Market Profile: A MediCal Managed Care Perspective on the Challenges and Opportunities Facing San Diegans | Healthcare Informatics Magazine | Health IT | Information Technology Skip to content Skip to navigation

Market Profile: A MediCal Managed Care Perspective on the Challenges and Opportunities Facing San Diegans

January 2, 2018
by Mark Hagland
| Reprints
Community Health Group’s Joseph Garcia shares his perspectives on the San Diego managed care market

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?


Cardiology of the Future: Today’s Realities, Tomorrow’s Possibilities

Cardiovascular care stands to be nothing less than transformed by the potent technologies emerging now and in the near-term future—ushering in changes to not only how readily and effectively we...

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.


The Health IT Summits gather 250+ healthcare leaders in cities across the U.S. to present important new insights, collaborate on ideas, and to have a little fun - Find a Summit Near You!


Precision Medicine Alliance Brings Democratization of Precision Medicine

October 5, 2018
by Damon Hostin and Robert Weil, M.D., Industry Voices
| Reprints
The goal is for every patient to have access to the best treatment possible, when and where they need it.

Hospitals are built on data. Most often, medical data for research pile up in silos instead of being appropriately shared to develop more innovative ways to treat patients.

At Catholic Health Initiatives and Dignity Health, we have started to think differently about the possibilities that surround the data and expertise our clinicians bring to solving our patients’ care needs.  It’s why we joined forces to create the nation’s largest precision medicine partnership.

Because of that spirit of innovation, investment and the information-sharing agreements we established under the Precision Medicine Alliance, LLC, about 12 million patients in 16 states will have access to more promising treatments based on a genetic understanding of their disease.

The alliance currently is focused on advanced diagnostic tumor profiling. However, we are preparing ourselves to provide more specific diagnostic and personalized therapies for a number of genetic and acquired conditions, including cardiovascular medicine, neonatology and pharmacogenetics.

Before the alliance was formed, access to precision medicine-based care was inconsistent to all populations, making it available primarily to the well-insured and those with the personal wealth needed to pay for the specialized tests.


Cardiology of the Future: Today’s Realities, Tomorrow’s Possibilities

Cardiovascular care stands to be nothing less than transformed by the potent technologies emerging now and in the near-term future—ushering in changes to not only how readily and effectively we...

In a sense, the alliance represents the democratization of precision medicine. That’s because, for the first time, we have created a cost-efficient program that allows community-based hospitals, both large and small, to become partners with the alliance and introduce these vital programs locally.

The alliance highly complements national oncological programs at CHI and Dignity Health, which together serve more than 100,000 patients annually. Starting this fall, each oncology patient at active sites will be matched to all biomarker-appropriate therapeutics and will be screened for eligibility to enroll in a clinical trial. This makes Englewood, Colo.-based CHI and Dignity Health, which is headquartered in San Francisco, the first health systems in the nation with their own precision medicine program with reach across a national footprint. Together, the two systems have 139 hospitals and hundreds of other care sites.

The alliance couldn’t have happened soon enough amid the rapid pace of advancement in cancer treatments. Identifying new genetic markers and their effects on cancer occurrence, prognosis, and treatment options occurs at a staggering pace. Even the best-informed physicians may struggle to keep up with new treatment regimens for the most common cancers, let alone rarer forms. 

The alliance is working to accelerate change. It is switching how we view and treat oncology patients throughout our network as well as working on wellness and prevention among our higher risk populations.

By actively screening patients and learning more about how genetic makeup and some environmental factors may influence health and care, we are far better positioned to identify and intervene earlier.

We already have hundreds of thousands of patients under management in the system today—a mega-community of actionable medical information. That community is enabling CHI and Dignity Health caregivers to share—in real time—their insights and outcomes on patients with cancer.

At CHI and Dignity Health, we see our early work as a catalyst for furthering this emerging science, using next generation strategies, technologies and a strong partnership.  Our precision medicine alliance is not centered on discovering the next major genetic marker.  We view our purpose as creating a model that disseminates the benefits of precision medicine to more patients and more caregivers.  Access is equity and it is dictated by our mission.

