1. Benefits and Challenges
of the Regional Model
Partnership HealthPlan and Humboldt, Lassen, Mendocino, Modoc, Shasta, Siskiyou, Solano and Trinity Counties
December 7, 2017
Introduce myself

4. What is the Regional Model?
Eight counties and PHC worked together to prepare the DMC- ODS Implementation Plan.
Meetings to develop the model have been ongoing for two years.
Affects approximately 285,000 PHC members.
Important considerations -
PHC is the sole managed care plan in the eight counties.
Physical health, mental health (mild to moderate) and SUD provided to all PHC members.

5. PHC’s Role in the Regional Model
Responsible for Managed Care functions.
Administration
Enrollment-Related Functions –
Outreach
Call Center/Initial Screening
Compliance officer responsible for fraud prevention
Member Services
Member handbook
Provider directory
Service provision
Utilization management
Prior authorizations for residential
Credentialing DMC providers
Contracts with network providers
Access –
Provider network adequacy
Access for people with disabilities

6. PHC’s Role in the Regional Model
More Managed Care functions handled by PHC
Care Coordination
Facilitate access to mental health and physical health services
Facilitate successful transitions between levels of care
Provide training on ASAM criteria and care coordination systems
Mulit-party bi-directional ROI
Grievance, Appeal, and Fair Hearing Process.
Quality
Quality management plan
Outcome measures
PIPs
Regional EQRO
Site Reviews
Provider trainings EBPs, compliance, etc.
Systems –
Payment systems
Encounter Data

7. How will the Contracts Work?
State/County intergovernmental agreement for all eight counties.
Modified CPE Protocol
Modified rate setting
County/PHC agreements designating PHC for all managed care functions.
PHC/Provider agreements with all providers.

8. How will the financing structure work?
PUPM: Per utilizer per month rate will be negotiated for each County with DHCS (rather than fee for service.) Aligns with fiscal structure for other PHC programs.
Interim Cost Settlement/Final Cost Settlement: Detailed projections are being built into the Fiscal Plan since there will be no cost settlement.
Realignment Contribution by County: PHC will contract with each county for a share of their realignment funds.
Rates negotiated with each provider: PHC will negotiate rates with each provider, whether County or community-based DMC-certified providers.
PHC financial support: The “risk” for the costs of care will be borne by Partnership HealthPlan; i.e., if the costs exceed estimates, the Plan will absorb the loss.

9. Flow of Funds – DMC/ODS 835-FFS County Realignment State/DHCS 837-FFS
Pmt. To Providers
837-FFS
Provider

10. Flow of Funds – Regional Model
835-PUPM
Partnership
State/DHCS
County
Realignment
Pmt. To Providers
837-PUPM
Provider

11. What are the benefits?
Knowledgeable people performing managed care functions.
PHC has the ability to affect other parts of the system such as medical providers.
PHC will be able to coordinate all aspects of healthcare – physical health/mental health/substance use disorder
Overall savings to the healthcare system.
Fiscal and administrative barriers for small counties are mitigated.
Flexibility and innovation.

12. What are the challenges?
SUD has not historically functioned within a medical model.
Non-licensed staff providing services
Group services
Providers who have no EHR and work with paper files
Big differences in County issues between very small, small, and medium counties.
PHC is not a County so sometimes left out of decisions, communication flow, etc. that has historically existed between Counties and the State.
DMC is not the only component of AOD system. Other components which remain with the Counties create added coordination requirements.
SAPT, EPSDT
Prevention
Youth treatment system development
DHCS difficulty integrating alternative payment methodology.

13. Next Steps
PHC will develop the new benefit with technical support from the Counties.
Implementation plan has been approved by DHCS; Fiscal plan has not.
Intergovernmental agreements needed for each County.
Contracts between PHC/County and PHC/Providers must be developed.
Other concerns
Criminal justice coordination/impacts, especially prior to being assigned to Partnership.
Impact of new hub and spoke clinics.
Workforce development issues.

14. Contact Us
Visit: ages/Drug%20Medi-Cal/Drug-Medi-Cal-Benefit.aspx Margaret Kisliuk: Liz Leslie: