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Managed Medi-Cal Planning Group

Frequently Asked Questions: The Managed Medi-Cal Planning Process

Why is Medi-Cal managed care for Sonoma County being studied at this time?
The Legislature adopted a Medi-Cal redesign plan in 2005 that called for Partnership HealthPlan of California, a Medi-Cal managed care plan, to expand into a number of counties, including Sonoma. The county needs to respond to that request.

Why was the Medi-Cal Managed Care planning group created?
A year ago, the county health director and board of supervisors established the planning group to get input from the people who are involved with the Medi-Cal program. The planning group was asked to study the options available and recommend the best course of action for the Medi-Cal program.

Who is on the planning group?
Members of the planning group include a range of health care providers and representatives of Medi-Cal beneficiaries, as well as county government leaders. Each hospital was invited to appoint a representative; the county medical society appointed representatives; community advocacy organizations nominated people to represent Medi-Cal recipients and county government representatives were selected. A list of all the planning group members is on the health department web site: www.sonoma-county.org/ManagedMedi-Cal.

How did the planning group get input into its decision?
The planning group heard from a number of experts, met numerous times with Partnership HealthPlan, and studied the issues thoroughly. The planning group also sponsored 10 focus groups of beneficiaries to get their input, and it received input from over 100 local physicians who filled out questionnaires. planning group meetings were open to the public with time for public comment. All agenda items are available on the website.

Why should we change the current Medi-Cal fee-for-service system?
The Medi-Cal fee-for-service program has many shortcomings: payments to providers are low and the administrative bureaucracy is cumbersome. This has led to low physician participation which in turn limits access for patients. It is very difficult for Medi-Cal patients to get appointments with specialists or to access certain types of health services. The Medi-Cal fee-for-service program lacks many of the features of a modern health plan: there are no member services staff, no way to resolve complaints and grievances, no quality improvement program and no guaranteed access to care. Medi-Cal managed care plans are highly regulated by the state and provide better services and access than does the fee-for-service system.

Must the county agree to change the Medi-Cal program or could it stay with the status quo?
Although the county could reject participation in some models of Medi-Cal managed care, remaining with the status quo is not a certain option. The state might choose to impose a managed care model that does not need county government approval but is not the best option for the county. In addition the current system is problematic for patients and providers.

What is the planning group recommending?
The planning group recommends that Sonoma County become part of our neighboring Medi-Cal managed care health plan, Partnership HealthPlan of California. This recommendation is contingent on the resolution of a number of issues including Partnership HealthPlan offering appropriate rates to providers, agreeing on an appropriate level of Sonoma residents serving on the governing board, the opening of a new local Partnership HealthPlan office, creating a local advisory body, and resolving various operational issues. Partnership HealthPlan and the county are hopeful that these issues will be resolved during the next year of planning.

What is Partnership HealthPlan of California?
Partnership HealthPlan of California is a County Organized Health System, or COHS, that was established in 1994. It currently serves all 85,000 Medi-Cal beneficiaries in Solano, Napa and Yolo Counties, and also offers the Healthy Kids Plan in these counties plus Sonoma County. The boards of supervisors in Marin, Mendocino and Lake counties have also decided to join Partnership HealthPlan. At the end of the expansion process, Partnership HealthPlan will serve 7 counties and have approximately 125,000 Medi-Cal members.

What is a County Organized Health System (COHS)?
A COHS is a governmental authority that is legally a subdivision of the State of California, but is not part of any city, county or state government system. A COHS is a publicly-owned and operated "health insuring organization" established with the express goal of serving Medi-Cal beneficiaries. The COHS is chartered by the state and governed by local residents of the counties it serves.

There are five COHS plans in the state covering eight counties. The board of supervisors in each participating county appoints members to the COHS governing board, which typically includes physicians, hospital representatives, nurses, consumers, community advocates, elected officials and public health leaders. The state delegates responsibility to the COHS to organize and manage the care for Medi-Cal enrollees within the terms of a contract.

How is a COHS different than other Medi-Cal managed care plans?
Counties that do not have a COHS have one or more commercial health insurance plans that manage care for Medi-Cal beneficiaries. Some counties also have a "local initiative," which is a non-profit plan established by the board of supervisors.

The COHS has a number of special characteristics. As a public entity, its board meetings and records are governed by the Brown Act and are open to the public. A COHS does not distribute profits to shareholders and has a higher degree of public accountability than do private commercial plans. All of the Medi-Cal funds in a COHS stay in the community and are used to improve access and care for beneficiaries. Unlike commercial plans, COHS plans are primarily focused on the Medi-Cal population, so they specialize in meeting the needs of that population.

A COHS has full responsibility for Medi-Cal services in a given county; all Medi-Cal beneficiaries are enrolled in the COHS and there are no competing plans. This results in lower administrative costs. Partnership HealthPlan's administrative costs were 5.6 percent of its total expenditures in 2006. (This compares favorably to commercial plans with overhead of 15 to 20 percent.)

