John Baackes Chief Executive Officer October 5 2016 What is LA Care Medi Cal Managed Care Plan serving LA County since 1997 Created by California State enabling legislation and LA County resolution ID: 711760
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Slide1
Health Care Delivery Innovation in the Safety Net
John Baackes
Chief Executive Officer
October 5, 2016Slide2
What is L.A. Care?
Medi
-Cal Managed Care Plan serving L.A. County since 1997
Created by California State enabling legislation and L.A. County resolution
Three state created options that serve most counties participating in
Medi-Cal Managed Care:L.A. County opted for Two-Plan model and L.A. Care was born as the Local Initiative, non-profit organization subject to public entity lawsStakeholder Board representing clinics, physicians, L.A. County, hospitals, and members
2
2 counties
22 counties
14 counties
Geographic Managed Care GMC)
Two-Plan
County Organized
Health Systems (COHS)Slide3
California’s Two-Plan Model
Two-Plan
Model
Counties
Alameda
Contra Costa
Fresno/Kings/Madera
Kern
Los Angeles
Riverside/San Bernardino
San Francisco
San Joaquin
Santa Clara
Stanislaus
Tulare
3Slide4
L.A. Care Mission and Vision
Our Mission
L.A. Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose.
Our Vision
A healthy community in which all have access to the health care they need. 4Slide5
Medi-Cal Enrollment - Pre –ACA to Current
California*
Los Angeles County**
% of
CA
Medi-Cal Population Residing in LA CountyL.A. Care**% of L.A. Care Medi-Cal Membership out of Total LA County Medi-Cal Population
Pre-ACA(2013)
7.8 million
2.26 million29%
1.15 million
50%
201613.61 million
3.81 million28%
1.97 million48%
% Increase
74%41%
42%
5
*Source: DHCS,
Medi
-Cal Monthly Enrollment Reports (MMCD) 2013 & 2016**Source: L.A. Care, Internal Membership Trend Analysis 2013 & 2015Slide6
L.A. Care Membership
Product Line
Enrollment
(August
2016)Medi-Cal1,939,606Temporary Assistance for Needy Families (TANF)1,055,061Medi-Cal Expansion 557,258
Seniors and People with Disabilities
160,524
Coordinated Care Initiative
166,763
Cal MediConnect (duals pilot)
12,620
L.A. Care Covered (Covered CA) +Direct
10,998PASC-SEIU
47,236
Healthy Kids481
TOTAL
2,010,941
6Slide7
L.A. Care Membership by Network of Providers
Provider
Membership Enrollment
(August
2016)
L.A. Care subcontracted Plan Partners962,560Kaiser191,803Anthem Blue Cross460,581
Care 1st (Blue Shield of CA)
310,176
L.A. Care delegated entities - 28
LA County Department of Health Services
~193K
Federally
Qualified Health Centers~280K
IPAs -26~504K
L.A. Care Directly Contracted Providers –
Antelope Valley
367
7
(August 2016 Medi-Cal Only Figures)
*Community
Clinics include FQHCs, Lookalikes, Other NonprofitSlide8
Who Is Not Covered In LA County?
