SEPTEMBER 2019 Issue Brief A Close Look at Medi-Cal Managed Care: Stories of Quality Improvement Success W ith more than 80% of Medi-Cal beneficiaries enrolled in managed care, assessing and mon- itoring the quality of care delivered by managed care impediments to be addressed: carve-out services; poor data exchange; and inadequate provider supply and participation. These lists are intended not to be compre- plans (MCPs) is critical to ensuring all Medi-Cal members hensive but rather to shed light on what must be done to receive high-quality, timely care. Among other oversight ensure all Medi-Cal enrollees receive high-quality care. activities, the California Department of Health Care Services (DHCS) monitors Medi-Cal MCPs’ annual scores on Healthcare Effectiveness Data and Information Set Approach (HEDIS) measures, which assess quality of care, including Chapman Consulting and CHCF established multiple cri- rates for preventive screening, control of chronic condi- teria to identify which MCP improvements to include in tions, and access to primary care. this study. Among the most important criteria, the MCP had to have improved its HEDIS quality score by at least A 2019 study conducted by the University of California, ten percentage points between 2009 and 2018; the San Francisco analyzed HEDIS scores and trends in Medi- MCP’s most recent score (2018) had to be at or above Cal managed care from 2009 to 2018. The study found the statewide average; and the MCP had to have dem- that quality varied significantly across MCPs and regions onstrated significant improvement across a minimum of and that, over this ten-year period, quality did not three HEDIS measures in a given service area. Also, mea- improve or declined for more than half of the measures.1 sures had to have been reported on for at least five years However, there are many examples of significant prog- to qualify. ress by individual MCPs on specific measures. In light of these findings, the California Health Care Foundation Several MCPs met these criteria on one or more qual- (CHCF) commissioned Chapman Consulting to examine ity measures. The six MCPs selected to study reflect the the experiences of a subset of successful MCPs to answer diversity of MCPs by ownership, plan type, and geo- two questions: First, how did the selected MCPs make graphic service area (Table 1, page 2). These MCPs were real, sustained improvements in quality and achieve not selected because they scored higher than other those gains? Second, what lessons do these experiences MCPs. provide to policymakers, Medi-Cal program officials, and MCPs seeking to broaden and accelerate quality Chapman Consulting conducted structured interviews improvement in Medi-Cal managed care? with each MCP to understand what actions were taken to improve HEDIS scores. This issue brief summarizes The experiences of the selected MCPs point to several, the common themes that emerged from these discus- interconnected strategies: leadership commitment; effec- sions. The information and findings presented in this tive data analysis; real-time data exchange; collaborating issue brief are based on the information shared during with providers at the point of service; increasing mem- the structured interviews, and no additional independent ber access to care and education; and targeted financial verification of the quality improvement activities and incentives. Shared experiences also surfaced several strategies was conducted as part of this analysis. Table 1. Characteristics of Featured Managed Care Plans OWNERSHIP TYPE COUNTIES SERVED Anthem Blue Cross Commercial For-profit Multiple/statewide CalViva Health Public Local initiative Fresno, Kings, Madera Community Health Group Commercial Nonprofit San Diego Health Plan of San Mateo Public County-organized health system San Mateo L.A. Care Health Plan Public Local initiative Los Angeles Molina Healthcare of California Commercial For-profit Multiple/statewide Findings: Common Themes in AA In 2014, Anthem reported it was below the minimum performance levels (MPLs) established by DHCS.2 In Quality Improvement response, Anthem’s leadership made an explicit com- mitment to implement targeted quality improvement Quality Improvement Starts with efforts. This process began with an analysis of data Plan Leadership and internal processes to revamp the MCP’s quality Each of the MCPs interviewed emphasized the impor- approach, which led to the development of a com- tant role senior leadership played in the development of prehensive plan to focus on quality across the MCP effective solutions to improve quality scores. Leadership with a clear message that the plan was an organiza- involvement not only signaled that quality monitoring tional priority. Anthem’s quality scores have improved and improvement were priorities for all MCP staff but significantly as a result, with 91% of measures above also ensured that necessary resources (staff, infrastruc- the MPL, and the MCP has been recognized as “Most ture, and funding) were available to support the MCP’s Improved Plan” by DHCS for the past four years. quality improvement efforts. Several MCPs commented that leadership’s involvement allowed quality staff to pilot AA The leadership team of L.A. Care Health Plan (LA different