Volume 60, Number 3 - Summer 2009

 

By Mary Maddux-González, MD, MPH

In 2005, the California Department of Health Services recommended that Sonoma County change from fee-for-service Medi-Cal to Medi-Cal managed care, also known as Managed Medi-Cal. The state called for Sonoma County to join Partnership HealthPlan of California (PHC), a “county organized health system” already in place in Solano, Yolo and Napa counties. 

In 2006, the Sonoma County Department of Health Services convened a planning group—including representatives from SCMA, local hospitals and community clinics—to examine Managed Medi-Cal and other potential options. After a year of study, the group—which I chair—agreed with the state’s recommendation and is now working with PHC to bring the program to Sonoma County.

The current schedule calls for implementing Managed Medi-Cal in October. PHC has already begun developing its network and is offering contracts for primary care, specialty care, hospitalization and other services. 

Nearly 50,000 residents (roughly 11% of the population) in Sonoma County are insured through Medi-Cal. Expenditures for these patients totaled almost $212 million in 2007. Most of the money was spent on hospitals, skilled nursing care and pharmaceuticals, but about 12% ($25.4 million) went to physicians and clinics for primary and specialty care. 

PHC has had great success working with physicians and other providers in Solano, Napa and Yolo Counties to improve care for Medi-Cal beneficiaries. The health plan, for example, has reduced Medi-Cal emergency room visits by 50% and hospitalizations by 15% in all three counties since taking over Medi-Cal administration. These reductions have allowed PHC to provide higher reimbursement to physicians than fee-for-service Medi-Cal. 

The arrival of PHC in Sonoma County represents an important opportunity for Medi-Cal enrollees and our medical community. I recently interviewed PHC’s medical director, Chris Cammisa, MD, to discuss the upcoming implementation and the impact it will have on Medi-Cal patients and physicians. 

A: PHC is the Medi-Cal managed care plan for Napa, Solano and Yolo counties. Since 1994, we have served most Medi-Cal eligible recipients in our three-county area. We are dedicated to maintaining the health of our 100,000 members and the communities we serve, and to improving the quality of care and services. In 2007, we began a Medicare managed care plan for about 3,300 dual-eligible members. We provide both Medicare and Medi-Cal benefits to this group. We are pleased to offer Medi-Cal benefits along with a number of enhanced services to the 48,000 Medi-Cal beneficiaries in Sonoma County. 

A: As medical director at PHC for the past 10 years, I have had overall responsibility for the medical management aspects of services provided by the health plan. This includes oversight of utilization management, which involves ensuring that PHC members receive medically necessary, evidence-based care and services. In addition, I have responsibility for the Quality Improvement Department, where the plan strives to continuously improve the quality of care and services delivered to PHC members. Another responsibility is to assist our Provider Relations Department and other staff to ensure that provider concerns and needs are met in a timely and efficient way.

A: Since we began reporting our HEDIS quality scores in 1999, we have consistently improved our performance on most measures and have achieved results at or above the 75th percentile for Medicaid plans nationally. We have also collaborated with community practices to achieve significant improvements in areas such as asthma care, diabetes care, back pain and prenatal care. Our quality bonus program, which incentivizes important improvements in care and services to our members, is widely recognized as being a model of innovation for other managed care plans. 

In addition, we have implemented evidence-based criteria to successfully control costs without compromising quality patient care during two serious financial crises, including the current crisis and one in 2002-03. In both instances, we continued to maintain excellent member satisfaction and provider satisfaction survey scores. 

A: Clearly, over the past 10 years our major challenge has been to maintain financial viability. In spite of annual increases in health care costs, we received only one rate increase from the state from 2002 to 2008. As a result, we have become more judicious and efficient in the use of our limited resources. 

My challenge as medical director is to ensure that our members continue to receive the highest quality care and service despite these financial challenges. By focusing on efficiency, evidence-based best practices, and close collaboration with our community practitioners, we have been able to maintain and improve services to our members in these tight financial times. Our current challenge is to smoothly transition the 48,000 Medi-Cal beneficiaries in Sonoma County to PHC while continuing to operate a financially stable organization.

A: In our previous expansions, we learned that each county has unique characteristics both in its patients and its provider network. This observation is especially true of Sonoma County, which has a well-organized system of primary care services provided through the RCHC clinics.

Access to specialty care will be challenging since some critically important specialty care is currently provided outside the county. Our goal is to work with the Sonoma County Medical Association to provide more specialty care when appropriate within the county. 

Early data appears to show a high proportion of beneficiaries in Sonoma County who have multiple chronic medical conditions and disabilities. This factor will provide unique opportunities for PHC to augment the providers’ efforts by identifying and closing gaps in access, quality and coordination. 

A: Because PHC is a managed health care plan, we are more actively involved in the care of members than traditional fee-for-service Medi-Cal. We offer a fully staffed Member Services Department to assist members with questions and concerns, and we supply case-management services for members with multiple chronic conditions. For certain homebound members, we provide a home-visiting nurse practitioner to prevent avoidable emergency room visits and hospitalizations.

Primary care physicians and specialists are likely to see considerable differences in our pharmacy benefit compared to fee-for-service Medi-Cal. We have a long history of using high quality generic medications whenever possible. Simply put, generic medications are far less costly, and in appropriate situations, equally as effective as high-cost, brand-name prescriptions. 

The initial transition to the PHC formulary may cause some strain. Over time, however, the transition will benefit members by ensuring that they receive appropriate, cost-effective, medically necessary medications. Our pharmacy system also benefits the primary care network through the primary care risk pools. 

A: The advantages for contracting with PHC include:

• A higher rate of reimbursement. On average, we reimburse specialists at 130% of fee-for-service Medi-Cal. The rate varies by specialty.
  
• Fewer hassles. Our Provider Relations Department will help practice sites eliminate or reduce any difficulties with authorizations and claims. The list of services requiring authorization is limited, and it is continuously revised based on input from the network. 
  
• Great customer service. Our staff, including me, are immediately available to respond to whatever concerns may develop. Our business model is built on excellence in customer service, and we consistently receive high rankings in our provider satisfaction surveys. We fully intend to continue our culture of customer service excellence in Sonoma County.
  

A: Local resources will include:

• A regional office located in Santa Rosa staffed by a regional medical director, provider relations staff, utilization management nurses, and support staff. 
  
• An experienced Member Services Department will assist members with their questions and concerns.
  
• Targeted case management to help members who have complex medical needs, along with their providers.
  
• Coordination of care with Sonoma County Mental Health, California Children’s Services and other organizations, so that members receive seamless care. 
  

A: Basically, we are offering Medi-Cal enrollees an organized system of care. We have developed systems to ensure that members receive medically necessary services and avoid unnecessary or low-value services. In addition, we assist members with their concerns and questions, and we help when appropriate with their complex medical conditions. 

A: They can visit our website at www.partnershiphp.org, or they can contact me at ccammisa@partnershiphp.org or 707-863-4261. 

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Dr. Maddux-González, Sonoma County’s Health Officer, chairs the Managed Medi-Cal Planning Group.