HomeMy WebLinkAboutMINUTES - 03042003 - C55 A Contra
TO: BOARD OF SUPERVISORS
FROM: 2002 FINANCE AND INTERNAL OPERATIONS Costa
COMMITTEES
DATE: JANUARY 7, 2003 {"'',,,County
SUBJECT: HEALTH SERVICES DEPARTMENT AUDITS
SPECIFIC REQUEST($)OR RECOMMENDATION(S)&BACKGROUND AND JUSTIFICATION
RECOMMENDATIONS
1. ACCEPT Health Services Department responses dated December 11, 2002 and May 6,
2002 to the recommendations of Toyon Associates, Inc., regarding the Contra Costa
Regional Medical Center's fiscal year ending June 30, 2000 Medicare and [Medi-Gat cost
reports.
2. ACCEPT Health Services Department responses dated October 16, 2002 to the
recommendations of The Lewin Croup regarding the management and organization of the
Health Services Department, with the following additions and clarifications:
a. Staff of the Health Services and Human Resources Departments should continue to
develop plans and procedures to improve the recruiting, selecting and classifying of
Health Services Department employees, particularly"market sensitive" positions and
positions that reduce costs;
b. The County Administrator should follow up on The Lewin Group recommendations to
study and improve the worker's compensation program, and to investigate granting''
additional purchasing authority to the Health Services Department.
c. The County Administrator should conduct an independent evaluation of Health
Services Department community-based contracts in the context of the Board's
earlier directive to develop a policy on administering requests for proposals, and
should report to the Finance Committee with an assessment of the costs and
benefits of implementing such a policy.
CONTINUED ON ATTACHMENT: YES SIGNATURE:
RECOMMENDATION OF COUNTY ADMINISTRATOR w --Y RECOMMENDATION OF BOARD COMMITTEE
APPROVE OTHER
ShGNATURE(S):
MARK DeSAULNIER GAYLE K MA
.___...___..__...__.-._--------_.._.__._.. .___ __._..___. _.._ __.__.____.-__.-._.----...__--_..___..__..__
ACTION OF BOARD ON MARCH 4 2003 APPROVE AS RECOMMENDED X OTHER
VOTE OF SUPERVISORS I HEREBY CERTIFY THAT THIS IS A TRUE
AND CORRECT COPY OF AN ACTION TAKEN
-4-UNANIMOUS(ABSENT` 4 ✓ _} AND ENTERED ON THE MINUTES OF THE
. BOARD OF SUPERVISORS ON THE DATE
AYES: NOES: SHOWN.
ABSENT: ABSTAIN:
DTSMCT III SEAT VACAi+
ATTESTED YOM 4,2003
CONTACT: JULIE ENEA(925)335.1077 JOHN SWEETEN,CLERK OF THE BOARD OF
SUPERVISORS AND COUNTY ADMINISTRATOR
CC: INTERNAL OPERATIONS COMMITTEE STAFF
FINANCE COMMITTEE STAFF
COUNTY ADMINISTRATOR
HEALTH SERVICES DIRECTOR
HEALTH SERVICES CHIEF FINANCIAL OFFICER
HUMAN RESOURCES DIRECTOR f
COUNTY PURCHASING AGENT BY {f, DEPUTY
Health Services Department Audits January 7, 2003
internal Operations Committee Page 2
3. ACCEPT Health Services Department responses dated October 17, 2002 to the
recommendations of Pacific Health Consulting Group regarding its "Assessment of
Enrollment and Retention in Healthy Families and Medi-Cal for Children," and DIRECT
the Health Services Director and County Administrator to work towards establishing a
partnership with local school districts to finance the costs of outreach in the Healthy
Families Program and Medi-Cal for children in recognition of the benefits accruing to
school from the increased average dally attendance that results from these programs.
4. DIRECT the Health Services director to report back to the Finance and Internal
Operations Committees on the progress of implementing the recommended actions in six
months.
BACKGROUND
On February 12, 2002, the Board referred to the Finance and internal Operations Committees
review of the results of several audits that had been commissioned to examine the Health
Services Department in response to Grand Jury findings that the Health Services Department
budget was experiencing "overruns". On February 26, the Board adopted the Auditor-
Controller's conclusion that Health Services Department expenditures and net costs were
within budgeted limits and that the overruns found by the Grand Jury did not occur. The
Board also authorized the County Administrator to execute contracts with The Lewin Group
and Pacific Health Consulting to conduct studies of the Health Services Department's
organizational structure and to assess the Department's collaborative efforts to secure and
maintain the enrollment of children in the Healthy Families Program. In addition, the County
Administrator hired Toyon Associates to study the Department's Medicare and Medi-Cal cost
claiming practices.
On December 2, 2002, the Internal Operations Committee and the Finance Committee met
independently with Health Services Department staff to discuss the audit findings and
recommendations prepared by The Lewin Group, Pacific Health Consulting, and Toyon
Associates, and the Auditor's Office, and to consider responses from the Health Services
Department on each recommendation. The Health Services Director indicated that he agreed
substantially with the recommended actions and is in the process of implementing many of
them. Staff from the Health Services Department provided the context for the reports and
answered the Committees' questions. Staff from the Human Resources and General
Services Departments were also present and made comments.
Both Committees independently concluded that a joint meeting should be held on December
16. As a result of our joint meeting, we proffer our recommendations to the Board of
Supervisors for consideration. It is as yet unknown how state budget reduction pians may
affect the audit recommendations from a financial, organizational, and service delivery
perspective.
Included in this packet are the:
♦ Audit reports
♦ Health Services Department responses to the audit reports
♦ Health Services follow-up memo regarding the Toyon report, as requested on
December 2, 2002
r Memo from the County Administrator summarizing actions taken to date and
planned to be taken regarding the evaluation of the worker's compensation
program.
y.
.A T4: BOARD OF SUPERVISORS Contra
FROM: Jahn Sweeten Costa
County Administrator
DATE: February 26, 2002 County
SUBJECT: STATUS REPORT ON THE HEALTH SERVICES MANAGEMENT AUDIT
SPECIFIC REQUEST(S)OR RECOMMENDATION(S)&BACKGROUND AND JUSTIFICATION
RECCIMMENDED ACTION
I. CONSIDER a report by the County Administrator on the Auditor-Controller's review of net County
costs incurred by the Health Services Department in the three fiscal years ending June 30,200 1.
H. ADOPT the Auditor-Controller's conclusion of the review that budget overruns mentioned in the
Grand Airy report No. 0103 did not occur,
M.APPROVE and AUTHORIZE the County Administrator or designee to execute on behalf of the
County, contract#47910 with The Lewin Group, Inc. in an amount not to exceed$74,260,for the
period from February 20,2002 through June 30, 2002, to provide an assessment of the strengths and
weaknesses of the organizational structure of the County Health Services Department in relation to
the legal and fiscal environment in which it operates,
IV. APPROVE and AUTHORIZE the County Administrator or designee to execute on behalf of the
County, contract#47637with Pacific Health Consulting Group LLC in an amount not to exceed
$30,000, for the period from February 20, 2002 through June 30,2002,to assess the Health Services
Department's collaborative efforts to secure and maintain the enrollment of children in the Healthy
Families Program, and to maximize revenue in this program.
BACKGROUND
Can July 17,2001,the Board directed the County Administrator to facilitate a management audit of the
Health Services Department to hear recommendations for maximizing cost efficiency, On December 11,
2002,the Board decided which components the audit should have and directed the County
Administrator to issue a Request for proposals for four of them:
A. Assess the strengths and weaknesses of the organizational structure of the Health Services
Department in relation to the legal and fiscal environment in which it operates.
B. Review the Hospital Medicam and Medi-Cal cost report to identify ways, if any,by which
revenues may be enhanced.
C. Review Department medical staffing ratios at the Martinez Detention facility.
D. Assess the Department's collaborative efforts to secure and maintain the enrollment of children
in the Healthy Families Program,and to maximize revenue in this program.
CONTINUED ON ATTACHMENT: _;�_YES SiGNA ''UU ZE�E'':
...�. . . _........ .......... _. ... ......._ ._. .
__iz:::5qECOMMENDATION OF COUNTY ADMINISTRATOR RECOMMENDATION OF BOARD COMMITTEE
n' APPROVEOTHER
SIGNATURE(S); r
ACTION OF 80 C> .. c%' ) ` .,`�� .,,�'r�F�fiPROVE AS RECOMMENDED
VOTE OF SIJ ISORS i HEREBY CERTIFY THAT THIS IS A TRUE
AND CORRECT COPY OF AN ACTION TAKEN
UNANIMOUS{ABSENT } AND ENTERED CAN THE MINUTES OF THE
BOARD OF SUPERVISORS ON THE LATE
AYES: NOES: SHOWN,
ABSENT: ABSTAIN:
/ l
CONTACT: ATTESTED
JOHN SWEET CLERK 0F THE BOARD OF
SUPERVISORS AND COUNT`/
CC:
ADMINISTRATOR
Wllllam Walker,MD,Director,Health Services
Past Godley,CFO,Health Services
Ken Corcoran,Auditor-Controller
DEPUTY
. 3
"Encumbrance"(column 6)means commitments, (i.e,purchase orders, contracts,etc.)for goods or
services not yet performed.
,unencumbered Balance"(column 7)is calculated as the Final Adjusted Budget Appropriation minus
the"Year-to-date Actual"minus Encumbrances. If this number is positive,the department spent less
than appropriated.
"Variance"(column 12)for revenues is calculated as the Final Adjusted Budget Appropriation minus
the"Year-to-date Actual"revenues.If this number is positive, the department accrued more revenue
than expected.
"Variance"(column 16)for net County cost is calculated as "Unencumbered Balance"of appropriations
minus"Variance"in estimated revenues. If this number is positive, the department achieved a fund
balance and incurred less net County cost than appropriated.
The following are the answers to the Board of Supervisors inquiries:
For fiscal years 1998-99 through 2000-01 ending June 30, 2001:
a) Who were thea e a L es revenues and resulting net County costs author zed in the
Adooted Final Buclgels.for these bu„ get units? The aggregated expenditures are shown in column I of
Attachment I,the aggregated revenues are shown in column 8, and the resulting net County costs are
shown in column 13. It is noteworthy that expenditures show a maintenance budget with only slight
increases in some Public Health, Substance Abuse and Mental Health mandated State programs. At the
same time, State and federal revenues decline from FY 99-00 to FY 00-01. In order to fill the gap,the
Board approved increased net County cost during its Budget Hearings,
b) Whilt e2Mgnditure,.rev ue re net Count cost adjustments includin c -overs were m de
durigg the f1sW Year to the ado- d Final Budgets for these budget units by fte pardf S 'sots?
Adjustments include Board-approved mid-year appropriation adjustments shown in column 2 for
expenditures,and in column 9 for revenues. During these three years,adjustments account for 5%to 8%
increases in expenditures and revenues and recognize new federal, State and local funds,
c) .Did these raid- ear adimptments result in a net County cost for these bud et unit that differed ftom the
net Count t owed in the adgpt4td Final Budgets? If yes, what were the reasons? The mid-year
adjustments resulted in net County cost as part of the normal budgeting process:
• During FY 98-99, $2.4 million General fund dollars were appropriated in Board-
approved Cost-of-Living-Adjustments(COLA). COLA dollars are appropriated
centrally in a General Government Budget Unit, and allocated during the second quarter
of the fiscal year.
• During FY 99-00, $5 million was appropriated for Cost-of-Living-Adjustments, and
$500,000 in new local Tosco refinery revenues were appropriated for capital
improvements to the Pittsburg Los Medanos Community Clinic.
+ During FY 00-01,$500,000 in Tosco refinery revenues were appropriated for capital
improvements to the Los Medanos Community Clinic, $648,000 was appropriated by
the Board to the Homeless program in response to a local emergency of homelessness,
and$624,000 was appropriated for Retiree Health Benefits and one-tune allocations for
expansion of emergency shelter services,
d) What were the ear-end actual net Counly,costs for these budget units for those ears? Column 16
shows year-end actual net County costs and fund balances. For the Budget Units listed in this report,
total fund balance was between$118,000 and$646,000, or 0,07%to 0.32%of total adjusted
appropriations.
e) Did the year-_=d.AgqMl a tCoco ta orthese bud et units for those ears exceed the amounts
authorized bX tht Board of Sunervisors? Column 16 shows that at no time during the three fiscal years
ending June 30 2001 did the total actual net County cost for these budget units exceed the amounts
authorized by the Board of Supervisors.
Conclusion
Based on the foregoing discussion and the attached schedules we conclude that the budget overruns
mentioned in the Grand Jury report X10,01.03 did not occur.
The Board.of Supervisors,however,inquired farther to review whether net County cost increases from
budget year to budget year were comparable to other counties. In 1999,the Board had directed the
County Administrator to conduct a survey among the ten largest California urban counties to determine
whether net County east for Contra Costa Health Services was comparably low or high. As part of the
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0-iicE bF THE DIRECTOR BOARD(3F SUPERVISORS B. WALKER, M.D.
DIRECTOR & HEALTH OFFICER Jom GIOIA,1sT DISTRICT
GAYLE B. UILKEMA,ZNo.DISTRICT
xa Allen StreetDONNA GERE€R,3Ra DSTRICT
Martinez, California CONTRA COSTA
PIFARK DESAULNIER 4TH DISTRICT
945 1
F (925} 37 003 r E A L T SERVICE
R1jCE S Ftonw D.GLOVER, STH DISTRICT
Fax (975) 37 .5098 COUNTYApvlhlSTRATOR
JOHN R. SWEETEN
To: John Sweeten, County Administrator
From: William B. Walker, M.D. !`'{
Health Services Director
Date: October 17,2002
Subject: Response to Recommendations from the Pacific Health Consulting Group,
"Assessment of Enrollment and Retention in Healthy Families and Medi-Cal for
Children"
The Department has carefully reviewed the Healthy Families and Medi-Cal for Children
assessment prepared by the Pacific Health Consulting Croup. We are in substantial-agreement
with all recommendations.
The report commends the Board of Supervisors for revising the Basic Adult Care Program, now
called Basic Health Care, to include uninsured children so that Contra Costa's children now have
access to a full range of health care options. The report highlights the significant effort Contra
Costa Health Services has undertaken already "to reach out to as many children as possible,
enlisting major foundation support to launch the process." It acknowledges the significant
strides we have made, and emphasizes the importance of state changes to improve the enrollment
and retention processes. The report underscores the importance of continuing the high level of
local partners' 'involvement and asserts that a continued stream of State funds to support the
majority of the outreach and enrollment functions is unlikely.
In anticipation of State funding constraints, we had started an internal process to restructure our
outreach and enrollment activities prior to the initiation of this assessment. As the report
recommendations were being formulated, Health Services staff was incorporating them into our
restructuring process. As a result, we are including in our response to the recommendations the
current program status, as well.
Recommendation 1: Continue Board"of Supervisors long-standing support for access to
health services for children, through health programs and outreach and enrollment
We agree.
Contra Costa Community Substance Abuse Services - Centra Costa Emergency Medical Services • Contra Costa Environmental Health • Contra Costa Health Plan
• Contra Coto Hazardous Materials Programs -Contra Costa Mental Health - Contra Costa Public Health s Contra Costa Regional Medical Center • Contra Costa Health Centers
John Sweeten,County Administrator
October 17,2002
Page 2
Recommendation 2: All outreach, enrollment and retention activities should be built into the
existing infrastructure within Contra Costa County in order to increase stability of the
program.
We agree, integrating the outreach, enrollment and retention activities into the operational units
responsible for similar functions is the best way to increase program stability and promote
ongoing effectiveness.
Recommendation 3A: A regular county position of health insurance/access coordinator
should be established to coordinate and facilitate all insurance enrollment and retention
activities. This position should have appropriate access to decision-making authorities so that
barriers can be addressed,problems solved, and successes promoted countywide.
We agree. The role of Health Access Coordinator has been assigned established in the Public
Health's Family, Maternal and Child Health unit. Funding for this position is provided by the
State MCH grant.
Recommendation 3B: The health insurancelaccess coordinator should facilitate a Steering
Committee composed of the appropriate representatives from Financial Counseling,EHSD,
CCHP, Mental Health, Community Services Department and Public Health.
We agree. The Health Access Coordinator is facilitating a Steering Committee of representatives
from Financial Counseling, EHSD, CCHP, and Public Health. Representatives from Mental
Health and the Community Services Department have been identified and will be invited to
future meetings. The Steering Committee began meeting monthly in February 2402, and has
been meeting quarterly since June 2002.
Recommendation 3G: The health insurancelaccess coordinator should facilitate and
organize the Health Access Coalition as well as report to other county committees,
commissions and advisory groups that would benefit from information and advocacy about
related health insurance committees.
We agree. The Health Access Coordinator facilitates the monthly meetings of the Health Access
Coalition. Between 15-25 people from county programs and community organizations attend
these meetings. Furthermore, the Health Access Coordinator has been working with the Public
and Environmental Health Advisory Board(PEHAB)to insure that there are effective links
between the two groups.
Recommendation 3D: The health insurancelaccess coordinator should organize the county's
ability to track outreach activities, enrollment targets and retention targets.
We agree. The Health Access Coordinator is working closely with CCHS Information Systems
staff and the Community Health Assessment,Planning and Evaluation group in Public Health to
develop an effective and meaningful system to track outreach activities, enrollment targets, and
.: ........................
John Sweeten,County Administrator
October 17,2002
Page 3
retention targets. Discussion of this tracking system is also taking place at the Steering
Committee meetings.'
Recommendation 3E: The health insurance/access coordinator should implement a tracking
system similar to the Consumer Union's Tracking Program for Healthy Families,
incorporating all the programs and divisions under the same Entity Number.
We agree. A tracking system similar to the Consumer Union's Tracking Program for Healthy
Familiesis in the process of being implemented'at this time.
Recommendation 3F: The health insuracncelaccess coordinator should implement an
ongoing countywide education and training program on insurance activities and work closely
with the enrollment efforts of the Financial Counselors, the retention efforts at CCHP, and
EHSD.
We agree. An initial training was held in September for several Public Health programs. A
training"road show is being developed which includes a PowerPoint presentation,staff quick
reference tools and a low literacy brochure for the public describing Healthy Families,Medi-Cal
and Basic Health Care. The brochure will be produced in English, Spanish and other languages
as needed.
Recommendation 4: A Steering Committee of Public Health, EHSD, CHDP, CCHP,Mental
.Health, Community Services Department,financial counselors should meet regularly at least
monthly to identify key barriers in the system, analyze system difficulties,problem-solve and
monitor•integration. It should report regularly to the Health Access Coalition and to internal
senior staff at CCHS and EHSD.
We agree. The Steering Committee is meeting on a monthly basis and continues to identify key
barriers in the system and problem-solve around integration. Regular reports are made to the
Health Access Coalition. Minutes of the meeting will be shared with senior staff at'CCHS and
EHSD in the future.
Recommendation 5: Outreach to the uninsured target populations representing the core
public health function of access to care should remain in Public Health, with monitoring by
the health insurancelaccess coordinator.
We agree. Outreach is currently being accomplished through the Public Health programs of
CHDP,Family PACT (family planning and reproductive health services), PCG(Prenatal Care
Guidance), CPSP(Comprehensive Perinatal Services Program) and WIC. A training session was
held on September 11,24132 for staff from Public Health Clinic Services, CHDP, WIC, MVIP
(Medically Vulnerable Infant Program)and PCG(Prenatal Care Guidance)to provide them with
the information necessary to inform and enroll eligible county residents in Healthy Families,
Medi-Cal, or Basic Health Care. In addition,plans are underway to insure that staff in programs
that provide broad based Public Health community education, wellness and prevention programs,
h
John Sweeten, County Administrator
October 17,2002
Page 4
public health nursing and home visiting are trained to conduct appropriate outreach activities.
The Health Access Coordinator will attend Public Health Management Team meetings
periodically to review outreach and enrollment efforts and to work closely with Public Health
program managers to insure that their staff are able to conduct outreach and enrollment activities
effectively.
Recommendation 6A: Enrollment o,f individuals/families in insurance programs should be
coordinated by and be the responsibility of Financial Counselors through the county clinics
and hospital. The current Healthy Families Enrollment Assistors/CAAs located in the health
centers should be reassigned to report to the.Financial Counselors with whom they already
interact regularly. Some Community Health Workers can be integrated into other Public
Health programs.
We agree. The Healthy Families Enrollment Assistors have been reassigned to work in the
Financial Counseling unit. In addition, three Community Health Workers(CHW) from Healthy
Families have been reassigned to work with CHDP. These CHWs will work with CHDP staff,
WIC staff, and Clinical Services staff to enhance the capacity of these Public Health programs to
assist with enrollment.
Recommendation 6B: Redesign CHDP to incorporate enrollment strategies at CHDP
provider offices.
The State Department of Health Services is planning to use CHDP providers as "gateways"to
children's health insurance. They recently convened a statewide group to begin defining the
changes,with implementation expected in July 2003, Contra Costa is laying the groundwork for
being able to implement the State's Gateway Program through the Steering Committee meetings
which promote intra-program communication and coordination. As the State's direction
becomes clearer,Public Health will make the necessary changes within CHDP to insure Gateway
Program success and to insure that Gateway activities are well integrated with the other elements
of the children's health insurance access effort.
Recommendation 6C: Employment and Human Services Department, through all of its
programs, should continue its aggressive enrollment of eligible clients in the Medi-Cal
program and when possible should also enroll eligible clients in the Healthy Families
program.
EHSD has informed Health Services that they agree with the recommendations. Specifically,
they are participating in the.Steering Committee, and the Health Access Coalition; they will
engage in necessary training and will continue to use their Medi-Cal Advocate positions to
aggressively promote Medi-Cal enrollment. Finally, EHSD has participated in developing
recommendations from the County Welfare Directors Association to remove barriers to Healthy
Families enrollment by EHSD staff. EHSD will identify for the Board of Supervisors'
consideration future relevant legislative changes which could be supported.
John Sweeten,County Administrator
October 17,2002
Page 5
Recommendation 7: Retention of members can be most effectively organized by the Member
Services Department at Contra Costa.Health Plan because the vast majority ofHealthy
Families enrollees are managed by CCHP. .For those children who are not CCHP enrollees,
it will be important to use the Health Access Coalition to share best practices on retention.
Qualified agreement. We agree that the Contra Costa Health Plan should take the lead in
retention of Healthy Families enrollees. CCHP is currently assessing haw to develop an overall
retention initiative which would include all relevant business units. In addition, the Health
Access Coalition will showcase retention best and promising practices at future meetings. It is
important to note, however,that the State has a very significant role to play, as well. Key to
improved retention rates is authorization of Certified Application Assistors to help current
enrollees with the Annual Eligibility Review.
Recommendation 8 The Community S'ervi'ces Department's CAAs and parent advocates,
who assist familles with applications, should continue to be integrated into ongoing education
and training with the Health Access Coalition.
We agree. The Community Services Department is participating in the Health Access Coalition,
and will be participating in upcoming trainings.
Recommendation 9: The Health-e-app should be utilized to every extent possible in all
community-based as well as county entry points to health care.
We agree. The Health-e-app is being implemented. The Health Access Coordinator is working
with designated staff to troubleshoot for problems with this application process. Discussion of
the Health-e-app has taken place at the Health Access Coalition to insure that community
agencies are also aware of this new application process.
Recommendation 10: An emphasis should be placed on Point of Service Enrollment, using
the opportunity at the time of service at county clinics, community clinics and soon at private
providers'offices through the CHDP Gateway Program.
We agree. Point of Service Enrollment is being instituted. The focus is to insure that Point of
Service Enrollment happens at all possible service entry points.
Recommendation ll: At every available outreach or enrollment contact, information and
encouragement about using health services should be another priority of the contact.
We agree. The training"road show"described under 3F emphasizes the importance of
information and encouragement to use available health services. The new health insurance
brochure, briefly explaining Healthy Families,Medi-Cal and Basic Health Care in both English
and Spanish, is being pilot tested and will be widely distributed to staff and the public.
John Sweeten,County Administrator
October 17,2002
Page 6
Recommendation 12: Advocacy by the Board of Supervisors and every relevant county
department will continue to be necessary to promote changes in the Medi-Cal and Healthy
Families programs to ensure easier access for eligible children and adults.
We agree. The Health Access Coordinator will work with the Health Access Coalition and
related regional groups to identify desired regulatory and legislative changes and organize
support for their adoption. The Board of Supervisors will be kept informed of legislative issues
which could be supported.
Recommendation 13: As resources are declining, the best possible return on investment
seems to be the integration of outreach and enrollment activities, the enhancement of
retention strategies, and the ability to track progress throughout the county's departments.
Key to the integration is the effective working together of the Steering Committee and the
departments'leadership.
We agree. The Health Access Coordinator is working closely with the Steering Committee,
Public Health Management Team, the Public Health Director, and other key staff to
institutionalize the integration of outreach and enrollment and retention efforts. The Steering
Committee members are working together effectively and are expected to keep their
departments' leadership informed of progress.
Health Services believes that the recommended changes set the stage for better enrollment and
retention of children in Healthy Families and Medi-Cal. While some issues can only be
addressed by the State action, Contra Costa programs are now in a better position to be effective.
cc: Senior Staff
County of Contra Costa
OFFICE of THE CouNw ADMINISTRATOR
MEMORANDUM
DATE: DECEMBER 16, 2002
TO: BOARD OF SUPERVISORS MEMBERS
FROM: SCOTT TAND hie ssistant County Administrator
SUBJECT: THE LEWIN GR P RECOMMENDATION TO STUDY'
THE WORKER'S COMPENSATION PROGRAM
In its Management Assessment of the Contra Costa County Health Services
Department, The Lewin Group, Inc., and Henry W. Zaretsky, Inc., recommended that
the County study and improve the worker's compensation program. In particular, the
report raised broad issues about the County's worker's compensation program that
cannot be addressed by the Health Services Department, but are of a Countywide
nature.
Nevertheless, as a result of the audit findings, the County Administrator, through the
Risk Manager, hired a consultant to conduct an analysis of the worker's compensation
program. The consultant's concerns and ideas were shared with Department Heads at
a regular monthly meeting held in September and, in addition, some of the County
Administrator's concerns were shared with the Board.
We have been working with the Risk Manager since then on this issue and plan to bring
to the Board of Supervisors in mid-January a formal report that will include a
comparison of our worker's compensation program with that of other urban California
counties; an actuarial analysis of the financial components of our program; a discussion
of the additional cost implications of AB 749, which will take effect on January 1, 2002;
and specific recommendations to reduce and contain County costs. As you know,
changes to our worker's compensation program will likely require changes to current
labor agreements. We plan to raise these issues with the recently formed Labor-
Management Task Force.
We thought this information would be helpful to you as your Finance and Internal
Operations Committees review the Health Services audit findings and recommendations
as they relate to worker's compensation.
cc: John Sweeten, County Administrator
Tony Enea, Staff to Finance Committee
Julie Enea, Staff to Internal Operations Committee
Ron Harvey, Risk Manager
. Fz
OFFICE OF THE DIRECTOR BOARD OF SUPERVISORS
WILLIAM B. WALKER, M.D. .a"
DIRECTOR & HEALTH Qfi10ER JOHN GIOfA, 151"DlSTRIC7
GAYLE B.UILKIMA,7NF DISTRICT
20 Allen Street DONNA GERSER,3Ro DISTRICT
Martinez, California CONTRA uCOSTA MARK DeSAULNtER 4Tm DISTRICT
54553-3151 H E A L T E f S E R V I C E
94 (525}390-5003 Feww D.GLOVER, 5TH DISTRICT
CO
Fax (925) 370.5016 COUNTY ADMINISTRATOR
JOHN R. SWEETEN
Date: December 11, 2002
To: Tony Enea, Senior
Deputy County Administrator
From: Patrick Godley Rt' "
Chief Financial Officer
Subject: Toyon Report
The Board of Supervisors on July 9, 2002 considered and accepted the Toyon
report concerning the preparation of the Regional Medical Centers Medicare
and Medi- Cal cost report. The Board acknowledged the Department's high
level of efficiency in claiming revenues of$64 million and concurred with the
independent auditor that the Health Services Department has done "a
commendable job with the preparation of the Medicare and Medi-Cal cost
reports". The report was then referred to the Finance Committee.
The Finance Committee, on December 2, 2002,reviewed the Toyon audit.'
During the review, two questions were posed: 1. Did the net potential
reimbursement number of$7,911 contained in the Department's May 6"'
response to the Toyon report reconcile to the consultant's findings and; 2. Did
the Department respond to the consultant's recommendations?
Question 1: Reconciliation:
A. The Medicare and Medi-Cal cost reports claimed$64,260,884 in
reimbursable costs from the state and federal programs(source page
one,paragraph one of the Toyon report).
B. Medicare Reimbursement Items:
Item 1. Disproportionate Share Hospital Reimbursement: The Toyon
report,page 2, estimated reimbursement for this item at$134,000 for
Contra Costa Community Substance Abuse Services + Contra Costa Emergency Medical Services -' Contra Costa Environmental Health + Contra Costa Health Plan
Contra Costa Hazardous Materials Programs •Contra Costa Mental Health - Contra Costa Public Health - Contra Costa Regional Medical Center + Contra Costa Health Centers
-2-
every IM Medi-cal days. The consultant identified a number of data
elements that the Department needed to review to determine the number of
days that could potentially be claimed. The review indicated that 750
additional days might be realistically identified($134,000/1000=$134 per
day x 750=$100,500 which was rounded to $100,000 in the Department's
response).
Item 2. Bad Debts: Page 3 of the Toyon report estimated$406,0001br-this-- --------- --__
item. Toyon indicated their estimate was done prior to the receipt of the
updated bad debt log and prior to the realization the outpatient bad debts
were not reimbursable under the Departments Federally Qualified Health
Center Designation. (Toyon reported Inpatient/Psych$259,000, Outpatient
$147,000; total $406,000. Department estimate; Inpatient/Psych per
updated logs $272,822, Outpatient$0).
Item 3. Interns and Residents: The Departments' estimate of$132,000
was taken directly from page 3 of the Toyon report ($91,000
overstatement of Indirect Medical Education reimbursement and$41,000
overstatement of Graduate Medical Education reimbursement).
Item 4. Medicare Capital: The Departments' estimate of$173,365 was
taken directly from page 3 of the Toyon report.
Item 5. Intensive Care Nursery Beds: The Departments' estimate of
$31,000 was taken directly from page 4 of the Toyon report.
C. Medi-Cal Reimbursement Items:
Item 1. Interns &Residents: The Departments' estimate of$53,209 is
taken directly from page 4 of the Toyon report.
Item 2. Directly Assigned Capital: The Departments' estimate of$58,000
is taken directly from page 4 of the Toyon report.
Item 3. Lower of Cost-or-Charges. The Departments' estimate of$-0-is
taken directly from page 4 of the Toyon report.
Item 4. FQHC CMSP Payments: The Departments' estimate of$2.3,755
is taken directly from page 4 of the Toyon report.
_. ......... ......... ......... ......... ......... ......... _...._.. _
...._ ................ ......... ......................... __....... ......... _....... ...._..._........
-3-
Question 2: Recommendations.
Pages 1-4 of the Department's May 6th response provided a detailed
review of the issues raised by the Consultant. Contained in bold in the detailed
response was the Department's position on the findings and observations. The
following are the excerpts from the original response, which highlights the
H 'nsiil r
needed,we have expanded the narrative beyond the information contained in
the May 6h response, those items are in italics.
Medicare Item 1A Assessment of Medicaid DUs: The consultant's
finding recommends that CCRMC review the final Notice of Program
Reimbursement(NPR) for FY 1999-2000 when the NPR is eventually issued by
the Medicare Intermediary. We concur with the recommendation and have
routinely conducted such review in prior periods.
Medicare Item 1B. Labor Room Days: The consultant is recommending
that we review the maternity unit statistics to determine if"labor room beds"
exist. No such "labor room beds" exist at CCRMC. We disagree with the
recommendation.
Medicare Item 2. I/P and.O/P Bad Debts: The consultant noted that there
were no inpatient bad debts reported on the Medicare cost report and that
outpatient bad debts were an estimate based on the prior years experience.
CCRMC employs an outside firm to compile the patient specific bad debt
information required by Medicare. The firm did supply CCRMC with the bad
debt information for FY 99-00 in March 2002,prior to the start of audit
fieldwork in April 2002. We agree with the observation.
Medicare Item 3. Intem/Resident FTE: The consultant noted that in the
prior fiscal year,FY 1998-1999, another hospital erroneously claimed a portion
of the time of one of our residents,thereby precluding CCRMC from receiving
the full reimbursementit was entitled to. We were aware of this situation and
had worked with the other facility to correct their error. We agree with the
recommendation.
Medicare Item 4. Capital Exception Payment: The consultant noted a'
discrepancy in the amount reported. The Medicare auditor will make an
adjustment to incorporate the correct amount into the final audited FY 99-00
cost report. We agree with the recommendation.
_.. .........._... ......... ......... ......... ......... ......... ..._._. .. . .__._... _
..... ........ ._....... .............. ......... .._...._.. ............ ......... _................._..._.. ......... ...._.........._...
-4-
Medicare Item 5. ICN beds—Indirect Medical Education: The consultant
noted that the hospital did not include the six ICN beds on the cost report. The
Medicare auditor will make an adjustment to incorporate the correct amount
into the final audited FY 99-00 cost report. We agree with the recommendation.
Medi-Cal Item L Intern/Resident Costs Understated: The consultant
noted that CCRMC filed bath the Medicare and Medi-Cal retorts based on the
Medicare cost reinibur-sarrmit prirwqixtis.- There is-no reiimburwa tent im-pac't
from doing so. We disagree with the recommendation.
Medi-Cal Item 2. Lower of Cost-or-Charges Restriction: The consultant
noted that CCRMC was subject to a lower of cost or charge penalty. The
consultant misinterpreted the cited section of the cost report. CCRMC was not
subject to a reimbursement loss due to the cost-to-charge restriction. We
disagree with the recommendation.
