The County of Santa Clara Greg Price CEO, Valley Health Plan Dr. Larry Bonham Assistant Medical Director, Valley Health Plan April 14, 2010 2010 Valley Health Plan
Presentation Outline I. Sustainability/Efficiencies Financial Structure Coverage documents Network Medical Home Demographics Costs Satisfaction II. Utilization patterns Hospital ED Diagnosis Economics Self reported Health Status Conclusion 2006 Valley Health Plan
Valley Health Plan is a. County of Santa Clara Agency Hybrid Staff Model HMO Management Services Organization Way for County and other public Employees to receive Health Care A Partner with Valley Medical Physicians and Valley Medical Center 2009 Valley Health Plan
2006 Valley Health Plan Systems Create Efficiencies
Valley Care Program
Santa Clara Valley Medical Center Valley Care Program What is Valley Care? Provides health care to adults who are documented county residents and ineligible for other publicly funded health care insurance Ensures participants receive high quality and timely access to health care Provides affordable health care services including preventative services This is not an insurance product
Covered Services
Collaboration is Essential for Safety Net System Valley Medical Center VMC Regional Clinics- eight locations Valley Health Plan Mental Health Drug and Alcohol Community Health Partnership Extended network of independent physicians and IPAs Laboratory Network Pharmacy Network 2006 Valley Health Plan
2006 Valley Health Plan Developing a Medical Home is a Central Feature of Valley Care
2006 Valley Health Plan Manage The Population Risk Factors
Create Peace of Mind Identified primary care location Identified PCP Guides and assistance to access services No detailed screening at point of service Understand the cost for accessing care Preventive services Health Education Chronic Care Management Continuity of Care 2006 Valley Health Plan
Active Enrollment September 2007 - February 2010
Program Cost Data
Valley Care Profile of Enrollees Valley care enrollees are a diverse group; many will soon qualify for Medicare. Few enrollees have full time employment, many are single, and some do not have a permanent place to live.
Valley Care Enrollees are a diverse group; most are over 35 Age Race African- American/Black 2009* 2010** 4% 6% White/Caucasian 41% 33% Hispanic/Latin- 27% American 26% Asian/Asian-American 23% 31% Other 3% 3% (Refuse) 2% 1% *12% of respondents took the survey in a language other than English **26% of respondents took the survey in a language other than English Valley Care Enrollees EMC 09-4024
Over half are unemployed; 7% are employed full-time Total unemployed 2010 =57% Valley Care Enrollees EMC 09-4024
About 1/3 are married or living with a partner; the majority do not have children at home Valley Care Enrollees EMC 09-4024
About ¼ didn t graduate from high school; many live with friends or family or don t have a permanent place to live Valley Care Enrollees EMC 09-4024
Access to the Internet has increased since last year Valley Care Enrollees EMC 09-4024
Satisfaction with Valley Care Enrollees are overwhelmingly satisfied with Valley Care
Enrollees are very satisfied with Valley Care Valley Care Enrollees EMC 09-4024
Enrollees are satisfied, regardless of how long they have been enrolled Valley Care Enrollees EMC 09-4024
Enrollees who speak Vietnamese or Spanish are very satisfied Valley Care Enrollees EMC 09-4024
Location, medication coverage, cost and quality are all viewed positively by the majority Valley Care Enrollees EMC 09-4024
Amount of co-pays, services covered, getting answers to questions, and doctor selection are also rated highly Valley Care Enrollees EMC 09-4024
Patient health and care prior to enrolling in Valley Care The majority of Valley Care enrollees are being treated for at least one chronic illness many were previously undiagnosed
Before they had Valley Care, enrollees worried about the cost of medical care, getting sick Agree a lot Agree a little (Don't know) Don't really agree When didn t have health coverage I worried about cost of medical care 2009 89% 88% 6% 1% 5% 7% 5% When didn t have health coverage, worried about getting sick/ hurt 2009 74% 82% 11% 1% 6% 15% 1% 11% When didn t have coverage, wasn't worried about cost of health care because could go to County hospital/clinics 23% 20% 5% 52% 2009 35% 19% 6% 40% Valley Care enrollees EMC 09 4024
The majority are being treated for at least one illness; some are receiving treatment for mental illness Total number of (these) illnesses currently treated 2009 2010 1 27% 24% 2 23% 22% 3 12% 15% 4 12% 5% 5+ 1% 3% None 34% 32% Valley Care Enrollees EMC 09-4024
