APRIL 2019 Medi-Cal Explained FACT SHEET Accountability in the health plan member to rank the managed care plan, doctors, and overall health care experience, Medi-Cal Managed among other questions. It is administered to a Care Program sample of plan beneficiaries by a third party on behalf of the state. The department also assesses enrollee griev- Introduction ances, utilization and encounter data, dis-enroll- California’s Medicaid program, Medi-Cal, is ment data, "secret shopper" information, and the administered by the state’s Department of Health results of quality audits. Care Services (DHCS). Approximately 82% of What MCP Quality Information Is Publicly Medi-Cal beneficiaries are enrolled in a Medi-Cal Available? Managed Care Plan (MCP), a private or public DHCS is required by federal law to contract with health insurance entity that takes responsibility for an external quality review organization, which most of an enrollee’s medical benefits, including compiles and provides detailed public reports to primary care, specialty care, and non-specialty monitor and assess health plan performance. The mental health services.1 There are more than 30 department makes public selected information full-service and specialty MCPs that participate in about health plan compliance, enrollment, and Medi-Cal’s managed care program, and federal quality. Other key activities include: and state payments to MCPs totaled approximately $49 billion in the state’s 2017-2018 fiscal year.2 lAs required by federal law, DHCS has devel- oped a written strategy for assessing and improving quality in its Medicaid managed care What Data Does DHCS program. Use to Assess Quality? lDHCS makes public the performance of MCPs DHCS assesses information on the quality of con- on an aggregate and individual basis through its tracted plans annually using measures from the online Managed Care Performance Dashboard. Healthcare Effectiveness Data and Information Set (HEDIS) and every three years using measures from The California Health Care Foundation is ded- the Consumer Assessment of Healthcare Providers icated to advancing meaningful, measurable and Systems (CAHPS). improvements in the way the health care delivery HEDIS, a national performance improvement tool system provides care to the in managed care, is a set of roughly 90 metrics people of California, particularly that measure access, the effectiveness of care, those with low incomes and those whose needs are not well and patients’ experience of care, among other served by the status quo. We domains.3 For example, HEDIS captures the per- work to ensure that people have centage of plan members receiving preventive access to the care they need, health screenings, like mammograms, and get- when they need it, at a price they can afford. ting best-practice care for chronic diseases like For more information, visit www.chcf.org. diabetes. CAHPS is a national survey that asks a California Health Care Foundation www.chcf.org | 1 APRIL 2019 l DHCS further assesses MCP performance Looking Ahead using an external accountability set, a subset Despite these monitoring and oversight activities of 30 HEDIS and CAHPS measures, as shown by DHCS, quality across the Medi-Cal managed in Table 1. care system varies widely among managed care Table 1. External Accountability Set for MCPs – plans and regions. There are opportunities for Measurement Year 2018 DHCS to use additional financial and non-financial ■■ Plan all-cause readmissions tools to hold plans accountable for achieving a ■■ Ambulatory care—outpatient and emergency department high level of quality and access for members. visits ■■ Monitoring for patients on persistent medications More information on quality in Medi-Cal is avail- ■■ Avoidance of antibiotic treatment able at www.chcf.org/collection/holding-plans-ac- Breast cancer screening ■■ countable-quality-medi-cal-managed-care/. ■■ Cervical cancer screening Childhood immunization status Endnotes ■■ ■■ Childhood access to primary care providers ■■ Comprehensive diabetes care 1. The Medi-Cal Program: An Overview, California Health ■■ Controlling high blood pressure Care Foundation, February 2019, www.chcf.org/ ■■ Immunizations for adolescents publication/medi-cal-program-overview/. ■■ Asthma medication ratio 2.Medi-Cal Facts and Figures: Crucial Coverage for Low- ■■ Prenatal and postpartum care Income Californians, California Health Care Foundation, ■■ Depression screening and follow up February 2019,www.chcf.org/publication/2019- ■■ Use of imaging for low back pain medi-cal-facts-figures-crucial-coverage/. ■■ Weight assessment and counseling for children and 3. "HEDIS and Performance Measurement," National adolescents Committee for Quality Assurance, accessed April 19, 2019, ■■ Well-child visits www.ncqa.org/hedis/. Source: California Department of Health Care Services 4. "CAHPS: Surveys and Tools to Advance Patient-Centered Care," Agency for Healthcare Research and Quality, accessed April 19, 2019, www.ahrq.gov/cahps/index.html. How Does DHCS Address Poor MCP Quality? DHCS primarily uses two tools to hold plans Medi-Cal Explained is an ongoing series on accountable for quality: Medi-Cal for those who are new to the pro- lAuto-Assignment Incentive: Medi-Cal has gram, as well as those who need a refresher. taken steps to encourage competition based on To see other publications in this series, visit quality in counties with multiple plans by auto-as- www.chcf.org/MC-explained. signing beneficiaries who do not make a choice to the plan within the county that demonstrated the highest quality scores on a pre-determined subset of measures in the prior year. lImprovement Plans: DHCS requires health plans to create improvement plans (IPs) related to measures in the external accountability set that fall below Medi-Cal’s minimum perfor- mance level set at below the 25th percentile among Medicaid health plans nationally. These IPs detail the health plan’s strategy to improve their performance, including what the plan will test, how it will measure improvement, the measurable target for that cycle, and the plan’s analysis of results. California Health Care Foundation www.chcf.org | 2