Medi-Cal Item 3. FC}HC---CMSP Payment: The consultant found that
when the Medi-Cal cost report was prepared, a small amount($23,755)of
CMSP receipts were excluded from the $19.5 million of interim payments
reported as being received on the filed report. The consultant is correct, the
CMSP receipts should have been included. We agree with the
recommendations.
In summary, as indicated previously,the Toyon review was thorough,
professional and conducted in a timely manner. The report disclosed no
material errors or discrepancies in the cost report preparation or submission.
Please advise if additional information or clarification is required.
Attachments: May 6'2002 Department Response
Toyon Report March 21, 2002
Cc: Julie Enea
William E. Walker, M.D.
- 'OEEteE*OF THE,DiRECTOP, BOAR[?OF SUPERyiSORS
WILLIAM i WALKER, M.D.
" JOHN Mara, i TRCOiRECTOR & HtALTH OFFICER CXY1E 8.VKMXr 2NO DISiRICT
20 Alien Street CONTRA COSTA
DONNA GaRBER,Inti DisxRiCT
Martinez, California MARx,DESAututER 4Tis DamicT
94553-3191 HEALTH SERVICE S
Ph(925) 370-5003 3 FEOERXt Cl,GcaYER,ST"C►tsTRrcx
Fax(9253 70-5 0COUNTYAi)mINISTRATOR
JOHN ft. SWEETEN
Date: May 6,2002
NEI —
Senior Deputy County Administrator
From: Patrick Godley ytJ t
Chief Financial Officer
Subject: Medicare &Medi-Call Cast Report Review: FY 1999/00'
We have reviewed the Toyon report of findings for the Contra Costa Regional Medical
Center's Medicare and Medi-Cal Cost Report for 1999/2400 fiscal year.
Attached, you will find a detailed response to each of the consultant's
findings/observations. In Summary.
* The Medicare and Medi-Cal cost reports claimed$64,264,884 in reimbursable
costs from the state and federal programs.
• The net reimbursement impact of each finding is as follows:
Medicare: Gain<Loss>
1. Disproportionate Share Hospital $ 100,000
2, Bad Debts 272,822
3. Interns &Residents <132,000>
4. Medicare Capital <173,365>
5. ICN Beds < 31,000>
Medi-Cal:
1. Interns &Residents 53,249
2, 'Directly Assigned Capital < 58,400>
3. Lower of Cost-or-Charges -4-
4, FQHC CMSP Payment < 23,755>
Total Potential Reimbursement 1 L211
• Contra Costa Community Substance Abuse Services + Contra Costa Emergency Medical Serkes + Contra Costa Environmental Health * Contra-Costa Health Plan +
• Contra Costa Hazardous Materials Programs •Contra Costa Mental Health , Contra Costa Public Health • Contra Costa Regional Medical Center + Contra Costa Health Centers
.2-
The Toyon review was thorough, professional, and conducted in a timely manner. The
report disclosed no material errors or discrepancies in the cost report preparation or
submission.
Please feel free to contact me should additional information or clarification be required.
Attachments
Cc: William B. Walker,M.D.
* Note: Subject to third-party audit
__....._. ......... ......... ......... ......... ......... ......... ......... _......._.......
_ _ ........ ........ ......... ............_. ......... ............._.........._.........__. ......._.. .. ......... ......... ..........
MEDICARE1. Disproportionate Share Hospital(DSH)
1A.Assessment of Medicaid Days:
The Medicare Program reimburses Contra Costa Regional Medical Center(CCRMC)
approximately$3.5 million per year based upon its Disproportionate Share;Hospital
(DSH)status. One factor utilized in calcul at n the DSH amount is the number of
t, M . LLJnpatt�t days=r y RMG Igthe f seal
period. The consultant's finding recommends that CCRMC review the final Notice
of Program Reimbursement(NPR)for FY 1999-2000 when the IPPR.is eventually
issued by the Medicare Intermediary. We concur with the recommendation and
have routinely conducted such review in prior periods. While CCRMC's inpatient
Prospective Payment System volume is modest(less than 1,000 discharges each year),it
is possible that the intermediary accidentally excluded some allowable.Medicaid days
that could result in additional revenue.
1B. Labor Room Days.
In some hospitals,maternity patients are admitted to a"bed"in the labor and delivery
department,or to a"bed"in an alternate birthing center within the hospital,where they
are counted in the hospital census statistics even though they may not give birth for
several days or in some cases, are discharged without having given birth. Medicare
requires that this type of"labor room day"be excluded from the count of inpatient
service days since the level of care provided to patients occupying such beds is typically
significantly less than the level of care rendered to patients occupying an acute hospital
bed. The consultant is recommending that we review the maternity unit statistics to
determine if 4°labor room beds"exist. No such `'labor room beds"exist)at CCRMC.
CCRMC does not count a patient service day unless the patient is admitted to an inpatient
bed on one of its' acute nursing units.
2. Medicare I/P and O/P Bad Debts
Medicare beneficiaries are expected to share in the cost of the medical care that is
provided to them. Medicare has both an annual inpatient deductible amountthat each
beneficiary is expected to pay and a 20% co-pay requirement on all outpatient and
physician services. In those cases where the hospital has unsuccessfully sought payment
from the beneficiary, the Medicare program has agreed that they will pay the hospital for
those uncollected"bad debts". The consultant noted that there were no inpatient bad
debts reported on the Medicare cost report and that outpatient bad debts were an
estimate based on the prior years experience. CCRMC employs an outside firm to
compile the patient specific bad debt information required by Medicare. An outside
firm is used because they have the specialized computer software necessary to sort
1
through the State's Medi-Cal payment files to isolate and quantify the unpaid coinsurance
amounts related to only the facility component(hospital charge as opposedto MD
charge) for beneficiaries that have both Medicare and Medi-Cal coverage, ;Due to Medi-
cal reimbursement limitations,Medi-Cal will not pay the coinsurance amount if the
amount already paid by Medicare exceeds what Medi-Cal would pay if the beneficiary
had only Medi-Cal and they were the primary payer. As a general practice,'in order to
ensure that the most current and complete listing of unpaid claims is used,CCRMC does
not secure the bad debt information from that firth until just prior to the start of the
Medicare audit. The firm did su l CCRMC with the bad debt informat c
il�,iii ,i IMarc ,p or u.o e s a o au t 1111elilwork In April 2002.
3. f it,.ra esident ME
CCRMC has an accredited Family Practice Medicine Teaching Program in!association
with the University of California at Davis,School of Medicine. To broaden their scope
of experience,part of the CCRMC teaching program involves these residents providing
services at locations other than CCRMC. The Medicare program reimburses hospitals for
the casts of their accredited teaching programs based upon the number of interns and
residents that participate in their program. if a resident is compensated by a facility,his
cost is reimbursed to that facility regardless of where he physically works. The
consultant noted that in the prior fiscal year,FY 19981999,another hospital
erroneously claimed a portion of the'time of one of our residents,thereby precluding
CCRMC from receiving the full reimbursement it was entitled to. We were aware
of this situation and had worked with the other facility to correct their error. In
March 2002,CCRMC confirmed with Medicare that the other facility had finally
submitted the corrected data and that Medicare was now able to increase CCRMC's
reimbursement to the higher amount it was entitled to.
4.Mg scar&Canital Exxceution Payment
During the nine year transition period from cost based reimbursement to a Prospective
Payment System(PPS)reimbursement of capital project and equipment costs,Medicare
pays for certain capital items based on the lower of(1)the amount of accumulated
depreciation since the inception of Capital PPS that would have been reimbursed had
Medicare not implemented Capital PPS or(2)the accumulated amount of capital project
and equipment payments that Medicare would make under the new Capital PPS
methodology. The consultant noted a discrepancy in the amount reported. The carry
over capital payment information from the prior year,FY 1998-99, Audited Cost Report
was not available at the time that the FY 1999-2000 cost report was submitted. As part of
the FY 1999-2000 audit, the Medicare auditor will make an adjustment to
Incorporate the correct amount into the flnal audited FY 99-00 cost report.
5. Y tensive Carers IC eds—Indire t Medical cation 1VLE
2
CCRMC operates six"Level 2"Nursery beds as part of its' licensure. Level 2 beds,
while not providing as high a level of nursing ease as an Intensive Care Nursery,do
provide a higher level of nursing care to newborns than is provided in a routine bassinette
setting. The consultant noted that the hospital did not include the six ICN beds on
the cost report. This was the first cost report year that CCRMC had Level 2 beds in
operation. The consultant is correct in stating that these six beds were inadvertently
included with the routine nursery Statistics on the filed cost report.As part of the FY
1999.2000 audit the Medicare auditor11 MAM U,a
V correct amount iota t e al audited FY 99-00 cast report. We will also incorporate
this change into all future report filings.
Nl£ED►I-CAL
FAding 1,InternlResident Costs Understated
The.Medicare and Medi-Cal Programs.each require a cost report to be filed after the close
of each fiscal year. The reports are essentially identical except that the Medicare report
identifies the costs of providing services to Medicare beneficiaries,while the Medi-Cal
report identifies the costs of providing services to Medi-Call eligibles. There are a few
reimbursement areas where the Medi-Cal reimbursement principles differ slightly from
Medicare reimbursement principles. The consultant noted that CCRMCfiled'the both
the Medicare and Medi-Cal reports based on the Medicare cost reimbursement
principals. vire are aware that in doing so, some minor cost amounts are not included in
the initial claim. There is no reimbursement impact from doing So,since when the
audited cost report is prepared,the correct version specific to the Medi-Cal Program is
used, and any such excluded costs are included in the final report. The hospital will
ensure that these costs are included when the State auditor reviews the FY 99-00 Medi-
Cal cost report in May 2002, and we will utilize the software report version specific to
each Program when filing reports in future years.
Finding 2.Directly Assigned Capital
Same response as above.
Finding 3.Lower of Cost-or-Charge Restriction
The Medi-Cal Program restricts the amount it will pay for services provided to.Medi-Cal
eligibles to the lower of what a provider's usual and customary charges are for those
services,or the provider's cost of rendering those services. An Administrative Day,is an
inpatient clay of service rendered by a hospital when there no longer exists a medical
justification for keeping the patient in an acute care hospital. This most often occurs
when a patient is well enough to be discharged to a facility that provides a lower level of
3
care,such as a Skilled pursing Facility,but there are no open beds available in the lower
level of care facility. The consultant noted that CCRMC was subject to a lower of
cost or charge penalty. The consultant misinterpreted the cited section of the cast
report. CCRMC was not subject to a reimbursement loss due to the cast to-charge
restriction.
fines 4 FQHC—!QMP Payment
CaMC receives payments from the.Medi-Cal.Program for services that we rendered to
Medi-Cal eligibles. Additionally,the State serves as the fiscal intermediary for the
County Medical Services Program(CMSP). Small counties have the option of either
operating their own Medically indigent Service Program,such as this county's Basic
Adult Care Program,or they may contract with the state to operate the program on their
behalf: When a county contracts with the State, the indigent care program is called
CMSP. The consultant found that when the Medi-Cal cost report was prepared,a
small amount($23,755)of CMSP receipts were excluded from the$19.5 million of
interim payments reported as being received on the filed report. The consultant is
correct, the CMSP receipts should have been included.
4
!IrUNASSOCIATES, INC,
HEALTHCARE FINANCIAL CONSULTING
Crepry Lane,Site 280 8 Mpasant H14,CA W23=3398
,68'3.9312 Fax 926.687.9013 IMI www.toyonassodates.com
March 21,2002
Mr. Pat Godley
er ,
Contra Costa Regional Medical Center
20 Allen Street
Martinez, CA 94553
RE: 'Medicare&Medl-Cal Cost Report Review
F'YZI 6/30/00
Dear Pat:
Enclosed is the Report of Findings for our review'of Contra Costa Regional Medical Center's
FYE 6/30/00 Medicare and Medi-Cal cost reports. The Report of Findings only addresses
material errors or discrepancies..The review was intended to disclose both positive and negative
items. We have previously provided a point sheet noting all our observations,as well as the
C3ME and IME reimbursement impact computations for the intern/resident FTE issue.
The Reimbursement Department has done a commendable job with the preparation of the
Medicare and Medi-Cal cost reports. Overall,the data inputted on the cost report were well
doumeented.
After you have reviewed the enclosed report, let us know if you have any questions.
Sincerely,
Tim Yuen
Vice President
Enclosure
ShVM-CC4B00C "U d1ug1tr-
....................................................................................................-...''I'll,
. .. .. ...................................................................................................................................................
Contra Costa Regional Medical Center
Report of Findings
Based on Review of the"As Filed"Medicare& Medi-Cal Cost Reports
FYE 6/30/00
Background
The Medicare and Medi-Cal "as filed"cost reports were reviewed to determine whether they
contained any material errors or discrepancies. The review was intended to disclose both
positive and negative items. The Medicare and Medi-Cal "as filed"cost reports claimed
$64,260,884 in reimbursable costs from the State and Federal programs.
Fin4jugs/Observaflons
MEDICARE
1. DisPLUortionate Share Hospital(DSH)
Based on our review of the Medicare disproportionate share amount(DSH),we noted the
following:
A.Assessment.ofNedicald Days
For the preparation of the"as filed"cost report, the hospital used readily available census
information for reporting Medicaid days for the Medicaid utilization ratio of the DSH
computation. Upon receipt of the Notice of Program Reimbursement(NPR),the Hospital
should do additi6nal analysis of patient financial and statistical data in identifying
additional Medicaid days. Since the issuance of HCFA Ruling 97-2, Medi-Cal days can
include more than just paid days.
Under HCFA Ruling 97-2,CMS, formerly HCFA, acquiesced on its long-standing
interpretation of the Medicaid ratio. Historically, CMS contended that Section 1886
(d)(5)(F) (vi)(11) of the Social Security Act required only those days for which a hospital
received Medicaid payment to be included in the Medicaid ratio. Under HCFA Ruling
97-2, all inpatient days of service for which a patient was eligible for assistance under a
State Medicaid plan, whether paid or unpaid should be included in the numerator of the
Medicaid ratio.
In his memorandum of June 12, 1997, Charles Booth, Acting Deputy Director at the
Bureau of Policy Development at CMS, clarified details of HCFA 97-2 He states in part,
The definition of Medicaid days for purposes of the Medicare disproportionate share
adjustment calculation includes all days that a beneficiary would have been eligible for
_. ......... ......... ......... ......... ...11.11
.. .... .......................... ......... .._...... ......... ......... ......... ......... ............._.
_. _ _........ ......... . ........ .........
Contra Crista Regional Medical Center FYE 6/30/40
Report of Findings Page 2
Medicaid benefits, whether or not Medicaid paid for any services. This includes,but is
not limited to,days that are determined to be medically necessary but for which payment
is denied, days that are determined to be medically unnecessary and for which payment is
denied,days that are utilized by a Medicaid beneficiary prior to an admission approval,
days that are paid by a third party, and days that an alien is considered a Medicaid
beneficiary, whether or not it is an emergency service."
We recommend that the Hospital prepare the required analysis to identify additional
Medi-Cal days for the following categories:
1. Partial denied days where Medi-Cal (regular and HMO) is the primary payor;
2. Total denied days where Medi-Cal (regular and HMO)is the primary payor,
3. Days in which Medicaid is the secondary payor,but the primary payor(excluding
Medicare Part.A)paid the claim, and
4. Medicare Part B/Medi-Cal Crossover days.
For FYE 6/,Vft�,_bkevery additional 1,004 Medi-Cal days,DSH reimbursement would
increase b $134,400
B.Labor Room Days
For the Medicare cost report, total patient days are to be reported net of labor room days.
Based on my understanding,the Medicare.Intermediary has concluded that the Hospital
does not have any labor room days.. For all prior periods, as well as the period in review,
labor room day has been a non-issue and the cost reports were properly prepared.
In a review of the patient daily census summary, there were 1,584 days for Nursing Unit
5A,which are entitled L&D/Recovery!Post Partum. We recommend further review'of
the days for Nursing Unit 5A, since it may be an unit similar to an Alternate Birth Center
(ABC),where all three functions(labor&delivery,recovery and post partum)are
perforined-in the:sax#o ntfrsing unit; If similar, the Medicare intermediary will wait
labor room days to be identified and excluded from the Medicare cost report.
Z. Medicare I/P and O/P Bad Debts
There was no inpatient bad debts reported on the Medicare cost report and outpatient bad
debts of$200,040 was an estimate based on the prior year's experience. The Hospital
utilizes a consultant to run computer-matching program to determine bad debts. No
supporting workpapers were available at the time of our review.
In discussions with hospital management,it is our understanding that the Consultant
engaged to compile Medicare bad debt information has only recently provided the
information to the Hospital. The Hospital has filed or will be filing an amended cost
report to claim the following amounts as bad debts:
Contra Costa Regional Medical enter EYE 6/30100
' Report of Findings Page 3
Inpatient Acute $214,000
Impatient Psych 45,000
Outpatient Acute 147,000
$406,000
The Hospital normally files its claim for bad debt reimbursement during the field work of
the cast report auditin order to ensure that bad debts for all Medicare paid patients,
including those identified after the cost report was initially filed, are included in the
claim.
3. Intern/R #dent FTEs an Prior Year Resident-To-Bed Ratio
The number of intern/resident FTEs for the computation of the three-year rolling average
was not completely reported for the IME(Worksheet E,Fart A) and GME(Worksheet E-
3,Part TV)computations. On the point sheet, I have provided the intern/resident FTEs to
be reported basedon a review of the audited FYE 6/30/99 Medicare cost report. Also,
the prior year resident-to-bed ratio is.198142 rather than.227757.
In discussions with hospital management,the prior year resident-to-bed ratio
overstatement was due to a loss of intern/resident FTEs for"intern/resident overlap"
with another hospital. An intern/resident overlap occurs when two or more hospitals are
claiming the same resident(s)for the same period(s). If the hospitals cannot agree as to
who get the resident,neither hospital will get to count the resident(s). This occurred for
EYE 6/30/99 and has resulted in the Hospital's overstatement of prior year resident-to-
bed ratio.
As reported,M and GME entitlements are overstated by$91,000 and;$41,000,
respectively.
4. Medicare Capital Exception Payment
The.Hospital did not report the carryover of accumulated capital minimum payment over
capital payment on line 11 (Worksheet L,Pt. IV). The amount to be reported is
$173,365.
This has resulted in exception payments being overstated by$173,365.
Contra Costa Regional Medical Center FYE 6134/00
Repbrt of Findings Page 4
5. ICN Beds-IME
The Hospital did not include the six.TCN beds on the cost report. The ICN beds need to
be included with ICU beds in the computation of IME entitlement.
For FYE 6130100, the inclusion of the six ICN beds as available beds mould decrease
IME reimbursement by approximately$31,000.
META»CAL
I. Intern/resident Costs Understated
Intem/resident costs on Worksheet B are not being included in computing the individual
cost-to-charge ratios on Worksheet D-4. There is a feature in the KPMG software that
must be activated when preparing the Medi-Cal cost report.
This has adversely impacted the CMSP, Administrative Day, and FQHC settlements,but
not considered material. The settlements have been reduced by the following amounts:
CMSP $ 225
Admin Day 48,713
FQHC 4.271
$53,209
2. Direct Assigned Canitai(014)and Old Capital Equipment Statistics
The Medicare version was used and has resulted in no allocation of capital cost to FQHC.
This is estimated to reduce FQHC settlement by approximately$58,000.
3. Lower of+l +nst---or CharPe(LOCOQ Restriction
The Hospital was subject to a$297,532 LOCOC restriction in its Administrative Day
settlement. The Hospital needs to raise its rate to avoid LOCOC restriction. This has no
reimbursement impact because the Hospital's routine cost is limited to the per diem rate.
4. FORC -CATS_ P Payment
FQHC—CMSP payments of$23,755 were excluded from the interim payments reported
in the FQHC cost report.
...............
Contra Costa Regional Medical Center FYE 6/30/00
Report of Findings Page 5
5. AdMJRJ1Lr_x&ve Day Settlement
The Administrative Day Settlement is overstated by$665,803 due to a flow-through
computation of the cost report software,which is not used for Medi-Cal settlement
purposes. The Medi-Cal Administrative Day settlement should only be for ancillary
services, since routine services are covered under a prospective rate. The settlement
should be a$10,840 liability rather than a$654,963 receivable,
Ancillary Reimbursable Costs $245,081
Ancillary Interim Payments 255,221
Cost Report Liability $ 10,840
Based on our understanding, the Hospital did not record any settlement on the books and
the$10,840 payable is considered immaterial for booking purposes. From a payment
perspective,the$10,840 liability due the State, at.the time the cost report is filed,is not
considered material and subject to change upon completion of the Medi-Cal audit.
Conclusion
The Medicare/Medi-Cal cost reports are extremely complex in both preparation and regulatory
interpretation. We believe that hospital management has filed a combined cost report,which
reasonably reflects the costs to the third-party programs, and we have not identified any material
.problems with the submission. We recommend the Hospital review the matters set forth in this
report to determine proper disposition.
.c
r,
OfF10E of THE DIRECTOR
13CJAR17 OF SUPERVISORS
WILLIAM B. WALKER, M.D.
DIRECTOR & HEALTH OFFICER JOHN GtotA, 15r MsTRtcr
CAYLE U , 2ND VISTRtc
20 Allen Street CV1VT R10 S TA DONNA GeAw, JR4 4TRtCt
Martinez, California RrM R94559-9i91 � L1LryH SERVICES
FEDERAL 0.GLOVER, S-rrDisTRici
LNIER icT
Ph (92 59711-5509
Fax (925) 970-51198 COUNTY AE>MINISTRATOR
JOHN R. SWEETEN
Date: October 15, 2002
To: John Sweeten, County AdministratI
From: William B. Walker,M.D.
Director, Contra Costa Health Services
Subject: Response to Recommendation in the Lewin Group Report"Management
Assessment of the Contra Costa County Health Services Department"
r
We have reviewed the Management Assessment of the Health Services Department that was
prepared by The Lewin Group and essentially agree with its conclusions. As the report points
out, Contra. Costa has an unusually comprehensive and integrated Health Services Department.
We have built on the advantages of having all health-related services under one roof: We are able
to apply funding where it is most needed, within the legal constraints of categorical funding. We
are able to share common functions and reduce overlap and duplication of services, especially in
the area of administrative support. We outsource services to community providers to gain
additional flexibility. Perhaps most importantly, the various disciplines within Health Services
are encouraged to collaborate in order to sustain a high level of quality and accessibility.
We have tried,to anticipate changes in the healthcare environment and to "right-size"our
activities.For example, the report points out that our Medical Center has a high level bed-
occupancy, the result of purposely restricting the capacity when it was designed. As another
case in point, when it became clear that Home Health Agencies would not be financially
practical,we closed ours down. On the other hand, when service demand and fiscal prudence
warrants it, we will expand capacity, as we are doing in several of our outpatient Health Centers.
.Health Services.is proud of our no-surprises record in managing an ever more difficult fiscal
environment. Budget issues are identified well in advance and presented to the Board for policy
discussions and deliberations during budget hearings. The Department's centralized'finance
process insures that all expenditures, for goods and services as well as for new positions, are
approved on an as,needed/as required basis. This is effectively a continual budget process. The
expenditure requests must reconcile with workload and with the revenue cycle. This process
provides the Department with a safeguard against County General Fund overruns and provides
for an cin-going review of program needs. As the Lewin Group points out, it is also helpful to
have the internal check-and-balance of an at-risk Health Plan,
Contra Costa Community Substance Abuse Services • Contra Costa Emergency Medical Services • Contra Costa Environmental Health • Contra Costa Health Plan
• Contra Costa Hazardous Materials Programs +Contra Costa Mental Health + Contra Costa Public Heafth • Contra Costa Regional medical Center 9 Contra Costa Health Centers
The report concludes and we concur that"the benefits and strengths associated with the current
structure and operation of the Health Services Department appear to outweigh the risks and
challenges of alternative designs. The current organizational structure, which integrates core
service functions into one cohesive agency, presents many opportunities for the County to
collaborate across health care and public health programs, enables quick response to the rapidly
changing health care social and financial environment, and makes efficient use of resources
dedicated by the Board of Supervisors".
RECOMMENDATION # 1:
Study the current personnel management systems.
RESPONSE:
Agree. We understand that Health Services has a very large number of different classifications,
each of which has its own selection process. We recommend an independent assessment of ways
to provide the flexibility and speed that HSD requires in order to meet the challenges of a
difficult labor market for certain positions. This study should include the feasibility of moving
certain functions unique to Health Services into this department. In this way the expertise of our
professional staff can be appropriately applied to recruiting and selecting within their respective
disciplines, while-speeding up a process that often leaves us shorthanded and reliant on agency
personnel.
RECOMMENDATION # 2.
Increase communication between HSD and County Human Resources regarding labor
agreements.
RESPONSE:
Agree. The report points out that County Human Resources may not fully understand the
competitive nature of certain positions. Increasing nursing salaries, for example,may appear at
first to merely raise HSD expenditures, but in fact it lowers them by reducing the need for costly
Registry nurses. Such considerations must be included in negotiation of labor agreements,which
are the sole responsibility of the Human Resources Department.
RECOMMENDAXION1 3:
Increase the involvement of HSD division managers in the annual budget preparation process.
RESPONSE:
As described previously, we attribute our favorable fiscal record to strongly centralized financial
management. Managers are not excluded from this process, but they have limited involvement in
the "revenue"budget or monitoring due to the integrated nature of the Health system (e.g.,DSH
revenue, Vehicle License fees, Sales tax, Health Plan) over which managers have little control.
On the other hand, there is considerable managerial involvement in areas where control is
possible, and managers have significant responsibility for the expenditure side of the ledger.
Along with this authority comes an expectation that managers will routinely monitor the
relationship between services and expenditures and will allocate resources wisely in order to
enhance productivity.
RECOMMENDATION#4:
Provide additional financial and clinical information to HSD division managers.
RESPONSE:
Agree. Our ability to provide this information on a routine basis is limited by the information
systems available. Mission-critical tasks such as billing and revenue collection take precedence.
It should be noted that a wide array of financial reports exists already; in some cases, additional
training of managers in their use would assist them in carrying out their responsibilities. Where
feasible,we have incorporated managers' suggestions to improve the usefulness of the reporting
system.
RECOMMENDATION # 5:
Develop or enhance infbnnation systems to identify high-cost clients and establish case-
management mechanisms.
RESPONSE:
Agree. The major systems limitation is the fact that client data is presently stared in a variety of
non-interacting systems, often mandated by third.parties. We do have the ability to identify high-
use clients within several divisions, but only limited information is currently available across
divisions. Strict confidentiality laws also limit sharing of information. On the positive side, we
have found that uninsured, indigent adults in our BAC program are among the largest consumers
of health care, and the Lewin report mentions favorably our unique(in California) intensive
approach to managing services to this population.
RECOM1tIENDAI'ION# 6:
Study and improve the worker's compensation program.
1tESPONSE:
Agree. We have hired an individual specifically to improve management of worker's
compensation cases. This person acts as liaison between HSD managers and:Disk Management,
maintains a database of all cases which is reviewed on a regular basis, and improves transition
from off-duty to limited-duty status. The major structural issues of the program are well known
e.g., 87%payment rate and restrictions on the choice of physicians. The structural issues cannot
be addressed by the Department.
...........
RECOMMENDATION #7:
Move the probate function out of HSD and into another County department.
RESPONSE:
Agree. This is primarily a legal function and is not consistent with the essentially health-related
mission of this Department.
RECOMMENDATION #.8:
Develop a business unit focused on elderly consumers.
RESPONSE:
Qualified agreement. We are aware of the growing needs of this population, and have pursued
several program expansion and financing options that, however, depend on Federal and State
action to alter current reimbursement mechanisms. For the moment,we feel it is better to
continue the collaboration between CCHP and Ambulatory Care than to establish a new
management unit.
Health Services is an active participant in the Long-Tenn Care Integration Pilot Project. This
effort is sponsored by Health Services and EHS, and includes a forceful community component
in its 27-member Task Force. This group, with the aid of consultants experienced in the design
and financing of health services for the elderly, is studying the feasibility of combining most
such services under one at-risk County unit, such as CCHP, with the goal of reducing
institutional care.
RECOMMENDATION #.9:
Conduct an independent evaluation of Health Services Department community-based contracts.
RESPONSE:
Qualified agreement. Given the number and diversity of our contracts, such an evaluation would
either be cursory or else would be very costly in order to achieve the requisite degree of
relevance and comprehensiveness. Most HSD divisions already have an evaluation component
with specialized expertise and data access. An outside evaluation would be welcome but is not
possible without additional funding.
RECOMMENDATION# 1.0:
Invite the County Purchasing Department to assess the purchasing process within HSD.
.....vvv�.
t ` `
RESPONSE:
See next item.
RECOMMENDATION # 11;
Investigate granting additional purchasing authority to HSD.
RESPONSE:
Agree. Purchasing is indeed an inefficient process under the current system, and both HSD and
General Services procedures should be examined to see how they can better work together, and
what functions can be transferred to HSD. The Lewin Report's arguments for transferring
certain Personnel functions to HSD may apply equally well to the Purchasing function.
CC: Senior Staff
t
Attachment#1
COMMENTS REGARDING STUDY RECOMMENDATIONS
Lewin Group Report Recommendation:
Study the current personnel management systems across HSD and the County Human
Resources Department to identify (in collaboration with a newly-hired HYD Personnel
Director)performance standards and approaches to achieving them.
.Health Services.Response:
Recommendation ##1: Study the current personnel management systems.'
Agree. We understand that Health Services has a very large number of different
classifications, each of which has its own selection process. We recommend an
independent assessment of ways to provide the flexibility and speed that HSI; requires in
order to meet the challenges of a difficult labor market for certain positions. This study
should include the feasibility of moving certain functions unique to Health Services into
this department. In this way the expertise of our professional staff can be appropriately
applied to recruiting and selecting within their respective disciplines, while speeding up a
process that leaves us shorthanded and reliant on agency personnel.
Human Resources Response to Lewin Group Report Recommendation:
Contra Costa County's Human Resources programs are administered centrally in
accordance with the provisions of the voter approved countywide Merit System,
collective bargaining agreements which cross departmental lines, ,and a federal
consent decree that addresses hiring and promotional practices. The centralization
of these programs has provided for a consistent approach to the formulation and
application of:personnel policy and practice and ensures a countywide standard for
ciiiripliarice with Federal and State employment statutes. This approach has been
effective in limiting the County's liability against employment-related lawsuits and
complaints.
Human Resources agrees with the report's recommendation for the Health Services
Department (HSD) and Human Resources Department (HELD) to work
collaboratively to identify performance standards and to developapproaches to
better meet the staffing needs of the Health Services Department. In an effort to
expedite the application, testing .and hiring processes, thirty-four (34) Health
Services specific classifications are currently tested for on an Open Continuous
basis, twenty-six (26) of which have been,delegated to and are fully administered by
HSD. A review of high turnover, critical classifications may indicate a need for
more aggressive recruitment/selection practices including increased use of:
• Continuous testing
• One-stop hiring processes
• On-line application processes
• More aggressive use of internet and outreach recruitment sources.
This study should include not only ways to streamline and expedite the hiring
processes themselves, but also techniques for forecasting vacancies and scheduling
the conduct of classification/compensation reviews.
Human Resources Response to Health Services Recommendation:
Human Resources disagrees with, the Health Service's response as it does not
address the consultant's recommendation. Furthermore, the current personnel
management system, as previously noted, is a voter mandated merit system subject
to a Federal consent decree and bargaining unit agreements. However, we believe
that the two departments can work collaboratively to streamline the current process
and address any concerns regarding specific recruitments and strategies. HRD and
HSD meetings have been effective in this regard.
Lewin Group Report Recommendation:
Increase communication between the HSD and County Human Resources regarding
labor agreements to improve the.LSD's success in recruiting needed health personnel.
Health Services Response
Recommendation #2: Increase communication between HSD and County Human
Resources regarding labor agreements.
Agree. The report points out that County Human Resources may not fully understand the
competitive nature of certain positions. Increasing nursing salaries, for example, may
appear at first to merely raise HSD expenditures, but in fact it lowers them by reducing
the need for costly Registry nurses. - Such considerations must be included in negotiation
of labor agreements, which are the sole responsibility of the Human Resources
Department.
Human Resources Comments
The Human Resources Department supports increased communications between all
departments, not only with regard to labor relations, but with regard to any other
matter or issue that has an impact on County departments. However, we do not
agree that the negotiation of labor agreements is the sole responsibility of the
Human Resources Department.
......... ....._... ......... ......... ......... ......... .........
. _ _ .. .. ......... .........._......................._..... ....._.._.. ......... . ......... ......... ......... ............ .
.................................
.........
. . I
Human Resources cannot negotiate labor agreements without the input and
participation of operating departments. Many of the demands of labor
organizations that are submitted to the County or raised during labor negotiations
are specific to a given department or job class. The Human Resources Department
not only makes departments aware of these demands but obtains their input with
regard to how they are to be addressed. In addition, it has been the ongoing
practice of Human Resources to have staff from operating departments, such as
Health Services, participate in the negotiation process as a resource person sitting
"at the table" as part of the County's management team during negotiations.
Consequently, the HSD has their own staff member representing the department
and insuring that their department is kept appraised of what is occurring during the
negotiation process. It also insures that there is a representative of the department
to advise the management spokesperson or to respond to questions that are raised
during the negotiation process.
Additionally, the Labor Relations Division holds meetings with operating
departments at the conclusion of negotiations to explain the results and outcome.
Finally, the Human Resources Department negotiates at the direction of the Board
of Supervisors, within the parameters established by the Board and County
Administrator. Ultimately, the Board of Supervisors sets policy and grants
authority for the negotiations package, determining what is in the best interests of
the entire County, as opposed to one department.
cc: E. Bitten
K. Ito
B. Ray
m+�
the E N G OUP
Management Assessment of the Contra
Costa County Health 'services
Department
Prepared By:
The Lewin Groin, Inc.
and
Henry W. Zaretsky & Associates, Inc.