Through the alliance, CHI and Dignity Health caregivers can more effectively identify the best drug therapies and possible clinical trials for their patients. Besides changing the way we treat some of our patients, we are also creating a repository of data to drive better clinical decision-making and treatment discoveries for generations to come.

We believe our early commitment to precision medicine through the alliance has helped set the stage for even greater and wider use of this promising methodology. With that, every patient can have access to the best treatment possible, when and where they need it.

Damon Hostin is the CEO of the Precision Medicine Alliance of Catholic Health Initiatives and Dignity Health.  Robert Weil, M.D., is senior vice president and chief medical officer of Catholic Health Initiatives and a board member of the Precision Medicine Alliance.

More From Healthcare Informatics


On Staten Island, a Highly Innovative Program That's Redefining What’s Possible Under Medicaid

September 17, 2018
by Mark Hagland, Editor-in-Chief
| Reprints
Healthcare leaders on Staten Island have been achieving exciting success in care management and population health management in their community’s Medicaid and uninsured populations

Even as one hears constant complaints and concerns about the challenges facing healthcare leaders who are attempting to help shift the U.S. healthcare system from volume to value, more and more truly encouraging stories are emerging about pioneering organizations that absolutely are moving the needle, in the present moment. One of those encouraging stories absolutely revolves around the Staten Island Performing Provider System (SI PPS), a unique organization whose leaders describe it as a “Medicaid redesign program implementation enterprise.” Under the leadership of Joseph Conte, Ph.D., CPHQ, its executive director, SIPPS has been forging a path forward around robust population health for Medicaid recipients on Staten Island, the New York City borough that is the by far the smallest in population (479,000, compared to Brooklyn, at 2.6 million in population) yet third-largest in land mass, among the city’s five boroughs.

The Staten Island Performing Provider System has been participating very successfully in the Delivery System Reform Incentive Payment (DSRIP) program under the aegis of the federal government. What is involved in New York State’s DSRIP? As NYSDRIP’s website notes, “DSRIP is the main mechanism by which New York State will implement the Medicaid Redesign Team (MRT) Waiver Amendment. DSRIP´s purpose is to fundamentally restructure the health care delivery system by reinvesting in the Medicaid program, with the primary goal of reducing avoidable hospital use by 25 percent over five years. Up to $6.42 billion dollars are allocated to this program with payouts based upon achieving predefined results in system transformation, clinical management and population health.” The federal Centers for Medicare and Medicaid Services (CMS) approved New York State’s Medicaid waiver requested in the amount of $8 billion over five years, in April 2014.

And SI PPS manages the care of 130,000 Medicaid recipients on Staten Island, in addition to managing the care of 50,000 uninsured Staten Islanders.

According to SIPPS leaders, “Staten Island Performing Provider System (SI PPS) is an alliance of clinical and social service providers focused on improving the quality of care and overall health for Staten Island’s Medicaid and uninsured populations, which include more than 180,000 Staten Island residents. We are co-led by Staten Island University Hospital and Richmond University Medical Center. Our network of over 70 partners includes skilled nursing facilities, behavioral health providers, home health care agencies and a wide range of community-based hospitals, clinical facilities, treatment centers, social service and community organizations, primary care physicians and medical practices across the island. SI PPS is expected to bring more than $200 million to Staten Island over 5 years if successful in transforming our care delivery system. Our mission is to engage partners and stakeholders in the planning and implementation of DSRIP as we move towards a value-based payment model for Medicaid in New York State.”

Among the goals that SI PPS leaders have set for themselves:


Cardiology of the Future: Today’s Realities, Tomorrow’s Possibilities

Cardiovascular care stands to be nothing less than transformed by the potent technologies emerging now and in the near-term future—ushering in changes to not only how readily and effectively we...