One third of those who are being treated for one of these illnesses did not receive the diagnosis until joining Valley Care Not diagnosed with at least one illness* before joining Valley Care 33% Diagnosed with illness(s) before Valley Care 33% No illness* 35% *Not including mental illness or drug/alcohol related illness Valley Care Enrollees EMC 09-4024
Impact of Valley Care on Patient Care and Health
Valley Care has allowed most enrollees to get the care, medications, and treatments they need Valley Care Enrollees EMC 09-4024
The vast majority would recommend VC to a friend Shorten the time to receive an appt. 24% Offer more doctor/specialists 13% Customer service/no Automated voice system 7% Offer Dental coverage 5% Continue the service/heard it will end 5% Shorten time it takes to get meds/prescriptions 4% Open more clinics 4% Easier access to primary physician 3% Offer this to more people 3% Shorten waiting time in the ER 2% Offer Vision coverage 2% Offer Mental Health coverage 2% Improve situation in the waiting rooms 1% Other/Don t know/nothing 41% Valley Care Enrollees EMC 09-4024
Coverage Initiative Reasons for Disenrollment
Coverage Initiative Valley Care Clinical Summary September 1, 2007 through December 31, 2009
Most say their health care has improved since joining VC Valley Care Enrollees EMC 09-4024
Inpatient Utilization Bed Days Admits Days
Inpatient Top 5 Diagnoses Females 1 Acute Appendicitis 2 Leiomyoma of Uterus Ages 19 39 Year 1 Year 2 Year 3 (Partial) Calculus of Gallbladder With Acute Cholecystitis Acute Appendicitis Calculus of Gallbladder Leiomyoma of Uterus; Unspecified Ages 40 64 Year 1 Year 2 Year 3 (Partial) 1 Chest Pain Chest Pain Leiomyoma of Uterus 2 Intramural Leiomyoma of Uterus Unspecified Transient Cerebral Ischemia Malignant Neoplasm 3 Asthma; Unspecified Type; With Acute Exacerbation Other Noninflammatory Disorders Diabetes Mellitus 3 Malignant Neoplasm Pyelonephritis; Unspecified Diabetes Mellitus 4 Other Chest Pain Cellulitis and Abscess of Face Acute Appendicitis 4 Calculus of Gallbladder Coronary Atherosclerosis of Native Coronary Vessel Subendocardial Infarction; Initial Episode of Care 5 Calculus of Gallbladder Acute Pancreatitis Acute Pancreatitis; 5 Asthma; Unspecified Type; With Acute Exacerbation Asthma; Unspecified Type; With Acute Exacerbation Pneumonia Organism Unspecified
Inpatient Top 5 Diagnoses Males 1 Chronic Pancreatitis Ages 19 39 Year 1 Year 2 Year 3 (Partial) Diabetes Mellitus Diabetes Mellitus Ages 40 64 Year 1 Year 2 Year 3 (Partial) 1 Chest Pain Chest Pain Atrial Fibrillation 2 Diabetes Mellitus Chronic Pancreatitis Acute Pancreatitis 2 Alcohol Withdrawal Congestive Heart Failure Coronary Atherosclerosis of Native Coronary Vessel 3 Acute Appendicitis Acute Appendicitis Diverticulitis of Colon (Without Mention of Hemorrhage) 3 Coronary Atherosclerosis of Native Coronary Vessel Coronary Atherosclerosis of Native Coronary Vessel Cellulitis and Abscess 4 Alcohol Withdrawal Cellulitis and Abscess of Leg; Except Foot Chest Pain 4 Cellulitis and Abscess of Leg; Except Foot Alcoholic Cirrhosis of Liver Diabetes Mellitus 5 Bimalleolar Fracture; Closed Other Infection Unspecified Septicemia 5 Congestive Heart Failure Acute Pancreatitis Alcohol Withdrawal
Outpatient Utilization Outpatient Visits Emergency Room Visits
Program Year 1 Utilization Charges % of Enrollees % of Total Charges Males over $50K Females over $50K Enrollees under $50k
Program Year 2 Utilization Charges % of Enrollees % of Total Charges Males over $50K Females over $50K Enrollees under $50k
Program Year 3 Utilization Charges % of Enrollees 1% 0.9% % of Total Charges 99% Males over $50K Females over $50K Enrollees under $50k
Top 5 Diagnoses Over $50K Females Ages 19-39 Year 1 Year 2 Year 3 (Partial) 1 Acute Upper Respiratory Infections of Unspecified Site 2 Routine Gynecological Examination Abdominal Pain; Unspecified Site Routine Gynecological Examination Acute Upper Respiratory Infections of Unspecified Site Routine Gynecological Examination Ages 40-64 Year 1 Year 2 Year 3 (Partial) 1 Diabetes Mellitus Without Mention of Complication; Type II 2 Unspecified Essential Hypertension Unspecified Essential Hypertension Diabetes Mellitus Without Mention of Complication; Type II Unspecified Essential Hypertension Diabetes Mellitus Without Mention of Complication; Type II 3 Lumbago Acute Upper Respiratory Infections of Unspecified Site General Medical Examination 3 Routine Gynecological Examination Routine Gynecological Examination Routine Gynecological Examination 4 Abdominal Pain; Unspecified Site Depressive Disorder; Not Elsewhere Classified Diabetes Mellitus Without Mention of Complication; Type II 4 Lumbago Other Specified Examination Other and Unspecified Hyperlipidemia 5 Depressive Disorder; Not Elsewhere Classified Lumbago Abdominal Pain; Unspecified Site 5 Other and Unspecified Hyperlipidemia Other and Unspecified Hyperlipidemia Vaccine For Influenza
