L.A. Care Health Plan - FY 2019-20 9+3 Forecast FY 2020 ... Financial...6 Membership: 2020-21...
Transcript of L.A. Care Health Plan - FY 2019-20 9+3 Forecast FY 2020 ... Financial...6 Membership: 2020-21...
FY 2019-20 9+3 Forecast
FY 2020-21 BudgetBoard of Governors Meeting
September 3, 2020
AgendaFY 2019-20 YTD Performance
4+8 Forecast vs. 9+3 Forecast July 2020 Financial Performance
FY 2019-20 9+3 Forecast & FY 2020-21 Budget Membership Budget Assumptions Financial Performance Comparison Administrative Expenses FTE Budget and History Community Programs Operating Margin by Segment Opportunities/Risks/Key Initiatives Balance Sheet Comparison TNE & Days of Cash On-Hand Comparison
Key 2020-21 Capital Projects and Programs
Informational Items Monthly Investment Transactions
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Consolidated Financial Performance4+8 Forecast vs 9+3 Forecast
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Consolidated Financial Performancefor the 10 months ended July 2020
Membership Trend
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Membership: 2020-21 Projections
The projected membership growth between FY 2019-20 9+3 forecast and FY 2020-21 is expected to be 2,500 members or 0.12 percent, with member months growing approximately 10,000 or 0.04 percent.
Medi-Cal membership is projected to drop to pre-COVID levels (March 2020) in October, once the State restarts monthly redeterminations and the delayed redeterminations are processed. Moving forward from that point, we project modest growth of 2% over the course of the year.
LACC & CMC are modeled to include retention and new membership driven by Broker support.
FY 2020-21 Budget Assumptions
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Pharmacy carve-out effective Jan 1, 2021 with significant reduction in revenue and healthcare expense for Medi-Cal
1.5% rate cut (except LTC) for the bridge period thru Dec 2020 Additional 1.5% rate cut (except LTC) effective Jan 2021 10% rate increase for LTC rate and healthcare expense through Dec
2021 FFS incurred costs based on current run rate 1.5% decrease in capitation expense effective Jan 2021 COVID risk corridor: $25 million in FY 19-20 9+3 Forecast and $278
million in FY20-21 Prop 56 programs to end in July 2021 (except Family Planning)
Financial Performance Comparison
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Financial Performance Comparison
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FY 2020-21 Administrative Expenses
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FY 2020-21 FTE Budget and History
FY 2020-21 Community Programs
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FY 2020-21 Operating Margin by Segment
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Opportunities Improvement of claims trends Provider contract re-negotiation Shifting more contracts to dual risk arrangement Better than expected CCI rates for CY 2020 Better than expected LACC membership due to favorable pricing Improved administrative efficiencies
Risks Claims trends continue to deteriorate Higher than expected rate cut by DHCS for CY 2021 COVID risk corridor is not extended through CY 2021 COVID risk corridor mechanism does not provide as much risk
mitigation COVID healthcare costs are higher than expected DHCS retroactive Institutional member reclassification CCI risk corridor/IHSS final reconciliation
Opportunities & Risks: All Segments
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Key Initiatives Revert claims floor holding periods back to the pre-
pandemic process to slow down claims paid and allow more time for review
Re-negotiate contracts with outlier groups and hospitals
Analyze and audit the root cause for continuous high monthly paid claims
Shifting more contracts to dual risk arrangement
Key Initiatives: All Segments
Balance Sheet Comparison
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TNE & Days of Cash On-Hand Comparison
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Key 2020-21 Capital Projects
and Programs
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2020-21 Capital Projects and Programs
Project Description Business Owner
Capital
Expense
Operating
Expense Total
Thrasys - Health Services Systems Health Services 2,898$ 4,029$ 6,927$
SAP/ERP - Finance System Finance 4,921 1,085 6,006
Total Provider Management (TPM) Provider 2,605 1,466 4,071
Voice Program - Member and Provider Customer Service 2,257 1,151 3,408
Encounters & Risk Adjustment/EDIFECS Operations 1,826 598 2,424
Compliance & Accreditation Enhancements Various 3,380 2,143 5,522
Operational Efficiencies & Other Initiatives Various 3,970 1,310 5,280
Subtotal 21,856 11,782 33,638
Leasehold Improvements Facilities 18,852 - 18,852
Total Capital Projects 40,708$ 11,782$ 52,490$
L.A. Care Health Plan
Capital Projects
Fiscal Year 2020-2021(dollars in thousands)
Portfolio Program Descriptions“Big 5” Programs
Strategic Project Portfolio | 20
• Thrasys – Health Services System (Care Catalyst Program) – A multi-
year program focused on replacing the existing Care Management
platform (Clinical Care Advance – CCA) to effectively and efficiently
manage the workflows, data integration, analytics, and reporting for all
core functions within L.A. Care’s Health Services organization.
