Healthy San Francisco Program: Providing Universal Access to Care Insure the Uninsured Project

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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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