Universal Access to Care: Healthy San Francisco

American Public Health Association 136 th Annual Meeting – San Diego, CA Tangerine Brigham, Director of Healthy San Francisco San Francisco Department of Public Health October 28, 2008

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Presenter Disclosures Tangerine M. Brigham The following personal financial relationships with commercial interests relevant to this presentation existed during the past 12 months: No relationships to disclose

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The Problem

 Magnitude of problem:  45 million uninsured in United States  6.5 million uninsured in California  73,000 uninsured adults in San Francisco  Uninsured persons have:  Less access to medical care  Present for care at later stages of illness  Greater mortality and morbidity due to illness  Fragmented health care delivery system 3

San Francisco’s Response: Universal Health Care Access

 Health Care Security Ordinance:  Employer Spending Requirement: Requires certain employers to make health care expenditure on behalf of designated employees. Implemented January 9, 2008.

 Healthy San Francisco Program: Universal health care access program for uninsured residents. Debuted July 2, 2007 and City wide implementation September 17, 2007.

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Healthy San Francisco Program

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Healthy San Francisco (HSF)

 Provides health care for uninsured San Francisco adults (18 – 64 years old), regardless of:  Employment  Immigration status   Pre-existing conditions Income level  Offers comprehensive, affordable health care services  Is not a health insurance plan/product  Restructures County indigent health system to encourage preventive care and continuity in primary care  Participants must be ineligible for publicly-funded health insurance 6

For Participants, HSF is an Organized Health Care Program

 Select and receive primary care medical home  Streamlines the eligibility and enrollment  Accessible and clear information on services and the costs  Coordinated health care delivery network of providers  Customer service (e.g., call center, HSF ID card, newsletter) 7

HSF Services

INCLUDED

Preventive Care Substance Abuse Primary Care Specialty Care Emergency/Urgent Inpatient Care Pharmacy Diagnostics DME Mental Health Laboratory X-rays

EXCLUDED (partial listing)

Allergy Testing Infertility Tx Cosmetic Services Long-term Care Organ Transplants Vision Dental 8

HSF Provider Network

 Primary Care Medical Homes  14 public health clinics   8 private non-profit community clinics (13 different locations) 1 private, non-profit hospital-affiliated clinic  1 private physicians association  Hospitals  San Francisco General Hospital (public-County)  Hospitals linked to specific medical homes  California Pacific Medical Center (private, non-profit)  Saint Francis (private, non-profit)   St. Mary’s (private, non-profit) Chinese Hospital (private, non-profit)  Hospitals providing specific services  Univ. of CA San Francisco (public-State) – Radiologic 9

HSF Population and Enrollment

 Estimated uninsured adults: (2005 CHIS)  Expected enrollment: 73,000 60,000  Currently enrollment (10/08):  Phased enrollment strategy – focuses    31,000 on those with lowest income first Over 100 HSF application assistors using One-e-App  35,000 HSF applications processed 5% of all applications (9% of all applicants) processed are for other health programs 10

HSF Participant Demographics

 74% incomes below 100% FPL; 26% above 100% FPL  51% male; 49% female  38% Asian/PI; 24% Hispanic; 16% White; 9% Afr-Amer.; 2% Other; 11% Not Provided  8% under 25 years old; 65% b/w 25 - 54 years of age; 27% b/w 55 - 64 years of age 11

HSF Fee Structure

 Participants pay:  participation fee to remain enrolled in program   point-of-service fees when accessing services cost of care delivered outside HSF provider network  Affordability impacts access – fees are tied to income and family size  Subsidy to those with incomes at or below 500% FPL  Fees are less than 5% of a household income

Income Level Fees as a Percent of Income GA/Hmls 0% 0 - 100% 0% 101 – 200% 2.30% 201 – 300% 2.90% 301 400% 3.90% 401 500% 4.40% 501% Over 5.20%

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HSF Funding

 Contributions from:  Government  City & County (redirecting existing local dollars)  State/Federal (existing funds to serve uninsured)  Federal (Health Care Coverage Initiative award)  Participants  Employers 13

Employer Spending Requirement (ESR)

 San Francisco employers are required to make health care expenditures. Can elect to:  Offer health insurance     Give Health Savings Accounts Reimburse employees for expenses Provide health care services Offer the City Option (incls. Healthy San Francisco)  Challenged by Golden Gate Restaurant Ass’n  Employer Spending Requirement went into effect on January 9, 2008 14

Employers are Selecting City Option

 If an employer selects City Option, then their employee receives either:  Healthy San Francisco or  Medical Reimbursement Account  To date, over 1,000 employers have selected the City Option  In total, $18.5 million in health care expenditures committed for 27,500 employees  One-half potentially eligible for HSF  One-half eligible to receive a MRA 15

INTERSECTING POLICY WITH OPERATIONS

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Moving HSF Policy Objective Toward Reality

 A policy isn’t a program, a local ordinance isn’t a program  Pushing operations, technology, our staff to achieve the policy objective  Crafting rules, regulations, processes, procedures, structure, etc. that take into account the existing infrastructure of your system(s) 17

Context for HSF Development

 Aggressive timeline for HSF implementation  Coordination across multiple entities  Three technology partners   Third-Party Administrator (San Francisco Health Plan) Two other City/County agencies  San Francisco Community Clinic Consortium  Highly visible program with significant public interest  GGRA Lawsuit 18

Lessons Learned

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Manage change and expectations

– frequent and consistent messaging required 

Be clear about trade-offs

– clarify prioritization since everything cannot be achieved 

Clearly define program needs

– designing program and developing technology simultaneously can create inefficiencies 

Phase implementation

– pilot and get the “kinks out” 

High level of resources

implementation – extensive level of resources pre/post 

Linking programs and operational activities is complicated

more interfaces  more complex systems for system “glitches”  – more opportunities 19

Replicability in Other Communities

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Factors in San Francisco’s Implementation

 San Francisco’s environment has made effort achievable  Political will and leadership     Public support for addressing problem Financial resources available to leverage Safety net providers serving uninsured Geographic boundaries  Implementation has gone relatively smoothly  Too early to say if HSF is a success on all measures – program evaluation needed 21

HSF Evaluation Components

 Participation  Access  Quality  Utilization  Financial viability  Replicability 22

Generalizable Features of Healthy San Francisco  Focus on primary care home to reduce duplication and improve coordination  Centralized eligibility system to maximize public entitlement and increase coordination of benefits  Centralized system of record creates accountability and comprehensive database for planning & evaluation purposes  Non-insurance (care) model potentially results in lower costs and leverages federal/state funds for localities  Establishment of predictable, affordable participation fees; may not be viewed as charity by participants  Public-private partnership maximizes available resources 23