Top 5 Diagnoses Over $50K Males 1 Unspecified Essential Hypertension Ages 19-39 Year 1 Year 2 Year 3 (Partial) Diabetes Mellitus Without Mention of Complication; Type II Other Psoriasis and Similar Disorders Ages 40-64 Year 1 Year 2 Year 3 (Partial) 1 Diabetes Mellitus Without Mention of Complication; Type II Diabetes Mellitus Diabetes Mellitus Without Mention of Complication; Type II 2 Diabetes Mellitus Without Mention of Complication; Type II Lumbago Diabetes Mellitus Without Mention of Complication; Type II 2 Unspecified Essential Hypertension Unspecified Essential Hypertension Unspecified Essential Hypertension 3 Lumbago Unspecified Essential Hypertension Lumbago 3 Lumbago Lumbago Other and Unspecified Hyperlipidemia 4 Pain In Joint Involving Lower Leg Other Psoriasis and Similar Disorders Acute Upper Respiratory Infections of Unspecified Site 4 Other Psoriasis and Similar Disorders Other and Unspecified Hyperlipidemia Vaccine For Influenza 5 Depressive Disorder; Not Elsewhere Classified Depressive Disorder; Not Elsewhere Classified Unspecified Essential Hypertension 5 Chronic Hepatitis C Without Mention of Hepatic Coma Chronic Hepatitis C Without Mention of Hepatic Coma Lumbago
The majority of Enrollees postponed getting care before they were covered by Valley Care Valley Care Enrollees EMC 09-4024
Percent of Charges By Age & Gender First 4 Months Last 4 Months
Clinical Criteria Medical Home UM Year October 1, 2008 Through September 30, 2009 Contains ALL Reported Utilization, Irrespective of Payment Priority 2 Priority 3 Priority 4 Priority 5 Group 2 Admits or 3 or more ED and/or Urgent Care Visits AND 1 Chronic Condition from Tier 1 Organ Damage 2 Admits or 3 4 ED and/or Urgent Care Visits AND 1 Chronic Condition from Tier 2 Risk Factors 1 Chronic Condition from Tier 1 Organ Damage; No Utilization Criteria Met Above 1 Chronic Condition from Tier 2 Risk Factors; No Utilization Criteria Met Above Commercial 1.075 7.528 53.6 289.6 Valley Care 4.565 17.388 107.8 489.8 Tier 1 Organ Damage Includes: Atrial Fibrillation, Coronary Artery Disease, CHF, Abdominal Aortic Aneurysm, Peripheral Vascular Disease, Cerebral Vascular Disease, Stroke, TIA Asthma, COPD, Emphysema, Wheezing, Bronchospasm, Hepatitis, Cirrhosis, Chronic Kidney Disease Tier 2 Risk Factors Include: Diabetes, Hyperlipidemia, Hypertension, Obesity
Clinical Criteria Medical Home UM Year October 1, 2008 Through September 30, 2009 Contains ALL Reported Utilization, Irrespective of Payment Commercial Valley Care
The longer they have been covered, the more likely enrollees are to say that their care has improved Valley Care Enrollees EMC 09-4024
The longer they have been enrolled, the less likely enrollees are to say they are healthy Valley Care Enrollees EMC 09-4024
About 40% consider their health to be only fair or poor Valley Care Enrollees EMC 09-4024
Valley Care enrollees are overwhelmingly satisfied. Valley Care Demographics Uninsured Unemployed Single Homelessness Conclusions High incidences of co-morbidities Enrollees are worried if they lost their coverage
Conclusions Significant use of services in first six months Statistical measure of their health care improved steadely Medical Home Managed Care Special Considerations High % Homelessness High % Mental Health High % Addiction Problems
Conclusions Increased efficiencies and cost containment will allow local resources to meet more of the increased demand for care but without increased State and Federal funding many residents will still access care in a crisis mode or not at all There will be a serious shortage of primary care physicians that will create parallel systems of care (medical home vs. episodic care) and different models employing non MD and RN staff for improving health status
Conclusions Efficiencies and product design developed for the Valley Care population will be transferred to all County uninsured patients over the next few years to control costs and improve health status Hybrid products such as Healthy Workers will be tested in SCC over the next few years to combine different funding sources with more local control
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