Advancing Health Care in California: CHCF's Philanthropic Mission

1. October 17, 2017 Welcome to CHCF!

2. Aristotle on Philanthropy “To give away money is an easy matter and in any man's power. But to decide to whom to give it and how large and when, and for what purpose and how, is neither in every man's power nor an easy matter.”

3. CHCF: Key Facts and Figures • Independent, nonprofit philanthropy • Founded in 1996 as a “conversion” foundation: • Conversion = when a nonprofit hospital, health care system or health plan is either acquired by a for-profit firm or converted to for-profit status • Strategic grant maker • Strategic = directs grants to address specific need(s) with defined impact in mind. Often contrasted with “responsive grant maker” (reacting to needs). • ~50 Employees • Offices in Oakland & Sacramento • Endowment of ~$750 million • Awards approximately $28-30 million in grants each year

4. CHCF’s Mission The California Health Care Foundation (CHCF) is dedicated to advancing meaningful, measurable improvements in the way the health care delivery system provides care to the people of California, particularly those with low incomes and those whose needs are not well served by the status quo. We work to ensure that people have access to the care they need, when they need it, at a price they can afford.

5. CHCF’s Goals Improving access to coverage and care for low-income Californians • Ensure low-income Californians have access to affordable health insurance coverage they can use. • Expand the capacity of safety-net organizations to provide timely, high-quality, and convenient care. • Support policies and care models that align with patient preferences, are proven effective, and are affordable. • Current funding priorities for this goal are: • Maternity care • Care for people with complex needs • End-of-life Ensuring high-value care Market analysis and insight • Provide easily accessible, timely, and reliable information to help spur positive change.

6. Laying a foundation for change:The Health Innovation Fund (IF) • Supports health care technology and service companies with the potential to significantly improve quality of care, lower the total cost of care, or improve access to care for low-income Californians. • Makes initial investments (not grants) of $500,000 to $1.5 million, with the expectation of a modest return that will then be reinvested in CHCF’s work. • Note: The IF team also makes grants to further IF-related projects (e.g., background pieces, evaluations, pilots). • Adheres to these investment criteria: • Significant Impact: Provide new or more timely access to care for 100,000 Californians and/or deliver $25 million in annual cost savings to the California health care system. • Strategic Alignment: Demonstrate a clear connection to CHCF's mission to dramatically improve quality, lower total cost of care, and/or improve access to care for low-income populations.  • Experienced Management Team: Employ a CEO and management team with a proven track record or the ability to attract such a team. • Scale and Sustainability: Leverage business models that show potential for significant growth and scale.

7. Laying a foundation for change:The External Engagement (EE) Team • In partnership with program staff, deploys its collective expertise in communications, state policy, digital publishing, and audience engagement to achieve CHCF’s goals. • Plays a leading role in maintaining and promoting CHCF’s brand and assuring that the brand evolves to reflect the organization and its goals as the Foundation grows and changes. • CHCF’s Top Audience Segments (the people we are trying to engage): • Networked leader: Highly connected leader responsible for the operation of organizations. • Policy wonk: Provides research and analysis for policymakers. • Influential amplifier: Has an established audience/network with whom they shares information • Focused champion: Shares specialized knowledge of the community they serves with colleagues. • Front-line provider: Gives information to patients and other providers.

8. CHCF’s Focus on Medi-Cal • NUMBERS: Medi-Cal is largest source of financing of coverage in California – no other program/payor touches/serves more people. (14 million enrolled today; 30% of state population.) • COST: Medi-Cal is the second largest item in state GF budget (only exceeded by k-12 education). $34B in GF 2017/18. Total budget (from all funds) $102B. A 1% savings to overall program costs represents $1B (all funds). • INFRASTRUCTURE: Medi-Cal’s infrastructure (plan contracts, eligibility system, etc) could be used as “chassis” for expansion to other populations such as undocumented adults or for other health care reforms/expansions such as a Medi-Cal Buy-In program for persons with incomes above Medi-Cal eligibility levels. • GROWTH: Medi-Cal is the only/fastest growing segment of the health insurance market; its size and market strength position it to have market-wide impact on health plans and delivery system partners.

9. Health Care WorkforceThe health workforce of the future will be influenced by the changing health care environment and expectations of the delivery system. • Team-based care • Integrated systems for clinical and community services • The changing role of primary care in care coordination and management • The integration of physical and behavioral health • Integration across the care continuum • Technology; medical/clinical innovations (e.g., telemedicine and e-consult) • The continuing development and adoption of HIT • Value-based care • Alternative payment models • Focus on the triple aim

10. Uneven Distribution

11. Distribution of Behavioral Health Providers Doesn’t Match Needs

12. CHCF’s Current Activity in Workforce

13. Opportunities for Targeted Improvement: Top 5% of Enrollees Account for More than Half of Medicaid Spending, FY 2011

14. Half have mental health and/or substance use disorders. • These individuals are among the most expensive users of health care and have the poorest health outcomes. The 5/50 Population: Estimated 650,000 in Medi-Cal • Source: The Faces of Medicaid III: Refining the Portrait of People with Multiple Chronic Conditions Center for Health Care Strategies, Inc., October 2009

15. Distribution of Spending Among Medi-Cal Eligibles Individuals Eligible For Medi-Cal Only Participating In FFS, FFS_MC, MC Eligibles = 7,914,215, Total Spending = $26 Billion Per Member Per Month (PMPM) = $340 Consistent with other research on this topic, RASD found that a small percentage of individuals accounted for a disproportionately large share of Medi-Cal’s total spending. Just 10% of Medi-Cal’s population accounted for roughly 64% of total spending on individuals eligible for Medi-Cal only. The most costly 1% of the Medi-Cal eligible only population accounted for 27% of all spending, while the most costly 5% accounted for over half of all spending on Medi-Cal eligible individuals. The least costly 50% of the population accounted for just 9% of total spending. Source: DHCS Research and Analytic Studies Division