• SAP/ERP – Finance System – Implementation of a new enterprise
financial management platform to enable streamlined, scalable business
functions including procurement, accounts payable, premium billing,
recoveries, reconciliations, budgeting & forecasting, and financial
reporting.
• Total Provider Management (TPM Program)– A multi-year program
focused on improving L.A. Care’s provider data quality and management,
including enhancements to data intake, validation, storage, and reporting
processes.
Portfolio Program Descriptions“Big 5” Programs (continued)
Strategic Project Portfolio | 21
• VOICE – A multi-year customer service infrastructure program enhancing
systems, tools, and processes that transform the way L.A. Care’s
members and providers navigate and find information, including self-
service options.
• Encounters & Risk Adjustment / EDIFECS – Leverage and extend the
new EDIFECS encounter platform to more effectively manage and report
risk adjustment data for CMC (Medicare) and LACC (commercial) product
lines.
“Big 5” Programs – Technology Architecture
Strategic Project Portfolio | 22
INBOUND FILES
EDI - 834 EDI – 837 Claims /
Encounters
TRR
SPF
EDI 274
COB(HMS)
ELDA
Reports
EDW
DATA LAKETPM
Optum Impact Suite (Analytics & Stratification)
Claims Workflow
CES
QNXT®
EDIFECS
ORACLE B2BEDIFECS EM
Claims Adjudication, Payer & Capitation System
Clinical Management System
Clinical Care Advance®
-to be retired
Syntranet® (Thrasys)
PCT
Encounter Reporting
Operational Reporting
Canon Therefore®
OUTBOUND FILES
ETO DHSExtracts
Compliance Reports
VendorExtracts
ORACLE SOA OSB
sFTP
Fulfillment Vendor
Enterprise Letters
Solution
Letters from Applications Letters from work-flows
Documents Archiving & Indexing ENTERPRISE SERVICE BUS
File Gateway
sFTP
Health Information Exchanges
APIs
Service Gateway
837 Processing 834 Processing
QNXTe-MAA
CARE COMMUNITYPORTAL (S)
ClinicalSystem
Authorizations
AssessmentsLOA
G&A Cases
Identification &Stratification
Edifecs
Premium InvoicePremium Payments
Broker Payments
Real Time Data
Batch Data
Grievances &Appeals
Collected Data
PCT
Master Data
SAP
Raw Data
Master Data(leftover)
CRM
Target Architecture - Contextual Diagram
MasterData
HEDIS Process
Data ScienceRisk Adjustment Processes
Member Eligibility & Enrollment
Self-Service Analytics
Provider Person
DemographicsRelationship
Mgmt
Clinical ClaimsSocial
Determinants Finance
EncountersReference
Data
sFTP
ACCIOProviderContracts
ProviderContracting
SAP®
Premium Billing
& Payment
SUCCESSFACTORS
CONCUR
GENERALLEDGER
IVR
Pay Now
Online Payment
FinancialSystem
Provider Incentives
CapitationPayments
Salesforce®
Provider Portal
Member Portal
Broker Portal
Member Data
ProviderData
Broker Data
Interaction Data
IDTServiceSales &
Marketing
Workflow Management
(NICE)
CCI
TelePhony
CISCO UCCE
IVR(NUANCE)
FINESSE
Outbound(Nobel)
CTICRM
Portals
EmployeePortal
HR Data
LANES, EDI-PREMANAGE, E-CONNECT
Encounters(LAC Claims – QNXT,
PPG EncountersPlan Partner Encounters
Vendor Encounters)
TPM Transaction
DocumentManagement System
Additional Portfolio Initiatives
Strategic Project Portfolio | 23
• Compliance & Accreditation Enhancements – Enterprise-scale enhancements to technology platforms and business processes to improve regulatory compliance and performance in areas impacting member experience, provider engagement, and clinical care.
• Operational Efficiencies & Other Initiatives – Enterprise-scale enhancements to technology platforms and business processes to improve operational performance and cost efficiency.
Questions & Considerations
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Motion FIN 105 To accept the Financial Report for the nine months ended
June 30, 2020 and the ten months ended July 31, 2020, as submitted.
Motion FIN 106 To recommend the draft FY 2020-21 Capital and Operating
Budget for Board Consideration.
Informational Items
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Investment Transactions As of June 30, 2020, L.A. Care’s total investment market
value was $1.6B $1.3 billion managed by Payden & Rygel
$72 million in Local Agency Investment Fund
$201 million in Los Angeles County Pooled Investment Fund
As of July 31, 2020, L.A. Care’s total investment market value was $1.6B $1.3 billion managed by Payden & Rygel
$72 million in Local Agency Investment Fund
$201 million in Los Angeles County Pooled Investment Fund