The California Department of Health Care Services (DHCS) has published a final population health management (PHM) strategy and roadmap, with details about a new Population Health Service to be launched in 2023 and the expectations of Medi-Cal Managed Care (MCMC) plans to offer coordinated and equitable care to all members.
The DHCS said the PHM Program would gather, share, and assess timely and accurate data on member preferences and needs to identify efficient and effective opportunities for intervention through processes such as data-driven risk stratification, predictive analytics, identification of gaps in care, and standardized assessment processes. One guiding principle is to use program and outcomes data to inform policy making and drive continuous quality improvement efforts across Medi-Cal delivery systems.
The state will seek to identify, measure, and develop solutions that address outcome differences by race, ethnicity, language, and other factors to advance health equity accountability, and develop a unified approach for PHM across DHCS and delivery systems to promote and transparency, integrating national standards and evidence-based practices.
In tandem with the PHM Program rollout, DHCS is building a statewide PHM Service designed to collect and integrate disparate information to support DHCS’ vision for PHM in myriad ways. Most notably, the PHM Service will:
• Provide MCMC plans, providers, counties, MCMC plan members, and other authorized users with access to comprehensive, historical data on members’ health history, needs and risks;
• Include a single, statewide, open-source risk stratification and segmentation (RSS) methodology with standardized risk tier criteria that will place all Medi-Cal members into high-risk, medium-rising-risk, and low-risk tiers;
• Improve data accuracy and timeliness by providing members with the ability to update their information;
• Promote trusting relationships for care teams to support individuals with access to health education, their rights and applicable benefits, and information on how their data are being used, among other features; and
• Improve DHCS’ ability to understand population health trends and strengthen oversight.
DHCS said the PHM Service will support whole-person care by integrating and aggregating historical administrative, medical, behavioral, dental, social service and program information from disparate sources to support risk-stratification, segmentation and tiering, assessment and screening processes, and analytics and reporting. It stressed, however, that the PHM Service is not being designed to provide real-time clinical decision support capabilities.
The PHM Service will be deployed statewide in July 2023, with additional PHM Service capabilities incrementally phased in thereafter. Based on stakeholder feedback, DHCS intends to test-launch the PHM Service with a subset of partners from January 2023 to June 2023 to optimize functionality before the statewide launch.
Prior to the launch of the PHM Service and prior to any requirements to use the PHM Service, DHCS will not require MCMC plans to develop new infrastructure that would subsequently be replaced by the PHM Service. DHCS will continue to work with stakeholders to identify the priorities and capabilities that the PHM Service will support.
The PHM Service is part of a broader, statewide effort to accelerate and expand access to health and social service information among health care entities, government agencies, and social services organizations under California’s new Data Exchange Framework (DxF). (See Healthcare Innovation’s recent article on the Data Exchange Frameworkincluding an interview with John Ohanian, chief data officer and director for the Center of Insights and Innovation at CalHHS.)
In early 2023, DHCS will release guidance and a template for the new comprehensive PHM Strategy as well as guidance for a modified Population Needs Assessment (PNA) structure. As part of the PHM Strategy, each MCMC plan will work alongside community leaders and partners to develop a single, focused strategy for its PHM program. The agency said that the PHM Strategy will help MCMC plans reduce bias and error in its decision-making; and track progress toward PHM goals. MCMC plans will be required to detail components of their PHM program, including prevention and wellness strategies and interventions, for children and youth, pregnant and postpartum individuals, and those with behavioral health needs, in their PHM Strategies. Because of the comprehensive scope of the PHM Strategy, MCMC plans will no longer need to submit a PNA Action Plan.
MCMCs will be held accountable for having well-functioning PHM programs to achieve these improvements. Under CalAIM and as a key component of the 2024 Re-Procurement and the CQS, DHCS is strengthening oversight of MCMC plans, adding robust accountability, compliance, and oversight programs, including for delegated entities, to ensure that members receive quality care and have access to needed services. DHCS is developing and implementing a Managed Care Monitoring and Oversight Framework as part of the implementation of the 2024 Re-Procurement and CQS. Accountability and oversight for PHM will be measured and implemented within this framework, with additional details outlined in forthcoming guidance.
Specifically, starting in 2023, DHCS plans to incorporate MCMC plan performance on key measures (including high-priority clinical quality measures and member experience) as a consideration within plan capitation rate setting. Building on efforts in 2022, MCPs are expected to further incorporate health equity measures and begin to achieve DHCS established targets to reduce disparities for MY2023. If quality metrics are not met, an MCMC plan will be required to allocate an additional 7.5 percent of its annual net income to community reinvestment, in addition to the amount that they would otherwise be required to contribute.
In addition, aligned with the overall vision of the PHM Program to strengthen and reinforce primary care as the foundation of healthcare for all Medi-Cal members and to shift from fee-for-service to value-based payment models of care, MCMC plans’ reporting requirements will also expand in 2024; they will include reporting on primary care spending as a percentage of total spending – stratified by age ranges and race/ethnicity – to understand investments in primary care as well as disparities in these investments. DHCS will consider setting targets for minimum primary care spending in the future. DHCS will also require MCMC plans to begin reporting on the percentage of their provider contracts (especially primary care) that are in alternative payment models (APMs) using the Health Care Payment Learning and Action Network (HCP-LAN) APM framework, and will consider setting minimum performance targets to support overall delivery system transformation to more value-based models of care.