COUNTY OF SAN MATEO

Inter-Departmental Correspondence

San Mateo Medical Center

DATE:

October 19, 2007

BOARD MEETING DATE:

November 6, 2007

SPECIAL NOTICE/HEARING:

None

VOTE REQUIRED:

Majority

TO:

Honorable Board of Supervisors

FROM:

Dr. Sang-Ick Chang, CEO

Dr. Susan Ehrlich, VP and Medical Director Ambulatory Services

SUBJECT:

SMMC Coverage Initiative contract with the San Mateo Health Commission, hereinafter referred to as Health Plan of San Mateo (HPSM)

RECOMMENDATION:

Adopt a resolution authorizing an Agreement between the County of San Mateo, and the Health Plan of San Mateo to provide services as the third party administrator (TPA) to implement the San Mateo Medical Center (SMMC) Coverage Initiative (SB 1448) program for the period of September 1, 2007 to August 31, 2010, for a total amount not to exceed $ 1,360,800.

VISION ALIGNMENT:

Commitment: Ensure Basic Health and Safety for All

Goal 5: Residents have access to health care and preventive care.

The Coverage Initiative creates the San Mateo Access and Care for Everyone (ACE) Program (previously called the WELL Plus program) and contributes to this goal by increasing access to healthcare and enhancing services for low-income patients with chronic diseases through a redesigned primary care model. The Health Plan of San Mateo will serve as the third party administrator (TPA) for the ACE program.

Performance Measures

Measures

Annual Target

% Reduction in cost per patient due to reduced hospitalizations, Emergency Department visits, and overall patient care costs

TBD

Number and % of patients enrolled in Coverage Initiative with improved measures of diabetes, blood pressure, and cholesterol control

TBD

Number and % of patients enrolled in Coverage Initiative who complete self-management plans

TBD

Number and % of patients enrolled in Coverage Initiative indicating improved satisfaction with clinical experience

TBD

BACKGROUND:

In a survey conducted for the 2004 Community Assessment: Health and Quality of Life in San Mateo County, thirteen percent of adults between the ages of 19 and 65 years reported being uninsured (approximately 52 - 60,000 adults). Seventy percent of these adults are estimated to have incomes at or below 400% of the federal poverty level (FPL), and of this smaller population fifty-eight percent are estimated to have incomes at or below 200% FPL (approximately 23,000 adults). On July 24, 2007, San Mateo County Board of Supervisors adopted a resolution to expand comprehensive coverage to qualifying adults at or below 400% FPL, by adopting the recommendations of the Blue Ribbon Task Force on Adult Health Care Coverage Expansion (BRTF).

San Mateo County successfully competed for funds from the State of California Department of Health Care Services, through the San Mateo Access and Care for Everyone (ACE), to begin implementing the BRTF recommendations. The San Mateo ACE funds are estimated to be $10.4 million each year for three years beginning September 1, 2007.

The accompanying agreement with the Health Plan of San Mateo (HPSM), as the third party administrator (TPA) for the San Mateo ACE program, provides details of HPSM’s role and commitments to this patient population. The HPSM agreement is contingent on the County executing a contract with the State Department of Health Care Services which has been delayed due to ongoing negotiations between the State and the Federal Government’s Center for Medicaid and Medicare Services (CMS), and may not be available before December 31, 2007. Administration by the HPSM will adapt managed care principles to ensure a medical home for all participants, reduce episodic and fragmented care, and emphasize preventative and primary care

DISCUSSION:

San Mateo County has requested and received an annual allocation of $ 10.4 million to implement the following two components of the San Mateo ACE program: 1) Serve 2,100 low income (200% FPL or less) who are citizens or legal residents, and 2) provide enhanced services through Radical Redesign of Chronic Disease Care.

Performance targets for the three years funded by the State Coverage Initiative will be developed by an established Initiative workgroup and included in the future Board report related to the agreement with the State.

FISCAL IMPACT:

The requested allocation from the Coverage Initiative for health care services is $7,564,172 per year. This allocation will be claimed through a cost reporting mechanism and requires equal local matching funds. San Mateo County also estimates that it will claim $2,753,600 in administrative costs for each of the three years through a separate claiming mechanism.

HPSM will provide TPA services for the ACE program at a cost of $18 per member per month. The projected amount of payment to HPSM is $453,600 per year for a total of $1,360,800 over the three years of the Agreement. The County will claim for reimbursement from the State once the expenses have been incurred at no net County cost. The protocol for claiming these funds are forthcoming from the State.

An Appropriation Transfer Request (ATR) and any additional changes to the Salary Ordinance will be brought to the Board at the same time as the agreement with the State.