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HomeMy WebLinkAboutMINUTES - 04111995 - H.3 H. 3 BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA Adopted this Order on April 11, 1995 by the following vote: AYES: Supervisors: Rogers, Smith, DeSaulnier, Torlakson and Bishop NOES: None ABSENT: None ABSTAIN: None SUBJECT: Workshop on Medi-Cal Managed Care. The Board of Supervisors held a Medi-Cal Managed Care workshop and heard a presentation on various topics from representatives of the Health Services Department and medical professionals. (see attached agenda) At the conclusion of the presentation, the Board APPROVED the establishment of a Managed Care Commission with a composition as outlined by the Contra Costa Health Plan Advisory Committee and the Medi-Cal Advisory Planning Commission. The Board further DIRECTED staff and County Counsel to prepare appropriate formal implementation legislation for Board consideration at a future date. cc: Health Services Director County Counsel County Administrator I hereby certify that this Is a true and correct COPY of an action taken and entered on the minutes of the Boats of S*wftors an the date dun. A�TEO� � �b M . Managed Care Workshop Board of Supervisors Board Chambers 651 Pine St., Martinez Tuesday, April 11, 1995 2 - 4 p.m. AGENDA Time Topic Presentor 2:00-2:15 p.m. Contra Costa County's Health Services Department's • Mark Finucane Integrated Health Care System Health Services Director 2:15 -2:30 p.m Linking Public Health & Managed Care:A Model Arrangement • Wendel Brunner. M.D.. M.P.H. Public Health Director 2:30-2:45 p.m. HMO Models: Strategies for Not Merely Enduring • Milt Camhi But Prevailing CCHP Executive Director 2:45 -3:00 p.m: Contra Costa Health Plan -Pioneering History and Key to the • Henry Tyson FutureHMO Advisory Board Chair f' 3:00-3:15 p.m. Medi-Cal Advisory Planning Commission (MAPQ • Michael Harris, O.D., 7.D., M.S. Annual Report MAPC Chair 3:15 -3:30 p.m. Medi-Cal Advisory Planning Commission Committee Chair Reports •Evelyn Rinzler. M.A. Beneficiary Issues •Heather Saunders Estes Provider Affairs •Bessanderson McNeil M.P.H. Access Committee 3:30-3:45 p.m. The Managed Care Commission •Henrik Blum M.D. M.P.H. Recommendation for Board of Supervisors Action *Hena Tyson 0 Michael Harris 3:45 -4:00 p.m. Discussion •Public Comment Next Steps <w Contra Costa County The Board of Supervisors HEALTH SERVICES DEPARTMENT OFFICE OF THE DIRECTOR Jim Rogers, tst District Mark Finucane, Director Jeff Smith,2nd District Gayle Bishop,3rd District - 20 Allen Street Mark DeSaulnier,4th District Martinez, California 94553-3191 Tom Toriakson,5th District ' : (510) 370-5003 County Administrator "^ FAX(510)370-5098 .�.,+. Phil Batchelor County Administrator April 5, 1995 Supervisor Gayle Bishop District 3 18 Crow Canyon Court, Ste. 120 San Ramon, CA 94583 Dear Supervisor Bishop: Enclosed is a briefing book for the Managed Care Workshop with the Board on Tuesday, April 11, 1995 at 2 p.m. in the Board chambers. The briefing book highlights the following areas which will be addressed during the workshop: A. The County's Integrated Health Care System B. Linking Public Health and Managed Care C. An Overview of HMO Models D. An Overview of Contra Costa Health Plan E. The Medi-Cal Advisory Planning Commission Annual Report F. Recommendation for a Managed Care Commission The book also includes a general information section with a review of literature and a managed care glossary. I hope these materials will be helpful in preparation for our workshop next week. If you have any questions regarding the information or would like anything additional, please feel free to contact me. Sincerely, Mark Finucane, Director Health Services Department MF:LM:km Merrithew Memorial Hospital&Clinics Public Health Mental Health Substance Abuse Environmental Health Contra Costa Health Plan Emergency Medical Services • Home Health Agency Geriatrics A-345 (12/94) • Ck O 1 t U wo n O V A d o T' � t)a d ca L tt: � Q ani �0 °�' U 0 � .o = LLZ c ai U � c ya mW 0 E E �' � U ° C ° EQCO = a ¢ G m vw a U O m m m � = i. s w � = m N i •� v m 0 c d a Q wCD a G° ° = so G c G ° Mi LM o. co c_o a 0 G "CCD a. vi C to ¢ N m m G G Cl .ECM c U 'C U E E C ID ° ° m ° ° ° .c to ._ (D co az q m U D W LL CD A • a � � � � y = y a o � � � x .r Jv O [� y .ra (,� C zooD � � c • = DD, D • • . a� • • � a �- '►s as � "' o0 G • as 4• x as C • • • � oa � C - �.� � � ADD vD (� D CI. 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F@•W • � 6@d@d@6@6@dpd.a ` .d 6 6e6 • • . • • • • • • -�_-- _--_--�- _--�- �--�"` ,, z �� 1 �, Public Health &Local,Initiative Areas of Collaboration Memorandum of Understanding. Delineates Responsibilities CHDP (Child Health & Disability Prevention) Immunization Services TB Services CCS (California Children's Services) STD (Sexually Transmitted Diseases) Home Health Services Publ *lc Health n Managed Care Managed Care Provides the Opportunity . . . • To link community-based Public Health with medical care of high risk populations • For a Coordinated Public Health approach to Maternal and Child Health population. Key problems that can be addressed are: * Prenatal outcomes Immunizations Abuse and violence • To collaborate around other public health issues including: * AIDS TB control Communicable disease Homelessness • To target community health promotion programs and allow the managed care plan to provide targeted and cost-effective services • To help the managed care plan fund community prevention pro- grams, and implement them in collaboration with Public Health • To continue to contract with Contra Costa Health Plan to provide public health services such as: * TB clinic services and follow up * Immunizations * Well child exams * Adult routine physicals * STD and Family Planning services * Home Health Services * Advice Nurse Services * Nutrition Services * Child Health and Disability Prevention * California Children's Service _PU_BLIC AND ENvnzoNmENTAL ITFALTH ADvisoRy BOARD Members:, Scott Anderson TO: Members of the Board of Supervisors Doris Copperman Carlote Dunhower FROM: Public and Environmental Health Advisory Joseph M.Hatay Board Vicki Harrington George Kaplan, PhD DATE: October 26, 1992 Edith Loewenstein, MD SoeswWorson McNeil Julio Mendoza, DOS SUBJECT: 1992 REPORT ON STATUS OF HEALTH IN CONTRA Carolyn Robinson COSTA AND RECOMMENDATIONS FOR ACTION Joan Sifi Lawrence Walleek. DrPH Pate Williams This report is a follow-up to the 1988 Report on the Status of Health in Contra Costa County. it Executive Assistant: examines the current state of health of Contra Costa Mary Anne Morgan, MPH in six priority areas: 0 Chronic disease prevention 0 Substance abuse 0 AIDS 0 Perinatal care 0 Trauma 0 Family and adolescent issues This report describes current demographic and socioeconomic trends in the county and discusses how specific populations and regions are differentially impacted by the six priority areas of concern. Contra Costa County Health Services Department 597 Center Avenue, Ste. 200 Martinez, CA 94553 (510)313-6715 FAX: (510) 313-6721 STATUS OF HEALTH IN CONTRA COSTA COUNTY EXECUTIVE SUMARY CHANGING PROFILE OF CONTRA COSTA COUNTY • Contra Costa County is experiencing a dramatic increase in ethnic diversity: the Asian/Pacific Islander population has grown 156%, and the Latino population 62%, while the Caucasian population has grown only 11% in the last decade. The majority of these ethnic groups reside in West and East County. • The county is also experiencing growing numbers of unemployed and working poor residents. Contra Costa ranks second among five urban Bay Area counties for number of homeless families, and women and children are the fastest growing segment of the county's homeless . Over 22,000 Contra Costa children live below poverty. 0 Growing numbers of teenage mothers, single parents, infants and toddlers, and elderly comprise Contra Costa families. There have been dramatic increases in the number of East and West County families for whom English is a second language. • Poverty, poor education and housing, and limited access to health care place growing numbers of these Id families, particularly those living in West and East County, at risk for poor health status. EMERGING HEALTH TRENDS • Chronic diseases accounted for 70% of all deaths in the county in 1988 . Now they account for 78%, causing over 3,500 deaths in Contra Costa each year. Cancer, cardiovascular disease, and respiratory disease death rates are rising and are higher than the state average. The county ranks first among the 15 largest counties in breast cancer incidence, and second in ovarian and prostate cancer. • Tobacco use accounts for 19% of all deaths in Contra Costa. There are over 143,000 smokers in the county and nearly 16,000 of these are adolescents . Women and girls are the fastest growing segment of new smokers . 0 In 1988 it was estimated that between 400-700 cumulative cases of AIDS would be diagnosed by 1990 . To date, 819 residents have been diagnosed with AIDS and an additional 3, 600 are estimated to be HIV-infected. There is a significant increase in the proportion of new cases among IV drug users, women, African Americans, and Latinos, and among West and East County residents . • Despite a 38% decline in the county's infant mortality rates in the 19801s, poor perinatal health continues to be a problem in certain communities . African American women in Contra Costa are three times more likely to give birth to low birth weight babies than White women, and African American newborns die at almost twice the rate of White newborns . West County residents continue to fare more poorly then other residents on key perinatal health indicators . 0 Injury is the primary contributor to years potential life lost in Contra Costa, with injuries the top killer of children and adolescents . Motor vehicle crashes account for nearly half of all unintentional injury deaths, while firearms are the major killer of children aged 10-18 years old. One half of all homicides occur in West County. 0 Substance abuse accounts for the hospitalization of approxi-, mately 1,200 Contra Costans each year. Eighteen percent of all AIDS cases in the county involve IV drug users . Nearly 2,000 women are estimated to use drugs during pregnancy each year and the extent of use of alcohol by pregnant women is unknown. Alcohol and other drugs are involved in 58% of all deaths from traffic collisions, 64% of all suicides, and 85% of homicides in the county. RECOMMENDATIONS FOR ACTION Local policy initiatives, prevention education, and community organizing and coalition building activities have made significant inroads in improving these public health problems . However, political advocacy at all levels is also needed to address the sources of poverty which lead to poor health status . In terms of program development, future efforts need tp focus on data reporting, staff training and development, policy and advocacy, and collaborative interdisciplinary approaches in order to augment and extend existing and new programs . Specifically, the Public Health Division should: 0 Work with communities to develop primary prevention programs for the economically disadvantaged, women, youth, and the African American, Latino and Asian/Pacific Islander communities. Prevention services need to be located in West and East Counties. 0 Strengthen linkages between programs serving clients in the six priority areas, and include schools, workplaces, the criminal justice system, the private medical community, and the religious community in the coordination of services . • Provide cross-training within the Public Health Division and with other divisions in the Health Services Department to educate providers on these priority public health issues and to enhance cultural sensitivity. • Improve the existing data, collection systems in order to enhance the ability to monitor progress and plan future interventions . 0 Act as a conduit to secure funds and provide technical assistance to local community-based organizations so that they can provide prevention services within their communities . 9 ' Facilitate communities organizing to advocate for responsible media and advertising, particularly as it relates to violence, alcohol use, tobacco use and nutrition. STATUS OF HEALTH IN CONTRA COSTA CODNTy INTRODUCTION This report is a follow-up to the 1988 Report on the Status of Health in Contra Costa County. It examines the current state of health of Contra Costa in six priority areas: • Chronic disease prevention • Substance abuse • AIDS • Perinatal care • Trauma • Family and adolescent issues Addressing these issues is a challenge in this time of fiscal crises and shrinking resources . As medical care, social services, and other support services are reduced, public health prevention programs will become even more essential. As a backdrop to this report, it is important to acknowledge the overwhelming evidence linking socioeconomic factors to health status . People in poverty experience higher incidence of disease, suffer greater severity of disease, and die at greater Orates from most diseases . Women, children, the elderly, and certain racial and ethnic groups are especially vulnerable to poverty and subsequent poor health status. Growing numbers of Contra Costans are at risk for serious health problems because of under and unemployment, low education levels, inadequate housing and poor access to health care. This report describes current demographic and socioeconomic trends in the county and discusses how specific populations and regions are differentially impacted by the six priority areas of concern. PROFILE OF THE COUNTY Contra Costa has become increasingly diverse over the last decade (see Table 1-3) . • In population size, Asian/Pacific Islanders grew the most ( 156%) , followed by Latinos ( 62%) and African Americans ( 22% ) . The population size of Caucasians in the county grew the least • West County contains 70% of the county's African American and 43% of its Asian/Pacific Islander populations . • East County is the region experiencing the largest overall growth in population and is home to 33% of the county's Latino community. Despite having one of the highest household and per capita incomes in the state, the county 'is experiencing growing numbers of unemployed, homeless, and "working poor" residents and families : Status of Heafth in Contra Costa County Page.2 0 Unlike other Bay Area counties which experienced an increase, inflation-adjusted income for workers in certain sectors in Contra Costa fell more than 12% during the last decade. 0 Over 57,000 Contra Costans live below poverty. 0 Contra Costa ranks second among five urban Bay Area counties in number of homeless families, with women and children the fastest growing segment of the county's homeless. 0 Over 22,000 children in Contra Costa live in poverty. Of children in poverty, four times as many are African American than White. The majority of the county's poor live in either West or East County. West County is home to the largest number of female-headed households and contains over half of the county's homeless population. East County has the lowest average household income of any region and , contains one-third of all the county' s AFDC recipients, despite having only one-fifth of the total population. As a result of the higher rates of poverty, residents in these regions are at increased risk for serious health problems . SIX PRIORITY AREAS co I . CHRONIC DISEASE PREVENTION rn In the 1988 Report, chronic diseases were identified as responsible for 70% of all deaths in Contra Costa. Today, they account for 78% of deaths and result in over 3,500 deaths per year. While the death rate for heart disease has declined, other chronic diseases are a growing problem in the county: • The county' s cancer death, rate is higher than the state average (based on preliminary age-adjusted rates from the Cancer Surveillance Section) . Among the 15 largest counties, Contra Costa ranked first in incidence of breast cancer and second in ovarian and prostrate cancers . While incidence rates for breast cancer are highest among White women, the rate of death from breast cancer is higher for African American women. • Rates of death from cardiovascular and respiratory diseases are rising and are higher than statewide rates . The rates for women dying of these diseases is increasing. • Richmond, Pittsburg, and Antioch are experiencing significantly higher hospitalization rates for chronic diseases than other cities and the county overall . Richmond' s rate of hospitalization for female reproductive cancers is more than double the county's overall rate. Status of Heafth in Contra Costa County Page 3 Areas of SpecialInterest Tobacco use remains one of the single most preventable causes of death from chronic disease. In 1990, over 5,800 Contra Costans died of smoking-related diseases, resulting in nearly 171000 years of potential life lost (YPLL) . Years of potential life lost refers to the number of years between the age at which a person dies and his/her expected age at death. Over 143f000 county residents still smoke and nearly 16,000 of these smokers are adolescents . The fastest growing group of smokers is young girls and women. Smoking during pregnancy places approximately 18% of Contra Costa women at greater risk for delivering premature or low birth weight babies . Approxi- mately 164,000 Contra Costa children are currently exposed to second-hand smoke in the home, increasing their i risk of respiratory infections, lung cancer. and other health problems . Poor nutrition places approximately nine out of ten people at increased risk of diet-related chronic disease such as heart disease, diabetes, and certain cancers . Half of the elderly are estimated to suffer from nutritional deficiencies . Poverty places approximately 21,000 Contra Costa children at risk for hunger and nutrition-related health problems . , The prevalence of iron deficiency anemia and growth retardation, two strong indicators of nutritional problems, are significantly higher in Contra Costa County than the state average. A recent county study showed that fewer than 10% of the 64 county teens surveyed ate nutritionally balanced meals . Recommendations for Action - Progress has been made in combatting tobacco and nutrition issues through policy initiatives, prevention education, and organizing and advocacy. The Public Health Department needs to expand these efforts by: • Developing a comprehensive chronic disease prevention plan, working with the local American Heart and Lung Associations and the American Cancer Society. • Involving communities in identifying priorities and implementing appropriate chronic disease prevention programs . • Improving existing data collection and surveillance systems to track incidence and prevalence of chronic disease locally. • Facilitating mobilization of communities in support of policies that protect citizens from exposure to secondhand smoke, eliminate public advertising targeting youth and minorities, and restrict youth access to tobacco. Taking- the lead in coordinating community-based and federal nutrition programs to insure that they meet the needs of underserved clients . Status of Health in Contra Costa County Page.4 II . SUBSTANCE ABUSE - Contra Costa has a serious and growing substance abuse problem. The National Institute on Alcohol Abuse and Alcoholism estimates that at least 25% of all hospitalized persons have alcohol related problems alone. In Contra Costa County, nearly 1,200 Contra Costans were hospitalized in 1988 for medical complications induced by alcohol and other drug use. Eighteen percent of all county AIDS cases involve IV drug use. Nearly 2,000 women are estimated to use drugs during pregnancy each year. The extent of alcohol use among pregnant women is unknown. Alcohol and other drugs are involved in 64% of the suicides, 85% of the homicides, and 58% of the fatal motor vehicle crashes occurring in the county. Recommendations for Action - The county has been at the forefront in responding to the substance abuse crises. In 1990 the local citizenry developed a County-Wide Action Plan addressing substance abuse education and prevention, treatment and law enforcement issues . Five regional planning groups (corresponding to each supervisorial district) were formed to implement the Plan's recommendations and are actively involved in this process . Public and private funding for alcohol programs4 has been steadily declining. In terms of prevention, future planning needs to emphasize collaboration with many sectors of the community: e Schools, the workplace, government, the criminal justice system, the health care delivery system, the business and religious communities, individuals and families, and the political system must all be involved in developing a coordinated response. e Public health, substance abuse, HIV, social services and mental health providers need to work together to develop programs meeting the needs of underserved and at-risk populations . e Communities must organize and call for reforms in the marketing practices of the alcohol industry. e The county must continue to implement all facets of the Action Plan including treatment and law enforcement needs . III . AIDS PREVENTION - The 1988 Health Status Report projected that between 400-700 cumulative cases of AIDS would be diagnosed by 1990. To date, 819 Contra Costans have been diagnosed as having AIDS. An estimated 3, 600 Contra Costa residents are infected with HIV, the virus which causes AIDS . while the majority of cases (69% ) continue to be gay and bisexual men, increasing proportions of the people with AIDS are injection drug users, women, African Americans, and Latinos . The rate of infection among women bearing children in Contra Costa is significantly higher than the rate for the state. There has Status of Heatth In Contra Costa County Page 5 been a geographic shift from most of the people with AIDS living in Central County to more new cases being diagnosed in West and East County. If the spread of HIV among injection drug users is not dramatically curtailed soon, this population could be saturated with HIV, approaching levels of infection found on the East Coast of the United States (60-70%) by 1996 . Currently the rate of infection among African Americans injection drug users in Contra Costa County is 30% . Recommendations for Action - The Public Health Division's AIDS Program has emphasized prevention education to'groups at risk, HIV testing and counseling, and case management for people with HIV disease. Future efforts need to include: * Strengthening the links between AIDS programs and substance abuse, perinatal, adolescent, and homeless programs to make AIDS education a priority in all programs which serve people at risk for HIV. e Educating and involving the entire community in fighting AIDS and expanding efforts to involve city, compunity and church leaders in delivering prevention messages to the most affected population. * Establishing a community-based "early intervention" program combining prevention and education with centralized, comprehensive case management and primary medical care. * Developing programs geared to the needs of families of HIV- infected clients, parents, infants and children. IV. PERINATAL _HEALTH - Although Contra Costa has experienced some improvements in perinatal health since the 1988 report, areas of extreme need remain. overall infant mortality rates have decreased by nearly 38% during the last decade and the county's rate compares favorable with the state rate. However, there has been no improvement in low birthweight (LBW) and little progress in improving access to early prenatal care. Certain communities in the county remain at higher risk for poor perinatal outcomes. Residents of West County continue to fare more poorly than the other regions of the county on key indicators of perinatal health, including low birthweight and inadequate prenatal care. African American women residing in the county are almost three times more likely to give birth to a LBW baby than white women, and African American infants die at almost twice the rate of White infants. The percentage of African American women receiving inadequate care .rose almost 290from 3. 9% in 1981 to 11 . 2% in 1989 . A drop in this rate in 1990 may be the effect of new perinatal programs . Status of Heafth in Contra Costa County Page-6 Recommendations for Action - Since 1988, a number of new programs have been developed to promote early care and to provide one-on-one support to underserved women, especially African American women. Progress is also being made in developing special services for. substance abusing women who are pregnant or have young children. Key issues for future action include: • Continuing to develop and improve perinatal outreach, comprehensive prenatal care and perinatal substance -abuse programs . • Integrating education and employment resources with perinatal and other family-focused services. V. TRAUMA - Over 400 Contra Costa residents died as a result of unintentional injury or violence in 1990 . Since nearly one in every three injury-related deaths are children and young adults, unintentional injuries are the leading cause of years of potential life lost (YPLL) in the county. African American children are disproportionately represented in these statistics; while making up only 12% of the population, they comprised 19% of injury deaths . Children in West and East County are twice as likely to be hospitalized due to injury than children in other regions of the county. Violence is also a serious concern in the county, with rape the fastest growing crime in Contra Costa. Although the county's suicide rate has declined since 1986, the homicide rate has increased. one half of all homicides in the county occurred in West County. Intentional injuries comprised one-third of all injury deaths to Contra Costa children between 1988-1990 . Firearms were the leading cause of injury-related death to children aged 10-18 years old; 86% of these deaths were intentionally inflicted. The homicide rate for African American youths is more than twenty times the county's overall rate; this distinction disappears when socioeconomic factors are controlled for. Recommendations for Action - Some of the most dramatic successes in injury prevention have resulted from communities organizing to support policy initiatives and demand changes in organizational and institutional practices . Future efforts should continue these approaches by: * Working for the passage and stringent enforcement of local, state and national legislation to prevent injury and violence. Advocacy for passage of laws to restrict the availability of firearms in the community should be a top priority. 