August 5, 2002
Table of Contents
I. PURPOSE................................................................................................................................................1
II. THE CURRENT ORGANIZATION STRUCTURE OF HSD........................................................2
III. MARKET, LEGAL, AND FINANCIAL CONTEXT........................................................................5
1. The HSD provides services that meet several legal and regulatory requirements.....................................S
2. Contra Costa has High Staffed Bed Occupancy Rates............-...... ...... ............... ..............____.... ..._...6
3. CC1;LMC is the Largest Medi-Cal and Uncompensated Care Provider......................................................9
4. The Contra Costa Health Plan has a High Medi-Cal Market Share................ .......................................10
5. The Governor's 2002-2003 Budget Further Constrains Revenue for Publicly-Funded Health Services 12
IV. A REVIEW OF OTHER CALIFORNIA COUNTY HEALTH DEPARTMENTS......................15
1. Substantial variation exists in the functions operated by health departments...... .......... ..........._.........15
2, All of the counties indicated they are operating in an increasingly challenging environment................16
3. Many of the County health departments recently have implemented significant organizational changes
in response to financial or management problems...................................................................................17
4. Several County health departments coordinate programs across divisions.......................... ...... ........._17
5. The finance function in the counties ranges from highly centralized to more decentralized...................18
6. County health departments are struggling with maintaining a highly qualified workforce and with
County administrative processes...............................................-.........................................,..................19
T County health departments generate significant workers compensation claims......... ...... __..... ....19
8. Effective relationships with Local initiative health plans are important to success...... ..........................20
9. Several cowities are encouraging the integration of rricntal health and substance abusc services by
forming ,:behavioral health`divisions...... ............... 20
10. Variation also exists regarding responsibilities for psychiatric emergency services, inpatient psychiatric
units,and probate functions.................................................................. ................................................,21
11. Summary-..... ...... - -.......
V. STRENGTHS AND WEAKNESSES OF THE CONTRA COSTA HSD.........................................23
A. HSD STRENGTHS...................................................................................................................................24
1. Because the Department includes a health care delivery system,a health plan,and a full array of other
services, the HSD is able to develop integrated programs that effectively meet client needs..................25
2. Operating the Contra Costa Health Plan provides numerous benefits to HSD and the County............26
3. The HSD is served by several County functions that are viewed as effective and helpful.......................27
4. Managing finances and information technology(1T)centrally allows the HSD to address financial
pressures more effectively than other California health departments......................................................27
5. The HSD has achieved sufficient scale to attract talented management to the organization..................28
B. WEAKNESSES OR ISSUES ASSOCIATED WITH HSD MANAGEMENT.......................................................28
1. The HSD struggles with workforce and personnel management issues.................................................28
2. Questions were raised regarding whether HSD's finance and information technology functions are
excessively centralized....... ..................__........ ......_...._....... .............___........ ..........30
3. Operating the Health Plan within the County HSD exposes the CCHP to political forces....................31
4. Like all California health departments,the HSD struggles with how best to coordinate case management
ofhigh-cost clients...................................................................................................................................31
5. Worker's compensation costs are particularly high for the HSD.-........... .Errorl Bookmark not defined.
6. The mental health division manages the County's probate function,diverting needed resource............31
7. The HSD has no management unit dedicated to the needs of the County's growing elderly population 32
8, The HSD's relationships with contractors should be independently evaluated.......... ................ ...... ....33
9. The HSD would benefit from expertise that exists within the County's purchasing department,..........33
VI, RECOMMENDATIONS TO IMPROVE THE EFFECTIVENESS CIT'THE HSD.......................34
L PURPOSE
In response to a Grand Jury report entitled "Health Services Financial Management
Performance", the Contra Costa County Board of Supervisors directed the County
Administrator to facilitate preparation of a management audit of the Health Services
Department (HSD), On December 11, 2001, the Supervisors directed that the audit should have
four components and that the County Administrator should issue a Request for Proposals
(RFP). The following report addresses one of these components: to assess the strengths and
weaknesses of the organizational structure of the Department in relation to the legal and fiscal
environment in which it operates.
Specifically,the report focuses on:
• The current organization structure of HSD;
• Market,legal and financial context within which HSD operates;
• A review of other California county health departments;
• Strengths and weaknesses of the Contra Costa HSD; and,
• Recommendations to improve the effectiveness of the HSD.
Information for the report was gathered from interviews with the HSD Director, division
directors, and the Contra Costa County Administrator's Office. Another series of interviews
was conducted with other California county health departments to inform the assessment.
Other information is derived from a literature review and data analysis.
The Lewin Group, Inc. 1 304746
II. THE CURRENT ORGANIZATION STRUCTURE GE HSD
The mission of the HSD is: "to care for and improve the health of all people in Contra Costa
County with special attention to those who are most vulnerable to health problems and their
consequences." To achieve this mission, HSD provides and finances a broad array of public
health and health care delivery services.
Measured by budget and number of personnel, the HSD is the largest department operated by
Contra Costa County government. The HSD includes:
• A 164-bed medical center and twelve ambulatory care centers;
• An interdisciplinary medical staff with more than 80 family practice and 150 specialty
physicians;
• The Contra Costa Health plan;
• Mental health treatment programs;
• Substance abuse services;
• A public health system charged with disease surveillance and prevention;
• Medical services at the Martinez Detention Facility and Juvenile Hall;
• Environmental health programs;
• Conservatorship,public guardian, and probate programs; and
• California Children's Service program.
As shown in Figure 1, HSD is organized into major programs areas including: Hospital and
Health Centers, Mental Health, the Contra Costa Health Plan, Community Substance Abuse
Services, Public Health, and Environmental Health. In addition to these program areas, the
Department has finance and personnel divisions that serve the entire Department.
The HSD administers many of these programs pursuant to state and federal requirements. In
recent years, state and federal funding for health programs has declined and the County has
increased local general funds to support and maintain service levels. While state and federal
resources have been constrained, demand for services has been increasing. In response, the
County and HSD have implemented initiatives to increase revenue and reduce costs.
There is no Health Commission in Contra Costa; the Department Director reports directly to the
County Administrator. A number of special committees and advisory groups provide direction
and input to HSD, including the Joint Conference Committee for Contra Costa County Medical
Center, the Alcohol and Other Drugs Advisory Board, the Contra Costa Health Access
The.Lewin Group, Inc. 2 304746
Coalition, HIV/AIDS Consortium, the Homeless Continuum of Care, the Mental Health
Commission,and the Managed Care Commission.
Figure I
Contra Costa Health Services
Contra County Board of Supervisors
Health Services Department Assistant Health
William Walker,M.D. Services
Health Services Director }director
Senior Medical C7rn)udsman Personnel Integrated Health
Director Program Services E
munications Programs
Icohttl&other Hospi#els& Finance Mental Health Contra Costa Public Health Emergency Hazardous EnvironmenW
Drugs Services Health Centers Hee}th PIa� Medical Materials Health
_ Jj _ _ cervices j
Principal components of HSD are described below.
Centra Costa Regional Medical Center (CCRMC) is a general acute care teaching hospital
providing a full range of diagnostic and therapeutic services including emergency, medical,
surgical, perinatal, NICU, pediatric and psychiatric services. Ancillary services include
diagnostic imaging, clinical laboratory, pharmacy, rehabilitation, and cardiopulmonary care.
The Psychiatric Emergency Services Unit provides psychiatric evaluationand treatment 24-
hours per day, and serves as the primary patient access point for the county's mental health
programs. CCRMC also provides health care for the adult and juvenile detention population.
CCRMC has a network of twelve ambulatory care centers that provide outpatient,specialty and
geriatric services. Many of the ambulatory centers provide services in collaboration with the
division of public health.
"The hospital recently completed the construction of a new Clinical and Public Health
Laboratory on the hospital campus, I
Contra Costa Health Plan (CCHP) is a county-operated, state-licensed, federally qualified
health maintenance organization (HMD). The CCHP was established in 1973 and was the first
county-sponsored health plan. in California to offer Medi-Cal managed care. The CCHP has
r Contra Crista County Health Services Performance Report
The Levin Group, Inc. 3 304746
approximately 58,000 members, of which over 40,000 are Medi-Cal, 2,000 are healthy Families
enrollees,8,700 are county employees, and 2,400 are county indigent patients (Figure 2)?
CCHP manages indigent care through a program called Basic Care (BAC), CCHP also offers a
SeniorHealth program and a Major Risk Medical Insurance Program for individuals with pre-
existing conditions unable to gain access to coverage in the private insurance market. The MSD
hopes to increase the number of CCHP enrollees both to maintain the Department's Medi-Cal
market share and so that the plan can approach 100,000 lives, a level associated with efficient
health plan operation and stable finances.
Figure 2
CCHP Membership, February 2002
BAC Other
f
4% d
County Employees
15%
4 k�
T,$
Healthy Families
4% 34 y�s pt q
i
Vk
Medi-Cal
s� 70%
Source: Contra Costa Health Plan Membership Report by Product Line. February 20,2002
The Division of Mental Health provides services for adults and children in care settings
ranging from inpatient hospital care to community programs. The Division serves about 10,000
adults and 5,000 children annually. HSD operates a separate Division of Substance Abuse that
offers drug prevention and treatment services. Seventy percent of the County's mental health
services (and 90 percent of substance abuse services) are provided through contracts with
community-based organizations, area hospitals, and physicians, The Division of Mental Health
also administers the County's Conservatorship Programs.
HSD also operates the Public Health Division that provides services including clinical care and
community outreach, maternal and child health, immunization assistance, nutrition services,
prevention programs,homeless programs,and health data collection and assessment.
2 Contra Costa Health flan Membership Report by Product Line. February 20,2002,
The Lewin Group, Inc. 4 304746
The Division-of Environmental Health, alsopart of HSD, operates food inspection programs,
consumer protection programs, land use development and solid waste management programs.
In collaboration with the State, this Division also oversees the numerous oil refineries and
chemical plants located in Contra Costa County. Due to the heavy concentration of refineries in
the County,environmental health issues receive substantial attention.by HSD's Director and the
Supervisors.
HSD also operates California Children's Services (CCS) programs that provide for the
habilitation and rehabilitation of children with specific handicapping conditions.
III.MARKET,LEGAL,AND FINANCIAL CONTEXT
Assessment of an organization's strengths and weaknesses must be informed by an
understanding of its operating environment. Accordingly,this section provides an overview of
the health-care environnnent in Contra Costa County, and reviews major legal and regulatory
requirements affecting HSD operations, hospital utilization and capacity, distribution of
uncompensated care and Medi-Cal resources among local providers, and Medi-Cal utilization
patterns. The section also discusses recent trends in financial resources available for health care
services.
1. The HSD provides services that meet several legal and regulatory requirements
California counties operate or finance health and public health programs as a result of legal and
regulatory requirements. The primary legal responsibility borne by counties is to provide
health related services to the poor and uninsured as required by Section 17/000 of the California
Welfare and Institutions Code. Each county has its own approach to providing these services.
Some counties provide coverage for low-income persons not eligible for Medi-Cal or Healthy
Families through contracting with private providers, while others provide services directly
through county hospitals. Contra Costa meets this requirement by operating the Basic Care
Services program. (through the Contra Costa Health Plan) and a full range of health and public
health programs.
In 1991, the State transferred substantial fiscal responsibilities for health services programs to
counties through a "realignment" of resources. Counties now have primary responsibility for
financing and operating mental health, substance abuse, and indigent care programs. Priority
for growth in realigrunent funding is given to Social Service programs;health and mental health
programs receive the remaining funds.
Counties also share with the State a myriad of legal requirements associated',with the financing
and administration of the Medicaid program. For financing, the State and the federal
government jointly fund the Medi-Cal and Healthy Families programs. The federal share for
Medi-Cal is 50 percent and 65 percent for Healthy Families. Early Periodic Screening Diagnosis
and Treatment (EPSD`l") also requires that the Medi-Cal program finance the costs of all
treatment services for children.
The State and counties also are responsible for ensuring compliance with the provisions in the
Heath Insurance Portability and Accountability Act (HIPAA) of 1996. The primary purpose of
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HIPAA was to improve the portability and continuity of health insurance for workers, to
increase access to health coverage, and to combat fraud and abuse. Some HIPAA provisions
require large investments in information systems to assure confidentiality of patient records.
Compliance costs for the Health Insurance Portability and Accountability Act (HIPAA) may
range from$725,000 to$3.5 million for each hospital,or more.
In January 2002, the state adopted nurse to patient staffing ratio requirements that must be met
by July of 2003. These requirements are likely to increase costs and may prove difficult to meet
given the high levels of competition that now exist for nurses in California and across the
United States.
2. Contra Costa has High Staffed Bed Occupancy Rates
Contra Costa County has 12 acute care hospitals. John Muir Medical Center is the largest
hospital in the county with 321 beds followed by Kaiser Foundation Hospital Martinez/Walnut
Creek with 213 beds.
The county has three general regions: east,central and west. The central region accounts for 80
percent of acute care patient days (medical, surgical, and psychiatric). CCRMC, with 164 beds,
is located in the central region and accounts for about 13 percent of all general acute care
hospital days (Figure 3).
John Muir is the county's only trauma center, but all general acute care (GAC) hospitals in
Contra Costa have a basic emergency medical service. CCRMC accounts for 11.5 percent of
county-wide emergency visits, compared to 11.3 percent for Doctors- Sari Pablo, 131 percent for
John Muir, 15.9 percent for Kaiser-Walnut Creek, 16.5 percent for Mt. Diablo and 14.1 percent
for Sutter Delta.
Only Doctors San Pablo has licensed burn beds. Two hospitals have rehabilitation beds (John
Muir and San Ramon Rehabilitation); two hospitals have psychiatric beds (CCRMC and Mt.
Diablo), and four hospitals provide cardiovascular-surgery services (Doctors-San Pablo, John
Muir,Mt. Diablo and San Ramon Regional).
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Figure 3
Share of General Acute Care Days for Contra Costa Hospitals
Other,9%
CCRMC, 13°fn
Sutter Delta Medical center
6%
Doctors Medical
Center{San Paulo}
11% :John Muir Medical Center,
21%
Mt. Diablo,20
Kaiser,21%
Source: Office of Statewide Health Planning, Annual Hospital Report 2000. Note: Does not include
spilled nursing facility{SNF}days.
In 2001,hospitals located in Contra Costa County collectively reported 55 percent occupancy for
licensed beds and 81 percent occupancy for staffed beds. The occupancy levels for CCRMC for
licensed beds has been steady at about 75 percent over the 1999 to 2001 period, and the rates for
staffed beds have been steady and hovering near 100 percent(Figure 4).
In general, hospital capacity (when measured by licensed beds) in Contra Costa County is
adequate with only potential shortages for obstetrics. However, occupancy rates based on
staffed beds are high, especially at CCRMC. There are several capacity and utilization
pressures that hospitals in Contra Costa will face in the near future resulting from a growing
and aging population, constraints on the availability of nurses and other human resources,
compliance with seismic standards,and other market forces.
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Figure 4
Occupancy Measures for County and CCRMC for 1999 to 2001
120% -
100% - W 1999 0 2000 13 2001 99%100%99%
80% - 7679% 81% 72 75% 75%
60% - 55% 54% 55%
1/6
IU/0
40% -
20% -
0%
Total Occupancy Licensed Total Occupancy Staffed Beds CCRMC Occupancy Licensed CCRMC Occupancy Staffed
Beds Beds Beds
Source: OSHPD Quarterly Utilization and Financial Reports, 12-month periods ending June 30, 1997-2001.
In Contra Costa (and across the nation), the population is aging which is likely to result in
higher utilization and sicker patients. Projected population growth for Contra Costa for the
aged is faster than for California on average (Figure 5).
In addition to demographic pressures, under current law all general-acute hospitals will be
required to meet new seismic standards. In Contra Costa County, four hospitals have non-
conforming buildings - housing about one-third of all licensed beds in the County. Under S13
1953,enacted in 1994,acute-care hospitals are required to meet new seismic-safety standards by
2008. If hospital buildings do not meet these requirements, they no longer can house inpatient
general-acute beds. The Office of Statewide Health Planning and Development (OSHPD) may
grant extensions up to five years to hospitals that can demonstrate area-wide capacity shortages
if they are forced to close non-conforming buildings.
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Figure 5
Growth Rates for Ages 65+ and 85+ for California and Contra Costa County 1990
to 2030
4 A f fy J00010
3500fo
347010 110 Contra costar California
300% -
252% 259°lo-
250% -
200% 183%
150%
100%
50%
0%
65 and Over 85 and Over
Source: Califomia State Department of Finance.
According to a 2001 OSHPD survey, CCRMC is in full conformance with Sia 1953 requirements
through 2030. Pour hospitals in Contra Costa County have certain non-conforming buildings
that house a combined 439 CAC beds (out of a total 1,550 GAC beds located in the County).
These hospitals are Doctors Medical Center, Sari Pablo (225 beds in non-conforming buildings),
Mt. Diablo (four buildings housing 42 beds),Sutter Delta (one building,48 beds),and John Muir
(one building, 124 bobs). Given that all of these hospitals are part of viable hospital systems,it
is likely the necessary retrofitting or replacement will take place. Capacity reductions, if any,
that occur would most likely reflect the hospitals' projection of service demand. Thus, it is
unlikely seismic-safety requirements would cause bed shortages to occur.
In the future, the Mt. Diablo-John Muir system, the largest system in the County, may make
further attempts to integrate services between the two campuses to improve financial viability
and improve health delivery.
3. CCRA4C is the Largest Medi-Cal and Uncompensated Care Provider
Contra Costa Regional Medical Center (CCRMC) accounts for 15 percent of total patient days
and 23 percent of hospital expenditures in Contra Costa; its Medi-Cal share is 46 percent,twice
that of the second-ranking Medi-Cal provider (Doctors Medical Center-Sart Pablo). CCRMC
provides virtually all the county indigent patient days (94 percent) and accounts for 98 percent
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of these expenditures. These shares have been relatively stable over the 1997 to 2001 time
period.3
Nine hospitals account for 92 percent of total Medi-Cal inpatient expenditures for County
residents. CCRMC has the largest market share (21 percent), followed by Children's Hospital
(15 percent). The two Tenet hospitals (San Pablo and Pinole) combined also account for a 15-
percent share. Three out-of-county hospitals appear on this list — Children's (15 percent), Alta
Bates (8 percent) and UCSF (4 percent). These are all tertiary-level care hospitals. Moreover,
Alta Bates' location is adjacent to the southwestern portion of Contra Costa County. As such, it
most likely competes with Doctors Medical Center-San Pablo for primary and secondary
hospital services as well.4
Figure 6
CCRMC Share of Medi-Cal and Indigent Care Days and Expenditures for Contra
Costa County In 2001
120% -
100% Ill Days il Expenditures 94% 98%
80%
60% 59%
T
45%
40%
2 3 9/6
20% 15%
0%
Total Medi-Cal Indigent Care
Source: OSHPD Quarterly Report, 12 Months Period ending June.30, 1997 to June 30,2001
4. The Contra Costa Health Plan has a High Medi-Cal JNfarket Share
In 2001, $292.2 million was expended on behalf of the Medi-Cal beneficiary population in
Contra Costa County, including fee-for-service and managed-care. Fee-for-service Medi-Cal
expenditures on behalf of beneficiaries residing in Contra Costa County were approximately
$233 million. This includes all services except dental. The latter adds about $7.6 million to the
3 OSHPD Quarterly Report, 12 Months Period ending June 30, 1997 to June 30, 2001. Excludes Kaiser hospitals
4 and psychiatric patient days.
Medi-Cal Paid Claims File,CY 2001.
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total.5 In Contra Costa County, as in most targe, urban counties in California, Medi-Cal
beneficiaries are essentially split into two groups: (1) those required to enroll in managed-care
plans (primarily TANF beneficiaries); and (2) all others (primarily aged and disabled), who
obtain care through the fee-for-service system, and are free to choose any providers that will
accept them. Of the 88,348 Medi-Cal beneficiaries residing in Contra Costa County during 2001,
a little over half(approximately 45,000)were in aid categories requiring enrollment in managed
care.b The rest obtained care through the fee-for-service system.
While fee-for-service beneficiaries account for 51 percent of all beneficiaries,they account for 80
percent of total expenditures, reflecting the greater health needs of aged and disabled compared
to other Medi-Cal populations.
On the fee-for-service side, the County health system providers received $36.4 million in Medi-
cal payments, 16 percent of the $233 million total In contrast, on the managed care side,
CCHP's Medi-Cal revenue of $53:4 million represented 90 percent of the managed-care total.
Fee-for-service expenditures per beneficiary were $470.55 per month in 2001 compared to
average managed care capitation rates of$108.89. The differential reflects greater health needs
of the fee-for-service population.
If the county were able to implement a County Organized Health System (COHS) and enroll all
Medi-Cal beneficiaries in managed care, capitation rates would be higher and revenue to CCHP
would increase substantially, providing the health plan greater influence over health-care
delivery and a source of new enrollees and revenue, which could further subsidize care to
uninsured, indigent residents of Contra Costa County.
Figure 7 illustrates Medi-Cal fee-for-service spending by provider type. Long term care
expenditures represent the largest share of spending at 34 percent followed by hospital.
inpatient (22 percent) and pharmaceuticals (21 percent).
Medi-Cal fee-fox-service expenditures for long-term-care services are broadly defined as: adult
day health care, hospice, home health, intermediate care facility, multipurpose senior services
program.,and skilled nursing facility. Skilled nursing facilities account for$67.2 million out of a
total of $78.9 trillion in expenditures for hong-term.-care services. The County health system
does not directly provide these services. Thus, if a County Organized Health System were
established, long-term care would be provided through contracts with private sector
organizations.
s Department of Health Services,"Month of Payment Report,2001."
G Department of Health Services,"Beneficiary Profiles by County,2001."
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Figure 7
FFS Medi-Cal Expenditures On Behalf of Contra Costa County Residents by Type
in 2001
FFS Medi-Cal Expenditures by Type in 2001
All OCher Acute Hospital
6% Inpatient
22%
Long-Term Care
39%
Clinics(including
hospital outpatient)
13%
Physician Services
4% Pharmacy
21%
Source: Medi-Cal Paid Claims File,Calendar 2001.
Like other counties and across the country, Medi-Cal payments for pharmacy are growing
rapidly and are a growing share of Medi-Cal expenditures. In Contra Costa these expenditures
represent 21 percent of total Medi-Cal fee for service spending.
5. The Governor's 2002-2003 Budget Further Constrains Revenue for Publicly-
Funded Health Services
Funding for the HSD comes from a variety of sources: state funds, federal disproportionate
share payments (DSH),county general fund contributions, and patient care revenue.
State. The largest component of state revenue is from realignment funds, followed by
Proposition 99 (the tobacco tax), and tobacco settlement funds. In 1991, the State transferred a
number of health programs from State to county control and provided counties with funding
for these programs from dedicated sales tax and vehicle license fees. State tobacco revenues are
derived from a $.25 per pack tax on cigarettes authorized under Proposition 99, These revenues
are dedicated to fund a variety of health care programs. In 2000-01, the largest share of this
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revenue was devoted to the California Health Care for Indigent Program (CHIP) at $1016
million.
Realignment funding may be constrained because these funds are based on tax revenues that
are vulnerable to economic downturns and state budget constraints. California is facing a 2003
deficit of $23.6 billion. The State will need to find ways to close this gap. The Governor is
seeking a $475 million increase in the State's cigarette tax; a $1.3 billion increase in the State's
vehicle-licensing fees, and a$255 million increase in bank income taxes to bring the State in line
with federal laws governing reserves. Also, one-third of the total budget deficit may be closed
with $7.6 billion in budget cuts, mostly aimed at health and welfare programs, including the
State's Medi-Cal program.
Despite the budget gap,California continues to explore a number of options to expand coverage
to the uninsured. In January and February of 2002,The California Health and Human Services
(CHHS) Agency sponsored four symposia to introduce nine proposals to expand health
insurance coverage in California. The plans fall into three groups. incremental reforms,
employer contribution requirements (otherwise known as gay-or-play) and single payer
proposals. These plans would have different implications for coverage,costs, and for existing
Medi-Cal and Healthy Families programs. Implementation of any major insurance reform
plans could reduce the number of uninsured in California and Contra Costa County.
Federal, Hospitals receive funding; through the Federal DSII program, which in California is
governed by SB 855. These funds are distributed based on a formula that reflects the proportion
of Medi-Cal and indigent patients served by each disproportionate share hospital. Total
supplemental Medi-cal payments State-wide for SB 855 are approximately $821 million
annually.'
Medicaid regulations related to Upper. Payment Limits recently have been implemented
limiting DSH resources. Estimates from the California Healthcare Association from March of
2002 show that the impact of reducing the 150 percent Upper Payment Limit (UPL) to 100
percent for public hospitals could have an impact of over$1 billion over the next several years.
The Balanced Budget Act of 1997 also included scheduled reductions in DSH funds. The impact
of the DSH reductions in Contra costa is likely to be approximately$2.1 million in 2403.
There has been considerable pressure on Capitol Hill to increase to the federal Medicaid
matching percentage this session as many states are experiencing significant increases in
Medicaid spending coupled with state fiscal constraints. It is unclear if these proposals will be
signed into law.
County General Funds and Patient Revenue. HSD receives county general fund support
which represents about 9 to 10 percent of expenditures. The hospital and clinics, community
mental health programs, and substance abuse services also generate patient cage revenue from
' The program uses intergovernmental transfers from public entities operating hospitals as the
state match required to obtain the federal payments.
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Medi-Cal, Medicare and private insurance payers. Medi-Cal is the largest payer to CCRMC.
The HSD has implemented numerous initiatives to maximize reimbursements, such as
obtaining-FQHC status for ambulatory care programs.
Financial pressures on California safety-net hospitals can be summarized as follows.
• Complying with the requirements of SB 1953 (Alquist) that requires all hospitals to meet
certain seismic safety standards by 2008, and stricter standards by 2030.
• Reductions in Medicare payment resulting from the federal Balanced Budget Act o€1997.
• Reductions in Medi-Cal disproportionate share funding, in part due to the "fixed
allotments"of DSH funding to states mandated by the BBA of 1997.
• Higher state administrative fees taken out from the DSH program, increasing from $30
million in 2002 to$116 million in the 2002-2003 budget.
• Growing numbers of uninsured relying on the state's emergency services system..
• Federal upper-payment-limit rules that constrain Medi-Cal payment rates.
• Eliminating selected optional Medi-Cal benefits such as adult dental services, medical
supply services,and others.
6. Summary
The following points summarize the market, legal and financial context for the Contra Costa
HSD:
• The primary legal responsibility borne by HSD is to provide health services for the poor
and uninsured (many of which were "realigned" from State to county responsibility), and
public health programs for all Contra Costa County residents. HSD also must meet
requirements associated with. Medi-Cal, the Health Insurance Portability and
Accountability Act(HIPAA), and new nurse-staffing ratios.
• Hospitals in Contra Costa County have high staffed-bed occupancy rates. The aging
population, nursing shortages, compliance with seismic standards and other market forces
will put continued pressure on hospital occupancy going forward.
• CCRMC provides the majority of the Medi-Cal and uncompensated care in the County.
This is partly attributable to the high Medi-Cal market share for the CCHP.
• HSD may experience continued constraints on revenue from federal, State, and local
sources.
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IV,A REVIEW OF OTHER CALIFORNIA COUNTY HEALTH DEPARTMENTS
This study included research into how five Cather California counties operate and manage their
health departments. The other counties that participated in this research process were: San
Joaquin, San Mateo, Santa Clara, San Francisco, and Ventura counties. This process provided
helpful comparative information to guide findings regarding the Contra Costa County Health
Services Department.
1. Substantial variation exists in the,functions operated by health departments
The table below portrays the principal functions operated by each of the county health
departments assessed.
rt
Ai 4f; n #1 R. lhH ii z n ? 411`a
Health Commission
Hospital
Health Plan
Skilled Nursing
Facility
Behavioral Health t
Mental Health
Substance Abuse '
Environmental Wealth ' ' "����.,,T7 ' a.
While all of these counties share the same legal responsibilities for providing or financing health
services, there is substantial variation in the array of services they operate in their health
departments. For example,
• San Francisco has established a Health Coma—fission which serves as an intermediate
governing body between the Department of Public Health and the Board of Supervisors.
The Commission, operating on authorities delegated by the Beard of Supervisors and
Mayor, reviews and recommends budgets and contracts, formulates policy
recommendations, participates in a Joint Conference Corcunittee (which serves as the
governing body for San Francisco General Hospital), and provides guidance for the
Director, The Commission meets bi-monthly. Meetings frequently include large
representation from the San Francisco community.
+ While all of the counties operate hospitals, San Mateo County recently moved its
hospital out of the Health Services Agency and into its own separate Department. The
CEO of San Mateo County General Hospital now reports directly to the County
Manager. This change was implemented in part to help the County improve the
attractiveness of the CEO position during the recently completed CECT search and to
achieve more direct oversight of hospital finances by the County Manager.
+ Only Contra Costa County HSD operates a health plan with primary responsibility for
Medi-Cal beneficiaries (in addition to county employees and other groups). Santa Clara
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County operates a health plan, but Medi-Cal consumers are the primary responsibility
of a separate "local initiative" health plan functioning in that County. In all of the other
counties, Medi-Cal beneficiaries eligible for managed care programs can enroll either in
a local initiative plan or a private-sector alternative plan (such as Blue Cross that
operates in Contra Costa and San Francisco). In most of the counties, while the local
initiative plan is not in the health department, a close relationship exists and the health
plan typically includes one or more health department representatives on its governing
board.
• Within the past two months, San Francisco consolidated the administration of its
community mental health and community substance abuse services into one Behavioral
Health administration. Ventura County operates a consolidated Behavioral Health unit
as well, while in San Mateo County, the substance abuse administration is not contained
with the Health Services Agency.
Variation also exists in how the county health departments manage health care services for
inmates.
• In San Mateo, jail health has its own budget. Services are provided in the hospital and
the Sheriff pays for a portion of the program.
• In Santa Clara and San Joaquin, jail health is managed by the health department, but
budgeted elsewhere (in the Sheriff's department in San Joaquin).
• In San Francisco, the health department maintains a budget for jail health and mental
health services, and places health care workers in the jails.
These counties seem to collaborate with other county agencies effectively to manage jail health
programs.
2. All of the counties indicated they are operating in an increasingly challenging
environment
Looking forward, the counties we interviewed anticipate an increased emphasis on
bioterrorism, prevention programs, and asthma programs. Many counties are facing staffing
problems for nursing and public health functions that may affect access to care. Declining state
and federal support may strain county health programs and lead to organizational changes
such as consolidation of divisions in an attempt to reduce overhead expenses.
For specific counties the following issues were raised:
• The San Mateo Health Plan has been losing membership due to Welfare Reform (down
from 55,000 to 38,000 members) and reserves no longer are available. The cost to rebuild
San Mateo County General Hospital also proved more expensive than anticipated,
leading to higher debt service costs than expected.
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• Santa Clara is facing a County budget deficit of$85 million for the coming year and the
health department is facing a$7.5.million reduction in its resources.'
• In San Joaquin, the health department represents a growing proportion of County
government expenditures; 10 percent of total county costs,up from 8 percent in 2000.
• In San Francisco, City Hotel and Sales Taxes declined since the beginning of the year,
and general fund programs are facing reductions. The San Francisco Department of
Public Health also is considering options for replacing San Francisco General Hospital in
response to SB 1953 requirements.
San Francisco and other counties also are addressing challenges associated with cost of living
adjustments (5.5 percent in San Francisco)passed without corresponding budget increases.
3. Many of the County health departments recently have implemented significant
organizational changes in response to financial or management problems
To a surprising extent, each of the counties we contacted recently has implemented some form
of organizational change. San Mateo separated its hospital from the Health Services Agency to
be better able to track and monitor finances and budget issues. San Francisco organized its
directly-operated health care programs into the Community Health Network (including
community-based ambulatory care clinics) then just recently shifted responsibility for
ambulatory care to another part of the Department. San Francisco also combined:mental health
and substance abuse into a Beha�rioral Health division.
Ventura County currently is considering separating behatrioral health into its own department
in response to management problems in the mental health division. SanJoaquin County is
assessing moving environmental health out of health agency and establishing a health plan..
Importantly,most of these changes have been considered or implemented in response to major
financial or management problems in the health departments.
4. Several County health departments coordinate programs across divisions
A key component of the interviews with other counties was to understand and highlight
examples of effective coordination within the department,with other county functions,and the
Board of Supervisors. When asked for examples of effective coordination among divisions of
the health department counties provided the following examples:
• In Santa Clara, the hospital is working collaboratively with public health to improve
outcomes and care for individuals with diabetes and for pre-natal and perinatal care.
• In San Joaquin, the mental health and substance abuse divisions are working
collaboratively on dual diagnosis programs and have received a grant from the State for
Spanish-speaking and homeless dual-diagnosis patients.
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• Santa Clara and San Joaquin have coordinated programs and divisions in co-located
clinics that plan to focus on public health, mental health, substance abuse and clinical
care.
• In San Mateo, mental health and primary care are reasonably well integrated; however
because substance abuse programs are not managed by the Health Services Agency,
program coordination is more difficult. HSA staff also believe that the recent movement
of the hospital out of the HSA is likely to complicate efforts to integrate public health
and personal health services.
• In Ventura, the Health Care Agency cited collaborative programs between public health
and ambulatory care nurses that work to refer clients to services, identify mental health
needs,enroll eligibles into Healthy Families,and focus on preventive care,
• Because San Francisco's Department includes a full continuum of directly-operated
services and public health programs, the SFDPH is able to "feel the outcome of public
health initiatives in our own delivery system.'
5. Tice finance function in the counties ranges from highly centralized to more
decentralized
Like Contra Costa, San Francisco and Ventura have more centralized finance functions. As a
result, these counties are more able to pool resources, manage revenue or budget variances by
balancing resources across divisions, and more easily shift resources within their departments.'
