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Healthy San Francisco Program: Providing Universal Access to Care

Insure the Uninsured Project Bay Area Workgroup (Roundtable on Local Efforts)

Tangerine Brigham and Danice CookSeptember 16, 2009

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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

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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

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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

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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

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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

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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

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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

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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

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Healthy San Francisco and Health Care Coverage Initiative

Health Care Coverage Initiative (HCCI) covers a subset of HSF participantsNot all HSF participants are HCCI eligiblesBut, all HCCI eligibles are HSF participants

HCCI status is “invisible” to the eligible HSF participantThey understand HSF eligibilityOutreach materials do not state “HCCI”

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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)

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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%)

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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

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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)

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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

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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