District of Columbia Department of Health

1. District of Columbia Department of Health Health Care Safety Net Administration First Three Years in Review and Plans for the Future Presented at the American Public Health Association 132nd Annual Meeting Brenda L. Emanuel, M.P.A. Director Health Care Safety Net Administration APHA – 132nd Annual Meeting - 1

2. A Success Story DC Healthcare Alliance Providing Health Care Coverage to Improve Health Outcomes for Uninsured Residents of the District of Columbia APHA – 132nd Annual Meeting - 2

3. Background • The Control Board considered health care spending in general and the cost of operating DC General Hospital (DCGH) in particular to be a driving force in the District’s finances and economic recovery. • Congress, in expressing its interest in the challenge to provide health care to residents, encouraged District Government to consider a new public health system • The Mayor proposed the closure of the DCGH and to replace it with a privatized public health system of care • The City Council unanimously opposed the closing of the DCGH. APHA – 132nd Annual Meeting - 3

4. Background Continued:Health Care Privatization Amendment Act of 2001 • To reorganize the Department of Health by establishing a HCSNA and to transfer functions of the District of Columbia Health and Hospitals Public Benefit Corporation (PBC) to the DOH; to authorize the Mayor to contract out any of the health care functions of the PBC. • The purpose of this act is to authorize implementation of alternative publicly financed health care delivery system to replace the health care services formerly provided by the PBC. • The HCSNA was established to administer and monitor compliance with the contract and to exercise oversight of the services contracted by the Mayor, and to ensure that the health of the District population is maintained. • Establishment of Non-Lapsing Revolving Account – receivables of PBC, Local Appropriations, grants, gifts, etc. APHA – 132nd Annual Meeting - 4

5. Components of the Service Delivery Model:The Health Care Safety Net Administration (HCSNA) HCSNA Goals: • To improve the health outcomes of District Residents • To decrease inappropriate use of ER and inpatient care • To increase primary and preventive care; and increase the use of the medical home model • To create a coordinated, patient centered system of care and adequate financial reimbursement strategy. APHA – 132nd Annual Meeting - 5

6. Service Delivery Model DC Healthcare Alliance • A patient-centered care model that targets resources and services to the people who need them the most and for whom the program is intended: the District’s poor and uninsured resident’s. • A network of providers that coordinate services with each member’s medical home and Primary Care Provider (PCP) for a continuous focus on primary care, disease management and prevention programs; and • A system for data collection and reporting that provides information on the disease status of patients, treatment plans, services provided, and cost of treatment provided through the DC Health Care Alliance. APHA – 132nd Annual Meeting - 6

7. DC Healthcare Alliance Program ModelMedical Homes: A Client-Centered Approach Healthcare Safety Net Administration Program Oversight Hospital (Inpatient & ER) • Outcomes • Healthy Families • Decrease Cost • Disease Profile of Population • Change in Healthcare Behavior • Prompt Payment to Providers y r a l l • Inputs • Adequate Funding • Program Rules • Stake- holder Support i c s e n c A i v r e S Administrative Services H o Community Support Resources including Support Groups, DOH-sponsored Health Programs Urgent Care Center • Enrollment of Eligible • Uninsured DC Residents • Enrollment from Clinics, • ER, Mail, Hospitals, etc • Utilization Management • Case Management • Claim Processing s p i t CLIENT a l s Community Support Resources including Support Groups DOH-sponsored Health Programs l a i c s o S e S p c e i v c r i R a e e l f S t Behavior Health Change Campaign, Enhance Care Management & Improve Clinic Facilities e y r r a l s APHA – 132nd Annual Meeting - 7

8. Alliance Partnership APHA – 132nd Annual Meeting - 8

9. Alliance Eligibility Criteria The DC Healthcare Alliance was established to serve those citizens who meet the following criteria: • District of Columbia Residency • No other form of health insurance • Family Income at or below 200% of Federal Poverty Level APHA – 132nd Annual Meeting - 9

10. Presumptive Eligibility Allows for care to be provided while the DC resident is being considered for coverage. Presumptive eligibility takes place when the individual verbally attests to 2 of the 3 criteria for entry into the Alliance, but does not have documentation of the requirements. Proof of District residency is required to receive services. APHA – 132nd Annual Meeting - 10

