HSD is the Medicaid-managed care oversight system for san Diego County. Organize

HSD is the Medicaid-managed care oversight system for san Diego County. Organized 25 years ago, HSD identifies its values as: patient choice in selecting health plans, value added by ensuring local involvement in assuring quality and access to health services, and local oversight for problem-solving and continuous quality improvement. This initiative provides a compelling case study in complex system leadership that has been sustained over time despite changes in the medical, clinical, public health, political, and financial reimbursement landscapes. The case study also provides emerging leaders with informative guidance about leading change within and across systems.
Background:
Discussions about the implementation of managed care for the California Medicaid population in the early 1990s led five key organizations to come together to form a partnership that is now known as HSD. Leaders from the hospital association, the county health department, the medical society, legal aid, and the council of community clinics convened to assess the three potential options available to establish a managed care process for their Medicaid population.
A county organized health system
A two-plan model whereby the county would have one plan and the commercial interests would provide another one that enrollees would have a choice of providence
A system whereby health plans would be certified to serve a specific geographical area (Geographic Managed Care, or GMC Model). Provision was made early on for two pilots. San Diego requested to be one of those two pilots.
After 2 years of planning, in October 1994, then California Governor Pete Wilson signed the landmark AB 2176 HSD Legislation. San Diego was selected as one of two pilot sites in the state to implement the GMC model.
Today, nearly one million individuals are enrolled in the model, and the initial partnerships that were established are still in place to ensure that HSD remains a strong and viable managed care initiative. A related component is the HSD Joint Consumer and Professional Advisory Committee, whose role is to monitor Medi-Cal managed care issues affecting San Diego County and to advise the director of the Health & Human Services Agency concerning those issues.
Role and Function of Health System Partners in Leading Systems Change:
The early engagement of the public health and healthcare system representatives provided a forum of high trust for leading this massive system change. The five original organizational representatives mentioned earlier remain the core group, while other organizations, including the health plans, provide for a broad base of systems representation.
This case study highlights the importance of partnerships in a community coming together with a common goal of ensuring access to healthcare services for the most vulnerable members of its population. HSD was working across sectors and across disciplines even as early as the 1990s. more than 60 organizations, representing a broad array of systems, were engaged and remain engages in the HSD efforts. Some of the examples of the system members include:
medicine
community health centers
public health
health plans
legal aid
consumer advocacy
other healthcare providers
State Department of Health Care Services (DHCS)/Med-Cal Managed Care Division
County of San Diego Health and Human Services Agency (HHSA)
The system partner roles with the HSD structure include the following:
State DHCS: Contracts for services directly with the health plans.
Health Plans: Provide healthcare services.
San Diego County HHSA: Provide day-to-day administration and presentations for Health Care Options enrollment. Identify issues and provide local forum for problem-solving and assistance.
Consumers/Professionals: Provide advice to County HHSA through the HSD Consumer and Professional Advisory Committee.
The Consumer and Professional Advisory Committee was once comprised of two committees who met both separately and jointly. Over time, as the level of trust became stronger, the two committees merged into one committee. The committee operates subcommittees focused on such topics as quality improvement, behavioral health, COVID-19, and other pertinent topics. The structure continues to provide an open forum for all system representatives and the consumers to work together to keep HSD strong.
Relationship to Health Equity
The work to establish HSD was rooted in the values of equity. The organizing parties were committed from the beginning to ensuring that managed care for the San Diego Medicaid population was implemented according to the values mentioned earlier in this case study. The work was established with intentionality around fairness, transparency, and equality in terms of healthcare access. With attention to ongoing quality improvement and timely complaint resolution, HSD remains grounded in the commitment to monitoring services provided to this population to ensure equity across healthcare plans. At the present time, meetings of the HSD Joint Consumer and Professional Advisory Committee, which are held monthly, are open for members of the public to address the Committee on any issues within its assigned purview and not on the agenda. They also make provisions for special accommodations as may be needed.
Advice for Others
When asked about their advice for others who are planning to effect major complex systems change, the HSD representatives interviewed provided the following observations based on their experience.
Monitoring the changing healthcare landscape and the potential effect of the introduction of managed care on the Medicaid population provided an early opportunity for this initiative to be pilot tested.
Relationships among the key systems representative existed prior to their work together on this initiative. Those strong relationships provided an early atmosphere of trust as the planning ensured.
A decision was made early on for the work to be apolitical. This commitment allowed the initiative to be developed and implemented with little to no political interference.
The role of public health leadership, while official and supportive, was also subtle. This was intentional so that the team of partners and stakeholders would maintain ownership and commitment to HSD. It was not seen as a health department-driven initiative. Even today, public health support HSD, but they do not set the agenda. It is still “owned” by the community.
The leadership for HSD has been consistent over the 25 years. However, some turnover in that leadership in anticipated soon. Deliberate work has been done to ensure succession planning so that the initial values, goals, objectives, and systems relationships continue.
Case Study Questions
1. What is the primary change in public health system that occurred or will occur because of this initiative?
2. Who are the system partners in this initiative, and what aspects of systems thinking are reflected in its structure?
3. Where do you see examples of systems thinking in HSD?
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