Health Centers Target Quality Improvement in Medi-Cal Managed Care 

The Medi-Cal program in California has grown exponentially in the past 5 years, now covering more than 13 million Californians.  Most of those Medi-Cal enrollees receive their care through Medi-Cal managed care plans, which are now available in all 58 California counties and cover 80 percent of Medi-Cal enrollees.  This is a vast expansion in managed care for Medi-Cal population – just a few years ago in 2010, managed care was only offered in 25 counties, and covered only 55% of enrollees.  This is a fundamental shift in the provision of Medi-Cal coverage, and the federal government, state government, managed care plans, and providers are all racing to keep up. 

In response to the huge growth in Medicaid managed care, the regulatory framework that guides the Medicaid program at the Federal level is changing too.  Just last summer, the federal government issued the Medicaid Managed Care mega-regulation, which requires state Medicaid agencies to develop new oversight activities and places new requirements on managed care plans around grievances and appeals, network adequacy, mental health parity, and many other issues. 

In response to greater guidance at the federal level, the state Department of Health Care Services has also been developing significant new rules guiding Medi-Cal managed care.  CPCA is deeply engaged in these policy conversations, with CPCA staff, CPCA board members, or staff from our affiliated advocacy organization, California Health+ Advocates, participating in all major state initiatives.  CPCA staff was appointed to the DHCS Access Advisory Committee, which worked with the state’s External Quality Review Organization (EQRO) to develop more robust network adequacy standards for Medi-Cal managed care.  We serve as a direct mouthpiece to the legislature about the managed care issues experienced by health centers around the state, most recently presenting on timely access challenges to Senate Budget Subcommittee #3 along with DHCS and other patient advocacy organizations.  CPCA staff has traveled around the state presenting to health plans, counties, and other stakeholders about the key role that CCHCs play in partnering with managed care organizations to further quality goals. 

In addition to greater oversight, DHCS has announced that they will be evaluating and procuring new commercial managed care plans over the next few years, with an emphasis on finding plans that can deliver on quality and patient satisfaction.  Commercial managed care plans hoping to continue serve the Medi-Cal population are going to have to increase their quality and prove their worth to the state.

Community health centers are key partners for health plans in improving quality and patient satisfaction, and commercial health plans that want to be selected in the procurement should be cultivating relationships and investing in quality improvement with health centers.  Through our Capitation Preparedness Program (CP3) and HealthManagement+ infrastructure, CPCA has already developed a strong and comprehensive quality improvement program that focuses both on facilitating external partnerships, building data infrastructure, as well as practice transformation within health center care teams.  As the state is focused on building a new Medi-Cal managed care infrastructure, CPCA and our member health centers are focused on making it work for our patients!

Current initiatives around improving quality, transforming care, and building data infrastructure in order to be strong players in the managed care delivery system include:

Pay for Performance (P4P) best practices

CPCA has developed a series of best practices in quality incentive programs for FQHCs.  The best practices developed by CPCA and community health centers include an emphasis on setting attainable goals, defining clear measures and benchmarks, and seeking standardization across P4P programs.  CPCA is meeting with health plans across the state and educating health centers on developing and implementing high quality and effective Quality Improvement and P4P programs.

Capitation Payment Preparedness Program (CP3)

CPCA through its Payment Preparedness Program (CP3) has invested in developing and implementing training and technical assistance to pilot sites signed up to participate in the Alternative Payment Methodology (APM) and have expanded participation to all members through the managed care trainings offered from June through October of 2017. These twelve trainings on six topics, reached 364 staff members from clinics across the state. From this effort the Payment Preparedness Program has also developed a series of managed care webinars to take deeper dives into specific areas of interest for sites such as empanelment and outreach and management of members. We have also begun to develop a number of community health podcasts delving into topics such as “What can we expect for the future of value based care?” and “Preparing to be financially ready in APM.” Additional podcasts will deal with care teams, member management, risk stratification and data governance. The first of these podcasts are available now.

Along with CP3, the Statewide Quality Improvement (SQIC) Workgroup has been exploring how health centers and health center networks, and payers are using risk stratification techniques to attribute risk and intervene accordingly for the highest acuity, highest need patients.  Understanding the role of risk and risk stratification is the first step to implementing an effective care management program with data informed decisions. This process will only become more important as health centers manage the health of their entire population.

Unseen Patients Workgroup  

After listening to members through the Managed Care Task Force, CPCA has identified the issue of assigned but unseen patients as a major barrier to improving care quality, patient engagement, and HEDIS scores throughout the state.

To explore and research this issue, CPCA has developed a workgroup to understand the factors that lead to unseen patients, best practices in aligning utilization and assignment, and spread solutions. The workgroup has examined a survey of unseen patients led by an IPA and health center, and the development of an algorithm at the health plan level to identify patients who are utilizing care where they are not assigned through claims data. The next best practice the workgroup will be studying is the development of data and IT infrastructure at the clinic level to manage assigned patients and track utilization. 

Investing in data

CPCA believes in the power of data to achieve quality improvement in community health center and managed care plan partnerships. CPCA hosts several user groups for electronic health records (EHR) where data entry into the EHR is the focus and health centers work with EHR vendors to ensure that systems are set up for data collection and standardization. In addition to these user groups, health centers are also provided data analytics user groups/peer networks where health centers come together to share best practices and increase peer learning. These user groups focus on the use of the data and achieving quality improvement by analyzing the data to achieve the triple aim. Lastly, CPCA believes in the improvement of health center HEDIS measures that are reviewed by health plans. CPCA plans to meet with health plans to determine the attainability of standardizing the codes and definitions of HEDIS measures across health plans.