9 Offering comprehensive education in the schools on violence, abuse and injury prevention. StatusofHeafth in Contra Costa County Page 7 • Conducting parenting classes and creating support systems for parents under stress. • Monitoring and advocating for responsible media portrayal of violence. • Examining injury patterns among older adults and workers in Contra Costa County and developing programs to respond to their needs . VI. FAMILIES & ADOLESCENT ISSUES - Contra Costa families and youth are deeply affected by each of the health areas described in this report, in ways that cut across racial, ethnic, religious and socioeconomic lines . Women, children and adolescents are at greater risk for substance abuse, unintentional injury and violence, and tobacco use. Research has shown that these groups are specifically targeted .by the alcohol, tobacco and fast food industries . Inadequate resources are available to counter these forces and provide appropriate education, support and intervention services . The profile of the family in Contra Costa is also 14 changing. The 1990 census indicates that there are increasing numbers of teenage mothers, single parents, female heads of household, infants and toddlers, and senior citizens . More families for whom English is a second language are moving here, particularly to West and East County. Many of these groups have limited resources and support systems and are at high risk for poverty and multiple health problems. They may have difficulty accessing health care due to barriers such as language, limited education, differing social and cultural norms, and lack of transportation and childcare. Recommendations for Action - Responding to the multiple needs of families requires innovative approaches . The Youth Service Board Plan identifies key priorities for planning future programs for children and families which include: • Establishing a coordinated, community-based system that provides a continuum of comprehensive services . • Promoting an interagency planning and collaboration model, involving schools, workplaces, the business community, government and private agencies. • Incorporating prevention approaches that respond to families at risk. ENVIRONMENTAL HEALTH Although environmental health has not been a focus of its work, PEHAB recognizes the important role the environment plays in maintaining a community' s health. As the third fastest growing Bay Status of Health in Contra Costa County Paae.8 Area county in terms of housing and second in terms of job growth, Contra Costa faces many challenges in balancing economic development with maintenance of a healthy environment. Community concerns about pesticide drift from farmlands adjacent to housing developments, building residential communities over toxic waste sites, community and worker exposures to releases from industries that handle hazardous materials, accidents during the transportation and storage of toxic chemicals, and reduced air quality from increased traffic congestion are a few key examples of the overlap between land use planning and public health. PEHAB encourages the Public Health Division to play a leadership role in facilitating discussions that acknowledge and address the potential health impacts of future land use decisions. CONCLUSION The six public health areas discussed here are frequently interconnected. For example, substance abuse is linked to chronic disease, accidental injury, unplanned pregnancy and pregnancy complications , and increased risk for HIV exposure. Chronic disease is associated with alcohol abuse, smoking ,, and poor nutrition. Certain underserved populations--women, youth, low income, and specific ethnic groups--are at greater risk for poverty and consequent poor health, more likely to experience multiple GO health problems, and more likely to die from these conditions. The health problems described in this report are occurring more frequently in West and East Counties, where higher percentages of low income families, single heads of household, homeless and other disadvantaged and underserved groups reside. These areas and subpopulations must be a priority for services . The entire community is affected by these problems . Chronic disease, alcoholism, motor vehicle accidents and child and spousal abuse are a few examples of public health problems that cut across social, economic and racial/ethnic boundaries . As more families and youth are involved, the impacts become more widespread. FUTURE ACTION STEPS The most significant advances in addressing these public health issues have resulted from local policy initiatives, prevention education, community organizing and coalition building, and inter- departmental collaboration and coordination efforts . PEHAB applauds the Health Services Department's commitment to facilitate these activities and encourages it to continue emphasizing these strategies . In addition, PEHAB recommends that the Public Health Division increase its efforts to: • Work with affected communities to develop comprehensive prevention programs. to meet the needs of women, youth, low income, African American, Latino, and Asian/Pacific Islander groups . Services should be located in East and West County Status of Health in Contra Costa County Page-9 and must address barriers to care such as language, differing social and cultural norms, educational limits, and transportation and childcare needs . 0 Evaluate the potential needs of older adults and workers, particularly in the area of chronic disease, injury and substance abuse prevention. • Work jointly with local neighborhoods and regions to define the major health problems and identify appropriate solutions. • Act as a conduit to secure funds and provide technical assistance to local community-based organizations so that they can provide prevention services within their communities . Strengthen linkages between programs serving clients in the six priority areas, and include schools, workplaces, the criminal justice system, the private medical community, and the religious community in the coordination of services . 0 Improve and expand existing data collection and surveillance systems to track health problems by census tract or zip code. Use this information to monitor progress and plan future interventions . • Diversify staff and the memberships of county advisory boards and commissions to reflect the county' s ethnic and geographic diversity. Provide cross-training within the Public Health Division and with other divisions in the Health Services Department to educate staff on these priority health concerns and to enhance cultural sensitivity. An effective response to the health needs described in this report will require commitment from the entire community. The Board of Supervisors must take the lead in identifying new and innovative funding sources, and in supporting the development of comprehensive approaches responsive to the needs of underserved populations . PEHAB also issues a "call to action" to all county residents to get involved in local organizing efforts and to advocate locally and at the State and Federal levels for health protection policies . Political advocacy at all levels is also needed to address the sources of poverty which lead to poor health status, including unemployment, poor housing, limited educational opportunities, and inadequate access to affordable health care. For its part, the Advisory Board priorities for the next year ,are to: 1) Work with county staff on local prevention policy initiatives. 2) Consult with the Public Health Division as it develops a long range program plan. 3) Develop media packages on health issues facing county residents . 4 ) Initiate chronic disease prevention activities particularly targeting underserved populations in East and West County. Status of Heatth in Contra Costa County Page 10 Table 1. t Contra Costa County Population Distribution, by Ethnicity 1980 and 1990 Erbaia Group 1980 z 1990 z z C6sage White 505,921 77.1 560,146 69.7 10.7 African American 59,367 9.0 72,799 9.0 22.6 Latino 56,164 8.5 91,282 11.3 62.5 Asian/Pacific Ial. 28,805 4.4 73,810 9.2 156.2 Native American 4,993 0.8 4,441 0.6 -11.0 Other 1,130 0.2 1,254 0.2 16.0 Total* 656,380 100.0' 803,732 100.0 22.4 Ourcei ornjA vaparaent O ce, lvvu Causus, ABAG, 19du Census, lhane Read, Consultant Table 2. Contra Costa County Percent Population Distribution by Ethnicity and Region, 1990 African Asian/ Total White American Pacific 191. County Total 803,732 69.7 9.1 9.2 West 207,636 44.6 25.0 15.8 . East 160,615 65.1 7,5 6,7 Central 249,166 81.4 2.1 7.1 r-+ t� South 141,080 87.2 1.0 7.3 ourcei uapar=ent ot Yinance, 19VU Census, VLane Reed, Uonsultant. - Table 3. Population by Age and Seg, Contra Costa County, 1980 and 1990 April 1, L980 April 1, 15990 A % Grote Male Female Total Male Female Total 0-4 22,421 24614 44,035 31,250 29,493 4743 379 519 23,649 . 72,0$9 45,738 29,694 28518 58,212 273 10-14 27,5M 26,664 54,244 27,164 25,750 52914 -24 15-19 30,136 29,752 59,888 26,211 24,728 50,439 -15.8 ?�1-2A 26,400 26,335 52,735 26,525 ?5,514 52,039 -13 25-34 54,357 57,943 112,300 69,600 71,447 141,047 25.6 35-44 43,936 45,596 89,532 68,763 72,361 1414M 57.6 45-54 35,385 36,529 71,814 47,005 47,482 94,487 31.6 55-59 17,771 18,987 36,758 .16,445 17,137 33,582 -8.6 60-64 L3,588 14,804 28,392 14,930 16,719 31,649 t b5+ 24,875 35.469 60,844 35,861 51,635 87,496 TOW 320,fl98 336,282 6564.380 393,448 410,284 803,732 =4 "Totah=y am Add to 10096 dmtwo SO==19W And 1990'0 HEALTH STATUS IN CONTRA COSTA COUNTY Report Sources: Kaplan, George, Socioeconomic Status and Health 1990 Census data Life in the Shadows, Contra Costa Times, February 23, 1992, Bureau of Economic Analysis data "The United Way Contra Costa County 1990 Needs Assessment Summary Report" "Kids First" Fact Sheets, Contra Costa County Children's Coalition, July 1991 Diane Reed-, consultant on 1990 census data Health Data Summaries for California Counties, 1992 California Health Services Department Cancer Surveillance Section, Preliminary age-adjusted cancer rates 4 Hospital Discharge Data California Public Health Foundation, 1992 Tobacco Prevention Program Rice, Dorothy and Max, Wendy, "The Costs of Smoking in California, 1989" Contra Costa County Master Plan Report, September 1992 Contra Costa County Master Plan Needs Assessment, July 22, 1991 Substance Abuse Program Contra Costa County AIDS Program Perinatal Health Program Health Services Department Prevention Program Youth Services Board Strategic Plan, 1991 Bay Area Clean Air Plan, 1991 California Cancer Facts and Figures, American Cancer Society, 1992 New York Times article series on nutrition, health and fast food, December 18-20, 1990 Status Report on Childhood Injury in Contra Costa County, April, 1992 Report Sources - Continued Annual Report of Fatal and Injury Motor Vehicle Traffic Accidents, California Highway Patrol, 1989 Vital Statistics of California, 1989 Economic Impact of Drug and Alcohol Abuse in Contra Costa County, 1989 "Diet, Nutrition and Chronic Disease Prevention, " The Nation's Health, September, 1992 Heartbeat: The Rhythm of Health, American Association for Health, April 7 , 1992 "Overall Cancer Incidence and Mortality Down in 1989, " California Morbidity, June 26, 1992 "Ten Leading Causes of Death, By Race/Ethnicity, " Data Matters, California Health and Welfare Agency, June 1992 Id "Alcohol and Tobacco Products, " position paper, The Nation' s Health, September 1992 Overview of the Contra Costa Drug Abuse Program, May 1992 "Premature Mortality in California, " Data Summary, Health Data and Statistics Branch, 1989 "Years of Potential Life Lost Before Ages 65 and 85, " U.S. 1989-90, MMRW, May 8, 1992 A Profile of Older Americans Report, January 11 , 1991 �'^"tl� G t �\ �' /, • om 1 • em C N6 • om 0 IL b, 1 1 � L • y i Alga 4m us d 4m W ago � o CD o c v VA96 -� i = u � a -s d a� 'a c 1 d y ; sN y o � Us- AML sip J Si O 120 � y .20 low � O A to ca � V � N W N � � J y � i = � V �40 O � Ah i a oil V � O L LLm u V L E O = 0 E E LE •_ O 06 > O .:_ 0 L � L, cY r , C�, 0 s = C o OEM *- •- E u C c t Q� , a •,. 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VU, t4 .......... Mg"o, Ems R M as ........... -ON No gg' BE NOV" Pill ev K� OR I M." 130M ll�"P ............ IN .11l­lll­l"­­'_'&..... 2"MEES `�g _S_K� ............... too, WI ............ Q�Qmw�� �WZI k R RAX 61A 02 go Sul MEMO- g Ad s'gwll"��_t� gjg W ............ SIN-j" .................. -----............ MAPC Members Public/BeneficiarY Representatives resentatives Provider Representatives Medi-Cal Beneficiary Representatives/Members Physician Representatives: at Large: * Stephen Heisler,M.D. * Margaret Dowling Gregg Sorenson,M.D. Beneficiary Representative Welby W. Bigelow,Jr.,M.D. * Evelyn E.Rinzler Pauline Wills,M.D. Contra Costa Legal Services Kathryn Bennet,M.D. * Dolores Sanchez,Ed.D. Educator/Counselor Community Based Provider Organization * Rosalind Love * Heather Saunders Estes Beneficiary Representative Planned Parenthood Linda Stephenson Jose Samaniego Community Hospital Representatives: Joyce White * Michael Lawson Brookside Hospital Community Based Organizations: * Antonie H. Paap * Mary Lavender Fujii Children's Hospital of Oakland County Food&Nutrition Policy Consortium * Janiece Nolan,M.P.H.,Ph.D. * Viola Luj an Eileen Lynette United Council Of Spanish-Speaking Organizations John Muir Medical Center * Claudette Garner East Bay Perinatal Council Other Provider Representatives: * Joan O.Lautenberger,R.N. (Nurse) Health Service Department Advisory Boards: * Raymond L. Smart(Pharmacist) * Reverend Curtis A. Timmons,B.A.,Th.D. * Michael G.Harris, O.D.,J.D.,M.S. Substance Abuse Advisory Board Terry Tanner,D.D.S. (Dentist) * Suzanne MacDonald Maternal and Child and Adolescent Health Advisory Board * Cynthia Miller \`\\ ♦, Mental Health Commission `s Bessanderson McNeil,M.P.H. ' a Public and Environmental Health Advisory Board * Paul Katz Contra Costa Health Plan Advisory Board Jack McGervey Contra Costa Health Plan Advisory Board a Board Of Supervisors Liaisons: * Jim Rogers 4 W Tom Torlakson MM! a .Tom Powers AMPC Chair, Dr. Michael Harris and Vice Chair Reverend Curtis A. Timmons *indicates current membership 1/95 f Medi-Cal Advisory Planning Commission (MAPA Staff Milt Camhi Executive Director Contra Costa Health Plan Bobbi Baron Planning Director Contra Costa Health Plan Lynn Morris Assistant Planning Director Contra Costa Health Plan Kathy McNutt Secretary Contra Costa Health Plan Jackie Lacy Office Assistant Contra Costa Health.Plan i r D N March 1993, the State Depart- reflects that diversity; 19%of the A. comm ,Ilmky Hmpu ment of Health Services issued Commission's members are African Commissioners believing it to be its Plan for Expanding Medi-Cal American; 10%are Hispanic; 62% vital that they hear from as many Managed Care. The Plan calls for a are women; 19% live or work in East, segments of the provider and benefi two-plan model of Medi-Cal man- County; and 29%in West County. ciary community as possible before aged care in 13 target counties, The current MAPC by its very making recommendations,used a including Contra Costa County. The nature,represents a diverse group of variety of methods to.obtain input. two-plan model consists of a locally interests. Commissioners include developed managed care system safety net and community hospital L YulbUk 10,21ir E3 called the Local Initiative and a non- administrators;community physi- The MAPC held three public hear- governmental commercial HMO to cians;a community pharmacist;a ings during 1994;April in San manage the care of the AFDC linked nurse;community health providers;a Pablo, June in Pittsburg, and Sep- and Medically Indigent Children nutritionist;an advocate for the tember in Martinez. Special efforts Medi-Cal eligibles.Fee-for-service disabled community; several com- were made to ensure the hearings Medi-Cal for these groups will be munity activists;.and representatives met reasonable accommodation phased out when the two-plan model of Health Services Department requirements with hearing enhance- is implemented. In Contra Costa advisory boards and commissions. ment equipment and microphones for County there are about 60,000 Medi- The Commission,with strong leader- the hearing impaired,speaker phones Cal eligibles who will be required to ship from its Chairman,Vice Chair, to allow the homebound to call in, join one of the managed care plans. and Committee Chairs has been able environmentally sensitive precaution The State has issued the RFA for the to reach consensus on many issues notices for individuals with EI/MSC, Commercial Plan and the Detailed and present them as enriched deci- notices with enlarged type for the Design Application for the Local sions often attained through spirited visually impaired,and all notices and Initiative. discussion. MAPC Reports published in Spanish as well as English.The hearings I MATO HH. 'rhiree MR10ir Alrezo were widely publicized with flyers; HE Medi-Cal Advisory Plan- OfAct'vRY notices posted throughout the com- ning Commission(MAPC) HE MAPC concentrated on munity;and mailings to extensive lists . was created by the Contra three mayor areas in its first of individuals and groups.Individual Costa County Board of Sup y p Supervisors year of operation: commissioners also publicized the • community in one year ago to ensure provider, y ut hearings.Although the turnout for p consumer, and coy put managed community in into • ed caresY stem unmet needs the hearings was not always as large g the planning for the County governance of the Local Initiative as hoped for,the Commissioners are y spon-al committed to reaching sored Local Initiative Medi-Cal ' out to the various na maed care system in Contra \a,„ g . Costa County.In its appointments Contra Costa commu- a , nities in 1995 and to the Board ensured that the Commis- � , expanding opportunities sion contained ethnic,geographic and \, ��,, for beneficiary input. cultural diversity and that the mem- in �' �"� bers were knowledgeable and experienced in meeting the special •eaxe a „• needs of vulnerable populations, including Medi-Cal and indigents. some ofthe MAPC The current MAPC membership . Commisioners at work -1- 1994 MAPC Annual Report 2. Commission Meetings as being an integral part of a man- 2, Mainstream Plan With Public Comment aged care system which best serves Requirements MAPC also held ten Commission its members. It heard from Dr. The MAPC set u a Mainstream Wendell Brunner,Director of p meetings during 1994 with a specific Plan Committee to help it ascertain time designated for public com- County Public Health, on how health the willingness and capability of ments. plans serving Medi-Cal should potential Mainstream Plan contrac- Among the key issues raised at interact with public health and other tors to serve the special needs of Count ices to provide broader both the hearings and public meet- y services p re a roader Medi-Cal enrollees and understand ings were those of access to primary scope of services which include how the Mainstream Plan will relate care; access for the disabled;the environmental and social aspects. Its to the committees heard from La safety net and traditional need for nutrition and other preven- Larry Cohen, providers who have historically tion programs;and other concerns Director of the County's Prevention served Medi-Calp atients. with the Medi-Cal fee-for-service Program,to learn more about how The Committee surveyed the program and with Medi-Cal managed prevention can be incorporated into responding plans using as a guide, , care. the system of care, and from acade- ten core requirements it had devel- micians such as Dr. Miriam Werner, o ed. These requirementsuirements included 3. Commissioner and practitioners like Dr. Kim Duir g ,among othersexperience with low Expertise/Knowledge ' in an effort to expand upon its income enrollees;iarrangements for knowledge and enrich decisions g In its pursuit of input,the MAPC kldih idspecial populations; evidence of Chair solicited information from the on cultural/ethnic access. The community support ort and involve- Commissioners themselves,-by following are areas in which MAPC ment; commitment to community virtue of their expertise and knowl- iprevention and health promotion edge in certain areas,and received activities; and contracts with safety valuable written m 1. Principles of Managed material as well as net providers. The full MAPC verbal statements about beneficiary Care r ' ry a pp oved the Mainstream Plan concerns. To provide a framework for making Committee's recommendations recommendations,MAPC developed which were then endorsed b the principles for a system of Medi-Cal Y 4. MAPC Reports Board of Supervisors and forwarded In addition to solicitation of informa- managed care. They incorporated to the State Department of Health theseprinciples into comments on p tion,the Commission made a mayor Services. effort to reach out to the community the States Draft Request for Appli- and communicate its activities cation for the Mainstream/Commer- throw h a MAPC Report hi cial Plans. The MAPC stated that the g p rt w ch was sent monthlyto a list of over 150Medi-Cal managed care program individuals and r • •on, should improve access to quality g oups. n itia ,4 the Commissioners distributed the primary and preventive health care ` Reports to their own constituencies. services; include quality assurance p and effective case management i ro demonstrate community B. Managed Care System prams•g � Y support mechanisms; and provide y' Unmet Needs Woven through many of the MAPC culturally appropriate services. By e following these principles Medi-Cal ' recommendations for Medi-Cal ' ed care i h managed care may hope to improve managed s the issue of"assur- ing prevention services are available beneficiary health status. ""y g accessible and culturallyappropri- ate". a pp p Contra Costa residents let their views be ate". MAPC focused on prevention known -2- 3. County Specific System Look-Alike which may be a Requirements separate Health Authority; a county ,Q The State Department of Health Non-Profit Corporation;a Private,. Services SDHS invited counties to Non-Profit Corporation;and a "county-specific Private For.-Profit Corporation. propose " require- ments" for commercial plans that would apply for participation in the 2. Factors To Be ,y h y iaa /y� Medi-Cal managed care two-plan Considered • fourteen factors , model. MAPC developed a list of MAPC considered ourt such Criteria including public in evaluation of the various gover- oversight;ongoing member input; nance options. Among these factors comprehensive nutritional and were access; cultural acceptability of perinatal services;prevention; services; ability to choose providers; p �p � % provider education; access stan- dards; ability to train providers; ability to p • in guidelines;use of offer combined human services; " dards,market g safety net providers and experience assessment of outcomes; and more. Dr.Henrik Blum,Pro .11 E Profess meritus,School f with low income enrollees;and more. of Public Health,UC Berkeley The Criteria were adopted b the 3. Staff and Expert p Y Board of Supervisors and sent on to Analyses 1995,the MAPC heard from Dr. the State. MAPC reviewed staff analyses and Blum on governance alternatives reports on various aspects of the within the County structure.His governance options. They also heard recommendations include an evoly- The Models studied from Mark Windisch, attorney with ing plan in which the Board of Weisburg and Aronson,who had Supervisors remains ns as the transi- • A County Madel prepared an analysis of the legal and tional governing body and that • County Organized Health financial implications of the various consideration be given to consolida- System(COHS)Look-Alike alternatives. tion of the current MAPC and HMO • County Non-Profit Dr.Henrik Blum,Professor advisory boards into one oversight Corporation Emeritus, School of Public Health, body. • Joint Powers University ty of California,Berkeley, • t Non-Profit met several times with members of III. MAPC Committees: Preva e orationGuidingp Corp MAPC on the impact of each form the Development of eve • A For-Profit Model of governance on the following the Local Initiative objectives: subscriber care concerns; p maximize its efforts and to enrollment concerns; administration deal with the myriad of issues C. Governance Of The and financing issues; community before it,the Commission has Local Initiative health concerns; and political made use of a committee structure Of all the issues considered by objectives. which includes an Executive Com- MAPC, "Governance"has been' Dr. Blum presented a schematic mittee;Access Committee; Benefi- robabl the most complex and time showing how well each alternative commit- met Y p clary Issues and related sub co • met the objectives and evaluated the consuming. tees; Provider Affairs Committee; results. Commissioners were able to Mainstream Plan Committee and a 1. Governance use this decision matrix to evaluate ScreeningCommittee. Throughout ' alternatives based upon their own set. Alternatives p the year the committees met, consid- MAPC reviewed various governance of criteria. eyed various issues,and made alternatives including County govern- At the request of the MAPC decisions which.became incorpo- ment;County Organized Health Executive Committee, in January -3 - 1994 MAPC Annual Report Mainstream Plan B. Provider Affairs Committee Committee �\ The Provider Affairs Committee eeWhen MAPC developed"County began with four separate subcom- Specific Criteria for Mainstream/ mittees which included physicians; Private Plans in Contra Costa \� County"the recommended to thehos hospitals; dental providers; and other providers (i.e. pharmacists State that all requirements made of etc.). Because of the pressure of the Local Initiative be made of impending work schedules the Mainstream Plans as well. ,�... members decided to meet as one This committee interviewed CCHP Members committee. They-have since been potential Mainstream Plans in Contra able.to incorporate viewpoints from Costa County using these criteria and "Health education to be effective needs to these various perspectives and the plans'ability to meet the health take cultural background and beliefs into review methods and requirements needs Of the community. account." for contracting with community- (Dolores Sanchez,Chair,MAPC Cultural, ba providers, ExecutiveCommittee sed ov ders, as well as selection E. Linguistic,Ethnic Access Committee) p criteria for those providers. MAPC's Executive Committee (the sum of its committee chairs and rated into various recommendations MAPC Chair and Vice Chair and and policy statements from the full C. Access Committee p Y The Access Committee approved one elected member)considers MAPC. pp a be ' Report of the Ad Hoc committee on issues to put on the Commission A. Beneficiary Issues Access Standards: "Points of Ac- agenda;deals with administrative and Committee cess"which recommends time and time sensitive mattters;and has distance standards as the relate to served as a guide for channeling the Recommendations from the Benefi- Y , • outpatient services. work of the Commission. ciary Issues Committee focused on P . prevention as a key theme. They The Access Committee also heard how the Medi-Cal plans agreed with the goal to have access should interact with other County to community inpatient services agencies and community groups to unless there are significant clinical • or financial reasons to do otherwise. promote prevention. y y G One of its subcommittees Cul- In considering consolidation of - tural,Linguistic, and Ethnic Access inpatient services they determined Subcommittee,heard a number of that numerical time and distance standards were inappropriate. They on cultural diversity, struggled with a definition of"cultural determined it should be the Local Initiative Medical Director's judge- competence" and made recommen- dations On provider education in this ment to decide where/if consolida- -� ; � ,� area. tion of clinical services is appropri- Father and son at Public Hearin The SSI Subcommittee, another ate based on criteria such as suffi- g important subcommittee, developed cient staffing capability, sufficient guidelines and has begun planning a number of cases for adequate "MAPC recognizes up to 40%of the focus group project for.1995 in experience;and specialized equip- county's managed care eligibles will be served . which they will target the SSI ment requirements. by a Mainstream Plan and we wish to learn q how potential...contractors will offer the population to garner input on their same protections to beneficiaries that the special access and health care Local Initiative is required to provide." services delivery concerns. (JackMcGervey,Chair,MAPCBenefits Committee) -4- i I - w HV. Plans For 1995 {' itsp lan for 1995,the MAPC has delegated the major part of its work to its committees.The following are workplans including timelines that each committee has drafted for work to be completed in 1995.In addition,the . ILffi ll MAPC will continue to consider the issue of governance and prepare for review and comment on the Local Initiative Application,which will be due to the State in the Spring of 1995. MCA EEDCal Advisory Planning Commission Ccmm(nWee December 1994 r in Harris,Chair Timmons,Chair Tirnrnons,Vice Char Lautenberger,McNeil Executive C@omt e Harris,Chair Timmons,Estes, Rinzler,Fujii onstr I AA ccess Estes,Chair McNeil,Chair erve Lu'an Dowling,Lautenberger, McG y, Lawson,Lujan,Paap, *Lopez,*Casey ® o eAffairsa d lss ;e Estes Chair Rinzler,Chair rBigelow, it I Ott r t r I® F e its pr@A r I i #Ic® ey,Chair n,Chair IF Chair e t ,..Smart,Chair Dowling,Chair 'ciii, Estes r,Katz, Tanner,Chair Rinzlernson, son, *CollinsLautenberger, cc s ner, llins llins MacDonald, Sanchez,Chairler Stephenson, Garner,Lujan, *Bakes,*Collins Rinzler 4! *non-voting members from the community -5 - 1994 MAPC Annual Report Beneficiary Issues Committee Draft 1995 Workplan Goals/Outcomes Timeline: 1. Review current procedures and make recommenda- Complete by , tions on mechanisms for monitoring Medi-Cal patient March 1995 a satisfaction, grievances and complaints. 