1. “Safety Net” Financing in Los Angeles County: Where do we go from here? Steven Asch, MD, MPH Jeffrey Wasserman, PhD September 29, 2004

2. Purpose of This Part of the Project –Collect ideas to stimulate discussion –No true policy analysis

3. Major Contributors to Safety Net

4. How is the Financial Burden Distributed Across Hospital Types?

6. Observations on Safety Net Financing –Mind boggling level of complexity –System is rife with conflicting incentives and objectives –Why? –No magic bullet, but…

7. Methods Interviewed 40 stakeholders late 2003 –LA County –State, Federal, Santa Clara County, and Alameda County Synthesized themes –Missed Opportunities –Current Problems –Potential solutions

8. Missed Opportunities LACDHS unprepared for advent of Medi-Cal managed care DSH allotments do not match burden of safety net patients LACDHS clinics need to obtain FQHC status Need to maximize enrollment in safety net insurance programs

9. Problems Burgeoning demand, increasing costs Micromanagement at political level Poor care coordination/ lack of service integration Uneven management of safety net institutions

10. Solutions: Increasing Revenue Expand or ease coverage –Simplifying enrollment forms –Enroll children at birth –Expand SCHIP (First Five) –Uncompensated care pool –Change Maddy fund rules –Less incremental approaches (SB-2) Broaden funding sources –Sin taxes –911 tax –Market safety net providers to privately-insured patients

11. Solutions: Reducing Costs Exclude elements of safety net population (e.g., non LA county residents, undocumented immigrants) Prioritize and reduce scope of benefits in safety net programs (e.g., Oregon Medicaid) Increase copayments to reduce utilization Negotiate better volume discounts for drugs, supplies

12. Solutions: Increase Efficiency Improve staffing flexibility Disease management programs Better coordination between safety net providers –Safety net card –Information exchange Shift care to more efficient venues –Urgent care visits for low acuity ER patients –Regionalization of procedures

13. Solutions: Better Matching of Funding to Need Change DSH facility caps Increase level of safety net care required from nonprofit hospitals Allow SCHIP funds to be spent on population based public health Change governance of safety net (Denver example, Alameda counterexample) to spread burden more equally

14. Guide for Discussion Many potential solutions not new: why are they still on the shelf? –Politically divisive? –Infeasible? –Cost ineffective? Innovative ideas