11. Alliance Benefits • Preventative Care • Urgent and Emergency Care • Prescriptions • Inpatient Care • Specialty Services • Dental Services • Wellness and Education Programs APHA – 132nd Annual Meeting - 11

12. Reimbursement Structure • Fee-for-Service • 110% - 150% of Medicaid Rates • Prior Authorizations for Inpatient care • 5-Tier Emergency Room Rate • Uniformed Fee structure across providers APHA – 132nd Annual Meeting - 12

13. Partnerships with other Governmental Agencies The Health Care Safety Net Administration has developed partnerships with other Governmental Agencies to provide health care services for special populations: • DC Public Schools • DC Department of Corrections • DC Metropolitan Police Department • Federal Bureau of Prisoners • Court Services and Offender Supervision Agency APHA – 132nd Annual Meeting - 13

14. DC HealthCare Alliance Program Goal is more than to provide Health Care Coverage but to Improve Health Outcomes APHA – 132nd Annual Meeting - 14

15. HCSNA- Strategies for Improving Health Outcomes • Partnership for Improved Health Outcomes • Creating a balance between the clinical approach to disease and social and behavioral determinates of disease, injury and disability • Create a Medical Home for all members • Integrated Case Management Program • Comprehensive Patient Education Initiative • Low Priority Ambulance Transport Initiative • Mayor’s Prisoner Re-entry Initiative • Build an information infrastructure to support care delivery APHA – 132nd Annual Meeting - 15

16. HCSNA- Populations Served • 22,000 average monthly DC Health Care Alliance enrollment; over 80,000 enrolled • 4,000 Inmates of the Department of Corrections • 71,566 DC Public School Children • Provided access for 95,490 visits to 6 former PBC clinics • Provided access for 11,325 visits to the Urgent Care Center on DCG Campus • Provided access for 46,304 visits to the Ambulatory Care Center on DCG campus APHA – 132nd Annual Meeting - 16

17. Progress: 2001 - Present • Strengthen Provider- Patient Relationship • Decreased ER utilization • Decreased inpatient utilization • Increase use of primary care services • Extended clinic and pharmacy hours • 24 hour pharmacy coverage • PMPM Expenses decreasing- $215.00 with projections over next 12 months $203.62 APHA – 132nd Annual Meeting - 17

18. Program Funding • Funded with 100% Local Funds • Application for HIFA Waiver (Health Insurance Flexibility and Accountability Waiver) APHA – 132nd Annual Meeting - 18

19. HCSNA- Budget $103.6 Million Total Budget for HCSNA in FY 2004 • $7.6 for Pharmaceuticals and Program Oversight and Monitoring • $96 Million DC Health Care Alliance Contract • Provider claims payments • Access to Care for clinics, Urgent Care Center and Ambulatory Care Center • School Health Program • Medical care to inmates of the Department of Corrections • 24 hour Pharmacy Program • Expanded Case Management Program • Expanded clinic and pharmacy hours • Expanded Outreach Program • Administrative services APHA – 132nd Annual Meeting - 19

20. Budgetary Challenges • Budget supports average monthly enrollment of 22,000 members • Current average monthly enrollment is 24,000 members • Currently no cap on the program • Current contract limits the District’s liability at 96M. • Decision must be made to protect provider payments and ensure access to care is maintained APHA – 132nd Annual Meeting - 20

21. Lessons Learned • Eligibility and Enrollment should be a Government function • Prompt payments to providers are key • Plan for patient education and PR in budget • Government has interest in ensuring coordination of care across systems • Planning is key to financial and operational success APHA – 132nd Annual Meeting - 21

22. Plans for the Future Strategic Planning Process • Strengthen program to empower members • Realign claims processing functions • Realign eligibility and enrollment functions • Redesign management structure of facilities • Rethink Public vs. Private management of health care services for school nurse program, inmates with Department of Corrections • Incorporate performance standards throughout the system. APHA – 132nd Annual Meeting - 22

23. Contact Information If you have any questions or need further information on the Health Care Safety Net Administration or D. C. Health Care Alliance Program Brenda L. Emanuel, M.P.A. Health Care Safety Net Administration (202) 442-9220 Brenda.Emanuel@dc.gov APHA – 132nd Annual Meeting - 23