2. Make general recommendations that would improve Complete by the Local Initiative's responsiveness to beneficiary May 1995 Commissioner Evelyn Rinzler,Chair, needs and that would improve health status and Beneficiary Issues Committee outcomes(taking into consideration limitations on resources). 3. Consider ways that both the County Local Initiative Complete by and Mainstream Plans can incorporate other county May 1995 services(e.g. Public Health) into their delivery of ...our beneficiaries should not suffer in health care services in order to benefit the Medi-Cal any way in the transition to Medi-Cal recipient. managed care.They should get the best p American medical care that they can get. They should be told whereto go to get 4. Review the work of its subcommittees(SSI,Benefits, Complete by services and if they have any problems,they and Cultural,Linguistic,Ethnic Access)incorporat- June 1995 should know where to go to get them solved, ing their suggestions into formal recommendations to i.e.we are beneficiary oriented." d the full MAPC and Boar (Evelyn Rinzler,Chair,Beneficiary Issues • Committee) 5. Use a variety of methods to obtain additional benefi- Continue ciary input including questionnaires,focus group throughout interviews,hearings,etc. 1995 6. Review the Ombudsperson Program that is part of Complete by San Mateo Health Plan and consider recommendation July 1995 to set up a similiar program for the Medi-Cal Local Current Medi-Cal Population Initiative. Percent of County Population Medi-Cal Population 10% Percent in Managed Care Fee For Service 77% Managed Care 23% -6- SSI Subcommittee County Specific ecific Criteria Draft 1995 Workplan For Private Plans In Contra Costa Goals/Outcomes Timeline: The 16 areas of the criteria 1. Conduct focus groups comprised of SSI recipients in Complete by are: order to hear and document their experiences in the April 1995 1. Public Oversight re services and their suggestions receipt of health ca on 2. Ongoing Member Input n better support their 3. Dietetic Services how the Medi-Cal health plans ca pp 4. Provision of Comprehensive health care needs. Nutritional and Perinatal Services 2. Make recommendations to the Beneficiary Issues Complete by 5• Provider Education Committee based upon input from the focus group May 1995 6• Community Prevention and Promotion Activities project. 7. Access Standards 8. Arrangements for Special Populations 9. Plan's Experience With Benerits Subcommittee Low Income Enrollees 10. Contra Costa County Plan's Draft 1995 Workplan Providers'Experience With Low Income Enrollees 11. Safety Net Providers Goals/OutcomesTimeli• ne. 12. Voluntary Eligibles 1. Review and update the Comparison Chart of Benefits Complete by e p _ p and recommend modifications to the required Medi-Cal April 1995 benefitp ackage which include considerations of cost, financing and any expected savings. 2. Assist in development of an educational campaign for Throughout the use of bothp roviders and recipients about the 1995 to begin benefits of preventive services through the County. March 1995 3. Promote a cooperative community health education Recom- prog ram to be implemented by the Local Initiative and mendations by recommended to the Mainstream Plan. May 1995 • Throu out 4. Encourage integration of preventive services(e.g. gh medical nutrition therapy,immunization,etc.,)into the 1995 by Local Initiative. vanous methods t N// .' / I Maggie Dowling,Chair SSI Subcommittee -7- 1994 MAPC Annual Report CulturLnguistic,i0 And Access Subcommittee ' 199 5 Workplan Goals/outcomes Timeline: 1. Determine a definition of""Cultural tural Competency" Complete b .�� and recommend to Beneficiary Issues Committee March 1995 Viola Lujan,member and Dolores Sanchez, for adoption. Chair of Cultural,Linguistic and Ethnic Access Subcommittee 2. Develop a list of criteria for Cultural Diversity Complete by Training Programs for Providers and recommend to March 1995 Beneficiary Issues Committee. 3. Invite speakers to make presentations on cultural Throughout 1995 diversity in order to broaden members'knowledge on the subject. 4.. Review current CCHP communication methods Complete by with Medi-Cal patients to see if they are culturally May 1995 sensitive and make recommendations to improve them where necessary to the Beneficiary Issues Committee. rovider Affairs Committee Draft 1995 Workplan Goals/outcomes Timeline: ' 1. Review and provide input on CCHP requirements As they are and model contracts for community providers. developed by CCHP a 2. Review and provide input on CCHP community As they are provider selection criteria. developed b p Y CCHP 3. Review and make recommendations ' � dations on the relation- Throughout 1995 ships of community and county providers to the Local Initiative(including requirements for quality, Heather Saunders Estes, Chair volume,efficiency,accessibility,and cultural sensitiv ProviderAffairs Committee ity issues . 4. Consider model reimbursement arrangements that Complete by include a discussion on the pros and cons of various June 1995 risk arrangements. -8- Access Committee Draft 1995 Workplan r' 4si Goals/Outcomes Timelioene. 1. Consider clinical assessment regarding access to Complete by local community hospital services and the use of January 1995 centralized facilities. 2. Review recommendations made by the SSI Complete within ° Subcommittee upon completion com letion oftheir SSI Focus 90 days of project by Group Project.ect. completion Michael Lawson,member of Access • Meet b May Committee 3. Meet Jointly with the Beneficiary Issues Commit- Y Y tee in order to coordinate recommendations on 1995&complete access to reflect cultural and linguistic concerns by July 1995 in addition to those of time,transportation and distance considerations. 4. Assure"confidentiality"is maintained to eliminate Complete by fear as a barrier to access and develop recom- March 1995 mendations to address this issue. 5. Listen for the concerns about access problems Throughout 1995 from public comments at MAPC meetings and MAPC hearings in order to be better informed about these issues and consider suggestions for remedial action. 6. Review drafts of detailed design application Complete as relevant sections. sections are drafted J 1,. 7 -9- 1994 MAPC Annual Report Mainstream Plan Committee Draft 1995 Workplan Goals/outcomes Timeline: 1. Interview potential new players i.e.private plans Throu out interested in securing Medi-Cal managed care 1995 as they contracts as the emerge. emerge y g Jack McGervey,member of Mainstream 2. Evaluate these potential new private plans as to their: Plan Subcommittee a. willingness and capability to serve the special needs of Medi-Cal enrollees; b. their plans for relating to safety net and tradi- tional providers; c. how well they meet the criteria established in MAPC County Specific Criteria for Private/ Mainstream Plans. 3. Make recommendations to MAPC based on these evaluations. l 1 r; k1 1F` -10- • a aV � � C H a � S arm d d tl1 V N ........... .......... r4 y 000 "W. CD o a �= X(UPI RS � to o a c) N v � OCD Q 7" + N ? cfl NNNN r p G o °? � �' cty� r � o r/'* W TOO 0 _ i�+ 1 .•- CIO Via! 0 3� Y .w o u r �= �.. trccs � t? 6000 a C: 2-• c1� TOO � o �Y � o o a. o � v _ c o 0 _ ai = of v Ln >- � C)- - N Qi E c E c mcE•.. v 6 v c a E a v v C; U o D .... u 0 = v � _ U 0 u -6 4 0 s O Q _ ° a a pw p < o U a � J �} t3 c C� p oc LL, I 0, a Ln ; ! u o 4 E o > = Tc " s a ° o r� . o U6 .� o s � a � c ' � an a a IW6Ln LC n v o T o o -c F— i (.n -� 4) V • U N > C ? LO a 3 � 0 v, a) to a� w v 4� a Ln 40 — s w a cn °� 16m NJC M `'� 0 Yz o. , to ' s N � o 00 .y l O O0000 woo a O O v uo ?.. d� u • W IA infj i I )I a � •m 0 i4m IL 0 16 c V • o Fm '�.■ CL .,.., ( V Elia Q Q a U. VAc 0 a LnCL s �-+ � LL u� Q 0 o of �•..� _ ._ .i cn r. •� M i N Lm o i.. > a. C 0 OO N O O t E n ,\p .� p O .... O .M o a tt t N Z, A.-' • O a0) p o z .► O ,C1Q� O��? N co .►-� .r+ M -C.: Ca 0 i o ' CC5 ` .. t*7 c w a 1 a � .o M N � 0 � Contra Costa County Top Six Medi-Cal Providers Rank Order Medi-Cal Payments - Fiscal Year 1991/92 for AFDC Linked and MIC Eligibles Hospital Physician Inpatient and Outpatient Groups 1 . Nferrithew Memorial Hospital 1 . Merrithew Memorial Hospital and Clinics and Clinics 1. Brookside 2. Antioch Medical Park 3. Los Medanos 3. Richmond Pediatric 4. Delta Memorial 4. Nfedicus Medical 5. John Muir 5. Allergy Specialists 6. Mt. Diablo 6. Vale Anesthesia Nferrithev,, Memorial Hospital and Clinics was the largest hospital and physician group 'Medi-Cal provider in Contra Costa County. Source: SDOHS Afedi-Cal Acriviry, Reports by Provider 1991192 • $ � y � � v° � = W = aa L i = V a O V V • i:f; ...�... •}:VtA j:f:t�{i;.;f:.?•i1;?:':Cll,:.'.:'.�::.•!.!:!. ;�?!!::::::��':;t:.:•••.: t':fJ:.!! .. :•r:.;.%l:h}{If�rii:a;}7?Yji�: i}i.{} i:;;h: ... ::N6^.:�::i5•::•• •.'}:Y;i:{:.}iii; i:;}?ri {Sy.;�i-}}}::i"%:t! !ir'f''�v,?rJ;':J,•;t i;cti.,•Sy,.;:,••...':.::?• ?'�ll'::;�}�%'.�r .. .. ��t i.f` R•+;:t'Sri,g4,i'ctNih!tf.:?;!:.:;��:lr•fr: .•:SSC?:?':?}:.;:2?ti!;},•, 'T�'�It'lS.t�l�f4•1�.��.thti:h:T.•;:!1.�::!•::.!:�:tf•?,?? t :. c}'!•tsyiuv�;vr{r;r l:•:y!::r?}k}• i'r;? • ......... •.;SHIN,'%:}5'%:{?:;vt'??}:??_vr:'�%�•' }:: ;�?t:�•t,Nlrjtj 1.rlJyr"t',! :!:'� •:•t::�f?{•�yi:r%% }.J.;l ♦::?:ht"'��t:lYft�..., ••f Y:t •::Yi':l�'ti�: t. ':•'i:i.y:J h :}.. !:cif??• .T r., •r s:..;;:iiil •••• iit:` ..t::;:::?'•-:'is y!:"::V:i•'' .i. '•irrriC•:i:i}r •v7:i{%ii;:i{?}::i:}i Srry{i:' rr? ?rf:: • t t •t t ;�yi..!:.;:t'%!:: ;!,l+••%??':t.:',;- ::'i.1h. .....!!fit!}r:.�.:. r{{i':;:¢::;;?::.;S'ri'{S;ii?ii: '4Sii??•iii:• '•istt,?.:;f:i;:i:t:Y;::':`"..!:.......... y,f,.;?:...:ii:r?i ri:i::.i: ... .::{'C:•;tiiis??:::f,y.t. t.;.''li jt,%;:?':ii: !i!S:t:tJ:?::?•}::?;?':::;.'::'�::'::•::::.,.• •iil,?•� . iitii!::}i. •:h•?S�tir::!!.•ii?:.;:.- >iiFi?�} _ •:if -':i.:?i'$:;N�;N17.?r::ifi::;:}};.:ii.i?{:iiii::::�{::I•`i's•?;_•.;� }:fl ':;:f{; .,. ..�r,..i••;ffNriti'}}F.:S:fi:;i}::.::.:};{.. :'?{:�{S.f•;iiriii;tir:it}Yfi::::SsY;{r,::?.i:;iiii;;�{'{i;':i}ii; :•ir• ;.}}?;.;?ytifftf;�lEtl::{:{titr,.�?r'n,�}:::?':.':i:•:y'i: i::!' .• :Slli.i::ill:�lf,.!.;!;i;. :?:'''fl}.-l•.s'!..::ii�• Y�f:::•:i•:l ;�;tl'!Ati7.:?%{�i:?r'1t Y.!ti:1i•tX. ..,..•h'�y .�il-• ;vir;{1,G}{t.'ls'f tt�ir7.,•r}iG:.�;} • iii o r 0 V 0 G O V c a Z -o v o -a t 0 G Ottz pas CA � z r'o .� r Q G Q o ♦ 100 a 0♦ O '" O 4' O, H i 3 00000 a ,� a 00000 N 00000 W W r 0000© ® El M� CL y a � C c x a X000000 -Q w000000 - ,� a �n 000000 000°0°0000 °d G ° N c, • Q? n ° W 0000 Q n 0000 ` Im 000 000 o 0� � U a 0 C �✓ t`j � J 7-+� E O00000000000000000000000000 000000000000000000000000000 � o N000000000000000000000000000�{ C 000000000000000000000000000C a O 0000000 0000000000000000_�Ov_ ^�r`0000n o- L L 0 0 0 0 0 0 0 0 0 h 40 u9 d' M N r � 0 u -%`'�, c f '� -� � \ � °, � o ,� ... � �� '� t� o i p � O G � v o �'� o. s n� o �; � CCS � = T Y • J ../ r � ! v C..0 // o ` J � Q '�. L� r � ,. rr i ""� X lJ � � N f '� � "J << � - � y � CCS �, �� _ +� G- � �„'"` v � �' � y ..� 0 i � C1� v � � `'' � �- �� c �. � v `� i ;� �� � c ;.' �% fl c nn,, T _ � U � '� � ,� F��r � �`�� ...,,,, ,- cam: 5 .� 2 L. _. r ,���,3 D- '�. /" ..� _ Vim,----- � H B m `4 M W d %0 �3 ® ❑ 0 C N CL co M O a o V co C4 IA O �y wco\° 0 M o r �• ON LM- _ �.. O W V ° N a • � M � 4i 0 0 0 0 0 0 o a o 0 0 O Off► O�0 h %0 LM 'd co) N C Icjol 10 aBcNU93a8d o r d s S 0 0 So IPO V y 7 � O• s � w. O o •� �- a o V �• too c 0 900 goo 0 o 0 o .• -° � o o � � a6olua��ad i Z G .s 7 Z V O C� ` G - �• .z o • a � a � ani o � V a a V = 0 O � V • Tom Torlakson ' - 300 Eas' Le!anc Rcad S peri scr. a stnct Five Suite 100 ontra Ccsta County `-- P t'sbury. CahIcrn.a 9.4565.436 i card of 5.;:)erv;sars �—'`- (510j 427-8138 June 21 , 1993 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 : This is to advise the S~...ate Department cf Health Services that the Board of Super­risors of Contra Costa County voted unanimously on June 14 , 1993 , to express its interest to , develop the local ' initiative for H'edi-Cal managed care in `- Contra Costa County. The Board also approved establishing a 25-member Medi-Cal Advisory Planning Commission to assure broad provider, consumer and corLmur.ity input into the planning for the local initiative . The Board of Supervisors will send its for7,al letter of intent by September 30 , 1993 . Sincerely, Tom Torlakson, Chair Board of Supervisors TT:BB:gro • � � N 000 � Q C6 � N7 ja (f) CP .� o = s woo, 40 woo 00000 (1) 3v 0 � C13 0 N Z # � • 0 v t0 o Ln C6 s• Q ,,,. slowd polo" tU y. 7 t4 0• a, to � 0, cn to •� s• t3� _ o ,,,� cv � � •'' � � N 7 �q C.� 'co U 2 NVOO • , ,, �, vo too cCS Effect of Enrollment on Utilization For every 1 ,044 AFDC members, there will be monthly: i ................................ 256 outpatient visits ....... 63 emergency room visits ........... 22 hospital days 'I For every 1 ,000 Other Medi-Cal members, there will be monthly: ................................ 443 outpatient visits ...........................0.... 74 emergency room visits ..............................0. 131 hospital days L Ci tCt � L -600O� OWN V , a� x , pC: �3 L � *Ono woo G„ Q � C UU o11 UU i p ' r s •+� L � mom IA C6. 0 » V .Q me won v i V ' c C v T C C: 0 3� > GC6G G r rD too C G C G C > O v C G y a 1 0 a � � c s2 Z s t a U v ti N o V u w a u U as N a ,. s 0 Q r r N 0 m = W U O d Z w 0. CP 0. .. i0 C t- C � � a N 'O � � a•► Q Qa N � ca C vi as C''"� JO) U "Ot1 O tQ � t0 O d N o i U ~ i. d TCA �'.� '0 i I► ate.. 3 � � 'C3 ° ea C c a _ 1EN ' •r- CL � d 000 v � °' o• a � �• ca �d 0woo 'C y► t6 tli r � N WON 't3 •0 N O C y i S, w 05 S C00 Z ate. am �+„► �• T cc N bs, -0 ass bw z 3 4) Blow b. sow> � =N r� co 4co ) — l0. 0 U U CC CL Mr- r- r- r- ,.. O MU C- VOO CD S Cf -oco m N o N U. C d d citi' > CO bo bom � 0 � � .z m so w s� >� •� b.boo 0 d c ca bm IMP -0 tly c v gid _ fop G .p t� boo IUD) .�3 ( o i - tNd c�- Us a. N c3 ._ „_ ._ p U ca RS G • t3 owom O d C ? CsoIWO cz _ m p •r m y = W Q z V woo omm sm -a ca o. U U dmf M � a m W N e- "� � �� i F J r MAPC Medi-Cal Advisory Planning Commission 595 Center Avenue,Suite 100 Martinez, CA 94553 (510)313-6 FAX(510)313-6 004 002 MEMORANDUM comwSsroArERS Margaret Dowling March 28, 1995 Claudette Garner,M-FA Paul Kat: TO: MAPC MEMBERS Joan Lautenberger,R.N. Michael P. Lawson FROM: MAPC EXECUTIVE COMMITTEE Rosalind Love Viola Lujan RE: RECOMMENDATIONS FOR A Suzanne MacDonald MANAGED CARE COMMISSION Gary B.Marcus,M.D. The Medi-Cal Advisory Planning Commission (MAPC) was created as a Stephen Heisler,MD. planning body for the County sponsored Local Initiative. We were charged Bessanderson McNeil,M-PR. with the responsibility to make recommendations that will be used in the Cynthia Miller planning of a new system of managed care for Medi-Cal recipients. We've Janiece Nolan,MPA,Ph.D made great progress in the year we have been in existence. MAPC is Tony Paap scheduled to be "sunset" (i.e. go out of existence) early next year. With hAft Raymond L Smart mind and in light of the fact that the MAPC and the CCHP Advisory Board M. Henry F. Tyson dealing with the very same issues, we decided to explore a possible reorganization. We searched for a way to continue the work of the MAPC and EXECU77VE COADf= provide an opportunity to achieve the goals we have set so we can have a more Michael G. Harris, O.D.,J.D.,M.S. effective means to managing the care of Medi-Cal recipients. Rev. Curtis A. Timmons,BA, Tka The CCHP Advisory Board and the MAPC met several times, met together, Heather Sounders Estes,M.S.W. and formed a joint work group that met several more times in order to Evelyn Rinzler,MA formulate a plan of restructuring. Options were examined with the assistance Mary Lavender Fujii,U.S.R.D. , of Dr. Henrik Blum who served as a consultant on the project. It was of utmost importance to those of us on the MAPC delegation that BOARD OFSUPERYLSORSLUISOM consumer/community input continue in a formalized manner. The committee Am Rogers structure that is being proposed provides the opportunity for existing MAPC Tom Torlakson members to continue the work we have begun as well as contribute an "institutional memory" to a new Managed Care Commission. The following recommendations are a result of a wide variety of perspectives. They have evolved as a product of many changes through discussion and understanding of our purpose on this commission. These recommendations were adopted unanimously by the CCHP Advisory Board; unanimously by the Joint Work Group which was appointed from both the Advisory Board and MAPC; and unanimously by the MAPC Executive Committee. As you look this ov we hope that you will think about what is in the best interest of the beneficiaries. We believe that this new managed care commission proposal reflects the basic concerns of the MAPC and hope that you will lend it your support. C C H PAdvismy Board Contra Costa Health Plan 593 CenterAvemu,Suite 100 red 9,x353 (310)313-600 INTEROFFICE MEMORANDUM 570) 60 FAX(310)313400? BOAW HenryF.Tyson,awr To: Michael G. Harris, Chair Date: March 9, 2995 Michael Garcia, roes cAwr MAPC Bobbi Bonnet,RX.,MPA Fronts Crrseme From: Henry F. Ty , Chair Subject: Proposed Managed JdrrvyA Xatin CCHP Advisory Board Care Commission Paul Katz Jack MtGerwy ,A)""Willan At our meeting last night, the CCHP Advisory Board extensively discussed Lisp y"', the recommendations of the Joint Work Group as contained in the attached report. The Advisory Board unanimously endorsed the report, including all of its recommendations, and look forward to being able to make a joint presentation with the MAPC to the Board of Supervisors at the April I I workshop. Please let me know if you have any questions or need more information. JM:BB:km Enclosure: HLB Report 3/7/95 4/28/95 Henrik Blum, M.D. Restructuring the CCHP Guidance Mechanism in light of the impending Local Initiative changes required by the State Medi-Cal program and the advent of intense competition for Medi-Cal enrollment by managed care organizations. Background The Recommendations for a single advisory body for CCHP were worked out with its Advisory Board and MAPC for presentation to the Board of Supervisors because: • The State Medi-Cal program is moving the bulk of the Medi-Cals into managed care. - In Contra Costa County there will be two or more private HMOs competing with CCHP both for those Medi-Cal now in CCHP and for the non-enrolled Medi-Cats who must select an HMO within the year. - There will be rigorous competition to sign up all these Medi-Cats between CCHP and the well-financed and free-wheeling non-public HMOs. - A county-run HMO like CCHP has to overcome the current stigma of being a govern- mental entity, no matter how superior its services might be or how efficiently it oper- ates. • CCHP needs to obtain a new level of rapid decision-making in order to make critical service and operating decisions that will allow it to meet its competition. - This is in major part dependent on its ability to obtain unified guidance in a more rapid fashion than is now achievable with its two advisory bodies; the Advisory Board and the MAPC. - The work of the Advisory Board and the MAPC inevitably intersects and has to be brought into meaningful agreement if CCHP is to move forward. Yet these two bodies are so oriented as to see things very differently and it becomes a time consuming and wasteful process to match up advice until each can be brought to see the position of the other. CCHP no longer can afford these built-in delays in decision making in what is a newly charged competitive environment. * If CCHP cannot change its policies and practices rapidly in order to maintain its attrac- tiveness, it will not only fail to maintain its competitive position, but will lose current subscribers. Loss of current members to other HMOs will not be easily overcome as has been shown by the competition between other HMOs in the East Bay. CCHP is too small to take a significant hit in membership. The consequences of less volume will be an increase in unit cost. As CCHP loses its Medi-Cal clients, it loses 0, much of its economic base and will soon be constrained to being less rather than more competitive at this critical time. This can result in a disastrous decline. A decline in CCHP membership and competitiveness also means less volume for the County Health Services on two fronts; 1) less CCHP volume and 2) a loss of non- CCHP Medi-Cal clients who currently come to County facilities, but as they join other HMOs will be getting their care elsewhere. These losses will increase County operating costs because the County must continue to care for Contra Costa's medically indigent even as its unit service costs go up. The County Government should continue as the major policy force in CCHP for some years to come. Because of probable but presently unpredictable changes in sources of funding, eligibil- ity criteria, extent of financing for Medi-Cal and indigent persons, it seems imperative that the County remain a key player and policy maker in the Contra Costa health care scene and that CCHP not be "turned loose", e.g. into for-profit, joint powers, or even a health authority or non-profit scheme at this time. Recommendations 0 A. CCHP continues as part of County government and as pan of the Department of Health Services. B. The Guidance machinery of CCHP must be streamlined by combining functions of the present Advisory Board and MAPC into one entity, such as a Managed Care Commission (MCC). C. The MCC takes on all the functions of the current Advisory Board and MAPC bodies. D. Meetings of the MCC and its committees are open to the public, consistent with the Brown Act and County statutes. E. Functions and duties of the proposed MCC: 1) Cover the health care concerns for the Medi-Cal, Medicare, Commercial and Medi- cally Indigent persons served by the County. 2) Assure provider, consumer and community, as well as gender, ethnic, cultural and geographically diverse population input to deliberations and decision-making. (The Board of Supervisors does this by its requirements for membership on the MCC, and the:MCC does likewise by its appointments to its committees.) 3) Do long range planning, policy formulation. Make goal and policy recommendations to Board of Supervisors, County HSD Director and Executive Director of CCHP/ Local Initiative, to include plans, development, goals, policies, and organizational structure. 4) Study and make recommendations to the Executive Director of CCHP on operational objectives, policies, procedures, to include (a) community and patient outcome goals, and specific measuring devices, (b) provider relationships, and (c) community health needs and how they can be addressed. 5) Assure effectiveness, quality (including good outcomes), efficiency, access, accept- ability of CCHP services by ongoing as well as periodic formal reviews of utilization information produced by an up-to-date Management Information System and other sources. 6) Regularly review and evaluate the CCHP budget, amendments thereto, contractual commitments and recommend changes as well as revised service, product develop- ment, marketing, and data gathering priorities. 7) Review, analyze and advise the Board of Supervisors, HSD Director and Executive Director of CCHP.of the overall progress, constraining or threatening needs and special problems of CCHP. 8) Encourage public understanding of CCHP and provide support throughout the County for its development. 9) Prioritize and assign issues to appropriate committees. Some issues will cross com- mittee lines and the MCC will resolve any differences. F. Structure and Governance of the Contra Costa Health Plan/Local Initiative: Board of Supervisors 15 Member Managed Care Commission Ad Hoc Executive Committee — Committees Membership I Medi-Cal subscriber I Medicare subscriber I Commercial subscriber I Person sensitive to Medically Indigent health care needs I Physician, non-contracting I Other Provider, non-contracting 9 At large members, non-contracting 15 - HSD Director, non-voting, ex-officio - CCHP Executive Director, non-voting, ex-officio ------------- Health Care Product Member & Planning, Delivery/ Finance & Development Provider Consumer Governance, Quality Administration & Marketing Issues Advocacy By-Laws Maintenance G. Names and Functions of the Six Standing Committees: 1) Health Care Delivery and Quality Maintenance Study outcomes of delivery approaches, of regionalization of services, of modes of access, of modes of treatment and of follow-up to determine if desired objectives are met. Make recommendations. 