Final Evaluation of California's Health Homes Program (HHP) Prepared for: California Department of Health Care Services (DHCS) July 2023 Final Evaluation of California's Health Homes Program (HHP) Nadereh Pourat, PhD Xiao Chen, PhD Brenna O'Masta, MPH Leigh Ann Haley, MPP Weihao Zhou, MS Menbere Haile, PhD UCLA Center for Health Policy Research Health Economics and Evaluation Research Program July 2023 This evaluation was supported by funds received from The California Endowment and the California Department of Health Care Services. The analyses, interpretations, and conclusions contained within this evaluation are the sole responsibility of the authors. This report contains analysis of data available up to September 30, 2020. Acknowledgments The authors would like to thank Atticus Binder, Anna Warrick, Maria Ditter, Wafeeq Ridhaun, and Sally Yao for their hard work and support of HHP evaluation activities. Suggested Citation Pourat N, Chen X, O'Masta B, Haley LA, Zhou W and Haile M. Final Evaluation of California's Health Homes Program (HHP). Los Angeles, CA: UCLA Center for Health Policy Research, July 2023. UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program Contents DRAFT: Final Evaluation of California's Health Homes Program (HHP) .......................................... 1 Executive Summary....................................................................................................................... 20 Health Homes Program (HHP) Overview .................................................................................. 20 Evaluation Methods .................................................................................................................. 20 Results ....................................................................................................................................... 21 HHP Implementation and Infrastructure .......................................................................... 21 HHP and COVID-19 ............................................................................................................ 22 HHP Enrollment and Enrollment Patterns ........................................................................ 22 HHP Enrollee Demographics and Health Status ............................................................... 23 HHP Service Utilization among HHP Enrollees.................................................................. 24 HHP Outcomes .................................................................................................................. 24 Conclusions and Implications.................................................................................................... 27 Introduction .................................................................................................................................. 29 Health Homes Program Overview ............................................................................................ 29 HHP Implementation Plan ........................................................................................................ 29 HHP Services ............................................................................................................................. 31 HHP Target Populations ............................................................................................................ 32 Funding and Payment Methodology ........................................................................................ 33 Transition to New Medi-Cal Services ........................................................................................ 34 UCLA HHP Evaluation ................................................................................................................ 34 Conceptual Framework ..................................................................................................... 34 Evaluation Questions and Data Sources ........................................................................... 36 HHP Implementation and Infrastructure ...................................................................................... 38 HHP Implementation ................................................................................................................ 39 HHP Delivery Models ................................................................................................................ 40 HHP Delivery Networks ............................................................................................................. 40 CB-CMEs by Organization Type......................................................................................... 40 UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program CB-CMEs and Projected HHP Capacity.............................................................................. 41 HHP Staffing .............................................................................................................................. 42 HHP Data Sharing ...................................................................................................................... 43 Communication with HHP Enrollees ......................................................................................... 43 HHP and COVID-19 ........................................................................................................................ 44 Progression of COVID-19 Cases and Hospitalizations in HHP Counties.................................... 45 Impact of COVID-19 on HHP Implementation and Infrastructure............................................ 47 Estimated Prevalence of and Trends in COVID-19 among HHP Enrollees and their Controls . 47 COVID-19–Related Health Service Use of WPC Enrollees and Controls ................................... 48 Changes in Healthcare Utilization trends before and during the COVID-19 Pandemic ........... 49 Changes in HHP Service Utilization before and during the COVID-19 Pandemic ..................... 53 HHP Enrollment and Enrollment Patterns .................................................................................... 55 Trends in Enrollment................................................................................................................. 57 Growth in HHP Enrollment Overall and by SPA ................................................................ 57 Growth in HHP Enrollment among Enrollees Experiencing Homelessness by SPA .......... 59 Enrollment Size by Group and County .............................................................................. 59 Enrollment from the Target Engagement List .................................................................. 61 Enrollment Patterns .................................................................................................................. 62 Enrollment Churn .............................................................................................................. 62 Enrollment Length ............................................................................................................ 63 MCP Exclusions of Specific HHP Eligible Populations ............................................................... 63 HHP Enrollee Demographics and Health Status ........................................................................... 65 Demographics of HHP Enrollees at Time of Enrollment ........................................................... 66 Health Status of HHP Enrollees Prior to Enrollment ................................................................. 67 HHP Service Utilization among HHP Enrollees.............................................................................. 69 HHP Services ............................................................................................................................. 70 Estimated Overall HHP Service Delivery to HHP Enrollees ....................................................... 72 Estimated Types of HHP Services Received .............................................................................. 74 Estimated HHP Core Services by Modality and Staff Type ....................................................... 75 UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program HHP Housing Services ............................................................................................................... 76 HHP Outcomes .............................................................................................................................. 78 HHP Utilization Metrics ............................................................................................................. 80 Outpatient Utilization ....................................................................................................... 