Inland Empire Readies Low-Income Health Plans

by Lauren McSherry, California Healthline Regional Correspondent

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San Bernardino and Riverside counties are poised to launch two new Low-Income Health Programs as a precursor to wider expansion of health insurance under the federal health reform law in 2014.

Officials in both counties anticipate the new health care plans could go live as early as Jan. 1, 2012. The federal government still needs to sign off on the final paperwork, but approval from CMS is expected to be issued by that date.

San Bernardino County's program, called Arrowcare, and Riverside County's plan, called Riverside County Healthcare, both will cover low-income residents who don't qualify for Medi-Cal. Medi-Cal is California's Medicaid program.

"It's a Medi-Cal-like program," said Koen Brown, deputy director for Riverside County's Department of Public Health. "It's a voluntary program the counties can participate in over the next two years."

The transitional period will come to a close at the end of 2013. The low-income plans then will be retired and participants in those plans will move into programs established by the Affordable Care Act. At that point, individuals in the plans can join Medi-Cal or choose among public or commercial health plans, most likely those offered in the state's new health insurance exchange.

Impetus for New Plans

The programs are part of California's "Bridge to Reform" waiver, which aims to expand health care services for low-income residents and cut Medi-Cal costs.   

The Bridge to Reform program aims to help the state prepare for wider reforms under the Affordable Care Act. Through the program, California is eligible for nearly $8 billion in matching federal Medicaid funds over the next five years. 

The federal government approved California's waiver in 2010. Since then, 10 "legacy" counties have created and implemented their own Low-Income Health Program. San Bernardino and Riverside counties were among the first wave of applicants chosen by the state Department of Health Care Services to launch low-income plans after the initial 10 counties.

Counties planning to implement low-income plans are getting some of their work done before health reform changes take effect in 2014. That work includes improving how public hospitals deliver care and developing systems with medical homes and health care teams, said Melissa Stafford Jones, president and CEO of the California Association of Public Hospitals and Health Systems.

"I think it's incredibly important work that they are doing now in advance of 2014," Stafford Jones said.

Jorge Valencia, spokesperson for Arrowhead Regional Medical Center, said, "It allows us to get ahead with reform and implementation in the next two years." Valencia's staff has been involved in the planning and implementation of the Arrowcare health plan.

Establishing Provider Networks and Expanding Coverage

In designing Arrowcare, San Bernardino officials aim to build a system that will be competitive with other managed care systems in the area. Ron Boatman, the plan's program coordinator, said officials plan to expand member benefits and add care options like medical homes and clinics.

The county also has doubled the number of primary care clinics with which it contracts and has formed an outpatient care management team to ensure a smooth transition between primary caregivers and specialists. The Arrowcare plan will enable the county to increase access to primary care, coordinate care more effectively and reach for better quality outcomes, Boatman said.

"This is an opportunity for us to expand all the different safety nets," he said.

In Riverside County, officials have formed alliances with a number of agencies. Ten primary care clinics and the Riverside County Regional Medical Center's primary care clinics will provide services.

"Upwards of between 18 and 20 primary care clinics will be available in this network," Brown said.

Because of federal requirements for the low-income plans, counties will have to cover some services they haven't previously. For example, counties participating in the program must cover emergency services anywhere in the U.S.

The requirements also set standards for access and care provider networks in addition to the types of primary, preventive and specialty care that will be covered, Stafford Jones said. She compared developing the low-income plans to building and driving a car at the same time.

Ultimately, the requirements should help improve the efficiency of care, so that the counties with large populations of uninsured residents can meet the needs of more patients, she said.

For San Bernardino County, the requirements also mean adding mental health coverage and coordinating care between medical doctors and psychiatric facilities.

"That is something new," Boatman said. "We haven't had that collaboration with the behavioral side of health care prior to this."

Enrollment and Costs Closely Linked

Demand for both Arrowcare and Riverside County Healthcare is expected to be high given the region's large number of uninsured residents. More than one million people are thought to be without insurance in the two counties. Additional economic factors, such as high foreclosure and high unemployment rates, indicate that demand will be high, Brown said.

San Bernardino County expects 20,000 people to enroll in its low-income plan, while Riverside County anticipates enrollment of 15,000 to 20,000. However, Brown said about 150,000 to 200,000 people in Riverside County will be eligible for the plan.

Cost is a factor for both counties and will affect how many people the plans can serve. The counties' spending on the plans will be matched by the federal government  

San Bernardino County estimates its low-income plan will cost about $64 million annually, Boatman said.

"This project is driven by the availability of local resources, so that's a number we will continually have to evaluate based on the financial ramifications of delivering these services," Boatman said.

Riverside County has yet to finalize cost estimates for its low-income plan, Brown said. The number of people the plan serves will hinge on how much funding is available, both from the county and the federal government.

Predicting Demand in a Diverse Region

San Bernardino and Riverside counties cover a vast amount of territory, only slightly smaller than the state of Maine. Meeting the demands of the urban populations that occupy the western portions of the counties, as well as the rural populations of their eastern portions, has been a particular concern.

Surprisingly, when San Bernardino County conducted a data analysis of uninsured people in the county, it found that a large volume of uninsured residents is concentrated in the area encompassed by Upland, Chino and Ontario, which are generally considered three of the county's more affluent cities. The Fontana-Rialto area and the city of San Bernardino were also identified as having a high number of uninsured, Boatman said.

Given the results of the study, the county has undertaken targeted efforts to add clinics and primary care providers to those areas.

The county's Department of Public Health also has converted three of its existing public health locations into primary practice clinics in Hesperia, Ontario and San Bernardino.

Riverside County has been studying patient patterns at its primary care clinics to gauge what demand might be once the new low-income plan goes live. One of the areas where demand is expected to be high is the Coachella Valley, an agricultural area heavily reliant on migrant labor.

"We think there may be higher demand in the east," Brown said. "The clinic system reaches from Jurupa out to Blythe. We're actually positioned really well for that."

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