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Communities
In Charge Jacksonville
”Jax Care"
Jacksonville,
FL
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Objectives
JaxCare
Inc., is a public/private partnership whose mission is to increase access to
healthcare for low-income, working uninsured residents of Duval County for the
purpose of improving overall community health, obtaining healthcare and
enhancing the economic foundation and social well being of our community.
JaxCare
Inc., is designed as a new public/private partnership committed to enabling
businesses to provide their low-wage, uninsured workforce with access to
healthcare. JaxCare is a resource management corporation that provides a
framework for coordinated, efficient, knowledge-based healthcare that reduces
uncompensated healthcare costs for medical facilities and other providers while
increasing access and improving health outcomes. JaxCare is designed for
the low-wage workforce who earn too little to afford commercial health
insurance, but too much to be eligible for Medicaid and other government
programs.
JaxCare
is the community-based strategy being developed by the Communities in Charge
- Jacksonville Coalition. Conceptualized and developed the
"Communities in Charge" grant initiative of The Robert Wood Johnson
Foundation, a two-year pilot test of JaxCare, is being financed by local and
national, private and governmental resources. JaxCare has the unanimous
support of the Jacksonville Mayor and City Council, the Jacksonville Regional
Chamber of Commerce, the Jacksonville Economic Development Commission, all 5
major hospitals, physicians, other providers and insurers. A key component
of the program involves electronically linking health and social service
providers in Northeast Florida into a shared database to facilitate eligibility,
screening, enrollment, referrals, and case management. This puts current
resources to maximum use before spending additional dollars.
The
governments of Duval County and the City of Jacksonville are consolidated to
include the entire 840 square miles of the jurisdiction. The total
population is approximately 80,000 with an estimated 15 percent of the
population uninsured. Survey data and population projections indicate that
there are approximately 100,000 to 130,000 uninsured individuals on any given
day - 70% of which work.
JaxCare
will concurrently pursue Four Business Objectives:
-
Implement
and evaluate the two-year pilot program. Designed to
demonstrate the viability and benefits of deploying a fully integrated,
community-based, managed care program for delivering healthcare to the
uninsured using a multi-hospital, community-service integration model.
The target population for the pilot is 1,500 working, uninsured, low-income
(defined as 150-200% of the Federal Poverty Level).
-
Strengthen
Jacksonville's capacity to contain costs by optimizing the appropriate use
of existing healthcare resources through integration and coordination of
health and social services using cutting edge information technology. CIC-Jax
(not JaxCare Inc.) and the United Way of Northeast Florida's First Call -211
Program have built an internet-based information-sharing network for safety
net providers. We are in the process of connecting all Duval County
safety net services and JaxCare providers into that system.
Communities in Charge Jacksonville has obtained nearly $1.7 million to date
in federal grant funds from the U.S. health Resources and Services
Administration to expand the United Way of Northeast Florida's Northeast
Florida Information Network (NEFIN) to include healthcare providers,
services, clients and health status indicators as well as to enable access
and data entry retrieval from any service site in the system.
-
Develop
long-term program and revenue models that are cost effective and financial
self-sustaining. During 2003 and 2004, JaxCare staff and
volunteer leadership will develop models to fund the program on a sustained
basis. They will explore long-term revenue sources and financing
strategies to expand access to healthcare strategies that involve self-pay
revolving fund models, pursuing legislative action, attracting additional
federal funding, and altering our local approach to caring for the indigent
and uninsured. In addition, they will collaborate with similar
coalitions in other Florida communities to discuss policy issues that affect
multiple locales and identify opportunities for collaborative action to
facilitate policy changes that will increase access to healthcare.
This will be facilitated through a series of policy meetings planned and
executed in partnership with the Winter Park Health Foundation and other
Florida Foundations.
