Loading...
HomeMy WebLinkAboutMINUTES - 03231993 - H.5 H. 5 THE BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA DATE: March 23 , 1993 MATTER OF RECORD ---------------------------------------------------------------------- SUBJECT: Workshop On The Health Services Department' s Managed Care Proposal "Health First" . On this date, the Board of Supervisors held a workshop on the Health Services Department' s managed care proposal, "Health First" . Mark Finucane, Director of Health Services, presented the staff report on the proposed plan. The Board discussed the proposed plan and the following persons appeared to speak: Dr. George Degnan, Martinez; Maggie Dowling, P.O. Box 783 , Pittsburg; Henry Clarke, representing Local 1. THIS IS A MATTER FOR RECORD PURPOSES ONLY NO BOARD ACTION TAKEN DATE: 3, 3 REQUEST To SPEAK FORM THREE (3) MINUTE LIMIT) Complete this form and place it in the box near the speakers' rostrum before addressin the Board. NAME: �~ (T �`F� PHONE: 2 Z ADDRESS: V�, �O .1� ,� �c `1� CITY: I am speaking formyself_ OR organization: Check one: NAME OF ORCAN17-V ION) I wish to speak on Agenda Item # My comments will be: general for against I wish to speak on the subject of �,�; �(. o� .(,z qfl��4A I do not wish to speak but leave these comments for the Board to consider. SPEAKERS 1. Deposit the "Request to Speak" form (on the reverse side) in the box next to the speakers' microphone before your item is to be considered. 2. You will be called to make your presentation. Please speak into the microphone. 3. Begin by stating your name and address: whether you are speaking for yourself or as a representative of an organization. 4. Give the Clerk a copy of your presentation or support documentation, if available. 5. Please limit your presentation to three minutes. Avoid repeating comments made by previous speakers. (The Chair may limit length of presentations so all persons may be heard.) DATE: REguFm To SPEAK FORM (THREE (3) MINUTE LIMIT) Complete this form and place it in the box near the speakers' rostrum before addressing the Board. NAME: �A PHONE: ADDRESS: CITY: I am speaking formyself OR organization: (1VAME OF ORGA".VI7.NTlOti) Check one: I wish to speak on Agenda Item # Cu My comments will be: general for against I wish to speak on the subject of I do not wish to speak but leave these comments for the Board to consider. SPEAKERS 1. Deposit the "Request to Speak" form (on the reverse side) in the box next to the speakers' microphone before your item is to be considered. 2. You will be called to make your presentation. Please speak into the microphone. 3. Begin by stating your name and address; whether you are speaking for yourself or as a representative of an organization. 4. Give the Clerk a copy of your presentation or support documentation, if available. 5. Please limit your presentation to three minutes. Avoid repeating comments made by previous speakers. (The Chair may limit length of presentations so all persons may be heard.) DATE: 3/.Z,3 43 REQUEST TO SPEAK FORM THREE (3) MINUTE LIMIT) Complete this form and place it in the box near the speakers' rostrum before addressing the Board. NAME: ��d �N G PHONE: s/D ` 'z7 ADDRESS: {' 0 . �� �c�3 CITY: '�►��ul�.�z '` I am speaking formyself OR organization: C_ Check one: NAME OF ORCANI7VTI0ti) I wish to speak on Agenda Item # _. My comments will be: general for against I wish to speak on the subject of I do not wish to speak but leave these comments for the Board to consider. SPEAKERS 1. Deposit the "Request to Speak" form (on the reverse side) in the box next to the speakers' microphone before your item is to be considered. 2. You will be called to make your presentation. Please speak into the microphone. 3. Begin by stating your name and address; whether you are speaking for yourself or as a representative of an organization. 4. Give the Clerk a copy of your presentation or support documentation, if available. 5. Please limit your presentation to three minutes. Avoid repeating comments made by previous speakers. The Chair may limit length of presentations so all persons may be heard.) DATE: REQUEST TO SPEAK FORM (THREE (3) MINUTE LIMIT) Complete this form and place it in the box'near the speakers' rostrum before addressing the Board. NAME: PHONE: ADDRESS: CITY: I am speaking formyself OR organization: Check one: (NAME OF ORCANIZ-V ION) I wish to speak on Agenda Item # My comments will be: general for against I wish to speak on the subject of I do not wish to speak but leave these comments for the Board to consider. .SPEAKERS 1. Deposit the "Request to Speak" form (on the reverse side) in the box next to the speakers' microphone before your item is to be considered. 2. You will be called to make your presentation. Please speak into the microphone. 3. Begin by stating your name and address; whether you are speaking for yourself or as a representative of an organization. 4. Give the Clerk a copy of your presentation or support documentation, if available. 5. Please limit your presentation to three minutes. Avoid repeating comments made by previous speakers. (The Chair may limit length of presentations so all persons may be heard.) a Contra Costa County The Board of Supervisors HEALTH SERVICES DEPARTMENT OFFICE OF THE DIRECTOR Tom Powers,1st District Mark Finucane,Director Jeff Smith,2nd District Gayle Bishop,3rd District 't '. 20 Allen Street Sunne Wright McPeak,4th District Martinez,California 94553-3191 Tom Torlakson,5th District (510)370-5003 °t' FAX(510)370-5098 County Administrator Phil Batchelor °sr• UU__..•: J County Administrator ... q .. MEMO TO: Board of Supervisors DATE: March 18, 1993 Phil Batchelor FROM: Mark Finucanefip- Health Services Director Attached is the background briefing material for the Board Workshop on the Health First Proposal scheduled for March 23 from 2-4 p.m. MF:MSC/lmb Attachment: March 1993 Edition of Health First Proposal t.27TH Menithew Memorial Hospital&CW4ca • Pubic Health • Mental Health Substance Abuse • Environmental Health Contra Costa Health Plan • Emergency Medical Services • Home Health Agency • Geriatrics A•345 (2193) 03-15-1993 04:22PM FROM CONTRA COSTA HEALTH FLAN TO 20 ALLEN P.02 Contra Costa County 4 The Board of Supervisors HEALTH SERVICES DEPARTMENT OFFICE OF THE DIRECTOR Tom Powers. 1st District Haney C.Fanden,2nd District Mark Finucahe, Director Rot•ert I.Schroder.3rd District Sunne Wright UcPeak,4th District 20 Allen street Tom Torlakson,5th District _ Martinez.California 94653-3191 . •�►'� t (510)3705003 County Administrator (510)370.8098Fax Phil Batchelor. County Administrator MEMORANDUM To: Board of Supervisors pate: March 15, 1993 Phil Batchelor From: Mark Finucane RE: Health First Next week (March 23rd, 2 - 4 p.m.) we will be conducting a special workshop on our Health Fust proposal. In advance of that meeting I am distributing widely a draft proposal on creating a Medi-Cal Advisory, Commission (MAC) to be appointed by the Contra Costa County Board of Supervisors ".... to assure provider, beneficiary, and community input into the planning for and implementation of the County sponsored Medi-Cal managed care system in Contra Costa County." (See draft enclosed). We will be sharing this draft with several community based advocacy and provider groups and we plan to specifically discuss this proposal with representatives of Brookside Hospital on Thursday March 18th. Enclosure 0 Draft Contra Costa County Medi-Cal'Advisory Commission - revised MOrflthaW MOMI' r Hospital i CtuMoe • Pu Due Heald+ - Memal Health • substance Abuse • Environmental Health • Contra costa Hearth Pun emergency Medical$ervIbea . Home Health Agency • GariatriC4 W ay.y 03-15-1993 04:22PM FROM CONTRA COSTA HEALTH PLAN TO 20 ALLEN P.03 4 DRAFT Contra Costa County MEDI-CAL ADVISORY COMMISSION OVERVIEW The Medi-Cal Advisory Commission (MAC) is a 25 member special committee appointed by the Contra Costa County Board of Supervisors to assure provider, beneficiary, and community input into the planning for and implementation of the County sponsored Medi-Cal managed care system in Contra Costa County. The Hoard of Supervisors will solicit nominations In April, 1993, and make appointments to the Commission in May, 1993. The Board of Supervisors will assure ethnic, cultural, and geographic diversity in its appointments to the Commission. It will also seek to appoint representatives who are knowledgeable and experienced in meeting the special needs of vulnerable populations, including Medi-Cal and indigents. The Commission will make recommendations directly to the Board of Supervisors,.the County Health Services Director, and the Contra Costa Health Plan (CCHP) Advisory Board. MAC will also report, at least annually, to the State Department of Health Services and the County Board of Supervisors on beneficiary, provider, and community issues related to the Medi-Cal managed care system in Contra Costa County. FUNCTIONS The Commission's purview encompasses the County sponsored Medi-Cal managed care system, its Plan members, and providers. Specific areas which the Commission will review, monitor, and make recommendations are: 1. Outcome Measures: The Commission will approve a set of community pnd patient outcome goals, and the specific measures to be used in determining'the extent to which these outcomes are being met. 2. Accessibility; The Commission will review access standards and report on the extent to which the County sponsored Medi-Cal managed care system Is meeting those standards. 03-15-1993 04:23PM FROM CONTRA COSTA HEALTH PLAN TO 20 ALLEN P.04 r page two 3. Quality The Commission will review and report on quality of care issues Including health status indicators and appropriate outcome studies. 4. Beof s• The Commission will review the scope of benefits and services offered by the County sponsored system and make recommendations for modifications. 5. Beneficiary Satisfaction: The Commission will monitor beneficiary satisfaction, grievances, and complaints. It will conduct annual member satisfaction surveys and make recommendations accordingly. 6. Pro ider Relat4nshius• The commison will monitor provider satisfaction;and will review trends in provider complaints, conduct provider satisfaction studies, and report on survey results. 7. Community Hg%jlj Related Needs; The Commission will review unmet hoalth related needs In the community and make recommendations to the Public & Environmental Health Advisory Board on community reinvestment fund priorities. MEMBERSHIP The 25 members of MAC shall be appointed by the CCC Board of Supervisors for a two year term and shall include: z 7 Advisory Board Representatives - 1 Substance Abuse Advisory Board representative 1 Maternal & Child Health Advisory Board representative 1 Mental Health Advisory Board representative 1 Public & Environmental Health Advisory Board representative 3 Contra Costa Health Pian Advisory Board representatives; Current Chair of CCHP Advisory Board Immediate Past Chair of CCHP Advisory Board 1 member elected by the CCHP Advisory Board 3 Community Based Organizations' Representatives 3 Medi-Cal beneficiaries 03-15-1993 04:23PM FROM CONTRA COSTA HEALTH PLAN TO 20 ALLEN P-05 y page three x 3 Physicians - nominated by the ACCMA: 1 from West County 1 from East County 1 from any region of the County 3 Community Hospitals' Representatives (Hospitals must include non-County facilities who have historibally demonstrated a loyalty and competence In serving the special needs of Medi-Cal beneficiaries.) 1 Community Based Provider Organization Representative-Planned Parenthood 1 Dentist nominated by the Contra Costa Dental Society 1 Pharmacist nominated by the Alameda/Contra Costa Pharmac9sts' Association 1 other community provider 2 at large seats appointed by the CCC Board of Supervisors. COMMUNITY PARTICIPATION To ensure that all providers, beneficiaries, and members of the public have the opportunity to participate in the planning for and Implementation of the County sponsored Medi-Cal managed care program, the Commission shall: 1. Have regular open meetings conducted at least quarterly and in accordance with the Ralph M Brown Act (Gov. Code 54950 et seq.) 2. Hold regional hearings to elicit broad community input. 3. Establish such special committees on an ongoing or limited term basis as necessary to conduct its work. In addition to the 25 Commission members any individual or organization may attend and participate on any appropriate special committee that is established. The Commission Chair shall appoint'the Chair of any special subcommittee. Examples of the types of special committees the Commission may establish are: committee on issues of the physically disabled; committee on cultural, linguistic, and ethnic accessibility of services; contract provider committee. 03-15-1993 04:24PM FROM CONTRA COSTA HEALTH PLAN TO 20 ALLEN P.06 page four Committee meetings shall be regarded as open "workshops" designed to elicit broad public participation. OFFICERS & RULES OF PROCEDURE The Initial meeting of MAC will be called to order by the Chair of the Contra Costa Health Plan Advisory Board. The Commission shall subsequently elect a Chairperson and a Vice-Chairperson for terms of one calendar year. The Chairperson and Vice- Chairperson may serve two consecutive terms of one year each. The Commission shall consider and adopt By Laws and other organizational rules. It shall adopt a work plan which includes mission, goals, and principles. In developing its workplan it shall consider and prioritize the following issues: Beneficiary Issues: ♦ Client education, rights, responsibilities ♦ Grievance procedures ♦ Needs of special populations, e.g. foster children, children with special needs, ethnic or cultural groups, mentally disabled, HIV/AIDs, homelbss, undocumented ♦ Accessibility issues provider & Svstem Issues: ♦ Roles of traditional providers ♦ Public/private linkages ♦ Integrated service networks ♦ Management of specialized services in regional and central locations ♦ Health professionals' training, e.g. in serving a culturally diverse population ♦ Episodic care/emergency care/urgent care Q=m-unity Issues: 4 Community wide prevention programs 03-15-1993 04:24PM FROM CONTRA COSTA HEALTH PLAN TO 20 ALLEN P.07 page five STAFFING The Commission and its special committees will be staffed by Contra Costa Health Plan and County Health Services Department administrative staff. SUNSET CLAUSE The Commission will assist in the planning and implementation of Phases 1 and II of the Health First Medi-Cal Managed Care Program, At the start of Phase III a Health First governing body will be established In accordance with federal and state laws and regulations. 41:HFP MSC:BB:smp March 15, 1993 03-15-1993 04:24PM FROM CONTRA COSTA HEALTH PLAid TO 20 ALLEN P,08 a V Al cis cr3 � i••t a x x -- cc �, 03-15-1993 04s25PM FROM CONTRA COSTA FEALTH PLAN TO 20 ALLEN P.09 Medi-Cal Advisory Commission Organization Chart Contra Costa County Board of Supervisors 40 ♦•••• Heatth Services ••.•• Departm=t • •.�:•`•• •••■•• Director ■ ■• Medi-Cal Advisory Commission (CMAC' Contra Costa Health Plan Reviews County- (CCHP) Sponsored Advisory Board Medi-Cal Program Reviews All Including CCHP Programs' Staff Model HMO Medi-Cat and Or Medicare O' Basic Adult Care Community or Comramial Contract (individual, Providers. smallgroup, larpegroup) NP MajorRisk Medk allnsluame Program �AIM TOTAL P-09 .J.Y •• .... •.LLLLLLLL::LLL•::•.LLL:::•:{.;.;.;f.;.;.;:' ............................ ....... .. ff•• rr:?{v:{??� :t': .r.4•t{-:•. :J•:'�}}:•vi:;{•}r rr{.. ;r?.{'lr 1L. . ...Y :.. .}............. .LLY:•t.tttY•Y• aa.. ..t.... x :•f }; :. l rr}. ::::: .f•f.. .}rrr h•1 ;ti$ C;::�:��:�:�:�:�:�'�:ti:•:tiff L .{f.... x�•. r.��[ }'f?':??•:•:ti?•:':?•:::::::::'::::::::f:.1.l`.•:.:•......JJ ':1�}r:r4r• ...:: ..................... . M. {;. .;{:.LL•r:::.:L•rr:f:.LLL•.;{.;.;.;.;.;.?.:':':':'.':':':•:':•:{Y:•}:•:•:•}}:L::LLL'............................l::f:f:::::::.:Y::::::.... ....... .. f •h...:L•ll::.LLL'::::.LL'.•rlI.LLLY�::':::::.: }}L:'::::::::};•;•;•;•::.;:.:.:.:.:.:.:.:.•.;............ .................................. ............... .............. ............. �•.}•L fes,{{{{{.••.••r,{;:�{{{{{{{{{{•}:{•}}:{{{L:};.}•,•:::;;••. :•:ti;{:x{:{{;.:•:;:.:L:?;X'}.r...v{.r rh• :•xom:l lhv } :titin:•:•:: tititi{ :•:titi{;:ti;:}}:•}}::::..WO.,. }r. {ti:}}::}};::ti:}}::y:::tip:::�}':: •:::�1.... J:ti':ti :�::•:•:• ti':tiff :?f:};:•:;r':; ??•::.. :FJfl .1�v ........................ . . ... [[ •:L•:: •'•}::{�}"•}r}:•:•'r:•:•�r}}} titi�:•:?ti�' :.L•:r.::L•:.:..tv........ f r#}.' :trr rr:ti r rfr: :•:}}:;:•}y::}f: ::::•::}:::;::::;:;}i f }::f?fir.%} . :tivlh?{?<•} {;?{?????;?:lr}?ti?????::}:$i ????{ }'• } ::r r:;{{{{'i{".•{r{".•{r•'{:•• ••'}i,7{frl�.f :•r•:::h•:h r:::::::::•r•{}h::::•.;:}h•:h::'::: :{:r.. .::ti {•r•{{. W. } 1 : .}}.::}}}:{�:{r{}:{�}{{}}}kY}?tiff{:?:::�'� ;:;1}}}ti!•• •{{}� f,yf•�' {;$#:y:: ::•`.:::yff:::ry:: •J.. .}x???.: L':$:: .$� .q�t�yy r}?�: '•{:•{{:???{?• {{{{r.r.Y{:L•lrr,}:�ti'.. :tiv:•:•v:•:•:•:•:•:•:•i:•}}:}{::. {:}.:{{: .;7L'•{ { { •'•{{:•:•{}}{}}}1�••'•+k,Lt,::{?{�: •:r:}}:{•}:..::•:.???•}:}:•:. •,:;'{ti}�} •�¢,' :;'q,;rt h':�: fr.L r�:l i}i:•:- Contra Costa County The Board of Supervisors HEALTH SERVICES DEPARTMENT OFFICE OF THE DIRECTOR Tom Powers, 1st District Mark Finucane, Director Jeff Smith,2nd District ........ Gayle Bishop,3rd District 20 Allen Street Sunne Wright McPeak,4th District Martinez,California 94553-3191 Tom Torlakson,5th District (510)370-5003 FAX(510)370-5098 County Administrator ., Phil Batchelor °si;•�.� -'JJ County Administrator MEMO TO: Board of Supervisors DATE: March 18, 1993 Phil Batchelor FROM: Mark Finucane,. Health Services Director Attached is the background briefing material for the Board Workshop on the Health First Proposal scheduled for March 23 from 2-4 p.m. MF:MSC/lmb Attachment: March 1993 Edition of Health First Proposal L27:FH M erftew Memorial Hospital&Clinics • Publk Health • Mental Hearth • Substart a Abuse • EnNiwrnantal MOM Contra Costa He&Nh Plan Emergency Machos!Services • Horne Hs&6 Agency • Geriatrics A-345 (2193) I/ Contra Costa County Board of Supervisors Workshop on Health First Tuesday, March 23, 1993 2-4 p.m. AGENDA Topic Health First Proposal Section 2 - 3 p.m. Presentation by Mark Finii'eane, Health Services Director ❑ Yety ew.................. 1.0 Executive Summary 2.0 Advantages urr t fedi U. Syst+ n �.ntra v Medi-Cal Eligibles...................... 9.0 Contra Costa Medi-Cal Eligibles Medi-Cal Providers..................... 10.0 Contra Costa Medi-Cal Providers eal Plaris ....................... 8.0 Community :.....:::::..:....................:......................... . Medi-Cal Advisory Commission (MAC) Participation . Meetings with Providers, Beneficiaries, Community Organizations ....... .................................................... ❑ tse 11.0 Correspondence :.:::..:::::...::............:.........:::.. ..:: . and Background Charter Health Initiative State Strategic Plan . Federal Waivers Other Implementation Issues 7.0 Health First Implementation Issues ❑ + t s .......................... 3.0 Beneficiary Choice Phase 1: Default and Conversion of County Facilities to Managed Care.. 3.6 - 3.9 - Phase I ✓Expansion of County Outpatient.... 4.0 Managed Care Systems I Topic Health Filst Proposal Sectign Phase II - Modified Geographic........... 3.10 - 3.17 - Phase II Managed Care: State Contracts Solely with PHPs and PCCMs in Contra Costa County /Beneficiary Choice /Contracts with Other Medi-Cal Providers Phase III - Health First Program.......... 3.18 - 3.21 - Phase III Assumes Total Fiscal and Administrative Responsibility for Providing and Arranging Care for All Medi-Cal ❑ € L27:WA • 4i \<ji?'iy:::i$};}v.n•}}:$:?ti:}:::{{r. ��i•:tii{:i n, 9' t{r{+ . ?v\i$T$'>.`v:???}�i}$i�??'{?'{:ii,t!+?' }}:\\.{•}:{:%;\;\v C4}.•+}�:}):{Ci\ } 44;. ^� 'i•?::ti:::'::`�',>.fir:{? �air:�y(p;+Lvt A Managed Care System Proposal for Contra Costa County • March, 1993 . ......... ..... TEN TAB Q ..:::CO N . . Pages •o Executive Summary 1.0 - 1.5 •o Advantages of Contra Costa County's Proposal 2.0 - 2.3 a Beneficiary Choice 3.0 - 3.22 �o Managed Care Systems 4.0 - 4.46 •v Assured Access 5.0 - 5.13 'o Global Budget Proposal 6.0 - 6.7 a Health First Implementation Issues 7.0 - 7.1 a Community Participation 8.0 - 8.18 �o Contra Costa Medi-Cal Eligibles 9.0 - 9.16 a Contra Costa Medi-Cal Providers 10.0-10.11 •a Correspondence and Background 11.0-11.32 � � 3 � d • � i • EXECUTIVE • SUMMARY 1.1 Contra Costa County Health First Proposal The Health First proposal transfers the management of the Medi-Cal program from the state to Contra Costa County. This proposal reflects Contra Costa County's long commitment and record of making accessible, affordable, quality health care for all a top priority. When implemented this proposal eliminates traditional fee-for-service Medi-Cal and adds approximately 64,000 eligibles to the 15,000 already in managed care systems in the county. Contra Costa County has operated a publicly sponsored managed care system with 20 years of prepaid Medi-Cal experience and has successfully integrated commercial and Medicare "paying" members with Medi-Cal and indigents. The county will now arrange public and private resources to assure beneficiary choice and increased access for all the county's Medi-Cal beneficiaries. Health First includes an innovative global budgeting arrangement with distinct advantages and protections for both the state and county. The county's Public Health Division will have an integral role in this new prevention oriented approach to Medi-Cal managed care. Health First also builds on a major (and about to be rebuilt) public hospital thereby preserving and stabilizing the health care safety net. Health First emphasizes a cost effective family practice centered primary care system and takes advantage • of a highly regarded family practice residency program. Health First also forges a new managed care partnership with the private sector, including new strategic alliances with Kaiser and Planned Parenthood. Furthermore, all appropriately licensed physicians and other providers who meet applicable state, legal, professional, and technical standards will have the opportunity to participate in the program through their relationship with Contra Costa Health Plan, Kaiser, or another contracting HMO. Advantages for beneficiaries include universal access to care through guaranteed Medi-Cal eligibility, increased access to primary care (including a 24-hour toll free telephone Advice Nurse service), and a choice of managed care systems. The county's proposal includes a realistic time-phased approach. In Phase I (January, 1993), the state reduces fee-for-service and expands managed care, while in Phase H (in six months), the state virtually eliminates fee-for-service Medi-Cal in the county and contracts with a variety of . managed care options. In Phase III, (in one year) the state contracts exclusively with Contra Costa County's Health First program to assume total fiscal and administrative responsibility for providing or arranging for services to all eligible Medi-Cal beneficiaries through prepaid health plans. Health First negotiates contracts with Kaiser, other HMOs, and providers and expands its county run plan, the Contra Costa Health Plan, to enroll approximately 80% of the Medi-Cal eligibles. • Health First offers a new approach to Medi-Cal managed care and holds the most promise to improve health status of the underserved and contain costs. 1.26:PROP 1 .2 Contra Costa County The Board of Supervisors HEALTH SERVICES DEPARTMENT OFFICE OF THE DIRECT Tom Powers. 1st District Mark FinuCane, Director Nanny C. Fattden, 2nd District IiODcrt 1.Schroder, 3rd District ok 20 Allen Street Sunne Wright MCPeak. 4th District Tom Torlakson. 5th District - Martinet, California 94553 3191 (5/0)370.5003 County Administrator :a (510)370-5098 Fax Phil Batchelor County Administrator December 8, 1992 Molly Coye, M.D., M.P.H., Health Services Director State Department of Health 714 P Street, Room 1253 Sacramento, CA 95814 Dear Dr. Coye: is We propose that the State of California enter into an exclusive contract to transfer management of the Medi-Cal program to Contra Costa County. The Contra Costa County Health First proposal offers the State a unique opportunity to demonstrate how an exaerienced publicly-sponsored managed care system can effectively arrange public and private resources to assure beneficiary choice and increased access. We believe that increased access to primary care and to other high quality, comprehensive health care services can be accomplished while controlling the skyrocketing costs of Medi-Cal. Our proposal includes an innovative, global budgeting arrangement with distinct advantages and protections for both the State and the County. In addition to our more than 20 years of managed care experience, we also offer an unusual opportunity to test new models for providing services to the special populations we serve. For example, our Public Health Division will have an integral role in the proposed delivery system. Our strategy anchors the essential elements of the public health care safety net while forging a new managed care partnership with the private sector. But, equally important we will also develop a new managed care partnership with the State. Our ability to carry out this plan of action and the success of this program is contingent upon the State making certain . guarantees and carrying out certain actions which we consider essential. • Ace!"ne% Me�oria'NDSD.:a 8 C.Mics . Pub-.c Nea,th • Me^ta'Nec-P • Suostance ADuse • Enwo^n e-w mea: Con:,a Costa Near- P-an - Eme'penc, Moo-ca'Ser-ces • Nome Neal:•, Agelc, - Ge•,a+•.cS 1 .3 Molly Coy% M.D., M.P.H. December 8, 1992 Page Two To implement the transfer of the Medi-Cal program to the County, we propose a realistic time-phased approach, as follows: PHASE I - REDUCED FEE-FOR-SERVICE AND EXPANDED MANAGED CARE - JANUARY, 1993: The State of California implements a special project in Contra Costa County limiting maximum fee-for-service enrollment and giving beneficiaries a choice of managed care plans. Contra Costa Health Plan expands its prepaid capacity. Aggregate fee- for-service enrollment is capped. PHASE II - STATE CONTRACTS SOLELY WITH PHPs AND PCCMs - JULY, 1993: Fee-for-service is virtually eliminated in Contra Costa County. The State contracts with an expanded capacity Contra Costa Health Plan and with Kaiser, proposed IPAs and PCCMs to manage the Medi-Cal population. PHASE III - HEALTH FIRST - JULY, 1994: State contracts with Contra Costa County's iHealth First program to assume total fiscal and administrative responsibility for providing or arranging for services to all eligible Medi-Cal beneficiaries through PHPs. The County's Health First program negotiates capitated contracts with Kaiser and proposed TPAs and expands its County-run PHP, the Contra Costa Health Plan. Contra Costa Health Plan contracts with Planned Parenthood for family planning, prenatal services and possibly primary care. At the time of the Phase III implementation, the Contra Costa County Health Services Department will have gained added experience in Medi-Cal and indigent care management. This will enable us to assume the responsibility of a regional Medi-Cal administrator, providing such service functions as primary and referral provider recruitment and training, beneficiary education, utilization review, quality assurance, and financial reporting. If, as we propose, Health First is implemented in July 1994, the Contra Costa County managed care system will have achieved the following: d Assured Access and Beneficiary Choice In addition to using the expanded County-run PHP (Contra Costa Health Plan), Health First will contract with community managed care systems such as Kaiser and IPAs. Contra Costa Health Plan (CCHP) will enroll approximately 80% of the Medi-Cal eligibles with Kaiser and the proposed IPAs at risk for the remaining 20%. All County beneficiaries will have access to a 24-hour toll-free telephone Advice Nurse • Program offering counseling for medical problems and referral to appropriate levels of care including emergency services. CCHP will increase its capacity through use of contract community M.D.s practicing in the County clinics as well as their private 1.4 Molly Coye, M.D., M.P.H. December 8, 1992 Page Three offices and will contract with Kaiser for selected specialty and ancillary care. HCO will perform the enrollment functions including the assignment of all eligibles using prior relationships, accessibility standards, and plan capacity as guidelines. Beneficiaries will have appeal rights to the State Department of Health Services. Community Provider Participation All physicians who meet applicable State legal, professional, and technical standards, and who are appropriately licensed will have the opportunity to treat Medi-Cal patients through their relationship with Contra Costa Health Plan, Kaiser, or a contracting IPA. V Strong Utilization and Cost Management • To help reduce unnecessary utilization of expensive emergency rooms, we propose instituting modest copays on ER by all Medi-Cal beneficiaries in Contra Costa County. • We will require that all beneficiaries be assigned a primary care case manager who will oversee their care. • We will case manage all medical care in Contra Costa Health Plan by using a combination of prior authorization, concurrent and retrospective review, targeted case management, and other accepted utilization management techniques. • We will pay the managed care systems on a prepaid risk arrangement. ./ Prevention Focus We will develop appropriate non-monetary incentives for Medi-Cal beneficiaries to seek out appropriate preventive services from their primary care provider. Similarly we will devise appropriate incentives to assure all primary care providers actively seek to meet specified outcome performance measures, e.g. immunization standards. Utilizing the resources of our Public Health staff, we will target prevention activities to address high-risk populations and high-risk behaviors. ./ Excluded Beneficiaries The County intends to cover all Medi-Cal beneficiaries in Phase III except those eligible only for limited services and those in long-term care. As you can see, our proposal emphasizes local administration, prepayment financing, increased primary care access, beneficiary choice, and a new public/private managed care partnership. We believe it offers the best opportunity for a cost-efficient, high quality, accessible Medi-Cal program that will improve the health outcomes in Contra Costa County. We also believe this basic system design can be expanded to cover other populations in the region. 1.5 Molly Coye, M.D., M.P.H. December 8, 1992 Page Four Our mode] is built on our own managed care and public health lmowledge and experience and is consistent with the latest research findings that improved access to primary erre is...*the most important indication of a Mulation's life chances" (The Relationship Between Primary Care and Iife Chan s, Leiyu Shu, Dr. P.H.). We propose to improve those "life chances" by reorganizing the medical care system in Contra Costa County to a more cost- effective, prevention-oriented, family practice centered primary care system. This new approach holds the most promise to improve health status and contain costs. Additionally, our financial proposal includes a commitment to reinvest a significant portion of any savings to prevention, health improvements and community outreach initiatives. I hope that you will agree that Contra Costa County offers a new approach to Medi-Cal managed care. We look forward to working with you and your staff to implement Health First in Contra Costa County. Sincerely, )ark Finucane, Health Services Director Attachments .December 14 Agenda .Phase 1, Il, III Patient and Funds Flow .Advantages of Contra Costa County's Proposal • s s . .. . ... . .. .......... ........... .......... ........... ....................... ........... ................... ... .... .............. . . ..... .................. .......................... ...... ............. . .... .................... . ... ......................... . ............ .. ............. ..... ................. ....... A ................ .. .............. ..... ....... ....................... .................... .DVA........NTA. ............... .GES ............... ........................ . .......... .... ..................... . ....... ........ .... .. . ... ......... . .................... .. ....... .......................... ..... ........... .... ............................... .......... ... ................ .. ...... .. ... U71P CONTRA � ... . ........................ .. ............ .................................. .. . .............. .. . ............ ...C.......O... .S. ....... .........T........... ........A ..................... ..... .......... ................. ............. ... . . .. ....................... . ........... . . .......... .. . .......... ... .... .... .. ....... .... . ........ .. .. .. .C.. .............. .O .............................. U ....... ....... . .......... .. ........... .... .. ............. .. ... ....................... ............... .............NTY..'.. ... ....................... S . .................. ... ..................................... .............................................................. .... .... . ............ PROPOSAL 2.1 Advantages of Contra Costa County's Health Fust Proposal ................................................................ • Alirtunates>fee=for;service`° 1. Eliminates traditional fee-for-service Medi-Cal in the ninth largest . .... -: county in the State and adds 64,000 eligibles to the State's managed care rolls. firer gihe s vubl c;safety 2. Builds on a publicly sponsored, public hospital-based model which Ott.. strengthens the public safety net and thus stabilizes indigent care provided through managed care. aids ori:3vte -Cal;prepaid 3. Builds on an HMO with 20 years of prepaid Medi-Cal experience. W.enerce: P.:..... :.. l3 tegrateS.P yVng r ierr bees 4. Builds on an HMO which has successfully integrated commercial and - Medicare "paying" members with Medi-Cal. .................. ..... .......... .............. Family pracEice:pr;mM 5. Utilizes a large family practice panel of primary care providers and care:and �'a nily prac#ice takes advantage of a growing, highly regarded family practice residency residency; program. ltlizes FNPs:aid;'PHM 6. Extensively utilizes family nurse practitioners as primary care givers, and public health nurses as case managers and telephone advice nurses. l icorporates public;health 7. Successfully incorporates various traditional public health services, e.g. ::::.::.::.. .... ........... . . ...... .. .. :. services`:. immunization clinics and home health, as part of seamless delivery system. Incorporates community based prevention services e.g. injury • control. ....... ... ...... ................................ �ibl clprivate;sirafegic 8. Includes community physicians, disproportionate share community Whan.c6.. hospitals and other providers serving Medi-Cal. Develops new strategic alliance with Kaiser and with Planned Parenthood. .............. .. ..... .................................. .. ........ iCoordinates financing and 9. Integrates financing and delivering health care through a global budget delivery: option. beneficiary choice: 10. Maintains on going relationships between primary care provider and patient. Offers managed care options (CCHP, Kaiser and proposed HMOs). ................................... .. Tirsts lock= i`ar d 11. Tests six month lock-in for all managed care members with six month guaranteed;e.b ibDh guaranteed eligibility for CCHP members. Maikelin Teform 12. Eliminates all door-to-door marketing in Contra Costa County. 'NOM NO.. ital partnership: 13. Utilizes an already approved new public hospital and community : .......:.........::....... hospitals. Pxte siveeou.n. 14. Gives further impetus to modernize and expand an already extensive ambulatory.care network of county run ambulatory care health centers. • Assures:access to;prirnary 15. Uses standards to assure members have timely access to care and qre. improved access to prevention oriented primary care provider (which is the single most important variable related to longer life expectancy). R6itei nvests' n rimunity 16. 25% of all County savings to be designated for community prevention health: and outreach programs. 60:AC 2.2 Health First 1. ZW + ' ilt .�"!it$t i`SI! 