Transcript Slide 1
Cross-Border Health Care:
The California Experience and
the Possibilities for Texas
By
Dr. David Warner,
Rachel Maguire, Kelly Shanahan, & Kimberly Tucker
LBJ School of Public Affairs, University of Texas at Austin
October 15, 2004
Presentation Overview
Agenda:
California
– History of cross-border healthcare
– Current cross-border insurance plans
– Lessons from California
Texas
– Case Studies
El Paso/Juarez
Lower Rio Grande Valley
Dallas/Fort Worth
– History of Cross-border Legislation
– Future of Cross-border Health Insurance in Texas
History of Cross-border Activities &
Legislation in California
PRIVATE INSURANCE PLANS
1957
1972
1974
1975
1983
1994
1996
1997
1998
2000
2001
2003
SELF-FUNDED PLANS
WGA Health Benefits
WGA Mexico Panel added
ERISA passed
Knox-Keene Health Care Service Plan Act
DOC issues Cease and Desist Orders
SB 1658
SIMNSA licensed, Access Baja launched
Salud Con Health Net launched
SB 798, Salud Mexico, Access Baja
Dependent Plan
2004 SB 1347
Amended to address MEWAs
SB 1430
HIPPA Provisions
Current requirements for crossborder HMO products in California
The product must:
Be licensed by California DMHC
Meet certain financial standards
Be sold to employers at group rates through
brokers, agents and TPAs
Provide emergency and urgent care coverage in
the U.S.
Basic Plan Definitions
Single Network – doctor network available only on one side
of the border.
Dual Network – doctor networks available on both sides of
the border.
Self-funded Plans – employer-sponsored, federallyregulated plans. These are ERISA plans that are not
subject to the same strict regulation as private insurance
plans.
Latino-oriented Plans – insurance products specifically
designed for and marketed to the Hispanic population in
the U.S.
California: Current Cross-border Plans
Private Insurance Companies
– Single Network:
SIMNSA, S.A.
Blue Shield - Access Baja
Health Net - Salud Mexico
– Dual Network:
Health Net - Salud Con Health Net
Blue Shield – Access Baja Dependent Plan
– Latino-oriented Plans:
Pacificare
Health Net
Employer-Sponsored Plans (ERISA)
– Dual Network:
Western Growers Association
Single Networks
Plans:
Sistemas Medicos Nacionales, S.A. de C.V.
(SIMNSA) (2000)
Blue Shield - Access Baja (2000)
Health Net – Salud Mexico (2003)
Single Network
Plan Model
HMO, PPO plans
Area Network – Doctor/Hospital Networks in Mexico
Out-of-Area Network: Emergency and Urgent Care only
Plan Members
Members must reside within 50 miles of the border
Focus is on Mexicans and Mexican Americans
Approximately 50% live in California and 50% live in
Mexico
Single Network
Employer industries include:
Service (Hotels/Restaurants)
Textiles
Landscape
Agriculture
Construction
Quality Control
Certification: Mexican Government, California
Department of Managed Care
Audits
Grievance Process
Legal Recourse
Single Networks: Plan Comparisons
SIMNSA
Mexican-owned company (Legally allowed to advertise and sell
employer-sponsored plans in US)
12,300 members (4000 subscribers)
90% 1st Generation Mexicans
Coverage Area: San Diego, Tijuana/Imperial Valley, Mexicali
Less expensive than Access Baja
Health Net – Salud Mexico
US company, contracts with SIMNSA network
Blue Shield – Access Baja
US company, contracts with General de Seguros, S.A.
2000 members (subscribers and dependents)
– 50 employers
Coverage Area: San Diego, Tijuana/Imperial Valley, Mexicali
2 Different plans offered (Gold Plan & Silver Plan)
Dual Networks
Dual Network – doctor networks available on both
sides of the border.
Plans:
Salud con Health Net
Blue Shield – Access Baja Dependent Plan
Dual Networks
Salud Con Health Net
Plan Model
Combines Health Net Providers in California with SIMNSA providers in
Mexico
20,000 members
–
Primarily 1st Generation Mexicans
2 Product Lines:
– Full Network
Adds Mexican Provider Group to Offering
– Narrow Network
Adds Mexican Provider Group to Offering
Provides “narrow” network in Los Angeles
Lower cost health plan option
Plan is 30-40% less expensive than Kaiser
Latino-oriented Plans
Latino-oriented Plans – insurance products
specifically designed for and marketed to
the Hispanic population in the U.S.
Plans
Pacificare
Health Net
PacifiCare Latino
Founded: in 2002 - Latino Health Solutions Initiative
Membership:
product
585,000 Latino members in the USA
over 500 companies have bought the Latino
Services:
• Offers the same products that PacifiCare does
• 1-800 number in Spanish
• Web based solutions in Spanish
• Emphasis on education and information
• Does not offer Cross-Border services
• Offered in 8 states: CA, AZ, TX, OK, CO, WA, OR, and NV
Health Net
Targets Latino Population (including low-income)
through various outreach programs,
community involvement
La Opinion
Combines government-sponsored programs with
private insurance products to cover families
MediCal/Healthy Families
Accepts Mexican Matricula Consular card as
Identification
Self-funded Plans (ERISA)
Self-funded Plans – employer-sponsored, federallyregulated plans. These are ERISA plans that are
not subject to the same strict regulation as
private insurance plans.
Plans
Western Growers Association (Dual Network)
Western Growers Association
Plan Background
Founded: 1926 as a trade association
Membership: 3000 regular and associate members in CA and AZ
fresh produce industry
Services: Many different services, including health care coverage.
