2011-12 Healthy San Francisco Annual Report Presented to San - - PowerPoint PPT Presentation

2011-12 Healthy San Francisco Annual Report

Presented to San Francisco Health Commission September 18, 2012

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Outline

 Milestones, HSF-SF PATH Transition & HCSO  Enrollment Trends & Participants Demographics  Service Delivery System & Utilization  Participant Experience & Satisfaction  Expenditures & Revenues  ACA Preparations

Five Years and Counting (A Few Key Milestones)

8/2006: Health Care Security Ordinance approved 7/2007: HSF launches as 2 clinic pilot 2/2009: Strength in Numbers launched in partnership with San Francisco Health Plan 8/2009: Kaiser Family Foundation survey finds 94% participant satisfaction 6/2011: Ends 4th year having served

• ver

100,000 uninsured adults 8/2011: Mathematica releases independent evaluation and finds HSF meeting its goals 2/2012: One

• f 6 finalist

in 2011 Innovations in Gov’t competition (Kennedy School) June 2012 forward: ACA preparation with Supreme Court ruling

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HSF- SF PATH Transition

 July 2011 movement of over 10,000 HSF participants into a new statewide, federally-supported health program (called SF PATH in San Francisco) in preparation for ACA individual health insurance mandate effective Jan. 2014  SF PATH’s provider network is the Dept. of Public Health  Disenrolling over 10,000 HSF participants impacts FY2011-12 HSF statistics:

• Enrollment
• Service utilization
• Customer service
• Expenditures and revenues

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Health Care Security Ordinance (HCSO) Amendment

 Mandates that certain employers make employee health care expenditures  Expenditure options under the Employer Spending Requirement (ESR) vary

• Health Insurance
• Reimbursement Plans
• Direct Reimbursement
• City Option (HSF or Medical Reimbursement Account)

 Analysis of calendar year 2010 found that among employers who had elected to use reimbursement plans, on average 20% of funds used by employees  Board of Supervisors sought to address this unintended consequence  San Francisco Health Commission supported amending the HCSO  Board amended HCSO (Ordinance #232-11) and effective January 1, 2012

• Employers must post the Official OLSE Notice at every workplace or job site
• New requirements for employers that impose surcharges on customers to cover ESR costs
• New requirements for employers that utilize reimbursement accounts

 Amendments were not made to any HSF provisions 5

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Enrollment Trends

 Ended FY2011-12 with 46,800 participants (12% ⇓ from FY2010-11)  Combining HSF and SF PATH enrollment - a total of 57,270 adults (89% of uninsured) were served through health access programs  Has served over 116,000 unduplicated adult residents (enrolled and disenrolled)

2007-08 2008-09 2009-10 2010-11 2011-12 # of HSF Participants 24,210 43,200 53,428 54,348 46,822 % Uninsured Enrolled 33% 72% 89% 85% 73%

• 10,000

20,000 30,000 40,000 50,000 60,000 25,269 59,698 80,565 100,237 116,036

• 20,000

40,000 60,000 80,000 100,000 120,000 2007-08 2008-09 2009-10 2010-11 2011-12 # Ever Enrolled at End of Fiscl Year

Disenrollment Trends

 As enrollments ⇑ - disenrollments ⇑  Disenrolled participants can re- enroll without penalty, if eligible  Ended FY2011-12 with 69,214 disenrollments  Targeted retention rate of 52.5%  60% disenrollment rate in FY2011- 12 (69,214÷116,036 ever enrolled)  Of multiple disenrollments

• 60% of people were in HSF 10 – 12

months & 20% in HSF 12+ months

• Over 80% not due to participation

fee disenrolment, 2% related to two participant fee disenrollments

2011-12 Disenrollment Reason % Annual Renewal 58% Program Eligibility 21% SF PATH Transition 13% Participation Fee 8% Other/Voluntary <1%

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20.0% 34.0% 46.0% 60.0% 0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0% 2008-09 2009-10 2010-11 2011-12 Disenrollment Rate

Participant Demographics

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9% 43% 23% 25% 0% 10% 20% 30% 40% 50% 18-24 25-44 45-54 55-64 % of Participants

Age

4% 44% 16% 27% 1% 5% 3% 0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 50% % of Participants

