San Francisco Department of Public Health : Readiness for Health - - PowerPoint PPT Presentation

San Francisco Department of Public Health:

Readiness for Health Reform

Health Management Associates Presentation to the SF Health Commission October 1, 2013

SFDPH Under Health Reform: Opportunities

• Health reform will move many currently uninsured patients into coverage that could

bring in additional revenue to support the services provided by SFDPH.

• Newly covered patients, and current MediCal patients, will move into managed care

plans that will require that patients receive access to a full array of health care services—most all of which are currently provided within the SFDPH system.

• SFDPH has always cared for these patients and has unique experience that will be

critical in shaping a care model that addresses their needs.

• The experience with Healthy San Francisco has helped SFDPH define needs and

utilization patterns of the patient population who will moving into coverage.

• SFDPH has long-established partnerships—SF Health Plan, Consortium Clinics, UCSF,

CBOs, etc.—that will be beneficial in meeting the demands of the new paradigm.

SFDPH Under Health Reform: Challenges

• Because Healthy San Francisco has covered most previously uninsured, it will be

important to keep those patients already in the SFDPH system—only about 1/3.

• SFDPH has a wealth of high quality and comprehensive services, but they have often

functioned in silos; further, institutionalization has been emphasized to a greater degree than in the country as a whole and will be problematic under managed care.

• SFDPH will need to meet managed care requirements to keep patients, including

timely access to services, coordination between all levels of care, and accurate data reporting.

• Financial accountability will be critical to assure appropriate allocation of resources.
• SFDPH will need to enter into creative relationships—with new expectations and

assurance of performance-- with their partners to assure a comprehensive network in which its patients are cared for in the right place at the right time.

SFDPH-HMA Partnership in Readiness for Reform

• SFDPH has been preparing for reform for more than two years and has

involved all levels of the Department in the planning process.

• The focus of HMA’s effort over the past six months has been to partner with

SFDPH leadership to develop a truly “integrated delivery system” that assures effective use of all SFDPH resources to address reform challenges and

• pportunities.
• Work has been accomplished through assessment of findings, Action Teams,

concentrated coordination with SFDPH leadership.

• HMA has been facilitating the production of deliverables in critical areas:
• overall change management and organizational development;
• managed care strategy and interim staffing/leadership;
• clinical reorganization, with a particular focus on ambulatory care;
• financial forecasting, tool development, strategy going forward.

General Findings: Clinical Organization

• SFDPH has excellent people, facilities, and a scope of services beyond any

similar system in the nation.

• There is the opportunity to build a national model for comprehensive

management of the population’s health by connecting current programs, contractors, primary care, and hospital components—but need to significantly change current approach.

• Services currently operate in silos, with multiple case management programs

and different information systems, etc. There is the potential for patients to be lost between the levels of care or services to be duplicated.

Clinical Organization, continued

• Primary care access to a Medical or Health Home is a critical requirement for

the patients to be served within SFDPH, and the capacity exists if productivity and limitations on infrastructure—phones, IT—are addressed. May need an interim “surge” to keep existing patients.

• SFDPH clinical organization and budget allocation heavily focused on

institutionalization (acute IP, LHH) and housing at a level that appears excessive compared to other safety net systems. Patients “get stuck” at different levels— this can lead to poor patient outcomes and critical financial problems for the system.

Clinical Organization, continued

• Behavioral health is a major opportunity for SFDPH but it needs to be better

integrated into the delivery system. More than 60% of BH patients currently get primary care outside of SFDPH (or not at all).

• Access to outpatient specialties will require significant collaboration with

UCSF to assure that resources are allocated to meet the needs of SF Health Network’s population, including both SFDPH patients and those referred by partners.

• Laguna Honda Hospital is a critical partner in assuring that patients do not

remain in acute inpatient care unnecessarily and building services (i.e., rehab) for the entire network and potentially other contractors.

Clinical Organization, continued

• A system-wide approach to IT is critical for meeting managed care reporting

requirements, for assuring transferal of patient information throughout all levels of the network, and for maintaining and evaluating utilization and quality performance metrics. This is an investment that must be made.

