DHCS Director Toby Douglas began the Medi-Cal Stakeholders Advisory Committee noting it was his last, as he would be in the private sector at month’s end, and thanking his staff and the assembled stakeholders. The appreciation is mutual–we know the work has been tough, the resources limited, but it has been a pleasure to work with Toby. And we fully expect that the administrative processes and structures he’s put in place and broad vision he’s articulated for some of the delivery system reforms now underway will benefit many more and ultimately all Californians.
So back to the meeting, to dig deep into issues impacting the most vulnerable Medi-Cal consumers (seniors, people with disabilities, or people living with mental illness or substance use disorders, for example) or to catch up on transformational processes, like waiver renewals, that have the potential to improve health outcomes or possibly extend care and coverage to the remaining uninsured.
Timely Access and Network Adequacy
SB964 brings dramatic changes to the timely access statute by standardizing health plan reporting, introducing an annual timeframe so that learning and correcting can happen from one year to the next; and separating the reporting processes for Medi-Cal and Covered CA. There will be a stakeholder process around this—starting in January.
Today we learned what a big deal it was to pass SB964; that DHCS had to staff up 10 times what they had in place to comply with the new access provisions; that a whole new division was needed for all the additional oversight. Bring it on: As more and more Californians gain coverage, some (like childless adults covered through the Medicaid expansion) for the first time; as providers and plans form themselves into new strategic configuration, it IS UNDOUBTEDLY important to ensure timely access to care.
The plans presented about what they were doing in terms of timely access and network adequacy (specifically Anthem, Inland Empire, Wellness, and CenCal Health), and we appreciated their frankness about their challenges in meeting the state’s current access standards, especially with specialists. At times the plans sounded as flummoxed as we are about rural provider shortages and related access issues, and telemedicine may not (or not yet) be all its’ cracked up to be to make up the difference. Maybe, suggested Toby, telehealth incentives could be built into bundled payment arrangements? Telehealth does have some potential to narrow gaps in access—and we would hope California with its high tech sector could be more in the forefront in this area.
Today we heard the plans are under a great deal of strain, from low rates to challenges finding all the needed providers. But that’s why it’ called managed care: If that means you have to contract outside the state border (as Anthem has) or contract with out of network providers, or pay for transport to a specialist (most plans do), that is what you must do.
Waiver Renewal Process and Workgroups
Most of the expert advisory groups have only had their first meeting, but already a few common themes or areas of interest have emerged:
- The need to align metrics across providers, plans and delivery systems
- Developing shared savings and accountable care arrangements to deliver better care
- Behavioral health integration: it’s striking how this imperative runs across all of the groups.
- Expanded workforce capacity
- Maximizing federal financing under waiver authority to achieve ‘triple aim’ and universal coverage goals.
- Evaluation design: how else will we know whether these initiatives are working?
The waiver staff did an admirable job summing up some early thoughts from each expert workgroup:
- The Housing/Shelter group: with strong consensus around the Whole Person care model, this group is digging into population and geographic priorities and evaluation criteria and metrics for success.
- Plan/Provider Incentives Group: a key question for this group is how to distribute the risk—and how to align payments to manage that risk. This group, like several others, also hopes to align with national (for example NCQA) standards and all of the service categories.
- DSRIP 2.0: in this go-round the DSRIP should be more focused on measureable outcomes and on the logistics, not to mention politics, around how to figure the non-federal share of financing in the delicate balancing act which is waiver budget neutrality.
- The Workforce Development Workgroup, by no surprise, is looking at the need for more providers across the state, and specifically providers willing to serve the growing Medi-Cal population and prepared to deliver ‘whole person’ care. This group is also wisely looking also at future workforce needs.
Drug Medi-Cal Waiver Submitted to CMS, Nest Steps
Though the Drug Medi-Cal “Organized Delivery System Waiver” waiver has been submitted to CMS, DHCS is still taking input through the 120 days. Mari expects approval. This iteration, like the other waivers, is decidedly more ambitious encompassing the broad continuum of care: from individuals living with substance use disorders, to their families, the criminal justice system, and the system as a whole.
Rural Managed Care Expansion
Stakeholders voiced skepticism about readiness for this expansion, especially if the vision is as limited as it was described today: aimed at the same access as we saw under fee-for-service. Western Center’s Elizabeth Landsberg stated that we need to do more to make up for the hard fact that non emergency and non-medical transportation is not covered as a distinct benefit: “If the specialist is far away, these are low income people so we need to help them get there.” Yes, that’s what managed care is supposed to be all about.