strategies to improve quality scores with the Care) implemented regular meetings with the lead- understanding that, although some strategies would be ership of clinics with which the MCP contracts to unsuccessful, trial and error would ultimately identify the discuss quality improvement goals and progress. most effective way to improve the MCP’s quality scores Signaling the importance of these meetings, LA Care and member outcomes. Examples include the following: participants include the chief executive officer, chief medical officer, and quality team leadership. AA Molina indicated the leadership team made signifi- cant investments in both staff and financial resources to drive improvements in quality. Molina shared that a “top-down” approach fostered shifts in the organizational culture to emphasize collaboration. For example, a framework that created connections and communication across departments within the MCP was implemented. This framework resulted in the development of a data analytics team, practice facilitation teams, and care connections teams that worked together to develop strategies to improve Molina’s quality scores. California Health Care Foundation www.chcf.org 2 Data Analysis Is Key AA In 2014, DHCS put a corrective action plan (CAP) Every MCP interviewed referenced the importance of in place with LA Care as a result of the MCP’s low data analysis and improvements in data collection as a scores for two measures related to monitoring use critical component to improving quality performance. of persistent medications for the treatment of high For example, all the MCPs discussed the importance of blood pressure: angiotensin-converting enzymes data analysis for identifying both high-volume provider (ACE) inhibitors and angiostensin receptor blockers sites with low HEDIS scores (i.e., “high-volume/low-per- (ARB). This action led the MCP to evaluate its data forming” providers) and member gaps in care to develop and determine which clinics and providers were specific interventions. Identifying the high-volume/low- performing poorly on these measures. LA Care also performing providers helped the MCPs target specific evaluated pharmacy data to identify the members quality improvement efforts initially before extending filling prescriptions for ACE inhibitors and diuretics successful transformation efforts to larger networks. and shared that data with pharmacies and providers. Other examples include the following: In addition, the MCP sent letters to members remind- ing them to schedule appointments and suggesting AA When CalViva Health (CalViva) launched in 2011, members bring the letter to their appointment to MCP staff reviewed the data on quality metrics in its provoke conversations about necessary labs and service area. This analysis revealed low HEDIS scores other follow-up appointments related to the mem- for eye exams and blood pressure control for diabetic bers’ persistent medications. LA Care’s score on patients among a few high-volume/low-performing monitoring patients using ACE inhibitors or ARB clinics. MCP staff used this information to conduct improved from 73% in 2012 to 89% in 2018. Similarly, outreach to the clinics and identified a need for staff the MCP’s score on monitoring patients using diuret- training on the use of the retinal camera, how to ics improved from 72% to 88% during this period. measure a patient’s blood pressure correctly, and proper documentation of results to meet the HEDIS Data analysis also is critical to evaluating interventions. requirements as well as to ensure proper follow-up While most MCPs did not cite “plan-do-study-act” by the provider. For the diabetic eye exams, CalViva (PDSA) cycles specifically, all mentioned that interven- learned one clinic was referring patients to an optom- tions must be assessed frequently and, if an effort is not etrist to complete the test rather than conducting the having the intended result, the MCP must be able to test on-site, and patients were not following through pivot quickly to a different strategy. Data analysis helped with the referral. Once the clinic began completing the MCPs realize the importance of emphasizing to pro- the test on-site, the related HEDIS score increased, viders the correct data to capture so providers receive and patients were more likely to complete the exam, credit for providing comprehensive, quality care. The resulting in better care. Similarly, once clinic staff MCPs interviewed discussed the importance of devel- learned how to measure a patient’s blood pres- oping a comprehensive “plain language” HEDIS guide sure correctly and document the results, the clinics’ to crosswalk quality measures with the corresponding quality scores increased, and the clinics were able to data necessary for collection, so all staff in the provid- better identify and implement appropriate interven- er’s office can easily understand HEDIS measures and tions. CalViva improved the rate at which members’ specifications. Consistent data capture, although not the blood pressure is under control, a component of the only element critical to improving the delivery of high- “Comprehensive Diabetes Care” HEDIS measure, quality care, is one of the most important aspects of the from 53% in 2013 to 68% in 2018. During