80 Emergency Department Utilization .................................................................................. 90 Hospital Utilization............................................................................................................ 93 Institution Utilization ........................................................................................................ 97 HHP Process Metrics ............................................................................................................... 103 Adult Body Mass Index Assessment ............................................................................... 103 Screening for Depression and Follow-Up Plan ............................................................... 105 Follow-Up After Hospitalization for Mental Illness ........................................................ 106 Follow-Up After Emergency Department Visit for Alcohol and Other Drug Abuse or Dependence .................................................................................................................... 108 Initiation and Engagement of Alcohol and Other Drug Abuse or Dependence Treatment 112 Use of Pharmacotherapy for Opioid Use Disorder ......................................................... 115 HHP Outcome Metrics ............................................................................................................ 116 Controlling High Blood Pressure ..................................................................................... 116 Plan All-Cause Readmission ............................................................................................ 118 Prevention Quality Indicator (PQI) 92: Chronic Conditions Composite ......................... 119 Estimated Medi-Cal Payments among HHP Enrollees and HHP Costs ....................................... 120 Estimated Payments for HHP Services.................................................................................... 121 Total Estimated Medi-Cal Payments............................................................................... 121 Estimated Payments for Outpatient Services ................................................................. 123 Estimated Payments for Outpatient Medication............................................................ 125 Estimated Payments for Emergency Department Visits................................................. 127 Estimated Payments for Hospitalizations ....................................................................... 128 Estimated Payments for Long Term Care ....................................................................... 130 Estimated Payments for Residual Costs ......................................................................... 131 UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program HHP Program Expenditures .................................................................................................... 133 Conclusions and Implications...................................................................................................... 135 Conclusions ............................................................................................................................. 135 HHP Implementation and Infrastructure ........................................................................ 135 HHP and COVID-19 .......................................................................................................... 135 HHP Enrollment and Enrollment Patterns ...................................................................... 135 HHP Enrollee Demographics and Health Status ............................................................. 136 HHP Service Utilization among HHP Enrollees................................................................ 136 HHP Outcomes ................................................................................................................ 137 Implications ............................................................................................................................. 138 Appendix A: Data Sources and Analytic Methods ...................................................................... 140 Readiness Documents ............................................................................................................. 140 Analytic Methods ............................................................................................................ 140 Limitations....................................................................................................................... 140 Enrollment Reports and MCP Quarterly Reports ................................................................... 141 Analytic Methods ............................................................................................................ 141 Limitations....................................................................................................................... 143 Medi-Cal Enrollment and Claims Data .................................................................................... 143 Analytic Methods ............................................................................................................ 143 Limitations....................................................................................................................... 155 Attributing Estimated Medi-Cal Payments to Claims ............................................................. 155 Background ..................................................................................................................... 155 Service Category Specifications ...................................................................................... 157 Attributing Payments to Specific Services ...................................................................... 162 Comparison of Estimated Payments with Medi-Cal Paid Amounts ............................... 168 Limitations....................................................................................................................... 169 HHP Rates................................................................................................................................ 170 Appendix B: UCLA HHP Evaluation Design.................................................................................. 171 Introduction ............................................................................................................................ 171 UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program HHP Evaluation Conceptual Framework and Questions ........................................................ 172 Data Sources ........................................................................................................................... 174 Methods .................................................................................................................................. 175 Limitations............................................................................................................................... 178 Timeline................................................................................................................................... 179 Appendix C: HHP Enrollees Enrolled Less Than 31 Days............................................................. 180 Appendix D: Enrollees with More than One Year of HHP Enrollment........................................ 181 Appendix E: Survey: COVID-19 Impact on the Health Homes Program (HHP) ........................... 183 Appendix F: MCP-Level Descriptives and Unadjusted HHP Core Metrics .................................. 193 UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program Table of Figures Exhibit 1: General Health Homes Program Acronyms and Definitions ........................................ 17 Exhibit 2: Managed Care Plans Acronyms/Abbreviations and Definitions................................... 19 Exhibit 3: Changes (DD) in HHP Core Metrics for HHP Enrollees vs. Controls from 24 Month Before to the 24 Months Following HHP Enrollment ................................................................... 25 Exhibit 4: Changes (DD) in Health Care Utilization per 1,000 beneficiaries per year for HHP Enrollees vs. Controls from 24 Month Before to the 24 Months Following HHP Enrollment...... 26 Exhibit 5: Changes (DD) in HHP Estimated Medi-Cal Payments per beneficiary per year for HHP Enrollees vs. Controls from 24 Month Before to the 24 Months Following HHP Enrollment...... 27 Exhibit 6: Timeline of HHP Implementation by Group and SPA ................................................... 30 Exhibit 7: MCPs that Implemented HHP across California, by Group and County ....................... 