In San Mateo, finance was centralized until the recent death of a long-serving Chief Financial
Officer. HSA leadership struggled for several months after this transition because the CFO had
not trained a replacement and because knowledge, data, and insights had been so heavily
concentrated in one individual. Public health, the hospital, mental health, and aging and adult
services now have dedicated finance staff, and the budget is developed in the divisions. The
HSA CFO coordinates and provides strategic oversight.
The San Joaquin finance function is more decentralized. Divisions are somewhat autonomous
and there is little movement of funds across divisions. During the budget process,each division
develops a proposed budget that is reviewed with the Department CFO. The Director sends the
entire budget to the County Administrator's office.
In Santa Clara, the department is not able to move funds across divisions without board
approval. Budget units are "fire walls" with separate appropriations, The Valley Medical
Center (VMC) prepares initial budget forecasts that include justifications of changes from the
previous year's budget. This budget is forwarded to the county budget unit for approval.
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6. County health departments are struggling with maintaining a highly qualified
workforce and with County administrative processes
Every county reviewed expressed great frustration with the human resources function and with
current difficulty recruiting health (and information systems) professionals. Common themes
expressed by all counties were:
• The processes required to reclassify or create positions are slow, paper intensive, and
require multiple levels of approval.
• County civil service and merit systems have a difficult time meeting]the needs of health
departments (which must compete with other health care systems and have highly
specialized personnel) while also assuring equity across county departments, the
integrity of labor agreements,and serving other agencies.
• Nurses, pharmacists, information technology, and other technician positions are
extremely hard to fill.
• When health departments are not directly involved in negotiating labor agreements, the
ability to attract and retain health professionals becomes more challenging. Across-the-
board pay increases that do not recognize current market conditions for nurses,
pharmacists, and other staff lead to particular problems.
Hiring problems often lead to the utilization of more expensive registry positions. Ventura.
spends $1 million on registry nurses for the hospital (they do not use registry for the clinics).
The registry nurses are mostly used for specialty services like neonatal, labor and delivery, and
surgical technicians.
Some mechanisms to improve the process have been implemented such as continuous
recruitment of nursing positions in San Francisco,hiring a "nurse recruiter" out-stationed at the
hospital in San Mateo, and efforts to have a personnel administrator work directly with the
County human resources process in Ventura. San Mateo and Santa Clara have personnel
classifications that are unique to the health system and are more flexiblethan other county
personnel categories.
7. County health departments generate significant workers compensation claims
San Joaquin County is self-insured for workers compensation. As of January 2002,San Joaquin
had 370 open claims for hospital employees, and 60 for other health department staff (as of
March 2002 there were 1,$130 hospital employees). In this program, physicians (chosen by the
employee) approve the amount of time injured employees are allowed to stay out of work on
workers compensation. The employer must accept these determinations and try to find tasks
that meet recommendations for the temporary modified duty. A risk manager is involved in
some cases (e.g., when special equipment needed, sets up ergonomic evaluations). Two-thirds
of salary is the maximum amount an injured employee can receive while on leave.
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Santa Clara's workers compensation program is self-insured and self-administered. Claims are
handled by the Workers Compensation Adjusters in the County's Division but there is a liaison►
in the Health and Hospital System that works to assist returning employees through the
Temporary Modified Return to Work Program. That program, effective since 1997, enables
employees to return to work with temporary assignments in the employees current department.
Santa Clara has the right to 30-day medical control; employee may request another physician
after that period. Workers receive a state mandated benefit level. As of May 2002, the Health
and Hospital System had 392 open claims (representing six percent of total employees).
8. Effective relationships with local initiative health plans are important to
success
All the counties interviewed indicated that the relationship they maintain with the local-
initiative Medi-Cal managed care plan or other entities that enroll public employees or publicly-
funded health care beneficiaries is vital to success. Health departments with "stronger" ties
benefit from these relationships because the plans serve as "marketing arms" for county
hospitals and physicians, and because the plans help improve the cost effectiveness of health
care delivery. Santa Clara, San Joaquin, and San Francisco have particularly effective
relationships with the local initiative plan — but no county except Contra Costa has a fully-
integrated Medi-Cal managed care plan within its health department.
9. Several counties are encouraging the integration of mental health and substance
abuse services by forming "behavioral health"divisions
All of the counties reviewed operate mental health and all but San Mateo also offer substance
abuse services either through separate programs or through one behavioral health program.
Coordination between mental health and substance abuse (and other health divisions) is viewed
as important particularly for meeting the needs of dually-diagnosed patients. Examples
include:
• San Mateo officials noted that they "have a long way to go" in terms of integrating
substance abuse and mental health services since they are in managed in separate
county departments.
• San Joaquin is considering re-integrating the mental health and substance abuse
divisions that were separated about 15 years ago into a behavioral health division, in
large part because decentralized finance functions complicate the ability to achieve
integrated programming.
• San Francisco recently created a Behavioral Health Division, unifying Community
Mental Health and Community Substance Abuse Services to achieve better service
integration and better serve dually diagnosed patients.
• Ventura has a behavioral health division within the health department, but this county
currently is considering establishing the division as a separate, stand-alone department
to provide greater autonomy and accountability. This change would be implemented in
response to recent criticism of patient care, the director, financial management, and staff
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morale, Prior, efforts to integrate behavioral health and socialservices were not
implemented due to licensing issues for the county's psychiatric beds.
10. Variation also exists regarding responsibilities for psychiatric emergency
services, inpatient psychiatric units, and probate functions
In San Mateo, psychiatric emergency services (PES) and inpatient psychiatry services both are
managed by the hospital. While this has been effective in the past,tension between the hospital
and community mental health services (which remains part of the Health Services Agency) may
grow since the hospital was recently removed from the health department. Control of PES may
be revisited if problems related to access, diversion controls, and authorization arise. San
Mateo, like Contra Costa, reports high numbers of administrative days in hospital'psychiatric
units.
Ventura has no separate psychiatric emergency services; 5150 and other psychiatric emergency
cases arrive at the VCMC emergency room. The inpatient psych unit (Hil:lntont) is physically
connected to VCMC. If the behavioral health division is separated from the health department,
the County will need to develop a Memorandum of Understanding to address staffing and
licensure issues.
San Joaquin's community mental health division operates both emergency and inpatient
psychiatric services (rather than the hospital). Patients with medical/psychiatric needs served
by SJGH,community mental health provides staff training.
Only one of the comparison counties we contacted, San Joaquin, manages probate functions
within the health department (the mental health division has this responsibility). All of the
counties conserve certain amental health consumers, including patients in state hospital, IMD
(institute for mental diseases) and community settings.
11, Summary
The comparative county review provided the following summary findings for this study.
• Contra Costa has the most comprehensive set of health department divisions and
functions relative to the counties we reviewed.
• Departments with strong health plan relationships achieve several' benefits from the
marketing and care management activities these plans perform..
• Counties are changing the way that they are organized (San Francisco created a new
behavioral health division, San Mateo separated the hospital from the department, and
Ventura is discussing the possibility of moving behavioral health' out of the health
department), Most of these changes are in response to financial problems or challenges
experienced when attempting to develop integrated programs for clients with multiple
needs.
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• Collaboration across health departments and between the health department and other
county functions is important to achieving cost-effective services. All county health
departments struggle with the interface with county administrative functions(especially
human resource issues),
• Departments with centralized finance functions are able more effectively to manage
resources across divisions; however centralized finance creates risks unless numerous
managers are trained in financial management and participate actively in the budget
process.
• In general, department divisions for mental health and substance abuse deal with
complicated patients, have integration barriers, and were the most volatile divisions in
most counties we reviewed. There is substantial amount of variation in the
administration of conservatorship and probate programs.
• In our assessment, counties able to achieve effective integration between mental health
and substance abuse services (because finance functions are centralized and managers
recognize the importance of collaborative programs for the dually-diagnosed) may not
benefit from forming behavioral health divisions. {ether counties with difficulty sharing
resources across these two programm areas can obtain value from this type of
organizational change.
• California counties have different approaches to managing PES, impatient units, and
probate functions. In some cases, PES and impatient psychiatric units are managed by
the public hospital, in others, by community mental health services. No one model has
proven "most effective." However, managing a cost-effective system of mental health
care requires careful coordination among these various components.
• Few California county health departments maintain responsibility for probate services.
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V. MANAGEMENT ASSESSMENT OF THE CONTRA COSTA HSD
This section discussesstrengths and issues we have identified within the management of the
Contra Costa County Health Services Department. Overall,the Department is viewed as one of
the most effective and successful health departments in California. HSD could be even more
effective if some of the management issues identified below were addressed'.
These observations have been guided by a report recently issued by the Institute of Medicine
which specifies that public health departments should be organized to provide three essential
functions:$
• Assessment, monitoring, and surveillance of local health problems and of resources for
dealing with them,
• Policy Development and leadership that foster local involvement and a sense of
ownership that emphasize local needs and that advocate equitable distribution of public
health resources and complementary private activities commensurate with community
needs,and
• Assurance that the high duality services needed for the protection of public health in the
community are available and accessible, that the conunw-tity receives proper
consideration in the allocation of federal and state as well as local resources for public
health, and that the community is informed about how to obtain public health services
or comply with public health requirements.
Health departments attempt to achieve these objectives in the context of their local delivery
system markets, legislative and regulatory mandates, and financial and resource constraints.
Based on this guidance from the Institute of Medicine regarding the key functions of effective
health departments, we have identified the following strengths and issues associated with the
Contra Costa County Health Services Department.
8 Institute of Medicine,"The Future of Public Health". 1988.
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yh
Strengths • Because the Department includes a health care delivery system, a health
plan,and an array of public health,mental health, and substance abuse
services,the HSD is able to develop integrated programs that effectively
meet client needs.
Operating the Contra Costa Health Plan provides numerous benefits to
HSD and the County.
• The HSD is served by several County functions that are viewed as
effective and helpful.
• Managing finances and information technology(1T)centrally allows the
HSD to address financial pressures more effectively than other California
health departments.
• The HSD has achieved sufficient scale to attract talented management to
the organization._.
Issues • The HSD struggles with work force and personnel management issues.
• Worker's compensation costs are particularly high for the HSD.
• Operating the Health Plan within the County HSD exposes the CCHP to
political forces.
• Like all California health departments,the HSD struggles with how best
to coordinate case management of high-cost clients.
• The mental health division manages the County's probate ftinction,
diverting needed resources.
• The HSD has no management unit dedicated to the needs of the County's
growing elderly population.
• Centralization of HSD's finance and information technology functions
presents certain risks and challenges
• The HSD's relationships with contractors should be independently
evaluated.
• The HSD would benefit from expertise that exists within the County's
purchasing department.
A. HSD Strengths
As described earlier, the Contra Costa HSD is unique in that the Department maintains a full-
range of program areas including: Hospital and Health Centers, Mental Health, the Contra
Costa Health Plan, Community Substance Abuse Services, Public Health, and Environmental
Health. Most other counties in California do not include a health plan within County
government, and many no longer operate public hospitals. Most local Medi-Cal plans are
independent organizations, though frequently include representation of the health department
or county in governance.
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1. Because the Department includes a health cure delivery system, a health plan,
and a full array of other services, the HSD is able to develop integrated
programs that effectively meet client needs
The HSD has developed numerous programs that operate across divisions and thus provide
effective integration and coordination to meet client needs. These initiatives only could be
implemented through operating the range of divisions and activities that now are included
within HSD. In addition to meeting client needs, these examples of program integration also
have helped the Department attract federal, state, and private foundation grants.
Specific examples that highlight this coordination across HSD divisions are:
s Breast Cancer. Contra Costa has one of the highest rates of breast cancer in the county.
As elsewhere, white Americans have the highest incidence of breast cancer but African
Americans have the highest mortality rates due to delayed diagnosis and inadequate
treatment. In 1995, the Public Health Community Wellness and Prevention Program
(CW&PP) began implementing a new state-funded program to provide breast cancer
screening to uninsured women with particular outreach strategies to target African.
American women. The program also received funding through'. the Robert Wood
Johnson Foundation as part of study called "Addressing Health Disparities in
Community Settings". The diagnosis efforts have been tied to treatment services
provided through the CCRNIC system without regard to insurance status. By 1997,
African American women were diagnosed early with breast cancer at the same rate as
white women and by 1999 data were shoving a downward trend in African American
breast cancer mortality.
• Sunshine Pediatrics / North Richmond Center for Health (CFH). Sunshine Pediatrics
combines the public health model of patient education, nurse practitioners, bilingual
community aids and public health nurses with pediatricians and medical resources of
the Ambulatory care system to provide comprehensive pediatric care. This model is in
operation at three HSL Ambulatory Care Division sites. The Sunshine clinics are co-
located with Women, Infants and Children (WIC) programs operated by Public Health.
WIC clients are encouraged to sign up for Healthy.Families and many choose Sunshine
Pediatrics, a Contra Costa Health Plan provider. CFH Center also blends the goals of
ambulatory care and public health to service related to primary care,HIV clinics,mental
health services, enrollment in Medi-Cal and Health Families efforts, and environmental
and health education activities.
• Asthma. Asthma is a major public health issue with environmental justice, quality of
housing, access to health care,health disparities and disease management ramifications.
African American children in Contra Costa are four times as likely to be hospitalized for
asthma which is primarily related to inadequate primary care management.
Representatives from. the Public Health CW&PP and Clinic Services, Ambulatory Care
and CCHP worked to develop a comprehensive,integrated approach:to prevention and
management of childhood asthma. The program was also able to obtain $1.5 million in
grant funding from the California Endowment and Robert Wood Johnson foundations
due to this integrated approach.
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0 Homeless. Homeless programs are administered through the Public Health Division,in
coordination with mental health, substance abuse and public health outreach and
advocacy needed to address this population. The department was able to obtain grant
funding from three federal pilot grants to find homeless individuals with health
problems, provide direct services, or get patients into ambulatory care clinics or the
hospitals for treatment.
0 Dual Diagnosis Programs. There are several examples of successful coordination
between mental health and substance abuse. These divisions jointly operate a dual
diagnosis program which started as a state-funded demonstration program and is now
county funded. Health, Housing and Integrated Services Network (HHISN) is one of
these programs. SAMHWORKS is a program for both substance abuse and mental
health services for about 700 CaIWORKS participants. Specific staff is dedicated to
maximizing the combined resources of the two divisions.
0 Born Free Program. The Born-Free Program is a perinatal outpatient substance abuse
program serving pregnant and parenting women. These programs are co-located at
CCRMC, CFH and the Pittsburg Health Center. The programs collaborate to provide
client substance abuse and medical care as well as substance abuse intervention and
treatment. The program also collaborates with programs that target women with
substance abuse and domestic violence issues.
0 Other. Other important examples of effective coordination are between mental health
and public health to operate the pediatric/primary care liaisons program, lead
poisoning prevention programs where public health and environmental health work
collaboratively, and the Advice nurse program which illustrates collaboration between
CCRMC and CCHP. In addition, the CCHP provided consultation to the mental health
division when Contra Cost established its mental health plan in response to state
requirements.
Senior management from each of the HSD divisions meet at least weekly to discuss priorities,
and also have established regular meetings between specific divisions to facilitate coordination
and develop new initiatives.
2. Operating the Contra Costa Health Plan provides numerous benefits to HSD
and the County
In addition to facilitating development and operation of integrated or coordinated programs,
the CCHP provides other benefits to HSD and the County as well.
• CCHP is instrumental in helping the entire delivery system become more responsive
and cost effective. The CCHP's managed care infrastructure and expertise have been
helpful during the implementation of the Mental Health Plan. CCHP managers within
HSD help to monitor and influence the efficiency of the HSD hospital and clinics as well.
• CCHP helps to support the County's delivery system by capturing market share, which
helps to assure access to Medi-Cal patients for HSD's patient care programs. CCHP
now has a 90 percent market share of the AFDC population.
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• CCHP provides the benefits of a managed care approach for uninsured adults who
participate in the BACs program. Managing indigent care through a managed care
system helps monitor and influence utilization, benefiting consumers and reducing the
overall cast of care. No other California county we reviewed provides care management
through this kind of managed care infrastructure.
• In addition to providing benefits to the County, the CCHP in turn receives certain
benefits through its status as an entity of County goverment. For example, the CCHP
is somewhat protected from liabilities to which private health plaits are exposed. The
CCHP also has lower reserve requirements (because the County's resources can be
pledged to meet these requirements). The CCHP also receives administrative and
technical support from several County departments (County Counsel, contracts, and
others)that are viewed as providing effective and substantial assistance.
3. The HSD is seared by several County functions that Are viewed as effective and
helpful
Several managers within HSD indicated that the department was well served by the County
Counsel's office, by staff who assist with developing contracts, and by staff from the
Controller's Office, in addition to other County functions. As mentioned below,there are other
County departments that appear to be challenged by the wtique demands of the Health Services
Department.
4. Alan aging finances and information technology (IT) centrally allows the HSD to
address financial pressures more effectively than other California health
departments
Both within and outside the HSD, the health department is known for having effective,
centralized finance and information technology functions. Centralized finance provides the
ability to manage resources across HSD-division lines, facilitating development of integrated.
programs.
Strong, centralized finance and information technology functions provide benefits to HSD and
the county. For example, the Contra Costa HSD is more able to manage; inevitable budget
negative variances that occur at the division level(e.g.,higher than expected claims costs for the
CCHP) through the positive variances that also occur within the Department(e.g;,if the higher
claims costs are for services rendered by CCRMC - thus higher costs are offset by higher
revenue). The Department also has not experienced a mid-year "budget surprise" since 1384.
Upon adoption by the Board of Supervisors,the HSD pursues its budget goals aggressively.
HSD's financial managers can focus on maximizing resources for the entire;organization (e.g.,
obtaining l~QHC reimbursement for various outpatient departments). A centralized finance
staff provides greater assurances that policies and procedures are enforced, that the revenue
budget is prepared consistently and accurately, and that finance staff and resources are
deployed based on the direction of the Board of Supervisors and the HSD Director, The
Department's centralized finance function also assures that all expenditures are reviewed and
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approved on an as-needed basis. Communication with the Beard and County Manager staff
also is facilitated by a centralized finance function.
While there are benefits associated with highly centralized finance and information technology
functions, there also are certain risks that can evolve over time from this approach. These
concerns are discussed in the next section below.
5. The HSD has achieved sufficient scale to attract talented management to the
organization
Because HSD is a large, innovative department, it has a better ability to attract managers and
staff. There has been a great deal of stability with comparatively few changes in senior
management over time. These relationships facilitate effective management, continuity of
experience, and relationship-building with other County departments and functions.
S. Issues Associated with HSE? Management
This section discusses the weaknesses or issues we found associated with the management and
operation of the Health Services Department during the study.
1. the HSL struggles with work force and personnel manageanent issues
As in other counties, Contra Costa relies on certain centralized, county= functions and is affected
by certain policies that affect all County departments (such as cost of living adjustments). As
mentioned above, several of these functions receive high marks from all concerned. Others
have been identified as problematic, primarily due to the specialized nature of the mission and
services maintained by the HSD. The human resources management area has been identified as
the most problematic management issue for the health department.
HSD has 2,500 FTEs and another 1,000 contracted or per diem staff. There are 335 position
classifications in the county and that are used by HSD. There are 275 classifications that are
specific to HSD.
Contra Costa County operates on a Merit System,indicating that(unlike in other counties)there
is no independent Civil Service Conunission to review position changes. The Human Resources
Department processes P-300 forms and gives exams to assist with the personnel selection and
employment process (P-300s create positions, add/change positions, add classes of positions,
reclassify positions). The HSD requests that the Human Resources Department process 180-200
P-300 actions and perform.50-60 exams per year.
If a position is authorized and there is an eligible list, the recruitment process can be completed
quickly. If there is no list of eligible candidates, then HSD or the central county human
resources office must conduct an exam. HSD offers a set of exams and the county offers
additional exams.
P-300 requests to create or re-classify positions require approval by the County Administrator's
Office and by the County Human Resources Department. While these requests affect 1 to 2
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percent of the positions in the HSD,the process is viewed as a highly comply and long process.
The HSD has indicated that because it operates in a highly competitive environment in which
there is active recruitment for nurses, pharmacists and pharmacy technicians; information
technology professionals, and other staff, delays in filling positions create significant problems
in managing the costs of "registry employees„ (temporary workers who are paid based on per-
diem costs that are much higher than regular employees) and in some cases the operation of
health care programs (such as intensive care nursing units). In our experience,health care labor
markets indeed are highly competitive and the ability to act quickly to hire needed staff is an
important management requirement.
Based on our review, the following aspects of personnel management appear to be most
problematic:
• Time required to process a P-300 request to create a new classification, reclassify an
existing position,or add positions (or position hours);
• Time required to conduct the examination process, particularly when lists no longer
have eligible candidates (because they have accepted other positions);
• Lack of coordination between HSD and Human Resources regarding the terms of labor
agreements - in particular the need to have salary adjustments for certain classes of
personnel that are in short supply and for which substantial competition exists (e.g.,
nurses and pharmacists);
• Vacancy of the Personnel Director position within HSD; and
• Periodic communication lapses between HSD and the Human Resources department
regarding labor agreements.
According to data provided by HSD,requests for new position classifications can require 2 to 3
months; requests for reclassifications from 2 to 7 months; and requests to add positions or
increase hours approximately 2 months. Virtually all of these personnel actions require
approval by the Board of Supervisors.
One specific example regarding the personnel classification system is that all clerks throughout
the county are under one class (described by Human Resources as very"broad"). HSD staff are
concerned that dedicated classifications may be needed to assure positions for medical records
clerks,billing staff, laboratory technicians, and secretarial staff (all of which represent different
personnel "markets")remain competitive.
The Human Resources Department is affected by the desire to provide due process, to satisfy
the terms of labor agreements, and the important goal to achieve equity across County
departments.
In recent months, HSD and Human Resources Department staff have been meeting on a regular
basis to identify and resolve problems. These meetings have been highly productive. In our
view, these interactions should continue and be made more visible to County and HSD
leadership,
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The HSD is actively recruiting for a new Personnel Director. We suggest that the Human
Resources Department and HSD collaborate in this recruitment process to encourage continued
progress in the working relationship between the two departments. HSD also has indicated the
need for a study of the personnel function and the ability to improve its responsiveness. We
concur with this request and suggest that the study examine:
• Whether additional functions should be decentralized from the Human Resources
Department to HSD, such as authority for examinations for classifications that are used
exclusively by HSD;
• Whether separate processes and rules would be feasible for Enterprise Funds operating
within Contra Costa County government, providing additional flexibility for revenue-
generating departments such as HSD;
• Performance standards (timelines) that reasonably could be met while meeting HSD and
Human Resources Department needs;and
• Process improvements needed to achieve performance standards.
2. Worker's compensation costs are particularly high for the HSD
According to HSD financial records, in fiscal year 2002 the Department spend $7.1 million on
worker's compensation costs. This amount represents about 4.3 percent of total salaries and
wages paid by the HSD. There are 400 to 450 worker's compensation cases currently under
active management (out of 1,800 HSD's non-contracted employees). While an employee is off-
duty due to injury, the HSD must find another employee to perform those duties until a return
to work can be arranged. Thus the full cost of injuries and the worker's compensation program
is very significant for HSD and the County.
Other counties spend less than this amount. For example,
0 San Francisco spends approximately $8.2 million on worker's compensation claims, or
about 2.5 percent of salaries and wages expense.
0 San Joaquin spends approximately $1.5 million on worker's compensation claims for
hospital employees, or about 2.6 percent of salaries and wages expense.
At 4.3 percent of salaries and wages, Contra Costa County HSD spends an amount
proportionately higher(65 percent higher) than these other counties.
The current Worker's Compensation (WC) policy in Contra Costa County allows six months of
limited duty for employees that are returning g to work. Employees on workers compensation
receive 86 percent of their salary. A rehabilitation Committee (comprised of a rotating two
members of management and 2 members from one or more unions) make decisions, including
allowing extensions upon request and when warranted.
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injured employees are allowed to select physicians who evaluate them for purposes of
determining worker's compensation claims and the ability to return to work. Many of these
physicians are HSD employees.
The worker's compensation program is subject to numerous state mandates and laws, and to
labor agreements. Given the implications of the program for HSD expenditures, we
recommend that this area be studied further to improve the cost-effectiveness of the program.
3. Operating the.Health Plan within the County HSI)exposes the CCHP to political forces
Because the CCHP includes County employees and operates within the County HSD, certain
issues (such as how best to manage pharmacy costs) are more exposed to political debate than is
the case for other health insurers. The CCHP thus is differentiated from private-sector
counterparts that have more management discretion regarding cost containment decisions.
4. Lilo all California health departments, the HSD struggles with how best to
coordinate case management of high-cost clients
Numerous divisions within the HSD operate case management functions, including programs
in CCHP, mental health, substance abuse, CHDP, and public health nursing. In 2001, a study
was completed for the HSD that recoxnmended developing an integrated structure for case
management, building linkages between case management programs and primary care
providers, and other suggestions.
In our experience, coordinating these efforts can be very challenging, while also beneficial
particularly in managing care for high-cost patients. We reconunend that the HSD continue to
examine opportunities better to manage care for identified high-cost consumers,marry of whom
have multiple,chronic conditions.
5. ne mental health division manages the County's probate function, diverting
needed resource
In Contra Costa, the Division of Mental Health administers the County's conservatorship
programs. There are two types of conservatorships that are the responsibility of California
counties: probate and LPS. Probate involves county staff who oversee the disposition of estates
and assets for the deceased. LPS involves conserving individuals, almost all of whom are
mental health clients. These conservatorship functions have an investigative arm, as well as
staff roles. The investigative function is often separate from the staff role to maintain
independence.
Several years ago, the Mental Health division in Contra Costa became responsible for probate,
LPS and investigation. In other counties, probate and investigation functions are managed by
social service departments. Since assuming this responsibility, staff has been reduced from
sixteen to nine and then again to the current level of six people.
Due to these limited resources, Contra Costa can conserve (through LPS) only 120 mentally ill
people (those at Napa State Hospital and in IMDs) but there are another 200 who could be
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conserved,but are not and are admitted to the acute units at the Medical Center. The ability to
conserve individuals affects the success of treatment and medication schedules. Some useful
changes to the current program would be to 1)move probate out of mental health,2)create new
LPS positions for involuntary case management,and 3)reorganize LPS to re-locate staff into the
community-based clinics. This would promote continuity of case management.
In general,it appears that the mental health system in Contra Costa County would benefit from
additional resources to develop community-based alternatives to inpatient hospital or IMD
care. Resources to expand residential treatment, case management, and related resources may
prove effective in reducing the number of administrative days now occurring at CCRMC.
6. The HSD has no management unit dedicated to the needs of the County's growing
elderly population
With the aging of the population in Contra Costa County, and the CCHP's desire to expand
services for elderly Medicaid patients, we recommend that the HSD consider developing a
managerial unit focused on identifying and meeting the public health and health care needs of
elderly consumers.
7. Centralization of HSD's finance and information technology functions presents
certain risks and challenges
As previously mentioned, the HSD finance and information teclu-Iology functions are highly
centralized. While centralization provides several benefits, it also can create longer-term
challenges.
The top-down budgeting process includes more limited involvement of division managers than
is present iri other California county health departments, which typically rely more extensively
on division-level budget proposals. This may have occurred because in recent years the ani-tual
budget process has been characterized by "status quo" general fund budgets (i.e., the HSD
receives the same amount of County general funds as the prior year with partial funding of
awarded cost of living adjustments). Some of the issues associated with this approach include:
* A "bottom-up" approach to budgeting is more likely to identify community needs and
reflect those needs in budget requests;
0 Some managers we interviewed in other counties perceive that HSD division directors
do not have substantial'budget responsibilities and have decided not to apply for
management positions in HSD as a result;and
* Several division managers indicated that they would benefit from having additional
dedicated financial management expertise available to help them generate reports
including key indicators and to help guide decisions.
Information technology also is perceived as a highly-centralized resource dedicated first to
supporting core business functions (such as billing and collecting) and second to providing
clinical information. While this function is resource constrained, HSD division managers
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believe that additional input into how best to meetdepartment-wide information technology
needs given the current constraints on available IT staff would be valuable.
While we find that financial management within HSD has been very effective, particularly in
identifying new revenue sources and controlling expenditures,we believe these functions could
be even more effective if there were more participation in the budgeting process by HSD
managers.
These suggestions do not suggest decentralizing the finance function within HSD, but rather
examining the current budget process, access to information, and allocation of current finance
and information technology resources to better equip HSD managers for greater levels of public
accountability.
8. The HSD's relationships with contractors should be independently evaluated
Other counties, including the San Francisco Department of Public Health, retain the services of
an independent contractor to perform Program Reviews that assess the quality and quantity of
services provided by community-based organizations under contract for mental health,
substance, abuse, and other programs. This process could be highly beneficial to the HSD and
provide independent assurances that these resources are effectively managed before new
contracts are signed.
9. The HSD would benefit from expertise that exists within the County's
purchasing department
CCRMC participates in group purchasing arrangements (primarily with the University Hospital
Consortium). UHC negotiates contracts with vendors, and CCRMC has "blanket purchase
orders" for the vast majority of supplies, pharmaceuticals and equipment needs (about 90
percent).
For those items not covered by the blanket purchase orders, staff who need supplies fill out an
"L-3" form and forward this to materials management. Materials management, after
establishing need and preferred vendor arrangement forwards the document to finance,which
approves if budget resources are available and forwards the request to purchasing. Purchasing
enters the request into a computer system and the purchase is made.
The county operates a small business enterprise program, with outreach to small local
organizations for various purchases. If items exceed $10,000, requesters are expected to
perform a solicitation (RFP) for multiple bids. Capital equipment items over $5,000 require at
least three competitive bids. The L-3 process takes several weeks if items are covered by group
purchasing arrangement. For items not included in group purchasing contracts, it may take
several more weeks. If clinicians needs key supplies,a fast-track process is available.
The County purchasing office works with HSD to help negotiate the blanket agreements and to
review the major items that exceed threshold levels. (Ince a requisition has been authorized by
HSD finance, it takes 17 to 21 days for his office to process the purchase. County purchasing
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office staff have indicated their willingness to work with HSD to continue to improve the
effectiveness of this process and we encourage continued dialogue along these lines.
V1. RECOMMENDATIONS TO IMPROVE THE EFFECTIVENESS OF THE HSD
We provide the following recommendations designed to improve the effectiveness of the HSD.
• Study the current personnel management systems across HSD and the County Human
Resources Department to identify (in collaboration with a newly-hired HSD Personnel
Director) performance standards and approaches to achieving them;
• Increase communication between the HSD and County Human Resources regarding
labor agreements to improve the HSD's success in recruiting needed health personnel;
• Increase the involvement of HSD division managers in the annual budget preparation
process;
• Provide additional financial and clinical information to HSD division managers to
improve accountability and management tools within the Department;
• Develop or enhance information systems to identify high-cost clients and establish
mechanisms to provide coordinated case management for these individuals;
• Study the worker's compensation program for Contra Costa Coi-inty and HSD, and
identify whether opportunities exist to improve cost effectiveness while complying with
State laws and other regulatory requirements;
• Move the probate function out of HSD and into another County department, with an
effort to freeing up resources to expand case management and LPS resources for mental
health consumers;
• Develop a business unit focused on identifying and meeting needs of elderly consumers;
• Conduct an independent evaluation of HSD contracts for mental health, substance
abuse, and other public health or health care services;
• Invite the County Purchasing Department to assess the purchasing process within HSD.
Investigate the potential of granting additional purchasing authority to HSD to reduce
or eliminate duplication of work effort between HSD and the county purchasing
department and shorten time associated with delivery of goods.
In conclusion, the benefits and strengths associated with the current structure and operation of
the HSD appear to outweigh the risks and challenges of alternative designs. The current
organizational structure, which integrates core service functions into one cohesive agency,
presents many opportunities for the County to collaborate across health care and public health
programs, enables quick response to the rapidly changing health care social and financial
environment, and makes efficient use of resources dedicated by the Board of Supervisors.
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SUMMARY BRIEF
Assessment of Enrollment and Retention in Healthy Families and Medi-Cal for Children
Prepared by Pacific Health Consulting Group
The Board of Supervisors requested an outside review of enrollment and retention in Healthy
Families and Medi-Cal for children to assess the effectiveness of outreach and enrollment efforts.
The consultant conducted meetings with staff members, site visits and a review of written
materials, as well as a review of best practices throughout California and a survey of other
counties' programs. The consultant's recommendations follow:
1. Board of Supervisors should reiterate their long standing support for access to health
services for children through health programs, outreach and enrollment.
2. Responsibilities for different segments of the health insurance access effort should rest
with already existing and appropriate agencies within Contra Costa County.
3. Establish the position of Health Insurance/Access Coordinator within Public Health to
coordinate and facilitate all insurance enrollment and retention activities.
4. Establish a steering committee to identify system barriers, problem-solve and monitor
integration. The steering committee should report to the Health Access Coalition and senior staff
at Health Services Department and Employment and Human Services Department.
5. Outreach to uninsured target populations through Public Health programs working
closely with Health Insurance/Access Coordinator, including provide data for tracking.
b. Have financial counselors coordinate enrollment of individuals and families through
County clinics and the hospital, locating them at service delivery points where both enrollment
and access can be accomplished.
7. Have Contra Costa Health Plan organize retention activities by educating members on
how to use the system,and sponsoring health fairs and enrollment activities.
8. Integrate Community Services Department CAAs into ongoing education and training
with the Health Access Coalition.
9. Utilize Health-e-app to the fullest extent in all community based and County entry points.
10. Emphasize point of service enrollment at the time of service at County and community
clinics through the CHDP Gateway Program to enroll eligible children.
11. Information and encouragement about health services should be a priority at every
available outreach or enrollment contact.
12. Continue advocacy by the Board of Supervisors and departments.
13. Integrate outreach and enrollment activities, enhance retention strategies, and track
progress throughout the County's departments through,point efforts of the Steering Committee
and departmental leadership.
