In previous installments in this series of articles on the San Diego healthcare market, we looked at such important topics as the decades-long history of collaboration among stakeholder groups in that metropolitan area, and the challenges and opportunities involved in moving ahead on population health management and care management in that market.
In this installment of the series, we look at the health plan perspective on the San Diego metro market. For this article, Healthcare Informatics Editor-in-Chief Mark Hagland spoke this past autumn to Joseph Garcia, COO of Community Health Group, to get a community health plan-based perspective on the challenges and opportunities facing the metropolitan San Diego healthcare market.
Community Health Group (CHG), is a local health plan with 290,000 members, 280,000 of whom are MediCal (California’s version of Medicaid) members. Community Health Plan actually started out as a federally qualified health center (FQHC) decades ago, and its leaders remain committed to sticking close to their community. Garcia’s perspective is also enriched by the fact that “We work with practically every primary care physician in San Diego County” outside the Kaiser and Sharp HealthCare organizations, as he notes.
As mentioned in the first article in this series, CHG has been participating in a county-wide effort, led by the county’s health department, to control and end an outbreak of hepatitis A that has caused many problems and been difficult to control, especially given a very large homeless and transient population in the county. More broadly, CHG has been working collaboratively with providers for its entire existence. Below are excerpts from Hagland’s interview with Garcia.
How many providers do you work with in the San Diego metropolitan area?
We work with practically every primary care physician in San Diego County, and with most specialists. Kaiser and Sharp don’t contract with us, but nearly everybody else does; 95 percent outside those groups don’t.
What is the operational and care management landscape like for you and your colleagues, at a health plan that is 95-percent MediCal (Medicaid in other states)?
I’ve been here 30 years, and we’ve been here for over 30 years, and I have a very good historical perspective. And the message we have for our staff is, treat our members as they were your own loved ones. That’s our goal, and that’s held us in good stead all this time. And a key reason for our market presence is our commitment to customer service. We bend over backwards to provide service. We answer 90 percent of the calls to our customer service center within 10 seconds, and it’s a real, live person, 24/7, all year long. That’s a financial and operational commitment on our part.
What has it been like working with providers in San Diego County?
This is the only county we’re in; and every provider knows our corporate headquarters is right here, and they can meet with the CEO, COO, CMO—they can come over or call. We have 30-year relationships. We were born out of a community health center, San Isidro Health Center. We were a provider, then a provider and health plan together, and then 20 years ago, we separated. And I and others have worked at both. So we understand the doctors, and the stresses that they face in doing their jobs, and they know that we understand. San Isidro is one of the top-three largest FQHCs in San Diego County.
What have been the biggest challenges and opportunities in pursuing population health management strategies, for you and your colleagues?
The biggest challenge is that trying to change individuals’ behavior is the most difficult thing. Most plan members with chronic conditions have two, three or four of them: asthma, diabetes, COPD [chronic obstructive pulmonary disease], CHF [congestive health failure], hypertension, obesity. And if you know that you have hypertension, and eat a lot of salt, you know that’s a problem. The same thing is true with not taking the medication if you’re diabetic. And the reality is that our own staff face challenges themselves in terms of not always doing what they’re supposed to do. Maybe they don’t because it’s hard, or because they just don’t do it; but it’s that much harder for MediCal patients, because it’s very hard to initiate behavioral changes; but it’s a lot cheaper to go to McDonald’s and buy cheap food that’s not as healthy, as to cook healthily. And the issue is one of finances.
Could you mention one or two advances that you and your colleagues have been able to make recently?
One of the areas we’re very proud of us around our HEDIS [Healthcare Effectiveness Data and Information Set] scores. For the past ten years, we’ve pretty much been able to improve our HEDIS scores year over year. And those scores are used to determine whether a health plan is delivering quality care. And one or two years, we’ve been number one in the state, and nearly every year, we’re in the top five to seven. We’re nearly always in the top tier in terms of making sure the care we provide our members, is on the higher end of that spectrum.
Tell me a bit about how you and your colleagues have been using data, IT, and analytics, to help with your work?
It’s been extremely important in terms of focusing on our members’ needs. We have a dedicated analytics team. They’ve been running any number of reports for us on how to better target our members. It might be something as simple as whether we have contact information for our homeless members? And what are their utilization rates, especially in terms of ED visits? If we see we have a few thousand super-high-utilizing members, we analyze that. So we’re very strong users of and supporters of, informatics, to more effectively manage members.
Tell me a bit about how you’ve been sharing data with providers?
We are doing that, and we bought software we could put on providers’ desktops, and gave them a whole bunch of data—how many ER visits, hospital bed days, meds, etc.—and unfortunately, there’s very little utilization of the data. And we bring it up to the CEOs, CMOs, and we say, hey, we’ve given you the data. And they say, we’ve been really busy, can you train us again? There’s been very little uptake. And the pilots we’ve done—we’ve done two so far—with the large FQHCs. And the first one we’ve had operational for three or four years. And I remember going to the CEOs’ offices, and asking them, why don’t you use the data? One CEO who’s no longer there, and he said, we’re just too busy. Still, they use the HEDIS measures, and use those regularly. We send them monthly gap reports; the providers do use the HEDIS data with a ton of frequency. Any other type of utilization data, we’ve had a hard time getting uptake on the part of the providers. Hopefully, that will change, because we think that data is very valuable.
From your perspective, is there anything that makes San Diego’s Medicaid managed care landscape different from that of other metro areas around the country?
One thing is that there are six, soon to be seven, health plans working with MediCal here. And every other county except ours and one other, only has one or two MediCal plans. Also, we’re right on the border.
All of that adds to your costs and challenges?
Not so much the costs, but the challenges. When they go to Tijuana for care, that’s not a cost we bear. But we can’t manage the care, because we don’t have access to their data from that outside care.
Could you provide an example of something that healthcare leaders from elsewhere might want to know about healthcare/managed care in San Diego?
All the health plans here get together in a program called Healthy San Diego, sponsored by San Diego County, and we talk to each other and share information. The one classic success story is, in California, anytime you contract with a provider, you have to do a site review, visit the provider, and determine they’re qualified to serve Medicaid providers. And if there are six plans, you have to do that six times; and you can imagine how frustrating that is. So we split up the task, the provider only has to go through one review, and the data is shared among the six providers. But with some of the other plans that are national, their corporate offices force them to replicate the process anyway. We keep trying to work together as a team, to minimize the negative impact on the providers.
What will happen in your organization and in the San Diego healthcare market, in the next few years?
I think the changes will be modest. We did not participate in the health insurance exchanges. And if Medicaid expansion is scaled back and we lose 50,000 members, we’ll be OK; there will be negative impacts, but as a plan, we’ll be able to carry forward and meet the needs of the Medicaid members in the market.
Is there anything you’d like to add?
I would only add that in SD County, we’ve made a big effort to work closely together as health plans, and we’re very lucky to have been here for over 30 years. That history has made it helpful for us. We were founded in 1985 as a health plan, so the collaboration has been going on for a long time.