> Develop an infrastructure that lays the foundation for delivery system reform by transforming the Staten Island community through investment in technology, tools, and human resources that will strengthen the ability of providers to better serve our community

> Improve health literacy and share cultural competency knowledge

> Expand access to the appropriate level of care for all patients, including reducing barriers to care

> Expand outpatient and community services including home care, ambulatory detox, behavioral health/substance abuse, and primary care to reduce avoidable hospital/emergency department use on Staten Island

> Improve coordination of care and develop an integrated network

> Improve care management and disease management for high-risk patients, including patients with chronic conditions and behavioral health diagnosis

> Improve population health by addressing social determinants of health

> Integrate technology to allow for the secure exchange of health information across the PPS

> Reduce the per person cost for providing care

> Engage the uninsured, and underutilizing/low utilizing Medicaid patients and connect them to primary care and social services

> Implement innovative and evidence-based care models throughout the care continuum

> Implement training programs and learning collaborations between PPS partners that allow for the sharing of best practices

SI PPS leaders state that “These goals are being reached by implementing 11 DSRIP Projects, identified by a Community Needs Assessment, to address primary care, mental health, substance abuse, chronic disease, long term care, social determinants of health, and population heath.”

SI PPS leaders add that “We leverage a seamless platform that gathers data from multiple sources -- claims data, core reports, department of health information and the like -- and that data is inserted directly into the electronic data warehouse. With geo-mapping, we can identify areas that are lacking in key services. In creating maps of the population, we can filter in on specific conditions, and if we hover over a specific area within a specific map, we can see three years of claims data. We can figure out utilization trends, including hospitalization, medications, etc. We can also filter by demographics, types of chronic illness, etc.” Among the data sources they are make use of include direct data feeds from partners; lead providers’ clinical data; other partners’ clinical and billing data; data from care management partners; and public data; among other sources.

In addition, the SI PPS leaders have plunged into behavioral healthcare management. They note that they are pursuing “a population-health and community wide effort that aims to build capacity across systems by leveraging and developing partnerships to provide a quality integrated health care system, effective, high quality, person-centered care that supports improved health outcomes and optimal physical and emotional well-being. BHIP priorities focus on increasing and sustaining mental health/SUD provider service capacities, assisting community members to navigate behavioral health services, providing support to individuals and providers through education and technical assistance, addressing co-morbidities and co-occurring disorders, and reducing stigma and raising awareness about behavioral health wellness.” Among the numerous individual programs encompassed by the Behavioral Health Infrastructure Program (BHIP) are programs to expand the capacity of professionally certified peer workers in addiction and mental health, to help tackle the substance abuse program; the engagement of patients in the Emergency Department with substance use issues by clinicians and certified Peers to expedite linkages to behavioral health providers and reduce preventable ED visits; an innovative pre-arraignment diversion program designed to redirect low-level drug offenders to community-based health services instead of jail and prosecution; and numerous other programs.

Recently, Dr. Conte spoke with Healthcare Informatics Editor-in-Chief Mark Hagland regarding the progress being made at SI PPS, and the implications of his team’s work for transformation across the U.S. healthcare system. Below are excerpts from that interview.

Can you explain the basic funding mechanism or model that is supporting your organization?

The New York State Department of Health negotiated a waiver with CMS, and received $7.2 billion over five years to fund the program. About 50 percent of that was guaranteed for pay-for-reporting and program implementation, and 50 percent was set up as pay for performance, so it is very much a pay for performance program. There are 6 million people on Medicaid, and the state spends $65 billion a year, and the federal government pays for half of that; that’s why it’s very much in their interest to fund population health; it pays dividends to everyone.

To take care of the entire Medicaid population on Staten Island?

It’s interesting. We do not pay claims or intervene on behalf of providers, with managed care companies. Our sole purpose is to create innovation and reach population health milestones with providers in the community. So the hospitals, nursing homes, FQHCs, physicians, continue in their payment systems. We exist solely to create innovation and to incent innovation. It’s very much a pay for performance program.

Tell me about some of the main programs that you and your colleagues have been involved in, around this work?

The main initiatives relate to creating integrative care models where we bring in behavioral health providers to work with medical providers and medical providers who work in behavioral health organizations, so people don’t have to shuttle around to access care. We’ve done a great deal in the prevention of avoidable use of EDs for medical and behavioral care; that’s down over 60 percent in the past three years. And a lot of that has to do with looking at data form multiple sources and identifying where initiatives should be implemented. So we have a very big focus on asthma and a very big focus on diabetes. And a lot of the work involves engaging patients with peer educators who suffer from these conditions themselves.

