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2. Service Delivery Reform Options

This section of the paper looks at a variety of changes that could be made in the waiver to address the need for the waiver to be a demonstration and to address the cost of the Medi-Cal program.  These are options that can be implemented individually or in various combinations.

2-A. Restructuring Delivery Systems into Population-Based Collaborative Networks

As health care reform is contemplated at both the state and federal levels, it will be critical to look at new ways of delivering care, not simply new ways to pay for it. Increased coverage does not automatically equal increased access, particularly if care continues to be provided through the current delivery system.  Creating population-based networks can address the inefficiencies in the current system, and help build capacity where it can be most effective.  Public hospital systems, and even local governments, in their role as the hub of most local safety nets, offer a vehicle to begin to look at community-specific delivery system reform, generating models that could be supported by federal and state reform efforts.  Already, some counties are moving outside of the traditional public hospital focus into integrated systems of care that recognize the value of solid connections with ambulatory care providers (primary and specialty care), the integration of behavioral and acute care, and the collaboration of multiple providers in meeting the needs of a defined population. These efforts could be supported and expanded under a waiver.

Current Status in California

California counties face a perfect storm of factors related to the delivery of health care services for underserved people:

Counties are obligated through Section 17000 to assure access to health care services for the indigent populations under 200 percent of the FPL, although this obligation is interpreted differently throughout the state;

Some private providers are increasingly unwilling to provide care for the Medi-Cal population;

Public hospitals and clinics are faced with the same increased cost as other providers; and

Counties are increasingly burdened by the escalating reliance on local funding as the payer/provider of last resort for both the growth in the uninsured and what is perceived to be the inability of the state to adequately assure access for the Medi-Cal population.

Despite these challenges, local counties are beginning to develop innovative approaches to delivering care for the medically indigent. These initiatives, if supported, could become “laboratories” to determine cost-effective models to assure access as well as coverage.  Some examples include:

San Mateo County has restructured all of its county-funded health care programs (acute care, behavioral health, long-term care, etc.) into one entity to assure maximum integration of effort. The county also has facilitated the development of an innovative

Health Management Associates/Harbage ConsultingPage 13

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