Fourth, Fifth, and Sixth Years of Life Adolescent Well-Care Visits Immunizations for Adolescents – Combo 1 Breast Cancer Screening Cervical Cancer Screenings Chlamydia Screening in Women Prenatal & Postpartum Care (2 measures): Timeliness of Prenatal Care, Postpartum Care Use of Appropriate Medications for People with Asthma Comprehensive Diabetes Care (4 measures) Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis Appropriate Testing for Children with Pharyngitis Annual Monitoring for Patients on Persistent Medications – Total Rate
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Member Satisfaction: 20%
Available Data Sources Measures Clinical Group Consumer Assessment of the Health Plan (CG-CAHPS) Reporting year: 2014, Measurement year: 2013 Methodology: Independent Vendor Survey of Member responses who had a provider encounter within the survey period Elements: Adult Timely Care and Service for PCPs Adult Coordination of Care Combined Adult Health Promotion Combined Adult Doctor-Patient Interaction PCP Adult Doctor-Patient Interaction Specialist Adult Office Staff Combined Adult Rating of All Healthcare Combined Adult Rating of PCP Child Timely Care and Service for PCPs Child Timely Care and Service for Specialist Child Coordination of Care Combined Child Health Promotion Combined Child Doctor-Patient Interaction PCP Child Doctor-Patient Interaction Specialist Child Office Staff Combined Child Rating of All Healthcare Combined Child Rating of PCP
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Utilization Management: 15%
Available Data Sources Measures Encounters & Claims Data Measurement year: 2014 Methodology: HEDIS Technical Specifications Elements: Hospital Admission Rate (Inpatient Utilization IPU): Risk adjusted by 3M CRG methodology All Cause Readmission Rate (ACR): Risk adjusted by 3M APR-DRG methodology and weighted by SPD/non-SPD Avoidable ER Visits (AER): Weighted by SPD/non-SPD only
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Encounter Timeliness: 15%
Available Data Sources Measures Encounter Submission Data Measurement Year: 2015 Methodology: Encounter Volume Data Submitted by IPA within 60 days of Date of Service: Inpatient Outpatient LTC, if the IPA is responsible for Institutional Care (IPPG) Data not yet available
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Example Scorecard (cover page)
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Example Scorecard (page 1)
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Example Scorecard (page 2)
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Score Rankings by IPA: Based on 2013 and 2014 data
Pilot using data
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L.A. Care Added Direct Contracting Options For Providers
Rationale: Add capacity to L.A. Care network and improve quality measures and access 1) Fill geographic gaps Antelope Valley 1/1/16 Assess entire county for additional gaps Two additional geographic areas in 2017 2) Uphold Medi-Cal contract standards with delegated entities In addition to other delegated entities provider may belong to Offer direct contract option to providers in delegated entities that fail to meet quality and access standards
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Current Provider Array
Pre-2006 Post-2006 Plan Partners Kaiser DHS Community Clinics* IPA Direct Contract Antelope Valley Anthem BC Care 1st 963k 193k 280k 504k 367 (August 2016 Medi-Cal Only Figures) *Community Clinics include FQHCs, Lookalikes, Other Nonprofit
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Clinical Innovation in Managed Care
Care managers at Family Resource Center locations Health Information Technology (HIT) eConsult eConnect Transforming Clinical Practice Initiative (TCPI) – 3,000 providers Provider Incentive Program P4P program Community Health Investment Fund (CHIF) $10M to safety net
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Two Questions That I Have Asked Since Coming to L.A. Care
What value does L.A. Care add to our members’ health care experience? What value does L.A. Care add to our providers’ participation? What value does L.A. Care add to our staff’s experience?
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L.A. Care Value Proposition
What value does L.A. Care add to our members’ health care experience? Access to care Quality/outcome focus from providers Humane/compassionate treatment Member advocacy What value does L.A. Care add to our providers’ participation? Timely, accurate information Ease of administration Responsible reimbursement Informed members What value does L.A. Care add to our staff’s health care experience? Meaningful work Healthy workplace Wellness programs Fair compensation Professional development “Injustice in health care is the most shocking and inhumane.” -Martin Luther King, Jr. 1966
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This hangs over my desk……
At every crossway on the road that leads to the future, each progressive spirit is opposed by a thousand men appointed to guard the past Maurice Maeterlinck, Our Social Duty
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