this same HEDIS process and was a starting point to identify the period, CalViva also improved its rate of eye exams root causes of low HEDIS scores. Once the MCP identi- (retinal screening) from 49% to 59%.3 fies the underlying causes of poor quality scores (e.g., data collection, quality of care delivered, member educa- tion and outreach), the appropriate interventions can be implemented. A Close Look at Medi-Cal Managed Care: Stories of Quality Improvement Success www.chcf.org 3 between 21 and 56 days after delivery. By producing Real-Time Data Exchange with the report on a weekly basis, the health promotion Providers Is Critical coordinators have virtually real-time information The MCPs interviewed noted the importance of exchang- about deliveries, which increases the likelihood ing data with in-network providers on a real-time basis the member will see her provider within the HEDIS to drive immediate action when issues are identified. required time frame. HPSM’s score on the postpar- Examples include the following: tum care measure improved from 60% in 2009 to 75% in 2018, which is 11 percentage points above AA CalViva developed provider profiles to identify and the statewide average (64%). track members with gaps in care. These profiles are shared with providers to encourage follow-up with their patients. CalViva also sends information about Quality Improvement Efforts Are individual providers’ HEDIS scores based on the raw Most Effective at the Point of Service data providers submit to the MCP. CalViva found that Sending health plan staff on-site with providers. The successful quality improvement interventions require MCPs interviewed identified the importance of having provider champions who can lead practice trans- staff on-site with providers to observe best practices and formation and provide the MCP with data. Provider identify areas for improvement. Being on-site allows the profiles were created to support clinic staff engaged MCPs to develop targeted interventions that reflect the in this work. local landscape and needs of both members and pro- viders. The MCPs then use this information to scale up AA Community Health Group (CHG) provides monthly the interventions, when feasible, and identify best prac- reports to its providers identifying members who tices for other provider sites. This process also allows have not followed medical recommendations or the MCPs the opportunity to identify other issues at the taken their medications. As the end of the HEDIS provider sites that otherwise might not have been uncov- measurement year approaches, reports are sent out ered, often leading to additional quality improvement biweekly and then weekly, and CHG’s providers use efforts. For example: this information to work with their patients to close gaps in care. CHG provides countywide dashboards AA Anthem implemented on-site patient-centered so each clinic can compare its scores with other care consultants, leading to the development of its clinics in the county. The MCP believes this level of “clinic days” initiative. Anthem invites members with comparison spurs “friendly competition” among the diabetes to attend a clinic day for a comprehensive clinics and fosters improvements. diabetes care visit, initially targeting clinics with a high volume of diabetes patients. Anthem staff are AA For several years, the Health Plan of San Mateo’s on-site during the clinic day to assess current prac- (HPSM) score on the HEDIS “Prenatal and tices and identify additional steps the MCP can take Postpartum Care — Postpartum Care” measure fell to support in-network health care providers. While below the MPL. This measure reflects the percentage at the clinic, members also can complete other lab of women giving birth who had a postpartum visit work and address unrelated gaps in care (e.g., if a within the first eight weeks after delivery. To improve member is overdue for another preventive service the quality score, HPSM implemented several strat- such as a mammogram, the member can complete egies, including the revision of an existing report it during the same visit). Anthem noted significant tracking recent deliveries by members. Originally, improvements in several measures of diabetes care, this report was produced monthly, but the report is including the “Comprehensive Diabetes Care — Eye now produced weekly. Health promotion coordina- Exam (Retinal) Performed” measure, which improved tors at the MCP use this report to identify postpartum from 49% in 2009 to 90% in 2018.4 Anthem found members for telephonic outreach to encourage the initial diabetes-focused clinic days were so suc- them to schedule an appointment with their provider cessful that it replicated the model to address care California Health Care Foundation www.chcf.org 4 needs specific to women’s health. The MCP also Small and local interventions. Several of the MCPs high- implemented the model at nonclinic locations, such lighted the importance of piloting interventions that are as homeless shelters, to increase the ability to reach small and locally focused. Nationally, Anthem has found members. it beneficial to create local quality teams that include clin- ical staff focused entirely on ensuring the MCP improves AA To improve its HEDIS scores