31 Exhibit 8: HHP Services Provided through MCPs and CB-CMEs ................................................... 32 Exhibit 9: HHP Eligibility Inclusion and Exclusion Criteria............................................................. 33 Exhibit 10: HHP Evaluation Conceptual Framework ..................................................................... 35 Exhibit 11: Health Homes Program Evaluation Questions and Data Sources .............................. 36 Exhibit 12: Distribution of California Counties by Health Homes Program Implementation Group and MCPs Implementing Health Homes Program by County....................................................... 39 Exhibit 13: Health Homes Program CB-CME Network by Organization Type as of December 2021 ....................................................................................................................................................... 41 Exhibit 14: Total Projected CB-CME Capacity for Health Homes Program Enrollment by CB-CME Organization Type as of December 2021...................................................................................... 42 Exhibit 15: Cumulative COVID-19 Cases per 100,000, as of December 2021, HHP Counties and California ....................................................................................................................................... 45 Exhibit 16: 14-day Average COVID-19 Hospitalization Rate per 100,000, April 2020 to December 2021, Statewide and Selected HHP Counties .............................................................................. 46 UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program Exhibit 17: Proportion of HHP Enrollees and their Controls with a COVID-19 Related Service by month, April 2020 to December 2021 .......................................................................................... 48 Exhibit 18: Proportion of COVID-19-Related Health Services used among HHP Enrollees and their Controls with a COVID-19 Diagnosis by Service Type .......................................................... 49 Exhibit 19: Monthly Utilization of Primary Care and Specialty Care Services per 1,000 Member Months among HHP Enrollees and their Controls, 2019 Compared to 2020 and 2021 .............. 50 Exhibit 20: Monthly Utilization of Emergency Department Visits and Hospitalizations per 1,000 Member Months among HHP Enrollees and their Controls, 2019 Compared to 2020 and 2021 51 Exhibit 21: Proportion of Primary Care and Specialty Care Services Provided through Telehealth by HHP Enrollees and Control groups, March 2020 to December 2021 ...................................... 52 Exhibit 22: Proportion of HHP Enrollees with Reported HHP Services, July 2018 to December 2021 .............................................................................................................................................. 53 Exhibit 23: Proportion of HHP Services Provided In-Person or Telephonically, July 2018 to December 2021 ............................................................................................................................. 54 Exhibit 24: Unduplicated Monthly and Cumulative Enrollment in HHP, July 1, 2018 to December 31, 2021 ....................................................................................................................................... 57 Exhibit 25: Unduplicated Quarterly Enrollment in HHP by SPA, July 1, 2018 to December 31, 2021 .............................................................................................................................................. 58 Exhibit 26: Enrollment of Individuals Reported as Experiencing Homelessness or At-Risk of Homelessness each Quarter in HHP by SPA, January 1, 2019 to December 31, 2021 ................. 59 Exhibit 27: Unduplicated Cumulative HHP Enrollment by Group and County as of December 31, 2021 .............................................................................................................................................. 60 Exhibit 28: Proportion of HHP Enrollees that were identified in the Target Engagement List (TEL), Overall and by MCP ............................................................................................................. 61 Exhibit 29: Enrollment and Disenrollment Patterns in HHP as of December 31, 2021 ................ 62 Exhibit 30: Average Length of Enrollment in Months in HHP by Group as of December 31, 2021 ....................................................................................................................................................... 63 UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program Exhibit 31: Percent of Eligible Beneficiaries Excluded by MCPs by Reason for Exclusion in the First Year of HHP Implementation ................................................................................................ 64 Exhibit 32: HHP Enrollee Demographics, Overall, and by SPA, at the Time of HHP Enrollment as of December 30, 2021 .................................................................................................................. 66 Exhibit 33: Top Ten Most Frequent Physical and Mental Health Conditions among HHP Enrollees, 24 Months Prior to HHP Enrollment ............................................................................ 67 Exhibit 34: Complexity of HHP Enrollees' Health Status by SPA, 24 Months Prior to HHP Enrollment as of September 30, 2020 .......................................................................................... 68 Exhibit 35: HHP Services ............................................................................................................... 71 Exhibit 36: Estimated Overall HHP Units of Service Received by HHP Enrollees by SPA, July 1, 2018 to December 31, 2021 ......................................................................................................... 73 Exhibit 37: Estimated Average Number of HHP Units of Service Provided to HHP Enrollees in Months HHP Services were Received by Service Type and SPA, July 1, 2018 to December 31, 2021 .............................................................................................................................................. 74 Exhibit 38: Estimated Average Number of HHP Core Units of Service Provided to HHP Enrollees in Months those HHP Services were received by Modality and SPA, July 1, 2018 to December 31, 2021 .............................................................................................................................................. 75 Exhibit 39: Homelessness Status and Receipt of Housing Services by HHP Enrollees, July 1, 2019 to December 31, 2021 .................................................................................................................. 77 Exhibit 40: Trends in Primary Care Services per 1,000 Beneficiaries per Year Before and During HHP by SPA as of December 31, 2021 .......................................................................................... 81 Exhibit 41: Trends in Specialty Services per 1,000 Beneficiaries per Year Before and During HHP by SPA as of December 31, 2021 .................................................................................................. 82 Exhibit 42: Trends in Mental Health Services per 1,000 Beneficiaries per Year Before and During HHP by SPA as of December 31, 2021 .......................................................................................... 86 Exhibit 43: Trends in Substance Use Disorder Services per 1,000 Beneficiaries per Year Before and During HHP by SPA as of December 31, 2021 ....................................................................... 89 UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program Exhibit 44: Trends in Ambulatory Care: Emergency Department Visits per 1,000 Beneficiaries per Year Before and During HHP by SPA as of December 31, 2021 ............................................. 90 Exhibit 45: Trends in Percentage of Patients with Any ED Visits Before and During HHP by SPA as of December 31, 2021 .................................................................................................................. 91 Exhibit 46: Trends in Inpatient Utilization per 1,000 Beneficiaries per Year Before and During HHP by SPA as of December 31, 2021 .......................................................................................... 93 Exhibit 47: Trends in Percentage of Patients with Any Hospitalization Before and During HHP by SPA as of December 31, 2021 ...................................................................................................... 94 Exhibit 48: Trends in Average Inpatient Length of Stay in Days Before and During HHP by SPA as of December 31, 2021 .................................................................................................................. 