Dear providers,

At SFHP, we are preparing for two major changes in 2011: 

• Timely Access Regulations
• Possibility of Mandatory Enrollment of Seniors and People with Disabilities (SPDs) into Managed Care

As of January 2011, SFHP and other managed care organizations are responsible for ensuring that members can schedule a primary care appointment within 10 days of the call, and to receive medical advice and triage by phone within 30 minutes, along with other requirements (see link).

We will be working closely with the medical groups to figure out how we can meet this mandate. We are also supporting four clinic sites in an advanced access initiative, Optimizing the Primary Care Experience.  All four sites are making progress on their backlog reduction plan.  Reducing backlog, measuring supply and demand, and managing predictable variation are key steps  that will allow the providers to “see their own, and not make them wait.”  In other words, to allow patients to see their own provider, when they need to be seen, without delay. 
 
As of February 2011, we anticipate that the State may start mandatorily enrolling Seniors and Persons with Disabilities into SFHP, if the State’s waiver proposal is approved by the federal government.  We do not expect that dual eligibles (those with Medicare) will be included in mandatory enrollment, although they would be allowed to voluntarily enroll.  This is a tremendous opportunity, as these patients have previously been in the fee-for-service state Medi-Cal system. Unlike managed care, patients in state Medi-Cal have no requirement to access primary care, and frequently suffer from uncoordinated care and emergency room over-use. There is no customer service line to help resolve issues nor care coordination for hospitalized patients being discharged home. We will be working on preparing for this population, in particular focusing on effective interventions for the highest risk members (such as complex case management, and assisting with the high-risk transition from hospital to home). We also will be working on assessing the capacity of our network, to ensure we can facilitate moving patients into primary care if they have not accessed primary care in the past.   We will be working with the State to provide resources to help providers best manage this population.  For more information about this population and SFHP plans visit the PATH-SPD Expansion update. 
 
We have launched our first Patient Navigator program at St. Francis Hospital. The goal of this program is to help SFHP members and HSF participants access primary care services, instead of over-utilizing the emergency room.  Melanie Chincilla, who has substantial experience in substance abuse and care coordination is on-site at St. Francis, meeting with patients and helping coordinate their primary care appointments.  We will keep you posted about our progress.
 
We got some great news this spring –our 2009 HEDIS quality results show 17 out of a total of 22 measures in the 90th percentile for Medi-Cal, and 10 out of 11 measures for Healthy Families.  As always, this success is due to our excellent provider network.

Enjoy your summer.
 
Yours in health,

Kelly Pfeifer, MD