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Universal Access to Care:

Healthy San Francisco

American Public Health Association

136th 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

The following personal financial relationships with commercial interests relevant to this presentation existed during the past 12 months:

Tangerine M. Brigham

No relationships to disclose

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The Problem

Magnitude of problem: 45 million uninsured in United States6.5 million uninsured in California73,000 uninsured adults in San Francisco

Uninsured persons have:Less access to medical carePresent for care at later stages of illnessGreater mortality and morbidity due to illnessFragmented health care delivery system

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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

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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)

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HSF Services

INCLUDEDPreventive Care Primary Care Specialty Care

Emergency/Urgent Inpatient Care Pharmacy

Diagnostics DME Mental Health

Substance Abuse Laboratory X-rays

EXCLUDED (partial listing)Allergy Testing Cosmetic Services Dental

Infertility Tx Long-term Care

Organ Transplants Vision

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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

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HSF Population and Enrollment

Estimated uninsured adults: 73,000 (2005 CHIS)

Expected enrollment: 60,000

Currently enrollment (10/08): 31,000 Phased enrollment strategy – focuses 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

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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

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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

GA/Hmls 0 - 100% 101 – 200%

201 – 300%

301 - 400%

401 - 500%

501% - Over

Fees as a Percent

of Income

0% 0% 2.30% 2.90% 3.90% 4.40% 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

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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

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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

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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 programPushing 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)

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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

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Lessons Learned

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 – extensive level of resources pre/post implementation

Linking programs and operational activities is complicated – more interfaces more complex systems more opportunities for system “glitches”

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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

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HSF Evaluation Components

ParticipationAccessQualityUtilizationFinancial viability Replicability

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Generalizable Features of HealthySan 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