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Emma Dolan, MPP, MPH, Policy Analyst
INTRODUCTION

Health reform ... is a real opportunity for physicians, hospitals, and other organizations to work together to create better mousetraps in the Medi-Cal delivery system.

On November 1, 2011, IHA and CAPG hosted a Safety Net ACO roundtable as part of the Second National ACO Congress in Los Angeles. This roundtable focused primarily on a case study of HealthCare First South Los Angeles, a safety net ACO initiative that includes Daughters of Charity Health System (DCHS), St. Johns Well Child and Family Center, St. Francis Center, the Southside Coalition of Community Health Centers, Los Angeles Department of Health Services, and a number of private primary and specialty care physicians, in partnership with L.A. Care, Los Angeles Countys public health plan. The panelists were Jim Mangia, CEO of St. Johns, Conway Collis, Senior Counselor and Chief Government Affairs Ofcer for DCHS, and Dr. Elaine Batchlor, the Chief Medical Ofcer of L.A. Care. The session was moderated by Dr. Kevin Grumbach, who is Chair of the Department of Family and Community Medicine at the University of California, San Francisco, as well as a practicing physician at San Francisco General Hospital. A number of themes emerged from the roundtable, including the necessity of evolution in the healthcare delivery system to provide high-quality, efcient care in the safety net; the difculties of overcoming access and demographic challenges to deliver integrated, coordinated care; the importance of gaining and maintaining support from a wide variety of stakeholders; and the primacy of a strong primary care base upon which to build accountable care organizations.
IMPLEMENTING HEALTHCARE REFORM: THE IMPORTANCE OF A STRONG DELIVERY SYSTEM

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Dr. Batchlor began the panel with a discussion of the changing Medi-Cal landscape in California, specically stemming from the Affordable Care Act and the states Section 1115 waiver, under which many Medi-Cal fee-for-service enrollees will be transitioned into managed care. L.A. Care is undertaking pilots to better integrate care for certain populations, such as dual eligibles who are already transitioning into managed care, and children with special healthcare needs. The plan is also working with L.A. County on early expansion of insurance coverage in preparation for 2014. L.A. Care is seeking to encourage the development of a stronger healthcare delivery system that can provide high-quality, coordinated care for an increasing number of Medi-Cal enrollees, who have traditionally been challenging to manage. Health reform, Dr. Batchlor stated, is a real opportunity for physicians, hospitals, and other organizations to work together to create better mousetraps in the Medi-Cal
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delivery system. Although there are a number of organizations that are under-performing, the current emphasis on quality and cost is a window to build a better system. As a payer, L.A. Cares role is to support the development of the new delivery system in terms of funding, contracting, setting standards and performance measures, and aligning incentives to reward high-value care.
THE CHALLENGE OF INTEGRATING CARE IN AN AREA WITH SIGNIFICANT HEALTH DISPARITIES AND ACCESS CONCERNS

HealthCare First South L.A. is located in Service Planning Area (SPA) Six, which is an area in south Los Angeles that encompasses the cities of Compton, Lynwood, Paramount, as well as parts of Crenshaw, Jefferson Park, Watts, and Willowbrook, and has a population of approximately one million residents.1 Both provider organization panelists highlighted the challenges of delivering care to residents in this area, due to both demographic and access factors. SPA Six faces a number of demographic challenges: 37% of the population (390,511 people) lives below the Federal Poverty Level 44% of which are children between the ages of 0 to 17 (170,727), and a large percentage of residents (32%) receive public assistance.2 The area also has high rates of chronic illnesses and mental health problems conditions that can benet from care management and provider coordination. On top of this, residents face access challenges stemming from a lack of healthcare provider capacity. 40% of patients are without a usual source of care, with many having to travel to get access to basic healthcare, or facing long waits to see specialists. South L.A. lacks the healthcare infrastructure that exists in wealthier areas, and has historically been characterized by a lack of cooperation between providers, as well as a lack of capital owing to lower reimbursement associated with serving vulnerable populations.
BUILDING ACCOUNTABLE CARE FROM THE GROUND UP: HEALTHCARE FIRST SOUTH L.A.

Facing both a challenging population and healthcare reform, it became clear to participants that greater
1. SPA Six is one of eight Area Health O ces in Los Angeles which were created to plan public health and clinical services based on the needs of local communities (for more information, please see http://publichealth. lacounty.gov/spa6/).

coordination between healthcare providers was needed to provide effective care to SPA Six residents. In response, a group of providers, including St. Johns, DCHS, and St. Francis Medical Center, came together to conduct a needs assessment of SPA Six residents. They subsequently brought together a larger group of community organizations, including the local Service Employees International Union (SEIU) to begin planning. What emerged out of this historic level of cooperation between stakeholders was HealthCare First South L.A. Early on, a steering committee was formed to guide the work of HealthCare First South L.A. The Steering Committee formed a number of workgroups, including: population focus and nancial modeling; clinical integration; IT and case management; workforce development; and governance. Participants also created a set of goals for the initiative: improvement in the quality of care delivered illustrated with concrete metrics; primary care-centricity; integration and care coordination to link primary, secondary, and tertiary care; and a decrease in healthcare costs. Currently, the initiative covers only L.A. Care enrollees. While the participants are working towards building a sustainable nancial model for the initiative in partnership with L.A. Care, they would also eventually like to expand to other payers in the region. The necessary IT infrastructure is being built in partnership with HITEC L.A., Los Angeles HIT Extension Center, and the Los Angeles Network for Enhanced Services (LANES), a county-wide health information exchange. A pay for performance framework that will provide financial incentives for participants to improve the quality of care delivered has been developed, and benchmark data are being collected. While the focus of the steering committee has been on forming the necessary physician network, clinical care and nancial models necessary to run the ACO, it has also developed a balanced governing structure: each of the participating physician and institutional providers, as well as SEIU, are represented on the permanent Board of Directors. There is a great deal of excitement about the formation of this new care delivery system, which participants
2. South Service Planning Area, Los Angeles County Department of Health Services. The Health of the Residents in the South Service Planning Area of Los Angeles County. Los Angeles, California: May 2002.

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hope will translate into long-term gains in quality and decreases in cost for the healthcare delivery system in South L.A. Leaders are currently working on submitting an application for long-term federal funding to keep the initiative going.
A STRONG PRIMARY CARE BASE

An underlying theme that all panelists touched on was the need for a strong primary care base upon which to build ACOs. Dr. Grumbach described the ACO as a medical neighborhood, and primary care practices as medical homes that form the basis of any strong neighborhood. He also discussed the move from old school primary care, which was largely uncoordinated and episodic, to new school primary care, an idea that is best captured in the patient-centered medical home

(PCMH), which focuses on care management, coordination, and maintaining the relationship between the PCP and his or her patients. A number of barriers to strengthening the primary care infrastructure were noted, including current reimbursement systems that reward the provision of specialty care over primary care, which can be exacerbated in the safety net context because of lower reimbursement rates from Medi-Cal and a higher percentage of uninsured. Despite the challenges, HealthCare First South L.A. has primary care-centricity as a principal goal, and is committed to building a strong primary care infrastructure. In the future, participating primary care providers will act as medical homes for enrollees, and will form part of a fully coordinated and integrated system that also includes specialists, ancillary and supportive services.

This roundtable was funded by the Blue Shield of California Foundation and the California Endowment