Ethnicity/Race

Male 50% Female 50%

Gender

At/Below 100% FPL, 59% 101-200% FPL, 27% 201-300% FPL, 11% At/Above 300% FPL, 3%

Income

Ge nde r: inc lude s174 tra nsg e nde r pe rso ns

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Service Delivery System – Medical Home is Foundation

 HSF medical homes increased from 35 to 37 in FY 2011-12  SFCCC medical homes have 55%

• f HSF

enrollment with transition of over 10,000 HSF participants into SF PATH – all of whom had a DPH medical home  On average, 50%

• f HSF medical

homes were open to new participants

27 29 31 35 37 5 10 15 20 25 30 35 40 2007-08 2008-09 2009-10 2010-11 2011-12 # of HSF Medical Homes 1.0% 2.3% 2.7% 2.9% 6.0% 30.0% 55.0% 0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% BAART CCCHA SMP B&T Kaiser DPH SFCCC # of HSF Participants

Context for Service Utilization

 Trends examined in

• Preventive and primary care services
• Appropriate utilization
• Quality

 Calculation–rates per 1,000 participants per year

• Standard measure for reporting/comparing utilization
• Calculation is A multiplied by B:

 A: # of “things” in a month ÷ # of participants in a month  B: 1,000 * 12 (# of months) = 12,000

 Utilization analysis dependent upon complete data from all providers -- medical homes, hospitals, etc.

• 90% of hospital data is San Francisco General; likely underreporting

 Almost 63% of participants have a chronic condition – participants not evenly distributed across medical homes  HSF-SF PATH transition resulted in changes in utilization

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Overall Service Utilization Trends

 Over the past three years, the percentage of all HSF participants receiving at least one service (primary care/ specialty, inpatient and/or prescriptions) in a 12-month period has remained relatively constant

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Primary/Specialty Care Inpatient Admit Prescription 2009-10 75.4% 2.4% 47.9% 2010-11 73.3% 1.6% 45.5% 2011-12 74.6% 2.0% 48.9% 0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0% 80.0% Percent of Participants Utilizing at Least One Service

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Service Utilization (Primary Care & Appropriate Use)

 HSF participants continue to utilize primary care at the same rate as the National Medicaid Average – 3 visits per year  73% of HSF participants continuously enrolled received primary care visit  Emergency department utilization (133 per 1,000) is lower than state average (275 per 1,000) – note potential underreporting and HSF-SF PATH shift  Use of ED for avoidable conditions (8%) remains lower than State benchmark for Medi-Cal (18%)  Decreases in hospital admissions, acute hospital days, and average length of hospital stay – note potential underreporting and HSF-SF PATH shift

Service Utilization (Measurements of Quality)

 30-day hospital readmission rate

• f 7% is lower

than the 18% national rate (Agency for HealthCare Research and Quality)  Follow-up care after an inpatient discharge constant from 2009-10 to 2011- 12 at 72%  HSF met the National Medicaid Average for patients with asthma 13

80.4% 82.04% 82.34% 87.46% 86.90% 86.90% 86.90% 86.90% 76.0% 78.0% 80.0% 82.0% 84.0% 86.0% 88.0% 2008 2009 2010 2011 % of Individuals with Asthma Receiving Asthma Test Medication HSF Nat'l Medicaid Avg 67.85% 72.25% 72.43% 72.49% 72.18% 76.54% 76.96% 77.01% 63.96% 67.34% 67.55% 67.53% 60.00% 80.00% FY2008-09 FY2009-10 FY2010-11 July 2011 - Mar 2012 Follow-up Office Visit w/i 30 Days of Discharge All Participants With Chronic Disease Without Chronic Disease

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Participant Experience and Satisfaction - Complaints

 HSF participant complaint rate remained relatively constant at FY2011- 12 at 0.79 per 1,000 participants  435 complaints in FY2011-12 with top complaints in areas of access (21%) and quality of service (20%)

1.50 0.90 0.70 0.80 0.79 0.00 0.20 0.40 0.60 0.80 1.00 1.20 1.40 1.60 FY2007-08 FY2008-09 FY2009-10 FY2010-11 FY2011-12 Rate Per 1,000 Participants

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Participant Experience and Satisfaction - HAQ