8
Remaining Uninsured
Number
Medi
-Cal Eligible*270,000Exchange Eligible**337,000With subsidies153,000Without subsidies
184,000
My Health LA***
145,000Others**
601,000
TOTAL1.3 million
*Source: UCLA Center for Health Policy Research,
AskCHIS 2014**Source: Estimated using CalSIM data from UC Berkley Labor Center report, “Which Californians will Lack Health Insurance Under the Affordable Care Act?”***Source: L.A. County Department of Health Services, My Health LA Program Key Demographics and Enrollment SummarySlide9
Challenges for the Community
Access
Need more physicians in
Medi
-Cal and Covered CaliforniaEducation
Orient newly insured on how to use coverageMedi-CalCovered CaliforniaHoles in the safety netPovertyHomelessnessNutritionImmigration statusComprehensive Medi-Cal Funding StrategyACA non-recurring funds9Slide10
Growing Pains for L.A. Care
Complexity of populations served and increased risk
Tailored models of care for specific populations
Focused shift from well care to complex care
Organization structure
Infrastructure and work processes need to catch up with growthInternal audit, enterprise risk assessment, and single source for data management and analyticsAccountability unclearInsideOwners needed for accountability for population segment/product successOutsideDelegated entities need to be held accountable to increased scrutiny10Slide11
Strategic Vision – Launched 9/2015
To address growth at L.A. Care
Matrix structure
Operating plan
4 attributes, 16 initiatives
TechnologyNew operating systemOperational 8/15/16PerformanceIPA report cardsDirect network11Slide12
CHIEF
OPERATING OFFICER
CHIEF
MEDICAL OFFICER
CHIEF
FINANCIAL OFFICER
CHIEF
OF
ENTERPRISE INTEGRATION
GENERAL
COUNSEL
CHIEF COMPLIANCE
OFFICER
CHIEF
OF STAFF
Executive
Director,
CMC
& Medicare Ops
Executive
Director,
Medi
-Cal
TANF/ MCE
Executive
Director,
Medi
-Cal
SPD/ CCI
Executive Director,
Medi-Cal
Plan Partners
Executive
Director,
Commercial
Products
L.A. Care Executive Leadership Matrix
CEO
12Slide13
Strategic Vision (2015-2018)
13Slide14
IPA Scorecard
Medi
-Cal moving to value-based contracting
New CMS Medicaid Managed Care- Mega Rule
L.A. Care quality performance consistency mediocre
NCQA – Managed Care accreditation agency – score for L.A. Care droppingIPA scorecard ranks all 28 delegated entitiesProvides insight into opportunities for employment14Slide15
IPA Scorecard
Domain
Score
Weight
Access and
Availability0.00-1.0025HEDIS 0.00-1.0025
Member Satisfaction
0.00-1.00
20
Utilization
0.00-1.00
15
Encounter Timeliness
0.00-1.00
15
TOTAL
100
15Slide16
Access & Availability: 25%
Available Data Sources
Measures
Medi
-CalProvider Appointment Availability Survey (PAAS)
Reporting Year:2014Measurement Year: 2013Methodology: Independent vendor survey of office site responsesMeasures with most data and best reflection of IPA ManagementElements:
After-Hours Survey: Overall AccessEmergency
InstructionsMethod to contact provider
After-Hours Survey: Overall TimelinessProvider call-back within 30 min
Appointment Availability Survey: Urgent 48 Hours (PCP)
16Slide17
HEDIS (Medi-Cal only): 25%
Available Data Sources
Measures
HEDIS
17 Measure CompositeDomain Score
Reporting year: 2015, Measurement year: 2014Methodology: Administrative data only (Not Hybrid)Same measures as L.A. Care Pay For Performance ProgramElements:Childhood Immunization StatusWell Child Visits in Third, Fourth, Fifth, and Sixth Years of LifeAdolescent Well-Care VisitsImmunizations for Adolescents – Combo 1
Breast Cancer ScreeningCervical Cancer Screenings
Chlamydia Screening in WomenPrenatal & Postpartum Care (2 measures): Timeliness of Prenatal Care, Postpartum Care
Use of Appropriate Medications for People with AsthmaComprehensive Diabetes Care (4 measures)
Avoidance of Antibiotic Treatment in Adults with Acute BronchitisAppropriate Testing for Children with Pharyngitis
Annual Monitoring for Patients on Persistent Medications – Total Rate
17Slide18
Member Satisfaction: 20%
Available Data Sources
Measures
Clinical Group