for the comprehensive its quality scores and outcomes for members. Anthem diabetes care measures, CHG staff visited several has made significant investments in provider incentives provider sites where the MCP determined providers and data analytics, which allow for root-cause analysis were unable to complete the required eye exams to determine how best to structure an intervention (e.g., because the providers lacked retinal cameras. As a with a focus on provider education, member outreach, result, members were referred to another provider data improvements) and have led to implementation of to complete the exam, and compliance rates were interventions specific to the local service area and popu- low, which negatively impacted both quality scores lation needs. and outcomes. CHG purchased retinal cameras for several providers and trained staff on their use. Additionally, CHG provided cameras for clinical staff Increasing Access to Care and who perform in-home visits, which increased the Member Education ability to reach members and ensure the test was The MCPs interviewed noted that impediments to mem- completed. Data from the cameras is sent to spe- ber access are often major barriers to quality improvement cialists who analyze, interpret, and send feedback efforts. The MCPs shared that quality scores improved within 24 to 48 hours so appropriate action can be when interventions made it easy for members to address taken and monitored by the MCP. CHG’s score on the several needs at the same time — for example, to receive “Comprehensive Diabetes Care — Eye Exam (Retinal) care for multiple complex needs and obtain preventive Performed” measure improved from 47% in 2009 to care in a single visit rather than across several appoint- 67% in 2018. ments in different locations. Anthem’s “clinic days,” described earlier, are one example of an MCP taking Educating providers and front-line office staff on steps to make it easier for members to get the care they HEDIS specifications and documentation. Most MCPs need. Other examples include the following: noted challenges with ensuring provider staff are fol- lowing the HEDIS specifications for each measure and AA Molina created care connection teams comprised of reported that problems recording the correct information in-home nurse practitioners. The teams were initially were a significant barrier leading to low quality scores. To deployed to work with members with diabetes to address this problem, CHG, for example, developed a assist them in connecting with the right resources HEDIS quick reference guide that includes every measure and help them understand how to obtain assistance and the corresponding ICD-9 or ICD-10 codes, common to avoid delays in care. This initiative was quickly procedure codes, and information on co-testing. The expanded to conduct outreach to members, identi- HEDIS guide is updated every year and designed to be fied through data analysis, who had not seen their easy to understand, so providers, as well as front-line primary care practitioners within a specified time staff, can familiarize themselves with the specifications. frame. While in the home, the nurse practitioners can Additionally, CHG provides voluntary HEDIS training ses- conduct thorough examinations that would other- sions throughout the year, which low-scoring clinics and wise require several trips to provider’s office and the providers are encouraged to attend. HEDIS trainings also lab. Nurse practitioners also identify barriers to care are available on the MCP’s website for providers and clin- and improved health, such as transportation needs ics to review. and food insecurity. Once an unmet need is identi- fied, the MCP can link members to both internal and external resources for social services and supports A Close Look at Medi-Cal Managed Care: Stories of Quality Improvement Success www.chcf.org 5 to address social determinants of health. Molina has Molina found that providing incentives for practices seen improvements in its HEDIS diabetes scores. For to utilize nonphysician staff to work to the “top of example, its score for the “Comprehensive Diabetes their licenses” also was key to closing gaps in care, Care — HbA1c Control” measure improved from as well as creating an internal champion who would 41% in 2010 to 89% in 2018.5 engage in constant monitoring and reporting related to quality. Further, Molina’s P4P incentives are aligned AA HPSM’s health promotion coordinators connect with the targeted interventions at the provider level. postpartum members to community resources (e.g., the Black Infant Health Program or the county home visiting program). The health promotion coordinators Challenges to Health Plan also can help members access appropriate care by connecting them to a provider and helping to sched- Quality Improvement Efforts ule appointments. In addition, HPSM noted it sends While an exhaustive review of impediments to success- text messages to postpartum members regarding ful and sustained quality improvement was beyond the the importance of scheduling timely appointments scope of this study, a few common challenges emerged with their providers. Given the sensitive nature of from the MCP interviews: postpartum care, successful member engagement requires the