2) Finance and Management Study budgets, expenditures, income streams and discrepancies between budgeted versus actual occurrences. Create and maintain up-to-date financial practices. Main- tain forward looking personnel practices. Review and coordinate with County busi- ness and personnel practices. Make recommendations. 3) Product Development and Marketing Study needs of current and potential subscribers for scope of services, scope of benefits, coverage, price, access, acceptability, satisfaction including concerns of providers. Examine patterns of enrollments and disenrollments of CCHP members and of competitors. Study alternative procedures. Make recommendations. 4) Provider Issues Determine and analyze issues of recruitment, retention, satisfaction, loss of provid- ers, as well as factors affecting productivity, patient relations, means of covering hard to serve areas, seniority, bonuses, termination, interprofessional relationships, utility of teams, travel, referral and specialist issues, as well as provider concerns regarding facilities. Make recommendations. 5) Member and Consumer Advocacy Obtain feedback from current and potential subscribers, analyze issues raised, also trends of difficulties and desires, geographic, gender, ethnic and other facets of consumer concerns, and cover access and beneficiary issues, overview grievance procedures. Make recommendations. 6) Planning. Governance and By Laws Crucial long term function is to carry out continuing study of impending and threat- ened Federal and State program and financing changes and their relationship to CCHP growth trends and functional needs. Create plans accordingly and recommend policy, structural and governance changes, as well as strategic plans. H. The Executive Committee Details on its role as a creature of the MCC and its membership and functions can be worked out by the MCC once it is constituted. At least one member is a subscriber member of the CCHP. I. Ad Hoc Committees These are created by the MCC for special issues or concerns that do not fit into the work of the standing committees or that may involve several of them. The assignment, membership, and duration will be set by the MCC. J. MCC Membership 1) The Board of Supervisors as a whole make the appointments to the MCC. 2) The Board of Supervisors appointments reflect the County's ethnic, cultural, gender and geographic diversity. 3) Members of the MCC should be appointed who are dedicated, health-care interested, capable, public-spirited individuals, who want to make CCHP an outstanding health care provider. They are voluntary, unpaid positions, but actual and necessary ex- penses are to be reimbursed. These people would not be selected because they fit any specific skill or area of expertise, nor would they represent contractors with CCHP. However, a list of desirable capacities is attached to be used in making the choices for the members to be appointed. These are in no way prerequisites for a position on the MCC, but do bring valuable areas of experience to the MCC when present in a suitable candidate: Ambulatory care Business interests Consumer advocacy Evaluation of outcomes Finance Health care law Health Issues: children, women, elderly, cultural, ethnic, linguistic, disabled HMO administration Hospital administration Labor Marketing Nursing administration and practice Nutrition education and services Personnel Public health and prevention 4) Persons who are involved as contractors with CCHP cannot be members of the MCC. 5) In the first round of MCC appointments, the Board will appoint a majority from current members of the Advisory Board and MAPC bodies if there is sufficient interest among the current membership. 6) Once selected by the Board of Supervisors, the 15 initial appointees will be chosen by lottery, 1/3 for I year, 1/3 for 2 year term, and 1/3 for 3 year term. 7) Reappointment can be made to a maximum of 2 consecutive full 3 year terms. Subse- quently, after an absence of 1 year, a former MCC member can be appointed for a full term. 8) The current chairs of the MAPC and CCHP Advisory Board will be appointed to the MCC as part of the majority who are drawn from the current MAPC and Advisory Board. They will serve as interim co-chairs of the MCC for a period not to exceed 4 months. They will appoint the initial chairs and members of the MCC standing committees. The MCC will elect its chair once the co-chair term is over. 9) A special recommendation committee of 2 members each from the MAPC and the Advisory Board, plus CCHP staff, will recruit widely for MCC applicants, assure that all applications including those of current Advisory Board and MAPC members are forwarded to the Board of Supervisors, and recommend to the Board initial members for the MCC. t 10 There are 4 consumer members one from each of 3 CCHP consumer groups, Medi- ) g p , Cal, Medicare and Commercial, and one person experienced in and sensitive to the needs of the medically indigent, as from a local church, legal aid or other community group. l l) There are 2 non-contracting health professionals; one a physician, one other health care discipline. 12) The Director of Health Services in an ex-officio, non-voting member. 13) The Executive Director of CCHP is an ex-officio, non-voting member. 14) The Board of Supervisors function as ex-officio, non-voting members. 15) MCC committee chairs are appointed by the commission chair (co-chairs) and shall be commission members. 16) Committee members are appointed in the same way, but need not be MCC members. K. Work of the committees, once accepted by the MCC, would be the basis for MCC advice to relevant bodies. L. Next Steps for the Advisory Board and MAPC 1) The document agreed to by the joint workgroup at its March 6, 1995 meeting will be presented to the Contra Costa Health Plan Advisory Board for a vote on its approval at its March 8th meeting. 2) The same document will be presented to the MAPC Executive Committee for ap- proval and to the full MAPC for a vote on its approval at its April 6th meeting. 3) A joint presentation of the MCC proposal will be made to the Board of Supervisors at the April 11 workshop by chairs of the two CCHP advisory boards, Dr. Henrik Blum, with assistance of CCHP staff. 4) If and when the Board of Supervisors accepts the proposal, they will have it fleshed out with the level of detail and legal phraseology that allows the MCC to replace the Advisory Board and MAPC. a k\hb1um4.pmd G F I o � 1 _ _ q kn�r twa , s � a r i f�;�ast N kk '' �te'�'F'"�k'',�,j x't,�� .�.� ` q�c4.,� +''' � h•r r,_ �t�x �'ti1'� �,.. � �., r=..?i i'�.ar:'�'� '3-.r I"f^ri �.t.F,,•i ; ' t (� t �„� t "t r r r : } .dry QUALITY OF CARE IN HMOs: A REVIEW OF THE LITERATURE tumm, The legislative debate and writings in the popular press about health care reform often include anecdotal accounts of poor quality care in HMOs.These anecdotes rest on the common sense proposition that because ID40 care is less costly and because its financial incentives may encourage less intensive care,the quality of care and resulting patient outcomes should suffer. The California Association of Health Maintenance Organizations(CAHMO)commissioned a review of the literature on the quality of care in HMOs in relationship to traditional indemnity insurance .coverage in order to determine whether these anecdotal and common sense arguments were borne out by independent research findings. CAHMO believed that a broad review that summarized the trends in the findings of the literature would be useful to policy makers.To assure a minimum level of methodological adequacy and objectivity, only peer-reviewed studies in major journals were examined.The over 80 studies reviewed included a number of large multi-site studies,the major evaluations of managed care programs for the Medicaid and Medicare populations,studies of the outcomes of care for specific diseases,and assessments of the quality of preventive care. This review concludes that there is no pattern of evidence supporting the proposition that the quality of care in HMOs is inferior.The research findings confirm the alternative hypothesis that the quality of care in HMOs is at least equal to that found in the indemnity insurance sector. This paper presents in summary form the results from this body of research. m.mr-mmi-r-1-sm Scope of the literature review. The purpose of this comprehensive review of independent research was to determine whether there was a pattern of evidence of inferior quality of care in HMOs vis a vis the traditional indemnity fee-for-service system.The intended product was a relatively short paper that summarized the major conclusions in a format that would be readable by policy makers. To ensure an adequate standard of objectivity and methodological soundness the review was limited to articles appearing since 1980 in major peer reviewed journals that contain evidence on the issue of comparative quality of care in HMOs in relation to indemnity plans. Over 80 studies were located that met these criteria- Only statistically significant results are reported. Many of the studies have methodological problems,and almost all are limited either in the scope of the population studied,the length and extent of the follow-up of study subjects,the comprehensiveness of the outcome measures used,and/or the extent and nature of statistical control for initial group differences in non-randomized studies.Because of these general limitations, consistent patterns of findings across studies were sought.Greater attention has been paid to the results of the few large well known studies that because of their sounder methodology, comprehensives,nature of the population studied,and/or the stature of the researchers are most well known and carry more import in the field.Additionally,considerable weight has been given to a 1994 review by Miller&Luft that included only studies that met rigorous methodological criteria including"reasonable attempts at statistical adjustment for non comparable managed care and indemnity insurance enrollees." Ttvo.types of studies have not been included: Studies that document differences in utilization and/or costs with no measurement of quality of care indicators. Studies that compare results across HMO model types with no comparison to the fee-for- service sector. HMOs differ from the traditional indemnity insurance system on a number of dimensions including the usual scope of benefits,the nature and amount of cost sharing,and the organization and financing of the service delivery system. Separating the influences of each of these differences is a large task which has not yet received much research attention.While authors speculate on what features of HMO care might have led to a particular result,most of the studies done so far simply compare the results of care in one or more types of HMO to a group of patients enrolled in a variety of indemnity plans. Therefore,this review does not address the issue of the specific effects that the scope of benefits and extent of cost sharing undoubtedly have on the kind of care that is delivered under alternative types of insurance plans. Terminology. i Adding to this complexity is the evolution in the last few years of the concept and practice of managed care and traditional indemnity insurance.The distinction between HMO and fee-for- service financing and organization of care is no longer as simple and straightforward as it was when the earlier studies reported here were conducted. Now there are elements of alternative financing arrangements and management of care within traditional indemnity plans,and elements of fee-for-service reimbursement exist within some HMO models. This paper generally uses the terminology of the studies being reviewed,thus referring often to comparisons between HMOs and fee-for-service.The review uses a more generic term "managed care"for those instances,largely in the Medicaid arena, in which the prepaid system studied does not have all the features of a standard HMO.It also indicates,as appropriate,the HMO model types that were included in the study. The comparison fee-for- service system in all the studies refers to care provided under indemnity insurance coverage. Types of quality of care. The variety of measures used to assess quality of care can be divided into two general categories: 1)assessments of the process of care and 2)measurements of the actual outcomes of care. The ultimate test of the quality of a system of care is the health outcomes for its users.A wide variety of measurements have been used in outcome studies including rates or risk of mortality,physiological health status variables such as blood pressure or blood sugar levels, nature and degree of symptoms,perceived health status,and the extent of functional impairments. Methods used to assess these include physical examination,review of hospital and physician records, and physician and/or patient.questionnaires. When assessing outcomes is not feasible researchers use process measures as proxies for outcomes. Process measures are most valid when they have a demonstrated relationship to outcomes.Absent this,process standards are often based on the opinions of expert panels or 2 on the accepted standard of care in the field. For example,Carlisle, Siu,Keeler,McGlynn, Kahn,Rubenstein&Brooke(1992)used a panel of experts to establish a set of standards for the appropriate treatment of acute myocardial infarction and then assessed HMO and indemnity insurance care against these standards. The appropriateness standards for preventive care,for example for the use of screening tests, are often based on the recommendations of expert panels that utilize all the available empirical information on the relationship of the timing and intensity of preventive care to outcomes. Patient satisfaction. The fairly extensive literature on patient satisfaction has not been reviewed in depth since it is complex and of less importance to the issue of quality of care than actual process and outcome data.Included here are the patient satisfaction results in the major studies reviewed and useful summaries or insights from a few patient satisfaction review articles(Cleary& McNeil, 1988;Davies&Ware, 1988;and MIller and Luft, 1994). Organization of the paper. This review is divided into the following sections: • Conclusions from two review articles on the work done before 1980; • Results from the Rand Health Insurance Study(HIS),a seminal study in the field; • Summary of findings from smaller scale studies on specific disorders and on prevention; • Results thus far from the Medical Outcomes Study,a major current study-, • Findings from studies on the Medicare and Medicaid populations; • Results from measures of patient satisfaction; • Brief discussion of the relevance of the study findings. Early studies concluded that the quality of care in HMOs was at least equal to that found in the fee-for-service sector. Luft(1981)and Cunningham&Williamson(1980)reviewed studies published from the early 1950s to the late 1970s that compared the quality of care in HMOs to that in the fee-for-service sector. Findings on outcomes suggested little difference between the HMOs and the fee-for-service sectors. The evidence suggested that the structural(facilities,staff,monitoring systems)and process (suitability and timing of diagnosis,treatment,and follow-up)components of HMO care might be better than that available in the fee-for-service system.Luft(1988)attributed the better performance by the HMOs on these process measures to the more organized structure of the physician practices in the early HMOs. For example,the HMO medical groups had more systems for review of physician practice and better record keeping protocols than did physicians in solo practice. The Rand Health Insurance Study(HIS)found the quality of care in the HMO studied was comparable to that in the fee-for-service indemnity plans. The Rand HIS was a large randomized controlled trial of the effects of alternative methods of financing health care conducted in six cities during the 1970s.A series of reports on the HIS appeared in the mid to late 1980s. One component of the study consisted of comparisons between persons randomly assigned to Group Health of Puget Sound, a well established staff model HMO, and persons assigned to either a free(no copay)or a variety of copayment fee-for-service 3 indemnity plans in the Seattle area.An HMO control group of persons who had voluntarily enrolled in Group Health was also included in the study. The results are summarized below. I Preventive services. Adult enrollees in the HMO hada higher number of preventive ambulatory visits than the free and cost-sharing fee-for-service plans(Manning,Leibowitz, Goldberg,Rogers, &Newhouse, 1984); and children in the HMO had more preventive visits than those in the cost sharing fee- for-service plans(Valdez,Ware,Manning,Brook,Rogers,Goldberg, &Newhouse, 1989). Health status outcomes for adults. The overall results on health status for adults indicated little difference between the randomized HMO and the fee-for-service groups.As Brook, Kamberg,Lohr, Goldberg,Keeler &Newhouse(1990)conclude the study"supports the conclusion that on average the HMO we studied did not adversely affect the health of the average patient." One result from the Rand HIS received considerable publicity as a potential negative finding for HMO care and is still frequently cited.The fust report of outcomes for adult enrollees (Ware, Brook, Rogers,Keeler, Davies,Sherbourne, Goldberg, Camp&Newhouse, 1986)on 13 health status measures showed no differences between the HMO and fee-for-service groups taken as a whole. Sub analyses by income and initial health status,however,revealed that lower income HMO enrollees who were initially sicker had a higher number of bed days, more serious symptoms,and a higher risk of dying than comparable patients in the free fee- for-service plan. On the other hand,middle income initially sicker persons enrolled in the HMO had better general health ratings and better cholesterol levels than comparable persons in the fee-for-service plans. A second study on another 23 adult health status measures(Sloss, Keeler, Brook, Osterskalski,Goldberg&Newhouse, 1987)confirmed the first study in finding no differences between the HMO and the free fee-for-service plans on the indicators for the overall groups and found no differences on sub analyses by income or initial health status. The negative results on adult health status were thus limited to one subgroup on three measures. Further,as Wagner&Bledsoe(1990)point out even the interpretation of these three differences may be unclear since there were no differences in physical or role functioning despite the higher number of bed days and no differences on the physiological measures despite the higher ratings on serious symptoms. Health statues outcomes for children. A similar study on the impacts on 26 measures of health status of children(Valdez,Ware, Manning, Brook,Rogers, Goldberg&Newhouse, 1989)revealed only a few differences:the parents in the HMO worried more about their children's health than did the parents who had a free fee-for-service plan and they rated their children's general health lower than the parents in the cost sharing group. The authors of this study concluded that"the results of this experiment neither strongly support nor indict fee-for-service or prepaid care for children.... results support the hypothesis that there are no serious health effects for children receiving care in the staff model prepaid health plan compared to fee-for-service." A series of studies on specific conditions or diseases with one exception either favor HMOs or show no differences in quality of care processes or outcomes. The late 1980s and early 1990s produced a series of studies on specific disorders with a variety of different patient populations. The studies rarely entailed randomization and so utilized other research designs and statistical methods to minimize and/or control for any c(.vifounding differences between the HMO and the fee-for-service samples that could affect outcomes. For example,some study samples were drawn from population-based cancer registries to ensure that all patients with a particular disorder in a given geographical area would be included; some studies 4 compared HMO and fee-far-service patients within the same medical practice to control for differences in practice setting;some studies analyzed all the discharges from a particular hospital or a particular geographical region to ensure comprehensiveness.Regression analysis was generally used in these non-randomized study designs to control for initial differences between the groups on characteristics that could influence outcomes.Additionally many of the studies included a variety of types of HMOs in contrast to the earlier studies that were done predominantly with group or staff models. Thirteen of these studies are summarized in Figure 1.The overall conclusion from these studies is that HMOs perform at least as well as indemnity insurance plans on process and outcome measures related to the particular disorder in question.Some of the studies show no differences in diagnostic or treatment methods and no differences in outcomes. For example,Vernon,Hughes, Heckel&Jackson, 1992,studied 300 patients with colorectal cancer in one multispecialty group in Houston.They found no differences between the HMO and fee-far-service patients in duration of symptoms before diagnosis,the stage of the cancer at diagnosis,the type of treatment,or the survival rates. Some of the studies indicate better results for the HMO than the indemnity insurance groups. For example Carlisle,Siu,Keeler,McGlynn,Kahn,Rubenstein&Brooke(1992)found no differences between HMOs and fee-for-service plans in 30 and 180 day mortality in 1,578 Medicare patients admitted to hospitals with acute myocardial infarction.The HMOs did better on ratings of overall process of care and on three of five specific process measures whereas the fee-for service system did better on one. They conclude that"HMO enrollment of Medicare recipients may have resulted in improved process of care." A number of the other studies find less intensive treatment approaches by HMOs,but no evidence of poorer outcomes. For example,Young&Cohen(1991)reviewed records for 4,972 patients admitted to Massachusetts hospitals through the emergency room with acute myocardial infarctions.Patients enrolled in HMOs had lower rates of arteriography and bypass and shorter lengths of stay than patients in indemnity plans,but there were no differences in death rates in the hospital or within 30 days of discharge. Rapaport,Gehlbach,Lemeshow&Teres(1992)reviewed 548 emergency and surgery ICU patients in one tertiary hospital in Massachusetts and found that the managed care patients with lower severity cases had shorter ICU and overall hospital stays with no differences in mortality or in ICU re admissions. Fitzgerald,Moore&Dittus(1988)report better long-term outcomes for HMO enrollees among 338 Medicare patients treated for hip fractures in one hospital in the Midwest despite less intensive hospital care. The HMO patients had shorter hospital lengths of stay,fewer physical therapy hours while in the hospital,walked a shorter distance before being discharged,and were more frequently discharged to a nursing home.After one year,however, over twice as many fee-for-service patients were in a nursing home(351/16)as were HMO patients(161/16). A recently reported study analyzed differences depending on insurance status in the frequency of ruptured appendices among'all patients hospitalized for acute appendicitis in California from 1984 to 1989(Braveman,Schaap,Egerter,Bennett,&Schecter, 1994).The authors selected this outcome measure because"appendiceal perforation can be associated with severe morbidity and elevated mortality, and it can be prevented by timely treatment of symptomatic acute appendicitis."Those patients covered by indemnity plans were about 20 percent more likely than those in a prepaid plan(all model types)to develop a ruptured appendix.These results held when demographic variables such as age,sex,ethnicity, and community income levels and health status factors such as substance abuse,psychiatric diagnoses,and diabetes were controlled. The one negative outcome finding for HMO patients was reported in another recent study on . breast cancer patients hospitalized in HMO as opposed to community hospitals(Lee-Feldstein, Anton-Culver, &Feldstein, 1994). The study reviewed differences in treatment methods and rates of survival for 5,892 non-Hispanic women from a cancer registry in one California county who were treated for localized or regional breast cancer from 1984 to 1990. Patients with localized 5 1 tumors treated in HMO hospitals had poorer survival rates than those in small and large community hospitals;the comparison with small community hospitals was statistically significant for only the early years of the study. Survival rates for regional tumors for HMO hospital patients did not differ from the other hospital types but those treated in large community hospitals fared better than those in small community hospitals. Studies focused on preventive services favor HMOs over indemnity plans. Figure 2 summarizes the findings from five studies that focused specifically on the adequacy of ! preventive services for various disorders and population groups. These studies range from those involving specific practice settings to a national survey.In the former category,for example, Udvarhelyi,Jennison, Phillips&Epstein(1991)reviewed records for preventive cancer screening and blood pressure screening for 296 HMO and indemnity plan patients in the same four group practices.The HMO patients had more adequate breast and cervical cancer screening and better blood pressure control. The national survey consisted of the Cancer Control Supplement of the Health Interview Schedule which includes patients from all types of HMOs. Bernstein,Thompson&Harlan(199 1)found that on five of the six cancer screening tests studied HMO enrollees were more likely to report having had the appropriate tests in the last three years. ' The major studies summarized elsewhere in this paper support the general conclusion that on preventive services the HMOs studied did somewhat better than the comparison indemnity plan system. Both adult and child enrollees in the HMO in the RAND HIS had a higher percentage of preventive visits than the comparison fee-for-service groups;Medicare enrollees in managed care organizations in the Medicare Competition Demonstration had more screening tests and immunizations than beneficiaries in the regular Medicare system;and there were slight differences in child immunizations and frequency of PAPs and breast exams favoring the prepaid enrollees in the Medicaid Competition Demonstration. The comprehensive Medical Outcomes Study suggests differences in characteristics of primary care services and a potential problem in prepaid mental health services, but outcome data on other conditions have not yet appeared in the journals. The Medical Outcomes Study(MOS)was designed to determine the impacts on patient outcomes from different systems of care, clinician specialties, and clinician's technical and interpersonal styles. The study sample consists of 22,462 patients who visited a random sample of 523 clinicians ' from a variety of health settings in Los Angeles, Chicago, and Boston during a nine day period in 1985.A subset of 2,349 of these patients with tracer conditions of diabetes,hypertension,coronary heat disease, and depression were followed-up for the longitudinal part of the study. Primary care study. Patient ratings from 1,208 of the subjects with the non-depression tracer conditions and for i whom the MOS physician was the primary provider completed a questionnaire every six months fora two year period(Safran,Tarlov, &Rogers, 1994). For this study practice settings and payment methods were collapsed into three categories: group or staff HMO,IPA model HMO,and traditional indemnity fee-for-service. The group/staff HMO patients were more likely to have a primary care physician as the primary provider than the IPA or fee-for-service groups. I Seven characteristics of the process of care were measured. There were no differences on two of . the measures: interpersonal treatment manner and perceived technical skill. Differences on other dimensions are summarized below: I 6 • Accessibility:Group/staff and IPA model HMO patients had higher ratings on financial accessibility than did fee-for-service patients.Group/staff HMO patients had slightly lower ratings on overall organizational access. • Continuity:The measure used was the percentage of time the patient retained the same primary provider,indemnity patients rated higher on this dimension than either group/ staff or IPA HMO enrollees. • Comprehensiveness:The measure was the percentage of visits which were to the primary provider, group/staff HMO patients rated lower on this dimension. • Coordination:The scale consisted of four questions related to how much the patient's primary provider was aware of other clinicians seen and other medications prescribed. The group/staff model HMO rated slightly higher on this dimension. The primary care study highlights the differences in the relative strengths and weaknesses of the different models of care. These results should be viewed cautiously,however,since there were no actual measurements of clinical management or of clinical outcomes and because the measures used do not appear to capture the complexity of the dimensions of care they were designed to assess(Kelly, 1994). Depression study. The only longitudinal results from the Medical Outcomes Study published thus far concern the patients in the depression cohort. • Depressed patients in prepaid settings who are seen by medical clinicians were less likely to have their depression recognized than those seen in a fee-for-service setting(Tarlov, Ware,Greenfield,Nelson,Perrin,&Zubkoff, 1989). • There were no differences in outcomes between the prepaid and indemnity plan groups for the total group of depressed patients or for those seen by medical clinicians or non- psychiatrist mental health specialists.But the prepaid depressed patients seen by psychiatrists did worse in role/physical functioning at follow-up than did those seeing a psychiatrist in the indemnity plan settings(Kravitz,Greenfield,Rogers,Manning,Zubkoff, Nelson,Tarlov,&Ware, 1992). 