• The SFDPH currently does not evaluate its performance as a “system,” but,

rather, as individual components. The model of care must be set throughout all levels of care and the evaluation must be built around the success in assuring that all of the network’s patients got the right care at the right place at the right time.

• SFDPH has strong and smart delivery system leaders that can be brought

together to form an integrated network. Medical staff leadership will need to be cultivated as well.

General Findings: Finance and Managed Care

• Limited financial information and tools have been given to managers to assure

accountability.

• The growth rate in SFDPH spending is approaching 7% (i.e., wages/benefits, UCSF

contract, CBO contracts)—although not enough on critical infrastructure.

• There is a flat or decreased revenue forecast (i.e., realignment, no supplemental for

Covered California, decreased DSH, no supplemental for duals impacting LHH, DSH will no longer pay for excessive number of admin and denied days at SFGH)—and this forecast assumes ALL CURRENT PATIENTS ARE RETAINED.

• The lack of IT is a critical financial and managed care problem.
• Managed care will require holding entire system—not silos—accountable.
• Unlike other communities, little back-fill of patients after health reform.
• Clinical change (i.e., primary care access) will be critical to take advantage of State

initiatives like 75% auto-assignment to County systems.

Finance and Managed Care, continued

• There was no vehicle for retaining Healthy San Francisco patients going to the

insurance exchange (Covered California).

• Needed contractual partners to fill hospital as, under managed care, SFDPH patients

would not be enough to fill acute beds with appropriate patients (currently, extremely high level of patients who don’t need to be in the hospital).

• The estimation of the new hospital transition costs will require significant planning

for the role of SFGH in an integrated delivery network.

• There was no comprehensive SFDPH Managed Care Office.
• Out of Network costs are high and need to be contained—in connection with clinical
• rganization transformation into one delivery system.
• Overall high costs will be detrimental in contract negotiations.
• UCSF-SFDPH contract should be examined to align accountabilities and incentives in

preparation for health reform.

Examples of Initiatives for Financial Performance

• Physical health utilization improvements, denied administrative days, and LOS
• Behavioral Health reduction in denied days
• Out of network costs
• LHH rehabilitative focus
• Reduction in need for Patch Payments
• Nurse staffing
• Primary care shadow panels
• Conversion of behavioral health only patients to SFDPH complete coverage
• Specialty physician billing

$0 $100,000 $200,000 $300,000 $400,000 $500,000 $600,000 $700,000 $800,000 $900,000 $1,000,000 FY2013-14 Budget FY2014-15 (Year 1) FY2015-16 (Year 2) FY2016-17 (Year 3) FY2017-18 (Year 4) FY2018-19 (Year 5) 555,351 468,551 469,001 470,184 471,351 472,492 115,141 161,329 188,775 201,778 216,758 234,155 119,290 118,685 118,764 111,088 91,045 87,940 125,651 101,237 101,237 101,237 101,237 101,237

Projected Trend of FFS, Managed Care, DSH and Realignment Revenues FY13-14 Budget and Forecast Years 1 - 5 ($000)

Realignment DSH Managed Care (Capitation) FFS

Actions Taken to Address Findings

• Organizational structure for SF Health Network developed, action targets

established, leadership positions drafted and recruitment underway.

• Financial tools developed and are being implemented.
• Vehicle established for keeping Covered California lives.
• A Managed Care Office has been established.
• Agreement between SFDPH and UCSF has been reached to make managed care

capitation more transparent.

• New opportunities have been identified for increased reimbursement for LHH and

primary care within SFDPH.

• A financial forecasting tool has been developed to allow assessment of financial

impact of variables—as much is likely to change.

• Review of current UCSF contract completed to identify priority areas for discussion.
• Began the development of a new structure for SFDPH finance to support integrated

network.

Actions Taken to Address Findings, continued

• Reached agreement across system to increase and standardize panel size to assure

medical home capacity in primary care clinics (both in community and in hospital) for network patients.