health program coordinators to have Carve-out services. MCPs noted that the Medi-Cal strong customer service skills, and bilingual staff have “carve-outs,” which are covered services not provided been critical to the success of the postpartum pro- under the health plan contract (such as dental and spe- gram at the MCP. As noted earlier, HPSM’s score on cialty mental health services), can have a negative impact the postpartum care measure is now well above the on quality scores and care provided. Without the ability statewide average. to coordinate a member’s care across the continuum of services, the MCPs have less ability to impact the overall health outcomes for a member. Financial Incentives Can Spur Quality Improvement Data exchange. Many MCPs struggle to obtain complete Most of the MCPs interviewed found both member and utilization data for members. Problems occur in data provider incentives are useful tools to help prioritize exchange from within the network (e.g., from contracted improvements in specific quality metrics. For example: providers and groups) and in obtaining timely data from DHCS on carve-out services. Consistent data regarding AA HPSM includes the HEDIS postpartum measure in services provided outside the MCP’s contract or by non- the MCP’s provider pay-for-performance (P4P) pro- contracting providers also could help MCPs identify gaps gram, and payments are intended to encourage in care and could lead to better care coordination. providers to see postpartum members and schedule timely appointments. Because labor and delivery are Provider supply and participation. Access to care typically reimbursed globally (i.e., providers receive requires an extensive provider network, and the MCPs a single payment for the entire set of services), it shared that finding providers willing to see Medi-Cal was difficult to identify the postpartum component patients can impede efforts to improve quality. For provided to the member. HPSM instituted a specific example, the MCPs reported increasing difficulty with code to capture this visit, which triggers an incentive finding specialty provider types such as obstetricians/ payment of $50 per postpartum visit completed. gynecologists and cardiologists willing to accept Medi- Cal payment rates. AA Molina used grant funding to pay provider office staff to prioritize and participate in weekly meetings on quality initiatives and to monitor improvement. California Health Care Foundation www.chcf.org 6 Conclusion About the Authors California’s Medi-Cal managed care program provides Athena Chapman, MPP, is president and Elizabeth coverage to more than 10 million Californians. The exam- Evenson is policy director of Chapman Consulting, which ples of quality improvement success stories included provides strategic planning, meeting facilitation, organi- in this report demonstrate that state officials and MCP zational support, and regulatory and statutory analysis leaders can deploy strategies to significantly improve to organizations in the health care field. Caroline Davis, the quality of care provided to Medi-Cal beneficiaries. MPP, is president of Davis Health Strategies, which Most Medi-Cal MCPs still have room to improve on many provides strategic and analytical services, including gov- HEDIS measures. By shining a light on where progress ernment/public policy strategy, managed care program is occurring and what made it possible, this brief pro- development and implementation, regulatory analysis, vides lessons for accelerating quality improvement and and meeting facilitation to health care organizations extending it program-wide. focused on improving care for vulnerable and safety-net populations. Endnotes About the Foundation 1.Andrew B. Bindman, Denis Hulett, Isabel Ostrer, and Taewoon The California Health Care Foundation is dedicated to Kang, A Close Look at Medi-Cal Managed Care: Statewide advancing meaningful, measurable improvements in the Quality Trends from the Last Decade, California Health Care Foundation, September 2019, www.chcf.org. way the health care delivery system provides care to the people of California, particularly those with low incomes 2.Until 2019, DHCS set the MPLs at the 25th percentile of all Medicaid MCPs nationwide. MCPs that did not meet the MPL and those whose needs are not well served by the status were subject to increased oversight by DHCS and potentially put quo. We work to ensure that people have access to the on a corrective action plan (CAP). care they need, when they need it, at a price they can 3.Authors’ calculation of the average HEDIS scores across Fresno, afford. Kings, and Madera Counties. 4.Authors’ calculation of the average HEDIS scores across CHCF informs policymakers and industry leaders, invests Alameda, Contra Costa, Fresno, Sacramento, San Francisco, in ideas and innovations, and connects with changemak- Santa Clara, and Tulare Counties. ers to create a more responsive, patient-centered health 5.Authors’ calculation of the average HEDIS scores across care system. Sacramento, San Diego, and Riverside/San Bernardino Counties. For other reports in the “A Close Look at Medi-Cal Managed Care” series, visit www.chcf.org. A Close Look at Medi-Cal Managed Care: Stories of Quality Improvement Success www.chcf.org 7