96 Exhibit 49: Trends in Admissions to an Institution from the Community (Short-Term Stay) Before and During HHP by SPA as of December 31, 2021 ....................................................................... 98 Exhibit 50: Trends in Admissions to an Institution from the Community (Medium-Term Stay) Before and During HHP by SPA as of December 31, 2021............................................................ 99 Exhibit 51: Trends in Admissions to an Institution from the Community (Long-Term Stay) Before and During HHP by SPA as of December 31, 2021 ..................................................................... 100 Exhibit 52: Trends in Number of Long-Term Care Stays per 1,000 Beneficiaries per Year Before and During HHP by SPA as of December 31, 2021 ..................................................................... 102 Exhibit 53: Trends in Adult Body Mass Index Assessment Before and During HHP by SPA for HHP Enrollees and the Control group as of December 31, 2021 ....................................................... 103 Exhibit 54: Trends in Screening for Depression and Follow-Up Plan Before and During HHP for SPA 1 HHP Enrollees and the Control group as of December 31, 2021 ..................................... 105 Exhibit 55: Trends in Follow-Up After Hospitalization for Mental Illness within 7 Days Before and During HHP by SPA for HHP Enrollees and the Control group as of December 31, 2021 .......... 106 Exhibit 56: Trends in Follow-Up After Hospitalization for Mental Illness within 30 Days Before and During HHP by SPA for HHP Enrollees and the Control group as of December 31, 2021 ... 107 UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program Exhibit 57: Trends in Follow-Up After ED Visit for Alcohol and Other Drug Abuse and Dependence within 7 Days Before and During HHP by SPA for HHP Enrollees and the Control Group as of December 31, 2021 ................................................................................................. 110 Exhibit 58: Trends in Follow-Up After ED Visit for Alcohol and Other Drug Abuse and Dependence within 30 Days Before and During HHP by SPA for HHP Enrollees and the Control Group as of December 31, 2021 ................................................................................................. 111 Exhibit 59: Trends in Initiation of Alcohol and Other Drug Abuse or Dependence Treatment Before and During HHP by SPA for HHP Enrollees and the Control Group as of December 31, 2021 ............................................................................................................................................ 112 Exhibit 60: Trends in Engagement of Alcohol and Other Drug Abuse or Dependence Treatment Before and During HHP by SPA for HHP Enrollees and the Control Group as of December 31, 2021 ............................................................................................................................................ 114 Exhibit 61: Trends in Use of Pharmacotherapy for Opioid Use Disorder Before and During HHP by SPA for HHP Enrollees and the Control Group as of December 31, 2021 ............................. 115 Exhibit 62: Trends in Controlling High Blood Pressure Before and During HHP by SPA for HHP Enrollees and the Control Group as of December 31, 2021 ....................................................... 116 Exhibit 63: Trends in Plan All-Cause Readmission Before and During HHP by SPA for HHP Enrollees and the Control Group as of December 31, 2021 ....................................................... 118 Exhibit 64: Trends in Prevention Quality Indicator (PQI) 92: Chronic Conditions Composite Before and During HHP by SPA for HHP Enrollees and the Control Group as of December 31, 2021 ............................................................................................................................................ 119 Exhibit 65: Trends in Total Estimated Payments per Beneficiary per Year Before and During HHP by SPA as of December 2021 ...................................................................................................... 123 Exhibit 66: Trends in Payments per Beneficiary per Year for Outpatient Services Before and During HHP by SPA as of December 2021 .................................................................................. 124 Exhibit 67: Trends in Outpatient Medication Payments per Beneficiary per Year Before and During HHP by SPA as of December 2021 .................................................................................. 125 Exhibit 68: Trends in Payments for Emergency Department Visits per Beneficiary per Year Before and During HHP by SPA as of December 2021................................................................ 127 UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program Exhibit 69: Trends in Payments for Hospitalizations per Beneficiary per Year Before and During HHP by SPA as of December 2021 .............................................................................................. 128 Exhibit 70: Trends in Payments for Long Term Care per Beneficiary per Year Before and During HHP by SPA as of December 2021 .............................................................................................. 130 Exhibit 71: Trends in Residual Costs per Beneficiary per Year Before and During HHP by SPA as of December 2021 ...................................................................................................................... 133 Exhibit 72: Estimated HHP Supplemental Expenditures by Enrollees Type and Implementation Group, as of December 31, 2021 ................................................................................................ 134 Exhibit 73: Evaluation Questions and Data Sources ................................................................... 140 Exhibit 74: Beneficiary-Level Variables ....................................................................................... 142 Exhibit 75: HHP Service Utilization Indicators ............................................................................ 143 Exhibit 76: HHP Services ............................................................................................................. 144 Exhibit 77: Demographic Indicators............................................................................................ 145 Exhibit 78: Health Status Indicators............................................................................................ 145 Exhibit 79: Healthcare Utilization Indicators .............................................................................. 147 Exhibit 80: HHP Core Metrics, Definitions, and Reporting Status .............................................. 148 Exhibit 81: Variables Used to Select the Control Group ............................................................. 151 Exhibit 82: Comparison of Select Characteristics of HHP SPA 1 Cohort 5 Enrollees (Enrolled July to September 2019) and Matched Control Beneficiaries ........................................................... 153 Exhibit 83: Description of Mutually Exclusive Categories of Service* ........................................ 158 Exhibit 84: Percentage of 2019 Total Estimated Payments by Category of Service for HHP Medi- Cal Claims .................................................................................................................................... 160 Exhibit 85: Category of Service and Payment Descriptions ........................................................ 162 Exhibit 86: Payment Data Sources .............................................................................................. 163 UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program Exhibit 87: Comparison of Estimated Fee-for Service Payments and Paid Amounts for 2019 HHP Medi-Cal Claims .......................................................................................................................... 169 Exhibit 88: Comparison of Average Fee- for-Service and Managed Care Payments per Claim for 2019 HHP Medi-Cal Claims ......................................................................................................... 169 Exhibit 89: Evaluation Conceptual Framework ........................................................................... 172 Exhibit 90: Evaluation Questions and Data Sources ................................................................... 173 Exhibit 91: Evaluation Timeline and Deliverables....................................................................... 179 Exhibit 92: Count of SPA 1 Enrollees by Number of Months of HHP Enrollment as of December 2021 ............................................................................................................................................ 