 Health Access Questionnaire (HAQ) captures applicant’s self-reported pre- and post-HSF health access experience  Four year HAQ comparison for participants with continuous enrollment found no consistent response for general health, but consistent responses in the following:

a usual source of care; an improved rating of medical care ED utilization; difficulty accessing care; delays in getting care/medication; delays in care due to cost

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Employer Spending Requirement (ESR)

 Health Care Security Ordinance (HCSO) mandates that certain employers make health care expenditures on behalf of employees  City Option is available to employers – employees receive

• Healthy San Francisco or
• Medical Reimbursement Account

 By end of FY 2011-12, 1,427 employers had used the City Option to meet the ESR (from FY 2007-08 to 2010-11)  $40.96 million contributed to City Option in FY 2011-12

• $25.37 (62%) million for Medical Reimbursement Accounts
• $15.39 (38%) million for Healthy San Francisco

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HSF Financing and Costs

 Prior to HSF, County allocated General Fund to provide services to indigent patients – still does under HSF  In FY2011-12, incremental revenues to support HSF included:

• Employer Spending Requirement contributions
• Participant fee contributions

 Previous federal reimbursement shifted to supporting SF PATH under California’s new 1115 Medicaid Waiver

• Effective July 2011 HSF does not have budgeted federal

reimbursement

 SF PATH resulted in decrease in expenditures and revenues

Estimated HSF Expenditures and Revenues (4-Year Trend)

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Total Est'd Expenditures Non-DPH Provider Expenditures (Less HSF Funds) DPH Expenditures for HSF DPH Revenues for HSF DPH Revenues Less DPH Expenditures (General Fund Subsidy) 2008-09 $124,540,040 $124,540,040 $36,535,514 $88,004,526 2009-10 $163,887,568 $23,629,093 $140,258,475 $40,449,475 $99,809,000 2010-11 $177,774,847 $28,141,067 $149,633,780 $49,933,839 $99,699,941 2011-12 $139,865,602 $38,733,482 $101,132,120 $23,759,825 $77,372,295 $0 $20,000,000 $40,000,000 $60,000,000 $80,000,000 $100,000,000 $120,000,000 $140,000,000 $160,000,000 $180,000,000 $200,000,000 2008-09 2009-10 2010-11 2011-12

Estimated Per Participant Per Month (PM) Expenditures

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Estimated Per Participant Per Month Expenditure (DPH and non-DPH) DPH Per Participant Per Month Expenditure 2008-09 (421,058 PMs) $296 2009-10 (594,102 PMs) $275 $235 2010-11 (654,129 PMs) $271 $228 2011-12 (549,525 PMs) $255 $184 50 100 150 200 250 300 350 2008-09 (421,058 PMs) 2009-10 (594,102 PMs) 2010-11 (654,129 PMs) 2011-12 (549,525 PMs)

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Estimated DPH FY2011-12 Costs

• f Serving Indigent & Uninsured

 In addition to HSF uninsured participants, the Department provides services to uninsured individuals ineligible for HSF and/or in SF PATH, and provides services that are not in the HSF scope of benefits  Costs for HSF, Non-HSF and SF PATH uninsured populations estimated at $179.8M for 2011-12 (does not include behavioral health for non-HSF population)

Uninsured Patient Population Estimated Cost HSF Uninsured Population $78,157,725 Non-HSF Uninsured Population (not including LIHP) $61,541,624 LIHP/SF PATH Population $40,105,341 Entire Uninsured Population $179,804,690

HSF and ACA Preparations

 It is estimated that 60% of the combined HSF and SF PATH populations will be eligible for health insurance beginning January 1, 2014 (based on current enrollment)  First foray  In January 2014 HSF will have been in operation for 6.5 years and in many respects San Francisco will be ahead of the curve

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HSF (9/2007) SF PATH (7/2011) Med-Cal or HBEX (1/2014)

24,000 (51%) HSF 10,500 (100%) SF PATH 34,500 (60%) Combined

HSF and ACA Preparations

 Transitioning population (into insured status)

• Community-wide communications/outreach to

supplement Statewide communication activities

• DPH and HSA partnership
• Monitoring California Health Benefits Exchange

 Qualified Heath Plans  Customer Service  Navigators

 Residually uninsured

• Maintenance of HSF
• Advocate for continuance of State Realignment

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QUESTIONS