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Backup Documents 09/06/2001 WBOARD OF COUNTY COMMISSIONERS WORKSHOP MEETING SEPTEMBER 6, 2001 BOARD OF COUNTY COMMISSIONERS PUBLIC WORKSHOP ON THURSDAY September 6, 2001 from 9 A.M. - 12 P.M. AGENDA Health Care Planning and Finance Committee Formal Presentation by members of the Committee and Guests Public Comment Questions and Comments by Commissioners August 29, 2001 Ms. Pam Perrell Naples Daily News 1075 Central Avenue Naples, FL 34102 Re: Notice of Board of County Commissioners Primary Healthcare Proposal Workshop Dear Pam: Please advertise the above referenced workshop on Sunday, September 2, 2001, and kindly send the Affidavit of Publication, in duplicate, together with charges involved to this office. Thank you. Sincerely, Ellie Hoffman, Deputy Clerk Enclosure Account #001-155110-649110 NOTICE OF PUBLIC MEETING BOARD OF COUNTY COMMISSIONERS, COLLIER COUNTY, FLORIDA PRIMARY HEALTHCARE PROPOSAL WORKSHOP Thursday, September 6,2001 9:00 A.M. Notice is hereby given that the Collier County Board of County Commissioners will meet in the Board's Chambers on the Third Floor of the W. Harmon Turner Building (Building F) at the Collier County Government Complex, 3301 East Tamiami Trail, Naples, Florida, to conduct the business of Collier County at the above stated time and date. Copies of the agenda for said meeting will be made available to the press and may be obtained at the Public Information Office, located on the First Floor of the W. Harmon Turner Building. Any person who decides to appeal a decision of this Board will need a record of the proceedings pertaining thereto, and therefore may need to ensure that a verbatim record of the proceedings is made, which record includes the testimony and evidence upon which the appeal is to be based. BOARD OF COUNTY COMMISSIONERS COLLIER COUNTY, FLORIDA James D. Carter, Ph.D., Chairman DWIGHT E. BROCK, CLERK By:/s/Maureen Kenyon Deputy Clerk !Maureen K. Kenyon From: Kathy Mclarty Sent: Tuesday, August 28, 2001 3:04 PM To: Maureen K. Kenyon Cc: Mary Brock; 'maria_snyder@doh.state.fl.us' Subject: FW: 9/6 BCC Workshop Importance: High Notice of Primary Health Care ... Mary Jo: Thanks so much for the heads up on this. Maureen: You will find the legal notice attached. Maria: I discussed this with Leo, and we are requesting that you coordinate with Tom Schneider to have the appropriate agenda info available at the PlO office by Monday a.m. Thanks, all. <<Notice of Primary Health Care Proposals Workshop.doc>> ..... Original Message ..... I From: brock_m Sent: Tuesday, August 28, 2001 2:22 PM To:ochs I; mclarty_k Subject:- 9/6 BCC Workshop Importance: High Leo and/or Kathy, Maureen from Minutes and Records called looking for the advertisement for the September 6 BCC/Health Care Workshop. She said if you e-mail it to her today at Maureen. Kenyon@clerk.collier.fl.us she'll be able to forward it to the paper for Sunday's edition. Thanks, Maw-Jo Ellie J. Hoffman To: Subject: paperrell@naplesnews.com BCC Workshop re Primary Healthcare Proposal Good Morning, Pam, Please advertise the above referenced workshop as indicated on the attached. Thanks, Ellie Healthcare.doc Health Care Proposals Workshop... Ellie J. Hoffman From: Sent: To: Subject: System Administrator [postmaster@naplesnews.com] Wednesday, August 29, 2001 8:45 AM Ellie J. Hoffman Delivered: BCC Workshop re Primary Healthcare Proposal BCC Workshop re Primary Health... <<BCC Workshop re Primary Healthcare Proposal>> Your message To: 'paperrell@naplesnews.com' Subject: BCC Workshop re Primary Healthcare Proposal Sent: Wed, 29 Aug 2001 08:46:31 -0400 was delivered to the following recipient(s): Perrell, Pamela on Wed, 29 Aug 2001 08:45:05 -0400 Naples Daily News NapLes, FL 3410E Affidavit of Publication Naples Daily News BOARD OF COUNTY COMMISSIONERS CHRIS HORTON PO BOX 413016 NAPLES FL 34101-3016 REFERENCE: 001230 0011551106491 58312683 NOTICE OF PUBLIC MEE State of Florida County of Collier Before the undersigned authority/ personally appeared Angela Bryant, who on oath says that she serves as Assistant Secretary of the Maples Daily News, a daily newspaper published at Naples, in Collier County/ Florida: that the attached copy of advertising was published in said newspaper on dates Listed. Affiant further says that the said Naples Daily News is a newspaper published at Naples, in said Collier County, FLorida, and that the said newspaper has heretofore been continuously published in said Collier County, Florida, each day and has been entered as second class mail matter at the post office in Naples, in said Collier County, Florida, for a period of I year next preceding the first publication of the attached copy of advertisement; and affiant further says that she has neither paid nor promised any person, firm or corporation any discount/ rebate, commission or refund for the purpose of securing this advertisement for pubLiction in the said newspaper. PUBLISHED ON: 09/02 AD SPACE: 64.000 INCH FILED ON: 09/03/01 Sworn to and Subscribed before me this /7'~/~ day of ~ 2(~t PersonaLly known by me ~-}\~C'[[~_ ~__t_' ('~C-~'~OT~ ~' NOTICE OF PUBLIC MEETING BOARD OF COUNTY COMMISSIONERS COLLIER COUNTY, FLORIDA - PRIMARY HEALTHCARE PROPO, SA~ ,W. ORKSHOP Thursdoy, September e, ZUUl 9:00 Notice Is hereby given that the Collier Cou..ntY Board of County Co~..mls_s.l.one. r_s. wlll .m..eet..!n.~e Board's Chambers on me Tmra FlOOr OT_1~..e.w._rlar- mort Turner Building (Building Fiat the col.er coun- fy Government Complex, 3301 East Tam ami Trail, Naples, Florida, fo conduct the business of Collier th,ata, s .......... ~""PU~b~iC I~.Office,.~ on me rlr~ Floor of file W. I-Iormon ~urner su O: .... A ~v oerson who decides to op~)e~l a aecls~on m J'hls B )~rit will need a record of the proce.