-
Educate
and advocate for public policies and financing strategies to sustain
expanded access to healthcare for the target group. JaxCare
was designed and structured for execution through the Jacksonville Community
Forums on Health Care and the Uninsured. communities in Charge
partnered with the Jessie Ball DuPont Fund during 2002 to convene these
forums allowing local policymakers, stakeholders and professional challenges
to meet with national and regional experts for discussions about the local
challenge of financing and delivering healthcare to the uninsured. The
forums offered policymakers an opportunity to engage in informed discussions
and issue analysis in a neutral setting. This resulted in the
definition of strategies appropriate for Jacksonville and the development of
this business plan.
A
grassroots community education and communication initiative will be executed in
Duval County during 2003 and 2004 in conjunction with our coalition partners.
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Program Design
JaxCare
will implement a two-year pilot program to test the design, infrastructure and
delivery strategy of a countywide managed care program for the low-income,
working uninsured. Careful evaluation will track results and measure
impact, allowing fine-tuning approaches and thorough value and cost analysis
prior to any program expansion.
This
two-year pilot period will allow time for development of a detailed financial
strategy to sustain and expand the program. We have examined funding
strategies, from revolving loan funds to tax-supported funding most of which
require time, planning and consensus building before implementation.
Further, a number of issues that might ultimately affect financing options
require the attention of the Florida Legislature.
Consequently
this two-year window is crucial to our ability to strategically address these
topics, develop a framework that accurately determines full program parameters,
and solidify a comprehensive long-term financing mechanism. Assuming
positive evaluation and successful financial planning, program expansion will
begin in Year Three.
Timeline
- The JaxCare Program is anticipated to begin in the Spring with construction of
the administrative, operational and program infrastructure. Member
enrollment begins Summer 2003. This relatively short ramp-up schedule is
possible because of the administrative groundwork already laid by Communities in
Charge - Jacksonville. This pilot plan will be active through Summer 2005,
with final evaluation activities requiring an additional three to six months.
Eligibility
Criteria:
JaxCare
requires initial eligibility through Duval County Businesses. Each
participating business must meet the below listed Employer Eligibility
Criteria. Once it is determined that a business meets the eligibility
criteria, employees (individuals) of such businesses, who meet the Individual
Eligibility Criteria may be enrolled in JaxCare.
Employer
Eligibility Criteria:
-
Duval
County businesses with three or more employees who either;
-
Do
not provide health insurance benefits to employees, and have not provided
these benefits for the preceding 12 months and or,
-
Have
a non-benefit eligible workforce (excluding employees during their
healthcare probationary period).
Individual
Eligibility Criteria:
-
Residency:
Duval County
-
Age:
18-64
-
Income:
150-200% of the Federal Poverty Level (FPL)
-
Employed
through participating JaxCare businesses
-
Not
eligible for any health insurance program
Recruitment
Strategy
Public
notice of the employer-based, two-year, time-limited JaxCare pilot program will
be given, and eligible businesses will be contracted on a first-come first-serve
basis. In addition, JaxCare staff will work with the Chamber of Commerce,
United Way and other similar organizations to recruit businesses for the pilot
program. Member enrollment will be ramped up progressively over the course
of twelve months and managed in such a way that the program infrastructure can
effectively and cost-efficiently serve the membership.
Benefits:
JaxCare
members will have access to a full continuum of healthcare services available
through a network of private practitioners and public providers, specifically:
-
Primary
and specialty doctors
-
Laboratory
and diagnostic services
-
Generic
pharmaceuticals
-
Hospital
Care (inpatient and outpatient)
-
Proactive
care management including; risk screening of all enrollees; health education
and promotion; case management for those at risk for chronic or serious
illness; disease mangement for patients with chronic or serious illness.
Exclusions:
All
services for which JaxCare does not have contracted providers for are
excluded. Any serices not expressly included are excluded. Only
medically necessary services are included. In addition, certain services
are specifically excluded from the JaxCare Program such as:
-
Abortions
-
Acupuncture
-
Artificial
insemination in-vitro federalization and other procedures, pharmaceuticals
and treatment modalities intended to induce pregnancy
-
Biofeedback
-
Chiropractic
Therapy
-
Dental
care or Orthodontic services
-
Electrolysis
-
Experimental
or investigational care
-
Eye
glasses, contact lenses, or orthopotics
-
Lasik
eye surgery
-
Hearing
tests (routine) and hearing aids
-
Massage
therapy
-
Non-formulary
medications
-
Non-skilled
custodial care
-
Obstetrics
-
Private
duty nursing
-
Respite
care and retirement home care
-
Services
that are not authorized by the PCP and/or JaxCare, except in the event of a
life or health threatening emergency
-
Sex
change procedures
-
Transplants
-
Work
related injuries or illnesses
A
number of services will be limited. Full information about covered
services and exclusions will be provided to employers and employees prior to
program enrollment.