1 • Depressed patients in prepaid plans were twice as likely to be prescribed minor tranquilizers which according to the authors is a treatment approach of questionable efficacy(Wells, Katon,Rogers&Camp, 1994). Major studies of the Medicare population suggest that the care of HMO enrollees is gener- ally as good as that of beneficiaries in the regular fee-for-service Medicare program. The federal government sponsored a study in the mid-eighties of the impacts of enrollment in HMOs on Medicare beneficiaries. The multifaceted study explored access to care,health status, and the process of care.The access to care and health status impacts were assessed on a total sample of 3,157 patients from 17 HMOs(five IPAs,three group,six staff,and three mixed models) and from fee-for-service patients in 10 other comparable communities.There were no differences between the HMO enrollees and the fee-for-service beneficiaries on either access or health status,, and process measures tended to favor the HMOs(Langwell&Hadley, 1989). • Access to care. The proportion of symptoms that were cited by patients in their initial interview that were subsequently followed-up was not different for patients in the HMOs compared to those remaining in fee-for-service plans. While potentially important,this finding should be qualified by the small sample on which it is based,and the fact that the outcomes were noted in only some of the prepaid organizations in the study. 7 t • Health status outcomes. After controlling for health status at intake there were no differences in reported symptoms or in activities of daily living or instrumental activities of living. • Process measures. The process of care results were based on the review of medical records in eight HMOs(four group or staff and four IPA models)and in fee-for-service physician practices from the same communities. Processes were compared for routine care(N= 1,590)and for resource intensive conditions(N=692 patients with colorectal cancer and congestive heart failure). — For routine care,the HMO physicians took better medical histories,performed more complete physical exams,conducted more screening tests,and provided more immuni- zations. Further there was better documentation of physical exams,histories, lab tests, and interventions with hypertensives. The only difference in favor of fee-for-service was more control with hypertensives at follow-up(46°x6 Vs 60%with poor control). — For the resource intensive care the HMOs were more likely to advise salt restraint and fee-for-service to prescribe medications for chronic heart failure;HMOs were more likely to hospitalize with an increase in angina There were no differences regarding the stage of diagnosis of the cancer or in operative procedures for the congestive heart failure. The conclusion of the demonstration was that the"quality of medical care in Medicare HMOs is no worse and in some areas better"than in fee-for-service(Retchin, Clement,Rossiter, Brown,Brown &Nelson(1992). Langwell&Hadley(1989)report that there was no evidence from the study of under treatment in HMOs and that HMO quality of care was at least equal to fee-for-service for the Medicare population. Clement,Retchin,Brown, &Stegall(1994)conducted household telephone surveys of over 13,000 • Medicare enrollees in 1990,half of whom were randomly selected from the 75 HMOs with established Medicare risk contracts and the other half of whom were selected from beneficiaries receiving regular fee-for-service Medicare services in the same 44 market areas.The study focused on patient reported care for the roughly one third of the respondents who had joint pain during the prior year and the roughly one tenth who had repetitive chest pain.The authors report three findings from the study: ! • HMO enrollees were less likely to report having seen a specialist.The authors note that the appropriate level of specialty referral for these conditions is unknown making this result difficult to interpret. • HMO patients were less likely to report follow-up care or being monitored on the progress of their symptoms • There were no differences in the percentages of beneficiaries who were pain free and no difference between the chest pain groups in the amount of symptom relief,but the fee-for- service beneficiaries still suffering from joint pain reported more symptom relief than those in the HMOs. While expressing some concern about this finding,the authors acknowledge that the lack of an initial measurement of the severity of the symptoms is a I significant study limitation. Studies of Medicaid prepaid plans show no diminution in quality of care. The initial negative finding from the Rand HIS relative to low income/initially sick persons enrolled i in the HMO created early concern about the effects of HMO enrollment on Medicaid recipients.' 2 Parenthetically,the authors of the Rand HIS recognize that their comparison might be misleading as applied to the Medicaid population generally.The physicians who treated the low income fee-for-service patients in the Rand HIS were reimbursed at rates considerably above the Medicaid rates in Washington at the time.Thus any comparison of the low income fee-for-service outcomes to what might be expected with regular fee-for-service Medicaid is questionable. 8 Some well publicized Medicaid managed care demonstration project implementation failures added to these concerns.Medicaid managed care has rapidly expanded in recent years: 39 states offered some type of Medicaid managed care by June of 1993 covering roughly 15°x6 of the Medicaid population(Rowland&Salganicoff, 1994)with an expectation that all but one state would have some type of managed care program by the end of 1994(State Health Notes, 1994). Conducting relevant research on the quality of care in Medicaid managed care plans is particularly difficult. First,the types of managed care programs implemented vary widely and until recently rarely included mainstream HMOs(Witek&Hostage, 1994). Of the 4.8 million managed care beneficiaries,just under two million are enrolled in HMOs, 1.2 million are in other prepaid health plans, 1.5 million in primary care case management programs(PCCMs),and the balance in health insuring organizations(State Health Notes, 1994). Second,implementation is often too hasty resulting in dislocations and confusion, improper financial and management system supports,and general patient and provider dissatisfaction. Third,the need to make political compromises in order to implement a new program often reduces the ability of the managed care plans to operate as intended(Witek&Hostage, 1994). The most significant research effort in this area,the evaluation of the Medicaid Competition Demonstration,explored the implementation and results from a series of Medicaid managed care demonstration projects in six states in the early 1980s.3 The demonstration models were mixed with only a few relying on existing mainstream full risk plans. Outcomes for AFDC mothers and children in two of the demonstration sites were compared against those for a comparable population in similar communities where the regular fee-for-service Medicaid system remained. The demonstration sites were Santa Barbara County'in California (control was Ventura County)and Jackson County,Missouri(control was St. Louis,Missouri). Major data sources were consumer surveys and reviews of patient records.The major results (Freund, Rossiter,Fox,Meyer,Hurley, Carey&Paul, 1989)are summarized below: • There were no differences in the number or timing of prenatal visits,the proportions of low birthweight births,or the percentages of C-sections. • There was a slight trend towards more immunizations within the two prepaid demonstration sites than the comparison sites. • A higher percentage of PAPs were conducted on women 15-44 in one of the prepaid sites and physician breast exams were somewhat more likely than in the fee-for-service sites. • Comparison of the sites on diagnostic practices and return rates for three common ambulatory problems(urinary tract infection,pelvic inflammatory disease, and vaginitis) slightly favored one of the demonstration sites on the diagnostic testing and showed no differences in return rates. • Enrollees'self assessed health status did not differ between the prepaid demonstration and fee-for-service sites. The authors conclude that"...the presence of a capitated, case-managed program did not appear to significantly harm the health status of the individuals enrolled."It should be noted, however, that the study highlighted some generally poor practices in both the demonstration and fee-for-service sites leading the authors to encourage careful monitoring of the quality of care in any Medicaid system of care. • 3 Significant implementation problems led to the subsequent failure of two of the demonstration sites,and one never actually began operation. 4 The Santa Barbara Demonstration was not an official Knox-Keene HMO but rather a Health Insuring Organization that was governed by a quasi-public board and in turn contracted with private providers in the community. 9 Data from the Medicaid Competition Demonstration in Hennepin County were used to assess impacts on a group of chronically mentally ill clients(Lurie,Muscovice,Fitch,Christianson& Popkin, 1992)and a group of elderly who were also Medicaid recipients(Lurie,Christianson,Finch &Moscovice, 1904).The former study reviewed outcomes over a one year period for 739 chronically mentally ill patients who were randomly assigned either to prepayment(choice of a county-sponsored network,a Blue Cross/Blue Shield plan,or two smaller IPAs)or to continuation in the regular fee-for-service system.There were no differences on follow-up in general health, physical health,mental health functioning,psychiatric symptoms,or community and role functioning. The results may not be generalizable to other situations,however,since only 15 percent of the prepaid group actually changed providers. The other study analyzed outcomes for roughly 800 elderly Medicaid beneficiaries,half of whom were assigned to one of seven prepaid plans including a closed-panel group,a county-sponsored network,or five IPAs.There were no differences at a one year follow-up on numbers of deaths,the proportion in poor health,physical functioning,activities of daily living,instrumental activities of daily living,blood pressure or diabetic control. Outcome results are also available from the HealthPASS experience in Philadelphia in which segments of the city's Medicaid population were mandatorily enrolled in a prepaid case management program.A sample of deliveries at the Hospital of the University of Pennsylvania of women enrolled in HealthPASS were compared to women in the regular Medicaid program. There were no differences in prenatal care nor in rates of low birth weight(Goldfarb,Hillman, Eisenberg, Kelley,Cohen&Dellheim, 1991). A study from AHCCCS,the mandatory managed care Medicaid program in Arizona,indicated that there was no difference in the rates of mammography and Pap smears between AHCCCS enrollees and women with other types of insurance coverage(Kirkman-Liff&Kronenfeld, 1992):There were • no differences in the use of prenatal care and modestly improved rates of low birth weight for Medicaid enrollees in three mainstream HMOs compared to the regular Medicaid program in a study of 5,936 beneficiaries in the state of Washington(Krieger, Connell,&LoGerfo, 1992), The General Accounting Office(GAO)in 1993 reviewed available published research on Medicaid managed care and studied in greater depth the managed care programs in Michigan, New York, Kentucky,Arizona, Oregon,and Minnesota_ The overall GAO conclusion was that Medicaid managed care provided slightly improved access to care with essentially equivalent quality of care to that found in the traditional fee-for-service Medicaid program.An earlier 1992 GAO report did cite a concern,however,about the potential negative consequences on quality of care in situations in which individual clinicians are at financial risk for high cost care and have too small a base of enrollees against which to spread the risk. A recent comprehensive literature review on HMOs concludes that the quality of care between HMOs and indemnity plans is roughly comparable. Miller&Luft(1994)applied rigorous standards to studies appearing in the peer-reviewed journals since 1980 resulting in 54 studies yielding 127 observations on 15 different dimensions. The findings relevant to quality of care are summarized below: • Prevention and health promotion. Seven observations from six studies showed HMO enrollees consistently receiving more preventive tests,procedures,exams, or health promotion activities; • Process and outcome quality of care. Fourteen of 17 observations from 16 studies showed . either better or equivalent(same or a mixture of better and worse)quality of care results for HMO enrollees compared with fee-for-service enrollees for a wide range of conditions, 10 diseases;or interventions.The only two solidly unfavorable results for HMO care were the two Medical Outcome Study results on the diagnosis and treatment of depression. Patient satisfaction results are mixed with patients generally preferring HMOs on some dimensions and indemnity plans on others. While the link between measures of patient satisfaction and objective outcomes is largely undocumented(Cleary&McNeil, 1988)the argument is made that satisfaction with the patient- provider relationship is critical to patient understanding,compliance,and involvement in health care decision making. Patient satisfaction ratings are related to the rate with which persons change providers(Davies&Ware, 1988;Rubin,Gandek,Rogers,Kosinski,McHorney,&Ware, 1993)so health care systems have an incentive to achieve high levels of satisfaction. The Rand HIS compared patient satisfaction between the fee-for-service plans and two groups of HMO enrollees,those that had been randomized into the HMO as part of the study and those that had previously joined the HMO voluntarily(Davies,Ware,Brook, Peterson,&Newhouse, 1986). There were no difference in overall satisfaction ratings between the fee-for-service group and the voluntary HMO group.Both the randomized and voluntarily enrolled HMO groups had higher satisfaction ratings on certain dimensions than those in the fee-for-service groups(length of office waits and costs of care)and lower ratings on some(length of waits for appointments,parking arrangements,availability of hospitals,and continuity of care). The fee-far-service group had higher overall satisfaction than the randomized HMO group and higher ratings on travel time, convenience,availability of specialists,and interpersonal aspects of care. There were no differences in overall satisfaction in the Medicare Competition Demonstration between the HMO and the fee-far-service groups,but there were differences in ratings of speck components of care some of which favored the HMOs(wait times and experiences with claims processing)and some of which favored the fee-for-service system(perceived professional competence of physicians and willingness to discuss problems)(Rossiter,Langwell,Wan,& Rivnyak, 1989). The fee-for-service AFDC recipients in the two Medicaid Competition Demonstration comparison sites'expressed more overall satisfaction than those enrolled in the prepaid demonstration Medicaid programs although more than 80°10 of the demonstration enrollees rated their care as satisfactory.A special study on the demonstration enrollees in three of the sites indicated that those enrollees whose usual provider became their gatekeeper were significantly more satisfied with their care than those who had to change providers under the demonstration with the satisfaction levels of the former being similar to those in the fee-for-service comparison communities(Hurley, Gage,&Freund, 1991). One of the prepaid demonstration projects(Monroe County in New York)compared the satisfaction ratings of beneficiaries with the regular fee-for- service Medicaid program before the demonstration to their satisfaction ratings after they were enrolled in prepaid care. Ratings of overall satisfaction showed no differences,but the ratings for the humaneness of care and quality of care were higher under the prepaid demonstration than with the prior regular Medicaid program. The Medical Outcomes Study findings on satisfaction are more complex(Rubin, Gandek, Rogers, Kosinski,McHorney, and Ware, 1993). Overall the differences in satisfaction appeared to be strongly related to the size of the physician practice setting with some impact from payment type (prepaid Vs fee-for-service). Patients in the smaller solo/single specialty groups were more satisfied than those in larger organizations(multispecialty groups or HMOs). Those in solo/single specialty/fee-for-service settings were more satisfied than those in solo/single specialty-prepaid settings,but there was no comparable difference between the fee-for-service and prepaid multispecialty group practices. Miller&Luft's(1994)review article concludes the following about studies that compare patient satisfaction in HMOs and traditional indemnity plans: 11 • Four of five observations showed HMO enrollees as highly satisfied with most aspects of care; • Seven of eight observations from five studies showed fewer HMO enrollees satisfied with the perceived quality of care and doctor-patient interactions; • Five of five observations showed HMO enrollees more satisfied with the financial aspects of care. Cleary&McNeil(1988)in a review of general patient satisfaction literature conclude that the largest contributors to high patient satisfaction are"those characteristics of providers or f organizations that result in more`personal'care."Some of the perceived differences in satisfaction favoring the traditional indemnity system result from organizational features of some HMOs that make care less personal,e.g. longer wait times for appointments and reduced availability of providers. Weighed against these factors for consumers making choices among health care coverage is the greater satisfaction with the financial aspects of HMO care. . 1 Ratings of perceived technical competence appear to favor the traditional fee-for-service system, but as noted by Davies&Ware (1988)patients might be influenced in these ratings by the quantity of care delivered regardless of whether or not it is necessary. I The research findings do not support the hypothesis that the quality of care is poorer for enrollees of managed care plans than for those in indemnity plans. The general conclusion is rather that care appears to be roughly comparable on process and outcome measures of quality for different types of populations and different types of conditions with the edge to managed care in the area of prevention. Patient satisfaction results are mixed with HMOs preferred on financial aspects and • indemnity plans generally perceived to be better in access and convenience and sometimes rated higher on provider interpersonal and perceived technical competence dimensions. A fundamental question is the relevance of this paper's findings to current public policy debates. Miller&Luft(1993)in a recent review of the literature on HMOs argue that their findings-that the quality of care in HMOs is at least as good as in indemnity plans-may be of limited relevance to the newer models of managed care. This is an argument that was made by Luft in his 1988 review as well,and is one that can be made about any subject of inquiry that is evolving or changing. One of the limitations of high quality peer-review research is the significant time lag between data collection and publication of results. Clearly the impacts on quality of care of the significant changes that are occurring in both indemnity and managed care plans require the continued scrutiny of the research community.As more attention is paid to quality of care research issues and as managed care growth continues,we should expect not only more relevant studies but also higher quality studies.As Relman(1994) notes in a recent editorial in the New England Journal of Medicine, "The opportunities for useful research on this subject[the relation between methods of insuring and organizing the delivery of medical care and the health and comfort of patients] seem unlimited,and the need is obvious."In the meantime, however,relying on what we do know from the research literature would seem a wise course in public policy debates that are often sprinkled liberally with anecdotal accounts. 12 d O O cn O ++ ✓ ✓ O G rL )X03 V rli N E G N fl O E NO O O-N O 9G ✓ Z N G rn L e So 3 Q G d o o 0 2 v. 0 p Q O d N y o D a 0> N N G N y o v 6'N'' S SQ- a �c ». 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Wells KB,Manning WG Jr,Benjamin B.Use of outpatient mental health services in HMO and FFS plans:results from a randomized controlled trial.Health Services Research. 1986;21:453474. Wells KB,Manning WG Jr,Valdez RB.The effects of a prepaid group practice on mental health outcomes.Health Services Research. 1990;25:6154625. Wells KB,Rogers W,Burnam A,Greenfield S,Ware JE Jr.How the medical comorbidity of depressed patients differs across health care settings:results from the Medical Outcomes Study.American Journal of Psychiatry. 1991;148:1688-1696. Wells KB,Stewart AL,Hays RD,et al.The functioning and well-being of depressed patients:results from the Medical Outcomes Study.JAMA. 1989;262:914-919. Wilensky GR,Rossiter LF Patient self-selection in HMOs.Health Affairs.1986;5:66-80. Wilner S,Schoenbaum SC,Monson RR,Winickoff RN.A comparison of the quality of maternity care between a health maintenance organization and fee-for-service practices.New England Journal of Medicine. 1981;304:784-787. Witek JE,Hostage JL.Mediciad managed care:Problems and promise.JAmbulatory Care Manager. 1994.17:61-69. Wolinsky FD.Marder WD.Spending time with patients:the impact of organizational structure on medical practice.Medical Care 1982;20:1051-1059. Wright CH,Gardin TH,Wright CL.Obstetric care in a health maintenance organization and a private fee-for-service practice:a comparative analysis.American Journal of Obstetrics and Gynecology. 1984;149:848-856. Yehn EH.Henke CJ.Kramer JS,Ne-vitt M,Shearn MA,and Epstein WV.A comparison of the treatment of rheumatoid arthritis in health maintenance organizations and fee-for-service practices.New England Journal of Medicine 1985;312:962-967. Yehn EH.Shearn MA,Epstein R'Yr.Health outcomes for a chronic disease in prepaid group practice and fee-for-sen-ice settings. Medical Care 1986;24:236-246, Young GJ,Cohen BB.Inequities in hospital care:the Massachusetts experience.Inquiry. 1991;28:250-262. 