~.lngs per- talnht~ ther _m~., and th.er_ .efore. may m~,a Tg. ensue Itlat c verbatim record at .we ~aceealng.s ~s..maae, I COLLIER COUNTY, I Jams ~ D. Carter, Ph,D., Chalrmon DWI(; HT E. BROCK, CLERK By:/! / Maureen Kenyon / Del~ Y Clerk - L Septe r~ber 2 No. ~83967 / Chanel A McDonald MY C©MMJ$$ ON # CC850752 ~XPLRES June 29, 200~ Boi',tg[b THRU TROY F~IN INSURANCE, INC Campaign Chairman Mark F. Rhcin President Patrick H. Neale Board of Directors Larry E. Block Block & Bluck, Inc. Dick Brinkmcycr R.G. Brinkmcyer Co. Deborah M. Brown Emily K. Bua Premier Properties Dr. Jnan Coller Collier Co. Health Dept. Steve Fain Collier County Public Schools Palina J. Fus(m NCtt Healthcare System Charlic Grau First National Bank of Naples Lynnc Gmth Gullshore Lilt Sbarnn M, Hanlon Zclman & Hanlon EA. William R Harrison City of Naples Robbert Hubbard Habbard's Lilniled Sidney T. Jackson Marine National Bank of Naples Father lira Navin St. Peter's Church Patrick H. Ncale Attorney alt Law Let) Ochs. Jr. Collier County Government Amy E. Orr Allen Systems Grnup, Inc. Ursula Pfahl, Ph.D. Yamron .Icwclcrs Jnc Raincy Publix Supermarkets Chip Reeves Fifth Third Bank Mark E Rhein SunTrust Bank David F. Rice Total Home Services Inc. Lillian Roche Bank of Amcrica Susan M. Roggc Fifth Third Bank Jerry Thirion La Playa Beach Resort Tuck Tyler Northern Trust Bank Susan Hebcl Watts The Bonita Bay Group UNITED WAY OF COLLIER COUNTY 852-1st Avenue, South, Suite 210 · Naples, Florida 34102 (941) 261-7112 · Fax (941) 261-3955 September 5, 2001 The Honorable James Carter, Chairman Board of County Commissioners Collier County, Florida 3301 East Tamiami Trail, Administration Building Naples, FL 33412 Dear Chairman Carter and Board: The Board of Directors of the United Way of Collier County has followed with great interest the work of the Health Care Review Committee regarding tax assisted medical care for the working poor of this county. We commend the committee members for their dedicated effort. Our review of the committee's findings bolstered the anecdotal evidence provided to us by United Way agencies: that medical services to the indigent and the working poor of Collier County do not meet the needs of that segment of the community. The consequences of this lack are wide. ranging:, though not readily from failure to obtain or pay for medical treatment. The issue of medical care for the working poor and indigent is a county problem. It must be acknowledged. Once acknowledged, the leadership of this community cannot turn away from seeking a resolution to these issues. As the elected leadership of Collier County, it is fitting for the county commission to take its place in resolving this pervasive problem that affects so many of its constituents. In overseeing the welfare of the citizens of this county, medical care for the working poor is no less within the jurisdiction of this commission than roads, parks, housing or sanitation. We are confident the commission will assume its rightful role in addressing this particular Collier County issue. Executive Director Campaign Development Director j~~ Shannon ~,V. Anderson -- Patrick H. Neale Finance & Administrative Coord. Robin Jones President, Board of Directors Administrative Assistant United Way of Collier County Jennifer M. Chanzes United ¥~ty - It Brings Out The Best In All Of Us. "No goods or services provided by thc Donee organization in whole or partial consideration for thc contributkm" A cop3' of the official rcgistration and linancial registration infurmation may be obtained frnm the Division of Cnnsumer Services by calling toll free within the state. Registration does not imply endorsement, approval, or recommendation by the state 1-800-435-7352 "Remember United Way in your will". AGENDA - PROPOSED COLUER COUNTY PRIMARY CARE PROGRAM FOR THE UNINSURED .TOPIC INTRODUCTION V/- Agenda Overview Highlights of Apdt Presentation Needs -- Pdorifies - Solutions v/THE NATIONAL SCENE - "WE ARE NOT THE ONLY ONES" k/CURRENT PRIMARY CARE PROVIDERS TO LOW-INCOME PEOPLE ~/PRIMARY CARE - THE BUSINESS PLAN v- Overview ~- Program Details %/- People to Be Served v .- Primary Care Services v,,- Pharmacy Services · ,/- Hospital and Specialty Referral Services - "We Care" Program - Govemance and Administration BUDGET LEGAL ISSUES COMMUNITY OBJECTIONS AND CONCERNS WRAP UP - Summary - Next Steps SPEAKER Tom Schneider Phyllis Busansky Dr. Bill Lascheid Tom Schneider Steve Rasnick Tom Schneider Steve Rasnick Wendy Witderman Tom Schneider Tom Schneider Ramiro Manalich Jim Tindalt Tom Schneider COLLIER COUNTY rimary Care Program Business Plan August 2001 BUSINESS PLAN PROPOSED COLLIER COUNTY PRIMARY CARE PROGRAM FOR THE UNINSURED September 4, 2001 BUSINESS PLAN PROPOSED COLLIER COUNTY PRIMARY CARE PROGRAM FOR THE UNINSURED INTRODUCTION: In 1999 The Collier County Board of Commissioners formed The Health Care Review Committee, an advisory committee, to determine whether access to health care was a problem for any major segment of our population. The Committee concluded that access to health care was indeed a huge problem. The Committee recommended that The Board seek ways to provide a safety net of funding to enable some kind of public/private partnership to provide health care to Iow income uninsured adults under 65 years of age. The Committee also advised The Board to form a second advisory committee to seek the best solution, estimate the related costs and recommend how the costs should be funded. The Board formed The Health Care Planning and Finance Committee in 2000. In Apdl 2001, the Committee presented to the Board its recommendations and requested the Board to provisionally approve funding of $2.8 million in the upcoming budget for the next fiscal year beginning October 1, 2001. The Committee's request for provisional budget approval was in response to the timing requirements of the County's budget cycle; and the Committee emphasized that it would complete its work on plan design and return to the Commissioners with all important program specifics before secudng the Board's final approval. In April, The Committee emphasized that one of its first priorities was to preserve the existing School Nurse Program in Collier County schools, which was in danger of losing much of its funding. With 43% of our school children qualifying for the federal free and reduced lunch program, the school nurse Program must be considered an integral part of the Community's health care system. Another priority was to fund aggressive enrollment programs for both Medicaid and Healthy Kids to ensure that the