Quality:
The
plan will use proven medical management principles and base program requirements
for care and service on nationally recognized standards, performance goals and
benchmarks. Shands Jacksonville will support costs of medical management
for the two-year pilot. Case management will be conducted through JaxCare.
Through
the process of outcome monitoring and evaluation, program adjustments will be
made to ensure improvements in:
-
Health
status of the population served;
-
Use
of most cost effective and efficient services;
-
Coordination
of care management services across agencies;
-
Inappropriate
use of services, including misuse, overuse and abuse;
-
Jacksonville's
ability to make healthcare available and accessible to the low-income
uninsured.
All
providers and practitioners will be required to participate in JaxCare
Improvement and Utilization Management activities.
Delivery
System
Services
will be delivered through a series of networks; Hospital Based Provider
Networks, Provider networks will be established around each participating
hospital. Hence, there will be:
-
JaxCare
- Baptist
-
JaxCare
- Memorial
-
JaxCare
- St. Luke's
-
JaxCare
- St. Vincent's
Brooks
Rehabilitation hospital will provide rehabilitation services for all networks
under arrangements defined prior to the program onset. Hospital services
include inpatient and outpatient care and services such as lab and diagnostic
services and outpatient surgery. Since the Hospitals will donate their
costs, the networks are designed to assure equitable distribution of care burden
among hospitals. JaxCare will establish this patient distribution formula
in consultation with Hospital CEO's. Each hospital is expected to assist
in building their physician network and in recruiting potential JaxCare members
through patient outreach.
Primary
Care Physician Network: This network will include both private
practitioners and public agencies such as the Duval County Health Department and
Federally Qualified Health Centers. The JaxCare primary care network will
be geographically compatible to member access needs.
Specialty
Physician Network: This network will be recruited according to
existing hospital affiliations. Specialists will be assigned by hospitals
and use only that designated hospital for their JaxCare patients. Use of
patient and outpatient hospital services by JaxCare patients will be carefully
monitored to ensure that no hospital receives more than its pre-determined
allotment of JaxCare patients.
Prevention
& Outreach Focused Approach: The medical management of JaxCare
members with chronic illness, acute illness and those relatively healthy
but-at-risk for serious health conditions. This will improve their health
status in the short term and prevent, delay or reduce the severity of long-term
complications and costs. This is accomplished through JaxCare's
aggressively managed and coordinated system of interventions, which include
disease management, case management and health education prevention programs.
Care
Management: There are four levels of care management interventions
that JaxCare will contract with the University of Florida Jacksonville Health
Science Center to facilitate improved outcomes to patient care:
-
Risk
Management - All JaxCare members receive risk and need assessments to
provide staff with the information needed to stratify patients into
appropriate risk categories for targeted care.
-
Health
Promotion - Activities that focus on health maintenance, health
education and self-management.
-
Case
Management - Personal one-on-one interaction between patient and case
managers to facilitate patient responsibility for care planning, accessing
appropriate care services, ongoing monitoring of health status.
Evaluation and follow-up are ongoing.
-
Disease
Management - A coordinated and evidence-based approach that emphasizes
prevention of exacerbations and complications using patient empowerment
strategies. The process also includes ongoing evaluation of clinical,
humanistic and economic outcomes with the goal of improving overall health.
Generic
Pharmaceuticals: These will be available under a strict generic only
formulary. Discounted pricing will be available through the Duval County
Health Department Pharmacy. Negotiated discounts will be pursued with
retail pharmacies. In addition "compassionate use"
pharmaceuticals (drugs donated by pharmaceutical companies to needy patients)
will be pursued for eligible patients. Finally, federal discount prices
will be pursued for qualifying patients through the assistance of a pharmacy
consultant provided through the Community Access Program (CAP) grant.
