Leading the Transformation from Provider to
Provider, Payer and Plan
While Focusing on the Patient
2013 Griffith Leadership Center Symposium
Ann Arbor, Michigan
Dr. Ram Raju, CEO
Cook County Health and Hospitals System (CCHHS)
October 2013
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CCHHS at a Glance
Nation’s third largest public hospital system; $1B budget;
largest proportion of uninsured patients
• 2 hospitals
- Level 1 Trauma Center
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175,000 ED visits
• Ambulatory Network
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16 health centers
Ruth M. Rothstein CORE Center
Immediate Care Center
600,000 visits annually
• Certified public health dept
• Correctional health services
• Teaching & research affiliations
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6,700 employees
700 doctors
1,600 square mile county area
Medicaid is largest payer
$600M in uncompensated care
County tax funds historically
supported up to half of costs
• Aging infrastructure; underfunded
reinvestment
Health Plan Opportunity Afforded by ACA
2013-2014 Agenda: Leverage ACA opportunity to build a health plan that
extends coverage to previously uninsured adults and families, and drives
system transformation through community provider collaboration and fully
capitated reimbursement design
2013
Launched “CountyCare” providing coverage for low income adults through
Federal 1115 Waiver demonstration program in collaboration with the state
Medicaid program
2014 and beyond
Create a sustainable Medicaid managed care plan as well as a
Marketplace plan covering employees, patients and small businesses
CountyCare Structure
• Federal 1115 Waiver permitted creation of a primary care-oriented, financially
viable County-wide CountyCare provider network
• CountyCare was the first CCHHS effort to establish system-wide contractual
relationships with other providers
• CountyCare currently contracts with all FQHCs and their hospital partners
-Allows members to obtain care in their own neighborhoods as well as
within the CCHHS system
-Permits member access to all area academic medical centers
• Plan eligibility is tied to Medicaid rules—undocumented remain uninsured
• CountyCare is structured as full-risk capitated plan, paying claims in first year on
fee-for-service basis
CountyCare: Early Impact
• CountyCare was implemented in 2013 well before other elements of
health reform were initiated
• Grassroots information and outreach for CountyCare is meeting with
unprecedented success: 110,000 low income County adults applied in first
9 months
• CountyCare represented the first Medicaid coverage in decades available
to some low income groups—students, women without dependent
children, men
• CountyCare coverage provided new purchasing power in the community-can be used at local pharmacies
• FQHCs in the CountyCare provider network received timely payment for
members at their enhanced FQHC Medicaid rate
• Timely payment of fee-for-service claims for formerly uninsured population
stabilized the entire system of care
CountyCare Sustainability
• Post-waiver (January 1, 2014), CountyCare continues as a Medicaid
managed care contractor through a state-authorized mechanism for
provider-led plans; minimal reserve requirement
• Primary care and subspecialty consultation capacity gaps will be met
through network expansion and service integration (CCHHS is currently
close to capacity)
• CountyCare revenue will allow CCHHS to invest in patient while drawing
on a lower level of County taxpayer subsidy
• Administrative goal is to move the provider network toward full-risk
arrangements with the plan
• Contractual intermediary manages back office functions
Plan Expansion
• State Medicaid moves to mandatory managed care for
women and children in summer 2014; CountyCare will
participate.
• CCHHS is currently working to create a plan to be included in
the Marketplace:
-using same provider network
-ready for October 2014 open enrollment
-targeting County employees, patients, small businesses, individuals
-resource for uninsured over 138% of poverty in CCHHS
system and in the community
Competitive Landscape--Adults
• CCHHS enters 2014 with strong Medicaid adult market share
• Voluntary plan coverage for employees reduces burden of
CCHHS insurance cost
• CCHHS Marketplace plan will enter with low premium
structure
Cook County uninsured adults:
Undocumented/no new path to coverage
Newly eligible:
Newly eligible for Medicaid:
Newly eligible for Marketplace--with subsidy
Newly eligible for Marketplace—no subsidy
818,000
175,000
643,000
270,000
296,000
77,000
Source: CCHHS estimates based on Health and Disability Associates data
Transformation and ACA
• Health reform provides new reimbursement opportunities
leveraged to increase coverage and access…But coverage and
access alone are insufficient to meet the promise of health reform
• Full-risk capitated plans can drive transformation—pushing toward
health promotion, primary care, home and community-based
services, service integration, care management and behavioral
health
• Much intervention can be accomplished outside the health care
delivery system through creative partnerships, i.e. churches,
community organizations, schools
4 Ps—Provider, Plan, Payer, Population
CCHHS is the only Illinois entity engaged in a “4Ps” transformation—drawing
on a sufficiently comprehensive approach to address population health goals
Provider
Delivery of direct CCHHS services
Plan
Development of CountyCare and Marketplace plans with enrolled membership and
expansive network
Payer
Provision of affordable coverage for County employees through Marketplace plan
Population
Administration of public health services and activities to improve population health
Driving Toward a Population Focus
• Need all four “Ps” to achieve population goals in Cook County—to
generate financial resources which in turn are invested to drive change
• Fully capitated plan with large primary care network drives models of care
toward patient-centered, home- and community-oriented practices
• Quality and patient satisfaction impact model design and reimbursement
strategies
• Large plan and population focus helps to identify resource gaps and to
pursue solutions including reimbursement design, increased clinical
integration, and training and recruitment strategies
Infrastructure for Population Health
Collaboration between state agencies and CCHHS (including the
Cook County Department of Public Health) fosters:
• Integration Innovation--for specific populations, such as partnerships to
reach and serve justice-involved patients
• Population Health Innovation--such as promotion of health behaviors,
both outside of and integrated within delivery systems
• Workforce Innovation--including creation of new, sustainable health
worker roles
• Innovative Training and Learning Mechanisms—to disseminate and
replicate leading practices
More to Do
• Network that attends to special populations
• Innovation in delivery of care--right level, right place
• Continuum of medical and non-medical community services that attend to
well-being
• Graduate medical education that fosters primary care and population
health-oriented training
• Escalation of risk-based models and demonstration of cost savings
• Program for remaining uninsured—undocumented and those not able to
purchase, even with subsidy