181 Exhibit 93: Count of SPA 2 Enrollees by Number of Months of HHP Enrollment as of September 2020 ............................................................................................................................................ 182 Exhibit 94: HHP Implementation and Enrollee Demographics for Aetna, Alameda Alliance, Blue Shield, and CA Health and Wellness as of December 31, 2021 .................................................. 194 Exhibit 95: HHP Enrollee Health Status and Utilization Prior to Enrollment and Service Delivery for Aetna, Alameda Alliance, Blue Shield, and CA Health and Wellness as of December 31, 2021 ..................................................................................................................................................... 195 Exhibit 96: Trends in HHP Metrics for Aetna, Alameda Alliance, Blue Shield, and CA Health and Wellness as of December 31, 2021............................................................................................. 196 Exhibit 97: Trends in Estimated Payments for Aetna, Alameda Alliance, Blue Shield, and CA Health and Wellness as of December 31, 2021 .......................................................................... 199 Exhibit 98: HHP Implementation and Enrollee Demographics for Anthem Blue Cross as of December 31, 2021 ..................................................................................................................... 202 Exhibit 99: HHP Enrollee Health Status and Utilization Prior to Enrollment and Service Delivery for Anthem Blue Cross as of December 31, 2021 ....................................................................... 203 Exhibit 100: Trends in HHP Metrics for Anthem Blue Cross as of December 31, 2021.............. 204 Exhibit 101: Trends in Estimated Payments for Anthem Blue Cross as of December 31, 2021 . 207 UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program Exhibit 102: HHP Implementation and Enrollee Demographics for LA Care, Community Health Group, Kern Health Systems, and CalOptima as of December 31, 2021.................................... 210 Exhibit 103: HHP Enrollee Health Status and Utilization Prior to Enrollment and Service Delivery for LA Care, Community Health Group, Kern Health Systems, and CalOptima as of December 31, 2021 ............................................................................................................................................ 211 Exhibit 104: Trends in HHP Metrics for LA Care, Community Health Group, Kern Health Systems, and CalOptima as of December 31, 2021 ................................................................................... 212 Exhibit 105: Trends in Estimated Payments for LA Care, Community Health Group, Kern Health Systems, and CalOptima as of December 31, 2021 .................................................................... 215 Exhibit 106: HHP Implementation and Enrollee Demographics for Inland Empire Health Plan and Kaiser as of December 31, 2021 ................................................................................................. 217 Exhibit 107: HHP Enrollee Health Status and Utilization Prior to Enrollment and Service Delivery for Inland Empire Health Plan and Kaiser as of December 31, 2021.......................................... 217 Exhibit 108: Trends in HHP Metrics for Inland Empire Health Plan and Kaiser as of December 31, 2021 ............................................................................................................................................ 219 Exhibit 109: Trends in Estimated Payments for Inland Empire Health Plan and Kaiser as of December 31, 2021 ..................................................................................................................... 222 Exhibit 110: HHP Implementation and Enrollee Demographics for Molina Healthcare Plan as of December 31, 2021 ..................................................................................................................... 224 Exhibit 111: HHP Enrollee Health Status and Utilization Prior to Enrollment and Service Delivery for Molina Healthcare Plan as of December 31, 2021................................................................ 225 Exhibit 112: Trends in HHP Metrics for Molina Healthcare Plan as of December 31, 2021....... 226 Exhibit 113: Trends in Estimated Payments for Molina Healthcare Plan as of December 31, 2021 ..................................................................................................................................................... 229 Exhibit 114: HHP Implementation and Enrollee Demographics for Health Net as of December 31, 2021 ...................................................................................................................................... 232 Exhibit 115: HHP Enrollee Health Status and Utilization Prior to Enrollment and Service Delivery for Health Net as of December 31, 2021 .................................................................................... 233 UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program Exhibit 116: Trends in HHP Metrics for Health Net as of December 31, 2021 ........................... 234 Exhibit 117: Trends in Estimated Payments for Health Net as of December 31, 2021 .............. 237 Exhibit 118: HHP Implementation and Enrollee Demographics for San Francisco Health Plan, Santa Clara Family Health Plan, and United Healthcare as of December 31, 2021 ................... 240 Exhibit 119: HHP Enrollee Health Status and Utilization Prior to Enrollment and Service Delivery for San Francisco Health Plan, Santa Clara Family Health Plan, and United Healthcare as of December 31, 2021 ..................................................................................................................... 241 Exhibit 120: Trends in HHP Metrics for San Francisco Health Plan, Santa Clara Family Health Plan, and United Healthcare as of December 31, 2021.............................................................. 242 Exhibit 121: Trends in Estimated Payments for San Francisco Health Plan, Santa Clara Family Health Plan, and United Healthcare as of December 31, 2021 .................................................. 245 UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program Exhibit 1 defines acronyms and terms referenced throughout the report. Exhibit 1: General Health Homes Program Acronyms and Definitions Acronym Definition AB Assembly Bill ACO Accountable Care Organization AHF AIDS Healthcare Foundation AHS Alameda Health Systems AOD Alcohol and Other Drug ASC Ambulatory Surgical Center ASP Average Sales Price BMI Body Mass Index CB-CME Community-Based Care Management Entity CBO Community Based Organizations CBAS Community-Based Adult Services CCA Clinical Care Advance CCW Chronic Condition Warehouse CDPS Chronic Illness and Disability Payment System Risk Score CKD Chronic Kidney Disease CM Care Management CMS Centers for Medicare and Medicaid Services COPD Chronic Obstructive Pulmonary Disease CPT Current Procedural Terminology CSH Corporation for Supportive Housing DD Difference-in-Difference DHCS California Department of Health Care Services DME Durable Medical Equipment DRG Diagnosis Related Grouping E&M Evaluation & Management ED Emergency Department EHR Electronic Health Record ER Emergency Room FFS Fee-for-Service FMAP Federal Medical Assistance Percentage FQHC Federally Qualified Health Center GRM General Risk Model HAP Health Action Plan HCPCS Healthcare Common Procedure Coding System HCSA Alameda County Health Care Services Agency HEDIS Healthcare Effectiveness Data and Information Set HH/HCBS Home Health and Home and Community-Based Services HHP Health Homes Program HIE Health Information Exchange HIT Health Information Technology HMIS Homeless Management Information Session ICD International Classification of Diseases LA Los Angeles LCSW Licensed Clinical Social Worker LTC Long-Term Care MCP Managed Care Plan UCLA Evaluation | Glossary 17 UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program Acronym Definition MFT Marriage and Family Therapist MM Member months NADAC National Average Drug Acquisition Cost NPI National Provider Identifier NPPES National Plan and Provider Enumeration System NUCC National Uniform Claims Committee OPPS Outpatient Prospective Payment System OUD Opioid Use Disorder PACE Program of All-Inclusive Care for the Elderly PCP Primary Care Provider PMPM Per Member per Month POS Place of Service PQI Prevention Quality Indicator RHC Rural Health Center RN Registered Nurse SCAN Senior Care Action Network SFTP Secure File Transfer Protocol SMI Severe Mental Illness