Emphasizing the CARE in Medi-Cal Managed Care
The California Association of Health Insuring Organizations (CAHIO) was formed in 1994 to promote and improve the common good and public welfare of Medicaid (Medi-Cal in California) beneficiaries, and beneficiaries to other publicly funded health care programs, enrolled in the member plans. This is accomplished through the ongoing administrative coordination and program development of the member plans which provide comprehensive quality health care through to their membership. Together the six member plans (defined in federal law as "Health Insuring Organizations," and in California state law as "County Organized Health Systems" manage the care of approximately 1.3 million Medi-Cal recipients in 22 counties.
What are the Benefits of County Organized Health Systems? Here is a case study in Innovative, Cost-effective and Accountable Public Service:
With a long history of public service to our members, the members of CAHIO have developed these reports that explain the numerous advantages to the health plan members and the taxpayers.
Case study in innovative, cost-effective and accountable public service
Objectives of the Association
To maximize the use of taxpayer funds through cost sharing and the joint development of mutually beneficial programs and activities.
To promote the effective and efficient operations of all member plans thought the regular sharing of information and expertise.
To advocate the creation and maintenance of sound health care policy, and promote issues of common interest to the federal government, California Legislature, California Department of Health Services, the California Medical Assistance Commission, and other governmental bodies and professional organizations.
To develop and implement research, demonstration and educational activities aimed at improving the quality of health care delivery at reasonable costs.
To provide for a common vehicle of communication and centralized source of information regarding the operations of County Organized Health Systems.
To increase the knowledge and skills of member plan staff through educational, technological, and training interaction among plans.
How important is your personal physician to you?
Who do you see when you need a physical exam or medical advice from someone you know and trust? Chances are, you visit and confide in a doctor you have been seeing on an ongoing basis; someone familiar with your health background. Now, just imagine how you would feel if each time you needed to visit a doctor, you could not find one who accepted Medi-Cal patients. Or, you had to see a doctor you did not know maybe after a long wait in the emergency room? How often would you want to go to the doctor?
This was a problem millions of Medi-Cal beneficiaries faced under the old fee-for-service Medi-Cal system. As a result, Medi-Cal beneficiaries were more prone to only seeing a doctor when they absolutely needed to, a problem that not only led to higher rates of emergency room care, but also made it impossible for the Medi-Cal program to effectively track and monitor the health of its members.
A primary care physician-based system enables each COHS plan to provide better, more effective care to Medi-Cal beneficiaries on an ongoing basis. It helps both the COHS and the provider ensure that each plan member receives quality care from a physician with a vested interest in his or her wellbeing. Most of all, it provides Medi-Cal beneficiaries with the security and peace of mind that comes with having a personal doctor who cares about their health.
Strong Partnerships with the Local Medical Community
Each COHS provides doctors with effective and efficient administrative support. By improving physician satisfaction with support services, the COHS plans are able to attract more physicians, thus increasing access for their members. Through their involvement in committees, the board of directors and other channels, COHS contracted providers play a central role in tailoring the process through which optimal patient care is provided as efficiently as possible and with the best possible medical outcomes. The COHS plans are able to manage the delivery of local Medi-Cal care within their finite budget resources. Savings achieved through the efficient dispensing of medical services are shared with providers. Savings are also a primary source of funding for many of the enhanced community and special care programs and services each COHS plan develops individually in response to the needs of its member community.
County Organized Health Systems are not only able to create and manage the best mechanisms for the financing and delivery of health care services, they are able to assemble the brightest minds from the local public and private sectors to ensure that their policies and activities are developed and executed in the best possible manner. While each County Organized Health System is a public agency, it is governed by an independent commission or board of directors comprised of local government representatives, provider representatives, Medi-Cal members or their advocates and representatives of the community at large.
The County Organized Health Systems benefit tremendously by their ability to assemble a board whose members are active in the local community and catalysts in furthering the programs and policies that achieve the best results for the county as a whole. Special committees also play a key role in each COHS plan, ensuring that the plan stays in constant touch with the needs of the local medical community and the Medi-Cal members it is contracted to serve.
Ongoing Commitment to Community Needs and Values
California’s six COHS plans strive to develop value-added benefits and programs geared toward the specific needs of their members and communities at large. You can find examples of these innovative programs listed in each COHS plans individual section within this guide.
Advocates for Plan Members
Through an ombudsman, member advisory committees, grievance procedures, patient advocates or other "customer support" mechanisms, each COHS plan provides its members with multiple channels of recourse, should a member have a problem or grievance about a provider or any aspect of his or her health care services. Member input is highly valued in the COHS model and regarded as a key component in the ongoing development and refinement of services.
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