County was taking maximum advantage of all available federal and state funding before spending any local taxes. These two programs accounted for $300,000 of the Committee's total funding request. The Committee's main priodty was the establishment and funding of a coordinated system of primary health care for the Iow income working uninsured of Collier County. In Apdl, the Committee requested initial funding in fiscal year 2002 of $2.5 million to provide pdmary care for the entire year for about 7,000 of the estimated 20,000 eligible Iow-income working uninsured adults with incomes under 200% of the Federal Poverty Guidelines (FPG). This included estimated administrative expenses and start up costs. Page 2 Since April, the Committee has been working diligently to complete its studies and deliberations of plan design and eligibility requirements, the best way to deliver pdmary care, and administration and governance issues. As a result of its further study and deliberations, the Committee has modified its primary care recommendations as follows: Changed recommended eligibility requirements to only those with incomes below 150% of FPG; this reduces the estimated number of eligibles to about 14,000. Delayed recommended planned start date until about April 1, 2001, to allow time for needed pre-implementation activities. Lowered the recommended maximum number of enrollees in the initial year and annually thereafter to recognize, among other things, a lower number of eligibles. Largely as a result of these changes, the Committee is reducing its funding request for the proposed primary health plan (The Plan) for fiscal year 2002 from $2.5 million to $7OO,OOO. Since April, the Committee has also secured the support of the local Medical Society and local hospitals to form a "We Care" program whereby local physician specialists and hospitals will agree to provide needed specialty care free of charge to patients referred by the Plan's primary care providers. Details of the Plan are presented in this Business Plan. The Committee believes the Plan responds to the unique needs of Collier County and will meet the health care needs of the uninsured Iow-income working poor in a very cost effective manner. Further, the Plan will add to the existing infrastructure of organizations already working to meet the needs of this segment of our population. We look forward to discussing our proposal and revised recommendations in depth at the workshop scheduled for September 6 and to responding to all your questions. Very truly yours, Thomas G. Schneider, Chairman Collier County Health Care Planning and Finance Committee Page 3 OVERVIEW: In order to improve access to health care for its Iow-income residents, Collier County is proposing an integrated system of primary and preventive health care services. Eligible enrollees will be 19 to 64 years old, working Collier County residents whose annual family income is equal to or less than 150% of the Federal Poverty Guideline (FPG). This program is considered to be the payor of last resort. That is, individuals eligible for other government subsidized health insurance (such as Medicare or Medicaid) or affordable pdvate health insurance will not be eligible for this program. Primary care providers (PCP's) will be responsible for the seeing patients, ongoing management of their care and, when appropriate, making referrals for hospital, specialty, and other services and therapies through the '~Ne Care" Program to be established. The graphic below gives an overview of the structure of services proposed to be provided as part of this system of integrated health care based on pdmary care services and case management. System of Integrated Primary and Preventive Health Care Services GOVERNANCE AND CONTROL COMPREHENSIVE, CASE MANAGED PRIMARY CARE AND PREVENTION ACCESS I '1 CORE SERVICES DISEASE · Primary Care * Outreach · Preventive Services INTEGRATIVE · Enrollment · Related Pharmacy REFERRAL . Health Educ. · Related X-Ray/Lab SYSTEM HOSPITAL SERVICES SPECIALTYCARE I I SOCIAL SERVICES THRU OTHER AGENCIES OTHER SERVICES I THERAPIES Page 4 MISSION AND OBJECTIVES: Mission: The mission of the Collier County Health Care Program is to facilitate access to a system of community-based, primary care and prevention-focused health care services for uninsured Iow income, working County residents. Community Goals and Pro¢3ram Objectives: The overall community goals of this Program are: · Improve the health and quality of life of Collier County's Iow-income working population. · Improve the productivity of this target population through improved health, therefore reduced absenteeism, turnover, and improved on the job performance. · Reduce the community's cost of uncompensated care. · As a result~ improve the health and quality of life of the overall Collier County community. To achieve these community goals, specific objectives of the Program will be to address the needs of Collier County's uninsured Iow-income working population by: · Increasing access to affordable health care. · Providing Iow-cost pharmaceuticals. Reducing inappropriate use of hospital emergency rooms as a site of primary care, thereby increasing emergency room capacity for more appropriate utilization. · Reducing unnecessary hospitalization for avoidable conditions. · Utilizing the success of the program to obtain additional state and federal dollars, as well as pdvate sector funds, to further support health care access. Page 5 PROGRAM SPECIFICS: People Served: The population to be served by this program will be 19 to 64 years old Collier residents (excluding undocumented aliens) whose annual income level is equal to or less than 150% of the Federal Poverty Guideline (FPG). Since this program is considered to be the payor of last resort, individuals that are eligible for other government subsidized health insurance (such as Medicare or Medicaid) or affordable pdvate health insurance will not be eligible for this program. The annual Federal Poverty Guidelines are a function of the size of the family. The following is the 2001 FPG formula for the 48 contiguous states: $8,590 annual income for a single person + $3,020 per each additional family member Therefore, for families up to 4 members, the following is the FPG (100%) and 150% of the FPG: Size of Family 100% . 