Outpatient
Laboratory and Diagnostic Services: These services will be provided by
hospitals and by contract with local providers.
Governance:
The program shall be organized through JaxCare, a new 501 (c) (3)
not-for-profit corporation. JaxCare will employ a public/private
partnership model. The Board of Directors will consist of representatives
from the public/private partnership, to consumers and industry experts.
This representative governance assures that the program will be responsive to
the needs and interest of both the public and private sectors and keep their
sometimes disparate interests in balance. It also will provide an internal
set of checks and balances as each member carefully evaluates the advantages and
disadvantages of the program and strive for mutually beneficial solutions.
The
JaxCare Board will seek to include leadership from:
-
City
of Jacksonville Mayor's Office
-
City
of Jacksonville City Council
-
Duval
County Medical Society
-
Duval
County Health Department
-
Faith
Community
-
Hospital
Systems
-
Insurance
Industry
-
Philanthropy
-
Small
Business and Corporate Sectors
A
committee structure including committees such as Budget & Finance, Medical
Management, Government Affairs, Marketing and Communications, Pilot Committees,
Member Relations, and Management Information Systems shall be developed and
delegated by the board to oversee various program activities.
Management:
The program will be administered and managed on a day-to-day basis by the
corporation-JaxCare, building on the work and resources provided by Communities
in Charge - Jacksonville. This strategy will maximize the use of existing
resources and provide work already completed, and make available Communities in
Charge grant funs for the start-up phase of JaxCare. These grant funds,
totaling $1.5 million in 2002 and $1.2 million in 2003, are targeted
specifically for the development of the JaxCare program; including staff
salaries and the development of organizational, administrative and electronic
infrastructure.
Further,
the structure will maximize certain program financial efficient and allow for
the further uninterrupted planning, development and integration of ongoing
related projects. JaxCare will outsource administrative services where it
is cost-effective. During the first six months of the pilot, request for
proposals will be let, and based on responses. JaxCare will determine the
best approach for providing:
-
Accounting
and finance
-
Third
party administration (provider billing and reimbursement)
-
Utilization
management
-
Care
management
-
Enrollment
and eligibility
-
Provider
credentialing and network development
-
Public
relations/marketing
Implementation
of these decisions were completed by May 2003, along with initial member
enrollment and system testing. The pilot program "go live" date
is projected for Summer 2003.
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Financing & Outreach Strategies
Financing Approach
The program will be
financed on a "pay -as-you-go" basis wherein all costs are immediately
shared on a percentage basis by a variety of funding sources both private and
public. These include contributions from employee cost sharing, employer
contributions, hospitals (Baptist, Brooks Memorial, Shands, University of Florida
Health Sciences Center Jacksonville, St. Luke's/Mayo St. Vincent's), physician
groups, the Jessie Ball DuPont Fund, Blue Cross and Blue Shield of Florida and
various other foundations and corporation and the City of Jacksonville (general
fund). In addition, the Communities in Charge grants for The Robert Wood
Johnson Foundation and the U.S. Department of Health and Human Services will be transferred
to fund the JaxCare Program.
Projected medical costs
for the program have been calculated by Reden & Anders, Inc., Consultants
& Actuaries. These costs have been determined by the characteristics
and size of the covered population and type of benefits to be offered. To
estimate the costs for this pilot program Reden & Anders completed an
actuarial analysis using its commercial costs. TANF cost models and the
following provider reimbursement assumptions:
-
Hospital
reimbursement at 80 percent of Medicare. (While these will be donated,
all parties desired a uniform measure to track costs across hospitals).