23 ABOUT THE AUTHOR Joan Meisel, Ph.D.,M.B.A.,is an independent health care consultant with over 15 years experience in policy analysis,strategic planning, and assessment and evaluation in the health care industry. Current projects include a multi-year evaluation of mental health demonstration projects sponsored by the state of California and a strategic planning and implementation project for a major mental health service provider. Prior to becoming an independent consultant,Meisel served as Vice President in the West Coast office of LEWIN-VHI,a major national health policy and consulting firm.Among other things,she directed strategic planning studies for a number of large hospitals;evaluated public policy issues in the areas of mental health, early intervention,long term care,and AIDS;assessed service delivery issues for a number of California counties;and conducted market analyses for a managed care organization developing preferred provider networks. Meisel also worked as a consultant with Booz Allen and Hamilton's Health and Medical Practice in San Francisco. In the late 1970s,Meisel served for five years as a legislative assistant to the California Assembly's Majority Leader,focusing on health issues. Meisel holds a doctorate in Psychology and a Masters in Business Administration,both from Stanford University. • c � ca • ENI)E X A AAPCC Benefit period Concurrent review AB BHC Continued stay review ABC Billed claims Conversion Acceptability Broker Conversion privilege Access BS Coordination of benefits ACR Copayment Actuary C Core benefits Acute care CALMEDS Corridor Acute disease CAO Cosmetic procedures Adjusted community rating CAP Cost reimbursement Administrative costs Capacity Cost sharing Administrative services only Capitation Cost shifting Admits Cardiac care unit Covered expenses Admitting physician Carrier Covered person Adverse selection Case manager Covered service AFDC Case mix CPI Age.'sex factor CAT CPT AIDS Catastrophic health insurance Creaming AIM Categorically needy CredentlaJing AKA Categorically related Crossover ALOS CCHP CSC Allowable costs CCS CT Ambulatory care CCU Customar} charge Ambulatory surgen, program 4= . Census Ancillar} charge CEO D Ancillary services Charges Deductible ASO Charity care Defensive medicine Assigned risk CHC Dependent Assignment of Benefits CHDP DHS ATD Chemical dependency services Diagnosis related groups At risk Claim Direct reimbursement Attending physician Clean claim Disenrollment Availability Clinic Disproportionate share Available beds Closed panel DME Average length of stay Closed staff model DOB AWP COB DOC COBRA DRG B Co-insurance DRG creep BAC/MIA COLA DRG rate Beneficiary Community rating Drug formulary Benefit Community rating by class Drug utilization review Benefit level's Composite rate- D U P, 0 Benefit package COMTEC Durable medical equipment E General practitioner Ind EAP Generic drug Indemnity Effective date GHAA Inpatient Eligible person Global rate Insurable risk Emergency GP Insurance Employee contribution Grievance procedure Insurance policy Employer contribution Group Insurance pool Encounter Group contract Insured Enrollee Group Insurance Insurer Enrollment Guaranteed issue underwriting Intensive care unit EO Guaranteed renewable Intermediate care facility EOB IPA EOC H EOMB H and P EPSDT Hawthorne effect JCHA Evidence of coverage HCFA Evidence of insurability HCO K Exclusions Health care service plan Experience rating Health coverage Knox-Keene Health Care M Experimental, investigation or Health plan Service Plan Act unproven procedures HHA Explanation of benefits HH&L L Extension of benefits HHS L-3 HMO Lag F HO , Lapse Family dependent Home care Last dollar coverage Family physician Home health agency Length of stay Federal qualification Horizontal integration Level of care Fee-for-service Hospital based physician Licensed practical nurse Fee-for-service reimbursement Hospital outpatient visit Lifetime benefit Fee schedule House physicians Long term ca-re FFS House staff Long term care insurance First dollar coverage HP LOS Fiscal year HRA Loss ratio Fixed cost HSD LPN FKO LTC FNP jLVN FO Iatrogenic FPC IBNR M Freestanding ICD-9 Malpractice FTE ICU Malpractice insurance FY Identification card Mandated benefits In-area services Mandated offering G. Increment cost Mandated providers Gatekeeper Incur Market share Gatekeeper model Incurred claims Maximum out-of-pocket costs 2 MCM ORG Primary care network MD OTC Primary care physician Medicaid Outcomes measurement Principal diagnosis Medicaid mill Outlier Private practice Medi-Cal Out-of-area Prior authorization Medical indigency Out-of-area benefits PRO Medical loss ratio Out-of-plan Professional component Medical record Out-of-pocket cost Prospective reimbursement Medically indigent Out-of-pocket limit or Provider Medically necessary maximum PSRO Medically needy Outpatient Public providers Medicare Outside provider Medicare beneficiary. Over-the-counter drug Q Medicare supplement policy OYO QA Member QS Member month P MFP Paid claims R MIA Part A MIC Part B Rate Nils Partial hospitalization Reasonable and customary Mixed model ion MMH Partial hospitalization services Referral provider MNO Participating provider Reimbursement Morbidity Participation Reinsurance Patient day Mortality Payor Related organization MRI PCRenewal MRMIP PCN Reopener NITZ PCP Residency program PCPM Retention N Periodicity Retrospective reimbursement Neonatal care Per member per month Retrospective review NNIR PHC Revenue Non-participating provider PHS RHC PM/PM Rider PO Risk 0 Risk analysis Point-of-service plan OAS Pool (risk pool) Risk contract OBRA RN PPA Occupancy PPO OHMO Pre-admission certification S OOA Pre-existing condition Same day surgery unit OOP Preferred providers Sanction OOP Maximum Prefer-red provider organization Satellite clinic Open-ended programs Premium SDHS Open enrollment period Premium rate SEA Open panel Primary care Secondary care Operating costs Primary care case management Self-insurance, self-funding 3 Service area V SH Variable cost Shared risk Vendor Skilled nursing facility Vertical integration Skimming Skimping SINIA W SNF Waiver Solo practice Waiver of premium Specialist Warrant SSA WIC SSI Withhold Staff model Stop-loss insurance Subrogation Subscriber Subscriber contract Supervising physician Supplemental services Swing beds T Targeted case management TCM Termination date Tertiary care Therapeutic alternatives Therapeutic equivalents Third party paver Title 10 Title XVIII Title XIX TPA Triage Triple option U UCR Uncompensated care Underwriting UR Urgent URN Utilization Utilization review. 4 Glossary of Managed Care Terms, Acronyms and Abbreviations January, 1995 AAPCC -- Adjusted Average Per Capita Cost. The ACR — Adjusted Community Rate. Used by HMOs and Health Care Financing Administration's(HCFA's)best CMPs with Medicare risk contracts. A calculation of estimate of the amount of money it costs to care for what premium the plan would charge for providing Medicare recipients urger fee-for-service Medicare in a exactly the Medicare-covered benefits to a group given area. The AAPCC is made up of 122 different account, adjusted to allow for the greater intensity and rate cells; 120 of them are factored for age, sex, frequency of utilization by Medicare recipients. The Medicaid eligibility, institutional status, and whether a ACR includes the normal profit of a equal to or lower person has both Part A and Part B of Medicare; the two than the APR, but can never exceed it. remaining cells are for individuals with end-stage renal disease. Actuary --in insurance, a person trained in statistics, accounting and mathematics who determines policy AB —Medi-Cal Category for the Blind rates, reserves, and dividends by deciding what assumptions should be made with respect to each of the ABC—Alternative Birthing Center risk factors involved (such as the frequency of occur- rence of the peril, the average benefit that will be Acceptability —an individual's(or group's)overall payable, the rate of investment earnings, if any, assessment of medical care available to him. The expenses, and persistency rates), and who endeavors to individual appraises such things as the cost, quality, secure as valid statistics as possible on which to base results,and convenience of care,and provider attitudes his assumptions. in determining the acceptability of health services provided. Acute care — inpatient general routine care provided to patients who are not in such a phase of illness which Access—an individual's(or group's) ability to obtain would require concentrated and continuous observation medical care. Access has geographic, financial, social, and care. ethnic and psychic components and is thus very difficult to define and measure operationally. Many Acute disease— a disease which is characterized by a government health programs have as their goal improv- single episode of a fairly short duration from which the ing access to care for specific groups or equity of patient returns to his normal or previous state and level access in the whole population. Access is also a of activity. While acute diseases are frequently function of the availability of health services, and their distinguished from chronic diseases, there is no acceptability. In practice access, availability and standard definition or distinction. It is worth noting acceptability, which collectively describe the things that an acute episode of a chronic disease(an episode of which determine the care people use, are very hard to diabetic coma in a patient with diabetes)is often treated differentiate. as an acute disease. Adjusted community rating —(ACR)community rating Ambulatory surgery program —a program for the impacted by group specific demographics. Also known performance of elective surgical procedures on patients as factored rating. who are admitted and discharged from the hospital on the day of surgery. Administrative costs —the cost incurred by an HMO for administrative services such as claims processing, Ancillary charge—the fee associated with additional billing and enrollment, and overhead costs. service performed prior to and/or secondary to a significant procedure, such as lab work, x-ray and Administrative services only — a service requiring a anesthesia. third party to deliver administrative services to an employer group and requiring the employer to be at Ancillary services —diagnostic or therapeutic services risk for the cost of health care services provided. This performed by a specific hospital department at the is a common arrangement when an employer sponsors a request of a physician. self-funded health care program. ASO—Administrative Services Only. An ASO plan is a Admits —.the number of admissions to a hospital or contract with an insurer to provide a fully self-insured inpatient facility. employer with certain administrative services only; no insurance protection is provided. Admitting physician —the physician responsible for admission of a patient to a hospital or other inpatient Assigned risk —a risk which underwriters do not care to health facility. The physician may remain responsible insure (such as a person with hypertension seeking for the care of the patient once admitted, or not(the health insurance)but which, because of State law or housestaff usually becoming responsible). Some otherwise, must be insured. Insuring assigned risks is facilities have all admitting decisions made by a single usually handled through a group of insurers(such as all physician (typically a rotating responsibility) called an companies licensed to issue health insurance in the admitting physician. State)and individual assigned risks are assigned to the companies in turn or in proportion to their share of the Adverse selection —a term used to describe a situation in State's total health insurance business. Assignment of which a carrier enrolls a poorer health risk than the risks is common in casualty insurance and less common average health risk of the group. in health insurance. As an approach to providing insurance to such risks, it can be contrasted with poling AFDC —Aid to Families with Dependent Children of such risks (see insurance pool)in which the loses rather than the risks are distributed among the group of Age/sex factor—a measurement used in underwriting insurers. which represents the age and sex risk of medical cost of one population relative to another. A group with an Assignment of benefits—authorization by the insured age/sex factor of 1.00 is average. An age/sex factor for the insurer to pay benefits directly to the medical above 1.00 indicates a higher than average demo- care provider. graphic risk of expected medical claims. An age/sex factor below 1.00 indicates a lower than average ATD —Aid to Totally Disabled demographic risk of expected medical claims. At risk—the state of being subject to some uncertain AIDS —Acquired immune deficiency syndrome. event occurring which connotes loss or difficulty. In the financial sense, this refers to an individual, organi- ABI— Access for Infants and Mothers zation (like and HMO)or insurance company assuming the chance of loss—through running the risk of having AKA —Also Known As(or by another name) to provide or pay for more services than paid for through premiums or per capita payments. If payments ALOS —Average Length of Stay are adjusted after the fact so that no loss can occur, then there is no risk. In fact, of course, losses incurred Allowable costs - charges for services rendered or in one year may be made up by increases in premiums supplies furnished by a health provider which qualify or per capita payments in the next year, so the 'risk' is as covered expenses. somewhat tempered. A firm which is at risk for losses also stands to gain from profits if costs are less than Ambulatory care— health services provided to patients premiums collected. 'A second use of the term relates who are not lodged overnight by a provider. to the special vulnerability of certain populations to certain diseases or conditions. 2 Attending physician the physician legally responsible BHC --Brentwood Health Center for the care given a patient in a hospital or other health program. Usually the private physician of a private Billed claims —the fees or costs for health care services patient who is also responsible for the patient's provided to a covered person submitted to a health plan outpatient care. The attending physician for a public or insurer for payment by a health care provider. patient is typically chosen by the hospital upon the patient's admission from among members of its medical Broker—a licensed insurance professional who repre- staff, or is one of its teaching physicians. sents plan sponsors in the purchase of insurance coverage. This contrasts with an agent, who represents Availability —a measure(in terms of type, volume and the insurer. location)of the supply of health resources and services relative to the needs(or demands)of a given individual BS—Board of Supervisors or community. Health care is available to an individual when he can obtain it at the time and place that he e needs it, from appropriate personnel. Availability is a Medi- function of the distribution of appropriate resources Cal CALAiEDS —State computer system maintaining Medi- and services, and the willingness of the provider to eligibility records. serve the particular patient in need. CAO--County Administrator's Office Available beds—health facility beds maintained and staffed to provide health care. CAP—capitation Average length of stay — the average length of hospital- Capacity —usually refers to licensed or certified bed ization of inpatients discharged during the period under count of a facility. consideration. Capitation —(CAP) in the strictest sense, a stipulated ANVP—Average Wholesale Price dollar amount established to cover the cost of health care services delivered for a person. The term usually B refers to a negotiated per capita rate to be paid periodi- cally, usually monthly, to a health care provider. The BAC/MIA —Basic Adult Care'Medically Indigent provider is responsible for delivering or arranging for Adults the delivery of all health services required by the covered person under the condition of the provider Beneficiary —a person entitled to receive benefits under contract. a plan, including a covered employee and his or her dependents. Carrier—an entity which may underwrite or administer a range of health benefit programs. May refer to an Benefit —in insurance, a sum of money provided in an insurer or a managed health plan. insurance policy payable for certain types of loss, or for covered services, under the terms of the policy. Case manager—an experienced professional (e.g., The benefits may be paid to the insured or on his behalf nurse, doctor or social worker)who works with to others. In prepayment programs, like HMOs, patients, providers and insurers to coordinate all benefits are the services the program will provide a services deemed necessary to provide the patient with a member whenever, and to the extent needed. plan of medically necessary and appropriate health care and who continues to follow the patient's care. Benefit levels—the limit or degree of services a person is entitled to received based on his/her contract with a Case mix —the relative frequency and intensity of health plan or insurer. hospital admissions or services reflecting different needs and uses of hospital resources. Case mix can be Benefit package—services an insurer, government measured based on patient's diagnoses or the severity agency, or health plan offers to a group or individual of their illnesses, the utilization of services, and the under the terms of a contract. characteristics of a hospital. Benefit period —period over which benefits are payable CAT—Computerized Axial Tomography under a plan or insurance contract. Alternatively, a period for satisfying a'deductible requirement, usually referred to as an 'accumulation period.' 3 Catastrophic health insurance—health insurance whi h CCS—California Children's Services provides protection against the high cost of treating severe or lengthy illnesses or disabilities. Generally CCU—Critical Care Unit such policies cover all or a specified percentage of medical expenses above an amount that is the responsi- Census —count of patients who, at "count or census bility of the insured himself(or the responsibility of time," were duly registered in the hospital. another insurance policy up to a maximum limit of liability). CEO —Chief Executive Officer Categorically needy—persons who are both members of Charges—prices assigned to units of medical services, certain categories or groups eligible to receive public such as a visit to a physician or a day in a hospital. assistance, and economically needy. As used in Charges for services may not.be related to the actual Medicaid, this means a person who is aged, blind, cost of providing those services. disabled, or a member of a family with children under 18 (or 21, if in school) where one parent is absent, Charity tare—care rendered to patients without the incapacitated or unemployed and, in addition, meets expectation of charging for or being compensated for specified income and resources requirements which such services. vary by state. In general, categorically needy individu- als are persons receiving cash assistance under the CHC —Concord Health Center AFDC or SSI programs. A state must cover all recipi- ents of AFDC payments under Medicaid; however, it is CHDP— Child Health &Disability Prevention provided certain options(based, in large measure, on its coverage levels under the old federal/State welfare Chemical dependency services —those services and programs)in determining the extent of coverage for supplies used in the diagnosis and treatment of alcohol- persons receiving Federal SSI and/or State supplemen- ism, chemical dependency, and drug dependencies, as tary SSI payments. In addition, a state may cover defined by the U.S. Department of Health and Human additional specified groups, such as foster children, as Services. categorically needy. A state may restrict its Medicaid coverage to this group or may cover additional persons Claim —information submitted by a provider or covered who meet the categorical requirements as medically person to establish that medical services were provided ,needy. to a covered person, and which includes a request for payment or reimbursement to the provider or covered Categorically related —in the Medicaid program, the person is made. The term generally refers to the requirements(other than income and resources) which liability for health care services received by covered an individual must meet in order to be eligible for persons. Medicaid benefits; also individuals who meet these requirements. Specifically, any individual eligible for Clean claim —a claim for payment (bill) submitted by a Medicaid must fall into one of the four main categories provider having no defect or impropriety or circum- of people who are eligible for welfare cash payments. stance which would require special treatment, thereby, He must be 'aged', "blind', or 'disabled' (as defined preventing timely payment. under the Supplemental Security Income Program, title XVI of the Social Security Act)or a member of a Clinic—an outpatient department of a hospital where family with dependent children where one parent is patients are treated. absent, incapacitated, or unemployed (as defined under the Aid to families with Dependent Children Program, Closed panel —A managed care plan that contracts with title IV of the Social Security Act). After the determi- physicians on an exclusive basis for services, not nation is made that an individual is categorically allowing members to see physicians outside of the related, then income and resources tests are applied to limited exclusive panel of providers for routine care. determine if the individual is poor enough to be eligible Examples include staff and group model HMOs, but for assistance(categorically needy). As a result.of this could apply to a large private medical group that requirement, single persons and childless couples who contracts with an HMO. are not aged, blind, or disabled and male-beaded families in states which do not cover such groups under Closed staff model —describes HMOs, like CCHP, that their AFDC programs cannot receive Medicaid require members to receive all their medical care coverage no matter how poor they are. through the HMO's own facilities(exception made when medically necessary). Most professional staff are CCHP— Contra Costa Health Plan salaried employees. 4 COB—Coordination of Benefits Conversion privilege—the right of a terminating employee to convert from group coverage to an COBRA —Consolidated Omnibus Budget Reconciliation individual policy without providing evidence of Act-a federal law that, among other things, requires insurability. employers to offer continued health insurance coverage to certain employees and their beneficiaries who have Coordination of benefits—(COB) an agreement using had their group health insurance coverage terminated. language developed by the National Association of Insurance Commissioners that prevents double payment Co-insurance—a provision in a member's(or covered for services when a subscriber has coverage from two insureds)coverage that limits the amount of coverage or more sources; for example,a husband may have by the plan to a certain percentage, commonly 80%. Blue Cross through work and the wife may have Any additional costs are paid by the member out of elected an HMO through her place of employment. pocket. The agreement gives the order for what organization has primary responsibility for payment and what COLA—Cost of Living Allowance organization has secondary responsibility for payment. Community rating — that rating methodology required Copayment—that portion of a claim or medical expense by federally qualified HMOs, and required of HMOs that a member(or covered insured)must pay out of his under the laws of many states. The HMO must obtain or her own pocket. Usually a fixed amount, such as$5 the same amount of money per member for all members in many HMOs. in the plan. Community rating does allow for variabil- ity by allowing the HMO to factor in differences for Core benefits—generaIly comprehensive major medical age, sex, mix (average contract size), and industry and hospitalization benefits. Dental and vision benefits factors; not all factors are necessarily allowed under are examples of noncore benefits. state laws, however. Corridor— range around a targeted amount within which Community rating by class --a method of determining a no penalty will be assessed. nremium structure that is not influenced by the ex- acted level of benefit utilization by specific groups, Cosmetic procedures — those procedures which involve iut by expected utilization by the population of a physical appearance, but which do not correct or specific geographical area as a whole. materially improve a physiological function and which are not medically necessary. Composite rate —a group billing rate which applies to all subscribers within a specified group, regardless of Cost reimbursement —a system that provides for whether they are enrolled for single or family cover- reimbursement to a provider to be based on a defined age. cost basis. CONlTEC —name of company that provides software Cost sharing —provisions of a health insurance policy maintenance, upgrades, etc. for CCHP Management that requires insured individual to pay some portion of Information System(data computers). covered medical expenses. Concurrent review — an assessment of hospital admis- Cost shifting —process wherein the responsibility for stun, conducted by trained managed care staff via costs is shifted from a particular department or payor to teiephone or on-site visits during a covered person's another department or payor, e.g., bad debts from rospital stay, to ensure appropriate care, treatment, other payors to self-pay patients. iength of stay and discharge planning. Covered expenses—an expense for which a health care Continued stay review —a form of utilization review plan will provide reimbursement. that monitors the continued appropriateness of hospital stays. Covered person —an individual who meets eligibility requirements and for whom premium payments are Conversion—the privilege given to the covered person paid for specified benefits of the contractual agreement. to change his/her group medical care coverage to a form of individual coverage without evidence of Covered service—a service provided by a provider to a insurability. The conditions under which conversion patient which is included in his scope of insurance can be made are defined in the master group contract. benefits. Conversion is usually made when a covered person leaves the group. CPI—Consumer Price index Direct reimbursement—a non-insured dental program in which an employer agrees to pay for a specified CPT— Current Procedural Terminology(numerical percentage or amount of dental expenses. codes) Disenrollment—The process of termination of coverage. Creaming— see Skimming Voluntary termination would include a member quitting because he or she simply wants out. Involun- Credentialing—a process of review to approve a tary termination would include leaving the plan because provider who applies to participate in a health plan. of changing jobs. A rare and serious form of involun- Specific criteria and prerequisites are applied in tary disenrollment is when the plan terminates a determining initial and ongoing participation in the member's coverage against his or her will. This is health plan. usually only allowed(under state and federal laws) for gross offenses such as fraud, abuse, nonpayment of Crossover—Health plan members who have both Medi- premium or copayments, or a demonstrated inability to Cal and Medicare. comply with recommended treatment plans. CSC — Computer Science Corporation Disproportionate share—refers to add-on to Medicare reimbursement rate that attempts to reflect additional CT —Computer Tomography costs incurred by providers who serve a significantly disproportionate number of low income patients and/or Customary charge—most prevalent charge existing for significant number of Title 18 patients. a specific test, service or procedure. DME—Durable Medical Equipment D DOB --Date of Birth Deductible—That portion of a subscriber's(or DOC —Department of Corporations member's) health care expenses that must be paid out of pocket before any insurance coverages applies. DRG —Diagnostic Related Group Commonly$100 to $300. Not allowed in federally - qualified HMOs and often not allowed under state DRG creep --manipulation of coding to maximize HMO regulations either, although copayment require- ments can achieve exactly the same result. Common in reimbursement. insurance plans and PPOs. DRG rate—a fixed dollar amount based on averaging of Defensive medicine--alteration of modes of medical all patients in that DRG in the base year, adjusted for inflation, economic factors and bad debts. practice, induced by the threat of liability, for the principal purposes of forestalling the possibility of Drug formulary—a listing of prescription medications malpractice suits by patients and providing a good legal which are approved for use and/or coverage by the plan defense in the event of such lawsuits. White surveys have shows that 50 to 70 percent of physicians say they and which will be dispensed through participating practice defensive medicine, it is difficult to define and Pharmacies to a covered person. The list is subject to periodic review and modification by the health plan. measure specifically and, except for increasing the costs of care, unclear what effects it has. Drug utilization review—an evaluation of prescribing patterns or targeted drug use to specifically determine Dependent —an individual who relies on an employee the appropriateness of the drug therapy. for support or obtains health coverage through a spouse or parent who is the covered person. DUR—drug utilization review DHS—Department of Health Services(State; also known Durable medical equipment—equipment which can as SDOHS). stand repeated use, is primarily and customarily used Diagnosis related groups —a system of classification for to serve a medical purpose, generally is not used in the absence of illness or injury, and is appropriate for use inpatient hospital services based on principal diagnosis, at home. Examples of durable medical equipment secondary diagnosis, surgical procedures, age, sex and include hospital beds, wheelchairs and oxygen equip- presence of complications. This system of classification meat. is used as a financing mechanism to reimburse hospitals and selected other providers for services rendered. 