SNF Skilled Nursing Facility SNOMED CT Systematized Nomenclature of Medicine-Clinical Terms SPA State Plan Amendment SUD Substance Use Disorder SW Social Worker TAR Treatment Authorization Request TEL Targeted Engagement List UBREV Revenue Code UCLA University of California, Los Angeles Center for Health Policy Research UOS Unit of Service 18 Glossary | UCLA Evaluation UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program Exhibit 2 defines acronyms and full names of participating Managed Care Plans. Exhibit 2: Managed Care Plans Acronyms/Abbreviations and Definitions Acronym/Abbreviations Managed Care Plan Full Name ABHCA Aetna Better Health of California AAH Alameda Alliance for Health Anthem Anthem Blue Cross of California Partnership Plan, Inc. BSCPHP Blue Shield of California Promise Health Plan CHW California Health & Wellness CalOptima CalOptima CHG Community Health Group Partnership Plan HNCS Health Net Community Solutions, Inc. IEHP Inland Empire Health Plan Kaiser Kaiser Permanente KHS Kern Health Systems L.A. Care L.A. Care Health Plan MHC Molina Healthcare of California Partner Plan, Inc. SFHP San Francisco Health Plan SCFHP Santa Clara Family Health Plan UnitedHealthcare UnitedHealthcare Community Plan of California, Inc. UCLA Evaluation | Glossary 19 UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program Executive Summary Health Homes Program (HHP) Overview The California Department of Health Care Services (DHCS) implemented the Medi-Cal Health Homes Program (HHP) to serve eligible Medi-Cal beneficiaries with complex needs and chronic conditions. HHP was authorized under California Assembly Bill 361 and approved by the Centers for Medicare and Medicaid Services under Section 2703 of the 2010 Patient Protection and Affordable Care Act. HHP was designed to provide six core services for eligible enrollees: (1) comprehensive care management; (2) care coordination; (3) health promotion; (4) comprehensive transitional care; (5) individual and family support; and (6) referral to community and social support services. DHCS selected 12 California counties where all 16 Medi-Cal managed care plans (MCPs) operating in those counties would implement HHP for their enrollees who met certain chronic condition and acuity criteria. HHP was implemented in phases by county groupings and two subsets of enrollees, with the first group implementing in July 2018 and the last group implementing in July 2020. Subsets of enrollees included those with chronic physical health conditions or substance use disorders (SUD) referred to as SPA 1 (State Plan Amendment 1) and those with serious mental illness (SMI) referred to as SPA 2. MCPs implemented SPA 2 six months after SPA 1 within each county grouping. DHCS published a program guide to ensure uniform HHP implementation, delivery of services, and reporting across all MCPs. MCPs contracted with Community-Based Care Management Entities (CB-CMEs) to deliver HHP services. MCPs enrolled eligible beneficiaries from a Targeted Engagement List (TEL) provided by DHCS but had discretion in enrolling other eligible beneficiaries. Evaluation Methods The UCLA Center for Health Policy Research was selected to evaluate HHP and developed a conceptual framework and evaluation questions to conduct a rigorous assessment of the program. This report presents the final summative findings of the HHP and is the last of three evaluation reports (the first and second evaluation reports can be found here and here). UCLA used all available data for the evaluation. These included MCP readiness documents that contained MCP's HHP policies and procedures for implementation and delivery of services; Targeted Engagement Lists (TEL) created every six months by DHCS to identify potentially eligible HHP enrollees per MCP; quarterly MCP enrollment and utilization reports that included beneficiary level enrollment data and homelessness status; Medi-Cal enrollment and claims data for all HHP enrollees with information on demographics, health status, and use of HHP and health services; and COVID-19 impact surveys of all participating MCPs and select CB-CMEs. 20 0BFinal Evaluation of California's Health Homes Program (HHP) | UCLA Evaluation UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program UCLA used readiness documents to describe HHP implementation including composition of HHP networks, types of staff, data sharing, enrollee outreach and engagement, and HHP service delivery approaches. UCLA used TEL, MCP enrollment and utilization reports, and Medi-Cal data to assess HHP enrollment patterns, demographics, health status, HHP service use, and health care service utilization. UCLA attributed a dollar amount to all claims and assessed change in estimated payments. The COVID-19 impact surveys were used to assess the impact of the pandemic of HHP implementation and infrastructure. Results HHP Implementation and Infrastructure • HHP was implemented by all 16 MCPs operating in 12 California counties, with six MCPs implementing HHP in more than one county. • In MCP implementation plans, 15 of 16 MCPs used delivery Model I, where CB-CMEs were typically medical providers that hired and housed HHP staff, including care coordinators. When HHP enrollees' medical providers were not able to take on these responsibilities, MCPs utilized Models II and III to deliver services centrally or regionally. • In their Quarterly HHP Reports, MCPs reported the HHP delivery network grew from 212 unique CB-CMEs as of September 2019 (first interim report) to 244 unique CB-CMEs as of September 2020 (second interim report) to 263 unique CB-CMEs through the end of the program. These CB-CMEs were primarily community health centers (39%), followed by community based social service organizations or local government entities (25%), and community based primary care or specialty physicians (17%). Six MCPs indicated that they acted as a CB-CME for a portion of their HHP enrollees in an effort to expand service capacity in regions where community-based infrastructure was insufficient. CB-CME type was relatively consistent across time. • MCPs reported that they anticipated that contracted CB-CMEs had an enrollment capacity of approximately 85,174 enrollees with 37% of that capacity in community health centers. The median capacity per CB-CME was 216 enrollees. Overall capacity grew significantly from the first interim report (September 2019), where MCPs reported that they anticipated CB- CMEs had an enrollment capacity of 47,010 enrollees. From the second interim report (September 2020), overall capacity grew by 5,804 and median capacity increased by 36 enrollees, with the addition of 33 CB-CMEs (who had a capacity for a minimum of 11 or more enrollees). • MCPs ensured that CB-CMEs had adequate staffing to deliver HHP services; utilized data sharing technologies including SFTP, dedicated email, electronic health records (EHR), care management platforms, or health information exchange (HIE); and used predictive modeling and risk grouping of eligible beneficiaries to identify and target beneficiaries for HHP enrollment. UCLA Evaluation | 0BFinal Evaluation of California's Health Homes Program (HHP) 21 UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program HHP and COVID-19 • The COVID-19 pandemic started in early 2020, near the end of the second year of HHP implementation. • Cumulative rates of COVID-19 cases from the start of the pandemic through December 2021 were higher in seven HHP counties (San Diego, Kern, Tulare, Riverside, Los Angeles, San Bernardino, and Imperial) compared to the overall state. COVID-19 hospitalization and death rates in HHP counties followed a similar pattern, with peaks in July 2020, January 2021, and September 2021. • In the second interim report, MCPs reported that the COVID-19 pandemic had impacted HHP processes, procedures, and/or policies, with the greatest impact on housing and homeless support services, comprehensive transitional care, and delivery of care coordination by frontline staff. MCPs were able to establish effective workflows and infrastructure to support their own and CB-CME's operation by transitioning to telehealth and strategically coordinating with shelters and other short-term housing services. • As of December 2021, UCLA estimated that 19% of HHP enrollees and 17% of a control group (of similar Medi-Cal beneficiaries not enrolled in HHP) had at least one service with COVID-19 as the primary or secondary diagnosis. The monthly rate of services with a COVID- 19 diagnosis was highest in January 2021 for both enrollees and the control group. HHP enrollees and controls with a COVID-19 diagnosis most commonly had COVID-19 related hospitalization (33% for HHP enrollees vs 31% for the control group), followed