10/17/02.
PACIFIC HEALTH CONSULTING GROUP LLC
72 Oak Knoll Avenue low Phone 415-459-7813 - Fax 415-46 -1541
San Anselmo, California 94960 bNunsch@pachealth.org
Assessment of Enrollment and
Retention in Healthy Families
and Medi-Cal for Children
A Report to the Contra Costa County Administrator
Prepared by Bobbie Wunsch
Pacific Health Consulting Group
September 15, 2002
PACIFIC HEALTH CONSULTING GROUP LLC
Assessment of Enrollment and Retention in Healthy
Families and Medi-Cal for Children
Executive Summary
This report provides recommendations for Contra Costa County's outreach, enrollment
and retention activities for the Healthy Families and Medi-Cal programs.
As the Contra Costa Board of Supervisors has understood for a long time, children's
access to health care is important to children themselves, to their families, as well as to
society at large. Health care can influence children's physical and emotional health,
growth, and development and their capacity to reach their full potential as adults, and be
contributing members of their communities. All children are at increased risk of
developing preventable conditions if appropriate care is not provided when they are sick
or injured. When children fail to receive necessary health care, their lives and the lives
of their families can be affected for many years, as well as potentially become a burden
on already stretched and limited county resources.
Access to health care services dramatically improves within 12 months of health
insurance enrollment. One study showed that at 12 months, 99% of the children had a
regular source of care and 85% had a regular dentist. The percentage of children
reporting any unmet need or delayed care in the past six months decreased, the
percentage of children seeing a provider increased and the proportion relying on the
emergency room decreased. Parents also related a significant decrease in stress, which
has important implications for education because the well-being of the entire family can
be critical to a child's readiness to learn.
An impetus for the drive for enrolling as many children as possible into health insurance
programs is the link between health insurance and school performance. According to
The Link Between School Performance ,and Health Insurance: Current Research, from
the Consumers Union, good health is connected with improved school performance and
having health insurance is linked to better health. Poor health has been found to affect
school performance in many ways, including contributing to absenteeism, affecting
concentration level in the classroom, producing disruptive behavior, and affecting
students' abilities to participate in extracurricular activities. Access to health insurance is
a solution to many of society's concerns, while also improving the quality of life for
individual children and families.
The Board of Supervisors requested an outside assessment of the county's outreach
and enrollment initiative, to better understand the effectiveness of the system. This
report's recommendations focus on how to enhance the effort to make in more effective
in the long run. Healthy Families and Medi-Cal are two complex state programs funded
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in part by the federal government, whose goals are to provide coverage and access to
health care for low income children. Contra Costa County undertook a significant
process with a large number of partners to reach out to as many children as possible,
enlisting major foundation support to Paunch the process. Given the significant strides
already made, it is important that the county continue to work in partnership with the
state, which must make its own changes to make the program better, and with local
partners, who must continue to stay as involved as they have been.
This report provides recommendations and review of information on the following.
= Organizational' structure for the Contra Costa Outreach and Enrollment program,
including organizational functions, reporting structures, accountability, integration
and coordination among and within County divisions and departments.
• Integration of Healthy Families enrollment and Medi-Cal eligibility
• Best practice models for streamlining and, where possible, integrating with
community-based efforts
• Analysis of Contra Costa County Medi-Cai and Healthy Families ;continuation rates
compared to other California counties and with commercial insurance programs.
■ Retention strategies in Medi-Cal for Children and Health Families
• Participation in Health-e-app.
The analysis of findings and recommendations is based on the following.
• meetings with Contra Costa County staff to review assumptions and current program
performance, key indicators, and major issues, to present analysis of key data
elements, to review recommendations and discuss implications for program
changes;
= review of written materials, staffing plan and data regarding enrollment activities,
targets and last three years` performance in Medi-Cal and Healthy'Families outreach
and enrollment in Contra Costa County;
■ site visits of a sample of community-based enrollment and outreach sites as well as
county sites, including meetings with key staff at each site, to gain understanding of
key issues on the ground;
feedback solicited from current outreach, enrollment and eligibility workers to gain
further insight into key issues;
= assessments of feasibility of participating in Health-E App for Contra Costa County;
and
= review of best practices throughout California and a survey of other counties
outreach, enrollment and retention efforts.
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A. Planning Assumptions
■ Having health insurance and access to health care services is a key determinant of
good health for children. The County of Contra Costa should embrace this concept
in every possible way, at every point of entry for children into the system.
■ There are four key components to a successful health insurance program:
1. outreach to eligible individuals without insurance or without adequate
insurance,
2. enrollment of eligible individuals/families into the most comprehensive
insurance program available,
3. retention of enrolled individuals/families in insurance and
4. access to and utilization of health care services for those who enroll.
• The Medi-Cal/Healthy Families outreach and enrollment program needs to be
integrated fully in an ongoing way into the infrastructure of the Contra Costa Health
Services and into other relevant departments throughout county government.
Building ongoing outreach, enrollment and retention efforts into the infrastructure of
the county's programs should be the goal of this effort. As new children enter the
system, whatever the system may be, regular ongoing pro-active measures should
assure that families have been screened, children enrolled in one of the public
coverage or insurance programs, and utilization of services secured.
■ The key points for integrating this effort are Contra Costa Health Services —
Financial Counseling, Public Health, Contra Costa Health Plan, Mental Health
Services, Community Services Department, and Employment and Human Services
Department.
■ State funds that currently support a majority of the outreach and enrollment activities
will probably not continue. They will either be dismantled totally in the impending
state budget or be reduced dramatically. Reliance on these funds to support this
program's sustainability cannot be counted on.
Every client accessing any type of services in the county, but particularly in Health
Services or EHSD, should be asked whether or not he/she has health insurance. If
the answer is "no", the client should be screened for the appropriate program at that
time.
■ Utilization of health care services is an important ingredient in retaining health
insurance. Point of service enrollment at county and community clinics should be a
priority. "in-reach" for existing clients has proven most successful in other counties.
PACIFIC HEALTH CONSULTING GROUP LLC
AWL
• The recant expansion of the Basic Adult Care program to children, now called Basic
Health Care program, will allow children to be screened at the point of service in
county clinics. If they do not qualify for Medi-Cal or Healthy Families and are
income-eligible, they can be enrolled in the Basic Health Care program. This allows
Contra Costa County to have options for the full range of children's situations. With
these programs now in place, integrated point of service enrollment and aggressive
retention activities should be the center point of the new program.
B. Recommendations
1. In its past decisions, Contra Costa County's Board of Supervisors has
consistently committed itself and the County's resources to ensuring access to
health care services for all children and enrollment in appropriate health
insurance and health coverage programs. The integration efforts that follow
would be supported if the Board of Supervisors reiterate, at this time, its long
standing support for access to health services for children, berth through health
programs and outreach and enrollment.
2. All outreach, enrollment and retention activities should be built into the existing
infrastructure, particularly in the Contra Costa Health Services and Employment
and Human Services Department. While state and other grant funds should be
used to support these efforts when available, the efforts need ongoing
operational support in an integrated way. Responsibilities for different segments
of the health insurance access effort should rest with already existing and
appropriate agencies within Contra Costa County in order to increase stability of
the program.
3. A regular county position of health insurance/access coordinator should be
established to coordinate and facilitate all insurance enrollment and retention
activities, county information updates and training on public.-sponsored health
insurance activities, expansion of coverage, etc. This position should have
appropriate access to decision-making authorities so that barriers can be
addressed, problems solved, and successes promoted countywide. The Health
Insurance/Access Coordinator:
■ should be located in Public Health;
■ should facilitate a Steering Committee composed of the appropriate
representatives from Financial Counseling, EHSD, CCHP, Mental Health,
Community Services Department and Public Health — each of whom have
responsibility for segments of the health insurance activities within the county;
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I o-
■
should facilitate and organize the Health Access Coalition as well as report to
other county committees, commissions and advisory groups that would
benefit from Information and advocacy about related health insurance
committees. Careful consideration about how the Health Access Coalition
links and intersects with Public Environmental and Health Advisory Board's
(REHAB} Access to Care Committee should be reviewed with consideration
given to establishing the Health Access Coalition as a subcommittee of
PEHAB, which is appointed by and reports directly to the Board of
Supervisors;
■ should be responsible for organizing the county's ability to track outreach
activities, enrollment targets and retention targets;
should implement a tracking system similar to the Consumer Union's Tracking
Program for Health Families as soon as possible, adapting the current
database, and incorporating all the programs and divisions under the same
Entity Number to share information more effectively; this work must be
coordinated with the State, which must provide better data;
■ should be responsible for implementing an ongoing countywide education and
training program on insurance activities and work closely with the enrollment
efforts of the Financial Counselors, the retention efforts at CCHP, and EHSD.
4. A Steering Committee of Public Health, EHSD, CHDP, CCHP, Mental Health,
Community Services Department, financial counselors should meet regularly - at
least monthly - to identify key barriers in the system, analyze system difficulties,
problem-solve and monitor integration. It should report regularly to the Health
Access Coalition and to senior staff at CCHS and EHSD.
5. Outreach to the uninsured target populations representing the core public health
function of access to care should remain in Public Health, with monitoring by the
Health Insurance/Access Coordinator.
■ Outreach should be accomplished through the variety of public health
programs such as CHDP, Family PACT, PCG, CPSP, WIC, community
education, prevention and wellness programs, public health nursing, and
home visiting, etc.
• Public Health managers of these programs should work closely with the
Health Insurance/Access Coordinator on these efforts.
■ Each of these programs should be equipped to conduct application
assistance, outreach, education on access and enrollment for any client in
need.
■ These programs should be required to provide data to the data tracking
component of the program.
PACIFIC HEALTH CONSULTING GROUP LLC
6. Enrollment of individuals/families in insurance programs should be coordinated
by and be the responsibility of Financial Counselors through the county clinics
and hospital. With each expansion in health insurance or health coverage
programs (Healthy Families, Healthy Families to Adults, BAC to Basic Health
Care), the financial counselors are continually updated on the technical
information necessary to assist clients. They are also located at the service
delivery points of entry at the health centers where both enrollment and access
can be accomplished.
The current Healthy Families Enrollment Assi.stors/CAAs located in the health
centers should be reassigned to report to tate Financial Counselors with wham
they already interact regularly.
■ Some Community Health Workers can be integrated into other Public Health
programs such as CHDP, WIC, Clinical Services or CCHP, to enhance the
capacity of those programs to assist with enrollment and retention.
Some administrative intems and student workers can be 'assigned to work
with Financial Counseling, when available.
■ With the changes occurring soon in CHDP, Public Health must work to
redesign efforts in CHDP to incorporate enrollment strategies at CHDP
provider offices.
• Employment and Human Services Department, through all of its programs,
should continue its aggressive enrollment of eligible clients in the Medi-Cal
program and when possible should also enroll eligible clients in the Healthy
Families program. Legislative changes about who can enroll children in
Healthy Families and assurance from the state that current funding to provide
for additional' staff needed to expand to Healthy Families enrollment are
essential to this change.
o EHSD should engage with Health Services in training related to all
aspects of improving access to health care services, including
comprehensive knowledge of Healthy Families, Basic Health Care, etc.
o EHSD's involvement in the Health Access Coalition is essential.
o Bay Area counties have made a proposal for Medi-Cal families with Share
of Cost, supported by the Medi-Cal Policy Institute: if the family wants to
enroll in Healthy Families, social services workers should' be able to
determine eligibility and fee collection for premiums. Contra Costa County
should actively support this effort.
o EHSD's Medi-Cal Advocate positions should be continued to assure its
continued ability to maintain aggressive enrollment.
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7. Retftof members on public health insurance programs can be most
effectively organized by the Member Services Department at Contra Costa
Health Plan. The vast majority of the clients enrolled are managed by CCHP
including those on Basic Health Care. Among the key responsibilities of the
health plan are the education of members on how to use the health care system,
health education and retention of members in the plan. For those children who
are not CCHP enrollees, it will be important to use the Health Access Coalition,
and use the Coalition to share best practices.
• In addition, CCHP should continue to take an active role in sponsoring health
fairs and enrollment activities in coordination with Public Health and include
such information in their health education materials and newsletter.
• Basic health education can include consumer education about how to use the
Contra Costa County health system, how to make an appointment, whom to
call for questions, etc., encouraging people to use the health system.
8. The Community Services Department's CAAs and parent advocates, who assist
families with applications, should continue to be integrated into ongoing
education and training with the Health Access Coalition.
9. The Health-e-app is already being implemented in Contra Costa County's
outreach and enrollment effort. It should be utilized to every extent possible in all
community-based as well as county entry points.
10. An emphasis should be placed on Point of Service Enrollment, using the
opportunity at the time of service at county clinics, community clinics and soon at
private providers offices through the CHDP Gateway Program to enroll eligible
children by on-site screening and enrollment or in the case of the private provider
offices by a "quick phone linkage" to enrollment workers.
11. At every available outreach or enrollment contact, information and
encouragement about using health services should be another priority of the
contact. Materials about available services, information about how to make
appointments and when should be key to the encounter.
12. Advocacy by the Board of Supervisors and every relevant county department will
continue to be necessary to promote changes in the Medi-Cal and Healthy
Families programs to ensure easier access for eligible children and adults.
13. As resources are declining, the best possible return on investment seems to be
the integration of outreach and enrollment activities, the enhancement of
retention strategies, and the ability to track progress throughout the county's
departments. Key to the integration is the effective working together of the
Steering Committee and the departments' leadership.
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Assessment of Enrollment and Retention in Healthy
Families and Medi-Cal for Children
Table of Contents
ExecutiveSummary......................................................................................................i
1. Purpose of Report.................................................................................................1
II. Background............................... ............................................ ........................2
A. Uninsured Children.............................................................. ........................2
B. Why Health Insurance isImportant................................. .............................6
C. History of Healthy Families/Medi-Cal Outreach and Enrollment....................10
D. History of Medi-Cal Application Changes ............................ ' ......................12
E. Enrollment Barriers.............. ........... ......... ........ ...........--....—.....-.......1.19
F. Retention Challenges ............................................................,.......................21
F. Access to Care ..............................................................................................26
G. Survey of Best Practices ...............................................................................27
H. Survey of California County Activities in Outreach, Enrollment
andRetention ........................................................................'_........,..............31
Ill. Contra Costa County System for Outreach, Enrollment and Retention ..............44
A. Organization Structure, Transition, Staffing and Budget................................44
IV. Assessment........................................................................................................47
A. People Interviewed.............................................................. ......................47
B. Key Findings..................................................................................................47
V. Recommendations for Change ...........................................................................43
A. Planning Assumptions...........................................................;.......................50
B. Recommendations................................................................ ......................51
VI. Bibliography........................................................................................................57
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1. Purpose of Report
This report provides recommendations within the context of the federal and state history
of the Healthy Families and Medi-Cal programs and best practice models for outreach,
enrollment and retention among target populations in Medi-Cal, Healthy Families and
other similar programs. Healthy Families and Medi-Cal are two complex state programs
funded in part by the federal government, whose goals are to provide coverage and
access to health care for low income children. Contra Costa County undertook a
significant process with a large number of partners to reach out to as many children as
possible. The County enlisted major foundation support to launch the process. The
Board of Supervisors requested an outside assessment of improving the system, which
has made a good start, using best practices. The recommendations focus on how to
enhance the effort to make in more effective in the long run.
It is important to note that the county must continue to work in partnership with the state,
which must make its own changes to make the program better, and with local partners,
who must stay as involved as they have been to date.
Recommendations and review of information are provided on the following:
• Organizational structure for the Contra Costa Outreach and Enrollment program,
including organizational functions, reporting structures, accountability, integration
and coordination among and within County divisions and departments.
• Integration of Healthy Families enrollment and Medi-Cal eligibility
■ Best practice models for streamlining and, where possible, integrating with
community-based efforts
• Analysis of Contra Costa County Medi-Cal and Healthy Families continuation rates
compared to other California counties and with commercial insurance programs.
• Retention strategies in Medi-Cal for Children and Health Families
• Participation in Health-e-app.
Efforts were made to look closely at appropriate staffing ratios of outreach and
enrollment workers for effective recruitment and retention of Healthy Families and Medi-
Cal applicants and participants. Unfortunately there is currently not enough information
available statewide to make recommendations on this issue.
The analysis of findings and recommendations is based on the following:
■ meetings with Contra Costa County staff to review assumptions and current program
performance, key indicators, and major issues, to present analysis of key data
elements, to review recommendations and discuss implications for program
changes;
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• review of written materials, staffing plan and data regarding enrollment activities,
targets and last three years' performance in Medi-Cad and HealthyFamilies outreach
and enrollment in Contra Costa County;
• site visits of a sample of community-based enrollment and outreach sites as well as
county sites, including meetings with key staff at each site, to gain understanding of
key issues on the ground;
■ feedback solicited from current outreach, enrollment and eligibility workers to gain
further insight into key issues;
• assessment of feasibility of participating in Health-E App for Contra Costa County;
and
• review of best practices throughout California and a survey of other counties
outreach, enrollment and retention efforts.
It was hoped that an analysis of staffing ratios and target numbers of potential
applicants could be undertaken. Unfortunately, these data were not available.
11. Background
A. Uninsured Children
According to the UCLA Center for Health Policy Research, 1 million (nearly 1 in 10) of
California's children are uninsured. Of these children, about 656,000 are eligible, but not
yet enrolled in, the state health programs of Medi-Gal or Healthy Families. These data
and the data that follow only emphasize the continued importance of outreach,
enrollment and retention activities. So many children are currently eligible but not
enrolled in these important public insurance programs in counties throughout California.
What is not known at this time is the complexity of reaching these families and how
many of these families have been enrolled before in either Medi-Cal or Healthy
Families.
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PACIFIC HEALTH CONSULTING GROUP LLC
California's 1 Million Uninsured Children
Nan-Eligible
{Undocumented
Immigrants)
� ligib
160,000 {incomesA abrn►
25ti° e
11!{bC itti al l#gibte 1$% °A F 130
`,35�,pt70 161,000
% '" 1 B%
Healthy Families Eligible
�n1,n�n
30%
Source: Brown ER, Ponce N, Rice T, Lavaredda SA. The State of Health Insurance in California: Findincis
from the 2001 California Health Interview Survey Los Angeles: UCLA Center for Health Policy Research,
2002.
According to the UCLA Center for Health Policy Research's recently released 2004
California Health Information Survey (CHIS), of the 2.6 million California children who
are eligible for Medi-Cal, more than eight in ten are enrolled. The CHIS also estimates
that of approximately 750,000 children who were eligible for Healthy Families in 2001 ,
about 458,000 (61%) were enrolled. As of June 7, 2002, 562,614 children were enrolled
statewide, an increase of 23% in one year. Of those, 67% were Latino, 16% were white,
13% were Asian or Pacific Islander and 3% were African-American.
Other data, such as those from the 100% Campaign (a collaborative effort of Children
Now, Children's Defense Fund and The Children's Partnership to ensure that all of
California's children obtain health coverage) show that an estimated 1.3 million of
California's 1.8 million uninsured children (72%) qualify for Medi-Cal or Healthy
Families.
Under current eligibility rules, children who are citizens or noncitizens with legal
documentation to live in the United States are eligible for either Medi-Cal or Healthy
Families, if their family income is 250% of the federal poverty guidelines or below. The
specific program for which they are eligible depends on a complicated variety of factors,
including their age, family income, allowed deductions from income, and family size.
Therefore, children in the same family may be eligible for different programs, creating
confusion and fragmentation to what could be a seamless system of coverage.
California has received federal approval to extend enrollment in Healthy Families to
parents of eligible children in families with incomes up to 200% of the federal poverty
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level'. The Governor had proposeddelaying this expansion due to the State's severe
decline in tax revenues, but it is now expected to be implemented in the period' October
2002 to January 2003. If it is implemented, an estimated 281,000 parents (about 20% of
uninsured parents) will be eligible for Healthy Families. It is hoped that it will be easier to
enroll and retain children on Healthy Families once adult members of the family are able
to be enrolled.
The CHIS interviews identified reasons why eligible children were not enrolled. Of the
355,0300 uninsured children eligible for Medi-Cal, parents of a third of the children
interviewed for the study thought that their children were not eligible. Another 8%
reported being unsure about their children's eligibility as the reason for not applying,
and lees than I% did not know the program existed. This shows than more than 4O% of
uninsured, eligible children could be reached by effective educational outreach
strategies. Parents of 12°,fie of the children objected to some part of the program,
particularly the heavy burden of paperwork that has been a hallmark of Medi-Cal. Only
3% of the parents objected to the stigma connected to a welfare program and 4% did
not perceive the need for coverage. Families eligible for Healthy Families had similar
issues, but the proportion of those who need effective education about the program is
significantly higher than the Medi-Cal program (60% among Healthy Families eligible
families compared to 42% of Medi-cal eligible families). Nearly one quarter of parents of
Healthy Families-eligible children did not knew the program existed, nearly 20%
believed their children were not eligible, and an additional 14% did not 'know if their
children were eligible.
Enrollment in Medi-Cal statewide dropped by 283,234 children between 1996 and 1909.
Healthy Families, begun in 1998, covered 133,273 children by July' 1999. In January
1998, Medi-Cal placed a moratorium on dropping most families from Medi-Cal when
they lust cash welfare. This was intended to give the state and counties time to develop
policies and reprogram their computers to carry out changes made by the new welfare
law. Approximately 240,000 children were affected by the moratorium, as the counties
worked through'a Mage backlog of cases.
According to a study just released (dune 2002) by the Kaiser Commission on Medicaid
and the Uninsured, Reaching Uninsured Children Through Medicaid. If You Build It
Right, They Will Carrie, the Medicaid enrollment decline among children and their
families declined was largely a result of welfare changes. However, in 1999, enrollment
rose in many states. Forty percent of all low-income children (under'200% of poverty)
were enrolled in Medicaid or SCHIP in 2000, 52% of poor children and 30% of near-
poor children. However, one fifth of low-income children still lack coverage, although
most are eligible for either Medicaid or SCHIP.
According to the most recent census data, one out of five children'nationwide and a
quarter of all children under age six were enrolled in Medicaid in 2000. Children's
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enrollment grew from fewer than 10 million children in 1980 to over 21 million in 1999,
the last year for which national administrative data are available. During this time, there
has also been a steady decrease In the proportion of children covered by Medicaid who
receive welfare.
A report from the Medi-Cal Policy Institute, The Impact of the Proposed 2002-03 Budget
on Medi-Cal and the Healthy Families Program, found that the proposed 2002-03
California budget assumes a 4.9% (304,100) increase in the Medi-Cal caseload from
2001-02 to 2002-03, largely because of policy changes enacted over the past several
years. The total public assistance caseload is expected to decline by 1% because of
families leaving CaIWORKs. The family-based portion is expected to decrease 2.8%,
which is a smaller decline than the 6.6% drop that occurred over the previous two years.
An increase of 137,400 children statewide enrolled in the Healthy Families Program is
also assumed in the proposed state budget. However, the budget also proposed to
decreases spending for Healthy Families-related costs in other departments, including
outreach activities.
According to the 100% Campaign, currently 46,000 children are statewide enrolled in
Food Stamps but are not receiving Medi-Cal or Healthy Families.
Given these estimates and as more and more children statewide are enrolled in these
public insurance programs, it will be more difficult to enroll the remaining children due to
barriers in the state-mandated program requirements and procedures and the fact that
100% will never be enrolled. Efforts in counties like Contra Costa will need to be re-
organized to focus on maintaining enrollment and to educating new parents, either
newly arrived or with new babies. The population of parents is always evolving.
Contra Costa County's Uninsured
It is extremely difficult to pinpoint the number of uninsured children in Contra Costa
County. There are competing methodologies and the numbers fluctuate regularly. The
best estimate is that of the recent California Health Interview Study of 2001 of the
Center for Health Policy Research at UCLA. used on interviews statewide, the CHIS
estimated that there are approximately 52,000 uninsured children and nonelderly adults
in Contra Costa County. This is 6.2% of the nonelderly population, amid a range of
4.6% — 7.9%, or 39,800—68,358 residents. By subtracting the adults (whose range was
5.1% - 9.2%), the range of uninsured children is estimated to be 8,800 — 12,500.
However, it is important to note that the Center states that the sample size of children
was too small to estimate a number with statistical confidence.
• According to the US Census and Children Now, 13.6% of Contra Costa County's
approximately 258,500 children under age 18 lived in poverty in 1997 (35,000
children) and 27% had incomes below 185% of poverty in 1999-2000 (69,795
children).
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According to the US Census, in 1999, approximately 30,000 Contra Costa County
families had incomes below 250% of poverty (the federal poverty line was $13,880
for a family of three and $16,700 for a family of four; 250% of poverty was between
$34,700 and $41,750 that year).
• According to the State Department of Health Services, there are currently 41,234
children in the county who are Medi-Cal beneficiaries and 6,228 children enrolled in
Healthy 'Families, for a total of 47,462. About 9% of all nonelderly in the county and
15% of the county's children have Medl-Cal or Healthy Families.
B. Why Health Insurance is Important
"Lack of insurance means that many low-income families take their children to the
doctor at the last minute, often relying on the emergency room as their primary source
of care."'
"My daughter complained of an earache and / waited a few days before taking her to the
doctor to see if she would feel better. 1 felt horrible waiting while my child was in pain
and 1 wandered if l would have waited if l had health insurance." (CDF's focus group
report—The Waiting Game)2
Children's access to health care is important to children themselves, to their families, as
well as to society at large. Health care can influence children's physical and emotional
health, growth, and development and their capacity to reach their full potential as adults.
All children are at increased risk of developing preventable conditions if appropriate
care is not provided when they are sick or injured. When children fail to receive
necessary health care, their lives and the lives of their families can be affected for many
years.s
Access to health care services dramatically improves within 12 imonths of health
insurance enrollment. One study showed that at 12 months, 99% of the children had a
regular source of care and 85% had a regular dentist. The percentage of children
reporting any unmet need or delayed care in the past six months decreased, the
percentage of children seeing a provider increased and the proportion relying on the
emergency room decreased. Parents also related a significant decrease in stress, which
has important implications for education because the well-being of the entire family can
be critical to a child's readiness to learn.
Parents want their children to receive routine preventive care, to have a place to go
when they are sick and to have a health provider monitor their child's development.
Parents want someone to explain children's allergies, to help manage their asthma or to
say when glasses or psychological counseling are needed. Studies show that uninsured
children, surrounded by the most expansive and expensive health system in the world,
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frequently cannot find their way to the care they need. Compared to insured children,
uninsured children receive only limited access to health services.'
An impetus for the drive for enrolling as many children as possible into health insurance
programs is the link between health insurance and school performance. According to
The Link Between School Performance and Health Insurance: Current Research, from
the Consumers Union, good health is connected with improved school performance and
having health insurance is linked to better health. Poor health has been found to affect
school performance in many ways, including contributing to absenteeism, affecting
concentration level in the classroom, producing disruptive behavior, and affecting
students' abilities to participate in extracurricular activities.
Access to health care can influence children's physical and emotional growth,
development, and overall health and well-being. Untreated illnesses and injuries can
have long-term—even lifelong—consequences. For example, untreated ear infections
can lead to hearing loss or deafness. Children who are unable to hear well can have
trouble performing well in school and trouble interacting normally with their families and
friends. Language or other developmental delays due to untreated neurological
problems also can frustrate normal development and social interactions.5
Overall, lack of insurance undermines children's health and damages their chances to
lead a healthy life. Without public subsidies or employer-provided health plans, families
with incomes near poverty 6 levels would have to pay a prohibitive 40 percent of their
income for family coverage.
Dental care is a serious issue for uninsured families. Oral diseases affect not only the
teeth, gums and the rest of the mouth, but they also can lead to serious general health
problems and significant pain, interference with eating, overuse of emergency rooms;as
well as lost school and work time. Preventive methods such as the use of fluoride and
dental sealant are comparable in effectiveness to immunizations against infectious
disease, but these services are not always readily available.'
Usual Source of Care
• Uninsured children are ten times less likely than insured children to have a
regular provider.8
• In California, 27% of uninsured children compared to approximately 6% of
insured children do not have a usual source of care, such as a doctor's office.9
• Of the uninsured children who do receive routine care, 24% overall and 52% of
poor children receive the care in a setting other than a physician's office.
Children who do not have a physician's office as their usual source of care are
less likely to be taken to a physician when care is needed and are more likely
than insured children to use higher-cost emergency rooms or clinics.10
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Likelihood of Doctor and Dental Visits
• In California, 56% of uninsured children comparedto approximately 25%� of
insured children did not have a doctor visit in the last year. '
• In California, 55% of uninsured' children compared to approximately 20% of
insured children did not have a dental visit in the last year, or 215 times less likely
to receive dental care. 12
Withholding Cars Due to Costs
• Twenty-one percent of parents of uninsured children compared to 3% of parents
of insured children were forced to delay or skip needed medical care for their
child' because they did not know how to pay for it.13
• Twenty seven percent of parents of uninsured children compared to 7% of
parents of insured children were forced to delay or skip needed dental care for
their child during the past year because they did not know haw they would pay
for it14
• Parents of uninsured children are seven times as likely as parents with insured
children to have delayed or skipped filling prescriptions for their child.15
• Uninsured children are less likely than those with insurance to receive medical
care for injuries, even serious injuries. Among children who are uninsured, one
study found that as many as 30% of all children with injuries and 40% of all
children with serious injuries may not receive medical attention.16
Unmet Health Care Needs
• Uninsured children are almost three times as likely as insured children to have an
unmet health care need within the past year.17
• Uninsured children are approximately twice as likely as insured children to not
receive care from a physician for acute earaches, recurrent ear infections,
asthma, or sore throat with a high fever. $ These can lead to hearing loss, central
auditory processing disorder, and life-threatening emergencies.
• Uninsured children are 30% less likely than insured children' to have received
medical care when they are injured.19
• Children's health status varies significantly by type of insurance. Among insured
children, those covered by Medicaid or other farms of public health insurance are
the most likely to have health problems: 17% had a serious illness in the past
year and 16 percent were in fair or poor health. In contrast, children covered by
private health insurance are the least likely to have health problems: only 5%
were in fair or poor health.211
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• A California study found that newborns who were uninsured were more Likely to
be sick but received fewer services in the hospital than newborns who had
insurance coverage.'
• Children living in low-income areas have two to four times as many preventable
hospitalizations as children living in high-income areas. These rates are likely to
be due to poorer general health status, poorer access to preventive and routine
care when needed, as well as to lack of insurance among low income families.22
• Uninsured children with chronic medical conditions also have been found to have
insufficient access to routine medical care. According to a national survey
sponsored by the Robert Wood Johnson Foundation, 17% of uninsured children
did not receive medical treatment needed for a chronic illness such as asthma,
diabetes or other conditions serious enough to keep a child from functioning at
school.23
• A study in New York found that they hospital death rate was 1.46 times higher for
uninsured children than for those who were insured. The uninsured children were
more likely to be admitted to the hospital in a critical condition, and their needs
for care were more urgent on admission.24
Unmet Preventive Care
• Uninsured are five times more likely to use the emergency room as a regular
source of care25
• In California, 68% of uninsured children compared to approximately 30% of
insured children did not have a well-child doctor visit in the last year.26
• Uninsured children between ages 1 and 3 are approximately twice less likely as
insured children to have up-to-date immunizations.27
Other Issues
• Twenty percent of parents of uninsured children ages 5-18 compared to 3% of
parents with insured between the same ages have kept or would keep their child
out of a sporting of athletic event because of fear that they might get injured and
have no way of being covered'.2$
• Uninsured children—when they receive needed care—are often charged more
than insured children. Since insurers, including Medicare and Medicaid, negotiate
large discounts with hospitals and physicians, providers often offset by raising
the costs to uninsured individuals such as children.s,29
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C. History`of Healthy Families/Medi-Cal Outreach and Enrollment
The State Children's Health Insurance Plan
The State Children's Health' Insurance Plan (SCHIP) was created. in the Balanced
Budget Act of 1997 (the BBA), appropriating $24 billion over five years and $40 billion
over ten years to help states expand health insurance coverage to children whose
families earn too much income to qualify for Medicaid (Medi-Cal in California), yet not
enough to afford private insurance coverage. SCHIP, the single largest expansion of
health insurance coverage for children since the enactment of Medicaid, presents a
significant opportunity reduce the number of uninsured children in the United States.
However, it has not always been easy, nor has each jurisdiction been successful in
identifying and enrolling all eligible children.
SCHIP offers states federal matching funds — with matching rates considerably higher
than standard Medicaid rates — to expand health care coverage for children using
Medicaid, a separate state children's health program, or a combination of the two. In
response to this new opportunity, all states have expanded coverage'for children since
1997; most states have elected to cover children in families with incomes up to 200% of
the poverty line or higher. Census data reveal that the proportion of low-income children
with publicly-funded coverage under Medicaid or SCHIP rase in 1999 and 2000 and that
this resulted in a reduction in the percentage of low-income children who lack insurance
coverage.
The federal goverment reports that states have aggressively sought' to simplify their
application, enrollment and re-enrollment processes to ensure that eligible families can
easily apply, enroll and remain enrolled. Steps such as using a' joint and mail-in
applications, offering presumptive eligibility, allowing retroactive eligibility, and providing
continuous eligibility are all considered important strategies for simplifying the
enrollment process and providing opportunities for families to apply and remain enrolled
in Medi-cal for Children (MCC) and the Healthy Families (HF) program.
California's program, Healthy Families, is a state- and federally-funded health coverage
program for children with family incomes above the level eligible for no cost Medi-Cal
and below 250% of the federal poverty line.30 Healthy Families provides low cost,
comprehensive physical health, mental health, dental and vision coverage to uninsured
children in low wage families. Families participating in the program choose their health,
dental and vision plan. Families pay premiums of $4-$9 per child per month'(maximum
of$27 per family)to participate in the program.