'd1�I$t 1t$ move�t tri • /Contra Costa is now willing and able to begin significant expansion of its already existing prepaid health plan. ./Contra Costa County's managed care system can expand immediately to 30,000 prepaid members or 38% of the Medi-Cal eligibles in the county. /Through a combination of expanding its county operated services and contracting with community providers and facilities, within six months Contra Costa Health Plan can have the capacity to enroll 75% of the Medi-Cal eligibles in the county (Phase II) and within 18 months can enroll 80% of the eligibles (Phase III). /No other county, no other traditional safety net provider can match this accelerated move to managed care. 2. n h� CbntFa+Ct�sts bounty'sIealthitsf prapasavefs;mire :.........:: ::;::::..::::::.:;;,.: ry res:;and<:a€d;date arses;; < ttv on the:;:S t as s rale 100 ...:...... g ................................................ /Health First intends to initially cover not just AFDC in a managed care system but also ATD, AB, OAS who do not also receive SSI benefits. /Dental services are covered in Contra Costa County's Health First proposal. • ./Ultimately, the only Medi-Cal eligibles to remain in fee-for-service under Health First are those with limited services cards and those in long-term care. ... ..................... ... ........:,::.: .:::::: ::..>:. 3. < :.......::: ........................ ....... ..:: >...::i:.a..........a.:...geYr o <min n:: n::...s.. .. .. ..:...:..:.:.r..:a....r..e...:;. : .. ............. . ............ s ...... edeeh5te` she €a ./Preventive health care services: Health First incorporates public health services, e.g. immunization clinics, as part of a seamless delivery system. Furthermore, 25% of all county savings will be designated for community prevention and outreach activities. /Outcome measurements: Health First has already committed to having specified outcome performance measures, e.g. immunization standards as an integral part of its contract. /Rate methodology: Health First calls for an innovative negotiated rate using a global budget, providing the State with a demonstration pilot on how to move in this direction. /Culturally competent services: Contra Costa County has already demonstrated its ability to provide "culturally competent" services. For example, the county has clinics tailored to its multi-ethnic clientele including special Laotian clinics in its Richmond Health Center. ./PPO ulation-based public health services: Health First includes community based • public health services including community oriented injury prevention activities. 2.3 */Children Services: Health First will include recipients of California Children Services • assuring they receive coordinated community based primary care and the specialized services they need; Health First is equally committed to providing Child Health Disability Prevention level of services to all Medi-Cal children. ./Family planning providers: Health First has developed a strategic alliance with Planned Parenthood for including their family planning and eventually primary care services. .................. 4. .........W..:.,:*.:., ....:..:T. :JT......t.. ................................ .... ............ r.V:a ......A. ..........S............t..0.......... . .... ...................................... .... ........................ Aknefit pgcka Health First proposes to restructure the'Medi-Cal benefit package to emphasize primary care and prevention activities and to discourage inappropriate use of ERs. ./Continuity of care: Health First proposes an innovative Children First program to assure that preschool children are guaranteed access to health care. ./School-linked Services: Contra Costa County is pursuing an opportunity to develop a new primary care center adjacent to a new high school in the county, linking health, education, and vocational training. ...........................W :0 A.RMW ... 4 W SY 5. iWdiniW8 xbenenU:,* r ................................. .......... ............ . ........................................... ................................. care. q 1 .. ....... . . ... .................................... ./Contra Costa Health Plan has successfully integrated commercial and Medicare "paying" members with Medi-Cal. .(Contra Costa Health Plan has already established a link between Medi-Cal and indigents by managing both populations in the same delivery system. .(Contra Costa Health Plan is a staff model family practice, primary care oriented HMO which incorporates a growing family practice residency program, critical elements which are not available in any other county proposal. ./Contra Costa Health Plan was one of the targeted case management pilot projects and has successfully integrated this core managed care concept into its operations. ./Contra Costa County has an already approved new public hospital and an existing extensive network of ambulatory care health centers. • 126:L1 • ..........................................B................................................. ........................... .. E................... ..... N.......... .................. EFICIA............................. ................................................X. ...................................... ............... ... .. .................................................................................R......................................................................Y � CHOIC ..... ........................... ..E ........................................ • 3.1 S ------------ f Assured Access Beneficiary Managed Choice Care • Systems 3.2 Health First County Phase PHP Percent Current 10,000 12.7% I. Reduced FFS and Expanded 30,000 37.9% Managed Care II. State contracts solely with 59,500 75% PHPs and PCCMs III. Health First - assumes 62,750 80% total fiscal and administrative responsibility for providing or arranging for Medi-Cal services. E 6 i Q • ♦♦♦♦♦♦ter♦♦ 1 • • �R e 1 • 1 s 0 ® •o 6 1 1 1 ♦•.•••1 ♦••♦• ♦i♦iii♦iii♦i♦i♦i� ►�i♦i♦i♦i�i�i�i♦i` � ,►i�i�i�i♦i�i�i�i�i� ►♦Oi�i♦i♦iii♦iii♦. ►i♦i♦i♦i�i�i�i�i�i�i ►iii♦i♦i�i♦i�♦�i�i♦i ►�i'•�i�i�i�i� NO�i�i�i�Ni♦i♦i♦i�i�i� X'ii�i���r�i�i�i�i�ir�i�i�i�i�i♦iii♦i .♦iii'♦♦i♦i�..�i•♦iii♦i�i�i♦i♦i♦i♦i♦i�i�i♦i ��i♦i♦i♦iii♦iii♦i�i�i�i�i�i�i�i♦i�i�i�i�i e � e 1 s .at■■■I .�■■■■■I OMNo I■■■�■■■I /- ■■■■■■■■I 1■■■M■■■■I �. /■■■■4b]■■■I 1■■■■mJ■■■I • lMMMMmrnm1MEN NMI aI ■MEN■■ 1■NMI ■■■■■■°71�■■■I / ■■■■■■■■■■► ° �N\EME%SE� �■■■■■►. • • d • 1 � � ° ��♦j♦�♦fit ® �o♦f+�♦♦♦f± ♦♦tom ♦f ♦♦♦GO o ♦�♦ice f ---------------- 0 e s s 0 1 • .%NONNI ' MESON ■■■■■■/ ■■■■■rte► �■■■■li. ■■■r� • �■■■L.► done • • � iii • � ® i'i'i'i'i'i'i'i�i�'i s • �i'i'i'i'i'i'i'ii a'i� ' W • �i'i'i'i'i'i'i'i'i'i � e e � 0 Q Q 3.7 P ase � R : ;: FF are educed Sand ExpandedVlanaged C: . Current Phase Chang CCHP 10,000 30,000 + 20,000 +31;500. �vICS Kaiser & 5,000 10,000 + 5,000 AL Other HMOs PCCMs -0- 6,500 + 6,500 HSD FFS 25,000 10,000 - 15,000 X31,500 FFS Private Provider 39000 22,500 - 16,500 FFS TOTAL 79,000 79,000 3.8 W pa c� c ° All� a �4 � x abog U .a .o.» t, els C C� 0� 4 U v o cuo ° +� �tA •i'' � O. � r�D o7 � � a o x x a x U U oo $ � � O w .qa u -41Ulu -M o > � U � w m ;� 3.9 v .q u o c I gi• e u V 6 � u C:6 'o. U o � w U � a cn A o v �vcd � � tt � ~ u � 0 • � m s 40 Ab w���������j a 00t��*���������������.���������f a ����wwww"r—wor Fm���������������� a ♦ 4 wk "0 0-0,������W,,ONO ��������������������I ��W�WM W"�w�������������I fp -------------------------------- ----------------------------------------------- 8 $ s r 8 b a s � s � m A 3.11 ;;. Phase II :... ::.:... ::;. ate Contracts Sole1 W11 P HP n a P s d M . CC. Phase I Phase II Change CCHP 30,000 59,500 + 29,500 32 5 IVIS Kaiser & 10,000 13,000 + 3,000 Other HMOs PCCMs 6,500 6,500 -0- County HSD FFS 10,000 -0- - 10,000 — Private 0,000 Private Provider 22,500 _0_ - 22,500 FFS TOTAL 79,000 79,000 3.12 � a aa. 0 LAS .00*1102 M � o U P• I °a ,a �p aSo v W 7p' � . �z � = gV � o � u � •.. � .o r. as A A t U C p as .0 Au C7 pA ^a A�..- pop„ pp� 4pQ rs A Q 4- 'j, V eA vi j �v • • 0 x pCd a U .� .°? l V � o T c vs 0 3.13 Is Beneficiary Choice 1. Beneficiaries in each zip code may choose to enroll in a Knox-Keene licensed managed care plan (HMO) or a PCCM. Beneficiaries who choose CCHP will be assigned a primary care provider based on accessibility and availability standards. 2. When an HMO or a PCCM's contract limit has been reached for that zip code, eligibles will be directed by Health Care Options to choose one of the remaining "open" HMOs or PCCMs which is not at contract capacity. 3. If all other choices are at capacity in zip codes in which CCHP operates, eligibles may choose a CCHP staff or community contract M.D. as primary care provider. 4. If the beneficiary doesn't exercise a choice, then HCO will assign the beneficiary to one of the remaining open HMOs or PCCMs using accessibility and availability standards. 5. If beneficiary doesn't choose a CCHP community M.D. in zip codes in which CCHP is the only "open", HCO assigns beneficiary to a CCHP staff model M.D. up to provider capacity. 6. HCO shall consider proximity, transportation, cultural and linguistic requirements and other special needs in making any assignment. 7. Eligibles may appeal the HCO assignment to the SDOHS. The eligibles are given 30 days to file an appeal; the SDOHS must make a decision within 15 days of receiving the appeal. Once the SDOHS has made its decision, eligibles will be required to remain in the same HMO or PCCM for five months. 8. All eligibles will be required to remain the same HMO or PCCM for five months. During the first month an eligible may choose another open managed care option; for the next five months the eligible is "locked in" to the same HMO or PCCM. 3.14 3 U O ig c� O U, � c �U a o ZZ U ro •m y U � LLJ� Y cn •N A U:::::: A v O >. C 00 2 o U O LE V u 7i>. 0 U M C Ur G "7 � d 3.15 U O a a o ° v � N O o U U a l � U v v �, l ev LLJ • U tv a .' E U .. .� VIV N LV N .L dwM tv le O N V 3.16 N - O O rz3 .t.. O -v Q U 3.17 ma a � u g� u w 8 o 8x o a c� o � � b tauCd 3 v H � OO 4 4. � O N iw 0 bO��G Q o � x a N •a I n 11 1 ►��������f.�G���WA�A�A�m������� t ►�������������������f w w���!�����������������������������1 m VA "m w�� ►��NN N-W-M4���������������������� r, 1 + �'�.���i�•� to m • Ht •� tl • r• t� • m i 3.19 Ph ' ;: : ase I II He l a t First . Stat e ontracts h . .. . t n . . ............ Co tr a Co sta Count . . ... t Which ..:..::.:::::...::::::. .:.::..:.:::::. rove des . ::.:::...:::::..::.....::.:.:....::.::.... ...... are Dir ect or an es .. .. ... ..:.. ...:::.:.::::..::...:.::::. or' +Care Thr ou P PH s Phase II Phase M Chang CCHP 59,500 62,750 + 3,250 MCS Kaiser & 13,000 16,250 + 3,250 Other HMOs PCCMs 6,500 -0- - 6,500 69500. PCOM County HSD FFS -0- -0- Private Provider —0- FFS TOTAL 79,000 79,000 3.20 a - "a a &� p v gua rod as 8oA a a 00 Otj a x -- vCA � m � �+ tea" sa6b h$a�3 a .60 ' om F IL t to d ar�"'" .G� d 0Z,V;�x' P • � a a a� � p T V � V 'S V ca lag y �.�+ ✓ H t7! V c � AQ o is m U �1 ryS d tn V a 3.21 a n v a 0 U x �{ w o � rj V � � 4 � gyp• � � � Q cis (3 •p o � o a 3.22 all Vol o cr% U �` o UV 17, coo rok t4 'An • .. ..... .............. ...... . .......... ...... MANAGED � .......... .......... ......... . . .................................. ........... ..... . . ............. .... .............. ................ .......... . ........... . . ........ ..... . ........... ........... ....... CA .......... . ......... R.........E .............................. ... .......... . . ...... . ... ...... ......... ..... ........................... .......... .... . .... ... ............................ SYS ..... T. .............. . ........... . ........... ........ . . . ........ . .......... . . ........................ ...... .. ...... ........ ........ ............ .. . ......... . . ............ .......... ... .E. . .... ............. . .... MS............................... .......... ............. ........... ........ ............ ...... • 4. 1 LUNAGED CARE OPERATIONS SUB-COMMITTEE CASE MANAGEMENT AND MODELS OF CARE CRAI Kim Duir, M.D. ADXINISTRATIPE NUPPORT: Kathy Jung MEKBERS: Rich McNabb Roger Barrow, H.D. Diane Dooley, M.D. Mitch Applegate, M.D. Dana Slauson, M.D. Kent Hobert, M.D. Tenki Tenduf-IA, M.D. Stephanie Bailey Rate Colwell , M.D. Jean O'Neill, R.N. Dan Thwaites, M.D. TASKS; 1. Define case management as it is intended to be applied in our case management system. 2 . Decide how urgent care, perinatal, and pediatric services should be provided. 3 . Define the proposed service delivery models (e.g. , IPA, group practice, multi-specialty group, and current clinic model) that will be used in our managed care system. XIKELINH: o Begin meeting week of 12/14/92 o Complete tasks #1 i 2 by 1/4/93 o Final Report complete by 1/31/92 o meekly meetings suggested (except week of 12/21/92) 4.2 REPORT FROM THE SUB-COMMITTEE ON CASE MANAGEMENT AND MODELS OF CARE �rrithew em"!W January 12, 1993 AND CL 114 Icy The original tasks of this committee included: 1. Define case management as it is intended to be applied in our case management system. 2. Decide how urgent care, perinatal and pediatric services should be provided. 3. Define the proposed service delivery models that will be used in our managed care systems. Additionally, we were asked to specifically consider the roles of FNPs and make recom- mendations concerning mental health and substance abuse services for primary care. Task #1 The committee revised an existing document on case management (Appendix #1) Please refer to that appendix now for basic philosophy and structure. Then read on. An area of potential conflict concerns our current health maintenance recommendations for adults and new proposed guidelines by the State. (See Appendix #la) The committee felt strongly that anything beyond the USPSTF recommendations should be at the discretion of the provider. We felt that our resources would be better utilized addressing lifestyle risk factors than through increased screening of dubious value. This will have to be negotiated with the State. Guidelines for prenatal care should be based on our current practices (Appendix #lb). We recommend that outside contractors be offered additional monies for providing CPSP level of care. We recognize that on-call coverage for enrollees must be provided and that participation of case managers in an on-call system is desirable. In an attempt to balance the competing priorities of small call groups, which increase the likelihood of knowing the patient, and large call groups which address the lifestyle concerns of providers (i.e. frequency of call, etc), we recommend the following for on-call coverage in our system: Create regional call groups of approximately 10 providers (does not include FNPs) who will 1) back up Advice Nurses, and 2) handle medical admissions to regional hospitals. We strongly recommend that the day after call be scheduled off. Develop teams consisting of five Family Practice physicians in each (East and West) region who will manage all our inpatients on the medical service at regional hospitals. Each physician would rotate out of their outpatient practice for one week at a time to cover inpatients and daytime admissions. Recognizing there are differing comfort levels among our staff with inpatient management, this would initially be provided by those who are most interested. 4.3 2 Our preliminary estimates of the number of inpatients at each of the regional hospitals (based on payor source and discharge statistics from regional hospitals) varied widely from 5-25. It is agreed that with more reliable statistics we will require one inpatient coverage team per 10-12 inpatients. Increased availability of consultation, preferably with our own registrar/ consultant staff, less desirably with contracted regional physicians, will be essential for Family Practitioners working at regional hospitals. We also believe this is key to cost containment in terms of minimizing multiple consultant fees. We felt it probably not possible at this time to case manage surgical inpatients at regional hospitals. Most surgeries will be pre-authorized, therefore this was felt to be of lesser priority in terms of cost containment. We recommend continuation of the Joint Venture in OB with the proviso that those case managers who wish to do their own deliveries and have appropriate privileges, may do so. Consider expanding Joint Venture to Los Medanos Hospital as well. All pediatric admissions should be kept at Merrithew. The numbers are quite small. We encourage the expansion of the Family Practice Residency Program, especially in terms of their involvement in regional sites, both for outpatient and inpatient services. We support immediate increase to 10- 10-10 and addition of another FPC in each year. To further strengthen the Case Management System, most case managers should be available to their patients a minimum of twenty hours or three days a week (may include some half days). The present fragmentation of staff across multiple sites should be discouraged. Primary site identi- fication is the goal. These recommendations are included to strengthen the Case Management System. Additionally, the system should facilitate keeping families intact with one case manager as much as possible. Task #2 Part A - Urgent Care This committee strongly recommends that urgent care be reincorporated into Family Practice clinics by the designation of additional urgent care slots. The advice nurse would assign patients to their own provider's schedule if possible, to a designated team . member's schedule, if not. Last resort would be a much scaled down urgent care clinic for patients new to the system (or without a PCP). Every attempt will be made to assign these patients (by making an appointment to a primary care provider) after their first Urgent Care or Emergency Department visit. Essential to the success of this model is Repon from Sub-Con n ittee on Case Management and Models of Care January 12, 1993 Page 2 4.4 3 good triaging from the advice nurse who needs to be aware of the capabilities of the various sites and with access to short notice as well as same day slots. A related concern is that we have some mechanism to monitor and/or encourage outside contractors not to underserve enrollees by referring Urgent Care requests to the Emergency Room. We recommend continuing current CCHP practice of requiring authorization for ER visits. Another related concern, is that in order to maintain efficiency while caring for acutely ill urgent care patients, each provider needs to have three exam rooms. We believe that this may also increase our productive capacity in general. The final related concern is the provision of skills building opportunities for physicians, FNP's and nursing staff who may currently feel uncomfortable with the broad range of problems presenting to Urgent Care. This last issue may require a transitional period where providers who feel uncomfortable with a particular case may refer them elsewhere, but these referral patterns could be used to document areas where we need skills building. Also, ready phone access to consultants needs to be improved. Task #2 Part B - Prenatal Care There was general agreement that routine prenatal care should be provided by the case manager. Prenatal clinics should be reserved for high risk patients and those without a primary care provider (large group to consider here are the TR's, mostly undocumented, not eligible for care after pregnancy, but their children are). We felt that clustering of a provider's prenatal appointments on a particular day would answer concerns about availability of ancillary staff. The success of this approach hinges on implementation of CPHW positions to integrate and increase availability of required "ancillary" services. As in Part A, there should be inservice opportunities for providers and nurses who need to update their OB skills. Likewise, there needs to be improvement in the availability of OB phone consults. Task #2 Part C- Pediatrics Within our system, we recommend that routine pediatric care be provided by Family Practice, preferably the mother's case manager. Pediatricians will act primarily as consultants except when case managing complicated patients by provider referral. They will have to notify Appointments to have their names registered as case managers for those cases. As in Parts A and B, inservice opportunities will need to be made available for providers wishing to improve their routine pediatric care. Pediatric teams would provide pediatric consultation at large regional sites and might include local contract pediatricians/subspecialists. Report from Sub-Committee on Case Management and Models of Care Jmtuan? 12, 1993 Page 3 1. 4.5 4 Task #3 Proposed Service Delivery Models The committee agreed that teams of 3-6 providers would constitute the best compromise between patients' needs for intimacy and providers not feeling isolated. For case managers not located in specialty hubs, it is hoped that offering a regular opportunity for rotation through specialty clinics will address the loss of more casual contact with specialists. Especially for these groups which may be mostly new hires, it was felt important to have some senior staff locate to these sites to transmit Merrithew culture and assist in orientation. FNP's would be full members of the case management team with the exception of inpatient call responsibilities. They would be expected to have the same space, nursing support and appointment profile as their physician colleagues. They would be expected to adjust the acuity/complexity of their patient load by referring to FP team members as necessary. We recommend 1-2 FNPs per provider team. Within our system, at current productivity levels, all providers should be provided with nursing support at a minimum ratio of 2 nurses:3 providers. If with the addition of clerical support in the clinical areas we are able to increase average productivity, the staffing ratio may need to be re-examined. We concur with the recommendations of Jean O'Neill and Stephanie Bailey with regard to clerical support in clinical areas. For details, please see Appendix #2. If there are FNP's who are not interested in being case managers, it was suggested that there may be roles available supporting some of the specialty services. A further concern is the availability of ancillary services, especially clinical laboratory and diagnostic imaging services at smaller sites away from current "hubs". We have been able to minimize ER usage at the larger sites in part because the availability of STAT lab and x-rays allows us to accurately "triage" and treat. We recommend that smaller sites have, if not on-site, certain basic diagnostic tools available nearby to maximize non- Emergency Room management. Likewise, certain STAT pharmaceuticals should be available for use on-site (e.g. avoid referrals of "migraine" headaches to ER for analgesia). We would like to reiterate here the goal of having case managers dedicated to a primary site, with a further goal of 20 hours or three days availability (may be 1/2 days) as a minimum. It is also expected that most case managers will participate in call, but widely agreed that increased reimbursement will be required to "sweeten the pot" in terms of this change. As previously stated, contracted case managers would be expected to provide their own on-call and inpatient coverage though some might arrange to participate in our call system. For our committee's recommendations to the Mental Health/Chemical Dependency sub- committee, please refer to Appendix #3. 0 Report from Sub-Canmiuee on Case Management and Models of Care Januan, 12, 1993 Page 4 4.6 5 Many thanks to all committee members for their time, energy, commitment and creativity. Committee members: Mitch Applegate, MD; Roger Barrow, MD; Kate Colwell, MD; Diane Dooley, MD; Stephen Daniels, MD; Kent Hobert, MD; John Lee, MD; Tenki Tenduf-La, MD; Rich McNabb, MD; Dana Slauson, MD; Stephanie Bailey, Jean O'Neill, Kathy Jung, Ann Schnake, FNP; LeAnn Winton Respectfully submitted, Kim Duir, M.D., Sub-committee Chair Repan from Sub-Committee on ase Managenicni and Models of Care • lanuany 12, 1973 Page 5 4.7 Medical Staff - Case Management Philosophy & Guidelines I. PHILOSOPHY It is the philosophy of the medical staff Merrithew Memorial Hospital and Clinics that most patients in our system are to be case managed. While it may not be feasible to case manage all of these patients at the present time, it is our goal to case manage all of these patients in the future. We believe that effective case management is necessary if we are to deliver the most efficient, cost effective, and highest quality care possible. II. DEFINITIONS A. Case Management means that each patient is assigned to one or two providers who is (are) the patient's Case Manager(s). The Case Manager(s) either provides or directs all care provided to that patient. When other providers become involved in the care of that patient, they will communicate with the Case Manager(s) regarding such care. B. A Case Manager must be a Family Practice physician, family nurse practitioner, internist or pediatrician. Within our system we propose that case managers be Family Practitioners or Family Nurse Practitioners primarily and that medical staff from Pediatrics and Internal Medicine be specialty consultants primarily and case managers by referral only. This need not apply to contract case managers outside of the Merrithew system. We do not recommend that OB- GYNs function as primary case managers whether contract or employed, unless it be as joint case management for complicated OB-GYN problems. C. Joint Case Managers. With the agreement of the patient and the involved providers, when appropriate, a patient may be assigned Joint Case Managers or a team of providers. For example: V A FPC physician and a Specialty Clinic physician; or N/ Two FPC physicians; or J A FPC physician and a FNP Page 1 of 4 4.8 Medical Staff - Case Management Philosophy & Guidelines III. CASE MANAGER ASSIGNTMENT A. In general, a patient is assigned to a Case Manager at the time that (s)he keeps his first appointment with that provider. Such assignment remains in effect unless and until it is changed. Other methods of Case manager assignment may be employed in certain specific circumstances with the agreement of the involved providers. B. A patient has the option of choosing a particular case manager and of changing to a new case manager on request. C. If after consultation with colleagues and the patient, an assigned Case Manager feels that a change of case manager is in the best interest of a patient, (s)he may request that the patient be reassigned to a new Case Manager. IV. RESPONSIBILITIES OF THE CASE MANAGER The basic responsibilities of the Case Manager are as follows: A. Assessing, evaluating and treating the patient's presenting problems to the extent of his/her ability; B. Authorizing consultation from a Specialist and transferring appropriate information as needed generally following at least some preliminary evaluation; C. Seeing the patient for follow-up visits as needed until the presenting problems have either resolved or stabilized; D. Perform a history and physical on all new patients and to collect an initial data base. This should include: 1. Physical exam. Appropriate for age and sex. Providers should use the CHDP recommendations as a minimal standard for health care maintenance exams in children. 2. Laboratory, x-ray and other diagnostic evaluation as indicated for evaluation of symptoms and for health care maintenance as deemed appropriate. 3. Indicated immunizations. 4. Assessment of lifestyle risk factors. Page 2 of 4 4.9 Medical Staff - Case Management Philosophy & Guidelines E. Completing and periodically updating the Problem List and Medication List as appropriate: 1. For pediatrics, use of the Pediatric Data Base form is encouraged instead of the Problem List; 2. Problem Lists: The use of a Problem List is encouraged for all patients with one or more chronic problem(s), or significant resolved problems, operations, drug allergies or significant adverse reactions. Completion of a Problem List is required for all patients with. three (3) or more chronic problems. 3. Medication List: A current Medication List should be completed for all patients on any chronic medication. F. Providing, follow-up and ongoing care: Following treatment for presenting problems and completion of the History and Physical, some provisions should generally be made for follow-up and ongoing care. For well children, this follow-up should follow the CHDP guidelines. For adults, the follow-up should be individualized. Ongoing consideration should be given to further health care maintenance evaluation, using the criteria for Prevention and Early Detection guidelines as a minimum. For patients with chronic problems, periodic follow-up visits should be scheduled, with periodic laboratory or physical parameters assessed to monitor the status of these diseases. G. The Case Manager is expected to participate in the care of his/her patients between visits. These responsibilities include: 1. Refilling medications. 2. Taking appropriate action on abnormal test results. 3. Responding to questions from ancillary staff regarding the patient's disposition and treatment. 4. Completing forms.presented by the patient when appropriate. 5. Discussing the patient's care as needed with other providers in the system, or when necessary, (and with the patient's written consent) with outside providers. This includes: Page 3 of 4 4.10 Medical Staff - Case Management Philosophy & Guidelines Responding to phone calls from or about his/her patients, including after hour calls at home, when in the opinion of the initiating provider, consultation with the Case Manager would be beneficial to the immediate care of the patient. 6. Whenever his/her patient is referred to a specialty clinic, the hospital, seeks care in Urgent Care, the Emergency Room, or from another provider; upon becoming aware of such care, should review the records, and consider appropriateness of care. 7. Whenever possible, and as indi- cated, seeing his/her patients between scheduled visits, in the clinic, the Emergency Room, or in the hospital. 8. Outside contract case managers are responsible for providing on call coverage and inpatient management for their patients. V. RESPONSIBILITIES OF CONSULTANTS A. When seeing a patient sent by a Case Manager for consultation, to respond to any specific questions contained in the referral note. B. When hospitalization or an invasive or costly procedure is indicated, unless the Case Manager's intent is clear in referral note, to contact the Case Manager to discuss the case prior to scheduling such procedure unless precluded by medical urgency. Notification to the Case Manager by chart review or follow-up appointment may be satisfactory. C. When seeing a patient without an identified Case Manager in a specialty clinic or as an inpatient, make the appropriate effort to refer the patient for case management. a:philos.lw• Page 4 of 4 4.11 SE--L Contra Costa County f - = Health Services Department �$, Y William B. Walker, M.D. Medical Director and " __ •c3� County Health Officer STA COUly� TO: William B. Walker, M.D. FROM: John Lee, M.D. DATE: December 8, 1992 SUBJECT: STATE GUIDELINES FOR ADULT PREVENTIVE HEALTH SCREENS - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - As Rich pointed out, there are some discrepancies between the new State guidelines and our Department of Ambulatory Family Medicine (DAFM) criteria. 1) Histon^and Phvsical, Initial: State: To be done at initial visit. Our DAFM: A data base is to be done within 3 visits 2) Repeating H & P's: The periodicity they define is not a problem. The question is what do they expect the repeating "H & P" to contain. Hopefully they are using the term synonymously with the 'Periodic Health Examination" as defined by the U.S. Preventive Service Task Force. The Periodic Health Exam-ination is a focused approach to universal age and sex specific risks as well as a reassessment of a patient's unique individual risks. Repeating the traditional H & P over and over has not been found to be cost effective and drains resources from more useful activities like lifestyle counseling. 3) Breast Exam - Age 19-39: State: "Physician, every 1-2 years DAFM: Physicians or FNP's .examine at least every 3 years as recommended by the American Cancer Society 20 Allen Street• Martinez,CA 94553 • (510)370-5010 office• (510)370-5098 FAX A-428 (9/91) 4.12 4) Mammographv: a. Baseline State: Age 35 DAFM: Start age 50 as recommended by USPSTF b. Age 40-49 State: Every 1-2 years DAFM: Start age 50 as recommended by USPSTF. (This position appears to have been vindicated by a study just released in Canada) C. Age 65+ State: Annually DAFM: Conclude at 75 unless pathology has been detected as recommended by the USPSTF d. High risk State: The State recommends starting at age 40 if at risk, but they lump together well accepted risks (family history) with controversial risks (high fat diet) and a non-existent risk (multiparity -- thev must mean nulliparity). DAFM: A general statement on increased screening for those at risk. Perhaps a specific statement on family history should be added. 5) Pap Smear 65+: State: Annual DAFM: May be discontinued at age 65 if previous smears have been consistently negative as recommended by the USPSTF. 6) Cholesterol: State: Every 5 years regardless of age, sex or risk factors DAFM: Age ranges to be screened varies with sex and risk factors leaving specific periodicity up to provider judgment. 7) Stool Occult Blood: State: Annually after 50 DAFM: No recommendation in keeping with the USPSTF (The definitive study on colon cancer screening is due in 4.13 the next couple of years.) 8) Flu and Pneumococcal Vaccination after 65+: State: Recommended DAFM: None, although the Department agreed on a statement recommending them in the owner's manual. I will recommend the Department consider adding this to our criteria as well as doing some other fine tuning. The State has taken the interventionist's side on many of the controversies in preventive screening. In contrast, the USPSTF has developed guidelines for primary care providers based solidly on what the literature has proven useful. While at variance with some specialty and advocacy groups, the USPSTF recommendations are the most cost-effective taking into account many hidden costs such as for false positives. The USPSTF philosophy recognizes the central role of lifestyle counseling which can be compromised when there is an excessive emphasis on testing. JL:cbc cc: Kim Duir, M.D. Dana Slauson, M.D. Ric Huie, M.D. David Hearst, M.D. Tenki Tenduf-La, M.D. Jim Tysell, M.D. Krista Farey, M.D. 4.14 PRENATAL CHECKLIST iF'ER S ;V f S I T: .. ............ . .. .. ... . . ........ .................................................. ........................................... Df$ CV$ ........... ............................ ........................................ ........................................... Planned pregnancy? Regular diet, well-balanced with fat de-emphasized (fatty foods aggravate nausea and vomiting), small frequent meals. Vitamins, iron, calcium supplements (if low dairy products intake) Expectations of pregnancy - any fears? sexual/emotional adjustment ETOH, cigarettes, meds/drugs/caffeine. Risk Factors (HIV., etc.) Sex, bathing, hot tubs, cat litter. Prenatal history and PE, lab results. LAB WORK: ROUTINE: CBC RUBELLA ABO RH PPD AB U/A & GC VDRL PAP SCREEN CULTURE ROUTINE CONTINUED: CHLAMYDIA I HBs Ag HIGH RISK: Sickle Prep. 1 Hr. GTT AIDS. (FH, Obese Lg. Baby Poor ob hx.) HIV. HIGH RISK CONTINUED: Hgb. Electrophoresis if mcv less than 70 Genetic Counseling (over 35 or F.H.) BEFORE. W;: 75EEK. : ... .... ..... D1 .SCUSS Weight and diet Activity and exercise Warnings: bleeding, urinary symptoms, fever, etc. Encourage father's participation in prenatal visits Thoughts on being a parent. Minor problems to discuss: Constipation, hemorrhoids, backaches, leg cramps, stretch marks, difficulty sleeping, edema, nausea, vomiting, and heartburn. Fetal development: review ETOH, cigarettes, meds., drugs, caffeine. Prenatal classes - enrolled class: date: type: Prepared childbirth options (type) 4.15 PAGE TWO ...18..... ...... .. ....... .... . ... . ........... Ul 'S C �'S S'>'. . ... . ... ..... .. ...... ..... ...... ......... ..................... .......................................... Quickening Sexual/emotional adjustment, ABC Review ETOH, cigarettes, meds., drugs, caffeine LAB WORK: ROUTINE: Alpha Feto Protein 21 ;to 25 :W`E :E:K S . .. ... D t S :C U'S S:; ............ ......................... Breast/bottle feeding Review ETOH, cigarettes, meds., drugs, caffeine 26 to 30 V1l:EEKS .... ...::.....:.:::.::.::.......... ::.. :.. . . .............................. O;;ISCUS'S ; Options of birth Family's involvement (sibling preparations, father, etc.) Partner in delivery room yes[] no[] anyone else? Nutrition (vitamins, iron, diet, fluids) Signs of premature labor (when to go to the hospital) Review ETOH, cigarettes, meds., drugs, caffeine. LAB WORK: ROUTINE: CBC 1 hr. GTT 2nd U =AJ HIGH RISK: HIV RH Screen & Rhogam (26-28 weeks) VDRL Report Hbs Ag 4.16 page three 31 T0:34 WEEKS . . .; DS:c.U.. ... . ..... ..... ... . .. ..... ... ............. ................... Preparing for hospital Preparing for baby (child safety, car seat, diaper service, baby care) Fetal development: review ETON, cigarettes, meds., drugs, caffeine. Episiotomy / anesthesia / analgesion Danger Signs: Bleeding, urinary symptoms, rupture membranes, fever, preterm labor symptoms, decreased fetal movement. Warnings: Third trimester (HA, pains, edema, etc.) Circumcision Complications of labor/delivery (fetal monitoring) Postpartum care, preparing for infant feeding - breast versus bottle. Examine breasts, nipple preparation. Contraception Plans: BCPs IUD _ Diaphram 4 Foam & Condom Tubal Ligation (get consent) Rhythm Method _ Vasectomy None Parenting Special requests related to birth 35.:TO.36 N:E E X S DA 'S>Z U,S S Fetal development: review ETOH, cigarettes, meds., drugs, caffeine. Family involvement Danger signs and warnings (see 31 to 34 weeks) Prepare family, sibs. Post partum care page four 3 .6.. WE `K;S ..................:.....::...........:. 0.11SCUSS : Danger signs and warnings (see 31 to 34 weeks) Review signs of labor (when to go to hospital) Review ETON, cigarettes, meds., drugs, caffeine LAB WORK: ROUTINE: ConsiderCBC HIGH RISK: Consider: Herpes Culture ChlamydiaGC HIV Hbs.Ag. VDRL Particularly if not done at 28 weeks. BEYOND. 36 ; `W.E .EK .S See weekly. Elements to be followed based on previous abnormalities. Review education each visit. Review ETOH, cigarettes, meds., drugs, caffeine. Dr. John Lee/smp April, 1988 S41:PC 4.18 � rrithew ernorisl AND CLINICS REPORT FROM THE SUB-COMMITTEE ON CASE MANAGEMENT & MODELS OF CARE Our current system is inefficient in that highly paid physicians, FNPs, and nurses are spending much of their valuable time on clerical functions. Also, their time is idle because of in adequate numbers of examination rooms. We propose a much more efficient, effective system with adequate support which would ultimately increase productivity and employee satisfaction. The ideal staff/space support for three providers is as follows: 2 Nurses 1 Clerk 9 Exam rooms Due to logistical or space limitations, other variations of support are as follows: 1 Provider 2 Providers 4 Providers 5 Providers 1 Nurse 1 Nurse 3 Nurses 3 Nurses 3 Rooms 1 Clerk 1 Clerk 2 Clerks 6 Rooms 12 Rooms 15 Rooms cmmcrep.ap2 4.15 REPORT FROM THE CASE NIANAGEMENT SUB-COMMITTEE RE MENTAL HEALTH & CHEMICAL DEPENDENCY SERVICES January 12, 1993 The committee identified a number of needs not served by our current divisions of . Mental Health and Chemical Dependency. 1. Availability of ongoing therapy groups for certain common primary care mental health problems. (e.g. grief and loss, chronic pain, post traumatic stress disorders, etc.). 2. Need for increased availability of evaluation/sbort term consultation (three to six meeting) for crisis care. Recommend consideration of MSW, MFCC, Psychology (interns?), to increase availability. 3. Availability of psychiatric med consults to primary case managers. 4. Increased availability of evaluation/consultation/referral services for chemical dependency. Consider merging function #2 and #4 listed above. S. Special need with regard to chemical dependency services is contact/liaison person aware (via database?) of available programs. Again, could merge with functions #2 and #4. 6. General agreement that with exception of #3, these services should be available on or near site as often as possible. 7. Need to improve records/feedback loop to primary care case manager once referral is made. 8. Consider increasing availability of methadone treatment for IV narcotic users. 4.20 MANAGED CARE OPERATIONS SUB-COMMITTEE DENTAL CRAIR: Frank Camodeca, D.D.S. MKINI8TRATIV7 SUPPORT: Stephanie Bailey Jean O'Neill TASK: Based on the location and number of enrollees, define where, how and when dental service expansion and enhancements should take place. TIKPLINT: Task completed by 3/15/93 4.21 Managed Care Operations Sub-Committee Report on DENTAL SERVICES I. CURRENT DENTAL SERVICES Currently, Merrithew dental clinics in Martinez, Richmond and Pittsburg provide approximately 11,000 visits per year, 58% of which are Medi-Cal visits (sticker and Health Plan Medi-Cal). It is estimated that our clinics serve I I% of the Medi-Cal eligibles in the county. The breakdown of Medi-Cal eligibles served by region is 19% central, 6% west and 14% east (see Appendix A for further detail). The dental staffing is currently 4.3 FTE dentists, 4.3 FTE dental assistants and 3.0 FTE clerks. II. UTILIZATION OF DENTAL SERVICES BY MEDI-CAL ELIGIBLES Unlike medical services, it is estimated that many Medi-Cal eligibles do not seek dental care. In fact, data we received from the State Dental Health Department indicates that only 17% of Denti-Cal and 200% program eligibles under age 20 received dental care in Contra Costa County in 1989-1990 (see Appendix B). In all of California, the highest utilization rate was in San Francisco County where 25% of this population received dental services. Because these statistics do not include the older population, it may be reasonable to project that no more than 30-50% of Medi-Cal eligibles will seek dental care. III. EXPANSION PLAN In planning dental services expansion, we planned in three stages: A. Stage 1: Exx2osion Needed to Meet Access Standards with Current Workload The Access to Care Committee determined that the waiting time standard for a routine dental appointment should be 6 weeks (see Appendix Q. Currently, the waiting time for appointments is 5 months in Martinez, 6 weeks in Richmond and 3 months in Pittsburg. Based on this, we project that the additional staffing needed to bring the waiting time down to 6 weeks would be as follows: Dental Dentist Assistant Clerk MTZ 1.5 FTE 1.5 FTE 1.0 FTE RHC --- --- --- PH C 1.0 FTE 1.0 FTE .5 FTE TOTAL 2.5 FTE 2.5 FTE 1.5 FTE Due to space limitations, in addition to some daytime expansion, the above would require Martinez dental to operate 4 evenings and Saturday and Pittsburg dental to operate one evening and Saturday. 4.22 B. Stege 2: Expansion Allowable by Maximizing Use of Current Space After the Stage 1 expansion is achieved, there is still some space remaining for additional expansion. If we maximize use of current space such that each dental clinic is open five evenings and each Saturday, we could add an additional 8,320 Medi-Cal visits per year. This would increase our total dental visits by approximately 76%. This would allow us to increase the Medi-Cal eligibles we serve from the current 11% to 22%. The breakdown of Medi-Cal eligibles to be served by region would be 19% central, 24% west and 23% east, (see Appendix D for detail). To achieve this, we project that the additional staffing needed would be as follows: Dental Dentist Assistant Clerk MTZ 0.2 FTE 0.2 FTE --- RHC 2.2 FTE 2.2 FTE 1.0 FTE PHC 0.8 FTE 0.8 FTE 0.5 FTE TOTAL 3.2 FTE 3.2 FTE 1.5 FTE C. Stege 3: Expansion Needed to Serve 40% of Medi-Cal Eligibles in the County by Hing a New Dental Clinic Site With Stage 1 and 2 expansion, we will be able to serve 22% of the CCC Medi- Cal eligibles. To serve any more than that requires opening new dental clinic(s). To make this stage the most cost effective, we propose re-distributing dental visits such that RHC and PHC see Medi-Cal patients only (in order to meet distance standards) and that all other patients are referred to Central County, where a new Dental clinic is opened. This would allow us to increase the Medi-Cal eligibles we serve to 39%. The breakdown of Medi-Cal eligibles to be served by region would be 56% central, 29% west and 44% east (see Appendix E for details). To achieve this, we project that the additional staffing needed would be as follows: Dental Dentist Assistant Clerk MTZ 1.8 FTE 1.8 FTE 1.0 FTE RHC --- --- -- PHC --- --- --- TOTAL 1.8 FTE 1.8 FTE 1.0 FTE 4.23 If additional Dental clinics were opened, beyond the one in Central County, we would recommend that the site be located in east county in recognition of that growing population and limited Medi-Cal providers. IV. REPENT MFDI-CAS. CHANGES IN REIMBURSEMENT RATES_WHICH_MAY AFFECT MANAGED CARE Effective November 1, 1992, as a result of a judge's ruling, Medi-Cal reimbursement rates were raised approximately 65% on the 56 most common procedures which represent 92% of all Medi-Cal claims. This ruling was made to hopefully encourage dentists to accept Medi-Cal patients and thereby improve access to care for Medi-Cal eligibles. This increase in reimbursement rates, while currently in effect, is pending appeals. The Medi-Cal program currently covers one cleaning per Medi-Cal eligible per year. V. DENTISTS CURRENTLY SERVING MEDI-CAL ELIGIBLES Data we received from the State Dental Health Department illustrates that in CCC there are: • 693 total dentists • 265 dentists actively taking Denti-Cal patients (though they may not be accepting Mw patients) • 41 dentists who saw 51 (or more) Denti-Cal patients in 1991 The CHDP program information indicates that there are ten private dentists in CCC who take care of most of the Medi-Cal eligibles we don't care for. These dentists are broken down by region as follows: 3 - central, 2 - east, and 5 - west. VI. EQUIPMENT NEEDS The dental equipment needed for Stage 1 and 2 expansion is listed in Appendix F. The approximate list price is $54,000. We are often able to obtain equipment at a 20%-25% discount so the estimated cost to us is $43,000. The equipment needed to open a new Dental Clinic site (Stage 3 expansion) is not included in the equipment list. 4.24 0 N r- a p en°_ n a .5 cin C4 t- ellu3 � r� a s Esq a U a, v E E H v 00 00 vl� ... t�•1 N M O, en H O en O h � N V N N h = ^' O C b u V 0 Z 4.25 AC'T'IVE EI-CAL EENI'IS'I5, LQ _-{'AL & 200 USERS, i VTIISZATZQI RATS, 1989-90 O%xrY 0 ODS ! TVR ACTV% TYR ACTV 9 2YR ACTV%2YR AM MGL EL 1 GS cm POV TOTAL KCAL USERS 6200%USERS TOTAL UT i L POL WS IR711 1105 MCAL ODS IGC [JOS 0.20 0-18 EL1GS 0-20 CT90 0-18 USERS RATE 1 2 3 4 S 6 7 8 9 10 11 12 Alam 1012 411 40.6 iib K.1 104,386 104,i6S 208,851 19,971 19,966 39,957 19.1 Alpin 0 0 0.0 0 0.0 188 24 212 7 / 8 3.8 AnmdMr 19 6 31.6 7 36.8 1,354 2,502 3,856 1% 288 444 11.5 Ltts IM 77 61.2 a1 67.5 21,425 11,421 32,846 3,655 1,918 5,603 17.1 catr na 13 7 53.8 a 61.5 2,785 2,148 4,933 342 302 694 14.1 Aoliaa S 5 Mo 4 00.0 2.,040 1.488 3,528 192 169 401 11.4 X836 � rltrtrClsam ;. $:,4.35 :-CA ---60,307 67,236 -116,S6T - :,�.-1.1.300 19,587 16.8 Oel Ibrtt-� 13 1• 53.8 6 66.2 3,783 a28 4,611. 450 98 548 11.9 El Darscb % 3B 40.4 42 44.7 7,890 10,525 18,415 955 1,274 2,229 12.1 Fraerfl 367 228 62.1 246 67.0 125,397 39,332 164,729 23,742 7,447 31,189 18.9 Glenn 8 7 87.5 8 10D.0 3,436 1,857 5,293 505 273 778 14.7 M+moldt 82 60 73.2 63 76.8 14,492 7,249 21;741 2,402 1,201 3,603 16.6 imperial 31 U 33.5 17 54.8 18,751 10,769 29,520 2,677 1,537 4,214 14.3 if" 18 9., 50.0 11 61.1 1,664 1,351 3.015 IS6 208 464 15.4 Kam 212 97 45.8 1% 49.1 68,406 47,503 115,909 12,028 8,353 20,381 17.6 Kir" 40 24 60.0 28 70.0 13,834 9,200 23,034 2,472 1,644 4,116 17.9 Late 20 11 55.0 10 50.0 6,990 2,849 9,839 S07 207 714 7.3 Lassen 25 7 m.0 11 44.0 3,016 1,632 4,648 281 152 433 9.3 Las Angeles 6275 M9 36.2 2x51 45.6 810,528 795,018 1,605,546 137,912 135,273 273,185 17.0 Mmdera 35 25 71.4 28 00.0 13,451 7,147 20,598 2,763 1,468 4,231 20.5 Marin 283 103 36.1 101 33.4 5,631 16,137 21,768 1,055 3,023 4,078 18.7 Mariposa 8 1 12.5 2 25.0 1,334 1,120 2,454 144 121 265 10.8 Merdxiro 69 37 53.6 39 56.5 9,567 6,083 15,650 1,835 1,167 3,002 19.2 Mesad 67 43 64.2 48 71.6 33,897 17,828 51,725 4,679 2,461 7,140 13.8 Marc 4 3 75.0 3 75.0 1,282 677 1,959 66 35 101 5.2 Nano 6 1 16.7 4 66.7 454 a" 1,349 62 122 184 13.6 ob to ey 244 129 52.9 137 56.1 27,744 32,505 60,249 3,852 4,513 8,365 13.9 laws 95 40 42.1 46 48.4 5,424 9,337 14,761 S86 1,009 1,595 10.8 Mevade 61 25 41.0 27 K3 4,242 6,701 10,943 747 1,180 1,927 17.6 orwoe, W46 S73 29.4 716 36.8 111,785 221,981 333,764 20,972 41,646 62,618 18.8 NOW 139 66 47.5 75 54.0 10,413 14,341 24,754 1,680 2,314 3,994 16.1 Plumes 13 S 38.5 7 53.8 1,850 1,S69 3,419 75 64 139 4.1 Riverside 497 197 39.6 231 46.5 95,399 85,098 100,497 15,882 14,167 30,049 16.6 Sarrwuito 766 368 493 413 55.4 123,852 67,019 190,871 25,296 13,688 38,984 20.4 San Berri to 11 a 72.7 10 90.9 3,492 3,749 7,241 335 360 695 9.6 San Bernardino 704 232 35.8 319 45.3 156,458 110,469 266,927 28,333 20,005 48,338 18.1 Sin Diego 1661 553 36.0 678 403 202,754 191,761 394,515 38,075 36,011 74,086 18.8 San Frncisco 10136 367 33.9 361 36.1 47,387 43,926 91,313 11,000 10,938 22,738 24.9 San iomglri n 2BB 141 419.0 148 51.4 73,704 38,227 111,931 14,422 7,4W 21,902 19.6 San Luis Obispo 158 73 46.2 82 51.9 12,348 18,375 30,723 2,287 3,403 5,690 18.5 San Meow 613 184 30.0 209 34.1 22,268 55,149 77,417 3,383 8,378 11,761 15.2 Santa Barters 295 96 32.5 124 42.0 26,362 29,%9 56,331 4,124 4,688 8,812 15.6 Sand More M9 450 35.5 499 393 92,297 133,402 225,699 19,335 27,946 47,281 20.9 Seta Cru& 172 74 43.0 01 47.1 13,109 22,335 35,414 2,056 3,503 5,559 15.7 Shotta 9, 70 716.5 71 75.5 19,772 9,739 29,511 4,587 2,259 6,846 23.2 Sierra 3 0 0.0 0 0.0 292 249 541 33 28 61 11.3 Siskiyw 22 16 72.7 20 90.9 5,871 2,835 8,706 1,172 S66 1,738 20.0 Solaro 196 75 37.9 A 37.4 23,990 29,171 53,161 3,846 4,677 8,523 16.0 Sarvma 322 153 48.1 166 51.6 23,840 31,110 54,950 3,091 4,034 7,125 13.0 $twist&& 1% 116 59.8 0 64.4 49,300 25,666 74,966 8,110 4,222 12,332 16.5 Sutter 46 32 69.6 3B 82.6 8,614 4,680 13,294 1,564 a50 2,414 18.2 TdWM 17 14 82.4 15 85.2 6,697 3,399 10,096 1,S17 770 2,287 22.7 Trinity 4 2 50.0 3 75.0 1,684 946 2,630 a8 49 137 5.2 Tulare 140 84 60.0 101 72.1 64,134 21,777 85,911 10,433 3,543 13,976 16.3 Tuolumne 42 22 52.4 26 57.1 3,911 3,432 7,343 685 601 1,286 17.5 VerCurs 459 177 3B.6 2M 44.7 36,260 69,230 105,490 7,411 14,150 21,561 20.4 Polo 78 3B 4B.7 41 52.6 14,384 9,609 23,943 2,743 1,832 4,575 19.1 Tmba 14- 9 64.3 11 78.6 13,760 1,955 15,715 1,830 260 21090 13.3 l►iviom+� - Q 38 0.0 0 0.0 TOTAL 21132 .x170 38.7 9530 45.1 2,628,685 2,466,995 5,095,680 467,841 439,064 906,905 17.8 .1. total L1cW% d dentists as of 1/1/91 poverty level, FT 1909-90 2, Fadi-Cal dentist,- rho saw 1 or more Modi-Cal 8. Colman 6 • Column 7- patients during 1989 9. Medi-Cal recipients who sae a dentist one or more 3. Column 2/Colum 1 times during CY 1990 4. Nedi-Cal dentists who taw 1 or more Medi-Cal 10. Estimmte of persons 0-18 below 200% of poverty level patients during post 2 years (am of 19/24/91) who sew a dentist one or more time during FT 1989- 5. Colum 4/Colum 1 90 (assumes same utilization rate as Medi-Cal users 6. Unduplicated count of Madi-Cal eligibles, FT pee 0-20) 1989-90 11. Column 9 • Column 10 7. Population age 0-18 belowi 200% of federal 12. Column it/Colon 8 4.26 POINTS OF ACCESS - DENTAL SERVICES TIME DISTANCE COMMENTS any ksowiedpble Appointments personnel sbould be aysllable during appointment unit bourn to respond to patients requesting to be seen before the next arallable appointment. Wait to make appointment 10 minutes FOR ALL APPOINTMENTS: Dental Services Patient aegis provider within 45 minutes of appointment time Routine appointment 6 weeks 30 miles F/U - routine appointment 6 weeks 30 miles F/U - urgent appointment 2 weeks 30 miles Urgent care - 24 - 36 hours 30 miles Specialist/Consuhant Urgent less than 2 weeks 15 miles Non-urgent 6 weeks 15 miles Telepbone Advice/Triage 10 minutes 24 hours/day, 7 days/week - o:6cum2M Ha.emb-cr 1992mv 4.27 }1 A N AN N 0 an p en P `Q P $3 � C I� f V r+ � � OQ N KS �a rn E ,C N r„ p V tVy � T sx � go ocN s G iE. .1•+ Qy in r ij 2 � o M > E '✓�' � v ova "' � a LodZ ... N ^ Z 4.2$ SO G N r "c3 C ap„ r �►` °1D °� H rw- t os co en � G��N O �►� �' 7 'moo 'fin •>' Gto. dGo d •• E •: V U ed ra 'aa� ddo •% 4 � E° � % ia' fs va 7 i G � w v TT F 4.29 DENTAL EQUIPMENT 8H� Adec Decade 4100 Unit . . . . . . . . . . . . . . . . . . . $5,500.00 ea. x 2 =511,000.00 Adec Decade 1020 Chair . . . . . . . . . . . . . . . . . . . $4,985.00 ea. x 2 = 9,970.00 Adec Light (Pole Mount) . . . . . . . . . . . . . . . . . . $1,595.00 ea. x 2 - 3,190.00 Allied AP 201 Automatic Film Processor . . . . . . . . . . . . . . . . . . . . 3,400.00 MDT Harvey Aquaclave Model 20 . . . . . . . . . . . . . . . . . . . . . . . 2,450.00 Super Dent Doctor's Stools #x952-0680 . . . . . . . . . . $219.00 ea. x 2 = 438.00 Super Dent Assistant's Stools #952-0684 . . . . . . . . . $319.00 ea. x 2 = 638.00 Den Mark Mobile Cabinet (EDP 21-500) . . . . . . . . . . . . . . . . . . . . 575.00 Midwest Shortly - I.,ow Speed Handpiece . . . . . . . . . 5696.00 ea. x 2 = 1,392.00 Midwest Quiet - Air L Handpiece . . . . . . . . . . . . . $380.00 ea. x 2 = 760.00 Impact Air 45 Surgical Handpiece . . . . . . . . . . . . . $448.00 ea. 448.00 $34,261.00 PHS Adec Decade 1020 Chair . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $4,985.00 Gendex GX-770 70KVP X-ray . . . . . . . . . . . . . . . . . . . . . . . . . . 3,400.00 Capital Remodeling for Above X-Ray . . . . . . . . . . . est. . . . . . . . 1.000.00 $9,385.00 Adec Decade 1020 Chair . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $4,985.00 Gendex G3110 Doctor's Wall Mounted Unit X-ray . . . . . . . . . . . . . . 4,130.00 Super Dent Doctor's Stool #x952-0680 . . . . . . . . . . . . . . . . . . . . . 219.00 Super Dent Assistant's Stool #952-0684 . . . . . . . . . . . . . . . . . . . . . 319.00 Midwest Shorty-Low Speed Handpiece . . . . . . . . . . . . . . . . . . . . . 696.00 Midwest Quiet Air Latch Handpiece . . . . . . . . . . . . . . . . . . . . . . . 380.00 $10,729.00 Total of RHC, PHC and MTZ $34,261.00 9,385.00 10.792.00 (List Price) $54,375.00 (Estimated Discount) (110.880.00) Estimated Cost To Us $43,495.00 In addition to the equipment needs for MTZ, one operatory needs to be equipped with a vacuum and drain which would require some modifications. 4.30 MANAGED CARE OPERATIONS SUB-COMMITTEE SERVICE EXPANSION/ENHANCEMENT. Steve Tremain, K.D. ADKINISTRATIOE SUPPORT: Stephanie Bailey MEKBERS : Pamela Hines, M.D. Anne Schnake, F.N.P. John Lee, M.D. David Hearst, M.D. Jim Tysell , M.D. Susan Nairn, R.N. Kaye Severson, F.N.P. Jean O'Neill, R.N. Michael Van Duren, M.D. Dick Ponder Michael Donnelly, R.N. TASKS: 1 . Based on the location and number of enrollees , define where, how and when service expansion and enhancements should take place. Plans should include: - primary care - urgent access - off hour services - telephone advice - appointment unit TIKELINB: o Begin meeting week of 1/4/93 o Complete tasks by 2/12/93 o weekly meeting suggested 4.31 DRAFT Managed Care Subcommittee Report Primary Care Service Expansion/Enhancements Committee Members Steven C. Tremain, M.D., Chair Stephanie R. Bailey, Administrative Support Michael Donnelly, R.N. Dick Ponder David Hearst, M.D. Maureen Scherzberg, FNP Helene Holbrook, FNP Anne Schnake, FNP John Lee, M.D. James Tysell, M.D. Susan Nairn, R.N. Michael van Duren, M.D. Jean O'Neill, R.N. 4.32 Primary Care Service Expansion/Enhancements I. Guiding Principles Developed by Other Managed Care Subcommittees Our committee based its planning on guiding principles developed by two other Managed Care subcommittees. Those principles are as follows: A. From the Access-to-Care Committee: • A routine primary care appointment, new or follow-up, shall be available within six weeks. • An urgent follow-up appointment shall be available within two weeks. • Urgent care services shall be available within 24 to 36 hours. B. From the Case Management and Models of Care Committee: • A goalwas set for most urgent care services to be provided in Family Practice Clinics with urgent care clinics significantly decreased. • A goal avers set for prenatal care (except for high-risk patients) to be provided in Family Practice Clinics. • A goal was set for Pediatricians to be case managers by referral from Family Practice Clinics only and that Family Practice Clinics would see most pediatrics visits. • A goal was set for family practice physicians and nurse practitioners to have the same productivity with nurse practitioners seeing less acute patients. II. Meeting Access Standards with Current Workload Our first phase of planning involved determining additional provider FTE needed to meet Access Committee Standards with current patient population. 'We reviewed the waiting time statistics for next available family practice appointments as follows: Martinez Health Center - 8 weeks Concord Health Center - 5 weeks Richmond Health Center - 11 weeks Pittsburg Health Center - 14 weeks Brentwood Health Center • 8 weeks Page I 4.33 Primary Cane Sen*e Expansion/Enbancements Except for CHC, we are clearly beyond the six-week access standard. We were unable to identify a statistical approach to determine the number of FTEs needed to bring the waiting time down to six weeks. Therefore, our committee projected that 5.0 provider FTEs would allow us to meet access standards with current workload. This estimate was discussed with several members of the medical staff and with the Executive Director and found to be reasonable. The committee then projected that the 5.0 FTE should be broken down by region as follows: Central County - 1.0 FTE West County - 2.0 FTE East County - 2.0 FTE It is our assumption that to be able to add this staff in a timely and cost-effective manner, we would use our existing Health Centers and expand into the evenings and on Sarurday. Based on this assumption, our recommendation for this phase of expansion is as follows: I. At CHC, expansion may be six provider hours Monday evening (currently closed) and 12 provider hours Saturday (clinic to be open all day with two providers). 2. In Martinez Family Practice Clinic, expansion may involve opening the clinic one additional evening per week. 3. In Richmond and Pittsburg Health Centers, expansion may require the Health Center to be open four evenings per week (with three or four providers). 4. In Brentwood, expansion may require the clinic to open one additional evening per week with two providers. It is, however, strongly encouraged that we continue to plan to open new, smaller primary care sites and that some of the provider hours currently at our larger health centers be shifted to smaller sites. Page 2 4.34 Primary Carie Service Expanrion/Enbancements III. Projecting Medi-Cal Eligibles At the time our committee reached the phase of planning to serve additional Medi- cal eligibles, we were unsure of the volume of new patients who might be served by our ambulatory care system. It was predicted that CCHP might "manage" the care for 80% of the Medi-Cal population in Contra Costa County but that Merrithm,Memorial Hospital and Clinics actually would serve anywhere from 60% to 100% of that 80% population. Therefore, we projected Medi-Cal eligibles seen by MMHBC using four scenarios: Scenario 1 (100%) Taking into consideration the location of private Medi-Cal providers in the county, we assumed in this scenario that MMHBC would take care of 100%, 90% and 60% of the Medi-Cal eligibles in Central, East and west County, respectively. Scenario 2 (80%) We projected to take care of 80% of the Scenario 1 Medi-Cal eligibles. Scenario 3 (70%) We projected to take can of 70% of the Scenario 1 Medi-Cal eligibles. Scenario 4 (60%) We projected to take care of 60% of the Scenario 1 Medi-Cal eligibles. See next page for details Page 3 4.35 Primary Care Service Expansion/Enbancements Current and Projected Medi-Cal Eligibles Seen by MMH and Clinics �a= . � . 100% 80% 70% 60% CCHP CCHP CCHP CCHP Central County 13,242 19,580 15,664 13,706 11,748 (MTZ✓CHC) West County 7,143 25,098 20,078 17,569 15,059 East County 7,613 24,831 19,865 17,382 14,899 (PHC,BHC) Tota] 28,000 69,509 55,607 48,656 41,705 (Approx.) ' Current breakdown of Medi-Cal eligibles by site was calculated using the following formula: 28,000 Medi-Cal Eligibles = X Medi-Cal eligibles in region 51,456 Medi-Cal visits Medi-Cal visits in region 2 Projected breakdown of Medi-Cal eligibles by site assumes 89,000 Medi-Cal eligibles in Contra Costa County (1993 estimate) with the same geographic distribution as our September 1991 data. In the 100% CCHP scenario,we assumed that Merrithew Memorial Hospital & Clinics would take care of 100%, 90% and 60% of the Medi-Cal eligibles in central, east and west county, respectively. Estimated 1993 Medi-Cal eligibles by region. are: 19,580 (Central County), 27,590 (East County) and 41,830 (West County). Page 4 4.36 Pri»iary Carte Service Expansion/Enhancements rV. Projecting Provider FTEs Needed with Managed Care Our committee took two approaches to projecting the additional provider FTEs needed with managed care: A. BY using, the formula 2.000 patients = 1 provider FTE: The CCHP planning staff has estimated that MMHBC currently takes care of approadmately 28,000 Medi-Cal patients. (This.includes Health Plan and sticker Medi-Cal patients.) In Section 1I1, we projected our"neve numbers of Medi-Cal patients based on four scenarios. Using the above formula and applying that to the additional patients we will serve, the estimated additional provider FTEs are: Scenario 1 (100%) = 21 FTEs Scenario 1 (80%) = 14 FTEs Scenario 3 (70%) = 10 FTEs Scenario 4 (60%) = 7 FTEs B. By proiecting new primary care visit statistics: With this approach, we made several assumptions: 1. That primary care would provide 90% of the prenatal care. 2. That primary care would provide 75% of urgently needed care and urgent care clinics would provide the remaining 25% of care. 3. That primacy care would provide 709► of pediatrics care. 4. That utilization patterns of"new" Medi-Cal enrollees mill mirror that of our current Medi-Cal patients (sticker and CCHP Medi-Cal). 5. That our volume and utilization patterns of non Medi-Cal patients ,will remain the same. 6. That 1 FTE provider provides 32 hours per week of direct care and that 1 FTE provider works 46 weeks per year. 7. That primary care provider productivity for both physicians and nurse practitioners will be 2.5 patients per hour. Given our four previously identified scenarios for projecting Medi-Cal eligibles to be served by MMH&C, we projected primary care and urgent care visits and FTEs. See next page for details Page 5 4.37 Primary Care Service Expanslon/Enbancernents r p •�•!•�� � K K K k K K K K K K h R1 �• r r r N N N W W W W W r i ^ M C�• O O r N r V W O+ W C� �0 M • P1 A 0 O� �1 �1 �D �• � M O� �1 J aR �ppG,, •p •11 nC M N M wM W ;rCp di W C W r r N ► ♦ r ♦ �w O• W M •' r Grp 1p. + • �'fl O� a A M � W O+ O O� OD �O � �• ,A Z ••I A O !D W r M •D R W O C �c C. .p �• � w r v a app C yt � .• � E 0 & 0 � r r r r r r r r r r r 5 A �,• •� C r W r N W M N N W 1A 6 A A R NO W M O� R O R C� ► A T A� E $ II�A C• R _ r r r r v� M M M r r' r r •� •i ,r r5 r 6 C N N < W V Q d W P M R M C C ~ J r r r V �'•' G 10 N N N J r M r M �D N tip Id f f f f ut f!i eA y p Fj r r �+ �+ N N N N r r r r •� O � b P, �o O !+ N W C g A Page 6 4.38 Primary Care Service Expansfon/Enbancaements Using this approach, the estimated additional provider FTEs needed for Managed Care are: Scenario 1 (100%) = 22 FTEs Scenario 1 (80%) = 15 FTEs Scenario 3 (70%) = 12 FTEs Scenario 4 (60%) = 10 FTEs While there is some difference between the number of. FTEs projected by these two different approaches, the numbers are, in fact, quite close. We based the remainder of our planning on the second approach (projecting visit statistics) because it more accurately reflects some of the unique aspects of our system for the following reasons: • In our system, provider FTEs include physicians and FNPs. Since FNPs generally see lower acuity patients, our physicians see higher acuity patients than the average private physician. As a result, our overall provider productivity is likely to be less than other HMO systems. • We believe that the acuity of Medi-Cal patients is higher than that of the general state population and, therefore, the 1 FTE = 2,000 patient ratio may not be appropriate with a Managed Care Medi-Cal population. • 'We are unclear about whether the 1 FTE = 2,000 patient ratio includes prenatal care. 'Therefore, since our model of care does include prenatal care and our visit projection approach includes prenatal visits, this is believed to be a more accurate projection of workload. V. Summary of Total Additional Provider FTEs In Section II, the number of additional provider FTEs needed to meet access standards with current workload was identified as 5.0 FTEs. In Section IV, the number of additional provider FTEs needed for managed care was identified as ranging from 10 FTEs (Scenario 4, 60%) to 22 FTEs (Scenario 1, 100%). In summary, the total additional provider FTEs needed are as follows: Scenario 1 (100%) = 5 FTEs + 22 FTEs = 27 FTEs Scenario 2 (80%) = 5 FTEs + 15 FTEs = 20 FTEs Scenario 3 (70%) = 5 FTEs + 12 FTEs = 17 FTEs Scenario 4 (60%) = 5 FTEs + 10 FTEs = 15 FTEs Page 4.39 Primary Cane Sen4ce Fxpansion/Enbancements V1. Recommended Distribution, by City, of Primary Care FTEs We reviewed statistics on the percent of Medi-Cal eligibles by city of residence and then applied those percentages to the total primary care FTEs needed under our four scenarios. In this phase, we excluded urgent care FTEs because it is anticipated that the smaller urgent care clinics that we continue to operate mill be held at our larger Health Centers. Also, in this phase, we included the 5.0 FTEs needed to meet access standards with current workload. Based on the residence of Medi-Cal eligibles, there are seven cities where our primary care FTEs should be concentrated: • ClaytonlConcord Pittsburg • Martinez Antioch • Richmond Brentwood • San Pablo See next page for details Page 8 4.40 Pri»say Care Service Expansion/Enhancements Recommended Distribution by City of Primary Care FTEs (7bese recommendations take into consideration the FTEs needed to meet access standards with current workload and FTEs needed with Managed Care.) :::.:.:...:.....:.. ..:.:: ::.:..: ..:......:. Locates of Medi-Cal es by:City of Residence x Central County West County East County Alamo, Danville, San Crockett . . . . . . . . . . . . . 1% Antioch . . . . . . . . . . .. 35% 'Ramon . . . . . . . . . 6% El Cerrito, Kensington . . . 2% Bethel Island, Discovery Clayton, Concord . . . . . . 58% El Sobrante . . . . . . . . . . . 5% Bay, Knigthsen . . . . . . . 2% Lafayette, Moraga, Orinda 49t; Hercules . . . . . . . . . . . . . 3% Brentwood . . . . . . . . . . 7% Martinez . . . . . . . . . . . . . 20% Richmond . . . . . . . . . . . . 56% Oakley . . . . . . . . . . . . . 6% Pleasant Hill . . . . . . . . . . 8% Rodeo . . . . . . . . . . . . . . 3% Pittsburg . . . . . . . . . . . 50% Walnut Creek . . . . . . . . . 4% 1 San Pablo . . . . . . . . . . . . 30% FTEs Needed to Meet FTEs Needed Total Recommended Distribution of FTEs Based on Residence Access standards with with Primary of Meda-Cal Eligibles Current Workload Managed Care FTE Carr Needed 100% 1.0 15.4 16.4 Clayton, Concord (12.1 FTE), Martinez (4.3 FTE) 80% 1.0 13.6 14.6 Clayton, Concord (10.8 FTE), Martinez (3.8 FTE) 70% 1.0 12.8 13.8 Clayton, Concord (10.2 FTE), Martinez (3.6 FTE) 60% 1.0 12.0 13.0 Clayton, Concord (9.6 FTE), Martinez (3.4 FTE) ii'est Conn t3 60% 2.0 15.8 17.8 Richmond (11.6 FTE), San Pablo (6.2 FTE) 48% 2.0 13.6 15.6 Richmond (10.1 FTE), San Pablo (5.5 FTE) 42% 2.0 12.5 14.5 Richmond (9.4 FTE), San Pablo (5.1 FTE) 36% 2.0 1 11.3 13.3 Richmond (8.6 FTE), San Pablo (4.7 FTE) FAst Cbiwry 90% 2.0 13.9 15.9 Pittsburg (8.1 FTE), Antioch (6.1 FTE), Brentwood (1.7 FTE) 72% 2.0 11.9 13.9 Pittsburg (7.1 FTE), Antioch (5.4 FTE), Brentwood (1.4 FTE) 63% 2.0 10.9 12.9 Pittsburg (6.6 FTE),Antioch (5.0 FTE), Brentwood (1.3 FTE) 54% 2.0 9.8 11.8 Pittsburg (6.0 FTE),Antioch (4.6 FTE), Brentwood (1.2 FTE) Current Primary Care FTEs by Health Center MTZ CHC RHC PHC BHC 9.4 2.3 5.4 2.5 2.0 Page 9 4.41 Primary Carr Sendre Fxpansion/Enbancements VII. Recommended Locations for New Primary Care Health Centers Taking into consideration the primary cam hours currently in our existing Health Centers and assuming that those FTEs will remain where they are, we projected the number of provider FTEs which should be at our five new Health Centers. The summary is as follows: • In Central County, it is recommended that the existing Concord Health Center must expand or a new site in the Concord area should be opened and staffed with 2 to 5 providers. • In West County,''it is recommended that two new Health Centers be opened. A new center in San Pablo should be staffed with 5 to 6 providers and a new center in Richmond should be staffed with 3 to 6 providers. • In East County, it is recommended that two new Health Centers be opened. A new center in Pittsburg should be staffed with 3.5 to 6 providers and a new center in Antioch should be staffed with 4 to 6 providers. See next page for details Page 10 4.42 Primary Care Service E%panslon/Enbancements Recommended Locations for New Primary Care Health Centers (These recommendations assume that the primary care FTEs at our current Health Centers will remain the same. We may, however, want to plan to shift some primary care FTEs from an existing Health Center in the same city for a variety of reasons.) . . Central County : Ma FPC :. CHC . New Site in Cuyt on, Concord 100% 9.4 FTE 2.3 FTE 4.7 FTE 80% 9.4 FTE 2.3 FTE 2.9 FTE 70% 9.4 FTE 2.3 FTE 2.1 FTE 60% 9.4 FTE 2.3 FTE 1.3 FTE rest County RAC FPC New Site in ::New Site in San Pablo Richmond 60% 5.4 FTE 6.2 FTE 6.2 FTE 48% 5.4 FTE 4.7 FTE 5.5 FTE 42% 5.4 FTE 4.0 FTE 5.1 FTE 36% 5.4 FTE 3.2 FTE 4.7 FTE East County PHC New Site in Site in BHC Pittsburg Antioch 90% 2.5 FTE 5.6 FTE 5.8 FTE 2.0 FTE 72% 2.5 FTE 4.6 FTE 4.8 FTE 2.0 FTE 63% 2.5 FTE 4.1 FTE 4.3 FTE 2.0 FTE 54% 2.5 FTE 3.5 FTE 3.8 FTE 2.0 FTE Page 11 4.43 MANAGED CARE OPERATIONS SUB-COMMITTEE SPECIALTY SERVICES CRAIR: Bark Wille, N.D. RDXINISTRATXVZ OUPPORT: Jean O'Neill, R.N. XZ KBERB: Rent Hobert, K.D. Gwen Johnson, M.D. Pauline Velez, M.D. Alan Casebolt, M.D. Debbie Warner, M.D. Stephanie Bailey BR: Based on primary care expansion, define where, how, and when specialty services should be expanded and enhanced. TIXELINE: o Begin meeting week of 1/4/93 o Final report complete by 2/12/93 o Weekly meetings suggested 4.44 MANAGED CARE OPERATIONS SUB-COMMITTEE ANCILLARY SERVICES CnIR: Joseph Barger, M.D. ADXINISTRATIQB DUPPORT: Stephanie R. Bailey KEKBERS: Mike Araki Cyndy abram Khalil Diab Jean O'Neill Darrell Williams Chris Grazzini Tom Odom Harriette Fisher Mattie Sawyers TASK; Based on primary care and specialty expansion, define where, how, and when ancillary services should be expanded and enhanced. Ancillary services may include: - clerical support - lab - x-ray - pharmacy - cardiopulmonary - therapy (PT, OT, speech) - medical records - registration - interpreters - transportation - MIS TIKELINE: o Begin meeting week of 1/18/93 o Final report completed by 2/26/93 4.45 MANAGED CARE OPERATIONS SUB-wOMMITTEE MENTAL HEALTH SIR: Joseph Hartog, N.D. APXINISTRATIVI DUPPORT: Dick Ponder KZKBERB: Steve Tremain, M.D. BK: Define mental health: primary versus specialty care?? TI1iELINE: Task completed by 1/31/93 4.46 • MANAGED CARE OPERATIONS SUB-COMMITTEE STAFF RECRUITMENT MIR: Rim Duir, M.D. UXINISTRATIQE OUPPORT: Frank Puglisi KZKBER.B: Krista Farey, M.D. ABR: Based upon all the defined service expansion and enhancements, develop a strategy and plan for provider recruitment. TIKFLan o Begin meeting week of 2/1/93 o Final report completed by 2/26/93 • . ......... .. .. ................................... . . ............. .... .................. ....... .. .. ......................................... . ....... ....................................... .. ............ .......... .... ...................................... . . . ................ ...... ..... .. . .............................. .. ...... ........ ....... .... .. .............. ................. . .. . .......................... ...... ......... ....... ....................... . ............ . ...................................... . . ......................... ...................................... .. . . .................. ...... .. . ...... ............... ....................... . . ......... .............. ........................... ....... ... .......... . ............ ...... ................................. . . . ........................ .. . . ................... .......... . . ............ .. . .. ................ . . . . ........... ........ .. ....... ......... .. ... ................. . .............................. . ........ ..... . . .......... .... .. ..................... ..... .. . ........ .. ... ...... .. .. ........... ...... .............................. .. . ................................ . ....................... .. ............ ........ .. . ................. .............. ................ . . .. ............................... ........ .. .. ..... . . .. .. ....................... .. ......................... ....... ........ ................................................. ..... ............. .............. . . ...... .................. ....... ............ . ............................... ..... ............. . . . .. ............. ............ . . . . .. ............. ... .......................................... .. ............................................. ................................. � ........ . ................................... .............. . ........... ........ .. . .. . ... .......... ... . . .. ................. S.S�UU:lRED ACCESS • 5.1 POINT'S OF ACCESS - PRIMARY FARE (Primary Care Defined As: Family Practice, Pediatrics, OB/Gyn, Internal Medicine, Dental ) TI�1JE ; ISTA1VVl^E Medically 1 Im0 wledg ab e 1 screening Pe rsonne should be available Appointments during appointment unit hours to respond patients d to ati P uesting to be seen before the next available appointment. Wait to make appointment 10 minutes FOR ALL Need to use health Primary Care APPOINTMENTS care maintenance (Primary Care & criteria as an audit Speciality): Patient tool (e.g. sees provider within Pediatrics: 45 minutes from time immunizations; of appointment Adults: pap, mamma, cholesterol) Routine appointment 6 weeks 15 miles Prenatal appointment 2 weeks 15 miles F/U - routine appointment 6 weeks 15 miles F/U - urgent appointment 2 weeks or less 15 miles Urgent care Within 24-36 hours 15 miles Routine H'& Ps Routine history and physicals should not be separated from routine primary care Telephone Advice/Triage 10 minutes 24 hours/day, 7 days/week BASIC RULES: 1) Routine primary and speciality care appointments to be available within b weeks. 2) Urgent primary and speciality care appointments to be available withing 2 weeks. cAsccess2/3 December 1992rev 5.2 POINTS OF ACCESS - SPECIALITY CARE Specialist/Consultant An alternative measure of accessibility o speciality services to possibly consider is the number of specialists per i0,000 visits Per speciality Urgent 2 weeks or less 30 miles Non-urgent 6 weeks 30 miles Telephone Advice/Triage 10 minutes 24 hours/day, 7 days/week BASIC RULES: 1) Routine primary and speciality care appointments to be available within 6 weeks. 2) Urgent primary and speciality care appointments to be available withing 2 weeks. OAccess2/3 December 1992rev 5.3 POINTS OF ACCESS - URGENT CARE : 24 HOUR PHONE TRIAGE (FOR ALL PRIMARY CARE SERVICES) TIME DIST141VCE COMMENTS, Call responded to within 10 minutes Level I Refer to ER 15 miles Level II Depending on 15 miles problem refer to ER or for primary care urgent care appointment Level III Appointment 15 miles within 24-36 hours c:laccess2/3 December 1992rev 5.4 POINTS OF ACCESS - EMERGENCY ROOM D MMENTS . TIME ISTANCE.: O ..... Triage Patient seen within 5 minutes of arrival Level I Immediately Nearest facility See MMH criteria Level II 2 hours 15 miles See MMH criteria Level 111 4 hours 30 miles See MMH criteria "Level IV" Refer for short or Not everyone who long term comes to the ER appointment must be seen in the ER cAaccessW December 1992rev 5. 5 POINTS OF ACCESS - ANCILLARIES . . flISTAN MMENTS 77ME CE CO Drop-in sees provider 20 min 15 miles from time of arrival Scheduled 1 week; sees provider 15 miles 20 min from time of appointment Imaging Services Drop-in 20 minutes from time of 15 miles arrival Scheduled 3 weeks; 20 minutes 15 miles; 30 15 miles for barium from time of miles for special studies, sonograms, appointment studies mammograms Cardiopulmonary . Drop-in 20 minutes from time of 15 miles arrival Scheduled 3 weeks; 20 minutes 15 miles; 30 15 miles for simple from time of miles for special PFTs; ABGs appointment until procedures patient sees provider Pharmacy 30 minutes 15 miles Therapy.Services PT 2 weeks 15 miles OT 2 weeks 15 miles Speech/Audiology 4 weeks 30 miles OAccess213 December 1992rev 5.6 POINTS OF ACCESS - DENTAL SERVICES MSN M TS TANCE .: CO ... . .::. ... .: .. .. .. DIS C Medically Y knowledg ab,e screening Aointments < . personnel should .. ....:.:::. PP be as v ilable during g appointment unit t . hours to respond nd to patients requestingbe to see before efore the next available appointment. Wait to make appointment 10 minutes FOR ALL APPOINTMENTS: Dental Services Patient sees provider within 45 minutes of appointment time Routine appointment 6 weeks 30 miles F/U - routine appointment 6 weeks 30 miles F/U - urgent appointment 2 weeks 30 miles Urgent care 24 - 36 hours 30 miles Specialist/Consultant Urgent less than 2 weeks 15 miles Non-urgent 6 weeks 15 miles Telephone Advice/Triage10 minutes 24 hours/day, 7 days/week c:laccess2/3 December 1992mv 5. 7 POINTS OF ACCESS - MENTAL HEALTH & SUBSTANCE ABUSE SERVICES . ... ...; TIME DISTANCE ; COMMENTS Appointments: Routine/Non-urgent 4 weeks 15 miles new, physician and self-referrals, triage Medication Vu 1 week 15 miles Crisis Vu 1 week 15 miles 24 hours/day, Psych Emergency 7 days/week; Services staffed by mental health professionals Triage 15 minutes 30 miles Level I Immediate 30 miles Level II 30 minutes 30 miles Level III 2 hours 30 miles Level IV Refer for appointment Phone Access Advice/Triage 10 minutes ISSUE. New patients need to be referred to a primary care physician and primary care physicians need to be informed when their patients receive services. c:leccess2/3 December 1992 5. 8 OPERATIONAL ACCESS ISSUES The following issues will be referred to Operations Committee o Monitoring of access standards - multi-disciplinary committee. Providers who don't meet standards will not be allowed to enroll new patients until they do meet the standards. o Language access o Appointments System o Need built in override capacity of 25% (may be tiered - 10% 2 days, 15% less than 2 weeks) o Urgent care slots o Adequate provider support required o Patient satisfaction needs to be a factor o How do new patients make first appointments? When do they get educated about system. o Multiple appointment access - telephone, in person, mail o Urgent problems - need to seen in 36 hours or less o Primary care physician ratio to patients need to be defined. Recommend no more than 2000 patients to 1.0 FTE. 1.0 FTE defined as 32 hours/week of clinic time). o Referrals to primary care physicians from mental health system. o FNP equivalency to MDs???? cAaccess2/3 December 1992rev 5 .9 UNIVERSITY OF CALIFORNIA, BERKELEY BER>;LLE1 DAMS IRVINE LOS ANC.ELEs RI\"EP.SIDF SAN DIEL".O SAN FRANCISCO t:: C SA\TA B�RS.kRi SANTA CF1'2 6 HEALTH.AND MEDICAL SCIEICES PROGRAM 570 UNIVERSITIHALL BERKELEY,CALIFORNIA 94720 November 30, 1992 To: Milt Camhi , MPH Executive Director Contra Costa Health Plan From: Henri k L. B1 um, MD, MPH Professor Emeritus of Health Policy and Planning Re: Access Standards for Medical Beneficiaries My evaluation of your proposal is broken down into several areas which appear important to me. Conceptual Framework As laid out in Dr. Tremain's discussion I feel that the bases are well covered. Matters left for the operations committee are equally important and listing them makes clear what more has to be done. These operational access issues have to be settled before you and any subcontractors get underway. Will the state go along? Probably, as they don't really address these issues so far in any systematic way as you do. Ir fact, the framework you have proposed may be a useful model for the state and other counties to adopt. Appropriateness of Standards You Propose Yes , these final standards are reasonable if lived up to. I think your plans for truly urgent and emergency care are probably as good or better than. I actually get in my personal private health plan. The relationship of the proposed standards to good clinical outcomes theoretically should be high. In the presence of your 24-hour telephone adwicc availability, triage, and ER, clinical outcomes are reasonably well safeguardec. The customary "quality of care" issues in practicing medicine should be more relevant safeguards than any shortcomings of your standards for access. Measuring Compliance with Standards (Monitoring) Having each clinic or office report "one day a month" about length of time to appointment does not make me comfortable. One day a month is not an adequate sample and the choice can be "gamed" too easily. Don't clinics keep F. log of who is seer. when,? Can't the date of giving an appointment be appended tc the date when it is tc take place and thus provide an easy way to sample situations? 5.10 Milt Camhi November 30, 1992 Page 2 Who Shall Vc^itor? Since meeting the standards which are adopted is the acid test of compli- ance, there is the issue of who shall monitor. I like the suggestion that you health plan access committee made. A monitoring committee has to be appointed by and report to the agency head. It should be multidisciplinary with members from Finance and the operations and access committees. Choice of Standards In addition to the overall achievement measure, I think that the median waiting time is another good marker for it shows the longest wait time for the half of the patients who are seen the soonest. Subcontractors and Individual County Clinics Each subcontractor-provider should have his/her own records made visible so that CCC can ascertain waiting time and see the extent of failures and where they occur. It is equally essential to keep these statistics for each of your own county health centers , and I would say for each of your specialty and ancillary urits as well . Averaging the various county waiting times with those of the subcon- tractors will simply disguise successes and failures , and the county will be shirking its responsibilities if it puts out meaningless, if not misleading, averages. Relationshic of Proposed Standards to Current Operating Parameters in Contra Costa County Because the current county clinics do not uniformly and consistently meet the proposed waiting time standards , it seems appropriate to have a time-phased action Plan CCC clinics into compliance. To get a reasonable product the mFcical staff, finance and operations staff need to be in agreement on the proposed timetable so that the CCC syster moves forward to compliance. in subcontracting with private providers, I believe that these same standards must be adopted as contract requirements. If the county ends up with a phase-in for its own clinics it could do the same thing for subcontractors. The County has to be held to the same standards as are demanded for the subcontractor. If not, there will be a prompt and unpleasant reaction from the providers, the press , and the public as well as from current and potential enrollees whc will see that if they want timely access they should go outside the County system. Relationship of County Proposed Standards to Employer Proposed Standards While the Contra Costa Countv proposed standards are acceptable, the_, are net as stringent as those proposed bythe employer coalition which is negoti- ating patient waiting times with HMOs on behE,f of the employers. For example, private plan members will presumably have access for a physical exam in 30 days 5. 11 Milt Camhi November 30, 1992 Page 3 versus six weeks in the CCC public plan. Will the County standard Therefore by characterized as the poorer tier in a two-tiered system? Probably. The employer proposed standards may in part be driven by their desire to look good in the eyes of their employees. In any case, private plans also have costs, and employers are also seeking lower premiums. Thus private plan stan- dards may end up not far removed from CCC proposals. This is a wait-and- watch situation, and CCC will probably have to reconcile significant differences. Initial 90-Day Health Assessment Appointment I would include this in the standards. It would be quite reassuring about the overall clinical quality in the sense that every client would have a basic general history and physical early and thus avoid overlooking important disease. You must assure timely access to this wellness service if you expect to have favorable impact on the amount of sickness among your enrollees , a critical factor in utilization and cost control . You may even want to establish a wellness center(s). This idea is controversial in the sense that most primary care providers would want to do the baseline examinations and advising them- selves. There are many ramifications of these opposing views , and only local experiences will point the way to the best practices in CCC. Defining Accessibility Given the size of Contra Costa Countv, the generally clement weather, and the generally adequate distribution of care sites , I would primarily specify the time clients wait to get an appointment as the most critical element. Quantity or ratio of providers to members would be next in importance. This shoulc be done by region of the county. Time is the overriding or critical criterion. Language seems next in importance and, in part, speaks to the worst ethnic-cultural mismatches. You must have ample experience with this problem already and know how you might best proceed to cover the diversity of language needs in CCC. What occurs to me -if I had to make a fresh start in this problem area is that some kind of observational sampling would seem indicated. The problem could be worse in less populated areas where any non-English-speaking patient is not likely to be matchable, but numerically failures to match could be a much worse problem where there are a lot of non-English speakers and no provision made for translators. Language matching is an area where observation of the situation is called for with an eye to creating more realistic provision of translators. Appoint- ments could be scheduled for Pittsburg, Martinez, and Richmond for clinic sessions where translators would be on call for certain, half-days. These three sites are well situated to cover the whole county. Walnut Creek or Concord could be substituted for Martinez, I suspect, if public transportation would be be--ter for the clients. 5. 12 Milt Camhi November 30, 1992 Page 4 The Key Concern Is Accessibility For the survival of your program, patient satisfaction is certainly key for this will determine enrollment of new clients and retention of current ones. This is especially true as it is realistic to expect competing plans to empha- size access and short waiting times. Financial and technical realities of pricing the services of course are critical for you but equally so for your competition. Notwithstanding, patient satisfaction will determine your ultimate viability. All plans have to strike a sensible balance between patient wait times and doctor wait times, but studies make clear that patient wait time, a critical factor in patient satisfaction, can be kept low without wasting physician time. One related aspect of short wait times is to have maximal enrollment and therefore a service that .has a more constant flow of patients and a minimum of delays thus providing a maximum of patient satisfaction -- a circular and self-reinforcing recipe for success. Assuring that your standards also meet provider satisfaction is critical for two reasons: 1) their willingness to participate and 2) patients respond to hcw they are treated and physician satisfaction is a positive force to keep patients in the plan. State-specified Reasonable Access Again, given CCC size, and weather and in spite of traffic jams around Walnut Creek, I would agree with your task force proposal to use 15 miles and 15 minutes as a better access pattern than the 10/20 suggested by the state. In all fairness to participatior, realities , fifteen miles brings everyone into reasonable proximity to a care giver and probably allows for the variances introduced by use of any of the currently available modes of transportation. As the State gets further into it, it may wish more uniform standards among the counties. However, as I see it, there is justification for you to ask for leeway that allows for standards you see as desirable, since no two counties face the same realities of distance, population density, language needs , distribution of providers, and so on. Good service to members will , therefore, call for quite a bit of individualizing within each county. Getting Ready CCC has only a very short time in which to get ready for the state transfer of Medi-Cal . County systems will be expected to keep their clients contented in a way that has never happened before. Moreover, they will have to retain clients to keep solvent. There has to be a realistic transition for the Health Services Department tc accept a significant and rapid influx of Medi-Cal patients. There must be immediate planning for expansion of resources , including providers , ancillary services , and sites of practice so that the services will be ready when the patients arrive. If there isn't an orderly way of handling the newcor•ers , there will be repercussions among Your present as well as the new members. You car. be 5.13 Milt Carchi November 30, 1992 Page 5 sure that any bad vibrations at this critical time will be picked up and aired by many interests, pro-consumer as well as anti-County. You can't afford significant dissatisfaction of old and new members. If it happens, you send your potential and current members to other providers. It is probably wishful thinking that you can woo them back once you lose them, and it will cost a fortune to try. Potential as a State Model The model Contra Costa County is proposing, whereby it will be providing or arranging for all the care for all Medi-Cal eligibles in the community will almost certainly receive statewide if not national attention. And the focus of many will be on whether the County can not only control Medi-Cal expenses better than has been the case in "unmanaged care", but equally important, whether access to primary and preventive services is measurably improved. The proposal offers an innovative approach to provide services to the Medi-Cal population through traditional safety net providers (primarily the County). The Contra Costs model promises to be a lesson for the nation in how to provide universal access to quality health care for all Americans. Caveats Since Contra Costa Health Plan also manages care to commercial , Medicare, and indigent subscribers, there have to be the same access standards for all its members. Any deviation such as shorter waits for commercial and longer for indicer.ts is unthinkable to propose and must not happen in practice. There should be sampliro waiting times for all the categories of members to guarantee equal access for all . Likewise, the County must not just promise access on paper; it has to deliver access . • .............. . ........ ... � .. ... ...... GLOBAL ...... . ......... BUDGET r� G 'o� S K,e r� Jr , ae 00,4 I: j j j i i i j i j is is i ! is i I i i i is is is j: I is 'I i i' j ii I !j is I I: I I: I: i. I: 'I I i. I: is i I i i I ii is I � i 1 i � I i I is i i I i i Ili I I i I j i I i i I i I j i I I' I I I i I I. I i i I I I ! j I I I' I i I I i I i i I I i is I i I I I i I I � i I I i I i ! i I I I i I i I i i I I i I j i i i I i I j i i is ii I i is I i Is I i I I I i ! I I I i I I I i i j I I 1 I I I! I I i i I i i I I i i I I i i I it I i I I I it I i I I I i i i I ii I I I I i I I I I I j i ! I ' I I i i I I I I i i i i I I i I I I 1 1 I I I is I it I i II I I I I i I i ! i I j I I � i j i I I I i I I I j I i I I I it I i I' i i 11. i � I i I i I!' I ! j I j I ! I � i is I I I j I I I i j I Rss�p2rO�'s. E e °t=at kap Ie '2h h @d ,g�g,3 Ohl h Fee, year t' h 0 ass. `e � t E : 1 = s; ? i. tt ': i; �t t t sE i t t �i 3 ` c3 st si 3 t 11 i } ;3 t et 3 3 i s3 .. i i 3 , t 3 3 t3 ; i e3 ; 3 3 ; t t t 3 t. t t t 1 l i t t 3 , 3 , 6. 1 ,1 MANAGED.:CARE;;:.;::;: a: :. DECEMBER ::8.: 1992... inancial Implementation 1992/93 o Current Prepaid Health Plan Rate Adjustment 1993/94 o Implements its authority to allow the County to pay CMAC rates to CMAC hospitals and supports the County's use of Medi-Cal rates to all other out-of-plan providers. 0 Hold Harmless on SB-855 o Hold Harmless on SB-1732/2665 CONTRACT PRINCIPLES o Reimbursement will include adjustments for the following: - federally qualified health center payments; - SB-1255 and all other related disproportionate payments - administrative costs - adjustments detailed in the State capitation manual - 1000 of the fee-for-service payment base - litigation settlements - service enhancements o Establishment of a Savings/Loss Corridor o Designation of a percentage of all county savings to a community reinvestment pool o Multi-Year In Nature o Predictable 0 Cost Effective 6. 2 -2- ASSUMPTIONS: (Example Only) Negotiated Bas,a Year Cost: Fee-For-Service Payments Federally Qualified Health Center Adjustment SB-855; SB-1255; etc. Adjustments TOTAL 120,000,000 ELIGIBLES ALL AID CATEGORY: TOTAL 80,000 REVENUE: Per Eligible Per Month. . . . . . . . . . . . . . . . . 125 Annual per Eligible . . . . . . . . . . . . . . . . . . . 1 500 RISK SHARING• L O S S E S R A T I O The First $1 - 5, 000, 000 County 50%/State 500 Amounts between $5, 000, 001 - 10, 000, 000 County 30%/State 70% Amounts between $10, 000, 001 - Above County 10%/State 90% S A V I N G S R A T I O The First $1 - 5, 000, 000 County 90%/State 10% Amounts between $5, 000, 001 - 10, 000, 000 County 75%State 25% Amounts between $10, 000, 001 - Above County 50%/State 50% COMMUNITY REINVESTMENT: 250 of all County savings to be designated for non-recurring prevention or health improvement programs, community outreach or other special health services based initiatives designed to improve access, quality and/or reduce future costs for Contra Costa Medi- cal patients. 6.3 -3- VARIABLES: - Price of Services - Utilization of Services - Mix of Eligibles - Number of Eligibles POSSIBLE OUTCOMES: v `::`:;:> ELIG.IBLB<IN..£BC$S$ SGOTIATED ..... ...:< ' ::«:: ;':° Annual Rate per Eligible $ 1,500 Annual Cost per Eligible 1, 625 Loss $ <125> Number of Eligibles x 80, 000 Total Loss S<10,000,000> County Share $ 49000,000 State Share 6, 000, 000 II ;; ; : :NEGOTIATSD >RATE>PERSLFC > ': >Y «> >> .. Annual Rate per Eligible $ 1, 500 Annual Cost per Eligible 1, 375 Surplus $ 125 Number of Eligibles x 80, 000 Total Surplus $ 10,000.000 County Share $ 8,250,000 State Share $ 1,750,000 6.4 -4- ZII _ <»;;<;:................. 1' ' UAL P WOLUKE RObT / SQ LtTM ECT D Annual Rate per Eligible $ 1,500 Annual Cost per Eligible 1,500 Loss/Surplus S -0- Eligibles 90,000 Total Program Cost (90,000 x $1,500) $135,000,000 Increased State Expenses/ Increased County Revenues S 15, 000,000 3V: <<>LCflS.T' RATE1<S ... DWERTHAN<: P_:;<fl:»:<;:;<:: .................. / 4 L 8 L R SECT >> . <»>` >>>i' :< Annual Rate per Eligible $ 1, 500 Annual Cost per Eligible 1,500 Loss/Surplus $ -0- Eligibles 70, 000 Total Program Cost (70, 000 x $1,500) 1105,000, 000 Decreased State Expenses/ Decreased County Revenues $15, 000, 000 6. 5 -5- PROPOSAL: o Establish a global budget based upon the contract principles. o Identify the base cost. o Identify the number of eligibles served by the base cost. o Project the number of eligibles to be served in the 1993/94 fiscal period. o Adjust base cost amount upward or downward. o Adjusted base cost becomes contract amount (base revenue) . o Monthly payments based upon 1/12th of contract amount. o County is responsible for all eligibles during the contract term at the negotiated base cost amount. o Year two contract adjusted based upon year one risk corridor. 6.6 OUTCOMES: Z 4 II No Change Total Program Cost $ 135,000,000 (90,000 Eligibles) Base Revenue (Negotiated Contract Amount) 120.000.000 Loss S <IS.000.000> County Share $ 4,500,000 State Share $ 10,500,000 IV Total Program Cost $ 105,0001000 (70, 000 Eligibles) Base Revenue (Negotiated Contract Amount) 120.000.000 Surplus $ 15. 000, 000 County Share $ 10,750, 000 State Share $ 4,250, 000 6. 7 -7- RISK BRAKING - EXAMPLES 108888: ;::>:::::::: ,:;. ,;.:<,:;::::,,;::;::<;:::.: <:.;::>>:::;:::8X1 .. . . Count :::::<:;; ;: 8tato:<. ::::::::::::::;:::. fount <. :::...:. ::::,: 8tate . $ 1,000,000 $ 500,000 $ 500,000 $ 900,000 $ 100,000 5,000, 000 2, 500,000 2,500,000 4,500,000 500, 000 7,000, 000 3,100,000 3,900,000 6,000,000 1,000,000 10, 000, 000 4,000,000 6,000,000 8,250,000 1,750,000 13, 000,000 4, 300,000 8,700,000 9,750,000 3,250, 000 15, 000,000 4 , 500,000 10, 500,000 10,750,000 4,250, 000 * Percentage to be directed to community reinvestment • .......... ...................... .... ....... .. .. . .................... ..... ............... ... ...... . ............... .......... ................ ................................. .... .......................... ... ......... .............. .............. . ............................. . ................... .. ................. .. ... .... ........ ..................................... ................ ......... .. .............. ....... .. ....................... ......................... .... ..... ....... . ......... . ......................... .... . ....... ................ .. . ......... ............ . . ... .......... .. . . . . ........... .. ... ....... . . .......... ................. .............. ........... ...... . ........... . ... ............ ... . ........... . ................ .... ... .. .... .............. . .... . . ......... ... .. ........ ......... .............. . ........ ................ . . .................. .. ............................. .. ........... . ....... .............. ........ .. ......... ...... ...... . ............ .. ............ ... .......... . ........... ............ ..................................... ................................................................ ......................................... .... ...... H................. ... ................. EAL................. .. .........T........................................................................ ..................H � FIRS........ T ............. ................................... ........... ............................................................................................................................................................................................................................ ............................ ...... ................. ...................................................................................................................................... ......... ...... .............. ............................................. ............................................................................................................................................................................................... ................................................................................................................. ....................................................................... .............................................................................................................. .......................................... ..... MpLEMENT...... .............. A............................................ ......... . ...............................................................................T....................... IO......... .................................................................... N ISSUES ................................................................................................................................................................................. .................................................................................................................... ........................................................................................................................................ 7.1 Health First Implementation Issues Prior to Contra Costa County implementing the Health First managed care plan, the follow- ing key conditions must be met. State Department of Health Services agrees to:: ❑ 1. Maintain present FQHC reimbursement. ❑ 2. Pay Contra Costa County disproportionate share SB855 reimbursement. ❑ 3. Support inclusion of PHP days for capital projects under SB1732/2665. ❑ 4. Shared risk/reward approach. ❑ 5. Support all necessary federal waivers. ❑ 6. Amend the state plan to allow 6 month guaranteed eligibility for Contra Costa Health Plan members. ❑ 7. PHP, PCCM and FFS contract capacities as proposed in the County's implementation plan. ❑ 8. Support the Contra Costa County's request to federal government for exemption from the Medicaid and Medicare composition rules. ❑ 9. Elimination of door-to-door marketing by expanding member services outreach. ❑ 10. Implement authority to allow Contra Costa County to pay CMAC or Medi-Cal rates to all providers. ❑ 11. Exempt Contra Costa Health Plan from mutually agreed upon Knox- Keene license and fiscal requirements. ❑ 12. Allow Contra Costa County to revise the Medi-Cal benefit package to be consistent with and not less than the standards for a Knox-Keene licensed, federally qualified HMO. ❑ 13. Allow Contra Costa County to implement a countywide emergency room copayment (not to exceed $10 per visit) under certain circumstances. LQPROPI • .... ........ .. .......... . ............... .......................... ..................................... ................. ................. .. ......... ...... ................... .. ................... .: :::: . . . ... ................ ........... . . ................ ... ................... ..... ........ . .............................................. ................. . ............................. ........................ ... ............................................ .. .................... .. .............. ........ ........................ . ... .............. .......... .. . ................. ................. . .......... .. . . .......... ... � ......................... ............... ........... ......... . .... .. ......... ......................................................................................... ...... .... ................... ................... ...............................................................................CO....................................... ............................................................................................ .................. M... ......... ...................................... M............................................... ................................ U........... ............................................ N.... ............. ...................................................... I......... T................. Y PARTICIPATIO............................................N ..................................................................................................................................................................................... .....• 8.1 DRAFT Contra Costa County MEDI-CAL ADVISORY COMMISSION OVERVIEW The Medi-Cal Advisory Commission (MAC) is a 25 member special committee appointed by the Contra Costa County Board of Supervisors to assure provider, beneficiary, and community input into the planning for and implementation of the County sponsored Medi-Cal managed care system in Contra Costa County. The Board of Supervisors will solicit nominations in April, 1993, and make appointments to the Commission in May, 1993. The Board of Supervisors will assure ethnic, cultural, and geographic diversity in its appointments to the Commission. It will also seek to appoint representatives who are knowledgeable and experienced in meeting the special needs of vulnerable populations, including Medi-Cal and indigents. The Commission will make recommendations directly to the Board of Supervisors, the County Health Services Director, and the Contra Costa Health Plan (CCHP) Advisory Board. MAC will also report, at least annually, to the State Department of Health Services and the County Board of Supervisors on beneficiary, provider, and community issues related to the Medi-Cal managed care system in Contra Costa County. FUNCTIONS The Commission's purview encompasses the County sponsored Medi-Cal managed care system, its Plan members, and providers. Specific areas which the Commission will review, monitor, and make recommendations are: 1 .. Outcome Measures: The Commission will approve a set of community and patient outcome goals, and the specific measures to be used in determining the extent to which these outcomes are being met. 2. Accessibility: The Commission will review access standards and report on the extent to which the County sponsored Medi-Cal managed care system is meeting those standards. 8.2 page two 0 3. Quality: The Commission will review and report on quality of care issues including health status indicators and appropriate outcome studies. 4. Benefits: The Commission will review the scope of benefits and services offered by the County sponsored system and make recommendations for modifications. 5. Beneficiary Satisfaction: The Commission will monitor beneficiary satisfaction, grievances, and complaints. It will conduct annual member satisfaction surveys and make recommendations accordingly. 6. Provider Relationships: The commission will monitor provider satisfaction and will review trends in provider complaints, conduct provider satisfaction studies, and report on survey results. 7. Community Health Related Needs: The Commission will review unmet health related needs in the community and make recommendations to the Public & Environmental Health Advisory Board on community reinvestment fund priorities. MEMBERSHIP The 25 members of MAC shall be appointed by the CCC Board of Supervisors for a two year term and shall include: �3 P�bl c:lBe ;e'fi;.ia; ;R'e'';res'e t t 'es ...................................... 7 Advisory Board Representatives - 1 Substance Abuse Advisory Board representative 1 Maternal & Child Health Advisory Board representative 1 Mental Health Advisory Board representative - 1 Public & Environmental Health Advisory Board representative 3 Contra Costa Health Plan Advisory Board representatives: Current Chair of CCHP Advisory Board Immediate Past Chair of CCHP Advisory Board 1 member elected by the CCHP Advisory Board 3 Community Based Organizations' Representatives 3 Medi-Cal beneficiaries 8.3 page three 3 d`;Prov der Repre5e...t 3 Physicians - nominated by the ACCMA: 1 from West County 1 from East County 1 from any region of the County 3 Community Hospitals' Representatives (Hospitals must include non-County facilities who have historically demonstrated a loyalty and competence in serving the special needs of Medi-Cal beneficiaries.) 1 Community Based Provider Organization Representative- Planned Parenthood 1 Dentist nominated by the Contra Costa Dental Society 1 Pharmacist nominated by the Alameda/Contra Costa Pharmacists' Association 1 other community provider ;Atl a;rge .:............................. 2 at large seats appointed by the CCC Board of Supervisors. COMMUNITY PARTICIPATION To assure that all providers, beneficiaries, and members of the public have the opportunity to participate in the planning for and implementation of the County sponsored Medi-Cal managed care program, the Commission shall: 1 . Have regular open meetings conducted at least quarterly and in accordance with the Ralph M Brown Act (Gov. Code 54950 et seq.) 2. Hold regional hearings to elicit broad community input. 3. Establish such special committees on an ongoing or limited term basis as necessary to conduct its work. In addition to the 25 Commission members any individual or organization may attend and participate on any appropriate special committee that is established. The Commission Chair shall appoint the Chair of any special subcommittee. Examples of the types of special committees the Commission may establish are: committee on issues of the physically disabled; committee on cultural, linguistic, and ethnic accessibility of services; contract provider committee. 