by COVID-19 related primary care services (22% vs 21%) and emergency department visits (14% vs 13%). • Examining the overall service utilization patterns from 2019 to 2021 showed no declines in use of primary care services for HHP enrollees during the pandemic compared to before the pandemic. In contrast, specialty care services, ED visits, and hospitalizations declined at the start of the pandemic compared to 2019. Specialty care services utilization returned to 2019 levels by September 2020 but the rates of ED visits and hospitalizations remained below 2019 levels through December 2021. • Telehealth service use was under 0.2% before March 2020 but rapidly increased to 25% of primary care services in April 2020 before declining to 9% by December 2021 among HHP enrollees. A similar pattern was observed for specialty care telehealth services. • The proportion of monthly HHP service use by HHP enrollees was declining prior to the pandemic from a peak of 77% in October 2018 and although there was a small increase in the proportion at the start of the COVID-19 pandemic (from 37% to 42%), the proportion continued to decline throughout the remainder of the program. • Prior to the pandemic, a similar proportion of HHP services were provided in-person versus telephonic. During the pandemic the majority of HHP services were provided telephonically. HHP Enrollment and Enrollment Patterns 22 0BFinal Evaluation of California's Health Homes Program (HHP) | UCLA Evaluation UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program • A total of 90,045 individuals enrolled in HHP between July 1, 2018 and December 31, 2021, with 66,017 enrolled in SPA 1 and 24,028 enrolled in SPA 2. At end of the program, 48,481 enrollees were actively enrolled in HHP. The proportion of enrollees in SPA 2 increased over time from 3% in the first quarter of 2019 to 27% in the last quarter of 2021. • The number of enrollees experiencing homelessness or at risk of homelessness increased over time and represented 8.2% of all HHP enrollees; a likely underestimate due to data limitations. • The number of enrollees varied by both group and county. Groups 2 and 3 had the highest levels of enrollment (21,505 and 65,421, respectively) and Groups 1 and 4 had the lowest levels of enrollment (1,568 and 1,551, respectively). Los Angeles County had the highest level of enrollment with 38,819 enrollees, followed by Riverside (11,773) and San Bernardino (9,732). • DHCS identified eligible Medi-Cal beneficiaries in the Targeted Engagement List (TEL) and shared the TEL with MCPs. Overall, 79% of HHP enrollees were reported on the TEL prior to enrollment. When examining the rate of enrollment from the TEL by MCP, the rate ranged from 67% to 98%. Overall, MCPs enrolled 8% of individuals identified on the TEL in participating counties. • Over half (53%) of HHP enrollees were continuously enrolled, 45% were disenrolled, and 2.1% enrolled multiple times through the end of the program in December 2021. The average length of enrollment in Group 1 was 12.7 months for SPA 1 enrollees and 10.1 months for SPA 2 enrollees. Overall, the average length of enrollment was 12.6 months for Group 2, 11.0 months for Group 3, and 9.2 months for Group 4 enrollees. • The most common reason MCPs reported for not enrolling from the TEL in Groups 2 and 3 was that an eligible beneficiary was not an MCP member, indicating the data informing the TEL did not always reflect current enrollment status (members are permitted to change MCPs every 30 days). The most common reason for Group 1 was eligible enrollee declined to participate and for Group 4 it was the eligible enrollee was already well managed. HHP Enrollee Demographics and Health Status • The majority of HHP enrollees were between 50 and 64 years old (48%), female (59%), and preferred English for communication purposes (71%). Nearly half of enrollees were Latinx (47%). Compared to SPA 1 enrollees, SPA 2 enrollees were more often between 18 and 49 years old (51% vs 32%) and more often female (65% vs 57%). • Prior to enrollment, the most common chronic conditions among all HHP enrollees and SPA 1 enrollees were hypertension (65%) and diabetes (49%). The most common condition among SPA 2 enrollees was depression (73%). UCLA Evaluation | 0BFinal Evaluation of California's Health Homes Program (HHP) 23 UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program • MCPs enrolled Medi-Cal managed care beneficiaries with multiple chronic health conditions, consistent with HHP's requirements. For example, 53% had hypertension along with chronic obstructive pulmonary disease, diabetes, coronary artery disease, and/or chronic or congestive heart failure and 44% had a combination of complex conditions such as chronic renal (kidney) disease, chronic liver disease, and traumatic brain injury. Nearly all (93%) of enrollees met at least one of the HHP chronic condition criteria based on their Medi-Cal data prior to enrollment. HHP Service Utilization among HHP Enrollees • MCPs reported challenges and significant lag with data reporting of HHP services by way of encounter data, which led to program data that reflected 25% of enrollees without any HHP service codes during their enrollment and these enrollees came from all 16 MCPs. The percent of enrollees without an HHP service use as reflected in the encounter data during at least one month was 26%, a decline from 38% as of September 2020. • Existing data showed that MCPs reported 1,819,484 HHP units of service (UOS) to HHP enrollees from July 2018 through December 2021. In months where encounter data for HHP services were present, enrollees averaged 3.1 HHP UOS per month. Enrollees had a higher average use of core HHP services (2.8 UOS per month) and other HHP services (2.5) compared to engagement services (1.7). • Average UOS per month where these services were reported were higher for services provided in-person (3.1 UOS per month) compared to telephonically (2.5) and by non- clinical providers (3.1) compared to clinical providers (2.6). • The percentage of enrollees reported as at risk or experiencing homelessness peaked at 10% during the first quarter of 2021 before declining to 8% in the last quarter of the program. Among enrollees at risk of or experiencing homelessness in the final quarter of the program, 62% received housing services and 6% were reported as no longer homeless by December 2021. HHP Outcomes UCLA assessed changes in trends in HHP outcomes from 24 months prior to enrollment to the first 24 months of HHP enrollment for HHP enrollees and a control group of beneficiaries with similar patterns of utilization. UCLA further measured the difference in change in outcomes between the two groups (difference-in-difference) overall and by SPA as shown in the following Exhibits. Core Performance Metrics 24 0BFinal Evaluation of California's Health Homes Program (HHP) | UCLA Evaluation UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program • HHP performance was assessed using 17 core metrics reflecting delivery of appropriate services (process of care) and outcomes of care (Exhibit 3). Of these, ED visits and hospitalizations are reported along with other measures of overall utilization of health care. • Among HHP process metrics, rate of Adult BMI Assessment declined during HHP, but this decline was smaller than the control group for SPA 1 (DD: 1.2% per year) and SPA 2 (DD: 2.2%) enrollees. There were no other significant changes for the remaining process metrics by SPA. However, data showed that the rate of Follow-Up After Emergency Department Visit for Alcohol and Other Drug Abuse or Dependence within 7 days declined for the overall enrollee population vs. their control group (DD: -2.2%). • Among outcome metrics, the rates of controlled high blood pressure improved during HHP and in comparison to controls for SPA 1 and SPA 2 enrollees. In addition, the Prevention Quality Indicator (PQI 92) significantly decreased during HHP overall and for SPA 1 enrollees. The rate of Admissions to an Institution from the Community for long-term stays also increased for the overall HHP enrollee population compared to controls. Exhibit 3: Changes (DD) in HHP Core Metrics for HHP Enrollees vs. Controls from 24 Month Before to the 24 Months Following HHP Enrollment Differences in trends for HHP enrollees vs. control group (DD) All SPA 1 SPA 2 Enrollees Enrollees Enrollees Process Metrics Adult Body Mass Index Assessment 1.4% 1.2% 2.2% Screening for Depression and Follow-Up Plan NR NS NR Follow-Up After Hospitalization for Mental Illness within 7 days NS NS NS Follow-Up After Hospitalization for Mental Illness within 30 days NS NS NS Follow-Up After Emergency Department Visit for Alcohol and Other Drug Abuse or