Health Plan of San Mateo marks 30 years

Dec. 1 marked the 30th anniversary of the county’s health plan, which functions as a health maintenance organization and offers a comprehensive network of providers who treat a range of clients from infants to seniors. 

“It changes peoples’ lives when they get insurance,” said Health Plan CEO Maya Altman. “It’s bad enough to be seriously ill, but then to have to worry about how you’re going to pay for it is just overwhelming.”

At its base, the agency was created to form a network of providers that would accept Medi-Cal patients, which was lacking for many years as doctors saw low reimbursement rates and clients struggled to find care. But in the decades since the plan was created through the county Board of Supervisors and state legislation, it’s expanded significantly.

With a range of programs to help disabled seniors, children, the undocumented and others who can’t afford insurance but don’t qualify for federal subsidies, the health plan now has nearly 150,000 members. That’s a significant uptick from the 28,000 members when it was created in 1987 and the estimated 50,000 who were enrolled about 12 years ago when Altman took the helm.

A major factor was the Affordable Care Act’s expansion of Medi-Cal, California’s version of federal Medicaid. The ACA and the state’s open marketplace Covered California helped bump San Mateo County into a nearly 96 percent rate of insured residents.

“We have one of the lowest uninsured rates in the state and it makes a huge difference, we’re very lucky,” Altman said. “There’s a direct correlation between good health and access.”

The local health plan was the second county organized health system created in the state and one of the oldest in the nation. The way it works is those who live in the county and receive Medi-Cal are automatically enrolled in the health plan, which functions as an HMO. A critical facet of its success was the fact that doctors helped advocate for its creation. The county was urged to step in when reimbursement rates were so menial it was prompting few providers to accept Medi-Cal patients, Altman explained.

The health plan is able to draw federal funding from the state and reimburse doctors in their network who treat Medi-Cal patients. Because the plan has steered more low-income patients away from emergency rooms and into preventative care, it proved providing insurance ends up saving the government money. Since the plan has scored so well, it’s actually able to reimburse doctors at a higher rate than the state normally pays due to those savings, Altman said.

Easy to use

For patients, it translates into more doctors to chose from and an easier-to-use system where they deal directly with administrators imbedded in the community if insurance issues arise, she said.

“The member consumers don’t have to worry about all that. They just have one place to call and we can help them navigate through the system,” Altman said.

Through its partnership, health plan clients now have access to 1,100 primary care physicians, 4,000 specialty care providers, five community health centers and eight hospitals. Khoa Nguyen, chief strategy office for the health plan, said a number of local nonprofit partners and health care providers have been instrumental.

“We’re really mission oriented, we want to make sure what we’re doing is impactful and in this case it’s giving people access to health care” Nguyen said.

A few key expansions have included the health plan in 1998 joining the state’s program to offer insurance for children whose families make too much to qualify for Medi-Cal but are still considered low income. In 2006, it began offering CareAdvantage which supports seniors and disabled adults who are dually eligible for Medicare and Medi-Cal. In 2009, the health plan began partnering with the San Mateo County Health System to administer a program for low-income adults, including the undocumented, who are not eligible for Medi-Cal or other health insurance. Known as Access to Care for Everyone, ACE enables patients to use the health system’s doctors and hospitals either for free or for a modest copay. And within the last few years, it has expanded coordinated care programs, including the Community Care Settings Program that helps members transition from nursing facilities back into their homes where they can receive medical and social services.

Eshoo’s impact

U.S. Rep. Anna Eshoo, D-Palo Alto, was serving on the San Mateo County Board of Supervisors when she championed the health plan’s formation in the 1980s.

It wasn’t a walk in the park. Establishing the health plan required state legislation to allow the Board of Supervisors to create the nonprofit as well as a waiver from the federal government to administer Medi-Cal, she explained.

Eshoo credited the local medical community that was “joined at the hip” with the county as advocates for the health plan’s formation at a time when everything they were doing was essentially new. Looking back, it’s clear the foundation they created was very much worthwhile, Eshoo said.

“What I think is the best proof of the idea, of the vision, of all the work that went into establishing it, is to see how much it has succeeded, how many people are helped and have been helped over now three decades, that’s a long time,” Eshoo said, noting it’s been a pinnacle of her career. “That San Mateo County was a county that distinguished itself not only in California but across the country, that has always been a source of enormous pride.”

Preventative care

Contributing to the plan’s success was the fact that directing people into preventative care as opposed to being reliant on emergency rooms is more cost effective. Having a local entity manage the federally-funded Medi-Cal insurance program ultimately allowed the health plan to reimburse doctors in higher amounts and in a more timely fashion, she said.

With access to data about where the majority of clients were located, it led to the establishment of community health centers in areas with high numbers of residents visiting emergency rooms.

Now, the health plan serves one out of every five San Mateo County residents with 41 percent of clients 17 years or younger, 46 percent adults up to 64 years of age, and 13 percent seniors, according to the nonprofit.

“Health care is profoundly personal. No one comes into the world with a warranty that nothing will happen to your body until God decides to call you. So while we have some of the highest levels of health care in terms of technology and innovation, it doesn’t reach a lot people,” Eshoo said, noting the health plan shows that doesn’t have to be the case. “It can be done, it is getting done and it has been highly successful.”

samantha@smdailyjournal.com

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Twitter: @samantha_weigel