California’s Health Care Coverage Initiative: C A L I FOR N I A County Innovations Enhance Indigent Care H EALTH C ARE F OU NDATION Overview As required by the state law that enacted the More than 100,000 low-income Californians have CI, all ten programs include the following begun to benefit from county-level innovations components: aimed at expanding access to health care, ◾◾ An identification system that demonstrates transforming provision of services, and maximizing enrollment of the uninsured person into the limited resources. The innovations are supported Issue Brief program (enrollees also must be ineligible for by the Health Care Coverage Initiative (CI) other public programs); component of California’s Medicaid hospital financing waiver,1 which is intended to help ◾◾ A medical records system; counties expand coverage to medically indigent ◾◾ Assignment of each enrollee to a medical adults. Ten California counties — Alameda, Contra home;2 Costa, Kern, Los Angeles, Orange, San Diego, San Francisco, San Mateo, Santa Clara, and ◾◾ A benefits package that includes preventive Ventura — are using CI funding to work toward and primary care as well as care management; specific improvements in their indigent care ◾◾ Promotion of preventive and primary care; systems, with a focus on patients with complex, and chronic medical conditions. Significantly, the CI counties have moved beyond coverage expansion ◾◾ A quality monitoring process. to transform the way care is provided, replacing fragmented, episodic care limited to urgent and Because the CI programs provide unique sets of emergency services to more organized, efficient, services to individuals and not comprehensive and financially sustainable systems that include insurance, coverage is only available within the primary and preventive care. county’s provider network and is not portable outside the resident’s county. To support these counties’ efforts and to learn from their experiences, the California HealthCare The historic structure of each county’s delivery Foundation (CHCF) and The California system has impacted the design of its CI program. Endowment (TCE) engaged Health Management For example, some of the counties (e.g., Contra Associates (HMA) to create a comprehensive Costa and Ventura) have existing systems that program of technical assistance for the CI counties include both a county-owned public hospital as working on the transformation of indigent care. well as county-owned clinics. Other counties Based on the counties’ experiences, this issue (e.g., Alameda and Santa Clara) have CI networks brief describes common elements of the county that include both county-based and private programs that are critical to reforming local health providers. Two counties’ networks — Orange systems. and San Diego — are comprised solely of private hospitals and clinics. S eptember 2009 The counties also differ in terms of where they fall along Systematic coordination and close communication the continuum of health system redesign. Prior to the between providers have been found to be crucial for the CI, San Francisco and San Mateo counties had already CI-mandated medical home model to succeed. Some invested heavily in redesign as part of a larger push to counties have implemented IT solutions to facilitate expand access and coverage to all local residents. Other provider communication, but others continue to seek counties have used participation in the CI to begin the assistance and information on best practices in supporting process or to test new methods for providing access for good communication. Coordination across providers also indigent populations. For example, Alameda’s CI program appears more difficult for counties with provider networks is testing a comprehensive chronic care model, with the that include a higher proportion of private providers. goal of expanding it countywide. (See Appendix A for an overview of county initiatives.) Financial Sustainability The CI programs are working to achieve financial Common Program Elements and Issues sustainability through the economic downturn. Many are The counties’ approaches and implementation experiences focusing on strategies to increase efficiency in practice highlight common elements and issues that are critical to management, use of specialty services, and chronic care effective system reform. management. Counties also are seeking to maximize every source of funding available for local systems and making Provider Networks the business case for their CI programs to maintain local To address the complex health needs of the enrollees, the support. CI counties have developed networks that include both primary and specialty providers, with the primary care The counties’ efforts have been affected by a long delay physicians serving as enrollees’ medical homes. To avoid in reimbursement for the first year of CI health care and both duplication and gaps in services, the counties have administrative expenditures. This was due to lengthy found it useful to analyze enrollees’ clinical needs, identify negotiations between the California Department of service gaps in their existing networks, and partner with Health Care Services (DHCS) and the federal Centers for providers around specific service needs. Medicare and Medicaid Services (CMS) regarding