150% (Persons) Poverty Guideline Poverty Guideline (Annual Income) (Annual Income) I $8,590 $12,885 2 11,610 17,415 3 14,630 21,945 4 17,650 26,475 It is estimated that there are approximately 14,000 uninsured adults (19 to 64 years old) under 150% of Federal Poverty Guidelines in Collier County. (The chart in Attachment 1 summarizes these projections.) Assuming that the number of people enrolled in the program over the first three fiscal years of operation will be capped at 7,000, the following are enrollment targets: · End of FY 2002 (Sept. 30) · End of FY 2003 (Sept. 30) · End of FY 2004 (Sept. 30) 2,000 Enrollees 5,000 Enrollees 7,000 Enrollees If a fiscal year enrollment target is reached, eligible Collier County residents will be enrolled on a first come-first served basis with a waiting list, if necessary. Page 6 Specific Eli.qibility Requirements: 1) Eligibility under the program is focused on the Iow-income working population of Collier County. A participant must be employed at the time of enrollment under the program or be in a government sponsored back-to-work project such as the welfare to work (VVAGES) program or be permanently disabled awaiting eligibility for health care under Medicare. 2) Family income qualifications will be limited to no moro than 150% of the Federal Poverty Guidelines. 3) The proposed program is the payor of last resort. 4) Only residents of Collier County will be eligible for participation under the program. 5) Undocumented aliens will be excluded from the program. 6) Eligibility for affordable health insurance at a place of employment and a unilateral decision not to participate disqualifies an individual from participation under the program. Affordable is defined that the person would pay 10% or less of gross income for health insurance premium. 7) The program will include at least an annual re-enrollment procedure, more frequently at the will of the program. Primary Care Services Description of Services: At the core of the proposed system of providing and managing health care are primary health cam services and related pharmacy and ancillary services (such as laboratory.) Pdmary care providers (PCP's) will be responsible for seeing patients, the ongoing management of their care and, when appropriate, making referrals through 'the "VVe Care" Program for hospital, specialty, and other services and therapies as well as for community social services. Primary care services will be offered initially in two geographic locations within the County, the urban area surrounding Naples and Immokalee. There is a shortage of primary care physicians for the entire population of Collier County, particularly in the winter when the nUmber of seasonal residents increases. This puts additional stress on already crowded emergency rooms. Services covered under the pdmary care program are listed in Attachment 2 and services not covered are listed in Attachment 3 with identification of the source of the service for the patient. Page 7 Vendor I Provider Selection: In order to build upon existing resources, information was collected through meetings with vadous health care providers to determine the level of interest and ability to provide these primary care services. Based upon these meetings, levels of interest, and the desire to have one principal provider of pdmary care, it is recommended that Collier Health Services, Inco (CHSI) be considered a preferred organization to provide these services. CHSI is the designated Federally Qualified Health Center (FQHC) for the Immokalee area and has expressed an interest in establishing a clinic in Naples to address the needs of program participants. The needs of program participants in the Immokalee area would be addressed through their current clinic. CHSI's mission is to assist in providing primary care access for the uninsured and people eligible for health care under state and federal government programs. They are provided certain advantages due to their FQHC status. Examples of advantages are: · FQHC's have advantages in recruiting primary care physicians to treat Iow income populations · FQHC's have access to preferred pricing such as the 340B pharmacy pricing described in the next section. President Bush's administration is emphasizing the FQHC's as a focal point for expansion of primary care services. Additional monies have been put into the federal budget to support FQHC expansion. However, in order for a community to leverage these funds there will need to be a demonstrated local financial commitment. It is recommended that the County negotiate with CHSI to provide pdmary care. CHSI has expressed interest and our estimated budget is based upon CHSI as the provider. However, this does not preclude the County from using a request for information (RFI) or a request for proposal (RFP) to select the provider. Financial Matters: The following are options for methods of reimbursing providers for services: 1) Fee-for-service based on a percentage of Medicare or Medicaid rates. 2) Capitation of the pdmary care portion. 3) A flat fee based upon a negotiated "Cost Plus" approach. The flat fee approach is the Committee's preferred reimbursement method for negotiation with the preferred provider(s). Each enrolled participant will be required to pay the provider a co-pay of $6 per visit. Page 8 Related Pharmacy Services: Description of Services: The pharmacy program will utilize a tight, limited formulary that optimizes the use of 340B discount funding and emphasizes generic drugs, compassionate drug funding, and free samples. A budget and structure will be set up that optimizes this mix and oversees it over time. The 340B pharmacy pricing structure is set up to give discounts to certain government supported organizations such as Federally Qualified Health Centers, disproportionate share hospitals, health department clinics, and veterans' administration centers. By law, the 340B discount must be the greatest given by the manufacturers, therefore would result in the lowest available prices. The Office of Pharmacy