Managed Care 101
Presented by
Ralph Silber, CEO
Community Health Center Network
March 16, 2012
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Fee-for Service
In a FFS system, a health care provider receives an
individual payment for each medical service delivered
to a beneficiary. Beneficiaries generally may obtain
services from any provider who has agreed to accept
Medi-Cal payments. This model does not typically
provide for the coordination of care for beneficiaries
who have several medical providers. The FFS
providers are reimbursed for each service after it is
delivered.
Managed Care
Under this system, DHCS contracts with managed care plans, also
known as health maintenance organizations, to provide health
care coverage for Medi-Cal beneficiaries residing in certain
counties. Managed care enrollees may obtain services from
providers who accept payments from the health plan, also
known as a plan’s “provider network”. The health plans are
reimbursed on a “capitated” basis with a predetermined amount
per person, per month regardless of the number of services an
individual receives. Unlike FFS providers, the health plans
assume financial risk, in that it may cost them more or less
money than the capitated amount paid to them to deliver the
necessary care.
Medi-Cal Managed Care
Medi-Cal Managed Care Beneficiaries Receive Coordinated Care.
Managed care plans typically contract with health care providers,
such as physicians and hospitals, to provide services to enrollees.
Medi-Cal beneficiaries enrolled in a managed care plan select a
primary care physician who provides their health care services on a
regular basis. Managed care plans provide assistance to enrollees
by coordinating care through referrals to specialist, telephone
advice nurses, and customer care centers.
Individual providers under managed care may be paid on a fee-forservice or capitation basis.
Managed Care Definition:
Health Maintenance Organization (HMO)
AKA
Managed Care Plan, Health Plan, Plan
•
Medi-Cal contracts with plans to provide defined set of covered
benefits for a set per-member per-month amount.
•
The plans then contract with medical groups, hospitals, and other
providers to provide a full range of health services for their
enrollees.
•
Examples: Local initiatives, Health Net, Blue Cross, Molina
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Managed Care Definition:
Capitation
or
“per-member per-month”
(PM PM)
The fixed amount of money paid on a monthly basis
to a health plan, an Independent Physician
Association (IPA), or medical group for a defined set
of medical services.
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Medi-Cal Managed Care:
• Medi-Cal beneficiaries are enrolled in managed care according
to the model in their given county
• Medi-Cal pays the managed care plan a set amount each month
for each member (PM PM)
• Beneficiaries select or are assigned a primary care physician
who coordinates care
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Medi-Cal Managed Care:
• The state began enrolling large numbers of Medi-Cal
beneficiaries in managed care in the 1990’s
• Three main Medi-Cal managed care models in
California:
•
County Organized Health Systems
•
Geographic managed Care
•
Two-Plan Model
• Also limited number of special managed care projects
(e.g., PACE)
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County Organized Health Systems
(COHS)
A local agency created by a county board of supervisors to
contract with the Medi-Cal program.
•
Enrolled recipients choose their health care provider from
among all COHS providers.
•
COHS serves about 885,000 beneficiaries thru 6 health plans
in 14 counties)
•
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•
•
•
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CalOPTIMA (Orange)
Central CA Alliance for Health (Merced, Monterey, Santa Cruz)
Health Plan of San Mateo
Partnership HealthPlan of California (PHC) (Marin, Mendocino, Napa,
Solano, Sonoma, Yolo)
CenCal Health (San Louis Obispo, Santa Barbara)
Gold Coast health Plan (Ventura)
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Geographic Managed Care
(GMC)
•
Implemented to provide medical and dental care for Medi-Cal
beneficiaries in San Diego and Sacramento Counties
•
The GMC model allows many plans to operate within a
designated geographic region
•
GMC serves about 450,000 beneficiaries in the two counties
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Two-Plan Model
•
In Two-Plan counties (with large Medi-Cal populations) MediCal contracts with two managed care plans.
•
One plan is commercial and the other plan is a locally
organized “local initiative” sanctioned by the county’s board of
supervisors.
•
Two-Plan serves about 3 million beneficiaries in 14 counties
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Medi-Cal Eligibility Categories
- Families with Children
- Seniors & Persons of Disabilities (SPDs) –
Medi-Cal only
- Dual Eligibles (Medi-Cal & Medicare)
- Pregnancy and Emergency Only Medi-Cal
- Medi-Cal Share of Cost
Carve Outs from
Medi-Cal Managed Care
 Specialty Mental Health.
 CA Children’s Services (CCS)
 Long Term Care (?)
How Does PPS Work Under
Medi-Cal Managed Care
 FQHCs receive primary care payment from health plans based
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on “market rate”
These payments may be fee-for-service or capitation
Each FQHC gets a “wraparound” PPS rate (code18) from the
state; estimate of difference between payment from the plan and
PPS rate
For each visit, an FQHC submits a “claim” to the plan and a
code 18 claim to Medi-Cal
Managed Care Reconciliation process
Bonus payments outside of reconciliation
Managed Care as A Solution
 Controls Costs
 Promotes Prevention
 Quality Focus
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Managed Care – Solutions/Advantages
Controlled Costs
 Reimbursement is fixed regardless of services offered - capitation
 At risk to lose money if costs are higher than expected
 Control costs by negotiating discounts
Increased Access
 Management of costs creates greater access
 Build contracted specialty network-obligated to see patients
Improve Quality
 Altering physician practice patterns
 Encourages coordination and integration of care – creating integrated
health care delivery systems
 Members have access to protection by regulators
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Care Management Populations
 Chronic conditions: asthma, diabetes, chronic renal
failure, cardiovascular disease
 Severe or unusual medical conditions
 Frequent or inappropriate ER and Urgent Care
 Frequent or inappropriate hospitalizations
 Disabled with special needs
 Members with special needs
homelessness, transportation, supplies, substance
abuse, inability to understand or use managed care
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