federal approval of reimbursement mechanisms for claiming Ensuring sufficient access to specialty care has been a federal funds. As of this writing, the CI administrative challenge for the majority of the CI counties, particularly funds still have not been paid to counties. The delay has where the number of CI enrollees with multiple stressed county fiscal capacity to sustain care management chronic conditions is greater than expected. Many of and continue to invest in administrative improvements. the CI counties with county-based systems developed or expanded partnerships with non-county specialty The CI counties are concerned about their ability to providers. Alternatively, Orange and San Diego counties, sustain their programs over the long term if federal which do not have county-based systems, developed funding is eliminated or reduced. Consequently, they contractual arrangements with a wide range of private are exploring ways to create efficiencies, generate savings specialty providers. In general, the counties with more from existing programs, and identify opportunities to comprehensive county-based health systems have reported secure additional federal funding. This often requires a fewer issues with specialty access than those that rely more detailed understanding of federal and state reimbursement heavily on private providers. mechanisms. 2  |  California HealthCare Foundation Enrollment Processes and Systems patient self-management tools, and disease registries — to The development of a formal, centralized enrollment all enrollees eligible for CI. In general, the CI counties process and system has allowed the CI counties to track indicate there is a continuing need for training, resources, and manage care for their enrollees. By tracking eligibility, and information about how best to serve populations the county enrollment systems also assist with the renewal with multiple chronic conditions. process, helping to maintain continuity of care. Alameda, San Francisco, and San Mateo counties use One-e-App3 Information Technology to manage the CI enrollment process. Other counties, Information technology (IT) offers important including Contra Costa and Orange, have developed their infrastructure for a county-based indigent health care own enrollment systems. system. It is used to support coordination of care across providers by facilitating shared access to patient During the first year of the CI, counties struggled with information, and can also be used to implement an the requirement to verify CI applicants’ citizenship using enrollment system and disease registries. original documentation, as required by the federal Deficit Reduction Act of 2005. This slowed the eligibility process A number of counties have implemented IT tools and considerably as the counties worked with applicants to systems as the underpinning of their system redesign. obtain the necessary documents. To assist applicants, a Orange County, for example, has contracted with an number of CI counties purchased vital statistics data from outside vendor to develop MSI Connect, an electronic the state (a valid birth certificate can be used to prove health information exchange that is available to all citizenship), and Orange County granted CI enrollees an medical home and emergency department providers. extended grace period to produce their documentation. Orange is now developing an e-referral tool to streamline the specialty referral process. Many counties, however, The counties also have become interested in improving continue to seek assistance with identifying, financing, their practices for eligibility, enrollment, and retention, and implementing effective IT solutions. including strategies for assuring timely identification of individuals who qualify for Medi-Cal. Strong Leadership The counties found that committed senior-level Chronic Care Management executives and policymakers have played an important The CI counties are implementing a variety of strategies role in their reform efforts. Leadership in the CI counties to better manage chronic care, which is critical to has been relatively stable over the first two years of the improving CI enrollees’ health status and shifting CI, which has likely helped the counties maintain their care from costly emergency and inpatient settings to momentum in the face of the economic downturn and outpatient settings. To be effective, care management delay in accessing federal funds. requires close collaboration between primary care and specialty providers, as well as between clinicians and social Looking Ahead service providers. The CI county experiences to date suggest there is strong potential for similar initiatives in other counties. But they Some counties focus on specific conditions. San Diego, also point to larger issues that bear consideration in view for example, is targeting diabetes and hypertension. of the upcoming renewal of the state’s hospital waiver. Others have introduced chronic care management tools — such as evidence-based practice guidelines, California’s Health Care Coverage Initiative: County Innovations Enhance Indigent Care  |  3 System Redesign and Financing DHCS’s limited ability to administratively support all In California, as elsewhere, the flow of money has of the county-initiated efforts at system