Affairs (OPA) in the federal government's Bureau of Primary Health Care administers the 340B pharmacy program.. OPA now allows 340B purchased pharmaceuticals to be distributed by commercial pharmacies, if the stock is accounted for separately. Therefore, utilizing a request for proposal, the distribution of pharmaceuticals for the Collier program will be contracted through commercial pharmacies with payments on an individual prescription distribution fee. This distribution fee will be collected by the pharmacy as a co- payment from the patient that is acceptable to the County. Compassionate drug programs are set up by many drug companies to distribute free pharmaceuticals to Iow-income people. These drugs are acquired for individuals and may take up to 60 - 90 days to acquire. This program is labor intensive but does allow acquisition of free drugs. Existing programs have experienced that the value of acquired drugs can be 4 times the salary paid to the pharmacy staff working on acquiring the drugs. Therefore, Collier County would budget for pharmaceuticals to be used for drug purchase and for the administration of the program. The administration of the program includes the cost of staff time to acquire comPassionate drugs and to collect free samples. This will maximize the amount of pharmaceuticals purchased within the budget. Vendor I Provider Selection: The County's choice of the pharmacy to dispense 340B pharmaceuticals to program participants would be the result of a competitive bid based upon the fee charged to the patient as well as the level of service and multiple convenience locations for the patient's pick-up of their prescription. If the majority of the primary care program were contracted to one entity, it would be more efficient to also contract the compassionate drug component of the program. A successful compassionate drug program requires frequent contact with primary care providers to determine acceptable drug substitutions. Contracting the function would also allow negotiation of paying for a full or portion Page 9 of a pharmacy assistant to do the work under the direction of a pharmacist already working for, contracting with, or volunteering with the organization. Financial Matters: The budget for pharmaceutical services includes the cost of purchasing the drugs, as well as the hiring of a pharmacy aide to acquire compassionate drugs.. The hiring of the aide would be done by the primary care vender, therefore would be part of negotiations for primary care services. The maximum annual cost of pharmaceuticals paid by the Plan for any individual patient will be $750. Hospital and SpecialW Referral Services: Based upon data collected from local providers it is estimated that currently, hospitals and specialists in Collier County are annually providing $30 - $50 million in uncompensated care. This care is being provided in an extremely inefficient and costly manner. The care is unmanaged and tends to be through emergency rooms. By better coordinating care for the underinsured and managing their care through pdmary care providers, the total cost of the uncompensated care will decrease. The Collier County Medical Society and the hospitals in Collier County have acknowledged their support for a We Care voluntary referral system for specialty care for free on a pro- bono basis. This We Cato program would address most of the program participants' specialty care needs. Active recruitment of all local specialty physicians will begin as soon as the Board of County Commissioners formalizes its financial commitment to the proposed program. The management of this program will be a joint effort of the County Health Department, the County Medical Society, and the Hospitals. Governance and Administration: The program will be governed by an advisory board reporting to the Board of County Commissioners (BOCC). This voluntary board will represent major stakeholders, including users, and will be appointed by the BOCC. Stakeholder groups to be represented include County government, the County Health Department, provider groups, physicians, not-for-profit social service and health care agencies, citizen groups, and clinic users. The advisory board will address major areas of program policy and oversight such as management and finanCial performance, medical issues, and patient relations. This is a governance structure that has worked, well in other programs for the uninsured in Florida and elsewhere in the United States. The administration of the program will be the responsibility of the Collier County Health Department or the Collier County Department of Social Services. Page 10 BUDGET: The chart below summarizes the proposed primary care budget for the first four fiscal years of operations. The program is projected to begin on Apdl 1, 2002. Therefore the first fiscal year has only six months of operations. The model used in making the budget projections (detailed in Attachment 4) is intended to show that the program can be achieved within budget. It is not intended to dictate specifics on how the clinic must operate. This would be determined during competitive bidding for the services followed by negotiations and be fine-tuned in future years. The program's budget for the fourth year, when it reaches 7,000 enrollees, is within the original projection for the annual cost of the program that was presented to the Board in April 2001, even after adjusting for estimated inflation for the three intervening years. Recognizing that other non-profit organizations will continue to treat some of our target population and that no other successful program we studied ever reached more than 65% of its target population in any one year, we believe projecting an annual cap of 7,000 enrollees is reasonable. Page 11 SUMMARY OF PRO-FORMA BUDGETS FOR PRIMARY CARE OPERATIONS - FIRST FOUR FISCAL YEARS (FYs) KEY OPERATING STATISTICS: Enrolled Members Target: Beginning of Time Period: 0 2,000 5,000 7,000 Midpoint of Time Period: 1.000 3,500 6,000 7,000 End of Time Period: 2,000 5,000 7,000 7,000 Number of Months In Time Period 6 12 12 12 Member Months In Time Period 6,000 42,000 72,000 84,000 Houra Open per Week: 40 60 60 60 CO~T CATEGORIES CLINIC OPERATION $323,000 $979 ,000 $1,369 ,000 $1,564 .000 PHARMACEUTICAL PURCHASE $15 ,000 $105,000 $180 ,000 $210 ,000 PROGRAM ADMINISTRATION $122 ,000 $269 ,000 $347 ,000 $347 ,000 (Includes Program Mgt.,Tracklng, Accountsblllty, TOTAL OPERATING COSTS $460 ,000 $1,353,000 $1,897 ,000 $2,122 .000 (Without Start Up Costs) START UP CAPITAL Clinic $175,000 Pharmacy $10 ,000 Program A~mlnlstmUon $45 ,000 TOTAL START UP CAPITAL $230 ,000 $0 $0 $0 I~TAL EXPEN~F.