California law requires the department of Health Services, in conjunction with the
Managed Risk Medical Insurance Board (MRM'IB), to develop a conduct a community
outreach and education campaign to help families learn about and apply for Medi-Ca
and Healthy Families. The state's activities to increase enrollment in Medi-Cal and
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Healthy Families focused in two primary areas: 1) removing administrative barriers and
2) a community-based outreach campaign. In the last two years, the state has allocated
millions of dollars each year for outreach activities for counties and community-based
organizations. At the time of this writing, the budget for 2002.2003 is still uncertain, but
it is clear that major cuts in the outreach and enrollment efforts will be sustained.
Effects of Welfare Changes
When the welfare system changed', there was considerable cause for concern that
families no longer eligible for cash assistance would lose their Medicaid coverage
nationwide, despite guarantees in the law, or that families discouraged from Temporary
Assistancefor Needy families (TANF) would also be discouraged fromi applying for
health insurance. Nationally, children whose families lost benefits or moved to a
different form of welfare assistance who were still eligible for Medicaid undoubtedly fell
through the cracks in the system, with no health coverage. However, Contra Costa
County's Employment and Human Services Department, responsible for this task here
in the county, has a formal, written procedure for identifying cash applicant families who
do not follow up or who are denied cash assistance, as well as for "diversion„
applicants.
According to a Medi-Cal Policy Institute Issue Brief, Medi-Cal After Welfare Reform:
Enrollment Among Former Welfare Recipients, the number of actual former welfare
recipients enrolled in Medi-Cal rose steadily throughout the 1990s. The number of
former welfare recipients with Medi-Cal increased sharply in 1998 and 1999, after
CalWORKs began, and then leveled off in 2000. It is important to note that the number
of people leaving welfare varied widely during this period. However, the percentage of
all people enrolled in'Medi-Cal after they left welfare — called the "take-up rate— actually
fell between 1992 and 1997 from 32% to 27.6%. However, this decline in former
recipients' enrollment rate reversed in 1998 and tape-up began' to increase rapidly,
again tied to the start-up of CaIWORKs. It is also important to note that there is wide
variation in enrollment rates among former welfare recipients by county, ranging from a
low of 17.7% in Sierra County to a high of 78.2% in San Francisco County for a
statewide rate of 48.8%. Contra Costa County is slightly below the state rate, at 43.0%.
The variation in rate is a factor of how well counties succeed in reaching former welfare
recipients.
Many families with Medicaid-eligible children apply for cash assistance but do not finish
their applications or are denied assistance due to welfare rules that irrelevant to their
children's Medicaid eligibility. Other families may not be receiving ongoing cash welfare,
but have been found eligible by their welfare agency for one-time "diversion" payments
or for noncash services. Nationwide, thousands of children are leaving the cash
assistance system each month when their parents find employment or when their
family's welfare case is closed for other reasons. Children in all of these situations in
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California are almost certain to be eligible for Medi-Cal and are at;high risk of being
uninsured if not for Medi-Cal.
D. History of'11 edl-Cal Application Changes
Streamlining application and enrollment processes for Healthy Families and MCC has
been a critical strategy for increasing enrollment of uninsured and eligible children into
HFP and MCC. An important and shared goal of MCC and HFP is to make the
application and enrollment process for both programs as consumer-friendly and efficient
as possible, so that children receive immediate access to preventive and medical
services. Improved coordination between MCC and HFP is a key step towards
streamlining enrollment.
According to Streamlining Application and Enrollment for the Health Families Program
and Medi-Cat for Children, a report from the California Department of Health Services,
an important goal of the programs should be to assess applicants to either program
without delay and burdensome, duplicative requirements.
MCC and HFP have continuously explored opportunities to improve i coordination and
streamline application and enrollment processes. The state has adopted many
strategies, including a shortened (4-page) joint application described below, the
introduction of 12-month continuous eligibility, and the elimination of quarterly status
reports under Medi-Cal. These strategies will be supported by the statewide introduction
of Health-e-App, described below, the nation's first online enrollmentsystem for public
health programs.
Another promising approach is to streamline MGC and HFP application and enrollment
processes for children applying to, or already enrolled in, other public programs. Called
"Express Lane El'igibil'ity," this approach seeks to expedite enrollment for children who
have already provided contact, income and other eligibility information to another public
program, particularly those with income requirements similar to MCC and HFP.
Two recent California laws have created the nation's first Express Lane Eligibility
enrollment policy to link uninsured California children who participate in certain nutrition
programs to subsidized health coverage. These implement Express Lane Eligibility
through Food Stamps (SB 493) and the School Lunch Program (AB 59). Using
information already provided by uninsured Food Stamp enrollees, the state and
counties will be able to more efficiently enroll eligible children and families into the Medi-
Cal and Healthy Families programs. In addition, school districts will:now be allowed,
with a parent's consent, to release information on school lunch applications in order to
expedite Medi-Cal enrollment for children. Also, children under age 6 receiving free
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qW
lunches (children with incomes below 130% of the federal poverty level) will be deemed
income-eligible for Medi-Cal, thus speeding their access to health coverage.
While the implementation of Express Lane Eligibility has been delayed for several
years, until at least 2005, due to budget constraints, a re-design of the CHDP program
called the CHDP Gateway will also assist in allowing newly enrolled CHDP clients to be
presumptively eligible for Medi-Cal for 60 days. This will allow an important assessment
of continued eligibility to occur while making it possible for these children to access both
preventive and other comprehensive health care services using Medi-Cal. As the CHDP
Gateway program unfolds over the next few months, it will become another important
linkage for outreach and enrollment and will focus efforts directly on provider offices and
locations (point of service enrollment addressed later in this report) rather than on
community outreach and enrollment efforts.
Keeping Applications Simple
A simple, family-friendly application process is at the core of an effective enrollment
strategy. For years, states relied on lengthy and complex Medicaid applications and
required interviews at welfare offices. Recently, however, complicated applications have
been replaced with shorter forms; mail-in applications have made welfare office
interviews unnecessary, at least for pregnant women and children; and an increasing
number of states have begun to rely on self-declarations and computerized data
exchanges in lieu of applicant-supplied verification of eligibility. In Contra Costa County,
all Medi-Cal applicants, except minor consent services) use the mail-in process and
need not participate in a face-to-face interview.
Neither federal nor state Medi-Cal rules require a lengthy, cumbersome mail-in
application. Recent federal guidance has encouraged states to take advantage of the
flexibility accorded them under federal law to eliminate verification requirements that
can be barriers to care. Some 34 states have implemented Medicaid applications for
pregnant women and children that are shorter than four pages. States that have
developed joint applications (for Medicaid and for their separate child health program)
have designed streamlined joint forms that are six pages or less (including instructions).
The model joint application form developed by the federal agency that oversees
Medicaid is two pages.
Until 1999, California stood alone among the states that administer a separate child
health program alongside its Medicaid program and that have created a joint application
for both programs in requiring families to figure out the program for which they are likely
to be eligible.
In short, there is nothing inherent in either the Medi-Cal program or in the fact that
California administers its two child health programs through separate entities that
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prevents California from developing a simpler and shorter application and a more
seamless mail-in application process for Medi-Cal and healthy Families.
California's Attempts To Keep It Simple
California has taken some important steps to revamp its Medi-Cal enrollment process.
Pregnant women and children no longer have to meet a resource requirement for Medi-
Cal, when family net income is at or below the appropriate federal poverty level amount,
depending on the age of the child and size of the family. They can submit their
applications by mail. In addition, when it enacted the Healthy Families program, the
California Legislature required a joint application to be developed for pregnant women
and children so that families would not have to sort their way through two enrollment
systems to determine which health program covered their child. In record time, the
Department of Health Services (DHS) and the Managed Disk Medical Insurance Board
(MRMl'B), with substantial public input, created a new mail-in packet through which
families and pregnant women can apply for either Medi-Cal or Healthy Families. The
state also made funds available to community-based organizations to help applicants
complete the required forms.
Despite these efforts, families are having difficulty making their ' way through the
process, and enrollment is lagging far behind expectations. Even allowing more time for
transition to the new mail-in enrollment system, there is widespread agreement that
further steps are needed to simplify the process. DHS and MRMIB plan to revise the
new 28-page mail-in packet and have assembled a working group to solicit feedback on
how the application process is working and suggestions on the changes that need to be
made. In addition, members of the Legislature continue to be attentive to the issue,
interested in teaming whether decisions made by the Legislature and by the
Administration have promoted or hindered the goal of providing coverage to uninsured
California children.
The mail-in application's length and confusing format was due largely to the design of
the joint application process, and specifically to the decision to require families -- rather
than the reviewing agencies — to determine, at least initially, if their children are eligible
for Medi-Cal or Healthy Families. This screening process accounts for four pages in the
application packet, not counting the related instruction pages. it requires applicants to
sort through financial eligibility rules and to make complicated calculations in order to
decide which other forms within the packet they must complete and>which documents
(verifying the information provided on the forms) they must submit. The process can be
difficult, and errors have been commonplace.
In April 1999, the state developed a four-page Healthy Families and Medi-Cal Mail-in
application. This application:
r eliminates all mathematical calculations
requires less information about citizenship or immigration status
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■ asks families to submit one pay stub to verify income
■ has a pre-addressed envelope for returning the application to one site for both
programs and
■ is available in eleven languages (English, Spanish, Vietnamese, Cambodian,
Hmong, Lao, Armenian, Cantonese, Korean, Russian and Farsi).
Health-e-App
Health-e-App was developed through a partnership among the California Health
Services Agency, the California HealthCare Foundation (CHCF), and the Medi-Cat
Policy Institute, in a contract with Deloitte Consulting to develop a software package for
use by Certified Application Assistors (CAAs) to help people apply for health insurance
completing electronic application of Healthy Families and Medi-Cal. It is an easy-to-use,
streamlined way to submit health benefit applications for children.
Health-e-App is one of the nation's first efforts to use the internet to enrol low income
children and pregnant women in the state's public insurance programs. This software
was piloted in San Diego County at three clinics, a public elementary school, a church
and at WIC offices. After the success of the pilot, the state set a goal of statewide
implementation by September 2002. However, this has been delayed.
Benefits of this electronic interface between the state and county include
■ Ability to electronically tie an applicant to current databases at the county,
such as tracking enrollment in Food Stamps.
■ Reduction in the amount of time and potential errors resulting in completion of
information.
■ Additional information, such as the Enrollment Entity (EE) number, CAA name
and number are available to provide a more direct point of contact regarding
the applicant.
■ Reduction in paper.
■ Earlier arrival of information for the county than by mail.
The rollout process is recommended to involve the following staff or departments:
County Finance Department
■ County Information Technology Department
■ County Manager/Board
= County Sponsor(s)
■ EDS Single Point of Entry
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■ EDS/father consortium technical contacts
■ County Case Workers.
Elements necessary to implement the system include a computer with intemet access
and an internet browser such as Netscape Navigator or Microsoft Internet Explorer.
Many counties working with the software have found that with some modification,
Health-e-App could support a "universal application" approach to a wide range of county
and state programs which gather information from potentialbeneficiaries. These include
County Medical Services Programs, Breast and Cervical Cancer Early Detection
Programs, Prostate Cancer Programs, Food Stamps, other county programs, WIC,
county-provided health insurance initiatives, CHDP, Adult Medi-Cal applications,
presumptive eligibility and express lane eligibility. Some counties have also found it
beneficial to interface electronically with state programs. At the same time, this software
could be the foundation for a county-driven electronic universal application}. Such an
application minimizes the number of step in the application process for potential
beneficiaries and for the agency administering the application. However, the universal
application would have to 1) be easily modified to adjust to new or changed program
eligibility rules, 2) provide the same or very similar results as current practice, 3) be
easy to use and 4) be portable. Some counties already using Health-e-app have begun
to express some concerns about its flexibility.
Contra Costa Health Services implemented the Health-e-apps program in September
2002 and equipped' Certified Application Assistants with the appropriate technical
devices and skills to participate in the program. Fourteen of Contra Costa Health
Services' CAAs have been trained and registered to use the system. Employment and
Human Services Department will not be included in this roll-out, as county welfare
departments have not been included.
The rise in the statewide Medl-Cal caseload described earlier is attributable to a number
of recent policy changes that have: extended eligibility and/or simplified enrollment
processes as well as to changes in the national and state economy. Substantial
enrollment increases are expected in categories related to the extension of eligibility to
parents in families with incomes of up to 100% of the Federal Poverty Level and
changes that increase children's eligibility. Anticipated statewide enrollment increases
between 2001-02 and 2002-03 are assumed to be due to the following:
■ Providing 12 months of continuous Medi-Cal enrollment for children (55,540)
■ Eliminating quarterly status reporting for families (28,000)
■ expanding the 1931(b) programs to parents in families with incomes up to 100%
of the Federal Poverty Level(34,971)
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• Accelerating enrollment for Medi-Cal through the single point-of-entry program
(6,970)
■ Providing Medi-Cal to former foster youth up to age 21 (537).31
At the time of this writing, we are still waiting for the outcome of the negotiations on the
2002-2003 state budget. It is unknown which, if any, of these programs will be
eliminated or reduced. We do know that the implementation of Express Lane Eligibility
programs will be delayed for several years. The Quarterly Status reports were
eliminated last year, but proposed for reinstatement in 2002-2003. It is widely expected
but by no means certain that the Quarterly Reports will not be reinstated in the final
outcome of the state budget.
Verification Issues
While California state regulations specify in detail what Medi-Cal items must be verified,
the regulations also give county eligibility workers discretion to. impose additional
verification requirements. According to the state report, Streamlining Application and
Enrollment, the MC210 does not identify the elements on the form that will need to be
verified but rather states that the applicant "may be asked to give proof and/or more
detailed information on residency, property/resources, income, or work history."
On the other hand, the mail-in application form does identify required verification. At the
same time, there are reports of local counties asking for additional documents, Thus,
Medi-Cat's verification requirements appear to vary depending on which form is used
and which county is revising the application.
Extensive verification requirements can create significant barriers for families applying
for Medi-Cal. Written verification of income and other factors often take a considerable
amount of time for applicants to gather and require the cooperation of third parties who
may not be willing or able to provide the information. Requests for verification can be
particularly difficult for low-income working families, because they have little time during
the work week and little flexibility to take time off from work to gather the necessary
paperwork. Verification also can be particularly burdensome for homeless and migrant
families, and it can lengthen the time it takes for the reviewing agency to process
applications.
State regulations require verification, prior to approval of eligibility, of blindness,
disability or incapacity (generally not relevant to applications for pregnant women and
children), alien status, situations where the parent and a public or private agency will not
accept legal responsibility for a child, identity, unearned income (which can be verified
through state computer data exchanges or through applicant-supplied documents), in-
kind income, earned income, child care costs, the cost of care for an incapacitated
person and other deductible expenses, resources (which should not be a factor for
pregnant women and children), health care benefits, and residency.
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Data collected by Los Angeles County on the Medi-Cal mail-in applications received
between the end of June and the end of August, 1998 show that verification
requirements are creating problems for families. Lack of required documentation was
the most significant problem area for the applications processed during that period —
almost one-third (32'%) of the applications were missing documents. These data are
consistent with the experience of other states. When states have reduced verification
requirements in their Medicaid programs, the percentage of applications denied for
procedural reasons has declined sharply.
Contra Costa County's Employment and Human Services Department has been a
leader statewide in working-to support applicants to the program. Through its advocate
program, Medi-Cal eligibility workers use advocates to remind applicants of necessary
paperwork needed and work to contact applicants for follow-up. At the time of this
writing, it is unclear how proposed state budget cuts will impact the ability of Contra
Costa County's Employment and Human Services Department program to continue the
advocate program and the outstationing of eligibility workers.
Successful Programs for Simplifying Application and Enrollment Processes
r North Carolina's Health Choice for Children Program has successfully
implemented strategies to simplify the application and enrollment procedures,
using a joint application for Medicaid and SCHIP, guaranteeing eligibility for
12 months in Medicaid and SCHIP, providing a simplified two page
application in English and Spanish, allowing mail-in applications, cross-
training eligibility workers to determine both programs' eligibility in one review,
and notifying families automatically when it is time for them to reenroll their
children in either program.
is Ohio s Healthy Start eliminated onerous eligibility verification
requirements, such as proof of residency and birth date for children applying
for Medicaid, which includes their SCHIP program. In addition, the state uses
a two page simplified application, allows them to be mailed in and eliminated
the requirement for face-to-face interviews before determining eligibility.
a Oklahoma's SoonerCare has been successful in outreach and
enrollment by simplifying their application process in the following ways: the
application was shortened from 16 pages to one; outstationed eligibility
workers travel the state and conduct on-site enrollment at community-based
sites; and they eliminated the asset tests and now accept self:declaration of
income.
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E. Enrollment Barriers
National data presented in the Kaiser Commission's Enrolling Uninsured Low-Income
Children in Medicaid and SCHIP show that low-income uninsured children typically live
in two-parent, working households and have little contact with the welfare system.
Nearly all low-income parents say that having health insurance coverage for their child
is very important, though many cannot afford to pay for it on their own. Most low-income
parents (81%) view Medicaid as a good program, but have difficulties accessing it.
Health Insurance and Small Business
Many uninsured children come from working families whose employers do not offer
health insurance. The California HealthCare Foundation sponsored a study, Why Don't
More Small Businesses Offer Health Insurance? to explore the reasons. The primary
challenge was cost. Small firms not offering health insurance tended to underestimate
substantially the costs of coverage and were willing to pay on average on 40% of what
they perceived to be the costa Recent returns to double-digit increases in health
insurance premiums and the current recession mean that cost will likely be an
increasingly important barrier to small firms' ability to offer health insurance to their
employees.
Another reason, more likely to offer hope for remediation, was low awareness of market
protections and options. While information about the health insurance market is not
likely to dramatically increase the number of small firms offering health insurance, it may
make a difference for some. In particular, the survey identified a group which was
predisposed to beginning to offer health insurance in the next two years. This group is a
promising target for outreach and education efforts about the health insurance market,
especially web-based strategies.
Other challenges that need to be addressed in reaching and enrolling eligible children
include the following:
■ Complexity of Public Insurance Programs. The number of programs, each with
separate criteria and enrollment procedures, provides a significant barrier for
families.
■ Immigrant Fears Still Exist. The fear of retaliation from the Immigration and
Naturalization Services remains a prevalent barrier to enrollment among immigrant
families, despite resolution of the Public Charge issue in favor of health benefits.
This fear of repercussions is particularly strong among legal residents who are
seeking citizenship.
Resource and Systems Limitations. Infrastructure and bureaucracy often create
large barriers, especially within county welfare systems.
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Ask
• Lack of information. As shown in the CHIS interviews, many families are simply
unaware of the availability of Healthy Families or of their children's eligibility for it.
• Complexity of Forms. A state report foundthat state health forms required college-
level reading skills and ask for four times as much information and supporting
documentation as federal income tax forms. The new shortened form was developed
with this in mind. A study conducted by the UCSF Institute of Health policy Studies,
Barriers to Enrollment in Healthy Families and Medi-Cal; differences by Language
and Ethnicity, found' that even with the shortened' application, a larger than average
share of Spanish-speaking Latinos described the application as difficult to
understand. As a result, 32% of Spanish-speaking Latinos in their study reported not
completing their application contrasted with 16% of non-Latinos and 12% of English-
speaking Latinos.
• Disparities Between High and Low Uninsurance Areas. While only 25% of
children live in high uninsurance areas, 40% of uninsured children live in these
areas. Enrollment efforts need to focus on these areas, both because they include a
large concentration of uninsured children and because take-up rues of public and
private coverage have historically been lower in these areas.
• Stigma of Enrollment in Public Programs. Some parents do not want their
children to be labeled as users of public systems, as described earlier in the CHIS
interviews.
Table 1 below shows the reasons the Managed Risk Medical Insurance Board
(MRMIB), which administers Healthy Families statewide denied coverage to children in
the nine Bay Area counties. The most common reason was "income application not
completed in 20 days" (17,800 or 46%). The regulations state that all documentation
and information for eligibility must be presented to MRMIB within seventeen calendar
days. The second most common was "Below 133% of poverty and ;age Tess than six
years" (4,529 or 12%), followed by "Below 100% of poverty and age greeter than six
years" (4,015 or 10%). Both of these reasons mean that the child is eligible for Medl-
Cal. Contra Costa County's top three reasons were the same as the Bay Area as a
whole,as well as the state.
The most common reason for denial' --- incomplete application -- could be remedied
through more effective enrollment follow-up. The: second and third most common
reasons .-. income eligible for Medi-Cal — offers an opportunity to enroll these children
into Medi-Cal. These three reasons, which could all result in more children'insured with
adequate staffing and systems for recruitment and application assistance, account for
71% of all of the county's 4,031 denials. With improved'tracking through systems such
as Consumers Union's system, these children could be enrolled quickly. Another 8%
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have incomes between 201% and 300% of the federal poverty line, who still are likely to
be unable to afford premiums. About 7% are not eligible because of immigration status.
Table 1: Healthy Families Program Children Ineligibility by County
For 12 Months Ending August 4,2002
o
E .r
IN
a. ' �' + cd M aU_ C3 ro a r°n
U_ u. > o= °= a Q � off •- ° + + v1 0 U m
o o ff ' o � ¢0 Lu flro t? a 12 �
o n c cis n LL u7 � 2) x, 0 e 0 5* m
cv cv m ariaji U d � m � c
County/ o °G o o o o Z •• o - _ o
Ineligibility m m LL � ¢ U z °i j U c z
Reason otal
Total CA
Ineligibles 47,52349,068 4,27313,542 7,334 2,03025,963161,07519,208 1,454 2,19917,017 47411,142 2,036 364,3381
�Bay Area 4,015 4,529 7331,907 1 083 299 2569 17,800 2,171 204 270 2 125 48 I137 20339,09
Alameda 9801 232 147 417 27 78 528 4,319 606 74 81 56 14 266 49 962
Contra Costa 495 566 55 221 ..130 44 348 2,359 312 17 32 283 2 1301 27 4,981
Marin 107 96 21 32 13 5 79 471 64 4 8 26 0 32 3 961
Napa 127 160 16 51 19 5 81 417 56 4 41 38 0 45 6 1,02
San Francisco 321 307 87 189 93 28 265 1,301 131 12 28 178 1 91 14 3,046
San Mateo 315 373 99 181 107184
146 1,840 230 14 23 297 7 102 9 3,764
Santa Clara 1,065 1,136 172 502 331 703 4,40 471 49 67 568 i 292 63 9,925Solana 291 324 47 132 54 200 1,223 177 20 _ 15 104 3 77 21 2707
Sonoma 314 335 89 182 61 261 1 464 124 101 12 68 5 102 11 305
Source: California State Department of Health Services. Managed Risk Medical Insurance Board. Healthy
Families urogram Children Ineligibility Statistics by County, as of 8.4.02. HFP Table 16.
* Eligible for Medi-Cal. ** Income too high to qualify. *** Immigration issue.
+ Not in compliance with regulations. ++ Age not eligible.
F. Retention Challenges
Enrollment retention is a concern. According to a study from the 100% Campaign:
■ One in four children lost coverage in Healthy Families a year after enrollment.
■ 162,000 children losing coverage compared to the 536,000 covered.
■ Over half of Medi-Calfamilies lost coverage a year after discontinuing cash
assistance.
60% of non-cash Medi-Cal families covered in 2000 lost coverage within a year.
There is significant county variation in retention (82%to 22%).
■ Healthy Families and Medi-Cal children have more rules to keep coverage
compared to employer coverage.
* Some leave because of other coverage.
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• Others lase coverage because they do not follow the rules, such as annual'
renewal or payment of premiums.
Five critical junctures in the coverage process where children are most likely to lose
coverage are:
• Transition between Medi-Cal and Healthy Families
• Annual Review
• Monthly premium payments
• Communications from Medi-Cal or Healthy Families
• Access to Care.
According to the State Department of Health Services, nearly 65% of Healthy Families'
72,500 disenroliment cases {about 22,000 children or 30%) may be attributed to a
family's failure to recertify annually or pay monthly premiums (about 25,000children or
about 35%). In 31% of applications received by the Single Point of Entry (SPE),
applicants indicate that they do not want their children to be enrolled in Med'I-Cal if they
are eligible. Below is a chart of SPE applications for the nine Bary Area counties.
Retention and Disenrollment Benchmarks
There are a number of different definitions and ways to measure retention, or its flip
side, disenrollment. They provide a range of numbers to debate the effectiveness of
retention efforts.
• In the insurance industry, the retention rate generally refers tothe year to year
stability of the enrolled population. The retention rate answers the question: if 100
children enroll today how many will stilt be enrolled at the end of the a year?
• MRMIB calculates the retention rate in the HFP for all new enrollees who renewed
during the annual renewal period.
• Healthy Families also uses an adjusted disenrollment rate which assesses the
reason for disenrollment and uses only the reasons it considers "potentially
avoidable.
• Another measure is the number of total disenrollments divided by the number of total
enrollments over the course of the programs.
• Disenrollment can also be measured by the number of disenrollments in the current
year divided by the number of currently enrolled members, as seen in Table 2.
In evaluating the HFP retention rate, DHS staff identified comparable benchmarks.
Enrollment in the HFP is most analogous to enrollment in the individual insurance
market. It is an individual purchase decision. Families pay a premium. The
consequence of non-payment is disenroliment. Data from National Blue Cross/Blue
Shield Association, which shows Individual Market Data of 70-75% retention provide the
closest approximation of a benchmark for enrollment in the HFP.
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Disenrotiment In The Healthy Families Program
MRMiB calculated that the retention rate in the HFP for all new enrollees from July 1998
through December 1999 was 76%, meaning that 76% of those enrolled renewed during
the annual renewal period. Later groups of new enrollees were not included in this
analysis because they have not had the opportunity to be enrolled for a year. Most
recent data is somewhat contradictory to these data.
The flip side of the retention rate is the coverage "lapse" rate or disenrollment rate.
Many factors influence disenrollment rate's:
■ ineligibility at Annual Eligibility Review or attaining age 19
■ Obtaining other coverage
■ Failure to comply with program rules
Some of these factors are the result of "good news," in which the family has found
private coverage for their child; others are inevitable given current program rules: the
child is no longer eligible for coverage in the program; others are hard to evaluate in
terms of whether they are good or bad news for the family. For example, it is unknown
why many families stop paying their child's premiums.
California reports that its adjusted disenrollment rate for Healthy Families is 16%, which
means that for every 100 children who enroll, 16 are disenrolling for possibly avoidable
reasons, instead of the overall number of disenrollments. But overall, the total
disenrollment rate (disenrollment for any reason) may be as high as 47%, with Contra
Costa County at 54%, as shown in Table 2. Table 2 shows the number of Healthy
Families subscribers and the number of disenroliments by county, with the percent of
disenroliments to enrolled subscribers for the nine Bay Area counties for the 12 months
ending June 7, 2002. Contra Costa County is in the middle of the group. This includes
all disenroliments, both avoidable and unavoidable.
There have been a total of 279,707 disenroliments from Healthy Families through 8/9/02
(regardless of reason) and a total of 824,796 ever enrolled as of 6/7/02, showing a total
disenroliment rate of 34%.
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Table 2. Healthy Families Enrolled Subscribers and Disenrollments by County
For 12 Months Ending June 7, 2002
County (A) (13 (C)
Number Currently plumber Disenroiled Percentage of
Enrolled in Previous 12 Disenrolled to Enrolled
Months S+A
California 562,614 262,182 47%
Alameda 12,0188 5,723 47%
Contra Costa 6,228 3,373 54°fo
Marin 1,641 882 54%
Napa 1,337 784 59%
San Francisco 10,003 4,089 41%
San Mateo 4,820 2,089 4301
Santa Clara 16,272 8,889 55%
Solano 3,140 2,442 78%
Sonoma 6,143 3,252 53%
Source:'California State Department of Health Services, Managed Risk Medical insurance Beard'.;Healthy
Families Program Subscribers Enrolled by County, Healthy Families Program Disenrollment by County,
as of 8.7.02.
Unavoidable Disenrollments
As of May 2002, there were 354,406 cumulative disenroliments from;Healthy Families,
of which 5,570 were described by MRMIB as unavoidable and 10,467 as avoidable.
This information is not currently available by county.
Some disenroliments are "unavoidable" given current program rules. Unavoidable
disenroliments in the HFP account for 8% of all children. For example, when
subscribers reach age 19, they are required to be disenrolled. This disenroliment as a
system failure of the HFP; it is the federal law that restricts SC'HIP eligible children to
those under age 19. Other"unavoidable" disenroliments include
■ those that result from the child no longer being eligible at the Annual Eligibility
Review,
a those that result from a family's failure to provide citizenship or immigration
documents, and
■ those.that.are the result of an applicant's request.
While these are classified for analysis purposes as unavoidable, they are in some cases
reflective of federal standards (immigration documentation) and in others of state policy
choices (birth certificate documentation).
Possibly Avoidable Disenrollments
The largest groups of disenrolled children are those that have disenrolled for "possibly
avoidable reasons. These account for 16% of children enrolled in the HFP.
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The caveat "possibly" is used because the two largest reasons for possibly avoidable
disenrollments are catch-ails:
non-payment of premiums is recorded as the reason for disenrollment when the
program does not have other information on why the family disenrolled — these
disenrollments are the result of a variety of factors including financial hardship,
attaining Medi-Cal or employer based coverage, moving out of state, family
income increasing above eligibility levels or dissatisfaction with the program. For
some families, the exact reason will never be known because the family can not
be contacted.
■ "non return of Annual Eligibility Review materials". All the reasons listed above
may be the underlying reason for disenrollment of these families. In addition, the
program's Annual Eligibility Review materials may influence this category.
Whether the materials are simple to understand and presented in the family's
language.
The DHS analysis suggests that there are opportunities to improve retention rates..It is
important to note that these improvements would require substantial commitment from
the State. Improvements in the billing process would appear to offer the greatest area
for gains in retention rates. Ideas include:
■ Redesign HFP billing statements
• Eliminate premium pro-ration. Begin premium payment obligations at first day of
the first full month of coverage
■ Translate all written correspondence into top 5 languages: English, Spanish,
Chinese, Vietnamese, Korean
■ Administrative Vendor initiate a courtesy telephone call 15 days prior to
disenrollment for nonpayment
■ Include e-mail address as a field on the program application so that reminder
notices can be sent to families regarding overdue payments.
In addition, more information is needed on disenrollments in the two large catchall
categories of non-payment of premium and Annual Eligibility Review information not
returned. Without this information, the following administrative improvements may
decrease disenrollments for these two broad categories.
■ Telephone survey/follow-up for Annual Eligibility Review packets not received
■ 30-day reminder to applicants disenrolled for Annual Eligibility Review not
received and incomplete still can turn in documents with break in coverage
Another area that may prove useful in increasing retention rates is to involve application
assistants more fully in the Annual Eligibility Review process. Ideas in this area include:
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■ GAA authorization on application to permit CAAs to assist with'problems on initial
applicationand Annual Eligibility Review
• CAA authorization on application to inform or remind applicant that Annual
Eligibility Review is due
MRMIB has decided to focus their improvements on the billing system and the Annual
Eligibility Review (AER), thereby achieving a better level than the current retention rate
of 76%. The following are some of the steps that have been outlined by MRMIB to help
increase retention.
Non-payment of premium:
■ Courtesy phone call 10 days prior to disenrollment for non-payment of premium
■ Re-design billing statement
■ Enhanced Interactive Voice Response System for billing inquiries Opening of
Parent Expansion
Annual Eligibility Review(AER):
• Courtesy phone call 30 days prior to disenroliment for not submitting AER
Package
• Second AER Disenrollment letter reminder
Material Translation
■ Translation of all correspondence (including billing statements and program
materials) into Chinese, Korean, and Vietnamese
Application,Re-Design
• implement CAA Authorization on application to assist applicants and subscribers
in completing application and AER packages.
While retention statistics that use the same methodology as above are not available for
Contra Costa County from MRMIB, a comparison for the twelve months ending June 7,
2002 shows that California had 262,182 disenrollments and 562,614 current enrolled
children (46% disenrollments to current enrollment) while Contra Costa County had a
higher rate of disenrollments -- 3,373 disenrollments and 6,228 currently enrolled (54%).
F. Access to Cara
Access to care has been recognized as an important retention activity. When children
have a medical home, they are much more likely to maintain their coverage. As
described above, national statistics show that uninsured children are significantly less
likely to have preventive and primary care and to have more unmet health needs than
insured children. Program evaluations for Healthy Families have not been completed
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yet, it is important to remember that the goal of having health insurance is in fact to
obtain preventive and other health care services easily and in a timely fashion.
If enrollment efforts do not include as essential components 1) ensuring a medical home
for children and 2) providing an understanding of where and when to access care and
easy access to the medical home, then the value of health insurance for the family will
be limited. Point of service enrollment--enrollment of children without insurance-- at the
time of service at county and community clinics, in particular, seems to be one of the
most cost-effective enrollment opportunities. The link then can easily be made between
health insurance and health access.
G. Survey of Best Practices
A number of studies already quoted above describe effective strategies to make
enrollment and retention more likely. Key lessons learned include
Successful outreach and enrollment programs at the local level build an ongoing
relationship with the family to help them obtain insurance, use services appropriately
and retain coverage over time.
■ More rigorous evaluations of outreach, enrollment, access and retention programs
are needed to determine which activities are most successful.
■ To date, there has been limited dissemination and replication of these strategies
throughout the state.
• The state should determine whether Medi-Cal and Health Families enrollment is
associated with more appropriate use of health care services by children.
• The lack of sufficient and sustainable funding presents a majorchallenge for local
organizations involved in these activities.
■ Due to high turnover rates among certified application assistants, local programs
have implemented continuous training programs.
A study conducted for DHS by the Center for Adolescent Services Research Center
found that successful outreach programs
• Build on prior experiences
■ Use tracking systems to monitor whether applications result in enrollments
■ Collaborate with WIC programs
• Give out information and make application appointments.