Why did the planning group recommend Partnership HealthPlan?
Partnership HealthPlan successfully met all of the criteria established by the planning group for an improved Medi-Cal program. The criteria called for improved access to care, a focus on quality care, adequate provider reimbursement, effective and efficient operations, and local governance of the plan.

How will Partnership HealthPlan improve access to care for Medi-Cal patients?
Partnership HealthPlan is able to reallocate Medi-Cal dollars in order to offer higher payments to primary care and specialty physicians and improve administrative and member services. This leads to more physicians accepting Medi-Cal patients and better access to care. Statewide, 55 percent of physicians participate in Medi-Cal fee-for-service. In COHS counties, 90 percent of primary care physicians participate. Each year Partnership HealthPlan conducts a provider satisfaction survey; in 2006, 95 percent of responding physicians expressed "overall satisfaction" with the Partnership HealthPlan.

Each Medi-Cal beneficiary enrolled in Partnership HealthPlan selects a "medical home" from the network of primary care providers. Partnership HealthPlan guarantees that beneficiaries can get doctor appointments within a reasonable period of time and has a member services department that helps to insure access and solve problems. It also provides case management for pregnant women and members with complex conditions to improve their access and outcomes.

Where do the savings come from to finance higher physician rates?
Partnership HealthPlan and the other Medi-Cal managed care plans have been successful in developing care management programs and increasing preventative services so that acute care costs are reduced. For example, by providing each patient with a medical home and expanding access to primary care, emergency room use declines. By educating and monitoring patients with chronic disease, the number of hospital days is reduced. Primary care providers are able to review and manage all of a patient's prescriptions, which usually results in some pharmacy savings. Savings from all of these changes are used to increase payment rates for physicians.

Will Medi-Cal patients be able to see their own doctors after managed care starts?
Partnership HealthPlan supports the continuation of existing physician-patient relationships whenever possible; all qualified health providers who meet its standards will be offered a contract. Physicians and clinics that currently care for Medi-Cal patients are usually willing to contract with Partnership HealthPlan, and some will agree to see more Medi-Cal patients. Primary care providers refer patients to specialists that have a Partnership HealthPlan contract. Partnership HealthPlan will offer contracts to specialists who want to see many Medi-Cal patients, as well as to specialists who want to care only for their existing Medi-Cal patients. It will also pay fee-for-services rates to some out-of-region specialists who have existing relationships with local patients.

How does Partnership HealthPlan improve the quality of care and health outcomes?
Partnership HealthPlan sets goals, educates providers, develops systems and monitors charts and encounter data to help improve the quality of care received by its members. Improving quality of care and health outcomes are important goals of Partnership HealthPlan. Partnership HealthPlan has special programs to help members with diabetes and other chronic diseases to improve their health. Pregnant women can participate in a special program, "Growing Together," that encourages healthy pregnancy. Partnership HealthPlan scores well in comparison to other state and national health plans in regard to specific quality goals that each plan must measure.

Are Partnership HealthPlan enrollees satisfied with the services and the care it provides?
Yes. The most recent member satisfaction survey carried out by Partnership HealthPlan showed 89 percent of the enrollees were satisfied with Partnership HealthPlan, and 89 percent were satisfied with the care they were receiving.

Will Medi-Cal eligibility and enrollment change under managed care?
Across the State, there are many complaints regarding the complex Medi-Cal eligibility rules and lengthy enrollment process for patients. The eligibility rules and enrollment process will not change under Medi-Cal managed care, although the member services department can assist enrollees who request help with renewing their eligibility.

What are the next steps for Sonoma County to become part of Partnership HealthPlan?
Once the county board of supervisors informs the state of its intent to join Partnership HealthPlan, there will be at least a year of planning. The current goal is for Medi-Cal managed care to "go live" in Sonoma County in the summer of 2008. The most critical issue is a commitment by the State to pay adequate rates for the Sonoma County Medi-Cal population. Once this is resolved Partnership HealthPlan will start implementation planning. It will hold dozens of open meetings with beneficiaries and community groups to educate them about the program and the transition. It will meet with the hospitals and other health care providers (such as pharmacies, skilled nursing facilities, and home health agencies) to answer questions, ask for their participation in Partnership HealthPlan and enter into contracts with them.

Will there be additional public input and public reports?
Yes, during the next year, members of the public will continue to be welcome at planning group meetings and can provide input via that process. Additionally, the board of supervisors will have one or more reports on their agenda regarding the managed care implementation process.

What actions will the board of supervisors need to take in the future?
Once the next phase of the planning process has occurred and the various issues identified by the planning group have been resolved, the board of supervisors will adopt an ordinance that officially allows Sonoma County to be part of Partnership HealthPlan. This ordinance will also specify how the board of supervisors will appoint local residents to the COHS governing board. Typically the board asks for nominations of potential governing board members from the provider and beneficiary communities. Sometimes the ordinance specifies that a member of the board of supervisors or the county health director will serve on the governing board. Once Partnership HealthPlan is operational in Sonoma County, there will also be opportunities for local residents to serve on various Partnership HealthPlan committees, including the member advisory committee, the strategic planning committee, the physicians advisory committee and others.