California Association of Health Insuring Organizations

SERVICES

While a number of key features differentiate the County Organized Health System from other managed care models, the underlying force behind the success of California’s six COHS plans is their emphasis on arranging access to appropriate, quality health care services that, collectively, improve the health and wellness of the member communities they serve. Serving the needs of low-income, disabled and long-term care (LTC) Medi-Cal beneficiaries, each COHS plan strives toward 100 percent quality care by providing the following:

Easy Access to Health Services

Each COHS plan works hard to eliminate physical, geographical, cultural and language barriers between members and providers. This is one of the main reasons why each plan has significantly increased the number of Medi-CaI contracted providers throughout its service area. Each COHS care network includes "safety net" providers — such as community and county clinics — as well as private providers and physicians. Enhanced access also helps members receive health services through the most efficient and effective channel: a primary care provider.

From the outset, one of the most costly strains on the Medi-Cal/Medicaid system has been members’ use of emergency rooms for unnecessary or non-emergency hospital care. This problem stemmed from the difficulty Medi-Cal beneficiaries had in accessing "fee-for-service" care providers. As a result, thousands of Medi-Cal beneficiaries would not seek medical care until they absolutely needed it. And when the time came for treatment, the emergency room at their local hospital was the quickest, least complicated — yet most expensive — place to receive it.

The COHS plans encourage their members to choose his or her primary care provider, or PCP. This approach has not only motivated members to take a more active role in managing their health, it has greatly decreased Medi-Cal member-related emergency room visits in all six of the COHS health plans.

With the establishment of each COHS plan, the number of Medi-Cal--contracted health care providers in each participating county has increased to more than 90 percent of those in active practice, making it easier for plan members to access Medi-Cal health care services. To further improve access to health care services, each COHS provides its members with a list of all available primary care providers. In some counties, improved access to health care among Medi-Cal beneficiaries has resulted in a 50 percent or greater reduction in emergency room usage. Shifting primary care from the emergency room to the more appropriate environs of a physician’s office saves the state millions of dollars annually in costly emergency room services without adversely impacting quality of care.

Case Management through Primary Care Providers (PCPs)

The COHS managed care model emphasizes case management and the "navigation" of members through the health care system by a PCP. Plan members either choose the PCP from a list of available providers, or they are assigned a primary care provider — most often a family practice, general physician or pediatrician — if they do not choose one. Members also have the ability to switch PCPs if they prefer another physician in the COHS plan.

Each COHS organization contracts directly with local providers or health maintenance organizations (HMOs) for a negotiated fee based on established criteria. This planned-payment fee structure guarantees a pre-paid fee arrangement between the COHS and the provider.

In addition to providing initial, non-emergency care and consultation, the PCP ensures the member’s access to all the care services within the local COHS system. Primary care physicians not only provide plan members with referrals for specialty care, they play a key role in monitoring the ongoing care of the member. This increased level of case management and practical patient guidance contributes tremendously to the high standard of quality and efficiency through which care is delivered in a COHS plan.