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Successfulstrategies within three components of outreach include
■ Identification of the Target Papulation
o Use census data and a Geographic Information System to create maps of
low-income uninsured children
o Administer brief surveys to all children in a school to obtain estimated of the
number of uninsured children as well as those needing follow-up
o Collaborate with publicly funded programs that have similar eligibility
requirements, such as WIC, including outstationing staff at the WIC office
o Use health fairs as an opportunity to educate parents about health insurance
and to set up appointments for enrollment
■ Use of Media and Communication
o Use press releases and news stories to disseminate information, rather than
purchase expensive advertising
o Use school mailings to reach large numbers of potentially eligible children,
such as mailings for the school lunch program — these should be followed up
with personal contact
o Word-of-mouth, especially in tight-knit ethnic minority communities, including
using parents to talk with ether parents
■ Use of incentives
o Ice cream party for each class that returns 100% of circulated surveys
o Small gifts for teachers to acknowledge their critical role in the process
Successful strategies in enrollment are less well-known. Overall, nearly two of every
three applications to Healthy Families are completed with assistance. Even the
strategies listed' below are not a surefire way to assure that a family will move from
interest to enrollment.
■ Enrollment Sequence
• Schedule appointments with application assistants to help families complete
the application
o Schedule evening and week-end hours to accommodate working parents
o Provide transportation vouchers and incentives
o Send promotoras to follow up on missed appointments
o Focus on one school at a time, with workers stationed at the school all day
and in the evenings to meet with parents, until every potentially eligible child
has been reached
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■ Productivity Standards
o These vary based on type of program and where it is located. Urban school-
based programs reported the highest average monthly enrollments per full-
time staff. The highest reported standard is 25 applications per month,
accounting for 25 children. In rural areas, the number may be as low as seven
per month.
Knowledge of successful strategies for appropriate use of health care services is
limited by small evidence demonstrating the impact of enrollment on utilization.
■ Appointment Assistance, Reminders, Follow-up and Written Information
o Provide written information about how to obtain care
o Provide education and assistance in scheduling an appointment either in
person or by phone
o Maintain a database to keep track of time a family is contacted.
o Contact families 30 to 60 days after they have enrolled to remind them to
make an appointment with their primary care provider and dentist, either by
phone or in person
o Help families make appointments directly
a Provide classes in how to use the health care system.
■ Client Tracking Systems
o All of the follow-up strategies require an information system that contains
accurate contact information and application status.
Successful strategies for retention focus on potentially avoidable disenrollments.
Each stage in the reenrollment process is essential for children to maintain coverage.
■ Reminders
o Contact families regularly (at least three times a year) to follow-up on
enrollment status, answer questions and prepare families for reenrollment
o Use tracking sheets that remind the outreach worker to follow up with every
family at reenrollment time.
■ Advance Payment of Premiums and Change of Address Forms
o Encourage families to pay multiple months of premiums at enrollment
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Creating a Sustainable Infrastructure to Support Best Practice Activities
Most successful programs view the application process as more than single transaction,
but rather the beginning of a yearlong relationship with multiple contacts. In order to
establish and maintain these relationships, programs report that they need a
sustainable infrastructure, with
w data and tracking systems
■ long terra funding
• ongoing training
action-oriented collaboration
■ access to information resources.
Without appropriate tracking systems, it is nearly impossible to develop an ongoing
relationship with newly enrolled families. Many organizations have developed them
using Microsoft Access or ether commercial software packages. Consumers Union has
commissioned consultants to develop a customized database application that can be
used to track outreach, enrollment and retention. Healthy Tracker is a stand-alone
database built on Filemaker Pro that is ready to use and available free to interested
outreach entities. Contra Costa has begun to incorporate components of the Healthy
Tracker into the Outreach and Enrollment Initiative's database in order to more carefully
follow-up on clients.
Other organizations engage in continuous quality improvement, 'producing regular
reports that allow them to evaluate the effectiveness of particular strategies and to
revise them accordingly.
Other Resources
Ongoing training is provided for CAAs through a number of resources, including the
National Health Foundation's CHAMP Program in Las Angeles and the Child Abuse
Prevention Council in Sacramento. The California Rural Indian Health Board holds
monthly conference calls with all outreach workers at all Indian Health, programs
throughout the state, updating staff, reviewing statistics, answering questions, and
providing guest speakers.
Curricula such as Community Health Councils, Inc.'s Health Insurance and Health
Services, a Consumer Education Curriculum, can train staff to educate community
members about the importance of health care, health insurance, health coverage
programs for children and adults, and where to go for health services.
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H. Survey of California County Activities in Outreach,
Enrollment and Retention
The Department of Health Services has awarded contracts for schools and
organizations to provide direct outreach and enrollment activities for HFP and MCC. In
March 2001, DHS requested applications for both community-based and school-
based/school-linked efforts, and in July 2001, announced their intent to award contracts.
A total of$11.5 million was disseminated statewide for these local efforts. The two year
contracts were scheduled to end in June 2003, but the current state budget crisis will
end many of them sooner.
Enrollment Entities (EEs) are organizations registered with the State of California
Department of Health Services with staff trained as Certified Application Assistants
(CAAs). CAAs help families complete the Health Families/Medi-Cal for Children
application form. The EE employer may claim a $50 application assistance fee from the
state for every successful application. When a'CAA assists enrollees in completing their
Annual Eligibility Review, which must be completed by every HI=P participant yearly, the
EE may claim a $25 fee.
Below is a list of some of range of activities carried out throughout the state. Afterwards
follows an inventory of selected outreach, enrollment and retention activities in selected
counties.
• CHAMP, the Children's Health Access and Medi-Cal Program, trains
school, hospital, and agency employees to help low- and moderate-income
families enroll their children in health care programs. CHAMP offers a
program-integrated approach to outreach and enrollment so that all uninsured
children can obtain access to regular health care. LAUSD CHAMP hires
parents from the community to serve as Health Care Community
Representatives, training them to educate other parents about children`s
health insurance programs and to help families enroll in these programs at
school sites. Health Care Advocates provide training, mentoring and support
to the parents. Outreach and enrollment staff members conduct presentations
and other outreach activities, in addition to organizing health insurance
enrollment events. The LAUSD CHAMP program is a pilot program of
Consumers Union's Healthy Kids, Healthy Schools Project. As a result,
District Medi-Cal enrollment rates have increased 28.81% over the previous
12 months.
■ The 49ers Academy, a middle school in the Ravenswood City Elementary
School District, focuses on outreach coupled with intensive follow-up. This
project is a partnership between the San Mateo Department of Public Health
and the 49ers Academy. The school's two counselors screen all students for
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health insurance as a part of the regular intake process. Students without
health coverage are provided with information about ,Healthy Families and
Medi-Cal, and are referred to an on-site Outreach Specialist to assist them
with the enrollment process. Because the Outreach Specialist is also a Medi-
Cal eligibility worker, he/she can help address insurance issues for the entire
family. In addition, the Outreach Specialist provides education about the
benefits of health insurance and follows up with parents once their children
are enrolled to ensure that they can effectively use available health care
services.
■ Alum Rack Union Elementary SchoolDistrict's Healthy
Students=Healthy Schools (HSHS) uses two strategies to reach out to
families in the district: Mass Enrollment Events and Request for Information
Forms sent to families in the back-to-school packets that include the School
Lunch Program application. The mass enrollment events led to the enrollment
of 1,437 children with an average enrollment per event of 135>. children.
Outreach using the School Lunch Program is estimated to have led to the
enrollment of approximately 1,5010 children. In addition, the state's enrollment
statistics for Healthy Families for the last year showed that enrollment in the
district's service area increased by 50%. The Food Service [director or ether
school personnel return the completed RFI form to the District's HSHS
Coordinator. The HSHS health care outreach and enrollment staff contacts
parents to screen for eligibility, and then schedule individual appointments at
convenient school sites or invite them to attend enrollment events. HSHS staff
mare follow-up calls to applicants to inquire if their applications have been
successfully processed and to offer assistance in completing farms received
from their insurance providers.
■ The Student Health Outreach Project (SHOUT) is an initiative of the
Children's ,defense Fund that involves students in the effort to enroll children
in free and low-cost health insurance programs. SHOUT works with high
school students, undergraduates, and medical school students to reach
uninsured children and sign them up for Medi-Cal for Children, Healthy
Families, or other insurance programs. The SNOUT project recruits the
students, trains them, and helps link them to community-based organizations
engaged in the outreach and enrollment process. SHOUT also provides
technical assistance to individual students who want to incorporate health
insurance outreach into their current activities, such as working in an after-
school program or attending church. At Stanford University, one SNOUT
project involves a group of medical students who run a free clinic in nearby
East Palo Alto, Most SHOUT participants are not trained Certified Application
Assistants (CAAs). Instead, they partner with community-based, organizations
who have CAAs on staff to help families with the enrollment process.
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Health Insurance Outreach of Pasadena Unified School District (PUSD)
uses District Outreach Workers who are bilingual school district employees.
They promote and coordinate outreach for Medi-Cal, Healthy Families, and
other free or low-cost health insurance programs. The PUSD program
conducts outreach in a variety of ways, including: distributing flyers, pencils
and rulers, and making presentations at parent meetings, back-to-school
nights, open houses and to other school staff. Program staff members follow
up with each family who expressed an interest in health insurance for their
children. Outreach workers provide Parent Education Classes to inform
parents about low-cost and no-cost health insurance and to educate parents
on how to effectively access health services once they are enrolled in the
programs. PUSD staff have learned that enrollment is more successful the
closer it occurs to the initial point of contact, so they schedule appointments
for the same day or within 24 hours.
� The Solano Kids Insurance Program (SKIP), a program of the Solano
oalition for Better Health, has developed a social services marketing model
that provides outreach to community-based organizations, faith organizations,
schools, and businesses. In 1999, outreach linked with the School Lunch
Program back-to-school mailing produced more than 1,000 responses from
families. Other outreach efforts include: use of a dedicated school phone line,
coordination with school nurses and principals, and enrollment event
coordination. Information about SKIP is included in both kindergarten and
new student enrollment packets in most school districts. SKIP uses incentives
to encourage families to complete enrollment. SKIP uses targeted flyer
distribution, brochures, posters, and focused advertising that includes bus,
newspaper, and free publicity, including local cable access. SKIP personnel
have learned that enrollment is more successful the closer it occurs to the
initial contact with a family, so they schedule appointments for application
assistance on the same day or within 24 hours of the initial contact. SKIP has
increased its number of walk-in enrollment sites as part of its overall strategy
to increase access. SKIP's Cerfified Application Assistants (CAAs) make
appointments to help families complete health insurance applications and
follow up on missed appointments. In addition to paid staff members (some of
whom are bilingual) and CAAs, SKIP encourages volunteers to donate time in
the office to make follow-up phone calls and to serve as CAAs.
The Monrovia Unified School District (MUSD) Healthy Start program
conducts outreach and enrollment for Healthy Families and Medi-Cal for
Children throughout the district (grades K-12) to enroll all eligible students. At
the high school level, HFIMCC outreach is part of MUSD Healthy Start's
"Teen Dayz," monthly events that focus on the health needs of students. This
program distributes posters printed in both English and Spanish throughout
the community to market free and low-cost health insurance available for
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children. Word-of-mouth referrals also have proven to be a very effective
outreach method'. Healthy Start staff provide information to parents who are
signing their children up for the after-school program and also focus on
enrolling high school students in health insurance through `Teen Dayz"
events. Healthy Start staff who are Certified Application Assistants are
available as needed to help families enroll their children in a health insurance
program.
The Santa Maria-Bonita-School District Healthy Start Program has a
dedicated full-time position for Healthy Families/Medi-Calapplication
assistance. In addition, all Healthy Start staff are trained Certified Application
Assistants. As a result, staff are continually booked with scheduled
appointments for application assistance and also see a large number of
parents that drop-in for assistance. Healthy Families/Medi-Cal outreach is
integrated into all Healthy Start activities. The Santa Maria-Bonita Healthy
Start program maintains a consistent and clear outreach message that is
communicated through multiple channels. Each: year, a Healthy
Families/Medi-Cal outreach flyer is sent home with every student in the
school district. The flyer is also distributed at regular community events like
church services and PTA meetings. Healthy Start staff ask all clients at the
initial point of contact if they are aware of Healthy Families/Medi-Cal. They
make presentations in all parent education classes (ESL, literacy, and GED).
The program has developed a radio advertisement in Spanish and ;English
that is regularly broadcast in the community. The program, provides "full
service" for families that receive Healthy FamilieslMedi-Cal application
assistance. As a trusted entity, the school district provides families with
important information on utilization and preventive services to assist families
in using the services and retaining the health benefits. Furthermore, this
program tracks and follows-up with families to ensure enrollment occurs.
■ The Health-insurance access Through Schools (HATS)>program is an
innovative effort to expand health coverage to uninsured children in San
Diego County through school-based outreach. HATS offers local school
districts the opportunity to have bilingual outreach workers stationed at school
sites to reach out to low-income families and enroll them in California's state-
sponsored children's health insurance programs - Healthy Families and Medi-
Cal - or other subsidized insurance programs. The program is managed by
the University of California at San Diego's Department of Community
Pediatrics. The University provides interested school districts with funding to
hire workers who will do outreach and provide application assistance,,and the
districts allocate work space and telephones for these workers at selected
schools. The University trains the outreach workers and then manages the
program within each school site. In addition, the University has a Program
Supervisor who ensures that each outreach worker becomes a state Certified
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PACIFIC HEALTH CONSULTING GROUP LLC
Application Assistant (CAA), oversees the daily operations, and maintains a
database to monitor and evaluateoutreach progress. This structure allows
the HATS program to operate'without additional school district costs and with
minimal' disruption to schools' academic' commitments. The University also
assists the districts in becoming enrollment entities. HATS uses various
outreach tools such as flyers,'telephone calls, individual meetings, and group
presentations to inform parents about health coverage options for their
children. Interested parents can meet with an outreach worker at their child's
school to receive assistance with the health insurance application form. The
outreach worker follows up with families to ensure that their child or children
become enrolled in the appropriate health insurance program. The HATS
outreach workers maintain contact with the families, continuing with follow-up
and assisting with problem resolution when necessary until the child or
children are successfully enrolled in a health'insurance program.
■ The San Diego'Kids Health Assurance Network (SD-KHAN) formed an
Outreach Committee to identify effective outreach strategies that would
expand' health' insurance coverage for children. The SD-KHAN Outreach
committee is responsible for facilitating a coordinated campaign with
public/private partners to bink uninsured children/youth with health care
options. SD-KHAN established a toll'-free telephone information and referral
system to help maintain a coordinated'method of linking children with a health
coverage option in the county. Operators are available to answer questions
and to refer interested families to the appropriate health insurance program or
to a 'local Certified Application Assistant (CAA). Modeled after the Health-
insurance Access Through 'Schools program (HATS), Healthl-ink stations
CAAs at school sites in San Diego City Schools once'a week to help families
enroll their children into a subsidized health insurance program. The CAAs
use the school district's health information exchange card to contact parents
who do not list a medical provider or health insurance plan for their child and
to help families apply for children's'health insurance.
• Healthy Families and Medl-Cal for Children Outreach and Enrollment
Project of the San Francisco Bay Area is a school-based outreach and
enrollment project that is park of the Health Access Foundation. Health
Access conducts outreach and enrollment for Healthy Families and Medi-Cal
for Children in the City and County of Sari Francisco, using a family-centered
model, which has been successful in informing and enrolling uninsured, low-
income children and their families.'Health Access works in collaboration with
the local school district and other community organizations distributing'simple
educational literature for partners and service providers, as well as a simple,
one-page Request for Information [RFI] form. The RFI forms are distributed to
families 'via the school district. If parents are interested in receiving
information on low- or no-cost health insurance for their children, they can
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PACIFIC HEALTH CONSULTING GROUP LLC
complete- the RFI and mail it back to Health Access in a postage-paid
envelope. Health Access and partner agency staff use the completed RFI to
follow up with the families. Certified Application Assistants (CAAa) make
multiple attempts to contact the parents, including contacting- them at
alternative times, such as during evenings and different days of the week.
CAAs provide an initial intake to assess eligibility and describe some of the
benefits provided by Healthy Families and Medi-Cal for Children (HF/MCC),
and then invite applicants to participate in a face-to-face enrollment
appointment. Adults are referred to other available health care programs and
encouraged>to contact the CAA if they have additional questions or concerns
about HF/MCC.
■ California Health Collaborative (Collaborative), Fresno, is a,nonprofit
health organization based in Fresno. The Collaborative administers three
health insurance outreach and enrollment programs--Access for Infants and
Mothers (AIM), Fresno County Medi-Cal Outreach Partners, and Interagency
Healthy Families/Medi-Cal for Children Outreach Project. Fresno County
Medi-Cal Outreach Partners promotes awareness of children's health
coverage options in the community and to enroll children into state health
insurance programs. This program utilizes several outreach and enrollment
strategies, including door-to-door outreach, health fairs/community events,
and school- and agency-based enrollment events.
• The ABC Project enrolls children in health insurance programs in South
Central Los Angeles and Long Beach. The project informs families about
available health insurance programs and provides application assistance for
Healthy Families, Medi-Cal, California Kids, AIM, Kaiser Cares for Kids, as
well as referrals to the CHDP program. The project offers follow-up services
through case management for enrollees to ensure that they understand how
to effectively use the health benefits. The ABC Project conducts outreach in
collaboration with local schools, community clinics, community-based
organizations, hospitals, WIC sites, and churches. At each of these sites, the
ABC Project has established "outstations" where an outreach worker usually
spends one half-day per week. Project staff follow up with enrollees at 30-,
64-, and90-days to ensure that they are effectively using their health benefits
and to answer questions or provide other assistance relating to their health
benefits.
a The Healthy Families Outreach Campaign of El Concilio seeks to
maximize health care access for children and families in San Joaquin County,
including Increasing enrollment into stag-sponsored children's health
insurance programs. El Concilio is a nonprofit social services community-
based organization in Ban Joaquin County which focuses its outreach at
schools, community partners, faith community, ethnic and cultural outreach,
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PACIFIC HEALTH CONSULTING GROUP LLC
106
employers, smallbusiness, health fairs and special events. The campaign
uses enrollment events, geographic canvassing and residential outreach, in-
office appointments and enrollment assistance at fixed sites., and home visits
to conduct outreach in each focus area. Lodi Unified School District, in
partnership with El Concillo, uses the School Lunch Program/RFI mailing
effort as one school-based strategy to enroll children into state-sponsored
health insurance programs. Interested parents return the RFI to the school
with their child and the school sends the form to the district school nurse, or
the parents can call the district school nurse. The district nurse reviews the
RF4 and sends the form to the Lodi Community Center. At the Community
Center, a representative from EI Concilio then contacts interested parents to
answer questions, schedule an appointment for application assistance, and
help parents complete the children's health insurance application forms.
In addition, the successful implementation in Santa Clara and San Francisco counties of
an insurance product for children who do not qualify for Medi-Cal or Healthy Families
called Healthy Kids has allowed more children to be enrolled in both Medi-Cal and
Healthy Families as well as the new insurance product. By enabling all families to
participate regardless of immigration status and other factors, all children in a family can
be enrolled in a seamless system of insurance. One child may be on Medi-Cal, two on
Healthy Families and one on Healthy Kids. Contra Costa County's recent expansion of
the Basic Adult Care program to include children in the Basic Health Care program
should result, if enrollment strategies follow, in more children enrolled in Medi-Cal and
Healthy Families as they are screened for Basic Health Care.
The following inventory was created to capture what is happening statewide vis-a-vis
outreach, enrollment, and retention for Medi-Cal and Healthy Families and to identify
changes made by Social Services to aid these efforts. Efforts underway are usually
within' health departments, at community' health centers, at, community-based
organizations and at local Medi-Cal managed care health plans and schools. This
survey was conducted as a part of this project specifically for Contra Costa County. It
was done in April and May 2002 in telephone interviews.
Questions asked included:
1. What specific outreach activities are you currently engaged in? How are they paid
for? What kinds of targets (numbers) or results are you hoping to achieve? Do you
have a collaborative community-wide to work on this project?
2. Who does enrollment for Healthy Families and where is it done? Can Medi-Cal only
be done by Social 'Services? How do your enrollment assistants help get people to
Medi-Cal? How do you track your success at enrollment? Hoe many people are
doing this? Do you have any standards for their performance or productivity?
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PACIFIC HEALTH CONSULTING GROUP LLC
3. Hove do you measure retention? What specific strategies do you use to track and
monitor and follow-up on retention?
4. What kind of tracking system do you use? Have you used the Consumers Union's
Healthy Tracker system?
5. How has Social Services changed what and how they do enrollment?
Page 38
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Ill. Contra Costa County System for Outreach
Enrollment and Retention
A. organization Structure, Transition, Staffing and Budget
The Contra Costa County Outreach and Enrollment program has four main
components:
■ Contra Costa Health Services, which assists clients at public health clinics,
CHDR Mental Health, CCS and WIC, and financial counselors at county primary
care sites and the Contra Costa Regional Medical Center
• the Health Access Coalition, comprised of a range of community-based
providers, advocacy groups, and county agencies
■ Contra Costa Employment and Human Services Department, which uses its
Medi-Cal Eligibility Workers and Medi-Cal Advocates
• Health Assistance Centers at West Contra Costa Unified School District, La
Clinica de la Raza and the perinatal Council,
In addition, the Community Services Department has worked actively to ensure that all
eligible children in its day care programs are enrolled in Medi-Cal and:Healthy families.
Through extensive training of its staff and parent advocates and through the use of
additional Medi-Cal Administrative Activity {MAA} funds, the Community Services
Department has had good success in both enrolling and retaining its families in the
public insurance programs.
Contra 'Costa Health Services has coordinated the overall outreach and enrollment
effort, by creatine contracts with the three community-based Health Assistance Centers,
conducting enrollment and outreach activities through several Health Services programs
and community sites and staffing the Health Access Coalition. Employment and Human
Services carried out the Medi-Cal enrollment and application efforts as well as akey
focus on retention activities, while the Health Assistance Centers focused outreach and
enrollment activities in specific geographic areas of the county.
Contra' Costa Health Services has also assigned student worker Certified Application
Assistants to its primary care sites and public health sites, including WIC, on a regular,
part-time basis.
Each of the subcontractors was responsible for hiring and training; staff, conducting
outreach and education activities in the community, and providing enrollment assistance
to families. They were also encouraged to attend the Health Access Coalition meetings
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PACIFIC 'HEALTH CONSULTING GROUP LLC
to enhance information sharing and to obtain updates about Medi-Cal and Healthy
Families.
East County was targeted with two Health Assistance Centers because it was found
that there were a large number of eligible families and that while La Clinica had a strong
presence in Pittsburg, other East County communities needed more comprehensive
outreach. West Contra Costa Unified School District (WCCUSD) provided a school-
based outreach component.
The Consumers Union provided technical assistance to WCCUSD`s outreach efforts to
families who applied' to the Free or Reduced Price Meal' Program, a methodology shown
to be effective in reaching eligible families. This effort, with applications completed by
CCHS staff, resulted in a substantial number of requests for more information. Between
October 2000' and September 2001, over 500 Healthy Families applications and 158
Medi-Cal applications were completed.
La Clinica offered Healthy Families enrollment assistance to 186 individuals on site and
by telephone contact. There were 41 families assessed as eligible for Medi-Cal who
were referred to a Medi-Cal eligibility worker for application assistance. During the
project, an eligibility worker was outstationed to La Clinica to make this referral easier. A
La Clinica staff member is a certified enroller dedicated to eligibility screening and
application assistance on site at the Pittsburg clinic.
The Perinatal Council Health Assistance Center offered Healthy Families enrollment
assistance to 127 families and Medi-Cal application assistance to 16 families. Its
outreach worker and Perinatal Case Manager provided outreach, education, assistance
and follow-up to families in need of health care coverage from Pittsburg to Brentwood
and worked with the Antioch School District, receiving forms completed by all parents
when registering their children for school. The Perinatal Council staff telephoned or
mailed information to all parents. The Health Assistance Center in _Brentwood rents
space to other nonprofit agencies, all of which have Spanish-speaking staff and all of
which ask their clients if they have health insurance for their children. Why a client does
not have insurance, s/he is referred to the Perinatal Council.
Contra Costa Health Services has worked closely with schools with "Request for
Information" (RFI) packets for families enrolling in the Free or Reduced Price Meal
Program. Approximately 2,000 RFIs were distributed. Of 500 distributed at Meadow
Homes Elementary, 130 (26%) were returned. From these, 61 families were assisted in
enrollment and 69 already had health insurance.
Enrollment Sites
Participating enrollment sites in the Outreach and Enrollment Initiative include Antioch
Health Center; Brentwood Health Center; Concord Public Health Clinic; Pittsburg Health
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PACIFIC HEALTH CONSULTING GROUP LLC
Center; CIS, Richmond; Health an Wheels Van; Richmond Health Center; Center for
Health, Richmond; Stanwell Office, Concord; and Bay Point Health Center.
Curing an intensive period of outreach anj enrollment supported both by state and
foundation funding, the Outreach and Enrollment Initiative during 20011-2002 was able to
track its efforts carefully through the various sites of outreach and enrollment. As funds
have been reduced, bath outreach efforts and tracking have been reduced somewhat.
Specific data on this current period are not available at the same level;
Budget and Staffing'
The Medi-Cal Outreach/Healthy 'Famil'ies Program budget for FY 2001 -• 2002 was
$549,103. Most of it was in salaries — approximately $420,000 or 76%. Most of the
salaries were for enrollment specialists, outreach workers, and student workers -
$222,200, plus benefits. The next largest line item was subcontracts to community-
based organizations - $95,000 or 17%. General operating expenses, covering
communications, space, and materials, totaled' nearly $14,000; travel`was $2,000; and
indirect expenses were $14,750. The state contract funded $300,0001(55%) of the total
and the county general fund made up the difference.
The staffing pattern includes
■ 5 student workers half-time
■ 3 community health workers working 32 — 40 hours
• 1 temporary Health Education Specialist
■ 1 clerk doing data entry
w 1' program manager.
Transition
Midway through 2001-2002, the Outreach and Enrollment initiative made the structural
transition from Contra Costa Health Services Administrative Unit to Public Health's
Family, Maternal and Child Health Programs. This change in the program's oversight
was intended to strengthened its efforts and to tie the outreach and enrollment program
more closely to other public health outreach activities. The Public Health Department is
focusing on better integration with other programs in order to institutionalize the effort.
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PACIFIC HEALTH CONSULTING GROUP LLC
IV. Assessment
The assessment of the Contra Costa Medi-Cal and Healthy Families outreach and
enrollment effort began with a series of interviews with key personnel involved
throughout the county.
A. People Interviewed
■ Sandy Baldwin, Employment and,Human Services Department, Medi-Cal Policy
■ Stephan Betz, County Administrator's Office
■ Wendel Brunner, MD, Director, Public Health
■ Milt Camhi, Director, Contra Costa Health Plan
■ Linda Crippen, CaIWORKs Program Analyst, Martinez
Mary Foran, Assistant Director, Contra Costa Health Services
• Pat Godley, Chief Financial Officer, Contra Costa Health Services
■ Paula Hines, CHDP Program, Public Health
Rebecca Kalfos, Community Services Department
■ Jeanette Lopez, Mental Health Financial Counseling, Antioch
■ Lorena Martinez-Ochoa, Project Manager, Outreach and Enrollment Initiative, Public
Health
■ Nancy McCauley, Director of Marketing, Contra Costa Health Plan
■ Cheri Pies, FMCAH Director, Public Health
■ Christina Reich, Community Services Department
■ Wanda Session, Financial Counseling, Contra Costa Health Services
■ Tom Tingley, Division Manager, Employment and Human Services Department
B. Key Findings
The County of Contra Costa, the 'Board of Supervisors and particularly the Contra
Costa Health Services and Employment and Human Services Department are to be
commended for taking a leadership role statewide in promoting and implementing
outreach, enrollment and retention efforts as well as the recent major change in
expanding the Basic Adult Care Program to include uninsured children, now called
the Basic Health Care Program.
■ Given impending and somewhat unknown fiscal constraints because of the state
budget and the overall state economy over the next two years, it is essential to
maintain and sustain the progress that has been made in the county's outreach,
enrollment and retention programs as well as the expanded access to care
programs.
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PACIFIC HEALTH CONSULTING GROUP LLC
• Maintaining progress that has been made is essential.
• There is currently no clearly articulated vision of how the Outreach & Enrollment
program should operate and how its segments can be integrated', reducing
fragmentation throughout the; county. Clients must often work with multiple staff in
different departments involved in the system of enrollment and coverage.
= The outreach and enrollment effort needs to be incorporated into the infrastructure of
the Contra Costa Health Services and integrated into all programming provided.
Currently, this is not the case.
• Ongoing concerns about consistent funding willexist as long as the outreach and
enrollment effort is not integrated into the daily operations of the Contra Costa
Health Services.
= Given impending and potential funding cuts for this type of activity,there appears to
be some reluctance to consider increasing further integration, particularly in a time of
budget cuts, reduced funding and increased responsibilities for staff. Participating
staff are fully committed to the enrollment effort and to ensuring that all children are
screened and enrolled' in the appropriate insurance or coverage program.
Participating staff are also concerned about the lack of both continuity in enrollment
efforts and the coordination of those efforts.
= Outreach events are helpful in raising awareness about Healthy Families and Medi-
Cal. Public events are also effective in spreading the word about 'programs but are
not proven effective enrollment tools. They should by chosen carefully, given
available resources. Applications require extensive documentation for enrollment,
which families were not prepared to do at public events. Only 10% of people who
received one-to-one contact at a public enrollment events returned for an
appointment.
= Retaining families on health coverage requires as significant a planning effort as
outreach and enrollment. Families have financial constraints and competing priorities
which result in non-payment of premiums or lapse in coverage. They don't always
understand how health insurance works or how to keep track of paperwork. Some
families do not value preventive health care in the same way as urgent care. Others
never use health services and see no value in paying insurance premiums.
Outreach, enrollment and retention strategies implemented in other CCHS
programs, need to tie coverage to service utilization. This education of the clients
can be done at various venues, such as clinics, through home visitors, and
community partners.
= The Health Access Coalition has established a strong collaborative relationship
between Contra Costa Health Services and the community-based organizations.
Collaboration allowed the sharing of resources, facilitation of referrals and
successful coordination of outreach activities. This effort should continue.
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PACIFIC HEALTH CONSULTING GROUP LLC
_ Collecting relevant data and tracking ,whether families who were assisted actually
were enrolled is a major challenge. A database designed to document all outreach
and enrollment efforts was created in 2000 and was in place at the start of this audit.
In January 2002, the database was adapted to better capture the data being
collected and reports to be generated. However, it does not link to the State Healthy
Families or Medi-Cal programs. Through the database, the number of individuals
assisted to enroll in Medi-Cal and Healthy Families can be tracked, but not the
number of actual enrollments.
= The use of part-time students workers for outreach and enrollment, often placed at
the county clinics, may not be the most effective use of staffing at this time. A more
unified approach coordinated with the financial counselors would be more effective
at this juncture.
■ Planning needs to take place to be ready to implement the CHDP Gateway program
in conjunction with outreach and enrollment efforts, driven by the state's timing.
= With the expansion of the Basic Health Care program to children, enrollment should
be focused on the point of service at the county clinics and coordinated by the
Financial Counselors.
■ Coordination and communication among CCHS, Community Services Department
and EHSD on enrollment efforts can be stronger. There is no doubt that Contra
Costa Health Services is working more closely with the Employment and Human
Services Department than ever before. The Medi-Cal Advocates working for the
Employment and Human Services Department received many referrals of families
who had recently lost their coverage or were in danger of imminently losing
coverage, and were able to many families retain their Medi-Cal coverage.
Communication has not been regular and on-going due to time and financial
constraints.
_ Between July 1, 2001 and March 31, 2002, the County's program assisted with
1,265 Healthy Families forms, 814 Medi-Cal applications, 71 annual forms, 44
California Kids forms, 20 Kaiser Gare for Kids forms, 12 "Add Child" forms, and 2
AIM applications.
V. Recommendations for Change
The following planning assumptions were used to develop the recommendations for
change. They are based on best practices, the current California budget environment,
and the findings from the assessment.
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P.►CiFIC HEALTH CONSULTING GROUP ILC
A. planning Assumptions
FA Having health insurance and access to health care services is a key determinant of
goad health for children, The County of Centra Costa shouldembrace this concept
in every possible way, at every point of entry for children into the system.
■ There are four key components to a successful health insurance program:
1. outreach to eligible individuals without insurance or without adequate
insurance,
2. enrollment of eligible individuals/families into the most comprehensive
insurance program available,
3. retention of enrolled individuals/families in insurance and
4. access to and utilization of health care services for those who enroll.
The Medi-Cal/Healthy Families outreach and enrollment program needs to be
integrated fully in;an ongoing way into the infrastructure of the Contra Costa Health
Services and into ,ether relevant departments throughout county government.
Building ongoing outreach, enrollment and retention efforts into the infrastructure of
the county's programs should be the goal of this effort. As new children enter the
system, whatever the system may be, regular ongoing pro-active'measures should
assure that families have been screened, children enrolled in rine of the public
coverage or insurance programs, and utilization of services secured.
The key points for integrating this effort are Contra Costa Health Services —
Financial Counseling, Public Health, Contra Costa Health Plan, Mental Health
Services, Community Services Department, and Employment and Hinman Services
Department,
• State funds that currently support a majority of the outreach and enrollment activities
will probably not continue. They will either be dismantled totally,in the impending
state budget or be reduced dramatically. Reliance on these funds to support this
program's sustainability cannot be counted on.
• Every client accessing any type of services in the county, but particularly in Health
Services or EHSD, should be asked whether or not he/she has health insurance. If
the answer is "no", the client should be screened for the appropriate program at that
time.
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101AIC1F1C HEALTH CONSULTING GROUP LLC
■ Utilization of health care services is an important ingredient in retaining health
insurance. Point of service enrollment at county and community clinics should be a
priority. "In-reach" for existing clients has proven most successful in other counties.