Health Benefits:
1957 - Creation of Western Growers Assurance Trust
(Not-for-profit, self-funded, and self-governed)
1972 - Cross-border option (aka Mexican Panel) started
Western Growers Association
Plan Model
Tailor-made for company’s needs
For care in US, work with:
• Blue Cross of California
• Blue Cross Blue Shield of Arizona
• Pinnacle Claims Management, Inc. (3rd party administrator)
• Blue Cross Life & Health, Vision Services Plan, RESTAT
Pharmacy
250 full-time customer service employees
Most seasonal workers are on “Harvest Series” plan (100%
employer contribution)
Western Growers Association
Mexican Panel
Optional “Rider” attached to plan
95,000 subscribers (employees + dependents) have rider
Physicians/Facilities:
• 23 PCP contracts
• 16 PCP subcontracts
• 90 specialty care physicians
• 10 hospitals (ER and surgical services)
• 15 dental clinics
Location of Services on the Border:
• Tijuana
• Mexicali
• Palaco
• Los Algodones
• San Luis
• Agua Prieta
Western Growers Association
Mexican Panel
Required Coverage:
No “required” services
WGA determines what services are available in Mexico
95% of the demand for services can be met by Mexican Panel
Cost = $29-35
Plan Membership
110,000 of member employees and their families
2002 = $90,000-100,000 paid in claims for Harvest Series plans - care
received in US
2002 = 30,000 Mexico claims
Provider Network Model
Latino Oriented Plans
PacifiCare
No cross-border services
HealthNet
Aimed at Latino population
Dual Network Plans
Western Growers
Salud con HealthNet
Access Baja Dependent plan
Services provided in both countries
Larger target market
Single Network Plans (Mexico)
Access Baja
SIMNSA
Salud Mexico (HealthNet)
50-mile radius from border
Small target market
Future of Cross-border Plans
Growth in individual plans
Target small and mid-size businesses
Expansion of dependent coverage into the
interior of Mexico
Rent network to other Blue/U.S. Carriers in other
states
Expansion of self-funded cross-border plans
Lessons from California
Small market niche
Inexpensive
Culturally sensitive healthcare
Education necessary to teach value of
health insurance
Texas
Case Studies:
El Paso/Ciudad Juarez
Lower Rio Grande Valley
Dallas/Fort Worth
El Paso/Juarez
Latino Population = 81% are Hispanic (2002 – El Paso
County)
– 25% born in Mexico (2002)
– 76% of those age 5+ speak Spanish in the home (2002)
Ciudad Juarez – 1.42 million (2004)
– Combined with El Paso County – 2.14 million (2004)
Uninsured = 33%
– Least insured major city of the U.S.
Uncompensated care
– Thomason General Hospital - $103 million (41% of total gross
patient revenue)
– Thomason + 9 private hospitals - $217 million
El Paso/Juarez
Employment Sectors
– Service
Call centers/back office operations
Health care
Business support
– Wholesale/retail trade
– Government
– Manufacturing
Employer-sponsored health insurance (non-elderly pop)
– El Paso = 49%
– Nationwide average in large urban areas = 67%
Many large employers have ERISA plans
– school districts
El Paso/Juarez
Border crossings (north from Juarez to El Paso - 2003)
– In general
30,278 buses
14,486,294 cars
8,939,791 pedestrians
– Work-related
44,651 daily (2002 average)
Current Cross-border Activities
– Medical Care Referral Group
Provider networks in Ciudad Juarez (ISES)
– Plan Seguro
– Mapfre Tepeyac
– Seguros Inbursa
Medical facilities in Ciudad Juarez
– Centro Médico de Especialidades
– Poliplaza Médica
– FEMAP/SADEC - Hospital de la Familia
Lower Rio Grande Valley
Cameron and Hidalgo Counties specifically
Latino Population = 88% of population (total pop = 958,144)
Uninsured rate = 32-33% (1999)
Mexican Cities on Border = Matamoros, Reynosa
Industries:
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–
–
–
–
Agriculture
Trade, Transportation, & Utilities
Government, Education, & Health Services
Manufacturing
Hospitality Industry
Current Cross-border Activities:
– Difficult to gauge
– Hidalgo Independent School District
– Interest in Western Growers plans
Medical facilities, provider networks in Mexico
– Facilities identified in Matamoros, Reynosa, and Nuevo Progreso
Dallas/Fort Worth
Latino Population = 22% of DFW pop (Latino pop = 1,120,350)
– 79% is Mexican-origin
– Uninsured rate = 37% (325,000 Mexican-origin)
Industries:
–
–
–
–
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Construction
Manufacturing
Hospitality Industry
Education, Health & Social Services
Professional Services
Current Latino-Oriented Healthcare Options:
– Limited Latino-oriented private insurance
– Discount cards
– Private clinics
Medical facilities
– Parkland (Dallas), John Peter Smith (Ft Worth)
– Community Health Centers (Los Barrios Unidos)
– Private Practices
Legislative History of Cross-border
in Texas
May 2001 - Texas Cross Border Health Care Act
(SB 1826)
– Coverage in Mexico for Mexican citizens and residents
– Died in Committee!
Legal Obstacles to Cross-border Coverage
– Definition of “provider” in a health plan
June 2003 - Texas Consumer Choice of Benefits
Health Insurance Plan Act (SB 541)
The Future of Cross-border Health
Insurance in Texas
Potential Plans
There is flexibility in…
1. Who a plan is designed to target
2. Plan structure and who offers it
The Future of Cross-border Health
Insurance in Texas
Potential Target Groups
1.
2.
3.
Individuals who live in Mexico, work in US
Individuals who live in US, dependents are in
Mexico
Spanish-speaking, low-income families in US
The Future of Cross-border Health
Insurance in Texas
Potential Plan Structures
HMOs
PPOs
Self-funded Plans (ERISA)
Consumer Driven Plans
– Consumer Choice Plans
– Health Savings Accounts