~ (Cmmnt D~lars) (Cash Flow Based-- ROallded to $50,0e0) ~0.000 $t.~50.000 $tJ~0.000 $2d5~ ~ Page 12 Attachment 1. ESTIMATED NUMBER OF LOW-INCOME COLLIER COUNTY POPULATION THAT IS UNINSURED · '. '. '. '. '. '. '. '. '. '. '. '. '. '. '. '. '. '. '.' '. '. '. '. '-'. '. '. ,' ,li, K~e'M~..(.~'VI~L.' · ', %:0¥ )a~P:U (.~?(O~ · '. 'U~IlflS.U'fiIEP .'.'.' :':,i~Ek4L:,~i~:~'~dNi"i'i'4):' ':':':':':':':': :':':':':'::::::::-.:.:.:-:.:.:.:':':':' ::::::::::::::::::::::::::::::::::::::::::: ::':':':':':':': :: :::: :::: ::;: :::: ::::: ::::::::::: · 1-:-:-:.:-;-;.:.:-:-:.:-:.:-:.:.:-;.:-:.; 1111::::::::;::: :.:.:.:-:.:.:.:.:.: ::::::::::::::::::::: '-:'~,,r',~.-: · · ..;.;,;..;.;.:.:.:.:.:.:.:.:. ,: ...... '~'.~o%'.'. ::::::::::::::::::::::::::::::::::::::::: :::::::::;:;::::: :::::::':':'- ................... '. · :.:.:.:.:.;-;-;.:.:.:.:.:-:.;.:-;.:.;.:. ,;.:.:-:-:.Z.:.:. -:-:-:.:-:';-:':':' ':':':':':':':':':':' ':':':':';' '.'.'.'.'.'.' 1 ~5 COLLIER COU #TY < 100% FPG 20,609 10.4% ( a ) 41.0% ( b ) 8,450 ( b ) Between 100% and 200% FPG 31.194 15.7% ( a ) 35.5% ( b ) 11.074 ( b ) < 200% FP~ 51,803 262% ( a ) 19.524 Total Population 198,0~3 100.0% 20~0 COLLIER COUNTY < 100% FPG 2~.153 10.4% ( a ) 41.0% ( b ) 10,723 8,578 Between 100% and 20~% FPG 39,,~85 15.7% ( a ) 35.5% ( b ) 14,053 11,242 < 20~% FPG 65,737 26.2% ( a ) 24,775 19,820 Total Population ( C ) 251,377 NOTE~: ( a } The 1998 Co~l~' percentage Of total populatiorl la pove~ level is utilized to elaimate 2000 statistic. SOURCE: Claritas Elatmates for Florida Department of Health ( b ) The 1598 uninsured rate by inoomo levid for Diet, ct 14 (in which Collier ia located) is utilized for 1998 and 2000 County esfimams. SOURCE: Department of Hee~th, Office of Planning, Evlauatio~ ired Data Analysi$. ( c ) SOURCE: Department of Helath, Office of Planning, Evlaulaion and Data Analysis. (d) It is estimated that 80% of uninsurecl me blaween 19 and 64 Years old (20% are betow 19 and ov~ 65 is c°vered bY Medicare-) Histodc County and district data indicate the number of people from 100% to 150% of FPG is about the same as from 150% to 200%. Therefore it is estimated that: People Below 150% FPG = People Below 100% FPG + 1/2 x People Between 100% FPG and 200% Page 13 Attachment 2. SCHEDULE 'OF PRIMARY CARE COVERED SERVICES (MUST BE THROUGH NETWORK PROVIDER) COST TO COVERED SERVICES PATIENT Physician Office Services Copayment per Visit $6.00 Routine Primary Adult Care (age 19 and over) Coverage includes: routine physical examinations, prostate exams, colon cancer screenings, gynecological exam, pap smear, mammogram, basic laboratory tests, health promotion and disease prevention activities, immunizations, diagnosis of acute conditions, medical management of chronic diseases, referral to specialists. Copayment per Visit (including all laboratory services) $6.00 Mammogram Frequency Schedule $6.00 Ages 35 through 39; one baseline Age 40 and after; one every year Routine Well Adult Care Limitations & Maximums Limited to 1 visit per Year per type of service (except as otherwise . $6.00 defined in schedule) Diagnostic Testing, Lab Out patient Services (Basic) Included in office visit copay. Prescription Drug Benefit Dispensing fee to be paid to Pharmacy for formulary drugs. To be (Maximum annual value of pharmaceuticals per person = $750) negotiated during bid process. Non-formulary drugs. Not covered. Page 14 Attachment 3. SERVICES NOT COVERED IN PRIMARY CARE PROGRAM (WITH SOURCE OF CARE FOR INDIVIDUAL) TYPE OF SERVICE SOURCE OF CARE Maternity Care Eligible for Medicaid Hospital Services - Inpatient Proposed to be part of We Care Pro Bono Services Hospital Services - Outpatient Proposed to be part of We Care Pro Bono Services Emergency Room - Hospital & Physician Services Proposed to be part of We Care Pro Bono Services Diagnostic Testing, X-ray & Lab Proposed to Hospital Based Services be part of We Care Pro Bono X-Rays, CAT Scans, CT Scans, MRI, Myocardial Studies, and Services Tomographic Studies Mental Disorders Alcoholism and/or Substance Abuse Proposed to be part of We Care Pro Bono Service or from Another Source Page 15 Attachment 4. DETAILED PRO-FORMA BUDGET CALCULATIONS -- FIRST FOUR FISCAL YEARS OF PRIMARY CARE OPERATIONS CATEGORY FIRST FISCAL YEAR APR. 2002 TO SEPT. 2002 KEY OPERATING STATISTICS: Enrolled Members Target: Beginning of Time Pedod: 0 Midpoint of Time Period: 1,000 End of Time Period: 2,000 Number of Months in Time Period 6 Member Months in Time Period 6,000 Hours Open per Week: 40 COST CATEGORY CALCULATION CLINIC PERSONNEL COST: Core (Fixed) Costs $27,675 Primary Cars Teams Hired Physician Team: $273,950 serves 2000 average members per yr 1.0 Team(s) $136,975 Hired Extender Team: $171,550 serves 1500 average members per yr 0.0 Team(s) $0 Contracted Physician Team: $289,950 serves 2000 average members per yr 0 0 Team(s) $0 Case Workem $32,595 serves 40 hours open per wk $16,298 Pharm. Tech (Comp. Drug Prog.) $32,000 per yr. $16.000 SUBTOTAL $169,273 FACILITIES SUPPORT $125.983 (Such aa rent, utilitiea, supplies, maintenance) CLINIC SUBTOTAL $322.931 PHARMACEUTICAL PURCHASE $30 per member per yr $15.000 PROGRAM ADMIN Administrative Staff $128,040 full year, 8 months in first yr. $85,36(3 Eligibility Clerks $28,380 per clerk 1 Clerks $14,190 Indirect Coats $10,00(3 Tracking, Accountability, QA: $12.500 TOTAL OPERATING COSTS $459.981 {Without Start Up Costs) START UP CAPITAL Clinic $175,0on Pharmacy $10,000 Program Administration $10,000 Tracking, Accountability, QA: ~35,000 SUBTOTAL $230,000 TOTAL EXPENSES ( Cash Flow Based} (Current Dollars) $689,981 TOTAL EXPENSES { Cash Flow Baaed) (Inflated at 5.5% per year} $689,981 Page 16 CATEGORY KEY OPERATING STATISTICS: Enrolled