Transforming Medi-Cal through Value-Based Care
For more than a decade, California’s 21 public health care systems have been leaders in Medi-Cal transformation, utilizing five-year 1115 Medi-Cal waiver programs and the Medi-Cal managed care rule to help spread innovation and advance high-quality care.
From early coverage expansion efforts to large-scale delivery system reform and value-based care, public health care systems have been on the forefront of the state’s advancements in Medi-Cal. Most recently, public health care systems led groundbreaking “Whole Person Care (WPC)” efforts to address social needs alongside physical health for some of our most at-risk populations, particularly individuals experiencing homelessness and other hardships. This effort set the groundwork for the State’s largest Medi-Cal reform initiative, CalAIM.
Learn more about public health care system’s role in Medi-Cal transformation in the key areas below:
CalAIM – Successful Transition and Growth of Whole Person Care Services
In 2022, the California Department of Health Care Services launched CalAIM, an ambitious multi-year initiative that aims to integrate Medi-Cal health care services with social supports and provide a more holistic approach to care.
Public health care systems’ innovative Medi-Cal pilots, particularly Whole Person Care (WPC), played a central role in the development of CalAIM. WPC, established as part of the Medi-Cal 2020 waiver in 2016, was led by public health care systems and their county and community-based partners. For over six years, twenty-five WPC pilots provided intensive case management and wrap-around services for patients with complex medical and social needs, including individuals experiencing homelessness, severe mental illness, and incarceration (among other hardships).
WPC demonstrated the value of cross-sector partnerships to address complex health and social needs. It provided a model for how these partnerships can succeed by breaking down longstanding siloes across health care providers, social services agencies, behavioral health providers, and community-based organizations.
Now, based on the successes of WPC, this critical work continues in CalAIM under a Medi-Cal managed care structure. Public health care systems are partnering with their managed care plans to transition and expand WPC services under CalAIM’s Enhanced Care Management (ECM) benefit, Community Supports to address the social drivers of health, and efforts to strengthen care for justice-involved individuals.
Global Payment Program
For over six years, the Global Payment Program (GPP) has helped public health care systems expand primary care and non-traditional and preventive services for uninsured persons by restructuring how uninsured care is financed. GPP creates incentives to shift care away from the emergency department and hospital settings to primary care settings. To accomplish this shift in care, public health care systems implemented strategies such as increasing capacity, expanding non-traditional services, improving data collection, and enhancing partnerships. An initial evaluation of the program showed a decrease in emergency and inpatient services (14% and 15% respectively) and a 12% increase in outpatient care, further reinforcing the value of right care at the right time and right place. The GPP will continue and expand its services to align with ECM and Community Supports, providing uninsured individuals access to this broader set of Medi-Cal benefits.
Quality Incentive Pool
The Quality Incentive Pool (QIP), a managed care directed payment program, challenges public health care systems to improve equity and quality via ambitious pay-for-performance targets for Medi-Cal managed care enrollees. Incentives are tied to achievement of performance in multiple domains of care, including health equity. In total, public health care systems report on 40 measures. These measures are selected from a larger group of two measure sets, known as priority and elective measures. Priority measures are closely aligned with the State’s Comprehensive Quality Strategy and assess chronic disease management, preventive care, cancer and depression screenings, and prenatal and post-partum care, among others. Elective measures include additional screening, chronic disease and preventive care measures, as well as measures focused on hospital care and care transitions.
To further advance health equity, public health care systems are required to improve equity on two measures (diabetes management and another measure selected by the system). Systems are also required to report performance data stratified by race and ethnicity for five additional priority measures. Learn more about the history of QIP and QIP’s current measurement and reporting requirements.
Since 2020, CAPH has been working in coalition with partner organizations and the Administration and Legislature to ensure permanent access to telehealth services, including audio-only services and other flexibilities tied to the COVID-19 federal public health emergency. In the 2022-23 State Budget, Governor Newsom authorized the continued coverage of both video and audio-only services across provider types, preserving this critical point of access for Medi-Cal patients. As efforts are taken to study the delivery and impact of Medi-Cal telehealth services, CAPH continues to stay engaged on this important issue to inform future policy making.
Alternative Payment Methodology Project: Federally Qualified Health Centers
Many public health care system clinics are designated as Federally Qualified Health Centers (FQHCs). CAPH has been partnering with the Department of Health Care Services and the California Primary Care Association to develop a voluntary Alternative Payment Methodology (APM) program for public and private FQHCs. This work, which began in 2021, is expected to launch in 2024. The APM is designed to shift volume-based clinic payments to a more flexible, capitated monthly per-member rate to incentivize delivery system and practice transformation, access, and quality outcomes. The program will also align with one of CalAIM’s goals to reduce complexity and increase flexibility in Medi-Cal and encourage collaboration between the Medi-Cal managed care plans and participating FQHCs.
Housing and Homeless Incentive Program
The Housing and Homeless Incentive Program (HHIP) allows Medi-Cal managed care plans to earn incentive funds for making investments and progress in addressing homelessness. This is a multi-system effort requiring participation from managed care plans, local Continuums of Care, and Homeless Housing Assistance and Prevention (HHAP) grant recipients, in partnership with public health jurisdictions, county behavioral health departments, public hospitals, county social services, and local housing departments. Medi-Cal managed care plans submitted their Local Homelessness Plans at the end of June and have begun implementation. Please visit the HHIP webpage to learn more.
As comprehensive systems, many public health care systems provide behavioral health services across the entire continuum, from prevention to crisis intervention and inpatient psychiatric care. Public health care systems are particularly focused on ensuring that patients’ behavioral health services, whether provided directly by the public health care system, by partnering county providers, or other organizations, receive coordinated, holistic care with their other medical and social needs.