Partnership HealthPlan of California MediCal Managed Care

1. Partnership HealthPlan of CaliforniaMediCal Managed Care Overview Health Alliance of Northern California Peer Network Day May 11, 2012 Presented by Lynn Scuri, MPH Associate Regional Director

2. Today

3. Med-iCal Managed Care - Three Models • Geographic Managed Care (Sacramento, San Diego) • Two Plan Model (LA, Central Valley, Bay Area) • County Organized Health Systems • CenCal (Santa Barbara, San Luis Obispo – 105,000) • Health Plan of San Mateo – 80,000 • Partnership HealthPlan of California (Solano, Napa, Yolo, Sonoma- Marin, Mendocino - 200,000) • CalOptima (Orange – 440,000) • Central California Alliance (Santa Cruz, Monterey, Merced – 220,000) • Gold Coast – Ventura - 115,000

4. Our Mission • In every aspect of the HealthPlan’s operations, from day to day activities to the strategic planning for our future, our mission is to help our members and the communities we serve be healthy

5. Our Goals • Create a local system of care for Medi-Cal Members • Improve access to care • Focus on primary and preventive care • Reduce use of Emergency Room for routine care • Improve the quality of care • Increase provider reimbursement • Increase scope of services to the member • Run a locally responsive organization

6. PHC History • 1988– Private/public discussion to address overall health of community; funding from Kaiser, NorthBay, Sutter, cities and other • 1992 – State Contract approved and Commission formed • 1994 – Solano Operations began! • 1998 – Expansion to Napa • 2001 – Expansion to Yolo • 2002 – County Medical Services Program (CMSP) Pilot • 2006 – Healthy Kids • 2007 – Medicare/Medi-Cal Partnership Advantage Product • 2009 – Medi-Cal Expansion to Sonoma County • 2010 – Healthy Families Provider • 2011 – Medi-Cal Expansion to Marin and Mendocino

7. More About PHC One of 6 County Organized Health Systems (COHS) in California covering six counties Not for Profit Organization Full range of aid codes including SPD and LTC 31% of enrollment is Seniors & Persons with Disabilities (SPD) 300 Employees $900 million Annual Budget Administrative costs < 5% Jack Horn, Chief Executive Officer, Partnership HealthPlan of California

8. Shasta Region Medi-Cal Members 100% 90% Modoc, Lassen, Shasta, Siskiyou and Trinity Counties

9. PHC Covered Services

10. Enhanced Services We Answer the Phone!

11. Preventative Care Model of Care • Primary Care Health Home • Referral to Specialty Care • Health Education and Healthy Lifestyles • Medical Care for Acute Chronic Illness

12. PCP Assignment

13. Referrals & Authorizations PCP initiates referral to: PHC contracted specialist or Medi-Cal certified provider Specialist performs initial consult Communication Referral faxed to specialist by PHC Specialty office requests Treatment Authorization* (TAR) from PHC (if needed) PHC reviews TAR & makes determination (3 – 5 day turnaround) Specialist provides care/service/supplies * Only select procedures/equipment/supplies require a TAR

14. $$ Claims Payment $$

15. Payment Structure

16. Payment Options • Hospitals • Primary Care Providers • Specialty Physicians • Ancillary Providers • LTC • Pharmacy • Capitation • Capitation • Fee-for-Service (enhanced rate) • Fee-for-Services • Fee-for-Service/Per Diem Rate • Contract through Pharmacy Benefit Manager • (MedImpact) • Fee-for-Service • CPSP • CHDP • Fee-for-Service/Per Diem Rate • Capitation • Quality Improve-ment Program

17. Working with a COHS Plan • Local Governance & Administration: • Access for community to policy making and management • Board meetings are open and transparent to the public • Community Involvement: • Advisory boards that participate in collective decision making regarding the direction of the plan • Board meetings are open and transparent to the public

18. Governance • Board of Directors • 22 members • Mix of providers, consumers, advocates and county officials • Committees • Finance Committee • Physician Advisory Committee • Quality, Credentialing, Peer Review, Pharmacy • Consumer Advisory Committee • Provider Advisory Group

20. Our Programs • MediCal: • 200,000 low-income members • Healthy Kids • 800 low-income, MediCal ineligible kids • Medicare Special Needs Plan • 7,500 low-income, senior/disabled members • Healthy Families • 1,500 kids

21. Benefitsfor Members • Member Services – PHC receives and services 1,000 calls per day helping patients (wait time < 1 min.) • Enhanced benefits • Care Coordination programs • Higher quality of care, improved HEDIS scores • Improved access to physician services We Answer the Phone!

22. Member Satisfaction2010 Survey Results • Overall satisfaction with: • Partnership HealthPlan: 98% • Personal doctor: 90% • Easy or usually easy to receive specialty care: 80% • Always got help they needed from Member Services Department: 87% Satisfaction scores based on a 8-10 of a 10 point scale.

23. Benefits to Providers • Health Care Centers / Primary Care Physicians • Rates enhanced • Quicker pay • Quality Improvement Incentive Program • PHC pays when State freezes payments • Specialty Care • 130% of FFS MediCal payment/80% of Medicare • Quicker pay – less than 14 days on clean claims • High quality referrals • Provider services and support • PHC pays when State freezes payments • All Other Providers • Payment at Medi-Cal rate • LTC enhanced rates for higher acuity patients. One week turn around, better cash flow We Answer the Phone!

24. Provider Satisfaction

25. Why Managed Medi-Cal? A Better System of Care Builds on strong Primary Care Foundation

26. Questions, and More Questions Contact Us At: Lynn Scuri, MPH Associate Regional Director (707) 863-4146 lscuri@partnershiphp.org Bob Moore, MD, MPH Chief Medical Officer (707) 863-4228 rmoore@partnershiphp.org

28. Milestones

29. And More Milestones