• Expanded the role of nurse orientation clinics to link patients with the system

immediately and determine who needs to see a provider.

• Identified sites for pilots on health homes to increase BH patients receiving primary

care within the network.

• Analyzed specialty need to set priorities for SF Health Network population.
• Established priorities for hospital and community-based coordination to minimize

admin and denied days, decrease out-of-network costs and assure best care for patients.

• Began the development of a national model for care coordination.
• Developed a potential role for network-wide medical leadership.

The Vision for SFDPH Under Health Reform

• SFDPH will create the “SF Health Network,” which will:
• consolidate all of its health care elements into one integrated delivery

system, maximizing the effective use of resources and enhancing the

• verall experience of its patients;
• provide and manage the care for a defined population;
• build an integrated operational infrastructure (including managed care

elements) that assures gaps are filled and duplication is eliminated and that resources are targeted appropriately;

• assure that all patients are cared for in the right place at the right time; and
• provide an ability to relate to other providers, to health plans as a

consolidated system, rather than individual services.

SFDPH Vision, continued

• In addition to the SF Health Network, SFDPH will provide services needed by

the entire San Francisco community (i.e., trauma, HIV/AIDs, behavioral health, long term care), beyond those that are needed for the Network.

• SFDPH will continue to expand its Population Health role in assuring that all

San Franciscans live in a healthy and safe environment and have access to the health care services that they need. SFDPH will also continue to monitor the effectiveness of the health system, including its own services, in addressing health care disparities and assuring that all populations and communities improve their overall health status.

San Francisco Department of Public Health

SAN FRANCISCO HEALTH NETWORK (INTEGRATED DELIVERY SYSTEM) (SFHN) POPULATION HEALTH HEALTH SERVICES FOR WHOLE COMMUNITY

Health Status Indicators to Evaluate SFH Services Required for SFH

The Reorganization of SFDPH to Support Integrated Delivery of Care

• Over the next year, SFDPH will be restructuring its organization in order to

create the SF Health Network, its integrated delivery system.

• The process will include changing reporting lines, setting clear goals and

assuring that they are met, establishing new entities (like a managed care

• ffice), filling newly-created leadership positions, refining its relationships

with its contractors to assure a shared vision and focus, implementing financial management tools to assure accountability, and entering into strategic partnerships to support the effective and comprehensive delivery of care.

• This massive effort has been well-planned; it is now ready to roll out.

San Francisco Department of Public Health

Health Commission Director of Health Finance SF Health Network San Francisco General Hospital Laguna Honda Hospital Managed Care Transitions Ambulatory Care Primary Care Behavioral Health Maternal, Child, and Adolescent Health Jail Health Policy & Planning Human Resources Information Technology Population Health Operations, Finance, and Grants Management Environmental Health Protection, Equity & Sustainability Community Health Promotion Disease Prevention & Control Public Health Emergency Preparedness & Response Emergency Medical Services Center for Learning & Innovation Applied Research, Community Health Epidemiology & Surveillance Center for Public Health Research Bridge HIV Public Health Accreditation, Equity & Quality Improvement Public Information Compliance Executive Secretary

Priorities: Next Three Months

• Establishing SF Health Structure and Leadership
• Providing access to a Medical/Health Home for all patient members of the

Network

• Increasing Behavioral Health integration into the Network and piloting Health

Homes

• Engaging UCSF to participate in efforts to improve access to Subspecialty Care

within the Network

• Budgeting through “Triple R” (reductions, reprioritization, revenue

generation)

• Securing commitment to IT and other key infrastructure investments
• Developing the new hospital budget based on its role in the Network

Priorities: Next Three Months, continued

• Aligning contract partners with Network approach
• Initiating aggressive communication plan throughout SFDPH (including

physicians) as well as key stakeholders and partners

• Building a culture of financial accountability—understanding that the

environment will grow more complex every day

• Establishing, supporting and holding accountable Network and SFDPH

leadership to guide Department through health reform changes