redesign. To shaped the way care is delivered, contributing to heavy expand their knowledge of health system operations and reliance on emergency and inpatient care. To offset this management, DHCS leadership and staff have attended influence, the funding streams need to be tapped in several CI-related convenings sponsored by CHCF ways that reinforce the financial sustainability of more and TCE over the last 18 months. State staff should efficient and organized systems of care over the long continue to seek opportunities to expand their knowledge term. Administrators will need to look for opportunities of county-based delivery systems and the operational to maximize available funding in one area (public health, parameters. for example) to offset the costs of providing services in another area, such as indigent care. Options for Additional Technical Assistance If the CI is expanded in the upcoming renewal of Clear Guidance from Federal Government California’s waiver, DHCS may want to include funding The CI was a new program for both DHCS and CMS. to provide technical assistance for participating counties. As a result, it took time to develop key parameters, such This could allow the counties to contract directly for the as the final protocols for claiming federal funds. CMS kinds of assistance that are most relevant to each county’s also changed its guidance on certain eligibility parameters reform strategy. In particular, counties are interested in after the counties had been selected. For example, CMS acquiring enhanced information technology to support imposed an income limit of 200 percent of the federal more efficient systems of care. DHCS also could poverty level and required the counties to adhere to the gather and synthesize the lessons learned and facilitate Medicaid requirement to document enrollees’ citizenship information-sharing across the counties. as part of the eligibility process. The CI counties were frustrated by these changes to the eligibility rules and lack of guidance regarding the claiming protocols, as well as delays in receipt of federal reimbursement. Going Authors Caroline Davis, M.P.P., is a senior consultant with Health forward, clear and timely guidance and reimbursement Management Associates (HMA), a national health policy from CMS will be important, particularly if California research and consulting firm. Barbara Coulter Edwards, seeks to expand the CI in the next waiver. M.P.P., is a principal with HMA. Strong Partnership Between State and CI Counties About the F o u n d at i o n While the state has not allocated new funding for CI, the The California HealthCare Foundation is an independent counties have indicated the need for DHCS to champion philanthropy committed to improving the way health care is delivered and financed in California. By promoting their efforts and to provide support to ensure the CI’s innovations in care and broader access to information, our success. DHCS has played a key role in implementing the goal is to ensure that all Californians can get the care they CI by serving as the intermediary between the counties need, when they need it, at a price they can afford. For more and CMS and interpreting federal guidance regarding information, visit www.chcf.org. eligibility requirements and financing mechanisms. The counties, however, have expressed frustration that DHCS may not fully understand the operational challenges of running a health care delivery system, as well as with 4  |  California HealthCare Foundation Appendix A: Coverage Initiative Overview* Y ear O ne E x pen d it u res — A nn u al F e d eral T arget E nrollment C o u nty A llotment F e d eral M atc h C o u nty F u n d s E nrollment as of March 2009 Alameda $8,204,250 $7,614,175 $7,614,175 5,500 6,393 Contra Costa $15,250,000 $15,250,000 $22,060,358 9,600 11,446 Kern $10,000,000 $10,000,000 $12,415,736 3,500 5,704 Los Angeles $54,000,000 $20,830,612 $20,830,612 94,000 34,429 Orange $16,871,578 $16,871,578 $33,029,042 17,000 31,440 San Diego $13,040,000 $620,411 $620,411 3,260 3,651 San Francisco $24,370,000 $11,053,828 $11,053,828 10,000 10,963 San Mateo $7,564,172 $5,907,394 $5,907,394 2,100 6,977 Santa Clara $20,700,000 $20,700,000 $23,730,376 12,500 21,828 Ventura $10,000,000 $10,000,000 $11,956,953 12,500 12,520 * or more information about the CI, see: R. Pizzitola, “California’s Coverage Initiative: Year One Challenges and a Forecast for Year Two,” Insure the Uninsured Project, December 2008 F (www.itup.org/Workgroups/PublicPrivate/Pizzitola.pdf). Source: California Department of Health Care Services, personal communication, August 24, 2009. California’s Health Care Coverage Initiative: County Innovations Enhance Indigent Care  |  5 Endnotes 1. Created as part of California’s Medicaid Section 1115 hospital financing waiver, the CI provides $180 million in federal funding for each of the last three years of the waiver period (September 1, 2007 to August 31, 2010). It was enabled through California Senate Bill 1448. 2. SB 1448 defines the medical home as “a single provider or facility that maintains all of an individual’s medical information.” 3. One-e-App is a Web-based tool that screens and submits eligibility data for a variety of public health coverage and insurance programs. 6  |  California HealthCare Foundation