1. 1 Healthy San Francisco Program: Providing Universal Access to Care Insure the Uninsured Project Bay Area Workgroup (Roundtable on Local Efforts) Tangerine Brigham and Danice Cook September 16, 2009

2. 2 Healthy San Francisco  Effort to improve access to care for uninsured adult residents without relying on expansion of health insurance  Provides universal, comprehensive, affordable health care to uninsured  Universal – available to uninsured residents regardless of employment status, immigration status or pre-existing conditions  Comprehensive – services include, primary, specialty, x-ray, pharmacy, emergency, hospital, behavioral health, etc.  Affordable – fees are based on income and family size (FPL) and participants with incomes below 100% FPL pay no program fees  Program available to those with incomes up to 500% FPL ($54,150 for one person; $110,250 household of four)  Weaves together existing health care safety net into a coordinated system of public/non-profit/private providers

3. 3 HSF is Local Health Reform Effort  HSF is part of a comprehensive San Francisco effort to address access to health care – Health Care Security Ordinance (includes Employer Spending Requirement)  Options available to local government are more limited than those available to either state or federal government  HSF expands access without relying on the creation of a publicly-funded, local health insurance product  HSF not designed to disrupt health insurance market  Since HSF is a voluntary program, not anticipated that all uninsured adults will enroll

4. 4 Program Goals  Access  Improve access to care via the primary care medical home  Expand access by increasing the number of clinics/providers participating in HSF  Promote Appropriate Levels of Care  Document appropriate utilization of preventive services, decreases episodic care and decreases in ambulatory care emergency room visits or hospitalizations  System Improvements  Give providers access to better health data to facilitate the monitoring health status and outcomes  Implement a single county-wide eligibility/enrollment system to reduce barriers to entry for applicants and participants  Document the financial viability of the program

5. 5 Participant Goal -- HSF feels like an organized health care program  Broad-based network of providers  Choice of medical homes  Comprehensive services  Affordable fee structure  Common eligibility and enrollment system  Identification card  Participant handbook  Centralized customer service

6. 6 HSF Enrollment – 46,400 Participants (77% Uninsured)  70% below 100% FPL; 22% are 101%-200% FPL; 7% between 201-300% FPL; less than 1% above 300% FPL  52% male; 48% female  39% Asian/Pacific Islander; 25% Hispanic; 18% White; 9% African American; less than 1% Native American; 3% Other; 5% Not Provided  11% under 25 years old; 41% b/w 25 - 44 years old; 24% b/w 45 - 54 years old; 24% b/w 55 - 64 years old  50% English; 27% Cantonese/Mandarin; 19% Spanish; 1% Vietnamese; 1% Filipino (Tagalog/llocano); 2% Other  14% are homeless individuals

7. 7 HSF Provider Network Strategy  HSF services provided through a public/private partnership  Provider network broader than the Department of Public Health (DPH) by design:  DPH does not have the capacity to be the sole provider of care to the uninsured  Before HSF, several safety net providers cared for uninsured and desire to preserve these patient/provider relationships  HSF creates a coordinated system of care for the uninsured  Provider network capitalizes on:  Existing safety net  Array of primary care providers  Provision of charity care by hospitals

8. 8 HSF Providers  Primary care medical homes  Public DPH (1 entity, 14 sites)  Non-profit SFCCC (8 entities, 13 sites)  Non-profit Sr. Mary Philippa (1 entity, 1 site)  Private physician’s group CCHCA (1 entity, multiple sites)  Non-profit health plan Kaiser Permanente (1 entity, 1 site)  Hospitals – for inpatient and specialty services  Public (1): San Francisco General Hospital  Non-profit (4): Catholic Healthcare West, California Pacific Medical Center, Chinese, UCSF Medical Center  Behavioral health services  Primarily through Community Behavioral Health Services  At some primary care medical homes

