1. Leading the Transformation from Provider to Provider, Payer and Plan While Focusing on the Patient 2013 Griffith Leadership Center Symposium Ann Arbor, Michigan Dr. Ram Raju, CEO Cook County Health and Hospitals System (CCHHS) October 2013 2

2. CCHHS at a Glance 2 hospitals - Level 1 Trauma Center - 175,000 ED visits Ambulatory Network – 16 health centers – Ruth M. Rothstein CORE Center – Immediate Care Center – 600,000 visits annually Certified public health dept Correctional health services Teaching & research affiliations 6,700 employees 700 doctors 1,600 square mile county area Medicaid is largest payer $600M in uncompensated care County tax funds historically supported up to half of costs Aging infrastructure; underfunded reinvestment Nation’s third largest public hospital system; $1B budget; largest proportion of uninsured patients

3. Health Plan Opportunity Afforded by ACA 2013-2014 Agenda: Leverage ACA opportunity to build a health plan that extends coverage to previously uninsured adults and families, and drives system transformation through community provider collaboration and fully capitated reimbursement design 2013 Launched “CountyCare” providing coverage for low income adults through Federal 1115 Waiver demonstration program in collaboration with the state Medicaid program 2014 and beyond Create a sustainable Medicaid managed care plan as well as a Marketplace plan covering employees, patients and small businesses

4. CountyCare Structure Federal 1115 Waiver permitted creation of a primary care-oriented, financially viable County-wide CountyCare provider network CountyCare was the first CCHHS effort to establish system-wide contractual relationships with other providers CountyCare currently contracts with all FQHCs and their hospital partners -Allows members to obtain care in their own neighborhoods as well as within the CCHHS system -Permits member access to all area academic medical centers Plan eligibility is tied to Medicaid rules—undocumented remain uninsured CountyCare is structured as full-risk capitated plan, paying claims in first year on fee-for-service basis

5. CountyCare: Early Impact CountyCare was implemented in 2013 well before other elements of health reform were initiated Grassroots information and outreach for CountyCare is meeting with unprecedented success: 110,000 low income County adults applied in first 9 months CountyCare represented the first Medicaid coverage in decades available to some low income groups—students, women without dependent children, men CountyCare coverage provided new purchasing power in the community-- can be used at local pharmacies FQHCs in the CountyCare provider network received timely payment for members at their enhanced FQHC Medicaid rate Timely payment of fee-for-service claims for formerly uninsured population stabilized the entire system of care

6. CountyCare Sustainability Post-waiver (January 1, 2014), CountyCare continues as a Medicaid managed care contractor through a state-authorized mechanism for provider-led plans; minimal reserve requirement Primary care and subspecialty consultation capacity gaps will be met through network expansion and service integration (CCHHS is currently close to capacity) CountyCare revenue will allow CCHHS to invest in patient while drawing on a lower level of County taxpayer subsidy Administrative goal is to move the provider network toward full-risk arrangements with the plan Contractual intermediary manages back office functions

7. Plan Expansion State Medicaid moves to mandatory managed care for women and children in summer 2014; CountyCare will participate. CCHHS is currently working to create a plan to be included in the Marketplace: -using same provider network -ready for October 2014 open enrollment -targeting County employees, patients, small businesses, individuals -resource for uninsured over 138% of poverty in CCHHS system and in the community

8. Competitive Landscape--Adults CCHHS enters 2014 with strong Medicaid adult market share Voluntary plan coverage for employees reduces burden of CCHHS insurance cost CCHHS Marketplace plan will enter with low premium structure Cook County uninsured adults:818,000 Undocumented/no new path to coverage175,000 Newly eligible:643,000 Newly eligible for Medicaid: 270,000 Newly eligible for Marketplace--with subsidy296,000 Newly eligible for Marketplace—no subsidy 77,000 Source: CCHHS estimates based on Health and Disability Associates data

9. Transformation and ACA Health reform provides new reimbursement opportunities leveraged to increase coverage and access…But coverage and access alone are insufficient to meet the promise of health reform Full-risk capitated plans can drive transformation—pushing toward health promotion, primary care, home and community-based services, service integration, care management and behavioral health Much intervention can be accomplished outside the health care delivery system through creative partnerships, i.e. churches, community organizations, schools

10. 4 Ps—Provider, Plan, Payer, Population CCHHS is the only Illinois entity engaged in a “4Ps” transformation—drawing on a sufficiently comprehensive approach to address population health goals Provider Delivery of direct CCHHS services Plan Development of CountyCare and Marketplace plans with enrolled membership and expansive network Payer Provision of affordable coverage for County employees through Marketplace plan Population Administration of public health services and activities to improve population health

11. Driving Toward a Population Focus Need all four “Ps” to achieve population goals in Cook County—to generate financial resources which in turn are invested to drive change Fully capitated plan with large primary care network drives models of care toward patient-centered, home- and community-oriented practices Quality and patient satisfaction impact model design and reimbursement strategies Large plan and population focus helps to identify resource gaps and to pursue solutions including reimbursement design, increased clinical integration, and training and recruitment strategies

12. Infrastructure for Population Health Collaboration between state agencies and CCHHS (including the Cook County Department of Public Health) fosters: Integration Innovation--for specific populations, such as partnerships to reach and serve justice-involved patients Population Health Innovation--such as promotion of health behaviors, both outside of and integrated within delivery systems Workforce Innovation--including creation of new, sustainable health worker roles Innovative Training and Learning Mechanisms—to disseminate and replicate leading practices

13. More to Do Network that attends to special populations Innovation in delivery of care--right level, right place Continuum of medical and non-medical community services that attend to well-being Graduate medical education that fosters primary care and population health-oriented training Escalation of risk-based models and demonstration of cost savings Program for remaining uninsured—undocumented and those not able to purchase, even with subsidy