M0mbere Target: Beginning of Time Period: Midpoint of Time Period: End of Time Period: Number of Mont~a in Time Period Member Monthe in Time Period Hours Open per Week: COSTCATEGORY CLINIC PERSONNEL COST: Cora (Fixed) Costs Primary Care Teems Hired Physician Team: Hired Extender Team: Contracted Physician Team: Case Workers Pberm.Tech (Comp. Drug Prog.) SUBTOTAL FACILITIES SUPPORT (Such as rent, utilities, supplies, maintenance) CLINIC SUBTOTAL PHARMACEUTICAL PURCHASE PROGRAM ADMIN Admiflictrative Steff EligiMlity Clerks Indirect Coats Tricking, AGcountebllity, QA: TOTAL OPERATING COSTS (Without atari Up Coats) START UP CAPITAL Clinic Phanna=y Program Adminiablfion Tracking, A==ountabllity, QA: SUBTOTAL CALCULATION $273,950 serves S171,550 serves $28g,950 serves S32,595 serves $32,000 per yr. 2000 average membera per yr. 1500 average members pet yr. 2000 average members per yr. 40 hours open per wk. $30 per member per yr. $128,040 full year, 8 months in first yr. $28,380 per clerk TOTAL EXPENSES ( Cash Flow Based) (Cuneof D~llare) TOTAL EXPENSES ( Cash Flow Based) (inflatmJ at 5.5% per y~ar) SECOND FISCAL YEAR OCT. 2002 TO SEPT. 2003 2,000 3,500 5,000 12 42,000 1.0 Team(s) $273,950 1.0 Taam(s) S171,550 0.5 Team(s) $144,975 $48,893 ~32,000 $106,550 $671,368 $201.544 $97g,462 $105,000 2.5 Clerks $128.04g ~0,0~ ~50,0~ $1,353,452 $1A27~91 Page 17 CATEGORY THIRD FISCAI~ YEAR OCT. 2003 TO SEPT. 2004 KEY OPERATING STATISTICS: Enrolled Member& Target: Beginning of Time Period: Midpoint of Time Period: End of Time Period: Number of Months In Time Period Member Months in Time Period Hours Open per Week: 5,000 6,000 7,000 12 72,000 60 COST CATEGORY CLINIC PERSONNEL COST: Core (Fixed) Costs Primary Cars Teems Hired Physician Teem: Hired Extender Teem: Contracted Physician Team: Case Workers Pharm.Tech (Comp. Drug ProB.) SUBTOTAL FACILITIES SUPPORT (Such as rent, utilities, supplies, nmintsnenoe) (~ LINIC SUBTOTAL PHARMACEUTICAL PURCHASE PROGRAM ADMIN Administrative Staff Eligibility Clerks Indirect Costs Tracking, Accountability, QA: TOTAL OPERATING COSTS (Wlthout S*-rt Up Costs) START UP CAPITAL Clinic Pharmacy Program ~dministrltion Treaklng, Accountability, QA: S U BTOTAL CALCULATION S273,950 serves 2000 average members per yr. $171,550 serves 1500 average members per yr. $289,950 serves 2000 average members per yr. $32.595 serves 40 hours open per wk $32.000 par yr. $30 per member per yr. S128,040 full year, 8 months in first yr. $28,380 per c~enV, TOTAL EXPENSES ( Cash Flow Based)(Curt'ant Dollars) TOTAL EXPENSES ( Cash Flow Based) (G,,&,:-d at 5.5% per year) 1.0 Team(s) $273,950 3.0 Team(s) S514,850 0.5 Team(s) S144,g75 $48,893 $32,000 3.5 Clerks S106,55( Sl ,014,468 S248,401 Sl ,369,419 $180,000 $128,04C S99,33¢ S20,000 ~1oo,ooo $1,896,789 $1~96,789 $2,111,173 Page 18 CATEGORY KEY OPERATING STATISTICS: Enrolled Members Target: Beginning of Time Per~od: Midpoint of Time Pedod: End of Time Period: Number of Months in Time Period Member Months in Time Period Hours Open per Week: COST CATEGORY CLINIC PERSONNEL COST: Core (Fixed) Costs Primary Cars Teems Hired Physician Team: Hired Extender Teem: Con.acted Physician Teem: Case Workers Pharm. Tach (Comp. Drag Prog.) SUBTOTAL FACILITIES SUPPORT (Such eo rent, utilities, supplies, maintenance) CLINIC SUBTOTAL PHARMACEU~CAL PURCHASE PROGRAM ADMIN Administrative Staff Eligibility Clerks Indirect Costs Tracking, Accountability, QA: TOTAL OPERATING COSTS (Without Start Up Costs) START UP CAPITAL Clink: Pherm~oy Program Admlnlatr~,tlon Tracking, Aooountability, QA: SUBTOTAL CALCULATION $273,950 serves 2000 average members par yr. $171,550 serves 1500 average members per yr. $289,950 serves 2000 average members per yr. S32,595 serves 40 hours open per wk. $32,000 per yr. $30 per member par yr. $128,040 full year, 8 months in first yr. $28,380 per c~erk TOTAL EXPENSES ( Cash Flow Based) (Cun~nt Dollars) TOTAL EXPENSES ( Cash Flow Based) (l~lated at 5.5% per year) FOURTH FISCAL YEAR OCT. 2004 TO SEPT. 7,000 7,000 7,000 12 84,000 60 1.0 Team(s) $273,950 4.0 Team(s) $686,200 0.5 Team(s) $144,975 S48,893 $32.000 $106,550 $I,186,018 $271.829 $1,564,397 $210,00~ 3.5 Clerks $128,04{~ $99,33~ $20,00C $100,000 $2,121,767 $2,t21,76] $2AgtA61 Page 19 Attachment 5. GENERAL ACTUARIAL EVALUATION OF FINANCIAL ASSUMPTIONS IN PROPOSED PRIMARY CARE INSURANCE PROGRAM (Separate Report is Attached) By ~ Vector Risk Analysis, LLC VECTOR RISK ANALYSIS, LLC 2800 West 44th Street, Unit 602 Minneapolis, Minnesota 55410 Tel. 612-926-1662 Fax. 413-669-5012 hobson.carroll@VectorRisk.com DT: August 7, 2001 TO: Steve Rasnick FR: Hobson Carroll, FSA RE: Collier County Primary Care Plan for the Uninsured CC: file Dear Steve: You requested that I review the proposed insurance program being put together for Collier County, Florida, to provide basic primary coverage for the working uninsured of that locale. Your firm has been assisting with the design. You have requested me, at this stage, to make a general actuarial evaluation of certain financial assumptions being made relating to expected costs of such the program. Summary of Benefits and Eligibility The proposed benefit plan, as I understand it from the materials you provided and our discussions, essentially provides coverage for primary care doctor's office visits (including certain routine and preventative elements, although limited to one well-adult visit per enrollee per year), "basic" x-ray and laboratory procedures in support of the office visits, and a prescription drug benefit. There is a $6 copay per doctor visit (including any associated x-rays and labs, i.e., One copay per episodic day) and a yet undetermined copay in the vicinity of $3 per prescription. The benefits are provided through an exclusive network of physicians, and the prescription drugs provided according to a firm formulary, which is expected to be as "generic" as possible. There are no surgical, referral, emergency room, hospital, maternity, or mental and nervous condition benefits. There might be visit or annual maximum benefit limitations yet to Steve Rasnick August 7, 2001 Collier County Primary Care Plan for the Uninsured Page 2 of 4 be determined. Referral/specialist