8.4 page four Committee meetings shall be regarded as open "workshops" designed to elicit broad public participation. OFFICERS & RULES OF PROCEDURE The initial meeting of MAC will be called to order by the Chair of the Contra Costa Health Plan Advisory Board. The Commission shall subsequently elect a Chairperson and a Vice-Chairperson for terms of one calendar year. The Chairperson and Vice- Chairperson may serve two consecutive terms of one year each. The Commission shall consider and adopt By Laws and other organizational rules. It shall adopt a work plan which includes mission, goals, and principles. In developing its workplan it shall consider and prioritize the following issues: Beneficiary Issues: ♦ Client education, rights, responsibilities ♦ Grievance procedures ♦ Needs of special populations, e.g. foster children, children with special needs, ethnic or cultural groups, mentally disabled, HIV/AIDs, homeless, undocumented ♦ Accessibility issues Provider & System Issues: ♦ Roles of traditional providers ♦ Public/private linkages ♦ Integrated service networks ♦ Management of specialized services in regional and central locations ♦ Health professionals' training, e.g. in serving a culturally diverse population ♦ Episodic care/emergency care/urgent care Community Issues: ♦ Community wide prevention programs 8.5 page five STAFFING The Commission and its special committees will be staffed by Contra Costa Health Plan and County Health Services Department administrative staff. SUNSET CLAUSE The Commission will assist in the planning and implementation of Phases I and II of the Health First Medi-Cal Managed Care Program. At the start of Phase III a Health First governing body will be established in accordance with federal and state laws and regulations. 41 :HFP MSC:BB:smp March 15, 1993 8.6 a U coy 6-4 .ay aoco UO a14 u PLO A ,o •per{ � '�'- � '�" �,::z� � ry � x..�+:- e O u *M M co Cd cd Cd CO � cd to as � � a�i -� U °' OO 8.7 Medi-Cal Advisory Commission Organization Chart Contra Costa County Board of Supervisors Health Services ••• Department •• •` " " " " " ' Director ■ ■ ■ Medi-Cal Advisory ' Commission ' Contra Costa (CMAC) Health Plan Reviews County- (CCHP) Sponsored Advisory Board Medi-Cal Program Reviews All Including CCHP Programs: Staff Model HMO Medi-Cal and EW Medicare Community 51" Basic Adult Care OW Commercial Contract (individual, Providers. small group, large group) 9W MajorRisk Medical Insurance Program 9W AIM 8.8 Health Services Department OFFICE OF THE DIRECTOR +� • 1- �..r�- ; Administrative Offices -_— - 20 Allen Street Martinez,CaMomia 94553-3191 �C Phone: (5101 kyti Fax (510)370-5098 r°sli — HEALTH FIRST ctSuK Mark Finucane, Health Services Director,and other senior staff have discussed the Health First proposal with numerous health-care organizations. Some representative recent and planned future meetings are listed below: Health Care Providers ■ Hospital Council of Central and Northern California -- February 17 ■ East Bay Hospital Board of Dircctors -- February 9 ■ Brookside Board of Directors -- January 28 ■ Los Medanos Community Hospital Board of Directors -- February 8 ■ Kaiser -- January 29 ■ Alameda;Contra Costa Medical Association Executive Committee -- Jan 12 11 Physicians — February ll., 16, and 25 ■ Medi-Cal Providers -- Meetings scheduled for March 9, 17 and 22 ■ Unions -- February 18 Health (are Consumers ■ Medi-Cal recipients — Meeting tentatively scheduled for April ■ Community-based organizations -- March 3 with additional meetings to take place in April Health Care Advisory Boards and Organizations ■ Mental Health Advisory Board -- January 28 ■ HMO Advisory Board -- January 20, February 10, March 10 ■ Public and Environmental Health Advisory Board --January 21 and February 9 with representatives from other health care advisory boards Supervisors,Legislators and State Health Officials--Various meetings over last few months a:mlgsched.Gr" A-34SA fc192j Contra Costa County 8.9 Contra Costa County The Sosrd of Supervisors HEALTH SERVICES DEPARTMENT OFFICE OF THE DIRECTOR sm Powvra. 1st otstrict Berk FlnuCane, Director Nancy C.Panden.2nd District Robert f.Schroder,3rd Dtstricl 20 Allen Street Sunne Wright McPeak.4th Drsrriet Martine=,California 94553-3191 Tom Tortak"n,53h District (SIC)970-500 County Admtnlstrstor _ lsiot 370-5098 Fox Phil Batchelor County Administrator October 27, 1992 Barry WoermaII, Administrator Brookside Hospital 2000 vale Road San Pablo, CA 94806 Dear Mr. Woerman: As a result of the October 4, 1992 article in the Contra Costa Times, I have recmived a number of inquiries regarding the County's plans and progress in assuming responsibility for Medi-Cal. Tberefore, 1 would like to take this opportunity to explain what our intentions are and where we are in this process. First, the article accurately reflected our intentions. Because of the slate's commitment to managed care and the expectation that funding for Medi-Cal next year will be further reduced, I believe it is in the best interest of the county health care system, the private providers and the Medi-Cal redpients to manage this program locally. To date,we have neither wet with the State nor submitted a proposal to them. Our plans are still very much in the formative stage,and of course,before anything is submitted to the State and during the planning process,we will be meeting with all interested hospitals and physicians about our proposed system and soliciting their input. We and the Board of Supervisors would want it no other way. For if this program is to be successful,it must have the support and participation of all the current major Medi-Cal providers. We envision a cDoperative/joint venture arrangement with those who have served the Medi. Cal population over the years. This is an opportunity to develop an organized health system that could serve as a model for all of California By managing the health care of this population,with an emphasis on prevention and primary care and stems,and by simplifying the reimbursement process for hospitals and physicians, more money could be spent on providing quality services to more people. Aternehera rA rowel Hospow A C ncs • Pubc Haatm - Mental 14aanh • Sumiance Abuse • Ernnronmenul Msaarl t.entia Cow Haam Pur. Imerpencr Ymm serrrcas HO+Oe meann/pancr • t3eniY.Cs ce 'ca N I WQt! Qt3H T e= 19- 1 Q3rq Z6—Z —73Q 8.10 Regrettably, we willhave to ame more quickly on this project than we would hike. The State is eag:r to establish managed care initiatives within the next six months. The alternative to participating in these initiatives is standing helplessly by while the State solves its next fiscal crisis by mating deeper inroads into health programs. All of us, public and private systems alike, are vulnerable in these budget struggles. Again, be assured that no plans will be submitted to the State without your input. You will be hearing from me within the nest few weeks about the progress of our plans. Nyou have aay questions or if you have heard some disturbing rumors about our Medi-Cal initiative, please give me a call at 370-5003. Sincerely, Marinucane Health Services Director cc: Supervisor Tom Powers Supervisor Nancy Fanden Supervisor Robert Schroder Supervisor Sunne McPeak Supervisor Tom Toriakson Phil Batcbelor, County Administrator 90 'd NIWQti QSH ZB= bi Q3M L6-L -�3Q 8.11 i DISTRIBUTION_EQR ATTACHED LETTIER Barry Woerman, Administrator Ed Glavin, Administrator Brookside Hospital Kaiser Permanente Hospital 2000 Vale Road 1425 South Main SL San Pablo, CA 94806 Walnut Creek, CA 94596 Ted Schreck, Administrator Cart Gerlach. Administrator Delta Memorial Hospital Los Medanos Community Hospital 3901 Lone Tree Way 2311 Loveridge Road AntioCh, CA 94509 Pittsburg, CA 94565 Thomas Mackey, Acting Administrator Michael Wall, Administrator Doctors' Hospital of Pinole Mt. Diablo Hospital 2151 Appian Way 2540 East Street Pinole, CA 94564 Concord. CA 94520 Lois Patsey, Administrator Tim Moran, Administrator East Bay Hospitaf San Ramon Valley Medical Center 820 - 23rd Street 6001 North Canyon Road Richmond, CA 94804 San Ramon, CA 94583 J. Kendall Anderson, Robert Riegg, Administrator Chief Executive Officer Walnut Creek Hospital John Muir Medical Center 175 Le Case Via 1601 Ygnacio Valley Blvd. Walnut Creek, CA 945% Walnut Creek, CA 94598 Marjorie Wolf. Administrator Kaiser Permanente Hospital 200 Muir Road Martinez, CA 94553 Sheila Manderson, Administrator Kaiser Permanente Hospital , 901 Nevin Avenue RicNnond, CA 94801 10 'd NIWQH as" TO= bT Q3m ZG-Z -03a 8.12 rw 2— mEy m S 9te _ Y m V Y 2 � miiZ e = mt Y cn ■ m ' 0 E a� c C m 3 V 7to,� m ` a� �rr T V j m � V ;�+f m Omem pSw bow xc E.c �9-1 .- -.a- v C. cw �L Y c.0 E- ■9 yi$� cy °V r:L m CY'O t V 9 y 1 J C E. {1Y. Y Y 2 a G a�{V 7 4 O-_'- V a 6 ~a G � �Y M 9 L pO Y.• s`c.ic � q ■ • m ■ a° •� pa ;`��€ = $� Ccmo o Y T ` • C Y • c m a J eco Y7 E cv c'� r 43 � ccL s „ 3 9 C a`c o � _� racEmrYOuy� ` $ E pa=; 1 - I2LIp c_�_•. ° cYcc _ - am 7YU V3aR •ZLv: wp0 °OL r Ea --c y VCy1 ° aU �� ■Lt m ,� ; �-='."L � cO°�Y rp c.4Yyayc o ■ rd. �nca �� r � � Q. ° n r C O m pp Y ■ ■L 9S aat ._ O ■ y X E L d ° ;�. c m = v MVC H V 5~ n~ ■S s --.0 c ` -� m c L o_ gg G ■ J`Y�T ' Y v9v � n°-°YY ELS 3m .6 Ll 2r ■- Oast oc u O.E�B ■ wi mt 3 E m8+ V >:.E E I w T. '9_ Ec °cmmr.JE 9' ocEmc C, O I myL� w C t•`' - m- nV m r C V �V�y Y O 1 •� V; O I > >V Tm >'m �- H C L m y ° m E B' Ngo h ` Q o3=_ c r m � Ec n V . pp pU, m� o c3 C V a m9S rTr y S -Ow 9 m V C 7 m-0 m I vQu E K E �f ^LYY 0 E i V Z � •� �' Q S i H m� c c O Y Y Cs m a�9 H au _ Q �•' > G� 2. ° C - ` E G- u c �E ° c9i C� v CC E �' 5I 3c n > a t u°tp _mo YY � dm YYE ti �� QQ Z., cc R c i ° �� dtE c y �oS Lw Q WS U ' EE- E3c Yos �mm'° ° E � Oc, Oc+° m9 Q � O � "Q E I ! C. Lmvc 0~ E ° m mDsL e y E > E9 �u Q V ►1C �_ c ° EL_2 I to t. c oC m y V °- V"m •j >� 4.�- 6 C L C S. = ac, � � yQym ��vEc °- � �•+► Q •� '•"' ,•Q C. EL $i: o C0.2 L 3 �bt.v u u V 3 Q nr'� o ccO- OSm �` Or � ZI y Q 3 c �+ epvcuQ .v'r C. m E�L mL $c o, Q y 8 c 6cLac biX V � ZS V O OV toa SEru } � m me V pyp SyY V u C �.J �6, m O Q j m O y y • C {■i Y L r E y C ^ C-.0 d CC Y a in : ' ` T ="Cgt .O x y _�.�m V }�`- $ : 9`Y NEE Ev amVO' Y.1c, 5-0 .. oS� ■ Y=-s ■ Eos Y :Y. E. `YE�;� yo cSCimmEm Yu c mfc =af p^p aOc 3�nm +�+ U Zoo'm L EU r e ° a C. Y._c yAy So c V ■ c m lpy. c� m '- E '-- ��� H] Q;�m m ` E g C V O K C V y ■-. > m V 4 2 y m a :C crE� a` eE iEE$ �p aoEYYy `m ■ �.� Ec- Flr -` e c Y E r9�___ c Tr �• 5 N`� V V C .' Y C am,m ■ y V e O 00,OY V y■j' V C_ = C r i. • 41 m c L C Y T� E y' C- Y- C F O C y C ■ ■ n■C V O omE� ° r'p r rnEE �• 9 rY m� ULY c_ 3'r ■ Ute' e_ U-0 V Y L t aE 4cO:J 3 a my : Zz L au Er m ar oc E n� A �5qNyn oG ■ C C •' yyp T my-+L C U m O V Y a>,Fi C G 9 L C CCCa ii O t Y n m E_ �u.�6�,9 c C ■m •� < c8 3 .E e�0Eo � c pie -0 cm ■ ■ 0.03 $$ k C i.E c o- E eo N Z O F ° bc �L ° P- Y g C E m s Y Y 6 c. 8.13 Contra Costa County The Board of Supervisors HEALTH SERVICES DEPARTMENT OFFICE OF THE DIRECTOR Tom Powers, 1st District Nancy C. Fanden, 2nd District Mark Finucane, Director Robert 1. Schroder, 3rd District Sunne Wright McPeak, 4th District ` 20 Allen Street Tom Torlakson, 5th District Martinez, California 94553-3191 40 j (510)370-5003 County Administrator (510) 370-5098 Fax Phil Batchelor County Administrator November 24, 1992 Barry Woerman, President Chief Executive Officer Brookside Hospital 2000 Vale Road San Pablo, CA 94806 Dear Mr. Woerman: There are two issues of importance that require collaboration of the Health Services Department and Brookside Hospital. First, in my October 27th letter to you I promised to keep your apprised of our progress in the Managed Care Initiative. Accordingly, I would like to be placed on the agenda of your next Board of Directors meeting. I will describe our plans and present thinking and answer any questions that your Board members or you and your staff may have about the impact of managed care on your hospital. It is important to the Board of Supervisors and to the Health Services Department that we keep communications open during this planning process, both to keep you informed and to solicit your input. I want to stress that we are in a planning process. We have not yet made any formal proposal to the state or federal agencies. We understand that any proposal must include the input of those who historically have shown an interest in and competence in serving the Medi-Cal population. I believe that all of us can benefit from a Medi-Cal managed care system. It is clearly the direction in which both the state and federal governments are moving, and with the specter of another state deficit, we can safely assume that Medi-Cal funding will fare better under managed care than fee-for-service. Merrithew Memorw Hospital 6 Clinics Public Health menial Health Substance Abuse Environmenta'Health • Contra Costa Health Pian Emergency Meo.cal Services • Home Health Agency • Ger atr,cs 8.14 -2- The second issue of importance is to open a dialogue with your Board members and the County Board of Supervisors about the possible projects that could be funded under the Series B bonds. You will recall that in March 1992 when the Board approved replacement of Merrithew Memorial Hospital and the bonds to finance it, they also approved issuance of additional bonds in the amount of $20 million to fund capital projects related to joint ventures with other hospitals. I believe that it is time for the Board of Supervisors,members of your Board, and staff from Brookside and the Health Services Department to continue the discussions on the use of these special bond funds. Please call Lorna Bastian of my staff at 370-5055 to arrange a mutually convenient time to discuss the Series B bonds. My office will call you to schedule my attendance at your Board meeting. Sincerely, Mark Finucane, Direc or Health Services Department cc: Board of Supervisors Phil Batchelor Carl Gerlach 8.15 Contra Costa County The Board of Supervisors HEALTH SERVICES DEPARTMENT OFFICE OF THE DIRECTOR Tom Powers, 1st District Mark Finucane, Director Nancy C. Fanden, 2nd District Robert I. Schroder, 3rd District Sunne Wright MCPesk,4th Districtr� ;. 20 Allen Street Tom Torlakson, 5th District Martinez, California 94553-3191 (510) 370-5003 : � County Administrator �"�--� (510) 370.5098 Fax Phil Batchelor County Administrator November 24, 1992 Carl Gerlach Chief Executive Officer Los Medanos Hospital 2311 Loveridge Road Pittsburg, CA 94565 Dear Mr. Gerlach: There are two issues of importance that require collaboration of the Health Services Department and Los Medanos Hospital. First, in my October 27th letter to you I promised to keep your apprised of our progress in the Managed Care Initiative. Accordingly, I would like to be placed on the agenda of your next Board of Directors meeting. I will describe our plans and present thinking and answer any questions that your Board members or you and your staff may have about the impact of managed care on your hospital. It is important to the Board of Supervisors and to the Health Services Department that we keep communications open during this planning process, both to keep you informed and to solicit your input. I want to stress that we are in a planning process. We have not yet made any formal proposal to the state or federal agencies. We understand that any proposal must include the input of those who historically have shown an interest in and competence in serving the Medi-Cal population. I believe that all of us can benefit from a Medi-Cal managed care system. It is clearly the _ direction in which both the state and federal governments are moving, and with the specter of another state deficit, we can safely assume that Medi-Cal funding will fare better under managed care than fee-for-service. Merrithew Memorial Hospital d Cynics • Public Heal!h - Mental Healtr: Substance Abuse - Environmental Heaiin Contra Costa Health Plan Emergency Medical Services Home Health Agency Geriatr!cs 8.16 -2- The second issue of importance is to open a dialogue with your Board members and the County Board of Supervisors about the possible projects that could be funded under the Series B bonds. You will recall that in March 1992 when the Board approved replacement of Merrithew Memorial Hospital and the bonds to finance it, they also approved issuance of additional bonds in the amount of $20 million to fund capital.projects related to joint ventures with other hospitals. I believe that it is time for the Board of Supervisors,members of your Board, and staff from Los Medanos and the Health Services Department to continue the discussions on the use of these special bond funds. Please call Lorna Bastian of my staff at 370-5055 to arrange a mutually convenient time to discuss the Series B bonds. My office will call you to schedule my attendance at your Board meeting. Sincerely, Ma k Finucane, it ctor Health Services De artment cc: Board of Supervisors Phil Batchelor Barry Woerman DISTRIBUTED TO ALL CONTRA COSTA COUNTY PHYSICIANS 8.17 Contra Costa County The Board of Supervisors OFFICE OF THE DIRECTOR HEALTH SERVICES DEPARTMENT Tom Powers, 1st District Mark Finueane, Director Nancy C. Fanden, 2nd District Robert I. Schroder, 3rd District 20 Allen Street 5unne Wright McPeak,4th District : '% Martinez, California Street Tom Torlskson, 5th District (510) 370 5003 County Administrator (510) 370-5098 Fax .4 Phil Batchelor T County Administrator r Novembcz 30, 1992 Z Alexander Aarons, M.D. 1260 Laverock Lane Alamo, CA 94507 Dear Dr. Aarons: Over the past few years we all have discussed the rapidly ewilating cost of health care and the various proposals for reducing the cost while ensuring basic coverage to everyone. Not swrprisingly, both the federal and state goversTrents are looldng for ways to control the OW of the Medicaid and Medicare programs. As part of that effort, the state is targeting a certain number of Medi-Cal eligibles to be in managed care systems in the coming fiscal year. Accordingly, they are encouraging counties, HMO's, and other current Medi-Cal providers to develop managed care systems or to expand existing ones. The Contra Costa County Health Services Department has had 20 years of experience in managed care through its Contra Costa Health Plan. Tire Placa now has 23,000 members including Medi-Cal eligibles, the indigent, ernployees of srnall businesses, the elderly, and county employees. This is;a dramatic increase from its early slow scat. I believe that with our experience and existing system, aye are well positioned to respond to the state's request. We ane beginning to develop our proposal. We wfil propose that most or all of the Medi-CW efigibies in the county be in the Contra Costa Health Plan or in HMO's or IPA's that are under contract to the county. However, I want to assure you and your colleagues that if you are intcrested, you will be involved in the planning process for the county's managed care system. Of the several hundred physicians in the county who currently we Medi-Cant patients, probably 70% of the voltune is done by 12-14 of you. I assume it is those few who will want to be involved, but I encourage anyone who has an interest to participate. It would be helpful if we had the luxury of several months or a year to plan our managed care proposal. We will, in fact, have less than a month to indicate our interest to the state and only a few months more to submit a plan. Of course, the timing will depend to some extent upon the federal government's willingness to grant certain waivers and the Weed with which they do so. Me:ranew Memonal Hospital 8 Clinics Public Health • Mental Health • Substance Abuse • Environmental Health Contra Costa Health Plan Emergency Medical Services • Home Health Agency • Geriatrics Z© d mi watt asH -6Q _ £ ii aam Z6-z -o3Q 8.18 Considering the grim projections for the state budget next year, I believe that bealth care will be severely cut,and that we,as health care providers, and the patients we serve will be better off in a managed care system. I encourage you to be involved in this process for change. During the month of January I will bold several meetings for Medi-Cal providers to discuss Ow ylw b awd Nuiyesa. IrYuu arc intcrcwA in attonding,plwm contact Lorna Ba6dw at (510) 370-5055 or send a short note to her at 20 Allen Street, Martinez, CA 94553. Sincerely, Mark Finucane Health Services Director MF:LB.nan W. Supervisor Tom Powers Supervisor Nancy Fanden Supervisor Robert Schroder Supervisor Sunne McPeak Supervisor Tom Torlakson Phil Batchelor, County Administrator Alameda-Contra Costa Medical Association £0 -�I FUI WQti QSH 00- b t Cram ZG-Z -C)3Q � � a �� � � • � � � " • • • .. ... . .................... ....... . .. . ........... . ............. ........ . .......... ........................ ......................... .................... ............ ..................... . . ... ....... .... .......... ................. ...................... ........ ............. ... ............................... . ................... ..................... ...................... . .. ......... ............. . .... ............. . .. .............. ...................... . .................. ............... ............. .................. .. ............. ........ ... ........................... .... ........ ........ ...... ........... ............................................... ................. ................. .................... ... ........................ ......... ................ ....... ..................... . ..... .... . ............ ...................... ...................... ... .. ..................... ....... ....... . . ..... :. .. :........................ ..... .................. ................ .................................. ............... .................. . ... ....... ................ � ................ ................ . .. ... ................ M................EDI-..CAL .... ....................... ..................... ... .. ...... ...... .... ....................................................................................................... ......................................................................... ...................................... ... E........................ ............. ...........L..... I ...................................... ........... ........ . ........ .... ............... ........... ........................ ..... ............... .. ............................ ... ........................ . .... ........ . . ................................ .... ................ . .. .. ............. ...........................................................G.......... ..................... .. .....I........ B....................... .............. ......................L............ ......................E.......................................................................S ............................................................................................................................................................................................. ......................................................................................................................................................................................................................................................................... ................................................................ ............................................. .... ... . . .. .. ................. ................... ............................. . .......................................................................................................................... ...................."...:................ .............................................................. . .......... .. . ............... . .. . ........... ................... .............. .......... ........................ ......................... ........... . ............. .......... ..................... . .............. ... ...... .. ........ ..... ... ......................................... ....................................................................................................................... ..................... ............ . ........ . ........................................................................... .............................................................................................................. . ............ . ..... .......................... ............ ................................. .................... . .................... ................................. .. .. ...................... ....... . ................ ............. ........... ............................. ....... ..................... .. ...... ............ .. ......... ........ ..................... ........................ ........... .......................... . .......... .. ........... .......................................... ... . ... .......... ................................................................... ... . . .................................. . ...................................................... . .................................. .. . ....... ................... .. • 9.1 Publicly Financed Health Care Programs Medi-Cal Health care program for low income individuals who also meet certain federal categories for public assistance. Medi-Cal Eli ig bles Major categories of low-income individuals who are eligible to receive Medi-Cal are: AFDC: Aid to Families with Dependent Children - ✓L,ow income children and adults in families with only one parent or with an unemployed parent MIC: Medically Indigent Children - ✓Uw income children in all types of families (e.g. one or two parents who are employed or unemployed) AB/ATD:Aid to the Blind, Aid to the Totally Disabled - VI ow income individuals under age 65 who are blind or disabled OAS: Old Age Security - ✓Low income individuals who are age 65 or older Note: Indigents are those low income adults.who do not fit into any of the Medi-Cal categories and who have no other medical insurance. The indigents are the responsibility of the county and rely on the county services for their health care. Fee-for-Service Medi-Cal Medi-Cal beneficiary receives Medi-Cal card which is used to obtain services from a provider willing to accept Medi- Cal payments. It is up to the eligible to find a provider willing to take care of Medi-Cal patients. The provider bills Medi-Cal for the services given and is paid at the Medi-Cal level. ./Example: A Medi-Cal beneficiary goes to a hospital emergency room which then bills Medi-Cal for the care. 9.2 Prepaid Medi-Cal Medi-Cal beneficiary is enrolled in a managed care plan. Plan assures that beneficiary will have access to all needed services. The plan is paid a capitation, which is a set payment each month for each beneficiary it enrolls. The plan is responsible to provide or arrange for all the care the enrollee needs. /Example: Contra Costa Health Plan Medicare Federal health care program for individuals who receive Social Security payments. There is no "means" test for Medicare, which is a health insurance program unrelated to the individual's income level. Individuals who have paid into the Social Security system are entitled to receive Medicare benefits when they reach age 65 or are disabled. L26:PF .. 11 9.3 cc swa � ; � � � • w ww N y 8 U °-3 LU U. O Ir N `7 m N N a ooN ^� N N � M1 u ca cqs ,,, �o y N �•, a < .9 u°� o z 9 Cd y Hi CA U CG (i7 U U U a U U a a OD IL 71 to is M Ld a > W _ StFmQ Q �p Fpo po °dee PE QQ > o to a LO s s 8 0 •2.3 � ::Y;:•� 5 � H y w � � y as u � w =° � pQ ^o � 8 < < w "` 9 �, M 9 1�fr���O�fr�f►�fr�l �fr♦fr♦fr•�•�♦fr♦�♦fr♦�• � e � ♦f►fr���frfrfr�♦ ►���fr�����i�i�fr�f+�fr���fr ►1fr1f �fr��� • ►�����fr�f a• ��fr�fr��� ►�frfaf �frf+�� ►���fr�fr�f a ������f+� w ►�f+���f+�f ��fr�fr�fr� • 1 ������N�tr�f+�fr�f►�f+�fr�f • ���fr���fr�����f►�fr�f e ° g,5 LnN o �g CD i , I 1Y 8 0 two $ d � a a � • �5 z • 9.6 Medi-Cal Eligibles by City of Residence September, 1991 i FAMILIES OTHER MEDI-CAL SSI TOTAL AND CHILDREN Ea. st'County 1 :Antoc6,496 610 1,410 8,516 :2 Bethel Island;; 346 64 161 571 Discovery Bay&. . Kn gfit'sen ... 3 Brentwood : 982 361 335 1,678 .k.-Owe 1,076 164 351 1,591 5: Pittsburg;':; 8,410 1,341 2,542 12,293 TOTALS: . 17,310,3 0 2,540 4,799 24,649 West County` ... ..... .. 1 Crockett 216 13 67 296 ...... El:Cerritos 504 121 595 1,220 Kensington ...... 3 Ei>Sobrante; ;; 1,083 136 445 1,664 4 Hercules 410 109 391 910 ;5: Richmond 14,567 1,250 4,562 20,379 fi Rodeo::::: 942 58 302 1,302 7 SariPablo 7,064 1,476 2,246 10,786 TOTALS `;'; '' ;' .. 24,786 3,163 8 608 36 557 ... .... . .......................... .. > . ........... Central County; •. 1 Alamo Danville; 436 165 467 1,068 . anRamon .... 2 Clayton`;;Concord ;; 6,437 1,334 2,317 10,088 3 .Ahyette Mora 242 87 438 767 Orinda . . .. ............................. 4 Martinez 1,968 438 1,052 3,458 5.`.Pleasant:Hill 505 298 484 1,287 ;. .. .:; 6 Walnut:JCreek .. i; ;:... 209 165 339 713 . . . . .. ........ ............ ... .. . .. ... ............................. .... .. .... .................................. ..... . ... ................. TOTALS 9,797 2,487 5,097 17,381 ,38 TOTAL:COUNTY '; 51,893 8,190 18,504 78,587 .. . .. ..... L26ACE s 0 6 j 2 � ......... v ` Z z o ..... L) N ........ Q � Q �N e e I�AM������ e 1 ►�������������������� e e 9.9 ........................................................................................................................................................................................... ............................................................................................................................................................................................. ............................................................................................................................................................................................... ................................................................................................................................................................................................. ................................................................................................................................................................................................. ................................................................................................................................................................................................. ................................................................................................................................................................................................. ................................................................................................................................................................................................. ................................................................................................................................................................................................. ................................................................................................................................................................................................. ................................................................................................................................................................................................. ................................................................................................................................................................................................. ................................................................................................................................................................................................. ................................................................................................................................................................................................. ................................................................................................................................................................................................. ................................................................................................................................................................................................. ................................................................................................................................................................................................. ................................................................................................................................................................................................. ................................................................................................................................................................................................. ................................................................................................................................................................................................. ................................................................................................................................................................................................. ................................................................................................................................................................................................. ................................................................................................................................................................................................. ................................................................................................................................................................................................. ................................................................................................................................................................................................. ................................................................................................................................................................................................. ................................................................................................................................................................................................. ................................................................................................................................................................................................. ................................................................................................................................................................................................. ................................................................................................................................................................................................. ................................................................................................................................................................................................. ................................................................................................................................................................................................. ................................................................................................................................................................................................. ................................................................................................................................................................................................. ................................................................................................................................................................................................. ................................................................................................................................................................................................. ................................................................................................................................................................................................. ................................................................................................................................................................................................. ................................................................................................................................................................................................. ................................................................................................................................................................................................. ................................................................................................................................................................................................. ................................................................................................................................................................................................. ................................................................................................................................................................................................. ................................................................................................................................................................................................ ................................................................................................................................................................................................. ................................................................................................................................................................................................. ................................................................................................................................................................................................. ................................................................................................................................................................................................. ................................................................................................................................................................................................. ................................................................................................................................................................................................. ................................................................................................................................................................................................. ................................................................................................................................................................................................. ................................................................................................................................................................................................. ................................................................................................................................................................................................. ................................................................................................................................................................................................. ................................................................................................................................................................................................. ................................................................................................................................................................................................. ................................................................................................................................................................................................. .... ::::::::::::::::::..............:::::::::...... ......::::::::::::............................ ::::::::::::::::::::::::::::::::::::::::: o::::::::::::::::: ::::::::::::::::::::::::::::c► ......................... ::::::::::::::.:::::::o' € ::.:.:.:.:.:.:.:.:.:. i€€ ............ :::.... ::::::::::......_...... ........................... ::::::......... ::.:........... Cf) ............................. N ... .............. :::::; -: : ::::::::::::::::::::::::::::::::::::.. .. ...::::::..:....:...:........ O .::..:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.: .QO .................................... ...... — ..... ............ . :: — 'cn ::�:: : : :::::::::::::::::. — cn ................. U 0 .............. :::::::.....m:::::: = cis ::... .. ::::::::::::::::::::::::::::::::: :::::::: ............ . ::: . :::: .::::::::::::: :::::::::::::::::: .:::::::..:::::...::::::::::::::: :::: : :::::::::: ..................:::::::: ..............................::::: ::.::::::o:::::::::::::::::::::::::::::::::::::::::::::::::: ::::::::::::::::::::::::::::::::......... :::::::::::::::::::::::::::::::::::::::::::: ........ ..... ................................................................................. :::::::c:.::::::::::::::::. ::::::::::::::::::::::::::::::::... :::::::::::::::::::::::::::::::::::::::�' ::::::::::::::::::::::::::::::::::::::::::::::::::::::::::... ::::::: :::::::::::.:::::: :::::::::::::::::::::::::::::::: ::::::::::::::::::::::::::::::::::::::3:::::: :::::::::::::::::::::::::::::::::::::::::: :::::::::::::: : :::::::::::::::c:::::::::::::::::::::::::::::::::::.. ::::::::::::::::::::::::.:::::::::::::: ::::::::::::::::::::::::::::::::::::::::::::::::::::::::::' ............: ::::::::::::::: ::::::::::::::::::::::::::::::: ::::::::::::::::::::::::::::::::::::::a::::: ::::::::::::::::::::::::::::..................::::::.....fl?:::::::::::::::::::::::::::::::::::::....::::::::::::::::::::::::::::::: ::::::::::::::::::::::::::::::::::::: ..... ..... ............k::::::::::::..... ::::: :::::::.:::::::::::::::::::::.. :::'::::::::::::::::::::::::::::::::::Fi J::'::: :::::::::.....::::::�::::::::::�::: :::::::::•::::::::::::: ................. :::::: :::::::.......::::::::::::::':: ..:::::::::::::::::::::::::::::::::::::::::::::::: .......... ::::::::::.'.::::::::::::::::: ....::::::::::::::::::....:::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::T...:::::::::::::: ::::::::::::::::::::::::::::::::::::::::::::::::::::::::: :::::::::::::: ....:::::::::::::::::::k::::::::::::::::::::::::::::::::: :.... ::::::::::::::::::::::::::::::::::::.....:::::::::::::::::::::::::::::::::::::::::::::::::: :::::::: .................. ::::....... :::: :::'::::::::�::::::::::::::::': .:::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: .: ........ :::::::::::::::::::':::::::::::::...........:::::::'::':::::: .. .. :::::::::::::::::::::::::::::::...: N Gf.............. w J `+.10 Contra Costa County Medi-Cal Eligibles Ethnicity October, 1990 Number White 31,476 41% Black 23,847 31% Hispanic 8,726 12% Asian/Pacific Islander 5,654 7% American Indian/ 182 <1% Alaskan Native Not Reported f4203 Source:State Department of Health Services' California Medical AssistanceProgram Annual Statistical Report,1990 9.11 � U J C �H p J O Z ° 00 o� Z Z U O v9 m O } Z c CD ^ m .i1 U cz CL U W Q m O U C� CD CD mE 5 U N >1 L m �-- L o 0 n' 0 C L o :::. t QD C/) c CD E m a � O t mm O ca VJ U v • T � t 0) co m T Q V �C Cw, -WW W Q C N U J 9.12 J C m N O Uj s C N N X T N N U 4-0 �? CD m Q O o o c W 4" LL z m a 2 U.0- O Cb Q� O 0,0 o Cl) O U � Q . MCV N N }' v Q Lf O O OL WEU oy U co 4Cc ., m O coE j Q .� *i a 0 -0 U N a) ° +� "� Z� c cc o 0 L zz I moi--+ •� O Cl) V O .Q^ O No-jm L / }� U) (D40 Z m N e> C N " L t m N Q w o a m � m CL a) T j U 0) ° QT Q 0 a � (n U J 9.13 ...................................................................................................................................................................................................................................................... .......................................................................................................................................................................................................................................................... ............................................................................................................................................................................................................................................................ ............................................................................................................................................................................................................................................................ .............................................................................................................................................................................................................................................................. .............................................................................................................................................................................................................................................................. .............................................................................................................................................................................................................................................................. .............................................................................................................................................................................................................................................................. .............................................................................................................................................................................................................................................................. .............................................................................................................................................................................................................................................................. .............................................................................................................................................................................................................................................................. .............................................................................................................................................................................................................................................................. .............................................................................................................................................................................................................................................................. .............................................................................................................................................................................................................................................................. .............................................................................................................................................................................................................................................................. .............................................................................................................................................................................................................................................................. .............................................................................................................................................................................................................................................................. .............................................................................................................................................................................................................................................................. .............................................................................................................................................................................................................................................................. .............................................................................................................................................................................................................................................................. .............................................................................................................................................................................................................................................................. .............................................................................................................................................................................................................................................................. .............................................................................................................................................................................................................................................................. 's€€II :::::::::::::.................................... ................................................................................................................................................................. . I€€? cis ........o 4 ........... C U ...... . RS c ' C0 O .............. Q :............................. . ..................................................................................................... .................. .....:........................................................................................................................................................................................................................................................ .............................................................................................................................................................................................................................................................. .............................................................................................................................................................................................................................................................. .............................................................................................................................................................................................................................................................. .............................................................................................................................................................................................................................................................. .............................................................................................................................................................................................................................................................. .............................................................................................................................................................................................................................................................. .............................................................................................................................................................................................................................................................. .............................................................................................................................................................................................................................................................. :::::::::::::::::::::::::::::::::::::... ... .... . . ..Q. .........................................p........................ .............................................................................................................................................................................................................................................................. 0 9.14 ....................... ....................................................................................................::::::.............................................................................................................................. ................................................................... ............ ui ....... cz .......� ............................. ............................. U co :: :::::::::: ::,�:: cz U cV :: :::::::: : : .............::: ......... ................. .......... ............. LU `. ............................. ............................. ...... CE m .......................................................... .. :...:............:::... ;.....:... ...... • ::::::::::::::::::::::::::::::::::: ...... ::::::::::::::::::::::::2sa:tua:3 � .:::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: .:::::: :::::::::::• :::::::•::.::::::::::•:::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: :::::::::......:�...................d:::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::gin:::::: o U J 9.15 � c a� 6 vy 1110,rr 0o rri rn '^ o � o � OON M r U 00 N p F A a C� 000 W ci ON cz all CN 00 00 N ON d W o ON "rte Q 0 ON Et 00 00 rn � o w a V > 000 A 0• c- o s a ON M 00 0 N Sia W ) �IJIS Q O rri a, Ua U � • ............ . .......... ...... M ..... . ........ . .......... .. .... ... ......E ......... ................... DI-........ .CAL � . .............. ...... .......................... .... . ......................... .......... ........... ............... .................... .......... .. PROVI ........... . .D.. .E.............. ......................... ... ... ....... ............... ................ ................................ ..RS • 10.1 C O cc U � N m O j, N Co 0 am U o L Ca' c � .0 M N �.ao'o U a i Nm C °�� od . > m = r u 65 O m p c 2 V N U. m E U L T cc V C r > 0) L T W L. U � v v }_ m CO m U � OCD Il •- m C CO c m ciS •` > :::: m r Lf) n m m m Co CD Ca m C Ca to 'O CD v c a 8 a� az L- o. m Co CL U) O d 0 Y o Eo d 0 Ci L LUL 2 0 U t LL C m : LL W C Q T3 o U a 2 LLI � a � U J 10.2 � _0 O U a � N o � � a O E U 'D _N co c O RS as Fd O � c U U- O m co LL = c o c ,c C a. m Cdm^ . N •c O - -- "� E m w 'o Z to 0 LL OL 0 •� 0 a U t/Q LL Q c r (L T T�T r s VJ O Q 0N T ci C 69. m U ` CD O m T O � •U OO m CD C � C NCO m E c o U U . E l L to :::::: V m d U a o CD ccc a a m cy 4 •� = C w E 0) _ 7 0 to = 0 0 ° N (� E O = c E (3 = E E m 0 •� O Q� a LL U Q CD � � V � Li _ LL w '0 CD 3 a c 'a CD m � � o � U J 10.3 • Contra Costa County Top Five Medi-Cal Providers Rank Order Medi-Cal Payments Fiscal Year 1991/92 . Hospi Groups Inpatient Outpatient 1.Merrithew Memorial 1.Merrithew Memorial 1.Merrithew Memorial Hospital Hospital and Clinics Hospital and Clinics 2.Brookside 2.Brookside 2.Antioch Medical Park 3.East Bay Hospital 3.Mt. Diablo 3.Comprehensive Psych 4.Los Medanos Hospital 4.Los Medanos 4.Richmond Pediatric 5.Mt. Diablo Hospital 5.Delta Memorial 5.Medicus Medical Merrithew Memorial Hospital and Clinics was the largest hospital inpatient, hospital outpatient, and physician group Medi-Cal provider in Contra Costa County. Source: State Department of Health Services Medi-Cal Activity Reports by Provider 1991/92 L27:TF 10.4 c c 0 ° E �n O T -- C- o E f _ rn o n o r 0 N to m 'i. b. CA 0 tG N 'E CD 0 L- N �.► ® �l . c � � N N O 2 co ItsJ tU Q >.. a C c O $ ccCo CIO UcC/' coo == Q v 0-01 . CZi(o 00 CM o � OR N _ N 'ELO t � 0 0 _ Z !d_ .Y N 'C U p o O O _r .• c 0 .� o C13 CDUa � -0a a CA co O o J 10.5 0-0- co C\l 0) 0-01 V- 0) C#) 0) V- 0, 0 cf) OD cr) _0 0 0 0 •> 00 6 0 c 4-0 0,0'm E co CD 4-j cu ....... CTJ 0 CL 0 ns CL CU o4-4 .......... ..... C 0 0 , *,*" ,,,,,,,",,,,,, a) coo ............. tom ......................... E O ......... . .. 0 cu , ..................... ... T- 0 ............................. 0 ... ....... C ......................... O RS ............................ E ................. 0 ........................ CL . ...................... V) ........................ V) ....................... —SC U) C 0 0 .............. ... .............. m -2:cd CL c ............ as CA N0 Cf) E cu o •E (D 0) 0 CD 10.6 oil OR 0 N 0 � o o N O to O O O CD �> .� p o . 0-01cuo w .. �. O cu4 : : ::.. Cl) m +� O � 01 CL Ocu ap1-0 i ::::::::::: 0- m O C3 U Q .� Np N Oo N Z .. N = p .` U C O c Z3 O 'C ., O .CO D O V 0 s o � m o w O O N U J 10.7 Major Medi-Cal Community Physician Providers Group and Solo Practices Number o ;Pro .. .. ... .. ...... . . : D.s or Grou s 1?a ment Levels ;; »: < ;: o . .. .... . .... ...... {M P ) Y Yts: :; 2 $400,000 to $999,999 $ 1,063,456 3 $300,000 to $399,999 $ 1,039,916 3 $200,000 to $299,999 $ 778,924 7 $100,000 to $199,999 $ 1.085.745 Total 15 $ 3,968,041 All Other Providers Up to $100.000 $ 6.118.304 Total Community M.D.s $10,086,345 Fifteen non-Health Services Department group and solo M.D. practices account for 39% of Medi-Cal payments to community physicians U7:MW 10.8 MEDT-CAL FFS PAYMENTS TO PHYSICIAN SOLO AND GROUP PRACTICES BY SPECIALTY TYPE - FY 1991 - 1992 # 'OF":SOLO O GROUP PAYMENTS PA'YMENT'} S;90 TYPE OF.PRACTICE PRACTICES 4:MOUNTS P TOTAL. OB/GYN 38 $1,894,475 21% General Practice 69 1,611,888 18% Pediatrics 40 1,027,749 11% Family Practice 48 705,138 8%. Surgery 96 486,105 5% internal Medicine 82 453,857 5% Radiology 21 418,626 5% Allergy/Dermatology 25 410,807 5% Emergency Medicine 5 335,583 4% Psychiatry 57 274,131 3% Anesthesiology 38 260,418 3% Ophthalmology 34 234,409 3% Mixed Specialty Clinic 10 219,913 2% Cardiology 24 204,983 2% Gastroenterology 15 94,998 1 % Other 89 $ 545.647 60/6 TOTAL SOLO AND GROUP PRACTICES: 691 $9,178,727 Payments to OB/GYN, general practice, pediatrics and family practice physicians accounted for $5,239,250 or 57% of Medi-Cal payments to all solo and group MD practices in Contra Costa County for FY 1991-2. Note: Payments for eligibles with a SOC or in'long term care are excluded. Source: SDOHS Special Report - "Payment to Provider Types by County" BB:smG 41:MCP Mach 10, 1993 10.9 Medi-Cal Fee-for-Service Payments to All Out of County Providers for Contra Costa County Eligibles (No SOC) Fiscal Year 1991/92 .:: ;:: : ; . Pa enf Coun .Medi Cai ym s . . . . .. . ... . os Eli 1 for Contra Co a g es Alameda $1998269420 . San Francisco 393609436 Santa Clara 190879588 Solano 1 ,075,811 Sacramento 5409359 San Joaquin 5389513 San Mateo 4969911 Marin 2009406 Napa 107,048 Nearby Counties $24209,097 . : $ 805 6S0 aliforma Coun Ohey `:: : Out-of-Stat : : '': .. .. e $ 84,b21 - . ...:.... ...:. ...: .T ota I Pa: meats to Out-of- Y $30,399,368 Count Providers .. Y In 1991/92, 31 % of the fee-for-service payments for Contra Costa County Medi-Cal eligibles (non SOC and non-LTC) went to providers outside the County. Source: State Department of Health Services Special Report "Payment to Provider Types by County" �:� 10.10 Medi-Cal FFS Payments to Out-of-County Hospital Providers for Contra Costa County Eligibles (No SOC) Fiscal Year 1991/92 Hospital Inpatient and Outpatient Payments mm ; n un Cou Co .... . . . . . .: ... .. ...... ...... . ..; t3' .. .: >; :To tal nt Hos i Ho itals Cou tal sP Alameda $11,824,476 $ 285,416 $12,109,892 San Francisco 1,617,415 203,824 1,821,239 Santa Clara 412,307 194,512 606,819 Solano 440,487 - 440,487 Sacramento 231,049 - 231,049 Marin 118,481 - 118,481 San Joaquin 71,226 19,524 90,750 San Mateo 52,495 11,780 64,275 Napa 38.066 - 38.066 Nearby Counties $14,806,002 $ 715056 >;' ;: $15,521,058 Los Angeles Count $ 89,007: $ :94,803 $ 183,814: County:.... . ... . .. .. ............. .... :.. Other California Counties $;; `554,691 . .. f. to Ho Out-o S to Hospitals::..... 215.939 :; :; ....... . ....... ..: :$16,475,498$i6 475 498, .Total Hospital Payments In 1991/92, almost $16.5 million in Medi-Cal payments went to hospitals outside of Contra Costa County. Payments to Alameda County hospitals accounted for $12.1 million or 74% of payments to out-of-county hospitals. Source: State Department of Health Services Special Report "Payment to Provider Types by County" Lr:MFx 10.11 Location of Inpatient Services Hospital Days Used by Contra Costa Medi-Cal Inpatients Fiscal Year 1990/91 :...:..::..:. Ho ital on Number of Das Percents e o Da s sP y.; ; g y . ... . . . . . . . b :Contra Costa County. <:;;. ... Contra Costa County 26,713 61% Oakland 8,735 20% Berkeley 3,294 8% San Francisco 2,632 6% Other _2,4_Q9 1 67v TOTAL 43,865 Thirty-nine percent of the hospital days used by Contra Costa County Medi-Cal inpatients are in out of county hospitals. Source: California Medical Assistance Commission "Origin and Destination Report" L-17:LM • . . ........ . ...... ......... :XXXX.... . . ............ ...... .... .. .. . ... .. .... ........................ .......... ......... .............. ............ ...................... ............ ..... ......... .......... .......... .. ...... ... . ............. ........ ............... .. .. . ... .. ..... ......... ................ . :::�xxxx� C................................................... ............. ........................... ............................O.............. ................................... .................R...... R............................. E....... S.....:.... ... ............................. ......... ............................:.P......................................... ........................................ O...... ........................................................-.........N................. ........................................ .. ............ ..D....... E.......................................... ......... N............: ................... ..................... .......................... CE • AND ............................­..... ....... .......................................................................................... ..... ....... ...... .. ........ .. ............................................. ....................................... ....................... ....... .................. .................................. ............................................ ..... ............ ............................... .. .. ...... ............................. ........................................ BACKGROUND ................................................................. 11.1 Contra Costa County The Board of Supervisors HEALTH SERVICES DEPARTMENT OFFICE OF THE DIRECTOR Tom Powers, 1st District Mark Finucane, Director Nancy C. Fanden, 2nd District Robert 1. Schroder, 3rd District 20 Allen Street Sunne Wright McPeak, 4th District Martinez, California 94553-3191 Tom Torlskson, 5th District f.= / (510) 370-5003 County Administrator (510) 370.5098 Fax Phil Batchelor County Administrator . March 5, 1993 Molly Coye, M.D., M.P.H. Health Services Director State Department of Health Services 714 P Street, Room 1253 Sacramento CA 95814 Dear Dr. Coye: We have been giving the State's Draft Strategic Plan for the Expansion of Managed Care Programs in Medi-Cal a great deal of thought and would like to submit a new managed care concept for your consideration as you revise the draft plan. As you know, we do not believe that either the consortium approach or geographic managed care as currently envisioned will work in Contra Costa County. We have come up with a new way to achieve what we both desire. We have borrowed a concept from the Charter School program, which was enacted into law in 1992 (SB1448 Chapter 781, Statutes of 1992). The concept of a Charter School is to allow a local community to focus on specific, defined educational objectives, rather than "process" requirements. The law essentially allows any Charter School to focus on results. We think that the same concept can work for managed health care: with a "Charter Area Managed Health Initiative" the State and the County would agree on the desired outcomes in a community. The State and the County would also agree on what indicators will accurately measure the County's progress toward each outcome. The State would agree in advance to waive compliance with all other State laws and regulations which stand in the way of the County's achieving the agreed- upon results. In addition, we would agree that all existing Federal laws and regulations to which the State cannot obtain a waiver will have to be followed. However, we will work with the State to obtain as many Federal waivers as are necessary to provide an environment in which the County can provide sound, preventive, managed medical care at a reasonable cost. Perhaps what is most important about the Charter concept, whether it is applied to education or to health care, is that once we mutually agree on desired outcomes, the County plan will be relieved from cumbersome, costly, and often unnecessary interference in operating our local programs. Merrithew Menoria! Hospital a clinics • Public Heath • Mental Health Substance Abuse • Envrronmentat Health Contra costa Health Plan - Emergency meoica! Services Home Hea!tr'.Agency - Geriatrics 11.2 Molly Coye, M.D., M.P.H. March 5, 1993 Page Two We will be presenting our 'Charter Area Managed Care Initiative' concept in testimony before the Senate Health and Human Services Committee chaired by Diane Watson on Wednesday, March 10. We are also prepared to introduce legislation in this legislative session. Alternatively, we might discuss your exercising your broad authority under SB485 to do a Charter Health Initiative pilot project. Our preliminary discussions indicate there is bipartisan and bicameral support for the Charter concept. It has also met with considerable enthusiasm from several of our counterparts in other parts of California. This indeed may be the vehicle for the State and the County to use in moving Health First and other pilot managed care projects from planning to implementation. We are always available to you and your senior staff to discuss this. We will be sending you an advance copy of our Charter Health Initiative testimony in the beginning of next week. Sincerely, Mark Finucane, Health Services Director MF:BB/lmb Enclosure: .San Francisco Chronicle Article of 2/17/93 Lr:MC 11.3 .. SF Ci+ran Charter School Plan Is Well Worth Watching ~TERRY WOE and John getting people who could read, Chubb, autbors of "Politics, write,compute and think out of Markets and America's high Pchool." Schools," believe British school Tompkins has helped reju- reforms have a better chance of venate a closed-down inner-city success than those is the United school be calls "E Campus" SVt Though the charter program Is Moe, a Stanford University siew, he is "0.5-percent certain professor, now is watching de- that astounding things will hap- velopmencs in California,which pea."Achievement of even two- may change the face of US.ad- thirds of his goals, he says, %cation. would be"better than what we The concept is called "char- have"now" 'ter schools."In exchange for an San Carlos Schools District agreement to be judged on per- Superintendent Don Shalvey formance, schools can create says his goal is that aU students their own programs largely free be able to attend a four-year of regulations. Unfortunately college. The district will stress the state's education code can't community service and allow Mandate high "student out- non-credentialed artists to comes,"educators'argot for re- teach special classes.Under the sulfa. standard education code, even State law,which took effect Albert Einstein as a d not be al- last month, allows anyone to foaled person".would not be al lowed W teach' write a charter to operate a school within an established dis- In Sonoma Valley,the char- trict. The charter must explain ter of the Bennett Valley dis- bow it will accomplish its goals trict focuses on home schooling. and measure performance. Of It recognizes that parents the 100 charter schools that can "know and understand their be approved for terms of five children better than anyone years, nine received the go- else and therefore are the most ahead last week- competent to choose the best Instructional setting for them." To succeed,promoters must gain approval at the district and Charter promoters ac- etate levels. Schools cannot be Imowledge that the concept is sectarian. Students cannot be not for everyone and that each tequired to attend charters nor district's needs are different. can teachers be required to Some view the idea as a bul- teach in them.Charters can use w'ark against the voucher plan. admission standards, but not But there is no denying that ones that discriminate on the charters provide considerable basis of race,ethnicity,disabili. latitude for those willing to ptit tty,or gender. to the effort. How well they work is up to those involved, According to Rod Tomp: parents,teachers and students. ldns,.a banking and business consultant in San Diego who 9.1. dllingsley k a media follow with has been involved in the char- she Fonio Reocni kalk ne.