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.
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Basic Plan Definitions
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Single Network – doctor network available only on one side
of the border.
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Dual Network – doctor networks available on both sides of
the border.
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Self-funded Plans – employer-sponsored, federallyregulated plans. These are ERISA plans that are not
subject to the same strict regulation as private insurance
plans.
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Latino-oriented Plans – insurance products specifically
designed for and marketed to the Hispanic population in
the U.S.
California: Current Cross-border Plans
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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
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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:
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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
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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
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La Opinion
Combines government-sponsored programs with
private insurance products to cover families
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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
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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
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Texas
Case Studies:
 El Paso/Ciudad Juarez
 Lower Rio Grande Valley
 Dallas/Fort Worth
El Paso/Juarez
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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)
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Ciudad Juarez – 1.42 million (2004)
– Combined with El Paso County – 2.14 million (2004)
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Uninsured = 33%
– Least insured major city of the U.S.
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Uncompensated care
– Thomason General Hospital - $103 million (41% of total gross
patient revenue)
– Thomason + 9 private hospitals - $217 million
El Paso/Juarez
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Employment Sectors
– Service
 Call centers/back office operations
 Health care
 Business support
– Wholesale/retail trade
– Government
– Manufacturing
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Employer-sponsored health insurance (non-elderly pop)
– El Paso = 49%
– Nationwide average in large urban areas = 67%
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Many large employers have ERISA plans
– school districts
El Paso/Juarez
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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)
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Current Cross-border Activities
– Medical Care Referral Group
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Provider networks in Ciudad Juarez (ISES)
– Plan Seguro
– Mapfre Tepeyac
– Seguros Inbursa
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Medical facilities in Ciudad Juarez
– Centro Médico de Especialidades
– Poliplaza Médica
– FEMAP/SADEC - Hospital de la Familia
Lower Rio Grande Valley
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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
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Medical facilities, provider networks in Mexico
– Facilities identified in Matamoros, Reynosa, and Nuevo Progreso
Dallas/Fort Worth
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Latino Population = 22% of DFW pop (Latino pop = 1,120,350)
– 79% is Mexican-origin
– Uninsured rate = 37% (325,000 Mexican-origin)
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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
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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!
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Legal Obstacles to Cross-border Coverage
– Definition of “provider” in a health plan
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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
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– Consumer Choice Plans
– Health Savings Accounts