services (not covered by the plan itself) may be "arranged" through separate charitable care programs, and pharmaceuticals will be obtained through compassionate/donated drug programs whenever possible. Physician services will be provided at 80% of RBRVS (Medicare), though the possibility of a capitation at $18 PMPM has been considered. Eligible enrollees are persons aged 19-64 who are "working" (according to standards of a definition to be established) adult persons with incomes 150% or under of the Federal Poverty Guidelines, who meet minimum residency requirements in the county, and who have no other access to coverage. This program is intended to be the coverage "of last resort." (The working requirement is waived for persons who are totally disabled, and not covered by any other government or private program.) Financial Projection You have made initial assumptions regarding expected costs of this program. These assumptions include $210 per member per year (PMPY) for the basic medical services (doctor office visits and associated DXL), $60 PMPY for prescription drug benefits, and $30 PMPY for administration costs. The basic medical and prescription costs are assumed net of copay, but do not consider the potential for discounts through 340(B) pricing or Compassionate Drug Programs. I have reviewed the benefit structure and certain available information on similar type primary access programs in other areas of the country, basic Medicaid data, and actuarial assumptions used for general commercial and special population insurance pricing models. In the attached exhibits, I summarize the data sources, range of data, and assumptions used in constructing two general pricing models in order to get an idea if your cost "budgets" appear reasonable. As you can see in Exhibit B, the two different developments of PMPY projected costs are $271 and $253. These compare with your non- administration budget figure of $270. I will not comment on the administration cost, since that element is not benefit cost related, and I assume you will "capitate" that risk in one form or another. The benefit portion appears to be in a reasonable range of the pricing models used. Steve Rasnick August 7, 2001 Collier County Primary Care Plan for the Uninsured Page 3 of 4 Comments In the pricing models developed, I have made certain assumptions relating to the cost components of diagnostic x-rays and labs, as well as average cost of a prescription drug. I have not yet been provided specific information relating to the likely range of costs of these items for the program, but believe that the assumptions I have made are reasonable based on my other sources of data. (Are DXL services only covered if provided in the doctor's office?) Clearly, the definition of "basic" x-ray and lab benefits to be provided, and the ultimate nature of the complete formulary for pharmaceuticals, will be critical to the accuracy of my assumptions. Also, I think it is important to provide a cap on the some combination of number and amount of prescriptions to be covered. I am not sure how you "value" the cost of the prescriptions given the source of many of the actual supplies. Perhaps the definition of the formulary will alleviate my concern in this area, but I think that this is one benefit area that has a bit of an "open-ended" nature, and some thought should be given to how much you are willing to spend on any one enrollee. My view is that if the discussed capitation option for physician services essentially covers everything but the prescription drug benefits, $18 PMPM is not a bad figure, and would provide at least frequency protection during the start-up year of the program, until actual utilization data is developed. Of course, it would be necessary and very important that even in a capitation environment, the data is collected on an "as if" fee-for-service arrangement so that the proper information can be pulled out later. Please let me know if you need anything else at this time. SincerelY, Hobson Carroll, FSA Exhibit A Collier County Primary Care Program Actuarial Cost Development Relevant Data Elements - Sources of Information and Assumptions Access to Care Program - Chicago, Illinois www.sphcc.or.q/prog ram statistics.htm Office visits PMPY 1.2 Radiology PMPY 0.117 Lab PMPY 0.363 Pharmacy PMPY 3.97 Also Demographic distriubition of population. Kaiser Family Foundation - Information on Medicaid by State www.statehealthfacts.kff.or.q Various data relating to adult Medicaid enrollees for Florida. Various data relating to breakdown of Medicaid expenditures by type of service. Proprietary Actuarial Pricing Assumptions for commercial and special population (working uninsured) program cost models. Various data relating to assumptions for frequency of office visits, DXL, prescription drugs. Various data relating to "generic" drug program costs. Exhibit B Collier County Pdmary Care Program Some Rate Development Models Model A: Access to Care Blended with other Actuarial Data PMPY Office Visits Range Use Frequency Cost/Unit PMPY visits 1.2-4.0 2.6 2.6 $55 Annual PMPY $143 DXL lab per visit .30-.44 0.37 0.962 $25 x-ray per visit .09-.13 0.11 0.286 $100 Total Basic Medical $24 $29 $196 Prescription Drug scripts PMPY 3.5-6.5 5 $15 Total Claims Cost PMPY (ail costs/unit are assumed net of copays - $6 per office visit, $3 per scdpt) Model B: General Medicaid Data (1997-1998 data) $75 $271 Number Flodda Adult Enrollees (assumed non-disabled or special status) Florida Adult Enrollee '"Total Care" Expenditure Average Medicare expenditure breakdown by type: pementage of total to "acute" classification items for ALL enrollees. Assumed "Acute Care" expenditure percentage for Florida Adult Enrollees Portion of Acute Classification for Office Visits, DXL, Drugs, Plus 10% margin This is the Program Benefit %. Crude Florida Adult Medicaid $ PMPY for Program Classification Benefits = Total Care Expenditure Average X Acute Care % X Program Benefit % Adjustment for trend, program limits, difference in reimbursement rate, copays, work status 1.10 X .65 X 1.30 X .95 X.90 400,324 $607,000,000 $1,516.27 53% 70% 30% $318.42 0.795 Projected Program Cost PMPY $253.1~.