ConsumerAssessment of the Health Plan
(CG-CAHPS)Reporting year: 2014, Measurement year: 2013Methodology: Independent Vendor Survey of Member responses who had a provider encounter within the survey periodElements:Adult Timely Care and Service for PCPsAdult Coordination of Care CombinedAdult Health Promotion CombinedAdult Doctor-Patient Interaction PCPAdult Doctor-Patient Interaction Specialist
Adult Office Staff Combined
Adult Rating of All Healthcare CombinedAdult Rating of PCP
Child Timely Care and Service for PCPs
Child Timely Care and Service for Specialist
Child Coordination of Care CombinedChild Health Promotion Combined
Child Doctor-Patient Interaction PCP
Child Doctor-Patient Interaction SpecialistChild Office Staff Combined
Child Rating of All Healthcare Combined
Child Rating of PCP
Available Data Sources
Measures
Clinical Group
Consumer
Assessment of the Health Plan
(CG-CAHPS)Reporting year: 2014, Measurement year: 201318Slide19
Utilization Management: 15%
Available Data Sources
Measures
Encounters & Claims Data
Measurement year: 2014
Methodology: HEDIS Technical SpecificationsElements:Hospital Admission Rate (Inpatient Utilization IPU): Risk adjusted by 3M CRG methodologyAll Cause Readmission Rate (ACR): Risk adjusted by 3M APR-DRG methodology and weighted by SPD/non-SPDAvoidable ER Visits (AER): Weighted by SPD/non-SPD only19Slide20
Encounter Timeliness: 15%
Available Data Sources
Measures
Encounter Submission Data
Measurement Year: 2015
Methodology: Encounter Volume Data Submitted by IPA within 60 days of Date of Service:InpatientOutpatientLTC, if the IPA is responsible for Institutional Care (IPPG)20Data not yet availableSlide21
Example Scorecard (cover page)
21Slide22
Example Scorecard (page 1)
22Slide23
Example Scorecard (page 2)
23Slide24
Score Rankings by IPA:Based on 2013 and 2014 data
24
Pilot using 2013-2014 dataSlide25
L.A. Care Added Direct Contracting Options For Providers
Rationale: Add capacity to L.A. Care network and improve quality measures and access
1) Fill geographic gaps
Antelope Valley 1/1/16
Assess entire county for additional gaps
Two additional geographic areas in 20172) Uphold Medi-Cal contract standards with delegated entitiesIn addition to other delegated entities provider may belong toOffer direct contract option to providers in delegated entities that fail to meet quality and access standards25Slide26
Current Provider Array
26
Kaiser
DHS
Community Clinics*
IPA
Direct Contract
Antelope
Valley
Anthem BC
Care 1st
Pre-2006
Post-2006
Plan Partners
963k
193k
280k
504k
367
(August 2016 Medi-Cal Only Figures)
*Community
Clinics include FQHCs, Lookalikes, Other NonprofitSlide27
Clinical Innovation in Managed Care
Care managers at Family Resource Center locations
Health Information Technology (HIT)
eConsult
eConnectTransforming Clinical Practice Initiative (TCPI) – 3,000 providers
Provider Incentive ProgramP4P programCommunity Health Investment Fund (CHIF)$10M to safety net27Slide28
Two Questions That I Have Asked Since Coming to L.A. Care
What value does L.A. Care add to our
members’
health care experience?
What value does L.A. Care add to our
providers’ participation?What value does L.A. Care add to our staff’s experience?28Slide29
L.A. Care Value Proposition
What value does L.A. Care add to our
members’
health care experience?
Access to careQuality/outcome focus from providers
Humane/compassionate treatmentMember advocacyWhat value does L.A. Care add to our providers’ participation?Timely, accurate informationEase of administrationResponsible reimbursementInformed membersWhat value does L.A. Care add to our staff’s health care experience?Meaningful workHealthy workplaceWellness programsFair compensationProfessional development
29
“Injustice in health care is the most shocking and inhumane.”
-Martin Luther King, Jr.
1966Slide30
30
This hangs over my desk……
At every crossway on the road
that leads to the future,
each progressive spirit
is opposed by a thousand menappointed to guard the pastMaurice Maeterlinck, Our Social Duty