-
Physician
fee schedule at 80 percent of Medicare for Jacksonville with certain
specialists at 100 percent of Medicaid or higher
-
Pharmacy
contracts with 35 percent discount on average wholesale price (AWP) for
generic drugs; $5.00 dispensing fee
Financial Risk Control
Mechanisms - JaxCare will have in place the necessary controls to assure
that program costs do not exceed budget. There are required to protect the
program for the risk of exceeding its budget. Multiple options are
available including:
Member Cost Sharing - Cost
sharing is integral to the program design. Member cost sharing will
provide more than $633,000 to the program. This will be contributed
through co-payments for care as follows:
-
$100
per hospital admission co-pay
-
$100
per emergency room visit co-pay
-
$100
per outpatient surgery visit co-pay
-
$100
per ambulance transport
-
$25
per MRI, PET, or CAT scan
-
$10
per physician office visit
-
$5
per routine laboratory visit
-
$5
per script for generic pharmacy
Employer Contributions
- Employer contributions will provide more than $1.26 million of total
program cost medical costs. This will be collected through a charitable
contribution to JaxCare through a $50 per member per month employer charge.
Hospital Contributions
- Hospitals collectively will contribute all care and services received on
an inpatient and outpatient basis by JaxCare patients for the duration of the
pilot program at no charge. The value of these hospital costs over the
two-year pilot is $2,131,301 calculated on a reimbursement rate of 80 percent of
the Medicare fee schedule.
Local Corporate and
Foundation - Will contribute $400,000 or more
City of Jacksonville - The
City will subsidize $2.5 million of the direct healthcare costs.
Federal Contributions -
Will exceed $1 million during 2003-2004 for JaxCare administration and staff
support as well as for other administrative and technological infrastructure,
which is not reflected in the financials.
The Robert Wood Johnson
Foundation - Will contribute over $340,000 for community education,
administration and staff support.
Cost Estimates - Costs
of the program have been calculated by Reden & Anders, Inc., Consultants
& Actuaries. These costs have been determined by the characteristics
and size of the covered population and type of benefits offered. To
estimate the costs for this pilot program, Reden & Anders completed an
actuarial analysis using its commercial costs, TANF cost models and provider
reimbursement assumptions.
In calculating these
annualized costs for this program Reden & Anders considered several factors
that impact unit cost:
-
Hospital
reimbursement at 20 percent of charges
-
Physician
fee schedule at 100 percent of Medicare for Jacksonville
-
Pharmacy
contract with 35 percent discount on generic drugs; $3.00 dispensing fee
-
Risk
selection and demographic mix
Table 1 displays all the
program funding sources associated with JaxCare Inc., meeting all of its two (2)
year objectives including financing for the JaxCare Pilot Program, the continued
development of the shared network infrastructure, ongoing long-term
sustainability plans for the program and educating and advocating for policies
and financing options to increase access to care. The JaxCare pilot is for
a population of 1,500 adults with income at 150%-200% of the Federal Poverty
Level, representing a cross-section of risks (neither positive nor adverse
selection).
Click
Here to View Table 1
Total program costs are
based on per member per month (PMPM) costs of $107.06. Table 2 illustrates
the distribution of PMPM costs.
Click
Here to View Table 2
Within the categories
defined in Table 2 above:
-
"Outpatient
Hospital" includes lab and diagnostic services
-
"Administration"
includes medical management (quality improvement, care management), billing
and enrollment, claims adjudication, member services, marketing, finance and
accounting;
-
"Other"
includes home health, durable medical equipment and ambulance.
Outreach
Recruitment Strategy - Targeted
enrollment efforts are through large and small employers of Duval County.
In addition, outreach strategy will be based on use of existing programs and
linkages. Linkages to social service, faith-based and other community
agencies will be a key component of the outreach and marketing strategy.
The health and social service community will identify appropriate access points
for entry into the system of care. Functional interrelationships among the
helping professionals and an understanding of the system, its services and
benefits and eligibility process will be a most effective marketing strategy.
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Accomplishments to Date
See
Above
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Challenges
See Program Design
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Contact
Us
Rhonda Davis Poirier, Ph.D., P.H
Executive Director
JaxCare
580
West 8th Street
Tower
II, 10th Floor
Jacksonville,
FL 32209
Ph:
904-244-9271
Fax:
904-244-9275
Email:
rpoirier@jaxcare.org Website:
www.jaxcare.org
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