6 E Evidence of coverage—a description of the benefits EAP—employee assistance program included in a health plan. The certificate of coverage is required by state law and represents the coverage Effective date—the date a contract goes into force. provided under the contract. A copy of the certificate is provided to the member. Eligible person —an individual who meets the eligibility Evidence of insurability—proof presented through requirements specified in the provisions of the health plan contract. written statements(e.g. an application farm.)andtar medical examination that an individual is eligible for a Emergency —a medical situation or condition which, if certain type of insurance coverage. This form is not treated immediately, could reasonably be expected required for eligibles who apply for excess group life to result in serious permanent injury or death. Also known as evidence of good health. Employee contribution —the amount an employee must Exclusions—specific conditions or circumstances listed contribute toward the premium costs of the contract. in the contract or employee benefit plan for which the policy or plan will not provide benefit payments. Employer contribution—the amount an employer contributes toward the premium costs of the contract. Experience raring —the grocers of setting rates based Employer contributions can be based on dollar partially or in whole on evaluating previous claims amounts, percentages, employment status, length of experience and then projecting required revenues for a service, marital or family status, or other variables or future policy year for a specific group or pool of combinations of the above. groups. Encounter—a face-to-face meeting between a covered Experimental, investigation or person and health care provider where services are unproven procedures—medical, surgical, psychiatric, provided. substance abuse or other health care services, supplies, treatments, procedures, drug therapies or devices that Enrollee —an individual who is enrolled for coverage are determined by the health pian (at the time it makes under a health plan contract and who is eligible on his/ a determination regarding coverage in a particular case) her own behalf(not by virtue of being an eligible to be either: (1)not generally accepted by informed dependent) to receive the health services provided health care professionals in the U.S:as effective in under the contract. treating the condition, illness or diagnosis for which their use is proposed, or(2)not proven by scientific Enrollment— the total number of covered persons in a evidence to be effective in treating the condition, health plan. The term also refers to the process by illness or diagnosis for which their use is proposed. which a health plan signs up groups and individuals for membership,or the number of enrollees who sign up Explanation of benefits --the statement sent to covered in any one group. Also sometimes referred to as lens by their health plan listing services provided, 'covered lives'. amount billed, and payment made. EO— financial class for Medi-Cal (ATD, OAS, AB) Extension of benefits—a provision of many insurer's Health Plan members policies which allows medical coverage to continue past the termination date of the policy for employees not EOB — explanation of benefits; a document that accom- actively at work and for dependents hospitalized on that paries a claims check and summarizes bow reimburse- date. Such extended coverage usually applies only to ment was determined and, among other things, explains the specific medical condition which has caused the the claims appeal process. disability and continues only until the employee returns to work or the dependent leaves the hospital. EOC —evidence of coverage. EONEB—explanation of Medicare benefits. EPSDT—early and periodic screening diagnosis and treatment; a program covering screening and diagnostic services to determine physical or mental defects of recipients under age 21. 7 F First dollar coverage—coverage under an insurance Family dependent—a person enrolled for coverage policy which begins with the first dollar of expense under a health plan contract who is: the enrollee's legal incurred by the insured for the covered benefits. Such spouse, or an unmarried dependent child(including a coverage, therefore, has no deductibles although it may stepchild or legally adopted child)of either the enrollee have copayments or coinsurance. or the enrollee's legal spouse and whose principal place of residence is with the enrollee unless other arrange- Fiscal year—accounting or reporting year adopted by an ments have been made with the health plan. The entity. definition also may be subject to certain conditions and Fixed limitations spelled out in the contract. cost—a cost which remains constant over a period of time or level of activity(known as the relevant Family physician—a physician who assumes continuing range)and is not affected by changes in volume. responsibility for supervising the health and coordinat- ing the care of all family members, regardless of age. FKO—for kids only Often viewed as low-level generalists, such physicians are now trained as specialists whose work demands FNP—family nurse practitioner specific skills. These skills include functioning as FO— medical managers, advocates, educators and counselors financial class for Medicare Health Plan members. for their patients. FPC — family practice clinic (Martinez Health Center). Federal qualification — a designation made by HCFA after conducting an extensive evaluation process of the Freestanding —e facility or activity which is not HMO's entire method of doing business: documents, hospital based, e.g., home health agency. contracts, systems, facilities, etc. An organization must be federally qualified or a designated CMP (competi- tive medical plan) to be eligible to participate in certain Medicare cost and risk contracts. F1' — fiscal year w Fee-for-service—a method of charging whereby a physician or other practitioner bills for each encounter G or service rendered. This is the usual method of billing Gatekeeper—primary care physician responsible for by the majority of the country's physicians. Under a monitoring patient's utilization of health care services. fee for service payment system, expenditures increase not only if the fees themselves increase but also if more Gatekeeper model —a situation which a primary care units of service are charged for, or more expensive physician, the "gatekeeper', serves as the patient's services are substituted for less expensive ones. This initial contact for medical care referrals. Also called system contrasts with salary, per capita or prepayment 'closed access' or "closed panel'. systems, where the payment is not changed with the number of services actually used or if none are used. General practitioner—(GP): a practicing physician who While the fee for service system is now generally does not specialize in any particular field of medicine limited to physicians, dentists, podiatrists and optom- (e.g. is not a specialist). Should be contrasted with a etrists, a number of other practitioners such as physi- family physician who has specialized(not all do)and cian assistants, have sought reimbursement on a fee for is subject to specialty board examination, in the care of service basis. families, and a primary care physician who may be a specialist in any of several specialties. Fee-for-service reimbursement—the traditional health care payment system under which physicians and other Generic drug —a chemically equivalent copy designed providers receive a payment for each unit of service from a brand-name drug that has an expired patent. A provided. generic is typically less expensive and sold under the common or 'generic' name for that drug, not the name Fee schedule --a comprehensive listing of fee maximums brand(e.g., the brand name for one tranquilizer is used to reimburse a physician and/or other provider on Valium, but it is also available under the generic name a fee for service basis. diazepam). Also called "generic equivalents'. FFS - fee for service GHAA —Group Health Association of America 8 Global rate—a rate or charge that includes both the Since health services research usually changes the professional and technical components. services being studied simply by being done or in unintentional ways, the resulting change in the GP—general practitioner . Hawthorne effect may well confound the results of the research. The name comes from classic industrial Grievance procedure—the process by which a health management experiments at the Hawthorne plant of the plan member or participating provider can air com- Western Electric Company. plaints and seek remedies. HCFA —Health Care Financing Administration—the Group—a collection of individuals grouped together for federal agency responsible for administering Medicare the purpose of treating them as single entity. 'Ile term and overseeing states' administration of Medicaid. usually refers to an employer purchasing medical coverage on behalf of its full-time employees. HCO—Health Care Options Group contract—the application and addenda signed by Health care service plan—an organized health plan both the health plan and the enrolling unit, which licensed in the state of California under the Knox- constitutes the agreement regarding the benefits, Keene Health Care Service Plan Act. exclusions and other conditions between the health plan and the enrolling unit. The term also is used to describe Health coverage—a protection that provides payment of the agreement with persons who obtain coverage for benefits for covered sickness or injury. This may themselves or for themselves and their children, include short and long term disability, dental, medical, whether under a group or individual program. vision care, and sometimes accidental death coverage as well as other benefits. Group Insurance —a single program insuring a group of associated individuals against financial loss resulting Health plan—health maintenance organizations, from illness, injury, or death. preferred provider organizations, insured plans and other plans that cover health care services. Guaranteed issue underwriting —the provision of insurance up to stated amounts of coverage without HHA--home health agency evidence of insurability, common with group policies. HH&L — Hayt, Hayt& Landau (legal film that_adminis- Guaranteed renewable -- the right to continue a policy ters Workmen's Comp cases). in force up to a stated age simply by making timely premium payments. During that time, the insurer may HHS —Department of Health and Human Services not change the policy, except to change policies for a class of policyholders. IDIO—Health Maintenance Organization—Pre-paid organizations that provide for health care in return for a preset amount of money on a per member per month H basis. H and P-- history,and physical HO -- financial class for Health Plan individuals/groups. Hawthorne effect — the effect (often beneficial, almost Home care—the administering of medical services to the always present)which an encounter with a provider, patient at his/her place of residence. health program or other part of the health system has on a patient which is independent of the medical Home health agency —an organization that provides content of the encounter. The Hawthorne effect is nursing and other health services within the patient's similar to the placebo effect, but is not obtained home intentionally and is the effect of the encounter with a provider or program on the patient rather than of what Horizontal integration—linking of providers at the they do for him. The effect may be changed (intention- same level of care. ally or not)by changing the provider or program (for instance by painting a clinic or changing its appoint- Hospital based physician —physician who furnishes ments system). services in a hospital based upon a contractual or employment relationship with the hospital. 9 Hospital outpatient visit—the visit of a hospital Incur—in insurance, to become liable for a loss, claim outpatient to one or more units or facilities located in or expense. Cases or losses incurred are those occur- or directed by the hospital. ring within a fixed period for which an insurance plan becomes liable whether or not reported, adjusted and House physicians —doctors employed by a facility to paid. provide health care to its patients. Such physicians may or may not be licensed. Incurred claims—a term that refers to the actual carver liability for a specified period and includes all claims House staff—generally, the physician staff in training at with dates of service within a specified period, usually a hospital, principally comprised of the hospital's called the experience period. Due to the time lag interns, residents and fellow. Members of the between dates of services and dates claims payments housestaff are called house officers. Occasionally also are actually processed, adjustments must be made to applies to physicians salaried by a hospital who are not any paid claims data to determine incurred claims. receiving any graduate medical education. Ind—individual HP—health plan Indemnity —an insurance program in which the insured HRA —Health Risk Appraisal (or Human Resources person is reimbursed for covered expenses. Agency) Inpatient—a patient who is provided with room, board HSD —Health Services Department (County) and continuous nursing service in an area of a hospital where patients stay overnight. I Insurable risk—a risk which has the following at- Iatrogenic —resulting from the activity of a physician. tributes: it is one of a large homogeneous group of Originally applied to disorders induced in the patient similar risks; the loss produced by the risk is definable by autosuggestion based on the physician's examina- and quantifiable; the occurrence of loss in individual tion, manner of discussion. It is now applied to any cases is accidental or fortuitous; the potential loss is condition in a patient occurring as a result of treatment large enough to cause hardship; the cost of insuring is by a physician or surgeon, such as a drug reaction. economically feasible; the chance of loss is calculable; • and it is sufficiently unlikely that loss will occur in IBNR — Incurred But Not Reported —refers to costs many individual cases at the same time. associated with health care services or claims that have been incurred during the financial reporting period but Insurance—contract that provides reimbursement for, or that have not been reported to an insurer until after the indemnification from, the results of a specific event. financial reporting date. Insurance policy —a written contract of insurance. ICD-9 —International Classification of Diseases, 9th RInsurance pool —an organisation of insurers or re- Revision. The classification of disease by diagnosis, codified into 4-digit numbers. Frequently used for insurers through which particular types of risks are billing purposes by hospitals. shared or pooled. The risk of high loss by any particu- lar insurance company is transferred to the group as a ICU—intensive care unit whole(the insurance pool)with premiums, losses, and expenses shared in agreed amounts. The advantage of a Identification card —a card issued by a carrier, health pool is that the size of expected losses can be predicted plan or third party administrator(TPA) to each covered for the pool with much more certainty than for any person, identifying the person as being eligible to individual party to it. Pooling arrangements are often receive coverage for services. used for catastrophic coverage or for certain high risk populations like the disabled. Pooling may also be done In-area services —health care services received within within a single company by pooling the risks insured the authorized service area by a participating provider under various different policies so that high losses of the health plan. incurred by one policy are shared with others. Incremental cost --cost that will be incurred or saved if an activity is performed or ceased. 10 Insured —an individual or organization protected in case L of loss under the terms of an insurance policy. The L-3 —form name used to order supplies through the insured is not necessarily the risk, the person whose storeroom. risk of loss from accident or sickness is protected against. In group insurance the employer is the insured, Lag —the period of time between the incurring of a the employees are the risks. claim and the payment of that claim. Insurer—the party to an insurance policy who contracts Lapse—the termination of insurance coverage for failure to pay losses or render services. to Pay Premiums. Intensive care unit—a specialized nursing unit which Last dollar coverage—insurance coverage without concentrates in one area within a hospital seriously ill upper limits or maximums no matter how great the patients needing constant nursing care and observation. benefits payable. Some intensive rare units limit their services to certain types of patients such as coronary care, surgical Length of stay —the number of days that a member stays intensive care, and newborn intensive care units. in an inpatient facility. Intermediate care facility --an institution recognized Level of care—refers to degree of medical and nursing under the Medicaid program which is licensed under involvement in the rare of a patient based on a medical State law to provide, on a regular basis, health-related assessment of that patient. rare and services to individuals who do not require the degree of care or treatment which a hospital or skilled Licensed practical nurse--a nurse who has practical nursing facility is designed to provide, but who because experience in the provision of nursing care but is not a of their mental or physical condition require care and graduate of a formal program of nursing education. services(above the level of room and board)which can The education, required experience, licensure and job be made available to them only through institutional responsibilities of LPNs are fairly variable. facilities. Public institutions for care of the mentally retarded, or people with related conditions are also Lifetime benefit—a benefit provided for an indefinite included. The distinction between 'health-related care period, up to the lifetime of the individual, such as a and services' and 'room and board' has often proven lifetime disability benefit. difficult to make but is important because ICFs are subject to quite different regulation and coverage than Long term care—assistance and care for people with institutions which do not provide health-related care chronic disabilities. The goal of long term care is to and services. An ICF/MR is an ICF which cares solely help people with disabilities be as independent as or particularly for the mentally retarded. possible, and thus is focused more on caring than on curing. Long term care is needed by a person who IPA —Independent Practice Association. An organiza- requires help with the activities of daily living or who tion that has a contract with a managed care plan to suffers from cognitive impairment. deliver services in return for a single capitation rate. The IPA in turn contracts with individual providers to Ung term care insurance—insurance designed to help provide the services, either on a capitation basis or on a pay some or all long term care costs, reducing the risk fee-for-service basis. that the policyholder would be forced to deplete all his or her assets to pay for long term care. Long term care insurance can help a person avoid relying on family or J friends for assistance with activities of daily living and JCHA —Joint Commission for Accreditation of Hospi- can reduce or eliminate the need to rely on Medicaid. tats LOS —length of stay K Loss ratio—the ratio between costs incurred for health Knox-Keene Health Care Service Pian Act—statute care services and premiums received. enacted by the California Legislature to regulate LPN—licensed practical nurse prepaid health plans. Knox-Keene licensed plans are regulated by.the State Department of Corporations. LTC —long term care 21 LVN—licensed vocational nurse Medical indigency —the condition of having insufficient income to pay for adequate medical care without . depriving oneself or dependents of food, clothing, M shelter, and other essentials of living. Medical indigency may occur when a self-supporting individual, Malpractice—professional misconduct or lack of ordinary skill in the performance of a professional act. able under ordinary conditions to provide basic maintenance for himself and his family, is, in time of Malpractice insurance—insurance either purchased or catastrophic illness, unable to finance the total cost of provided for by self-funding to reimburse or compen- medical care. sate one for the adverse effects of a completed malprac- tice suit Medical lass ratio—the ratio between the cost to deliver medical care and the amount of money that was taken Mandated benefits.