-Ne lees ter process,employers"weren't—in Son Digo. CONTRA COSTA 11.4 HEALTH PLAN 1 Senate Health and Human Services Committee Contra Costa County Testimony March 17, 1993 dntt I am Milt Camhi, Executive Director of the Contra Costa Health Plan. I have just four points that I would like to make today. FIRST, Contra Costa County has a long history of success in managed care for Medi-Cal. So we know prepaid Medi-Cal, which brings me to my SECOND point. Our experience tells us the State Strategic Plan is an incomplete blueprint for change. In fact, the State Plan presents false choices. We believe there are better choices to move Medi-Cal and other vulnerable populations to managed care, which brings me to my THIRD point. One of those better choices is a new solution, something we call a Charter Area Managed Health Initiative. Admittedly, we have borrowed the charter concept from the Charter Schools Bill, which the legislature passed and the Governor signed last year. The charter concept, which allows one to focus on performance rather than on process whether applied to education or managed care is a new, novel and much needed solution. And now my FOURTH point. The charter concept would also allow us the local flexibility to implement true integration of services. Integration of services is also something we in Contra Costa County have a lot of experience in doing. These are the four points I want to make today. Let me very briefly elaborate on each. POINT 1: Contra Costa Health Plan is the county sponsored and operated, federally qualified, Knox-Keene licensed staff model HMO with over 20 years of experience in operating a prepaid Medi-Cal program. Contra Costa Health Plan has a long history of managing the care of not just Medi-Cal eligibles but also the medically indigent. In fact, Contra Costa Health Plan is "unique" among HMOs; we not only serve the poorest of the poor, the disabled, the blind, and the elderly who are poor all in the very same prepaid delivery system, our HMO also enrolls Medicare and paying commercial members in the very same HMO. We've created one health plan for all. Perhaps no other HMO in the State or in the nation has more experience in serving the underserved and vulnerable populations in a prepaid setting. In summary, my first point is.......we know prepaid. Mata`strategic.:Mari Now let me go on to POINT 2: Our extensive experience in managed care is why we so strongly support the goals of the State's Strategic Plan to move all of the Medi-Cal population to a managed care system. The State of California, the Medi-Cal providers, and most importantly, . the Medi-Cal beneficiaries can no longer afford unmanaged care. a ' C ... .......... .................. .................................... .................................... As much as we support the general goals articulated in the Strategic Plan, we are greatly disturbed by its total lack of local flexibility to achieve the desired end. The State plan presents a false choice for achieving managed care. Contrary to what the State plan suggests, consortium and geographic managed care are not the only options. In fact, in my professional judgment, these two options may be the wrong choices in many, maybe even most communities. As presented, these two false choices underestimate the essential role of counties and public hospitals in serving Medi-Cal. These two false choices largely ignore the intrinsic relationship between Medi-Cal and indigent care. 11.5 M 2 We strongly believe that for Medi-Cal managed care to succeed it must allow for local flexibility within the overall prepaid framework. What may work in Sacramento may not be right for Orange County. What works in Contra Costa may not work in Los Angeles or Santa Clara County. I am sure we can all learn something about managed care from Kaiser. We know the Kaiser Health Plan recognizes the need for local flexibility in the organization of services within their overall commitment to prepaid financing. Kaiser has tailored their local delivery systems so that, for example, it contracts with community physicians for primary care in-Bakersfield; whereas in Fresno Kaiser currently has contracted with community hospitals for inpatient services; yet in the San Francisco Bay Area we all know Kaiser relies primarily on Kaiser- Permanente employed doctors and Kaiser owned and operated hospitals to deliver prepaid care. The State doesn't dictate to Kaiser that it provide managed care to its commercial members in exactly the same form throughout the State, so why should it now dictate how the 11 target counties should proceed with Medi-Cal managed care? The managed care model that ultimately develops in San Diego,where there is no county hospital may not be suitable in Contra Costa County where the public hospital is the major provider of inpatient Medi-Cal services and the county health services department is the largest provider of ambulatory care. POINT 2 is simply the State Plan presents false choices. We believe there are better choices. Let me now go to POINT 3. ©ices ................... ... ..... In the spirit of coming up with realistic new solutions, I offer a new choice. A new way to consider the relationship between the State and these developing local managed care entities. A new choice that allows for local flexibility but at the same time assures appropriate regulatory review by the State. A choice that focuses less on dictating process and more on assuring performance and on assuring results. A choice that reinvents State government's role and the county's role in developing and operating managed care systems. We are proposing today that the Legislature pass a Charter Area Managed Health Initiative. The concept of a Charter Area plan is new in managed care but admittedly it's one we've borrowed conceptually from the Charter Schools Bill (SB1448 Chapter 781, Statutes of 1992) which the legislature passed and the Governor signed last year. As you know, the concept of a Charter School is to allow a local community to focus on specific, defined objectives. As you know, a Charter School focuses on results. In exchange, for an agreement to be judged on performance, local schools can create their own programs largely free of State regulations. We think that the very same concept can work for managed care; let us in Contra.Costa County (and perhaps in one or two other pilot Charter Initiative areas) agree with the State on the desired outcomes of managed care. We're willing to commit to achieving measurable outcomes such as achieving specific infant mortality rates. Such as increasing the percentage of childhood immunizations in our Medi-Cal kids. Such as reducing our administrative costs per member per month. The Charter Area Initiative would also be required to specify what indicators will measure progress. The role of the State would be to determine whether we achieve these outcomes. As a Charter Initiative we would request the State to waive compliance with all superfluous State laws and regulations which stand in the way of our achieving the agreed-upon outcomes. Give us some latitude in exchange for our commitment to excellence. On the other hand, as a Charter Health Initiative we would agree that all existing State and Federal laws and regulations to which we cannot obtain a waiver will have to be followed. Perhaps what is most important about the Charter concept, whether it is applied to education or to health care, is that once we mutually 11.6 3 agree on desired outcomes we will be relieved from the cumbersome and costly and largely unnecessary interference in operating our local programs. We believe the Charter is the best vehicle the State can use to authorize the development and expansion of managed care in a local geographic area. A focus on performance rather than the current preoccupation with planning process and organizational structures is just what the doctor should order. That's POINT 3. A novel solution to the false choices presented in the State Plan. We call it a Charter Area Managed Health Initiative. Now let me conclude with POINT 4. tetiot We believe the Charter Health Initiative concept is exciting because it gives the State and the local community an opportunity to examine together what is really important: And the Charter idea has the potential for fostering realistic integration and coordination of services. We believe the Charter would allow us the flexibility to promote integration of services in managed care so that as appropriate we could create continuums of health services, rather than maintaining independent parallel, competing systems. For example, The Contra Costa County perinatal system is a prime example of the seamless system of care which could be made available under the managed care system to all Medi-Cal patients in our community. We have married County public health, community-based organizations, and our public hospital and clinics into a managed system of care. We have woven this together using Medi-Cal capitation and Medi-Cal fee-for-service payments, MCH funds, CHDP monies, disproportionate share monies, tobacco tax revenues, Federal demonstration funds, and foundation grants. Our perinatal approach brings together a number of categorically funded programs to complement rather than compete with each other. And we have achieved results. VIn West Contra Costa County, which admittedly has one of the highest infant mortality rates not only in our community but in the State, African American infant mortality was reduced by nearly 50 percent between 1981 and 1990. Results such as these are what we should be focusing all our attention on. Granting us Charter authority would allow us to do just that. Focusing on performance, no process, is what is really important to communities and Medi-Cal recipients. Iealth'Fr In conclusion, Contra Costa County is ready, willing, and able to move ahead now with Medi- Cal managed care. But we can't move ahead within the confines of the present draft of the State Strategic Plan. We need a new Charter. We need authorization from the State to establish a managed system of care in Contra Costa County. On December 14, 1992 we presented a proposal to the State Department of Health Services to create a managed care system in Contra Costa County. We call our proposal "Health First". Health First would eliminate traditional fee- for-service Medi-Cal in the ninth largest county in the State. Health First builds on a publicly- sponsored, public hospital based model, which strengthens the public safety net. Health First builds on a Knox-Keene licensed, federally qualified HMO with 20 years of prepaid Medi-Cal experience. If you are interested in the "Charter School" concept being applied to the Medi-Cal program, we want to be your partner in the design and implementation. We are ready to test the Charter , plan concept in Contra Costa County. We are ready now to provide universal access. We are ready now to provide patient-centered care. We are ready now to provide integrated care. We are ready now to contain costs. We are now one of the "....true laboratories for health care 11.7 4 reform" (AHA, 1993) in this nation. When you are ready to designate Health First as a Charter Managed Care Initiative, we promise you will have a proven model that works, that is focused on results, that is cost-effective, that provides access to high quality care and can be transferred to other area of the State. Thank you for your time today. We look forward to working with you. i 11.8 Senate Health and Human Services Committee Contra Costa County Testimony March 17, 1993 t��dutan I am Milt Camhi, Executive Director of the Contra Costa Health Plan, the county sponsored, federally qualified, Knox-Keene licensed HMO with over 20 years of experience in operating a prepaid Medi-Cal program. Contra Costa Health Plan has a long history of managing the care of not just Medi-Cal eligibles but also the medically indigent. In fact, Contra Costa Health Plan is "unique" among HMOs; we not only serve the poorest of the 1�vr, the disabled. the blind. and the elderly who are noor all in the same prepaid delivery system. our HMO also enrolls Medicare and paving commercial members in the very same delivery system. There are over 5,000 County employees and their families who carry the Contra Costa Health Plan card. Unlike any other HMO that I know, there are also 5,000 medically indigent adults in our community who likewise are given the same access to the very same system of care (this includes over 150 homeless). This same Contra Costa Health Plan membership card is issued to almost 10,000 prepaid Medi-Cal members who enroll voluntarily in our plan. County employees, medically indigent, and Medi-Cal members all have equal access to the very same comprehensive, coordinated prepaid delivery system. There are also over 1,200 seniors in our community who choose to carry our health plan card. And we also have hundreds of self- employed individuals and others not eligible for group coverage who have chosen our plan. And hundreds of employees of small businesses have voluntarily selected the Contra Costa Health Plan. We have special programs for single parents. And a special program just for kids. And a new program just for young adults. And there are also scores of medically uninsurable and low-income pregnant women and their babies who have our card as we offer special State sponsored programs through MRMIP and AIM. We've created one health plan for all. Perhaps no other HMO in the State or in the nation has more experience in serving the underserved and vulnerable populations in a prepaid setting. Our health plan meets the criteria set forth in the proposals of a number of national groups for better and more cost-effective care. In fact, in January, 1993, the Contra Costa Health Plan was highlighted by the American Hospital Association as an example of a "community care network" which they believe could serve as a model in any national health reform efforts. "The key characteristics of a community care network are community collaboration, a focus on community health status, and capitated or per person payment" (see enclosed "Hospitals and Health Care Reform: A National Vision, Community Action," American Hospital Association, January, 1993). So as a county hospital based, family practice oriented, staff model HMO, we are very familiar with managed care and Medi-Cal managed care in particular. Sia S", eg c Plan Our extensive experience in managed care is why we so strongly support the goals of the State's .Strategic Plan to move all of the Medi-Cal population to a managed care system. We totally 11.9 2 - agree that managed care is the preferred way to improve "beneficiary access to quality preventive and primary health care services in a cost effective manner." We certainly applaud the direction the State is taking. The State of California. the Medi-Cal providers. and most im,Qrtantly, the Medi-Cal beneficiaries can no longer afford unmanaged care. As much as we support the goals articulated in the Strategic Plan, we are greatly disturbed by its lack of local flexibility to achieve the desired end. The State plan presents a false choice for achieving managed care. Contrary to what the State plan suggests. consortium and geographic managed care are not the only options. In fact, in my professional judgment, these two options may be the wrong choices in many communities. As presented, these two false choices underestimate the essential role of counties and public hospitals in serving Medi-Cal. These two false choices largely ignore the intrinsic relationship between Medi-Cal and indigent care. If we followed the State plan, it would severely limit our County's ability to devise a managed care model responsive to our own local needs and conditions. Even the California Medical Assistance Commission has noted in their own comments on the State Plan that ".....Contra Costa County officials have already proposed a variant managed care model which mayest fulfill the needs of that county." We agree with the California Medical Assistance Commission that for Medi- Cal managed care to succeed it must allow for local flexibility within the overall prepaid framework. The only realistic way to accomplish managed care in the Medi-Cal program is to allow local communities and local governments and local traditional safety net providers the flexibility to develop managed care programs that make sense in their own communities. What may work in Sacramento may not be right for Orange County. What works in Contra Costa may not work in Los Angeles or Santa Clara County. I am sure we can all learn something about managed care from Kaiser. We know the Kaiser Health Plan recognizes the need for local flexibility in the organization of services within their overall commitment to prepaid financing. Kaiser has tailored their delivery system so that, for example, it has a pilot project in which it contracts with community physicians for delivery of primary care to Kaiser members who so choose in Bakersfield; whereas in Fresno Kaiser currently has contracted with community hospitals for inpatient services for its members; yet in the San Francisco Bay Area we all know Kaiser relies primarily on Kaiser-Permanente employed doctors and Kaiser owned and operated hospitals to deliver prepaid care. The State doesn't dictate to Kaiser that it provide managed care to its commercial members in exactly the same form throughout the State. so why should it now dictate how the 11 target counties should proceed with Medi-Cal managed care? The managed care model that ultimately develops in San Diego where there is no county hospital may not be suitable in Contra Costa County where the public hospital is the major provider of inpatient Medi-Cal services and the county health services department is the largest provider of ambulatory care. Each county must be able to develop its own unique managed care system. We must reject false choices and come up with realistic solutions tailored to meet local needs. stew host ........ ......................... . ..... ........................... ................................... In the spirit of coming up with realistic solutions, I offer a new choice. A new way to consider the relationship between the State and these developing local managed care entities. A new choice that allows for local flexibility but at the same time assures appropriate regulatory review by the State. A choice that focuses less on dictating process and more on assuring performance. A choice that reinvents State government's role and the county's role in developing and operating managed care systems. What I am proposing today is not another false choice but a new solution. 11.1 3 We are_prosing that the Legislature pass a Charter Area Managed Health Initiative. The concept of a Charter Area plan is new in managed care but admittedly it's one we've borrowed from the Charter Schools Bill (SB1448 Chapter 781, Statutes of 1992) which you passed and the Governor signed last year. As you know, the concept of a Charter School is to allow a local community to focus on specific, defined objectives. Charter Schools focus on results rather than bureaucratic "process" requirements. We think that the very same concept can work for managed care; let us in Contra Costa County (and perhaps in one or two other pilot Charter Initiative designated areas) agree with the State on the desired outcomes of managed care. The Charter Area Initiative would also be required to specify what indicators will accurately measure progress toward that outcome. Then the appropriate role of the State would be to determine whether we achieve that outcome. As a Charter Initiative we would request the State to waive compliance with all superfluous State laws and regulations which stand in the way of our achieving the agreed-upon outcomes. In addition, the Charter Health Initiative would agree that all existing State and Federal laws and regulations to which we cannot obtain a waiver will have to be followed. However, we will ask for the State's help in obtaining appropriate Federal waivers that are necessary in order to provide us an environment in which we can practice sound, preventive, managed medical care at a reasonable cost. Perhaps what is most important about the Charter concept, whether it'd applied to education or to health care is that once we mutually agree on desired outcomes with the State we will be relieved from the cumbersome and costly and largely unnecessary interference in operating local programs. The Charter is the vehicle the State can use to authorize the development and expansion of managed care in a local geographic area. I believe practically everyone testifying today agrees with the need for greater local flexibility: the Charter provides an appropriate way for the State to grant that local flexibility. And this is most important, it refocuses the State's concerns on desired outcomes. The Charter Health Initiative concept would require us and the State to focus our main attention on patient and community outcomes. What happens to patients as a result of their interaction with the managed care system and what happens to communities is really what is important here. Focusing on outcomes can also provide very useful information about a managed care plan's effectiveness. A focus on yerformance rather than the current preoccupation with planning process and or anizational structures is just what the doctor should order. A prescription for change - that is what is encompassed in the concept of a Charter Area Managed Health Initiative. For example, the Charter Health Initiative Plan might specify disease-specific outcomes such as reducing the expected incidence of pre-term deliveries for all Medi-Cal women enrolled in the plan. The Chapter Plan might specify general health outcomes (such as 95% of all patients undergoing ambulatory laparoscopy are able to return to work the next day.) The Charter Plan might specify patient performance outcomes (such as 90% of pediatric patients with documented and treated otitis media are seen for follow up within four weeks). The Charter Plan might specify patient satisfaction outcomes in appointment availability and waiting times. Looking at end results, we might propose various health status indices, especially those that may be highly correlated with quality of care. What the Charter Health Initiative Plan agrees to do is specify the desired results up front for the State's approval. The focus moves appropriately to measure performance, not dictate process. 11.11 4 ntant :tf Src We believe the Charter Health Initiative concept is exciting because it gives the State and the local community a real opportunity to examine together what is really important. The Charter idea has the potential for fostering realistic integration of services. To be successful in a managed care setting for Medi-Cal, we know the complex of services that are provided must include a full range of maternal and child health services, nutrition services, childhood immunization services, stop smoking programs, dietary programs, and perinatal HIV infection services. Our managed care experience has taught us that the appropriate array of services needs to also include drug and alcohol prevention and treatment programs. We may need to include some or all of these and other programs which are not now a traditional part of the Medi-Cal Program. We may need to request a waiver of some existing regulations. We certainly will need the flexibility to provide all of these integrated services as a part of our comprehensive treatment program, even if the services cut across traditional State bureaucracies and departments. A global budget also makes sense under the Chapter concept. We believe the Charter would allow us the flexibility to promote integration of services in managed care so that as appropriate we could create continuums of health services. rather than maintaining independent parallel. comneting_systems. We know that some of our managed care members present themselves to us for only one service (e.g. immunization, STD, or substance abuse treatment). Unfortunately many also present themselves in our emergency rooms, rather than in our primary care sites. But we also know that some members may nod a comprehensive case managed primary care and prevention-oriented approach by a multi-disciplinary team of health, social services, and other support staff. For example, the Contra Costa County perinatal system is a prime example of the seamless system of care which could be made available under the managed care system to all Medi-Cal patients in our community, not just those currently using County services. Today all women who enter prenatal care at the Contra Costa County sponsored ambulatory care health centers are enrolled in our Healthy Start program. Healthy Start is our Comprehensive Perinatal Services Program (CPSP). Today Healthy Start serves nearly 65% of the low income pregnant women in Contra Costa County. It could serve more of those in need. The County's Healthy Start service includes the standard CPSP assessments and follow-up services in nutrition, health education, and psychosocial needs. Special attention is given to pre-term labor prevention education, diabetes management, and smoking cessation. Enrollment in WIC is automatic for all Healthy Start mothers. The County's multi-disciplinary team includes social workers, registered dietitians, nurses, physicians, nurse practitioners, translators, and specially trained clerks. Overall case management is by public health nurses. Healthy Start includes a direct link with Born Free, the County's perinatal substance abuse model demonstration project. Born Free counselors are co-located at our Healthy Start sites and provide immediate substance abuse counseling, education, and intervention services for Healthy Start patients who have a range of risks for alcohol and/or drug use during pregnancy. The same comprehensive strategic thinking which created the Healthy Start/Born Free integrated approach to prenatal care is further extended to perinatal outreach and follow-up. We use our State MCH Black Infant Health funds to support the community-based East Bay Perinatal Council's Healthy Tomorrows program to reduce African American infant mortality. Together with our Prenatal Care Guidance outreach program these initiatives focus on finding very high risk pregnant women and keeping them in prenatal care and keeping their babies in pediatric care. With the aid of AB99 tobacco tax funds additional community outreach and education programs are planned. We have married County public health, community-based organizations, and our public hospital and clinics into a managed system of care. We have woven this together using Medi-Cal capitation and Medi-Cal fee-for-service payments, MCH funds, CHDP monies, tobacco tax 11.12 5 revenues, Federal demonstration funds, and foundation grants. This is one example of an integrated system of care. Let me cite just one more example of how we have responded to community need for increased access to local services. One quarter of the Healthy Start enrollees live in West County. It made obvious sense for us to assure a delivery site closer to where the services are needed. We created a joint program with Brookside Hospital where County family practice physicians who provide prenatal services also attend the women for delivery at Brookside Hospital. Since beginning in February 1991, over 350 Healthy Start patients have been able to deliver at their local community hospital. If you are looking for a model of a seamless system that is comprehensive, integrated, prevention- oriented, and primary care based, then look to Contra Costa County's prenatal care program. Our prenatal approach brings together a number of categorically funded programs to complement rather than compete with each other by planning and implementing activities together. My understanding is the Senate Health and Human Services Committee is interested in solutions and I submit Contra Costa County is an example of a working solution. In fact, the improvements we've seen in outcomes as a result of this integrated perinatal effort are impressive. ./In West Contra Costa County, which admittedly has one of the highest infant mortality rates not only in our community but in the State, African American infant mortality was reduced by nearly 50 percent between 1981 and 1990. ./And our infant mortality rate in East and Central Contra Costa County has decreased by 30 percent, falling below the State's rate. ............................... �c Health"First .. . . ........ . . ........ ................... ............................... ............................... Contra Costa County is ready. willing. and able to move ahead now with managed care. But we can't move ahead within the confines of the present draft of the State Strategic Plan. We need g new Charter. We need authorization from the State to establish a managed system of care in Contra Costa County. On December 14, 1992 we presented a proposal to the State Department of Health Services to create a managed care system in Contra Costa County. We call our proposal "Health First". Our Health First proposal addresses the problems in the current Medi- Cal system and provides realistic workable solutions. Health First would eliminate traditional fee-for-service Medi-Cal in the ninth largest county in the State. Health First builds on a publicly sponsored, public hospital based model which strengthens the public safety net. Health First builds on a Knox-Keene licensed, federally qualified HMO with 20 years of Medi-Cal experience. Contra Costa County's Health First proposal provides solutions. Contra Costa County has a proven track record in managed care. But we need your help to move forward, and we hope you will agree that you need the County health system's help in designing a managed care system for vulnerable populations. If you are interested in the "Charter School" concept being applied to the Medi-Cal program, we want to be your partner in the design and implementation. We are ready to test the Charter plan concept in Contra Costa County while the other debates go on about managed care. We are ready now to provide universal access. We are ready now to provide a patient-centered care. We are ready now to provide integrated care. We are ready now to contain costs. We are now one of the "....true laboratories for health care reform" (AHA, 1993) in this nation When you are 11.13 6 ready to designate Health First as a charter managed care initiative. we promise you will have a proven model that works that is focused on results. that is cost-effective, that provides access IQ high quality care. that concentrates on long term improvement of health and that can be transferred to other areas of the State. Thank you for your time today. We look forward to working with you. 11.14 k W. 8 � LD 0 Q > . a? „? g •� '�° � � � � � � � g � � °° 96 � �° � U .� 8 � a � 0° C' eo � Q' � � m � •v � g Lzeco a a g o •� ,� .� m V CF) .00 o Ud 0 0 o � '� .°.�. E 3 d Gn u° w Ue u CIL w8 arc IQ. w < < .0 G r .y r O too a eo > .5 c Z a --� E c�i o c•i w v vi $ �c e� oo c o; = 3 11.1.5 State Department of Health Services Draft Strategic Plan for Expansion of Managed Care Programs in Medi-Cal Contra Costa County Testimony January 27, 1993 Introduction: I am Milt Camhi, Executive Director of Contra Costa Health Plan, the county sponsored, federally qualified, Knox-Keene licensed HMO with over 20 years of experience in operating a prepaid Medi-Cal program. Contra Costa Health Plan has a long history of managing the care of not just Medi-Cal eligibles but also the medically indigent. In fact, Contra Costa Health Plan is unique in its diversity; we not only serve the poor, the disabled, the blind, and the elderly who are poor, our HMO also enrolls Medicare and paying commercial members in the very same delivery system. We've endeavored to create one health plan for all. Perhaps no other HMO in the State or in the nation has more experience in serving the underserved in a prepaid setting. Contra Costa Health Plan is a county hospital based, family practice oriented staff model HMO managing the care of about 23,000 Contra Costa County residents each month. So we are quite familiar with managed care and Medi-Cal managedcare in particular. Strategic Plan Goals: That is why we strongly support the goals and principles of the State's Strategic Plan to move the Medi-Cal population to a managed care system. We totally agree that managed care is the preferred way to improve "beneficiary access to quality preventive and primary health care services in a cost effective manner..." The principles the State Department of Health Services has used in guiding its plan are consistent with the ones Contra Costa County has used in developing its Health First Medi-Cal managed care program. We certainly applaud the direction the State is taking. The State of California, the Medi-Cal providers, and most importantly, the Medi-Cal beneficiaries can no longer afford unmanaged care. Strategic Plan's Ap..pro c�h: As much as we support the goals and principles articulated in the strategic plan, we are compelled by our 20 years of managed care experience to tell you that the suggested approaches are unworkable in their present form. While the State has correctly identified the desired end we seriously question the means employed for all of us to get there. The Strategic Plan appears to be based on a series of incomplete, inflexible if not incorrect assumptions. 1. The Strategic Plan appears to ignore the relationship between the counties' role in Medi- Cal and the State's financial problems. The strategic plan must be analyzed in the context of the effect of the State's budget situation on the counties. The counties will take the lion's share of the State's budget cuts made to help balance the State's budget. If the 11.16 2 State eliminates State optional Medi-Cal categories, then these former Medi-Cal eligibles will become part of the county responsibility medically indigent program. If the State reduces Medi-Cal benefits, then the counties will be forced to provide these services to Medi-Cal beneficiaries with no reimbursement from the State. When the Strategic Plan states that the counties must accept the prevailing Medi-Cal capitation rates when these rates haven't been changed in almost three years, it is shifting the State's budget .problems on to the counties. 2. The Strategic Plan greatly underestimates the essential role of counties in serving Medi-Cal. Counties throughout the State of California provide a significant and substantial portion of the health care services given to Medi-Cal eligibles and practically all of the public health services. In Contra Costa, the county health system is the largest single Medi-Cal provider of inpatient and outpatient hospital services. Yet counties are given only a minor role in the development and operation of the consortia. 3. The Strategic Plan also appears to underestimate the essential role of public hospitals in serving Medi-Cal. County hospitals have a substantial role in providing the medical care and they are often the only institutions that provide extensive mental health services in the county to the Medi-Cal population. Yet the Strategic Plan undermines the disproportionate share reimbursement mechanism. The consortium model offers no protection to county hospitals: Since the DSH requirements are on a countywide basis and are not hospital specific, the consortium could take all the DSH days from a county hospital and give them to a private facility. The requirement to settle all lawsuits before forming the consortium forces the county hospitals to give up all claims against the State, even if they are legitimate, before they can take part in the new system. And why strangle institutions which are training the family practice physicians who might be the salvation of the Medi-Cal system of care. Another problem in the consortia model is that not all public hospitals or other DSH hospitals are CMAC hospitals, which will complicate contracting and other relationships. 4. The Strategic Plan largely ignores the intrinsic relationship between Medi-Cal and indigent care. The counties rely on Medi-Cal revenue, including disproportionate share payments to help subsidize the costs of caring for indigents. The Federal government has made clear this is their intent in establishing the disproportionate share program. Requiring that only 80% of the DSH days remain undermines the clear congressional intent. 5. The Strategic Plan appears to take away the very tools managed care needs to be cost ff ive. The strategic plan seems to call for open panels of providers and facilities. To work, managed care systems must limit their providers to preferred panels. Not everyone can take part in managed care. Counties, as the major players must be included if they wish to be. Indeed managed care programs should give everyone the opportunity to apply to participate but should include only those providers and facilities that meet defined cost, quality, access and cultural competency standards. 11.17 3 6. The Strategic Plan is deficient in its understanding of organizational development. As a business plan for developing consortia it is understaffed, undercapitalized, has unrealistic time frames for both the consortia and the State (e.g. Knox-Keene licensure) and has no provision for a "managing partner" to guide the development and operation of a consortium. The composition of the consortium board is ideal for an advisory board but is inappropriate for a board of directors which bears major financial risk. 7. The Strategic Plan presents an unclear vision of the public policy implications of the proposed consortia. While the consortia appears to become regional purchasing pools for Medi-Cal eligibles, national health policy seems to be headed toward the establishment of purchasing pools covering the employed and the indigent together. Is California contemplating keeping the Medi-Cal and the other purchasing pools separate? Is the State contemplating using the consortia approach as the foundation for building integrated purchasing pools in California? There should be public discussion of the pros and cons of integrated vs separate purchasing pools. Recommendations: We do believe there are ways to alter the State's approach which will help the State to meet its goal of increased Medi-Cal managed care and solve the problems noted above. 1. Flexible Approach - The State's Strategic Plan now allows only two approaches to a county wide managed care program: either a consortium or GMC. In its haste to issue a policy document, the State hasn't given itself the flexibility to approve other approaches which meet the goals of the Strategic Plan. Yet national private managed care companies have found they must tailor the organization and delivery of services to the local area. The financing is uniform (all prepaid) but their approach to health care organization and delivery reflects the diversity of the areas they cover. The State must recognize that counties are unique and allow them the latitude to develop a managed care organization and delivery program that suits their special conditions. For example if a group of counties wish to do a regional PCCM then the State should allow this innovative, community responsive approach. Other counties,perhaps those without a county hospital, may wish to use an IPA model such as successfully employed in Santa Barbara. Still other counties, especially those with a major public hospital may choose to develop a staff model approach to organizing and delivering managed care. The Strategic Plan should advocate that all counties proceed with the function of managed care but should not dictate what form will work best in each community. 2. Variations Within Consortium Model - The Strategic Plan appears to allow for only two variations of the consortium model: one with and one without county government participation. Another variation is to have the consortium designate a managing partner such as the county or another major agency. While in the beginning a consortium may contract with PCCMs, group practices and individual M.D.s along with PHPs, the ultimate goal should be to contract only with 11.18 4 systems of care (PHPs). Furthermore, if managed care is going to work, from the very beginning a consortium must be designed around a closed panel of providers (while including the major Medi-Cal players, especially county hospitals and health systems). 