With an eye on California's Medi-Cal expansion only a few short months away, San Bernardino and Riverside counties are preparing to transition 54,000 people currently enrolled in Low Income Health Plans.
The counties launched LIHPs in 2012 as part of a "bridge" program to extend health coverage to low-income residents who at the time did not qualify for Medi-Cal, California's Medicaid program.
Starting Jan. 1, Medi-Cal eligibility will be broadened, and the state anticipates that the program's enrollment will increase dramatically. LIHPs were established as part of a strategy to prepare for the influx of newly insured residents under the Affordable Care Act.
"The idea is that everybody who is in an LIHP will be automatically transferred into Medi-Cal at the first of the year," said John Connolly, associate director of the Insure the Uninsured Project. "The goal is to transition folks as seamlessly as possible."
LIHPs targeted and extended health care services to select populations that would be eligible for Medi-Cal in 2014. San Bernardino County named its program ArrowCare. Riverside County's LIHP is called Riverside County Healthcare.
"Counties that stepped forward to set up LIHPs are ahead of the game," said Sandra Martinez, director of public policy for the California Wellness Foundation. "Counties that didn't have plans ... are going to be slightly more challenged. They have not been able to work out the bugs."
Only five of California's 58 counties chose not to set up LIHPs. Across the state, more than 500,000 people enrolled in the programs, Connolly said.
San Bernardino County officials expected 20,000 to enroll in their plan. Ultimately, 29,000 people enrolled. Riverside County officials expected 15,000 to 20,000 to enroll, but 25,000 people enrolled.
"I think it went really well," said Ron Boatman, San Bernardino County's ArrowCare administrator. "I'm pleased with the delivery system that we developed."
Boatman said one of ArrowCare's successes was in steering patients toward primary care settings and away from hospital emergency departments. In the Inland Empire, which was particularly hard hit by the recession, EDs have experienced a significant increase in demand.
Kimberly Trone -- spokesperson for Riverside County Regional Medical Center, which administers Riverside County's LIHP -- said enrollment exceeded expectations because of strong outreach. In addition, once health care providers in the county became aware of the program, they often referred uninsured patients for coverage under the LIHP, she said.
Both counties turned to their social services departments to assist with outreach and enrollment.
Changing How Patients Seek Care
In setting up its LIHP, San Bernardino County added more primary care clinics and met with emergency providers to educate them about ArrowCare. In some cases, ED staff members were assigned to specifically identify and enroll people who had health issues that weren't being managed, Boatman said.
One noticeable effect was that Arrowhead Regional Medical Center, the county's public hospital, had a reduction in visits to the ED, Boatman said.
"I attribute that to having more choice in primary care practices throughout the community," he said.
In Riverside County, the program also seemed to be effective. More than 70% of LIHP enrollees accessed primary care through the county clinics, Trone said.
Both counties spent a significant amount of money to establish their LIHPs. San Bernardino County anticipated that the low-income plan would cost $64 million annually, but the program ended up costing $91 million per year, excluding administrative costs, Boatman said. He attributed the increased cost to exceeding enrollment goals and offering a broader benefits package.
In Riverside County, the cost for the LIHP was approximately $106 million annually, Trone said.
While the amount might seem high, it is actually lower than the cost of treating patients in EDs, she said. It costs about eight times more to treat a patient in an ED compared to treating a patient through a medical home where the patient's care is managed by a medical team, she said.
Erica Murray, senior vice president with the California Association of Public Hospitals and Health Systems, noted that increased costs could be because patients who enrolled in LIHPs were likely to have previously been uninsured and have undiagnosed chronic conditions.
"They often are sicker than they realize, so those services can be more costly," she said.
High Number of Uninsured
The Inland Empire has approximately 620,000 uninsured residents, based on data provided by the California Association of Public Hospitals and Health Systems. In Riverside County, nearly 15% of the population is uninsured. In San Bernardino County, more than 16% of the population is uninsured.
Martinez noted that Southern California overall has a high number of uninsured compared with the rest of the state.
"In regions with the largest number of uninsured, these programs are critical," she said.
Connolly agreed. He said counties such as those in the Inland Empire region bear a disproportionate share of caring for the uninsured. A large number of uninsured are also well above the income caps for LIHPs, he said.
"It's great that we have a head start on Medi-Cal enrollment, but we still have a whole bunch of folks outside of the LIHPs who are uninsured and do need coverage," he said. "That's the new frontier."
Public Hospitals Led the Way
In both Riverside and San Bernardino counties, county-operated public hospitals took leadership roles in establishing the LIHPs.
Murray said this was not an uncommon practice across the state.
"That reflects a pattern across almost all counties with public hospitals," she said. "They are well positioned as county entities to understand what the full needs of patients are."
This is because uninsured patients often turn to county hospitals for care, experts said.
"It's a safety-net system," Boatman said. "It made sense for us to be involved."
After the Jan. 1 health care reform changes take effect, those who still do not have insurance are likely to seek care through county services, Trone said.
"We will continue to be a provider of care for people who are uninsured, which is one of the reasons we need to stay viable," she said.
Gearing Up for Transition
Once Jan. 1 rolls around, the LIHPs created by Riverside and San Bernardino counties will dissolve. However, patients can still receive care through their medical homes. Both counties have contracted with the managed care providers Molina and Inland Empire Health Plan to provide services to Medi-Cal patients.
Riverside County anticipates that many of the patients enrolled in LIHPs will choose to stick with their providers.
"Many of our patients have developed strong relationships with their medical home team," Trone said.
Martinez said a smooth transition will hinge on insuring that the people who are doing outreach and enrollments understand how to connect people with Medi-Cal and Covered California, the state's health insurance exchange.
Both counties are developing letters that will be sent to enrollees about the upcoming change. Officials expect the majority of patients to qualify for Medi-Cal and be automatically enrolled in the program. A small percentage may not qualify, state and county officials said, but will be eligible for coverage under Covered California. Those patients also will receive letters notifying them of the change.
The counties are training staff to assist patients with the change.
"Our goal is that every frontline provider be educated on the transition, so that every patient can navigate through and have a smooth transition," Boatman said.
Murray said LIHPs have been tremendously successful in preparing for the Medi-Cal expansion.
She said the programs have not only provided early coverage for people who will be eligible for Medi-Cal but also have started providing preventive care for patients, particularly those with chronic conditions such as hypertension and diabetes.
"So patents aren't waiting until they are very sick and getting emergency services," she said. "If you can get those conditions diagnosed and treated, it is good for the whole system."