—those benefits which health plans in by a plan. Insurance companies often have a are required by state or federal law to provide to policy medical loss ratio of 96% or more; tightly managed holders or plan members and their eligible dependents. HMOs may have medical loss ratios of 75% to 85%, although the overhead (or administrative cost ratio)is Mandated offering —similar to mandated benefit, except concomitantly higher. The medical loss ratio is that instead of being a requirement in each policy, the dependent on the amount of money brought in as well coverage need only be offered to a policyholder, who is as the cost of delivering care; thus, if the rates are too not required to purchase it.' low, the ratio may be high, even though the actual cost of delivering care is not really out of line. Mandated providers —providers of medical care, such Medical record—document maintained on patients as psychologists, optometrists, podiatrists and chiro- which contains sufficient information to clearly identify practors, whose licensed services must, under state or federal law, be included is coverage offered by a health the patient,justify his diagnosis and treatment, and substantiate the results accurately. plan. Market share --percentage that depicts portion of Medically indigent—a person who is too impoverished service area serviced by a provider vis-a-vis its com- to meet his medical expenses. It may refer to either petitors. pens whose income is low enough that they can pay for their basic living costs but not their routine medical Maximum out-of-pocket costs—a term referring to the care, or alternately, to persons`with generally adequate limit on total member copayments, deductibles and co- income who suddenly face catastrophically large insurance under a benefit contract. medical bills. MCM —medical case manager Medically necessary —a service or treatment which is appropriate and consistent with diagnosis, and which, MD-- medicaI doctor in accordance with accepted standards of practice in the medical community of the area in which the health Medicaid—a medical benefits program paid for by the services are rendered, could not have been omitted "Without adversely affecting the member's condition or federal government but administered by the states. the quality of medical care rendered. Medicaid provides medical benefits to persons who meet certain criteria and whose incomes fall below Medically needy—in the Medicaid program, persons specified maximums. who have enough income and resources to pay for their Medicaid mill —a health program which serves, solely basic living expenses(and so do not need welfare)but Medicaid beneficiaries, typically not enough to pay for their medical care. Medicaid law or primarily, yP y on an ambulatory basis. The mills originated is the ghettos of requires that the standard for income used by a State to New York City and are still found primarily in urban determine if someone is medically needy cannot exceed slums with few other medical services. They are 133% of the maximum amount paid to a family of usually organized on a for profit basis, characterized by similar size under the welfare program far families their great productivity, and frequently accused of a with dependent children{AFDC}. variety of abuses(such as ping-ponging and family ganging). Medi-Cal -- California's Medicaid program 12 In order to be eligible as medically needy, people M31H —Merrithew Memorial Hospital must fall into one of the categories of people who are covered under the welfare cash assistance program; MNO—Medically Needy Only i.e., be aged,blind, disabled, or members of families with dependent children where one parent is absent, Morbidity —an actuarial concept applied to setting health incapacitated or unemployed. They receive benefits if and disability insurance rates that shows the average their income after deducting medical expenses is low incidence of illness occurring in a large group of enough to meet the eligibility standard. Thirty-two people. states now provide Medicaid coverage to the medically needy. Mortality—an actuarial concept applied to setting life and disability insurance rates that shows the average Medicare—a nationwide, federally-administered health death rates for a large group of people. insurance program which covers the cost of hospitaliza- tion, medical care, and some related services for MRI —Magnetic Resonance Imaging (a type of x-ray) eligible persons. Medicare has two parts: Part A-covers inpatient costs(currently reimbursed prospectively MRMIP--Major Risk Medical Insurance Program using the DRG system). Medicare pays for pharmaceu- ticals provided in hospitals, but not for those provided MT —Martinez in outpatient settings. Part B-covers outpatient costs for Medicare patients (currently reimbursed retrospec- tively). N Medicare beneficiary --a person who has been desig- Neonatal care—care to newborn infants that is more Intensive in nature than care provided in a newborn hated by the Social Security Administration as entitled acute unit. to receive Medicare benefits. Medicare supplement policy --a policy guaranteeing NR'IR --Nuclear Magnetic Resonance that a health plan will pay policyholder's co-insurance, Non-participating provider—a term used to describe a deductible and copayments and will provide additional provider that has not contracted with the carrier or health plan or non-Medicare coverage for services up to health plan to be a participating provider of health care. - a predefined benefit limit. In essence, the product pays for the portion of the cost of services not covered by Medicare. Also called 'Medigap" or 'Medicare wrap'. O Member—a participant in a health plan (subscriber/ OAS —Medi-Cal category for the aged enrollee or eligible dependent) who makes up the plan's enrollment. Also used to describe an individual OBRA -- Omnibus Budget Reconciliation Act specified within a subscriber contract who may or may not receive health care services according to the terms Occupancy --ratio of actual patient days to total avail- of the subscriber policy. able bed days. Member month—a count which records one member for OlDIO — Office of Health Maintenance Organizations each month the member is effective. OOA --out-of-area. A term describing treatment ob- MFP— Martinez Family Practice tained by a covered person outside the network service area. h'IIA —Medically Indigent Adult OOP—out-of-plan. A term used to describe treatment MIC —Medically Indigent Children obtained by a covered person from non-participating provider. AIIS —Management Information System OOP Maximum —OuI-of-pocket maximum. The Mixed model —a managed care plan that mixes two or maximum amount that an insured employee will have more types of delivery systems. This has traditionally to pay for covered expenses under the plan. It is been used to describe an HMO that has both closed usually $504, $1,000, or$2,000. panel and open'panel delivery systems. 13 Open-ended programs —in the Federal budget, entitle- Outpatient —a patient who is receiving ambulatory care merit programs for which eligibility requirements are at a hospital or other health facility without being determined by law, e.g., Medicaid. Actual obligations admitted to the facility. Usually does not mean people and resultant outlays are limited only by the number of receiving services from a physician's office or other eligible persons who apply for benefits and the actual program which does not also give inpatient care. benefits received. Outpatient care refers to care given outpatients, often in organized programs. Open enrollment period —a period during which subscribers in a health benefit program have an Outside provider—any doctor, specialist, facility, etc. opportunity to select an alternate health plan being providing health care outside the County health offered to them, usually without evidence of insurabil- services department system. ity or waiting periods. Over-the-counter drug —a drug which is advertised and Open panel —a health care program that permits sold directly to the public without prescription. participants to purchase services or drugs from a provider of his or her choice. OYO—On Your Own Operating costs —costs directly attributable to opera- tions of business activities. P ORG — Organization. In County usage most often refers Pard claims —the amount paid to providers to satisfy the contractual liability of the carrier or plan sponsor. to cost center. Part A —a trust fund created under Title XVIII of the OTC — Over the Counter(drugs/medications that may be Social Security Act (Medicare) for hospital insurance purchased without a prescription). coverage. Outcomes measurement— a process of systematically part B —trust funds created under Title XVIII of the tracking a patient's clinical treatment and responses to Social Security Act(Medicare) for supplementary that treatment, including measures of morbidity and medical insurance. functional status. Outlier—a patient case that falls outside the established Partial hospitalization—formal programs of care in a norm of DRGs. hospital or other institution for}periods of less than 24 hours a day, typically involving services usually provided to inpatients. There are two principal types: Out-of-area —a term describing treatment obtained by a covered person outside the network service area. night hospitalization for patients who need hospitaliza- tion but can work or attend school outside the hospital during the day; and day hospitalization for people who Out-of-area benefits — those benefits that the plan require in-hospital diagnostic or treatment services but supplies to its members when they are outside the can safely spend nights and weekends at home. geographical limits of the HMO. These benefits always include emergency services. Partial hospitalization services —a mental health or Out-of-plan —a term used to describe treatment obtained substance abuse program operated by a hospital which provides clinical services as an alternative or follow-up by a covered person from a non-participating provider. to inpatient hospital care. Out-of-pocket cost —the portion of payments for health Participating provider—a provider who has contracted services paid by the enrollee, including copayments, with the health plan to provide medical services to co-insurance and deductibles. covered persons. The provider may be a hospital, Out-of-pocket limit or maximum —the total payments pharmacy, other facility or a physician who has toward eligible expenses that a covered person funds contractually accepted the terms and conditions as set forth by the health plan. for him/herself and/or dependents: i.e., deductibles, copay and co-insurance, as defined in the contract. Participation —the number of employees enrolled for Once the limit is reached, benefits will increase to medical coverage, usually identified as a percentage 1004E for health services received during the rest of relative to the total eligible population. that calendar year. Some out-of-pocket costs are not g eligible for out-of-pocket limits. 14 A 75% participation requirement means that at least PPA —Preferred Provider Arrangement. Same as a PPO, 75% of eligible employees must enroll for coverage. but sometimes is used to refer to a somewhat looser Participation requirements apply to eligible dependents type of plan in which the payer(i.e., the employer) also. makes the arrangement rather than the providers. Patient day —unit of measure depicting lodging in a PPO—Preferred Provider Organization. A plan that facility between two consecutive census taking periods. contracts with independent providers at a discount for services. The panel is limited in size and usually has Payor—person or organization which pays a provider some type of utilization review system associated with for services rendered to patients. it. A PPO may be risk bearing, like an insurance company, or may be non risk bearing, like a physician- PCCM—Primary Care Case Management sponsored PPO that markets itself to insurance compa- nies or self-insured companies via an access fee. PCN—Pharmaceutical Care Network Pre-admission certification —a review of the need for PCP—Primary Care Provider inpatient hospital care prior to the actual admission. Established review criteria are used to determine the PCPM—Per contract per month. The amount of dollars appropriateness of inpatient care. related to each effective contract holder, subscriber or member for each month. (PSPM-per subscriber per Pre-existing condition—any medical condition that has month)(PMPM)-per member per month). been diagnosed or treated within a specified period immediately preceding the covered person's effective Periodicity— term used for correct time periods between date of coverage under the master group contract. immunizations. Preferred providers--physicians, hospitals, and other Per member per month -- the unit of measure related to health care providers who contract to provide health each effective member for each month the member was services to persons covered by a particular health plan. effective. The calculation is # of units/member months. Preferred provider organization —a program in which PHC --Pittsburg Health Center contracts are established with providers of medical care. Providers under such contracts are referred to as PHS—Professional Hospital System-Health Services preferred providers. Usually, the benefit contract financial computer system. provides significantly better benefits(fewer copayments) for services received from preferred Pi1ITM —per member per month providers, thus encouraging members to use these providers. Members are generally allowed benefits for PO --Purchase Order non-participating providers' services, usually on an indemnity basis with significant copayments. A PPO Paint-of-service plan--it type of health plan allowing arrangement can be insured or self-funded. Providers the coveted person to choose to receive a service from may be, but are not necessarily, paid on a discounted a participating or non-participating provider, with fee-for-service basis. different benefit levels associated with the use of participating providers. Point-of-service can be Premium —the amount paid to a carrier or plan for provided in several ways: an HMO may allow members providing coverage under a contract. Premiums are to obtain limited services from non-participating typically set in coverage classifications such as: providers; an HMO may provide non-participating individual, two-party and family; employee and benefits through a supplemental major medical policy; dependent unit; employee only, employee and spouse, a PPO may be used to provide both participating and employee and child, and employee, spouse and child. non-participating levels of coverage and access; various combinations of the above may be used. Premium rate—a monetary amount charged employers or individuals to pre-pay the cost of health care Pool (risk pool) —a defined account (e.g., defined by services. The premium rates may vary by contract type. size, geographic location, claim dollars that exceed 'x' The premium is a specific contractual amount agreed level per individual, etc.) to which revenue and on by the HMO(or an insurer)and an employer to fix expenses are posted. - a cost for medical services for employees over an agreed-on period of time. 15 Primary care—basic or general health care traditionally Q provided by family practice, pediatrics and internal medicine. See also 'secondary care' and "tertiary QA --Quality Assurance-a formal set of activities to review and affect the quality of services provided. care" Quality assurance includes quality assessment and Primary care case management—a system where by corrective actions to remedy any deficiencies identified only the primary caroservices provided in the quality of direct patient,administrative and . w eligibles are support services. case managed. inpatient services are provided outside of the case management system and are reimbursed QS —computer system used by Central Appointments. differently. Primary care network —a group of primary care R physicians who have joined together to share the risk of providing care to their patients who are members of a Rate—the amount of money per enrollment classification paid to a carrier for medical coverage. Rates are gives health plan. usually charged on a monthly basis. Primary care physician—a physician the majority of whose practice is devoted to internal medicine, family/ Reasonable and customary —a term used to refer to the general practice and pediatrics. An obstetrician/ commonly charged or prevailing fees for health gynecologist may also be considered a primary care services`Within a geographic area. A fee is considered physician. to be reasonable if it falls within the parameters of the average or commonly charged fee for the particular Principal diagnosis—the condition, established after service within that specific community. study, as being responsible for requiring a patient's admission to the hospital. Referral -- the recommendation by a physician sad/or health plan for a member to receive care from a Private practice— the practice of a physician applicable different physician or facility, usually for consultation to patients seen principally in an office setting. or specialty care. Prior authorization—the process of obtaining coverage Referral provider—a provider that renders a service to approval for a service or medication. Without such a patient who has been sent to him/her by a participat- prior authorization, the service or medication is not ing Provider in the health plan.' covered. Reimbursement —the process by which the costs of PRO --Peer Review Organization services are calculated and paid to a provider of such services. Professional component —professional services pro- vided directly by physician to a patient. Reinsurance—insurance purchased by an HMO, insurance company, or self-funded employer from Prospective reimbursement — method whereby reim- another insurance company to protect itself against all bursement for a forthcoming period is determined in or part of the losses that may be incurred in the process advance of that period based on costs, trend factors, of honoring the claims of its participating providers, etc policy holders, or employees and covered dependents. Also called 'risk control insurance' or 'stop-loss Provider—a physician, dentist, or other person/institu- insurance'. tion that has primary responsibility for assessing the condition of the patient, for exercising independent Related organization —as organization which is related judgement as to the care of the patient, and for services to another organization by way of common ownership rendered for a given encounter. or control. PSRO —Professional Standards Review Organization Renewal —continuance of coverage under a policy beyond its original term by the acceptance of a pre- Public providers—any provider owned by a federal, mium for a new policy term. state, county, city or other local government agency or -instrumentality. .Reopener—provision in a contract to renegotiate specific terms at a specific time. 16 Residency program -an approved program which has S the approval of either the American Medical Associa- Same day surgery unit—a unit in the hospital wherein tion, American Dental Association or the American surgery is performed on patients who do not require Osteopathic Association. admission to the hospital. Retention—that portion of the cost of medicine benefit Sanction—a reprimand, for any number of reasons, of a program which is kept by the insurance company or participating provider. health plan to cover internal costs or to return a profit. Retrospective reimbursement—method whereby costs Satellite clinic—a clinic which is administered by a incurred during a reporting period are not finalized for provider physically apart from its main plant. reimbursement purposes until after the conclusion of SDjS — State Department of Health Services that period. Retrospective review —a method of determining medical SEA —South East Asians necessity and/or appropriate billing practice for Secondary care—services provided by a medical services which have already been rendered. specialist, such as a cardiologist, urologist and derma- tologist, who generally does not have first contact with Revenue—the pre6um/dollars received by the health patients. Also called 'specialty care'. plan from the employer group(s) for health care and administrative services. See also 'premium'. Self-funding, self insurance—a health care program in RHC —Richmond Health Center which employers fund benefit plans from their own resources without purchasing insurance. Self-funded plans may be self-administered, or the employer may Rider—s legal document which modifies the protection contract with an outside administrator for an adminis- of an insurance policy, either expanding or decreasing trative services only(ASO)arrangement. Employers its benefits, or adding or excluding certain conditions who self-fund can limit their liability via stop-loss from the policy's coverage. insurance on an aggregate and/or individual basis. Risk—generally, any chance of loss. In insurance, � Service area--the geographic area serviced by the health designates the individual'or property insured by an plan as approved by the state regulatory agencies. insurance policy against loss from some peril or hazard. Also used to refer to the probability that the SH-- SeniorHealth loss will occur. Shared risk — in the context of an HMO, an arrangement Risk analysis— the process of evaluating the expected in which financial liabilities are apportioned between medical care costs for a prospective group and deter- two or more entities. For example, the HMO and the mining what product, benefit level and price to offer in medical group may each agree to share the risk of order to best meet the needs of the group and the excessive hospital cost over budgeted amounts on a 50- carrier. 50 basis. Risk contract—an agreement between HCFA and an Skilled nursing facility —a facility, either freestanding HMO or CMP requiring the HMO to furnish at a or part of a hospital, that accepts patients in need of minimum all Medicare covered services to Medicare rehabilitation and care qualifying for Medicare-eligible eligible enrollees for an annually determined, fixed skilled coverage. SNFs must be certified by Medicare monthly payment rate from the government and a and meet specific qualifications, including 24-hour monthly premium paid by the enrollee. Ile HMO is nursing coverage, availability of physical, occupational then liable for services regardless of their extent, and speech therapies, and others. expense or degree. Skimming —the practice in health programs paid on a RN — Registered Nurse prepayment or capitation basis, and in health insurance, of seeking to enroll only the healthiest people as a way of controlling program costs(since income is constant . whether or not services are actually used). Contrast With adverse selection. Sometimes known as creaming. 17 Skimping—the practice in health programs paid on a Subrogation—a procedure under which an insurance prepayment or capitation basis of denying or delaying company can recover from third parties the full or the provision of services needed or demanded by some proportionate part of benefits paid to an insured. enrolled members as a way of controlling costs(since income is constant whether or not services are actually Subscriber—the person responsible for payment of used). The classic example is the denial or premiums or whose employment is the basis for eligibility for membership in an HMO or other health SMA—Schedule of Maximum Allowances(payment plan. guideline on claims) Subscriber contract—a written agreement, which may SNF— Skilled Nursing Facility also be called a subscriber certificate or a member certificate, describing the individual's health care Solo practice—lawful practice of a health occupation as policy. Also called 'explanation of benefits'. a self-employed individual, Solo practice is thus by definition private practice but is not necessarily general Supervising physician—medical doctor administratively practice or fee-for-service practice(solo practitioners and/or medically responsible for a department, service may be paid by capitation, although fee for service is or function. far more common). Solo practice is common among physicians, dentists, podiatrists, optometrists and Supplemental services—optional services that a health pharmacists; less common and sometimes illegal in plan may cover or provide in addition to its basic other professions. health services. Specialist—a physician, dentist or other health profes- Swing beds—beds whose use is altered to provide sional who limits his practice to a certain branch of services to various levels of care. medicine or dentistry related to: specific services or procedures, e.g., surgery, radiology, pathology; certain age categories of patients, e.g., pediatrics, T geriatrics; certain body systems, e.g., dermatology, Targeted case management— the medical management orthopedics, cardiology; or certain types of diseases, of specific groups of patients (i.e., AIDS, high risk, w e.g., allergy, psychiatry, periodontics. Specialists pregnant women, diabetics, etc.)to assure cost efficient usually have special education and training related to and effective treatment and optimal outcomes. their practice and may or may not be certified as specialists by the related specialty board. TCA1--Targeted Case Management SSA — Social Security Administration Termination date --the date that a group contract expires; or, the date that a subscriber and/or member SSI—Social Security Insurance ceases to be eligible. Staff model HMO— this health care model employs Tertiary care—those health care services provided by physicians to provide health care to its members. All highly specialized providers such as neurosurgeons, premiums and other revenues accrue to the HMO, thoracic surgeons and intensive care units. These which compensates physicians by salary and incentive services often require highly sophisticated technologies programs, and facilities. Stop-loss insurance—insurance coverage taken out by a Therapeutic alternatives—drug products containing health plan or self-funded employer jo provide protec- different therapeutic modalities,but which provide the tion from losses resulting from claims over a specific same pharmacological action or chemical effect when dollar amount pet member per year(calendar year or administered to patients in therapeutically equivalent illness to illness). Types of stop-loss insurance: (1) doses Specific or individual-reimbursement is given for claims on any covered individual which exceed a . Therapeutic equivalents —drug products which, when predetermined deductible, such as$25,004 or 550,000; administered in similar therapeutic doses, will provide (2)Aggregate-reimbursement is given for claims which the same clinical outcome or effect as measured by the in total exceed a predetermined level, such as 125% of control of a symptom or illness. the amount expected in an average year. ]s Third party payer—a public or private organization that Utilization review — function wherein use and consump- pays for or underwrites coverage for health care tion of services, along with level and intensity of care, expenses or another entity, usually an employer are reviewed for their appropriateness. (examples: Blue Cross, Blue Shield; Medicare; Medicaid: commercial insurers). V Title ld—California Code of Regulations title dealing Variable cost—a cost whose unit value remains rela- with the regulation of insurance. It includes language lively constant but whose aggregate value changes, which regulates the licensing and conduct of health care usually Proportionately to changes in volume. service plans in California. Title XVIII —section of the Social Security Act which is Vendor—a provider; an institution, agency, organization applicable to Medicare. or individual practitioner who provides health or medical services. Vendor payments are those payments Title XIX—section of the Social Security Act which is which go directly to such institutions or providers from applicable to Medicaid. a third party program like Medicaid. Vertical integration—linking of providers with immedi- ately related levels of care, but not the same level of administrative functions (e.g., claims processing, care. membership, etc.) for a self-funded plan or a start-up managed care plan. w Triage— the classification of sick or injured persons Waiver—document which provides relief or exception according to severity in order to direct care and ensure from usual requirement or regulation. the efficient use of medical and nursing staff and facilities. Waiver of premium --a provision included in some policies which exempts the insured from paying Triple option--a type of health plan in which employees premiums while he is disabled during the life of the may choose from an HMO, PPO or indemnity plan, contract. depending on how much they are willing to contribute to cost. Warrant — check U V1'IC —Women, Infants, Children (food program) UCR -- usual, customary and reasonable. See 'reasonable Withhold —an amount of money, usually a percentage, and customary'. of the plan's capitation revenue held back from Uncompensated care—services rendered for which the distribution to participating at-risk providers. The provider is not reimbursed or renumerated. withhold account may be used to cover the cost of such things as out of area or out of plan services received by Underwriting —in one definition, this refers to bearing plan members. the risk for something (i.e., a policy is underwritten by an insurance company). In another definition, this refers to the analysis of a group that is done to deter- mine rates, or to determine if the group should be offered coverage at all. UR —Utilization Review. A formal review of patient utilization or the appropriateness of health care ser- vices, on a prospective, concurrent or retrospective basis. Urgent—immediate but not emergent. URN — Unit Record Number Utilization — employment or use of a service or capacity. 19