3. Improvements in Geographic Managed Care Model -We are concerned that using GMC as a backup in so called "A" counties who do not form consortia has some perhaps unforeseen repercussions. It might make it more difficult for a consortium to make tough decisions in dealing with individual providers. Some providers might thwart the consortium's efforts in hopes of getting a better deal from the State. Although the calculation of DSH days on a hospital-specific basis in the GMC model is an improvement over the countywide approach in the consortium model, it could still result in a GMC county losing 20% of its DSH days and funding. It could also create some new organizations that serve AFDC only leaving just the indigent and Other Medi-Cal in the county system. The county system would lose the critical mass needed for subsidization of indigent care through DSH days. Most importantly, the competition concept embodied in GMC ignores the link between Medi-Cal and indigent care. Perhaps to remedy that inequity, the State should require that in GMC counties all entities which contract with the State for Medi-Cal must also take indigent members, with the county being given right of first refusal. Finally, in those counties which do not establish a consortium but in which the county operated health system is willing to absorb up to 80% of the Medi-Cal eligibles, then the State should contract with the county for the number of eligibles (up to 80%) that the county agrees to take and contract with private entities for the remaining business. 4. Build on Success - There are two successful COHSs operating in California (Santa Barbara and San Mateo) and three more in development. Why not allow any other counties who wish to develop a COHS to do so and work with the Federal government to obtain the Federal legislation needed to expand the number of COHSs. 5. Proceed with New Models - Counties which have firm proposals for new models of managed care should be allowed to go forward with them and not be forced to comply with only the models outlined in the strategic plan. The State should continue to work with us in Contra Costa County to bring our Health First managed care plan to fruition. With Health First, the State can accelerate its movement to managed care since Contra Costa County is willing and able to begin significant expansion of its prepaid health plan. In fact Contra Costa County presented a proposal on December 14 which outlined the elements of a new managed care approach. Health Fust is comprehensive; it covers more_ services and aid categories than envisioned in the State's strategic plan. It contains aspects of managed care that the State wishes to see developed and provides a laboratory for the State to test the impact of innovative services. And most important it builds on a proven system of county run managed care in the State (See Attachment A for more information on Health First). 11.19 5 Health First provides a new model for Medi-Cal managed care. Unlike Santa Barbara, San Mateo and what is proposed in Solano, et al, it is a county organizedn� county managed plan with the county government as the at risk governing body. Conclusion: To meet its goal of moving to Medi-Cal managed care in a timely manner, the State must be more flexible in its approach than is presently described in the draft strategic plan. The State must encourage counties with a willingness to expand on their experience with Medi-Cal managed care to go forward with new models. L26:TE 11.20 be -E= pe!'s F.a4•~ � Hoaith CWC DEPARTMENT OF HEALTH & HUMAN SERVICES Fin*=Ing Aorn+ristrat:on LN MK NCU-P- --�� 75 Howtnorno Sir@et 3 2l1r1 3 ria`: rism.st:;:o. CA 9,100' Jose Lernbndoz, Deputy Director b:edieal Care Services Department of Health Services 714 P Stroot, Room 1253 Secremento, California 95814 Lear Mr. . Fernandez On January 27, 1993, we met W th John Rodriguez to discuss California' s Draft Strategic Plan tc) expand its managed care enrollment through the dovolopment of a health care consortium. At that meeting, we offered our preliminary analysis on tete feasitility of the State's plan In relation to existing Federal- law and ;.eatil.ations . The cnclosed analysis, which has been reviewed both b7 our Central 01fice staff and our Of`:.ca- of the General Counsel , represents official HCYA-policy regarding the State':: Strategic Plan proposal . Our analysis Jnc!.udes a few modifications trom the document provJ ded to Mr. Rodriguez at our January 27 meed ng. Please contact mark Gorden of my staff, at (415) 744- 3591, if you or your staff !gave any questions . tie are cortmiL:ted to assist the State in any way possible to translate its plan: into reality, and wo look :onward to working wJ th you in developing creativu approaches to uteet that end. Sinz,:ere1;, Lawrence L. Mc ough Associate Reg nal Administ. ator Division of Medicaid Lnclobui_ cc: John Rodriguez Mary Dewane N.J ke FI ora ' 11.21 -� HZ7,LTH CONSORTIA AND L,-,CK-IN -Co?.spoNg : F ALIF F.N'T; 'o ATRAT GIC PLAN FOR MEP.T-CAL MANAGED CARE ISSUE: Is it possible for California to implement the above components of its strategic plan without requiring changes in Feaeral law? Are ei.ber of these components Implementable under Section 7915(b) freedom: of choice waiver authority? RACKGROUNn: DHS ' draft 1113193 strategic plan for its Nedi-Cal managed care program contains a proposal to ir,:ulament regional organ!.zed "wealth care consortia" in 11 priority counties, which would begin operating in State FI' 1993 - 1994. Each consortium wc,uld be comprised of "bzneficiar'_es, public and pirate providers, and, if the county elects to participate, representatives of county avvernzient. " A. F'r,gsibll itv of Imn-lenont.1n? HCZlth Care Carsor is Seligtiye to Governing Federal Recuirements The following analysis is based or. the State' s draft strategic plan and conversations with key DHS staff . Current =ederal law and regulation allow for th_-es tYpes of ,e-?Icaid capitated, risk managed care contractors: HMOs (Federally or State qualified) , Prepaid Health Plans (PHPs ) , and health Insuring Organizations lriIw:s ) . As defined by the State, a health e:ra consortium would only fit under the Federal defiriticn of an Hiro. :inc_ it would ir:cljde "traditi:tial Medi-Cal providers" in its Iletwork iind would eventueily (within 24 months ) assur:Hr "full tiriaricial risk. " I-ieetij;9 either of these requirements would mean the con.Eor.tium iS a risk cnmtprehens ve organization and suL,)ect to the requirements of sUc:.ior: _yrJl (::,) of .the Act (which def-::es and fists requS renents for HMOs and for HIOs ) . Thus, to legally operate and receive FFP under Xedicaid, a consortium would first s e.,e to qualify as either a State or Fodorall.y quallfled HM0. In California, this would also mean mccting all governing Knox-Reene requirements . The consortium could not be considered a PRP because its service package is risk' comprehenci:•e as defined by Section 1903 (m) , and exceeds the service bundling limitaticr:s of this statute. Even if the consort!a dere to qualify as an HID, it would have to meet all Section 1903(r,) requirements, {ncluding 7-5/25 and disc rollment on dan,and. 1 . How tiie State could 7mpl amer.r. Its Health Care Consortia P_qp_osal_ without Violating £x_st_inc Federal Law The State ' s draft strategic plan indicates that DHS "can proceed to imtlemer.t health care consortia without Federal statutory change, although Federal waivers will be required. " If tho State 11.22 5r1 TJ :6.•EFT *7C.-.9-T}., ERV I--- IS B7 r.C.G-i< ZZ-:zlrr t VZIIS �.Z:.�•� wishes to restrict recipients to roceivir. Medi-Cal services on 9 _1Y from the consortium operating in the county, this is not Possible under existing Medicaid law or waive' authority. This is because a recipient must be able to voluntarily disenroll from an HMO, and have an alternative source .from which to receive Medicaid services. Further, the consortium, if only comprised of Madi-Cal enrollees, would also be in violation of Section 1903(m) since WIOs may not have more than 75t maximum Federal enrollment. Section 1903(m) does, however, provide for the waiver of this requirement if continuouE progress is being made by new 10,'Os towards achieving the 75/25 enrollment mix. The only scenario in which tho :onsortia proposal would not require a change in Federal law is as follows: a. Each consortium must qualify and be certified as either a Federally or State qualified HMO and cannot be the exclusive vehi-la for receiving Nodi-Cal witllir: she county in which it operates. b. To --void the need for Federal freedom of. Choice waiver authcrrity, a residue] Medi-Cal fee-for-service (FF5) systera must be saintained in counties where consortia l:eci-Cal HNO contracts are executed. C. Using Section 1915(b) waiver authority, the State could incorporate conEortie which have qualified as HMOs into its proposed goc,grapric managed carp (G:•IC) waiver program. A consortium would be one of a choice of ::Edi-Cal contract plans available to recipients In a GMC target county. Under geographic Managed care, the State would have to assure that, tit any point in time, a new eligJ ble had a choice of at ]east two clans :n which to enroll . was ihil i t v ',f _r^123 nmPn`lno t:-e_ Stratea r s- an ' s ne irement. fol- a *;ne secs:-In Period 'Tho stategic plari'ss requirement for a one year lock-in period would renuire a cirerraP 1n existing Ferieral ) mw. However, ioc}:-in periods of up to six months are possible as follows : a. For Federally qualified HA:oa as perms tted by Section 1903 (m) -Cali!orria recently received approval of a State Plan amendment irsti nvtIng 6 month 1 ock-i n for its Federally qualified HLMOS. b. Under Section 1.915(10 authority, subject Lo HCFA approval, for PHPs. State crueliricd HripS would not be elioible for b n lath lock-in, since Section 1903(m) requires voluntary disenrollment and cannot be waived under Section 1915(b) authority. Tns Section 1903(in) exomption allowing 6 month :ock-in for Federally qualified HMOs does not extend to State qualified HMOs . 11.23 0c. t f-.FA-RE5ICN I::. S.F. ^41.. t DEPT WFA-TF+•SO.)I=E= ' .. LB�503;02-ZZ. Calm.CY1 agns F••'`S-CE C. App_iC)ilitv_ of Soction 1115 Demonstration Iijithority. The State could attemptto utilize Section 1115 . demonstration authority to implement its •strategic plan's hoalth care consortia and one year lock-in provisions. However, it is unlikely Lite State could satisfy the rigorous requirements for achieving a Section 3315 demonstration grant, as such programs must represont a clear . and novel experimental approach to delivering ldedicaid services. �RRCN'r STATUS: _ The State has not as yet translated the strategic plan into any - formal proposals for HCFA review. Region IX staff have informally discussed the above with DHS staff, achieving mut-ual understanding regarding the relevant Federal statutory, regulatory, and waiver requiraments and issues. These topics were formally addressed at a meets ng between DHE and }:CFA on 1/27/93. Region IX has also provided oral testimony to the California Assembly's Health CcM.a:iLLac� on February 9 regarding the above issuea . Eneure that all State parties are fully and accurately apprised of federal requirera&nt* arid HCFA position on health consortia and one year. lock- in. Region IX will offer to provide the State with tiny and all technical assistance it mal, require to achieve its Xedi- Ca] managed care ob;octives within the scope and limitations of existing Federal law and HCFA policy. CONTACT: Nark G.rden, HCFA, Division of Medicaid, Region IX, Tel . (41.5) 744-3591 P.epared by: Mark Gorden ( 43.5) 744-3591 11.24 Contra Costa County Health First Proposal The Health First proposal transfers the management of the Medi-Cal program from the state to Contra Costa County.This proposal reflects Contra Costa County's long commitment and record of making accessible, affordable, quality health care for all a top priority. When implemented this proposal eliminates traditional fee-for-service Medi-Cal and adds approximately 64,000 eligibles to the 15,000 already in managed care systems in the county. Contra Costa County has operated a publicly sponsored managed care system with 20 years of prepaid Medi-Cal experience and has successfully integrated commercial and Medicare "paying" members with Medi-Cal and indigents. The county will now arrange public and private resources to assure beneficiary choice and increased access for all the county's Medi-Cal beneficiaries. Health First includes an innovative global budgeting arrangement with distinct advantages and protections for both the state and county. The county's Public Health Division will have an integral role in this new prevention oriented approach to Medi-Cat managed care. Health First also builds on a major (and about to be rebuilt) public hospital thereby preserving and stabilizing the health care safety net. Health First emphasizes a cost effective family practice centered primary care system and takes advantage of a highly regarded family practice residency program. Health First also forges a new managed care partnership with the private sector, including new strategic alliances with Kaiser and Planned Parenthood. Furthermore, all appropriately licensed physicians and other providers who meet applicable state, legal, professional, and technical standards will have the opportunity to participate in the program through their relationship with Contra Costa Health Plan, Kaiser, or another contracting HMO. Advantages for beneficiaries include universal access to care through guaranteed Medi-Cal eligibility, increased access to primary care (including a 24-hour toll free telephone Advice Nurse service), and a choice of managed care systems. The county's proposal includes a realistic time-phased approach. In Phase I (January, 1993), the state reduces fee-for-service and expands managed care, while in Phase II (in six months), the state virtually eliminates fee-for-service Medi-Cal in the county and contracts with a variety of . managed care options. In Phase III, (in one year) the state contracts exclusively with Contra Costa County's Health First program to assume total fiscal and administrative responsibility for providing or arranging for services to all eligible Medi-Cal beneficiaries through prepaid health plans. Health First negotiates contracts with Kaiser, other HMOs, and providers and expands its county run plan, the Contra Costa Health Plan, to enroll approximately 80% of the Medi-Cal eligibles. Health First offers a new approach to Medi-Cal managed care and holds the most promise to improve health status of the underserved ng_d contain costs. L26:PROP 11-25 Advantages of Contra Costa County's Health First Proposal Eliminates fei-fcr-sem:-ccl. 1. Eliminates traditional fee-for-service Medi-Cal in the ninth largest ......................::........... county in the State and adds 64,000 eligibles to the State's managed cart rolls. Strengthen.' :pbl:icm.sa 2. Builds on a publicly sponsored, public hospital-based model which ... strengthens the public safety net and thus stabilizes indigent care .. ..... provided through managed cam. Builds on Med. i.-U. ..prep''aid 3- Builds on an HMO with 20 years of prepaid Medi-Cal experience. experience... Integrates parr)0metnbar5- 4. Builds on an HMO which has successfully integrated commercial and - Medicare "paying' members with Medi-Cal. Family practice primary 5. Utilizes a large family practice panel of prim ary care providers and care and family practice takes advantage of a growing, highly regarded family practice residency residency. program. UtilizesFNYPS and PHNs. 6. Extensively utilizes family nurse practitioners as primary care givers, and public health nurses as case managers and telephone advice nurses. Incorporates public health 7. Successfully incorporates various traditional public health services, e.g. . ..... ..... . services. immunization clinics and home health, as part of seamless delivery system. Incorporates community based prevention services e.g. injury control. Publicfprivate strategic. 8. Includes community physicians, disproportionate share community alliances. hospitals and other providers serving Medi-Cal. Develops new strategic alliance with Kaiser and with Planned Parenthood. Coordinates financing and 9. Integrates financing and delivering health care through a global budget delivery. option. Beacficiary choice.. 10. Maintains on going relationships between primary care provider and patient. Offers managed care options (CCHP, Kaiser and proposed HMOs). Tests 166k-in and 11. Tests six month lock-in for all managed care members with six month guaranteed eligibility: guaranteed eligibility for CCHP members. Marketing reform. 12. Eliminates all door-to-door marketing in Contra Costa County. Hospital parmershipl 13. Utilizes an already approved new public hospital and community hospitals. Extensive county 14. Gives further impetus to modernize and expand an already extensive ambulatory network of county run ambulatory care health centers. ...... ............. Assures access to primary 15. Uses standards to assure members have timely access to care and care. improved access to prevention oriented primary care provider.(which is the single most important variable related to longer life expectancy). Reirimis in -Comm.u 0.ity 16. 25% of all County savings to be designated for community prevention health. and outreach programs. 4&.AC Brookside Hospital TEL=1-51.0--236-8974 Feb 19.93 11.26 DIRECTORS e VOUM T.MCHIS^L.D,M.D. @1Trr2j.oA$H ku"OTTIuPP N�drir �I.N SAME MW wow IMYIM QV%AGMY,M.D. Twrw w...w M.r�rY BROOKSI®E HOSPITAL Fabrnary 19, 1993 The Hon. Tom Torlakson Chairsan, board of supervisors Contra Costa County 651 pine Street Martinez, California 94533 Re: Medi-Cal Managed Care Dear Chairman Torlakson: As you may know, Brookside Hospital has informed the State Department of Health Services that a group of Medi-cal providers in this county will send a "letter of intent" to form a Consortium for the provision of a Medi-Cal Managed Care program in Contra Costa County. This action is in accordance with the process outlined in the State's Strategic Plan for the transition of Nadi-Cal to a managed care system. Providers who have expressed an interest in signing such a letter include Los Madanos Hospital, the Martin Luther King, Jr. Family Clinic in Richmond, the Medicus Medical Group which has received approval to set-up a Medi-Cal clinic in East County, the Alameda-Contra Costa Perinatal Council, the Alameda-Contra Costa Perinatal Network, as well as physicians, pharmacists and other Nadi-Cal providers. Although we felt this action vas necessary, we took it with some reluctance and with a full understanding of the possible consequences. As we have told the Stats, there is such with which we can all agree in the •Health First■ proposal. No one believes that Medi-Cal managed care in Contra Costa can proceed without the County playing a primary role. As Mark Finucane correctly points out, the Couizty,a existing Madi-Cal zKo forms the logical foundation of xny future system. But other providers must be assured a polio+ role. Our concern has been and continues to be focused on the fundamental issue of govsrnanee. Despite the County Health Departmantils numerous and welcomed Beatings with providers and . other interested parties, there appears to be no movement from the 0 West Contra Costa Hospital District M Yale Road,San Pablo, CA 8+:806 (510) 235-7000 Brookside Hospital TEL*1-510-236-8874 Feb 19,93 11.27 EL Ron. Tam Torlakson February 19, 1993 Page 2 County's expressed intention to exercise exclusive control over this program. in addition to causing concern among virtually all other Medi-Cal providers in the county, this approach conflicts directly with the Statefs Strategic Plan, which calls for a more inclusive governance mechanise. We do not know if the Staters "Consortium" model is the best way to achieve this goal or whether some other joint powers model will prove more workable in Contra Costa, but we believe strongly that other major Fedi-Cal providers must be part of the governance structure. The advent of a Nadi-Cal managed care pr ram of this scope and magnitude is an extraordinary new direction in healthcare. we hope the board of Supervisors and the Health Department administration will work with us to find the best solution to this challenge. Very truly yours, MINOT W. TRIPP Chairman, Board of Directors West Contra Costa Hospital District ccs Son. Tom Powers Son. Jeff Smith Son. Gayle Bishop Son. Sunne NcPeak Nark Finucans I2/09/92 17:08 0310 Sas 1017 PI.M.PR.N-M S-D 11.28 Planned Parenthood' Shasta-Diablo December 9,1992 llviarlc Fianprne Hcabsb Service Dfre= Contra ChM Health Services 20 Alka Street Maitinm CA 94553 Dear M do Planned Pa=Wwod: Shasta-Diablo is Pleased to wane this ktbcr in suppco of the Costa CoLmty"Healtb Frit"Managed Cwt:Proposal so Dave the Medial clients in ow county. From Plivined Paraathood's Perspective,you bring three unique advantages: 1) ODmm Coam Conary has conscimnotWy and inomatively wa rl d closely with the ocantanniry to meet the needs of our lbw'-come cid2zas. It is clear you will bring that same kited of commrismrat and%nd-Hrod=perdw to a managed cave system We trust you to have the best is u==of the Medi-Cal population in mind_ 2) Planned Pareathood and tba Contra Costa Conaty Heahb DePartmctu have wodmd cooperatively O e6er over the years,and I expect this will confirm d=xagb the t ansidon to a full managed cant 3) Through the mangCMCZ3t of the Contra Costa Health Plan,you have = andcmusuali cq=x ace providing managed cart to a Medial population. I am hopeful that as we wade together,we will acatie a wooesa'ul,financially solvent and managerially sendble program. As we&scnssed,thea we three ways we a:cpect Planned Paremtbood to be involved in Your Pro'pow rmaaa ged can p W= 1) we will have a ab-contract to p mvide with family planaing/5T'D services dcvugh Dia au Planned Parenthood clime atter in CDn=Costa. This would not only be far managed=v measbers who wish to cwrd a their federal f mMy P-nnm8 sc '= bypass apdoa,but also for those who woald prtfcr to come to os and or wbo we can Save the most txpedbimW and . We also want m oona=to continue pmnaral c m through ��P�ro clicats,including those who would - be mroned n the mma 2) We understand that we woald omdnuc as R=Wly pmvidets in the anew managed part sys am and would be r imburwd an a foo-fir-aavice basis for the specialty surgical sea'Am we provide i.e.oolposoopy,abortions, va cermet, arc. Administration: 1291 Oakland Boulevard, Walnut Geek,CA 94596-4374 510/935.4066 FAX 510/935-1017 Semry Suaa Conn Coxa uke. Neon. Snesu. Soteno, W loAamo Counues 12/09/92 17:09 0510 935 1017 PLNn rRA'M S-D 11.29 Matic Fin== Par 2 Desmon 9. 1992 3) We are rdmudng to pwdcipate as fon pdmay cert provklus as member,of the Solano County Plarmetahip. We believe that we w mW also be abk d become hill pamary cut paovkkrs in Omn Costs as the ma--I cum oysm eroly L We have proven ora expadse saving low btcomt:women sad their M rough==' Ilraftsicauy placed nodical dm and oar kwwledgc of the oammsmby,we cora cahaaoe the of pommy care to those Nods- W Ween Saeb one of these items wID obviously entail si ne;atiaticq 00aveQaadoo and �acnssion to worksat the detans I am p u hear that you mt oomuittcd to Wmdcing closely with the eocwmnmty clifff in Contra Costa,sad specifically with llaaaaaaeedd Pareatbood,as ore amt into this ww ata of managed can for low' CHCM With this we are very soppcx ve of too trade ship rok of Contra Costa�Savi�pmposinI m y expand the provision of managed cave in our ommty. We hopeyou WM wavey b Dr.Ooye oar sapport of ymu a�� We hook forward to bearing from you aRa m your eeting witDr.Coyc as the of the priocmca for 1943 and 1994 bwome clearer. We at ever to wads with you and are p:wd of the fact that we wM be able to wtac so well oogaher for the benefit of all our diesel. Sincerely, ,MPA d Dinxliud tor Fnuak w' Milt Camhi DEC-11—'92 09:43 ID:FEGIONAL RjB AFFAIRS TEL NO:9-1 10-987-248'7 11.30 9AW PtrWAMt Meftd CM hWM 199Pmadn Sri PON 0EhVX,fi*MQL%91611-2W _ tSl9)961-I1D3 1'�L 6'�937•a1K i KAISER POUAANEMM December 9, 1992 Mark rinucane Director, Health services Department - Contra Costa County 20 Allen Street Kartine2, Calif rn a 94553 Dear Mr. ,F+inucane: I ar writing in support of the concept of the Medical managed care proposal you are developing. Because of your experience in running a federally qualified county-operated HMO, we believe Contra Costa County is in a unique position to organise a county-wide Medical managed care system. We also support your approach as a means of assuring continued Medical. and SB 855 funding to support county services to the indigent as well as Medical eligible individuals. As you know Kaiser Permanente also has a Prepaid Health Plan (PHP) MediCal contract with the State and has committed to enrolling 4,708 MediCal beneficiaries in Contra CostaCcunty by the end of 1993. At our November 16, 1992 meeting with Milt Camhi and Frank Puglisi of your staff, they shared the County's plan to redirect the county's current Medical system from predominately fee-for- service to, in a few years time, a managed care system made up of the County's AHO, Kaiser Permanente and other IPA's and JIM01s. Towards that end ve understand the County's HMO would eventually enroll 751 to 804 of MediCal eligible individuals and you are requesting that we, and other IPA's/HM01s, commit to enrollinq the remaining 20% to 25t. Messrs. Camhi and Puglisi also requested that we provide selective specialty physician services for County enrolled Medical patients. We are in the process of analyzing our capacity and discussing the specifies of your proposal with our hospital, outpatient and physician administrators at our Martinez, Richmond and Walnut Creek Medical Centers. We are not in a position to agree to specific numbers. Our initial analysis indicates that we would not have the capacity to meet .the numbers proposed in our November 16 meeting and would have to spread the numbers among other providers as well as over a greater time ,trame. DEC-11-'92 09:44 ID:REGIDNAI. PUB AFFAIRS TES W0:9-1-51e-987-2 11.31 while we are not in a position to commit to specific MediCal increases, we do support your general concept and approach and look forward to Working with you and other providers towards the development of a managed care MediCal system for Contra Costa County. Sincerely, ;eA 44W641� Bob Eisennan, Ph.D. Director, Community and Governuental Relations cc: Kaiser Permanente Distribution 11.32 C!' « Q14 y V w l0 L+ O Lsat t;o w ;= v r 'Q ilia � -mill " �° >.... Q•+ ,.1 �, �`'� _ ,�� •'�3� •�3'� g Q , -a :_ W �� '�•�s`�. +� ��"` Q Sys o � '�" s'b�Q o a E Sat � FE 11.33 1_,, 3 c c z h � Ot'i 0 7 !0 fII tis r .— to �. — •— V = �' 6! � ° r 16 ° —. �' Z cn O a A 0 LL, p.t� ° V = a A y a S5� 1° c`0, o: fa - Qtj � a. ,' o `° cAam �` a, r coo l'i �ecc r a'�, c d E N. c r Q r _ z, iQ r '� E - o � Z R oc o �o ` Q E A L Rs - c `-' c Hca, � � a, 'flya, ,.. a .. t . a, Qc c1° �a _ � R ."u, fa 'O ¢! d > g Oi w - s c 'v '^_j p�� ` 0` �_j H C w '> _ eD A 3 a E V cri _R f0 pa+ yzE � d � ccs � p_, EIn � c = foGato favi =y � eu � c � '.° > :. 3 y 6i �° > ar ' Z + c C R �i .° c w .r y £ 3 � ' r � '- o ai°, a °— 2 s c ffr GD R S9 O 2 Q y � r 7 � E _ a h c �, >+ 3 to g+ d = yb .— A — ep �+ O yQQ � aA �e4' a`� ' '; ere0r £ b cn = W60; EE °to 0 -- uc' ' .r � � F s >+r ag > S tea rtes � yREh•`° o E' >, - > �- Si >, t . s >, E A C Loy H R �' a gc8+ c .- Im Z`a c � :_ _ _ I � a, 3 $� v � fu 'a � Q c = E � c 4�F a� �+ i ,r`°c � ° d " s _y {/� ova =% c_ � raj , 51 :c ; �• � a•4Qs � � g '_ en Vl £ `� 'A 2 r r G. c A ` -0 01j fa .� �'' r V = £ R d v .— ° N > = r` C t0 � $ > y i• e0 r r V •rr fD l0 V •— ` •_ d £ t+ y V v•c Q r ° es > to Vi,� di.y •? 7 V = ��' z`d- ,au. ` � '�` aa � z'R .�>. QC �� � � > cz A R c E :E = t � ,8 2 c o � `° E � c ,£ Es c .0 c c o� r� .� � c+ 3 •d � e�'c= '�-u�� faa3 'n ;E , y � - > c EE •- rfa f o > crc; R4 Lu V, e, sfa = d afa - 3r £ ii ` 0! r r � " g � � :E cccc5 em EAC cr c > cc i � > g > W2 m y y c w .'7 . c L r f0 E f4 r b e0 r >m eD f0 = 2 !0 s0 to 2:1 MC t .0 cu 0 or-- -Cc j w 5 O pp.. c 2 who R 3 ` >, � � `` � A A = 64 a, E � dH6.fa r d >, OAC N b a > >,E a 'v Lu c TE O v' ON ..�. a! C y N r �+ 67 .�11 � 7, a15� :,,r � ^. m fD f N C •£ d NCqY c £ � gO�C 0+ = C 11.34 cCi zap Di �y y x �J N lN0 y (p c cg ep ° E =yz �'v � -' c t of7 ° E � opc Etg aE ` {aq• � o� � A a G $ v �3 was � L° zo' s°O " epr, 9 ,5 a > 2 " .c'E �, � 2 = 55- !a Hs L $off `° = E c �° 3 � a� h a�+ c `= as > a, = Ria ° goA3r� zdE ; � c � � ;v '$ c dt � � Rs_ tea.= �a., ; c " e a+ ,� gC Q � >� my a° E > c' o - ° i9 E �, j � oma .- oA �_ ; Q d OrO Tr r Og . •G M1 -10 F— ^ . G = A r G iy a00�` ^ — Crj V r 8to to � v v � ie �„ •A �ip G C O i0 Op " �C YZ .� ,p Z Z - �1 r �Ei R a c � r l0 3 v en 14Nac �+ a 'S �, _r '° V " en Y a _ a ES' a His a �.v H fQ G = R r G F �'•Capp a R �i a Q mu — 's .: � a a;o € s° c � Eg $ r. r: r H •� 3 H r � �0 4DOpm� � x aOO �.c ; u �+ t n ogg=° � 3V) a, aa CiS � tO o ooa' ^� ii� ap OR 11'f aD O Lnu^; .0P 00 oat LM Ln cr, C4 Rk M.N. Lu H v! NOS CoPQQ �� �P �m mv? ON PES N.• e.��f��pD�p •!!� leap [\ C e'+� O ` �p� �`^� �� �•^• nv �.�. Nv ,f! �•N•• �D� t+;in ry N� e� VVV11� � � x w ■ m . a 'a� �$ —' �■ Eek 5 �� cl a D G p r • �a Oo cn � � � � � E� d � N Z ��g � ■ 3 � allo� H cn O 9 0' Oi 6� �_Eyym� S.L6 i 8 a w �5 _ Q iQS gffiy 16. Zoc E cLa n < �� �E 05 2g N W � O � o 05 f- m z t a x tom-IL N > _ Z Z 0 a = b w 11.35 g �, p. � gcQE � � � � a", � 1ya � ; � a L-�. �a 3 'S+ o $ � r � Cr � v c r ,: g $„ '� A � .� � �°, �_ a`0, � � �5 � 3 t 10 it 00� In � � ay t r 1Q 0.Y G• „' c Y r F �� � �j � R V „" .�.: A A O � v E. C4 to C P � P %- G/ •- 474 " �._ � � � '" r v ` � n ` ` r 0. g� QQ � A r �� -. � r y •i Y y `��' xw bo eCp E hof •v vi Q i _� d Q i r ; A �. C ... > 67 ea , 1p d d •� t •vuc:8g = °° Depto-1lu ; I Rta+ .a3 ' .8 � �'i� o>i ;;. eo1�'a E a c y ti �, ,G C 13 _ O 1e 1a 2 .Y� Y SO C V = i��? O Vi td `a 0. . ,Vrs d o E >. � $ � v A ; 0 .- A > c •a Z% � •v O ac ;o a c c E° 9s° g o A 3 �4 � >,'a A c c-� c EE •- s_ r �. 0 d Q r r• 1p .> l6 it •� F 10 > cE ,� .� c Q ° � a `h �,' a �, �; � �, � ° a _. Ec1eo � ; s � .. oeo_ � � � aR � �- � •- � � y � :: � '° :° ave £ '° g � Q � � " �'� `° ; Es° a e .5 0 0 $ 10 E k 1oQ ac � 2 •u', `e� .c $� ; o ACV �cE E .2 palm-oAm'to->d. 0'1 NOLLV'Jnm 'Sl .£r- o'l 3wmtz •111 = 61' .t9' 0'1 ovi_; 1 '£I V .£F 90' 90' at A'Llt3a D Zl Q3HTV1]d90H 'I1 .St' 4z'- .i£'- .ri' 0'L p .l£'- .09' .L4' £D' £t'' 0'1 321V�111fVIH1Z1d 'Ol SL'- .ZC .69' 9l' £1'' .ZC 01 u'M03d5 '6 .ZY- or 90' IZ' 90' .t5 AZ 0'1 .1JNV1J3d1Q3jn 9 oz, £l SO'- 00' .9£'- 100' 099' at HMEMO-1 'L .£S 00' or t0' OV .6Z'• 01' .t9'• .ZC 0'1 'TV.LVN03N V .9Z'- £o- it' SO' .IV- tr- .u- .1L• AV at 1AIV31�II 'S C. .l£' SL'• .!1' .9Y ZZ'- Zl'• SO' Ol' Q or at 3)tOXLS 't .6£' LI' OZ .L9• .LV t0' .tt 90' 90' -W ZO' .00 at V3DNYJ '£ .Lt' t0' 01' .99' .9Y IV- ZZ• 01'- IV Ow LO .9C056* at .LIIV3H Z .lS• t0'- 90' .99' .LY tl•- 91• SI' St• .t£• ZI' .w .96' .96 0'l A.1.TIVISON1 '1 SI tt £l ZI it -01 6 9 L 9 S IF £ Z l 319VTHVA S•I.NML3330)NOLLV*13WNOJ 3UMS Z 319VJL 11.36 VN a v, a tin in B E L aC c i0 �- v 35 URI 14 LU Ln C' 3 ii ii d � as c ° cc 9 W z < LC.. ., C a 6 � z Z aN °C �t �_ em0 5 88 ° ttv t cay � W cn Z m C6 4.� p`�p 0 4, :2;79 Y �:n13 oc � gy� SEE ..+ aw A ICLw ti z AC Q1 pp C\�p • N O! cc N N N ^ p—�pp�� ^ N O� pp C OO � P N !� (n cOG .N.. to Z W YJ =� C 1° to r- O E v, O ° C �+ C yy v z C wcc 0 F V 19 X R V f W Vis s'v�^i e�u°C SN a°E°aS� °�eQry o � ve� �q av'q m OCC d V o FZ le'eG lz g�Nc ��a °a�LA LLM pps vii v�ado � jN . —N i.N !=� n/ 'R > h r F it C me - a. 3 t r j A C � r X1.37 V I to G M r � `,a r £fit �5rT. ai �o C to tg r" r �y, t1�► � � ,F �" Op U �' w � Goc a 'C✓. RC � oc a 19 �,aoa o0o pat,sd ✓ � oa O a o , O r R O y R Tp � C � ✓ � � � ✓ A f t G� � L v � C 0+ yr w w ✓ � Y �u% '�, � w. d•�' � = tri�' ✓ �, �{Ir. i a � �u.► •�• � .7 A W V M , a i C' � 6i p� G 3 A '' �, Gi� i I ww •�' y r^j'. .d„ v� SY yR t4 p'�CTi. O t6 T N A an (�y `�'i '�"p ; .♦ i > At. ty w y CO > Y G C w C A r •, .a p -S - ,, `i •o a d y y A 1ys��► G C OCl'$ O N ✓ y r t; 'S+ A A V V� T♦��j'O r i i. y.,Q .r^ ✓ y"• j r,, v' G wr� �.v � Ot+F y ✓ sf� •H w '� v � �... ,>� >.•,C� !s . . t4 i A A C^ >`v.I ,.. rw� ?,0 w •t��+ G, '�i y O L S, T ;yG iw :V%Z �r.iw. w> ✓s 'C=. o.A„ wA��i eya S A ry ri+G+CA • > A Z d✓"'a+ pOA(D�wT.�ra.•�4ECi J pA'O 6tLOiA•.� A � 9 OD V, a, va A Sy� '�•� be C b♦U b ���+ « O � �+ r L� R•V..• r iJ A pp {► r fj y Q. aLy pi Lp *� ,f+ `Q y r.I 7[ MA, .; b G ,• '�' w 't+ r ,. A rd+ 2-S ! O A.• j ,� TcrL,�•... A +� ✓ Ll l� �►rp a y` �, � A, � �'� � � x Q q�� ♦r7�, ;e A y V � �.A S©y,i`�,�;� ,f w G �f 'y r O� V •• �, Q v' {y 1 .r tl? A r+ Y A •�i ♦ OG �. Gy i+ •� t,G�� A3� �' i. �i � � C” DC✓ f'" ,�r r G•.�► w 0� �`, i'"'"' v �„' G v. Al w' opG O G 'G a � i+ GG A � A � ♦ ♦ � �� G Z C to A M V ." ; '✓ ri I y �+ _ �. r y .w � ++ �' �•A i1J ✓ `•" t',. A �` �o o. ac o � �' y� .. y a � � Q A �, • A � �' N✓ • i .G E'" J, A �'. Q G V 6� �$.Cy > A �„ w v+ y T�i G � ✓ a ... r' vr�,��%° �Q GAGGo °� � ��• � d � zA � �= yr ✓�g �� � ��•!m � ��`� +� G.♦+ r „w. to to ifl .► O. T H >� G 7 r>' ✓ "'-6T+7 0" C + y A C t > $ '{' >"Sj A C O to V�q O�C J a� ♦;r..� w w: � ai � �j6) �`', rqi VT" A ;1� 'r" v af�r� �` a yq+A6v0„�.► '✓ ,� ♦F, A yctf '�J' V AIto. vA. a y, p 'A :. C �, C r 'Q V �, C (6 ... A� G♦."O �i 'Y'♦ �! p� N A y ,�„ + 'm o s M A :� O G '�,y bj td"':♦ C '� G i ✓ tt� a, •y �, _a. `AflQ '. 'Q p► 00 t�a 'fr �5•�yT�+ .O�• G? 4 •V' �j .♦�.� •" �` Cab t¢G• C � A ? O = Nytyp�.�� p'.� 9C ✓`p�" y, � rR ;:�'V.• � ygA .yA � p � G, � yrs' � > >�d�• a � .��♦ W ���$ N � ��� � ODS i w � � A r + •4 v +E'd : O ¢F• � ��G� fl• �¢ m•Q >ws, vyOrA N c�`7oc+ DC7 .pry6► i� 40 � F' � i Sir •• 9Ct •G., w i� en y� 11.38 -6 te IS to O U N C z g� a 't3 •G.Tf �+ Bio 2 .2r a. N 0 w v t "` G LO y7 'Q "a. Ills .. t u G y N 44 R 6C C 10 + t0 0 O me p to c CC La � � � Ey ' � U k c p`y V 4r Yom! 'rp ��.' r. r„ 'G p '� RI 'fir' G. V C G C r .0 '°�•'�iJ •� U G. i V O U + ` tv c ° tN� _ Epp �Q '� o c .o 8 "y y ~3 }�� ;�'�' �^5 c Ca « CJ .G C C {i O •• U ► > N_ L Com! 7 wO L7 Ll f `. Nd O L}' O .� �[v jai _ > O v OC O. Ox► Ll..p i4 G.cn 6£i v� v O s�i C •: ri ei.4 ori vD , '° Eaoa '° . � E bac da, N � c ` SES ESO . � cmEcc � n. " � q � i� > > ccs „' to 2 - '" o ° - to °„,= = GL ua es O. COaL = $ � cq � P o x o .0 fa mg A �'.�r. � � P R IL EvAi to P {U y N « g C L � � W_ �u V i �p C 'C +� F: t6 w � � = 3� � lG0 1Qi Aj i. Q�� w roti C? ."T. 37i �"' G Q �Vi y�� '" r+ .L�` ".3 �. C, O E rr C L I a > ji O tz v v, � C � c '`�� a 1V=Vc a.= °° �' a 'C •� g' u.. C � .0 N�.20 E c7n o L « A .- � c .. E _ .40 o0 'tm 'too .� c > c E <a 8 � � x '� �' �' � � OD� C e14s 0.' ds 9 .2 r. Ell O t0.+ .0 G. N_ C C a : �J �i � % G? ea c > 3 �'• c ° saves d � r^Iwo. �o;� "' c °' = �s4d $ ' cG �, Q � a �5,9cNh go C 7 w rA C 11.3y t s gui •rim � r_ � � � M � -4 iC� �� "� :it �j � •��' �� 5 i `� "• - l jj ist rr�,,, .. . 5��, • , � 1p ,=cam, «- Y Z� � � � � �� � C �i � •� �,P"®,�i" �' �p ��i,.°� � "•��:•�rte+`, ;+ �5 62 S -6 to lit C, lit -0 4- 1% lit US G ' } �•y�� G�Uvgz+ i�r �3 °� = � Ag� W *ii '� t,.. Imo. �•�,,,, C•a 41L4 g�V�i �`�+ «�, ��y�P��.::.� .«.6i � s�G � {��•p CJ^ Z ,� A p�.:� C x'4/ A Won,U � 'a. ar'•8 �i � � �. � •� � � ;5� � � < M err..� � � �sv� c d ra g tSR . pox • � lk of GD• ,��' � +y��[+a r� � r 7�.� �.' �' 15 "� $ �^ 6 TS p '" � x s �i• t. .�� '"` s g� �+14 r �"+ � G �► �y � G�� �.t O 7Y� � QV�_ �5 e�♦ �. V ,aOuu� y ,5 $ .8w < Zlu It s-I i i �11 :a vi .:'' �s � o�.Ls• ^ 3: y� � x iyj1 EE11 t,3 SasyE� �— a ,�, p eh3 •u! o�-� -i ' lot `ki`,,�,,. LdQr' s- tit7.1 -macZ3� '`� tit 'r low _ - o Contra Costa County Health First Planning Group Mark Finucane,Health Services Director Milt Camhi, Executive Director- Contra Costa Health Plan Patrick Godley,Chief Financial Officer- Health Services Department Frank Puglisi, Executive Director- Merrithew Memorial Hospital&Clinics Steve Tremain, MD, Director of Medical Staff Affairs- Merrithew Memorial Hospital&Clinics Loma Bastian, Assistant to Health Services Director and Acting Director-Mental Health Division Wendel Brunner, MD,Director-Public Health Division Chuck Deutschman,Director- Substance Abuse Program Debbie Card, Director-Home Health Agency Mary Foran, Director- Off-ice for Service Integration Susan Nairn, Managed Care Coordinator- Contra Costa Health Plan . ......... 777�N ...... .... . ... ........ aron.: fil Di 66tor plann ...... Linda BhiADesi an :D d P ...... ..... ........ Jean."Rich; ..raph. 16� ...... .... . .. ..... ... D ...... ..... E y. Commuffication&TAt. .... ......