9. 9 Monitoring and Ensuring Access to Care  Segment HSF participants (self-identified at time of application)  74% Existing  26% New (not used medical home within 2 years)  Expansions in public (DPH) health care delivery system  Hiring new clinicians  Expanding clinic hours and additional exam rooms (primary care)  Expanding e-referral (specialty care)  Developed system to facilitate first clinical appointment for new participants that select a DPH medical home  Increased number of providers serving HSF participants  Not limited to public sector or non-profit community clinics  Two provider network expansions since program was implemented  Monitor primary care clinical capacity by surveying clinics twice a month for “open” versus “closed” to accepting new participants

10. 10 Healthy San Francisco and Health Care Coverage Initiative  Health Care Coverage Initiative (HCCI) covers a subset of HSF participants  Not all HSF participants are HCCI eligibles  But, all HCCI eligibles are HSF participants  HCCI status is “invisible” to the eligible HSF participant  They understand HSF eligibility  Outreach materials do not state “HCCI”

11. 11 Health Care Coverage Initiative (HCCI)  Three years of federal reimbursement for subset of HSF participants who meet HCCI eligibility criteria  DPH target enrollment of 10,000 over 3 year period  Target Met:  11,000 HSF participants have received HCCI designation since HCCI began on September 1, 2007  Challenge of collecting required identification and citizenship documentation  Similar experiences in most other counties  Funding  DPH has received reimbursement for services provided to HCCI designees  DPH has not received funding for administrative costs (neither has any other HCCI county)

12. 12 HSF Service/Utilization Findings  78% of participants utilized primary care services within a 12 month period (April 2008 – March 2009)  First to second year data indicates a 27% decrease in ER visits per 1,000 participants (216 to 157)  Hospital utilization among HSF participants is lower than that found within Medi-Cal (Medicaid) [among adults enrolled with San Francisco Health Plan]  7.9% of the ER visits for participants were avoidable (i.e., the visit could have occurred in a primary care setting); rate is lower than that of a San Francisco public HMO serving adult Medi-Cal recipients (15%)

13. 13 Participant Feedback Findings  An independent participant satisfaction survey conducted by Kaiser Family Foundation found  94% of participants were satisfied with the program  4 out of 10 revealed improvements in access to care  86% reported having a usual source of care  86% found the enrollment process easy  From July 2007 to June 2009 (a two-year period), the program’s customer service logged only 531 participant complaints with respect to access/quality of care/quality of services/ enrollment

14. 14 HSF Financing and Costs  Prior to HSF, County allocated General Fund to provide services to indigent, low-income and uninsured patients – still does under HSF  Incremental revenues to support HSF include:  Federal Health Care Coverage Initiative reimbursement  Employer Spending Requirement contributions  Participant fee contributions  DPH financial data indicate that for 2008-09, estimated HSF expenditures were $125.65 million with revenue of $36.08 million, and a City and County General Fund subsidy of $89.57 million  Based on estimated participant months, the monthly estimated per participant cost was $298 (or $3,580 annually)

15. 15 Additional Program Highlights  HSF has identified roughly 5,000 residents who were eligible for, but not enrolled in public health insurance (e.g., Medicaid) – thereby helping reduce the number of uninsured residents  To date, 980 employers have selected the City Option (which includes HSF) on behalf of 42,300 employees to meet the Employer Spending Requirement  HSF has expanded access to care -- 26% of the program participants are residents who had not received services from a primary care medical home within the last two years

16. 16 Generalizable HSF Features  Most critical feature imbedded in HSF is for an urban area to identify all of the existing safety net providers (public and private) and knit them together into a comprehensive health care delivery system  Other features  Focus on primary care medical home to reduce duplication and improve coordination  Centralized eligibility system to maximize public entitlement and reduce barriers to entry  Non-insurance (care) model that can potentially result in lower costs and leverage federal/state funds for localities  Establishment of predictable and affordable participation fees  Public-private partnership to maximize available resources