16. Health Care Utilization With Multiple Conditions: Individuals Treated for Diabetes Eligible For Medi-Cal Only Participating in FFS Adults 18+, N = 100,680 Multiple comorbidities greatly impacted ED health care utilization. Some conditions, when combined with mental health, had a dramatic impact on health care use. For example, individuals treated for diabetes, serious mental illness, and alcohol and drug dependency displayed emergency room department use rates that are up to 7 times greater than individuals treated for only diabetes. Acute care hospital inpatient days per 1,000 member months also increased with the presence of multiple co-morbidities. Individuals treated for diabetes and serious mental illness or alcohol and drug dependency produced an acute care hospital inpatient rate of 795, a rate that was nearly 3 times greater than those treated for diabetes only. Source: DHCS Research and Analytic Studies Division

17. Depression is Expensive50 % higher Annual Health Care Costs =# 1 Diagnosis in driving Disability Costs in US Annual Cost ($) Chronic disease score Source: Unutzer J, et al. JAMA. 1997;277:1618-1623.

18. Mental Illness Prevalence in California Percentage of population Source: Holzer, Charles and Nguyen, Hoang, Estimation of Need for Mental Health Services. Accessed from http://charlesholzer.com/ on October 10, 2016.

19. Abuse or Dependence on Alcohol or Illicit Drugs in California Population age 12 and over (in 000s) Source: SAMHSA, Center for Behavioral Health Statistics and Quality, National Survey on Drug Use and Health, 2013 and 2014. Table 20. http://www.samhsa.gov/data/sites/default/files/1/1/NSDUHsaeCalifornia2014.pdf accessed 10/30/2016.

20. Equity Adults with SMI by Income in California: Strong Relationship between Poverty & SMI Percentage of Adult Population Source: Holzer, Charles and Nguyen, Hoang, Estimation of Need for Mental Health Services. Accessed from http://charlesholzer.com/ on October 10, 2016.

21. “Specialty Care” or “Segregated Care” ? The two primary systems of care for Medi-Cal beneficiaries with mental health conditions: County MHPs: Responsible for authorization and payment of a full continuum of specialty mental health services, including inpatient/post-stabilization services, rehabilitative services and targeted care management for beneficiaries meeting statewide medical necessity criteria. MCPs / DHCS FFS: Responsible for outpatient mental health services, including psychotherapy and medication management for beneficiaries with “mild-to-moderate” mental health conditions. Source: Harbage Consulting

22. California’s Siloed System Results in Most Behavioral Health Conditions Left Untreated Source:Wang PS, Lane M, Olfson M, Pincus HA, Wells KB, Kessler RC. Twelve month use of mental health services in the United States: results from the National Comorbidity Survey Replication. Arch Glen Psychiatry, 2005.

23. “Mild-to-Moderate:” Varied Definitions Across the State Behavioral Health Severity Mild Moderate Severe Often managed in primary care • Many mild BH disorders are treated in PCP settings—goal is improve DX & rapid care • PCP support including PCP Toolkit, Psychiatric Consultation, and psychotropic drug monitoring • MH and SUD screenings including SBIRT and PHQ 9 • Co-location of BH staff • Specialist referrals when indicated with eventual return to PCP setting • Ensure rapid access for priority referrals • Reimbursable family therapy, collateral and care coordination, where appropriate • Peer support services • Use of rehab option, targeted case management, and array of community recovery services • Data Sharing to understand overlapping population and target interventions • Collaborative care with medical services provided in community mental health center or other specialty BH setting Managed by County Mental Health System Needs refinement and tailored services

24. High Health Care Costs Mental health specialty care accounts for only 3 % of overall costs. More effectively integrated mental health care could save billions. * APA Milliman report; Melek et al; 2013

25. It’s the Triple Aim, Stupid Whole Person Care Is Key to Controlling Costs Source: DHCS, Understanding Medi-Cal’s High Cost Populations (May 2015). Available at www.chcf.org/events/2015/medical-data-symposium

26. Strategy for Change • Integrated care “results from a practice team of primary care and behavioral health clinicians, working together with patients and families, using a systematic and cost-effective approach to provide patient-centered care for a defined population. This care may address mental health and substance abuse conditions, health behaviors (including their contribution to chronic medical illnesses), life stressors and crises, stress-related physical symptoms, and ineffective patterns of health care utilization.” • - Safety Net Medical Home Initiative, 2014 Whole Person Care Requires Integrated Care

27. Moving Beyond BHI and Collaborative Care to “Integrated Complex Care” Improve physical and behavioral health care integration Increase patient-focused, data-driven, team-based care Increase complex care management and population health management Improve population health outcomes, patient experience, health care team experience, and as a result, reduce total health care costs Lay the groundwork for value-based payment Increase use of quality improvement methods

28. For People with Complex/Chronic Health Conditions, Team-Based Care Differs 5 / 50 SMI Lives Here Many Studies tell us that Care Management needs vary for different populations. (Intermountain Healthcare, University of Washington AIMS Center, Oregon Health & Science University, UCSF, etc.) Source: Marc Avery, MD University of Washington

29. Focusing on the 5%/50% Target Population in Primary Care

30. Integrated Complex Care (ICC) Management Model Components Source: Jennifer Clancy, MSW JCC Consulting

31. Past, Present, and Future?Will Medi-Cal Fully Integrate BH with Physical Health Funding?Will Primary Care Provide Integrated Complex Care for SMI? Source: Inland Empire Health Plan