One of the biggest innovations has been doing this with people who have alcohol and substance abuse disorders. We have peers in the EDs 24/7; and the number of people who have engaged in treatment services has tripled in the past few years. We’ve paid the salaries for these individuals, we’ve paid their training, have paid them to go get certified; and as they’ve become certified, they’ve become hired by the organizations, because their services are actually billable. So it helps the individual, helps the patient care organizations, helps the community. And it all comes out of high-level data analytics, doing hot-spotting, geo-mapping, bringing in social determinant of health factors, looking at housing, crime statistics, poverty, graduation lists, things like that. So we’ve done things very fundamental to services, to healthcare services, but in a very smart way. The workforce transformation is also very important; we spend a lot of time and training preparing people for new roles.

What have your biggest lessons been learned so far?

I would say it is that the kind of collaboration that it takes to create transformation is something that people really want to do; but they need organizations like ours that can bring these high-level analytics and resources together. And that includes training to give people new education; as well as providing to organizations high-level opportunities to identify patients most in need. You know, you can hunt for ducks with a shotgun, but it’s not a good idea when you’re trying to conserve ammunition, right? So we’ve helped people put a fine aim on things that need to be worked on, and the community coalitions are very powerful; you can’t go it alone, so working with local governmental units is very important. Also, bringing in information form as many sources of information as possible essential. We bring in ambulance data, social determinants of health data, school data, community data; all are essential.

Have you done geo-mapping or hot-spotting? How did you figure out how to obtain those various types of data?

When we started up, we were a complete start-up; so we didn’t have any legacy systems. So we hired very bright IT people and analysts, and brought the right tools to bear so that we could really be focused on how the resources were applied; that was our core investment.

What advice would you offer the senior healthcare IT leaders in patient care organizations, including the CIOs, CMIOs, CQOs, chief data officers, etc., in terms of what they should think about around all of this?

I would tell them that turning data into business intelligence is critical, and that’s true with respect to everybody. For the medical people, it’s medical business intelligence; for the finance people, it’s financial business intelligence. Don’t get overwhelmed with data; use it to create good information for clinical and business practices, and that will allow you allow you to be successful.

What will happen in the next couple of years?

There are about 13 states that have Medicaid redesign waivers in place now; CA and TX have received extensions, and we’re hoping for an extension. We’re also looking for other opportunities to extend our work; we’ve set up an ACO. We’ve set up a form of consultancy as well.

Where do you hope to go in terms of accomplishments in the next few years?

The important thing is for us to do things that are sustainable in the community whether we continue on or not, and that’s a lot of the work we have done—it is to grow capacity in organizations in the community. And that’s why the workforce work is so important. When people have new skills and training and ability to bring change into their organizations, these certainly are sustainability factors that are important.

Is there anything you’d like to add?

I would say one thing that we’re spending much more time on now, is continuing to try to work in the behavioral health space, because especially in the Medicaid population, any number of people have co-occurring conditions—they have medical and behavioral problems. And these are the patients with the most problems and who need the most services. So giving them access to more services is important, but also being able to be more predictive about when they’ll need those services, so we can be smarter about it; that is really important.





Related Insights For: Population Health


Cardiology of the Future: Today’s Realities, Tomorrow’s Possibilities

Friday, October 12, 2018 | 1:00 p.m. ET, 12:00 p.m. CT

Cardiovascular care stands to be nothing less than transformed by the potent technologies emerging now and in the near-term future—ushering in changes to not only how readily and effectively we can diagnose and treat illness, but also in how accurately we can predict and even stave it off. From measurably more productive workflows to palpably more precise assessments, technology surely has much in store for us. Artificial intelligence, seamless data integration, remote image access, and other advances are, quite simply, game changers in cardiology, with cardiologists, their patients, and the healthcare system standing to benefit.

See more on Population Health