■ The recent expansion of the Basic Adult Care program to children, now called Basic
Health Care program, will allow children to be screened at the point of service in
county clinics. If they do not qualify for Medi-Cal or Healthy Families and are
income-eligible, they can be enrolled in the Basic Health Care program. This allows
Contra Costa County to have options for the full range of children's situations. With
these programs now in place, integrated paint of service enrollment and aggressive
retention activities should be the center point of the new program.
B. Recommendations
1. In its past decisions, Contra Costa County's Board of Supervisors has
consistently committed itself and the County's resources to ensuring access to
health care services for all children and enrollment in appropriate health
insurance and health coverage programs. The integration efforts that follow
would be 'supported if the Board of Supervisors reiterate, at this time, its long
standing support for access to health services for children, both through health
programs and outreach and enrollment.
2. All outreach, enrollment and retention activities should be built into the existing
infrastructure, particularly in the Contra Costa Health Services and Employment
and Human Services Department. While state and other grant funds should be
used to support these efforts when available, the efforts need ongoing
operational'support in an integrated way. Responsibilities for different segments
of the health insurance access effort' should rest with already 'existing and
appropriate agencies within Contra Costa County in order to increase stability of
the program.
3. A regular county position of health 'insurance/access coordinator should be
established' to coordinate and facilitate all insurance enrollment and retention
activities, county information updates and training on public-sponsored health
insurance activities, expansion of coverage, etc. This position should have
appropriate access to decision-making authorities so that barriers can be
addressed, problems solved, and successes promoted countywide. The Health
Insurance/Access Coordinator.
■ should be located in Public Health;
• should facilitate a Steering Committee composed of the appropriate
representatives from Financial Counseling, EHSD, CCHP, Mental Health,
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Community Services Department and Public Health -- each of whom have
responsibility for segments of the health insurance activities;within the county;
should facilitate and organize the Health Access Coalition as well as report to
other county committees, commissions and advisory groups that would
benefit from information and advocacy about related health insurance
committees. Careful consideration about how the Health Access Coalition
links and intersects with Public Environmental and Health Advisory 'Board's
(PEHAB) Access to Care Committee should be 'reviewed with consideration
given to establishing the Health Access: Coalition as a subcommittee of
PEHAS, which is appointed by and reports directly to the Board of
Supervisors;
■ should be responsible for organizing the county's ability to track outreach
activities, enrollment targets and retention targets;
■ should implement a tracking system similar to the Consumer Union's Tracking
Program for Health Families as soon as possible, adapting the current
database, and incorporating all the programs and divisions under the same
Entity Number to share information more effectively; this work must be
coordinated with the Mate, which must provide better data;
R should be responsible for implementing an ongoing countywide education and
training program on insurance activities and work closely with the enrollment
efforts of the Financial Counselors, the retention efforts at CCHP, and EHSD.
4. A Steering Committee of Public Health, EHSD, CHAP, CCHP, Mental Health,
Community Services Department, financial counselors should meet regularly - at
least monthly - to identify key barriers in the system, analyze system difficulties,
problem-solve and monitor integration. It should report regularly to the Health
Access Coalition and to senior staff at CCHS and EHSD.
5. ,QLAreach to the uninsured target populations representing the core public health
function of access to care should remain in Public Health, with monitoring by the
Health Insurance/Access Coordinator.
■ Outreach should be accomplished through the variety of public health
programs such as CHDP, Family PACT, PCC, CPSP, WIC, community
education, prevention and wellness programs, public health nursing, and
home visiting, etc.
■ Public Health managers of these programs should work closely with the
Health Insurance/Access Coordinator on these efforts.
r Each of these programs should be equipped to conduct application
assistance, outreach, education on access and enrollment for any client in
need`.
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PACIFIC HEATH CONSULTING VRVUP LLC
• These programs should be required to provide data to the data tracking
component of the program.
6. Enrollment of individuals/families in insurance programs should be coordinated
by and be the responsibility of Financial Counselors through the county clinics
and hospital. With each expansion in health insurance or health coverage
programs (Healthy Families, Healthy Families to Adults, BAC to Basic Health
Care), the financial counselors are continually updated on the technical
information necessary to assist clients. They are also located at the service
delivery points of entry at the health centers where both enrollment and access
can be accomplished.
■ The current Healthy Families. Enrollment Assistors/CAAs located in the health
centers should be reassigned to report to the Financial Counselors with whom
they already interact regularly.
■ Some Community Health Workers can be integrated into other Public Health
programs such as CHAP, WIC, Clinical Services or CCHP, to enhance the
capacity of those programs to assist with enrollment and retention.
■ Some administrative interns and student workers can be assigned to work
with Financial Counseling, when available.
With the changes occurring soon in CHDP, Public Health must work to
redesign efforts in CHDP to incorporate enrollment strategies at CHDP
provider offices.
■ Employment and Human Services Department, through all of its programs,
should continue its aggressive enrollment of eligible clients in the Medi-Cal
program and when possible should also enroll eligible clients in the Healthy
Families program. Legislative changes about who can enroll children in
Healthy Families and assurance from the state that current funding to provide
for additional staff needed to expand to Healthy Families enrollment are
essential to this change.
o EHSD should engage with Health Services in training related to all
aspects of improving access to health care services, including
comprehensive knowledge of Healthy Families, Basic Health Care, etc.
o EHSD's involvement in the Health Access Coalition is essential.
o Bay Area counties have made a proposal for Medi-Cal families with Share
of Cost, supported by the Medi-Cal Policy Institute: if the family wants to
enroll in Healthy Families, social services workers should be able to
determine eligibilityand fee collection for premiums. Contra Costa County
should actively support this effort.
o EHSD's Medi-Cal Advocate positions should be continued to assure its
continued ability to maintain aggressive enrollment.
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PACIFICHEALTH' CONSULTING GROUP LLC
7. Retention of members on public health insurance programs can be most
effectively organized by the Member Services Department at Contra Costa
Health Plan. The vast majority of the clients enrolled are managed by CCHP
including those on Basic Health Care. Among the key responsibilities of the
health plan are the education of members on how to use the health care system,
health education and retention of members in the plan, For those children who
are not CCHP enrollees, it will be important to use the Health Access Coalition,
and use the Coalition to share best practices.
• In addition, CCHP' should continue to take an active role in sponsoring health
fairs and enrollment activities in coordination with Public Health and include
such information in their health education materials and newsletter.
• Basic health education can include consumer education about how to use the
Contra Costa County health system, how to make an appointment, whom to
call for questions, etc., encouraging people to use the health system.
8. The Community Services Department's CAAs and parent advocates, who assist
families with applications, should continue to be integrated into ongoing
education and training with the Health Access Coalition.
9. The Health-e-app is already being implemented in Contra Costa County's
outreach and enrollment effort. It should be utilized to every extent possible in all
community-based as well as county entry points.
10. An emphasis should be placed on Point of Service Enrollment, using the
opportunity at the time of service at county clinics, community clinics and soon at
private providers offices through the CHDP Gateway Program to enroll eligible
children by on-site screening and enrollment or in the case of the private provider
offices by a "quick phone linkage" to enrollment workers.
11. At every available outreach or enrollment contact, information and
encouragement about using health services should be another priority of the
contact. Materials about available services, information about how to make
appointments and when should be key to the encounter.
12. Advocacy by the Board of Supervisors and every relevant county department will
continue to be necessary to promote changes in the Medi-Cal and Healthy
Families'programs to ensure easier access for eligible children and adults.
13. As resources are declining, the best possible return on investment seems to be
the integration of outreach and enrollment activities, the enhancement of
retention strategies, and the ability to track progress throughout the county's
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PACIFICHEALTH CONSU'LTIN'G GROUP LLC
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departments. Key to the integration is the effective working together of the
Steering Committee and thee departments' leadership.
The following organizational chart describes the functional analysis of the
recommendations provided.
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V1. Bibliography
California State Department of Health Services. Streamlining Application and
Enrollment for the Healthy Families Program and Medi-Cal for Children. June 2001.
Children Now. California County Data Book 2001.
Children's Health Campaign: Promising Ideas in Children's Health Insurance, May
1999.
Community Health Councils, Inc. Health Insurance and Health Services: A Consumer
Education Curriculum. April 2000.
Consumers Union. Healthy Kids Make Better Learners: A Guide to School-Based
Enrollment in State-Sponsored Health Insurance Programs, 2001.
Amy Cox, Jacob Klerman and Ingrid Happoldt. Medi-Cal After Welfare Reform:
Enrollment Among Former Welfare Recipients. Medi-Cal! Policy Institute Issue Brief
Number 4, December 2001.
Peter Cunningham. Targeting Communities With High Rates of Uninsured Children.
Health Affairs. Web Exclusive.
Families Foundation. One Step Forward, One Step Back.
Jocelyn Guyer, 'et.al. Missed Opportunities: Declining Medicaid Enrollment Undermines
the Nation'sProgress in Insuring Low-Income Children. Center on Budget and Policy
Priorities. October 1999.
Kaiser Commission on Medicaid and the Uninsured. Enrolling Uninsured Low-Income
Children in Medicaid and SCHiP. Key Facts. May 2002.
Peter Long. Local Efforts to Increase Health Insurance Coverage among Children in
California. Medi-Cal Policy Institute. February 2002.
---. County Efforts to Expand Health Coverage among the Uninsured in Six California
Counties. Medi-Cal Policy Institute. February 2002.
Cindy Mann. The Ins and Guts of Delinking: Promoting Medicaid Enrollment of Children
Who are Moving In and Out of TANF System. Center on Budget and Policy
Priorities. March 1999.
- Reaching Uninsured Children Through Medicaid: If You Build it Right, They Will
Come. Kaiser'Commission on Medicaid and the Uninsured. June 2002.
Carolyn Schwartz and Earl Lui, The Link Between School Performance and Health
Insurance: Current Research. Consumers Union. October, 2000.
Medi-Cal Policy Institute. The Impact of the Proposed 2002-03 Budget on Medi-Cal and
the Healthy Families Program. March 2002.
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` PACIFIC
' HEALTHCONSULTING GROUP LLC
--_. Opening the Door: Improving the Healthy Families/Medi-Cal Application Process.
October 1998.
---.
Using Market Research to Improve Enrollment of Families Eligible for Medi-Cal and
Healthy Families, March 2002.
Nalini K. Pande. Improving Retention in the Medi-Cal and Healthy Families 'Programs.
Meeting the Challenge. Successful Strategies for Healthy Families, Medi-Cal and
Other Health Coverage Outreach and Enrollment Initiatives. Presentation. May
2002.
UCLA Center for Health Policy Research. 2001 California Health Information Survey.
June 2002.
UCSF Institute of Health Policy Studies. Barriers to Enrollment in Healthy Families and
Medi-Cal: Differences by Language and Ethnicity. Policy Brief 3, February 2001.
US Census Bureau. Table DP-3: Prefile of Selected Economic Characteristics 2000, for
Contra Costa County.
US Department of Health and Human Services. The State Children's',Health Insurance
Report: Annual Enrollment Report. October 1; 1998 — September 30, 1999.
Jill M. Yegian, Why Don't More Small Businesses Offer Health Insurance? Summary
Report on the California HealthCare Foundation/Mercer Survey. California
HealthCare Foundation. March 2002.
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PACIFIC HEALTH CONSULTING GROUP LLC
ANk
Endnotes
1 Kaiser Commission.
Children's Defense Fund. Accessing Health Services:Moving Beyond Enrollment.
3 Margaret Edmunds and Molly Joel Coye, Editors. America's Children: Health Insurance and Access
to Care. Institute of Medicine. 1897.
4 Children Now, California's Working Families and Their Uninsured Children:A Big Problem with an
Affordable Solution. 2000.
s Margaret Edmunds and Molly Joel Coye, Editors. Op.cit.
s
Cathy Schoen and Catherine DesRoches. New York City's Children:Uninsured And At Risk. Findings
from The Commonwealth Fund Survey of Health Care in New York City, 1997.The Commonwealth
Fund, May 1998.
Margaret Edmunds and Molly Joel Coye, Editors,America's Children:Health Insurance and Access
to Care. Institute of Medicine. 1997.
8 Children's Defense Fund.Accessing Health Services:Moving Beyond Enrollment-
9 Urban Institute.
10 Margaret Edmunds and Molly Joel Coye, Editors. Op.cit.
" Urban Institute.
12 Urban Institute.
13 Wirthlin Worldwide Survey of American Families: Comparison of Household with insured children vs.
uninsured children eligible for SCHIP/Medicaid Coverage.
14 Wirthlin Worldwide Survey of American Families: Comparison of Household with insured children vs.
uninsured children eligible for SCRIP/Medicaid Coverage.
is Wirthlin Worldwide Survey of American Families: Comparison of Household with insured children vs.
uninsured children eligible for SCHIP/Medicaid Coverage.
16 Margaret Edmunds and Molly Joel Coye, Editors. Op.cit.
17 Urban, Children eligible for Medicaid but not enrolled: How Great a Policy Concern?
'B Stoddard et al. May 1994, New England Journal of Medicine.
19 Kaiser Commission.
20 Cathy Schoen and Catherine DesRoches. New York City's Children:Uninsured And At Risk. Findings
from The Commonwealth Fund Survey of Health Care in New York City, 1997. The Commonwealth
Fund, May 1998. Health status measures are based on parent's rating of their child's health.
21 Margaret Edmunds and Molly Joel Coye, Editors. Op.cit.
22 Margaret Edmunds and Molly Joel Coye, Editors. Op.cit.
23 Margaret Edmunds and Molly Joel Coye, Editors. Op.cit
24 Margaret Edmunds and Molly Joel Coye, Editors. Op.cit
25 Children's Defense Fund:Accessing Health Services: Moving Beyond Enrollment.
28 Urban Institute.
2' Urban, Children eligible for Medicaid but not enrolled: How Great a Policy Concern? and DHS CDC
data on immunizations.
28 Wirthlin Worldwide Survey of American Families: Comparison of Household with insured children vs.
uninsured children eligible for SCHIP/Medicaid Coverage
29 Wileawski, Irene, "Gouging the medically uninsured: a tale of two bills." Health Affairs,
September/October 2000.Vol. 19, No. 5 pp. 180-185.
30 The federal poverty line is $18,1000 for a family of four in 2002, as reported in the Federal Register
for Department of Health and Human Services programs. htto://aspe hhsgov/poverty/02poverty htm,
31 California State Department of Health Services. Streamlining Application and Enrollment for the
Healthy Families Program and Medi-Cal for Children. June 2001.
Page 59
'0
ASSOCIATES, 1N .
HEALTHCARE FINANCIAL CONSULTING
140 Gregory Lane,Suite 230 a Pleasant Hill,CA 94523.3395
925.685.9312 Fax 925.687.9613 IN www.toyonassoc[ates.com
March 21, 2002
Mr. Pat Godley
Chief Financial Officer
Contra Crista Regional Medical Center
20 Allen Street
Martinez, CA.94553
RE: Medicare &Medi-Cal Cost Report Review
FYE 6130/00
Dear Pat.
Enclosed is the Report of Findings for our review of Contra Costa Regional Medical Center's
FYE 6130/00 Medicare and Medi-Cal cost reports. The Report of Findings only addresses
material errors or discrepancies. The review was intended to disclose both positive and.negative
items. We have previously,provided a point sheet noting all our observations,as well as the
CAME and IME reimbursement impact computations for the intern/resident FTE issue.
The Reimbursement Department has done a commendable job with the preparation of the
Medicare and Medi-Cal cost reports. Overall, the data inputted on the cost report were well
documented.
After you:have reviewed the enclosed report,'let us know if you have any questions.'
Sincerely,
Tim Yuen
Vice President
Enclosure
S hVah-ccclpgOOCRfindingttr
a,
R<:
Contra Costa Regional Medical Center
Report of Findings
Basedon Review of the"As Filed" Medicare & Medi-Cal Cost Reports
FYE 6/30/00
Background
The Medicare and Medi-Cal "as filed" cost reports were reviewed to determine whether they
contained any material errors or discrepancies. The review was intended to disclose both
positive and negative items. The Medicare and Medi-Cal "as filed"cost reports claimed
$64,260,884 in reimbursable costs from the State and Federal programs.
Findings/Observations
MEDICARE
1. Disproportionate Share Hospital (DSH)
Based on our review of the Medicare disproportionate share amount(DSH), we noted the
following:
A. Assessment of Medicaid Days
For the preparation of the"as filed" cost report, the hospital used readily available census
information for reporting Medicaid days for the Medicaid utilization ratio of the DSH
computation. Upon receipt of the Notice of Program Reimbursement(NPR), the Hospital
should do additional analysis of patient financial and statistical data in identifying
additional Medicaid days. Since the issuance of HCFA Ruling 97-2, Medi-Cal days can
include more than just paid days.
Under HCFA Ruling 97-2,CMS, formerly HCFA, acquiesced on its long-standing
interpretation of the Medicaid ratio. Historically, CMS contended that Section 1886
(d)(5) (F) (vi)(11) of the Social Security Act required only those days for which a hospital
received Medicaid payment to be included in the Medicaid ratio. Under HCFA Ruling
97-2,all inpatient days of service for which a patient was eligible for assistance under a
State Medicaid plan,whether paid or unpaid should be included in the numerator of the
Medicaid ratio.
In his memorandum of June 12, 1997, Charles Booth, Acting Deputy Director at the
Bureau of Policy Development at CMS, clarified details of HCFA 97-2 He states in part,
"The definition of Medicaid days for purposes of the Medicare disproportionate share
adjustment calculation includes all days that a beneficiary would have been eligible for
Contra Costa Regional.Medical Center FYE 6/30/00
# Report of Findings Page 2
Medicaid benefits,whether or not Medicaid paid for any services. This includes,but is
not limited to days that are determined to be medically necessary but for which payment
is denied,days that are determined to be medically unnecessary and for which payment is
denied, days that are utilized by a Medicaid beneficiary prior to an admissionapproval,
days that are paid by a third party, and days that an alien is considered a Medicaid
beneficiary, whether or not it is an emergency service."
We recommend that the Hospital prepare the required analysis to identify additional
Medi-Cal days for the following categories:
1. Partial denied days where Medi-Cal (regular and HMO)is the primary payor,
2. Total denied days where Medi-Cal (regular and HMO) is the primary payor;
3. Days in which Medicaid is the secondary payor,but the primary payor(excluding
Medicare Part.A)paid the claim; and
4. Medicare Part B/Medi-Cal Crossover days.
For FYE 6/30/00, for every additional 1,000 Medi-Cal days, D H reimbursement would
increase by$134,000.
B. Labor Room Days
For the Medicare cost report, total patient days are to be reported net of labor room days.
Based on my understanding, the Medicare Intermediary has concluded that the Hospital
does not have any labor room days. For all prior periods, as well as the period in review,
labor room day has been a non-issue and the cost reports were properly prepared.
In a review of the patient daily census summary,there were 1,584 days for Nursing Unit
5A, which are entitled L&.D/R.ecovery/Post Parturn. We recommend further review of
the days for Nursing Unit 5A,since it may be an unit similar to an Alternate Birth Center
(ABC),where all three functions(labor&delivery,recovery and post partum)are
performed in the:sa. a nursing unit; If similar,the Medicare intermediary will want
labor room days to be identified and excluded from the Medicare cost report.
2. Medicare I/P and O/P Bad Debts
There was no inpatient bad debts reported on the Medicare cost report and outpatient bad
debts of$2',00,000 was an estimate based on the prior year's experience. The Hospital
utilizes a consultant to inin computer-matching program to eterminea e ts. o
supporting workpapers were available at the time of our review.
r
In discussions with hospital management, it is our understanding that the Consultant
engaged to compile Medicare bad debt information has only recently provided the
information to the Hospital. The Hospital has filed or will be filing an amended cost
report to claim the following amounts as bad debts:
Contra Costa Regional Medical Center FYE 6/30/00 .
Report of Findings Page 3
Inpatient Acute $214,004
Inpatient Psych 45,000
Outpatient Acute 147.000
$406,000
The Hospital normally files its claim for bad debt reimbursement during the field work of
the cost report audit in order to ensure that bad debts for all Medicare paid patients,
including those identified after the cost report was initially filed, are included in the
claim.
3. Intern/Resident FTEs and Prior Year Resident-To-Bed Ratio
The number of intern/resident FTEs for the computation of the three-year rolling average
was not completely reported for the TME(Worksheet E,Part A) and GME(Worksheet E-
3,Part IV)computations. On the point sheet, I have provided the intern/resident FTEs to
be reported based on a review of the audited FYE 6/30/99 Medicare cost report. Also,
the prior year resident-to-bed ratio is .198142 rather than .227757.
In discussions with hospital management, the prior year resident-to-bed ratio
overstatement was due to a loss of intern/resident FTEs for"intern/resident overlap"
with another hospital. An inter-/resident overlap occurs when two or more hospitals are
claiming the same resident(s) for the same period(s). If the hospitals cannot agree as to
who get the resident, neither hospital will get to count the resident(s). This occurred for
FYE 6/30/99 and has resulted in the Hospital's overstatement of prior year resident-to-
bed ratio.
As reported, TME and GME entitlements are overstated by$91,000 and$41,000,
respectively.
4. Medicare Capital Exce
ption Payment
The Hospital did not report the carryover of accumulated capital minimum payment over
capital payment on line 11 (Worksheet L, Pt. TV). The amount to be reported is
$173,365.
This has resulted in exception payments being overstated by$173,365.
Centra Costa Regional Medical Center FYF 6/30/00
. port of Findings Page 4
5. JCN Beds-IME
The Hospital did not include the six ICN beds on the cost report': The ICI beds need to
be included with ICV beds in the computation of IME entitlement.
For FYF 6/30/00, the inclusion of the six ICN beds as available beds would decrease
IME reimbursement by approximately$31,000.
MEDI-CAL
1. Intern/resident Costs Understated
Tnte ,rresident casts on Worksheet B are not being included in computing the individual
cost-to-charge ratios on Worksheet D-4. There is a feature in the KPMG software that
must be activated when preparing the Medi-Cal cost report.
This has adversely impacted the CMSP,Administrative Day, and FQHC settlements, but
not considered material. The settlements have been reduced by the following amounts:
CMSP $ 225
Admin Day 48,713
FQHC 4.271
$53,209
2. Direct Assigned Capital Old and Old Capital E ui ment Statistics
The Medicare version was used and has resulted in no allocation of capital cost to FQHC.
This is estimated to reduce FQHC settlement by approximately$58,000.
3. LgweE of Cost—or-Chane(LOCOC)Restriction
The Hospital was subject to a$297,532 LOCOC restriction in its Administrative Day
settlement. The Hospital needs to raise its rate to avoid LOCQC restriction. This has no
reimbursement impact because the Hospital's routine cost is limited to the per diem rate.
4. FQHC - CN1SPPayment
FQHC--CMSP payments of$23,755 were excluded from the interim payments reported
in the FQHC cost report.
Contra Costa Regional Medical Center FYE 6130/00
Report of Findings P e 5 '
8 .
5. Administrative I?ay Settlement
The Administrative Day Settlement is overstated by$665,803 due to a flow-through
computation of the cost report software,which is not used for Medi-Cal settlement
purposes. The Medi-Cal Administrative Day settlement should only be for ancillary
services, since routine services are covered under a prospective rate. The settlement
should be a$10,840 liability rather than a$654,963 receivable.
Ancillary Reimbursable Costs $245,081
Ancillary Interim Payments 255,921
Cost Report Liability $ 10,840
Based on our understanding, the Hospital did not record any settlement on the books and
the$10,840 payable is considered immaterial for booking purposes. From a payment
perspective, the$10,840 liability due the State, at the time the cost report is filed, is not
considered material and subject to change upon completion of the Medi-Cal audit.
Conclusion
The MedicarelMedi-Cal cost reports are extremely complex in both preparation and regulatory
interpretation. We believe that hospital management has filed a combined cost report, which
reasonably reflects the costs to the third-party programs, and we have not identified any material
problems with the submission. We recommend the Hospital review the matters set forth in this
report to determine proper disposition.
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llfi`1__E Of THE DIRECTOR BOAPD Of SUP€RVISOPU
WILLIAM �. WALKER, AD,
Dme roR & HEALTH OFFICER { JOHN GrO}A, IST Disnicr
20 Allen Street T 1 k COSTA T L 1 G�AYLE 0.UIL MA, 2144 D46TttKT
Martinez, California — CONTRA{ DONNA CSERM€R, UD l`315TRILP
9455;3.3191 L ) MARx DiSAULNtER 4TR flIMICT
Ph (925) 370-5003 fEpERAt D.GLovEx. STH t3rsTatcT
Fax (925)370-5093COUNTY.Al7tvtiNISTRATOR
JOHN R. SWEETEN
.Date: May 6, 2002
To: Dorothy Sansoe,
Senior Deputy County Administrator
From: Patrick Godley N a
Chief Financial Officer
Subject: Medicare & Medi-Cal Cost Deport Review: FY 1999100
We have reviewed the Toyon report of findings for the Contra Costa Regional Medical
Center's Medicare and Medi-Cal Cast Report for 199912000 fiscal year.
Attached, you will find a detailed response to each of the consultant's
findings/observations. In Summary:
• The Medicare and Medi-Cal cost reports claimed $64,260,884 in reimbursable
costs from the state and federal programs.
The net reimbursement impact of each finding is as follows:
Medicare: Gan <Loss>
1. Disproportionate Share Hospital $ 100,004
2. Bad Debts 272,822
3. Interns &Residents <132,000>
4. Medicare Capital <173,365>
5. ICM Beds < 31,000>
Medi-Cal:
1. Interns &Residents 53,209
2. Directly Assigned Capital < 5g,000>
4. FQHC CMSP Payment < 23,755>
Total Potential Reimbursement 7
+ Contra Costa Community Substance Abuse Services + Contra Costa Emergency Medical Services + Contra Costa Environmental Health • Contra Costa Health Pian +
Contra Costa Hazardous Materials Programs +Contra Costa Mental Health + Contra Costa Public Health + Contra Costa Regional Medical Center + Contra Costa Health Centers +
..........................
-2-
The Toyon review was thorough, professional, and conducted in a timely manner. The
report disclosed no material errors or discrepancies in the cost report preparation or
submission..
Please feet free to contact me should additional information or clarification be required.
Attachments
Cc: William.B. Walker, M.D.
* Note: Subject to third-party audit
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MEDICARE
1. Disproportionate Share hospital (DSH)
IA.'Assessment-of Medicaid hays;
The Medicare Program reimburses Contra Costa.Regional Medical Center(CSC)
approximately$3.5 million per year based upon its Disproportionate Share Hospital
(DSH) status. One factor utilized in calculating the DSH amount is the number of
Medicaid (Medi-Cal in California) inpatient days rendered by CCRMC during the fiscal
period. The consultant's finding recommends that CCRMC review the final Notice
of Program Reimbursement(NPR) for FY 1999-2000 when the NPR is eventually
issued by the Medicare Intermediary. We concur with the recommendation and
have routinely conducted such review in prior periods. While CCRMC's inpatient
Prospective Payment System volume is modest(less than 1,000 discharges each year), it
is possible that the intermediary accidentally excluded some allowable Medicaid days
that could result in additional revenue.
IB. Labor Room Dam
In some hospitals, maternity patients are admitted to a "bed"in the labor and delivery
department, or to a "bed"in an alternate birthing center within the hospital, where they
are counted in the hospital census statistics even though they may not give birth for
several days or in some cases, are discharged without having given birth. Medicare
requires that this type of"labor room day"be excluded from the count of inpatient
service drays since the level of care provided to patients occupying such beds is typically
significantly less than the level of care rendered to patients occupying an acute hospital
bed. The consultant is recommending that we review the maternity unit statistics to
determine if `labor room beds" exist. No such "labor room beds" exist at CCRMC.
CCRMC does not count a patient service day unless the patient is admitted to an inpatient
bed on one of its' acute nursing units.
2. Medicare IIPand O/P Bad Debts
Medicare beneficiaries are expected to share in the cost of the medical care that is
provided to them.. Medicare has both an annual inpatient deductible amount that each
beneficiary is expected to pay and a 20% co-pay requirement on all outpatient and
physician services. In those cases where the hospital has unsuccessfully sought payment
-
these uncollected "bad debts". T'he consultant noted that there were no inpatient bad
debts reported on the Medicare cost report and that outpatient''bad debts were an
estimate based on the prior years experience. CCRMC employs an outside',firm to
compile the patient specific bad debt information required by Medicare. An outside
firm is used because they have the specialized computer software necessary to sort
l
through the State's Medi-Cal payment files to isolate and quantify the unpaid coinsurance
amounts related to only the facility component (hospital charge as opposed to MD
charge) for beneficiaries that have both Medicare and Medi-Cal coverage. Due to Medi
Cal reimbursement limitations, Medi-Cal will not pay the coinsurance amount if the
amount already paid by Medicare exceeds what Medi-Cal would pay if the beneficiary
had only Medi-Cal and they were the primary payer. As a general practice, in order to
ensure that the most current and complete listing,of unpaid claims is used, CCRMC does
not secure the bad debt information from that firm until just prior to the start of the
Medicare audit. The firm did supply CCRMC with the bad debt information for FY
99-00 in March 2002,prior to the start of audit fieldwork in kpril 2002.
3. Intern/Resident FTE
CCRMC has an accredited Family Practice Medicine Teaching Program in association
with the University of California at Davis,School of Medicine. To broaden their scope
of experience, part of the CCRMC teaching program involves these residents providing
services at locations other than CCRMC. The Medicare program reimburses hospitals for
the costs of their accredited teaching programs based upon the number of interns and
residents that participate in their program. If a resident is compensated by a facility,his
cost is reimbursed to that facility regardless of where he physically works. The
consultant noted that in the prior fiscal year, FY 1998-1999, another hospital
erroneously claimed a portion of the time of one of our residents, thereby precluding
CCRMC from receiving the full reimbursement it was entitled to. We were aware
of this situation and had worked with the other facility to correct their error. In
March 2002, CCRMC confirmed with Medicare that the other facility had finally
submitted the corrected data and that Medicare was now able to increase CCRMC's
reimbursement to the higher amount it was entitled.to.
4 Medicare Capital Exception Payment
During the nine year transition period from cost based reimbursement to a Prospective
Payment System(PPS) reimbursement of capital project and equipment costs,Medicare
pays for certain capital items based on the lower of(1)the amount of accumulated
depreciation since the inception of Capital PPS that would have been reimbursed had
Medicare not implemented Capital PPS or(2)the accumulated amount of capital project
and equipment payments that Medicare would make under the new Capital PPS
methodology. The consultant noted a discrepancy in the amount reported. The carry
over capital payment information from the prior year, FY 1998-99, Audited Cost Report
the FY 1999-2000 audit, the Medicare auditor will make: an adjustment to
incorporate the correct amount into the final audited FY 99-00 cost report.
5 Intensive Care Nursery(ICN)Beds—Indirect Medical Education(IME)
2
CCRMC operates six"Level 2"Nursery beds as part of its' licensure.. Level 2 beds,
while not providing as high a level of nursing care as an Intensive Care Nursery,do
provide a higher level of nursing care to newborns than is provided in a routine bassinette
setting. The consultant noted that the hospital did not include the sic ICN beds on
the cast report. This was the first coast report year that CCRMC had Level 2 beds in
operation. The consultant is correct in stating that these six beds were inadvertently
included with the routine nursery statistics on the filed cost report. As part of the FY
1999-2000 audit,the Medicare auditor will make an adjustment to incorporate the
correct amount into.
the final audited FY 99-00 cost report. We will also incorporate
this change into all future report filings.
MEDT-CAI.
Findine 1.Intern/Resident Costs Understated
The.Medicare and Medi-Cal Programs each require a cost report to be filed after the close
of each fiscal year. The reports are essentially identical except that the Medicare report
identifies the costs of providing services to Medicare beneficiaries,while the Medi-Cal
report identifies the coasts of providing services to ;Medi-Cal eligibles. There are a few
reimbursement areas where the Medi-Cal reimbursement principles differ slightly from
Medicare reimbursement principles. The consultant noted that CCRMC filed the bath
the Medicare and ]Medi-Cal reports based on the Medicare cost reimbursement
principals. We are aware that in doing so, some minor cost amounts are not included in
the initial claire. There is no reimbursement impact from doing so, since when the
audited cost report is prepared, the correct version specific to the Medi-Cal Program is
used, and any such excluded coasts are included in the final report. The hospital will
ensure that these coasts are included when the State auditor reviews the FY 99-00 Medi-
Cal cost report in May 2002, and we will utilize the software report version;specific to
each Program when filing reports in future years.
Finding 2,:Directly Assigned Capital
Same response as above.
Finding 3. Lower of Cost-or-Charge Restriction
eligibles to the lower of what a provider's usual and customary charges are for those
services, or the provider's cost of rendering those services. An Administrative lay,is an
inpatient day of service rendered by a hospital when there no longer exists a medical
justification for keeping the patient in an acute care hospital. This most often occurs
when a patient is well enough to be discharged to a facility that provides a lower level of
3
care,such as a Skilled Nursing Facility, but there are no open beds available in the lower
level of care facility. The consultant noted that CCRMC was subject to a lower of
cost or charge penalty. The consultant misinterpreted the cited section of the cost
report. CCRMC was not subject to a reimbursement loss dine to the cost—to-charge
restriction.
Finding 4. EQH C--CMSP Payment
CCRMC receives payments from the Medi-Cal Program for services that we rendered to
Medi-Cal eligibles. Additionally, the State serves as the fiscal intermediary for the
County Medical Services Program(CMP). Small counties have the option of either
operating their own Medically indigent Service Program, such as this county's Basic
Adult Care Program, or they may contract with the state to operate the program on their
behalf. When a county contracts with the State,the indigent care program is called
CMSP. The consultant found that when the Medi-Cal cost report was,prepared,a
small amount($23,755) of CMSP receipts were excluded from the$19.5 million of
interim payments reported as berg received on the filed report. The consultant is
correct, the CMSP receipts should have been included.
4
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