Dependence within 7 days -2.2% NS NS Follow-Up After Emergency Department Visit for Alcohol and Other Drug Abuse or Dependence within 30 days NS NS NS Initiation of Alcohol and Other Drug Treatment NS NS NS Engagement of Alcohol and Other Drug Treatment NS NS NS Use of Pharmacotherapy for Opioid Use Disorder NS NS NS Outcome Metrics Controlling High Blood Pressure 2.9% 2.5% 4.8% Plan All-Cause Readmissions NS NS NS Prevention Quality Indicator (PQI) 92: Chronic Conditions Composite -79 -90 NS Short-Term Admission to an Institution from the Community NS NS NS Medium-Term Admission to an Institution from the Community NS NS NS Long-Term Admission to an Institution from the Community 1 NS NS UCLA Evaluation | 0BFinal Evaluation of California's Health Homes Program (HHP) 25 UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program Source: Medi-Cal claims data from July 1, 2016 through December 31, 2021. Notes: Blue indicates significant increase and orange indicates significant decrease compared to the control group. NS means the DD result was not significant. NR indicates that the analysis was not reported. SPA 1 includes enrollees with chronic conditions and substance use disorders. SPA 2 includes enrollees with serious mental illness. Health Care Utilization and Associated Payments • Ambulatory Care: Emergency Department (ED) Visits and Inpatient Utilization were also core HHP metrics. The number of ED visits declined more for HHP enrollees than the control group overall, with a greater decline among SPA 2 enrollees (Exhibit 4). The rate of hospitalizations also declined overall more than the control group, but the rate of decline was greater for SPA 1 enrollees. • UCLA categorized all services received and paid for by HHP enrollees and the control group and examined the patterns of health care utilization and the associated costs. • Assessment of patterns of health care utilization showed a greater decline in all categories of service overall with the exception of a slightly greater increase in long-term care stays. • Among outpatient services, primary care and specialty care service use increased in the first six months of HHP enrollment. After the first six months, there was a greater decline in primary and specialty services for SPA 1 enrollees than the respective control group. In contrast, there was a greater decline in mental health services, substance use treatment services for SPA 2 enrollees compared to their respective controls. • UCLA also examined utilization of all forms of long-term care stays regardless of length of stay and where the patient resided prior to admission, and found a greater increase among HHP enrollees than the controls overall. Exhibit 4: Changes (DD) in Health Care Utilization per 1,000 beneficiaries per year for HHP Enrollees vs. Controls from 24 Month Before to the 24 Months Following HHP Enrollment Differences in trends for HHP enrollees vs. control group (DD) All Enrollees SPA 1 Enrollees SPA 2 Enrollees Utilization Measures Per 1,000 Beneficiaries Per Year Primary Care Services -772 -778 -755 Specialty Services -236 -239 -236 Mental Health Services -409 -272 -823 Substance Use Disorder Services -217 -175 -345 Ambulatory Care: ED Visits* -31 -23 -56 Hospitalizations* -42 -46 -30 Long-Term Care Stays 2 NS NS Source: Medi-Cal claims data from July 1, 2016 through December 31, 2021. Notes: Blue indicates significant increase and orange indicates significant decrease compared to the control group. 26 0BFinal Evaluation of California's Health Homes Program (HHP) | UCLA Evaluation UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program NS means the DD result was not significant. NR indicates that the analysis was not reported. SPA 1 includes enrollees with chronic conditions and substance use disorders. SPA 2 includes enrollees with serious mental illness. *Indicates an HHP core metric. • Assessment of estimated payments per beneficiary per year for all services received by HHP enrollees and the controls showed a greater decline for the HHP enrollees overall (Exhibit 5). The decline in estimated payments was greater for SPA 2 in contrast to SPA 1 enrollees. • Comparing payments by broad categories of service indicated a greater decline for HHP enrollees overall in all outpatient services, outpatient medications, ED visits, and hospitalizations. The rates of decline were greater for SPA 1 enrollees in outpatient medications and hospitalizations and greater for SPA 2 in outpatient services and ED visits. • In contrast, the estimated payments for long-term care stays increased for HHP enrollees compared to the control group overall. Payments similarly increased for SPA 1 enrollees but declined for SPA 2 enrollees. • All other payments in a residual category of service also declined overall and for both SPA 1 and SPA 2, with a greater decline among SPA 2 enrollees. Exhibit 5: Changes (DD) in HHP Estimated Medi-Cal Payments per beneficiary per year for HHP Enrollees vs. Controls from 24 Month Before to the 24 Months Following HHP Enrollment Differences in trends for HHP enrollees vs. control group (DD) All Enrollees SPA 1 Enrollees SPA 2 Enrollees Estimated Medi-Cal Payments Per Beneficiary Per Year Total Payments -$1,113 -$1,074 -$1,232 Outpatient Services -$547 -$490 -$718 Outpatient Medication -$126 -$134 -$100 Emergency Department Visits -$30 -$25 -$43 Hospitalizations -$580 -$606 -$503 Long-Term Care Stays $16 $26 -$14 Residual -$14 -$6 -$38 Source: Medi-Cal claims data from July 1, 2016 through December 31, 2021. Notes: Blue indicates significant increase and orange indicates significant decrease compared to the control group. NS means the DD result was not significant. NR indicates that the analysis was not reported. SPA 1 includes enrollees with chronic conditions and substance use disorders. SPA 2 includes enrollees with serious mental illness. *Indicates a HHP core metric Conclusions and Implications Two earlier HHP reports highlighted successful implementation of HHP by MCPs. This third and final summative report describes the overall findings of HHP as of December 30, 2021. By the end of HHP, MCPs had succeeded in building and expanding their CB-CME networks to address UCLA Evaluation | 0BFinal Evaluation of California's Health Homes Program (HHP) 27 UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program the needs of over 90,000 program enrollees and despite the occurrence of the COVID-19 pandemic early during the implementation. MCPs successfully employed multiple methods to identify enrollees and succeeded in enrolling significant number of both SPA 1 and SPA 2 enrollees. The more frequent use of non-clinical HHP service providers may have been responsible in greater gains in reduced service utilization and costs reflecting greater needs of patients for care coordination and navigation, transportation, and education on self-care. The reduction in services and associated payment was likely to also be due to more intensive assessment of patients for medical, behavioral, and social needs and redirecting patients to needed services. HHP has implications for Enhanced Care Management (ECM) and Community Supports (CS) programs under the California Advancing and Innovating Medi-Cal (CalAIM) initiative. The implications include the need for greater understanding of how MCPs have implemented ECM and CS services. 28 0BFinal Evaluation of California's Health Homes Program (HHP) | UCLA Evaluation UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program Introduction This evaluation report is the third and final report describing the implementation and outcomes of the Health Home Program (HHP) by the end of the program in December 2021. The findings may differ from earlier reports that described progress in earlier phases of HHP implementation, with fewer and different enrollees, and a shorter observation period for many enrollees. Health Homes Program Overview The Health Homes Program (HHP) was created and implemented under the statutory authority of California Assembly Bill (AB) 361. The legislation authorizes the California Department of Health Care Services (DHCS) to create HHP under Section 2703 of the 2010 Patient Protection and Affordable Care Act. Section 2703 allows states to create Medicaid health homes to coordinate the full range of physical health, behavioral health, and community-based long-term services and supports needed by Medi-Cal enrollees with chronic conditions. HHP was implemented in 12 California counties for Medi-Cal Managed Care Plan (MCP) enrollees who met certain chronic condition and acuity criteria. All Medi-Cal MCPs in the 12 participating counties were required to participate in HHP. HHP had a phased implementation schedule. Individuals with chronic physical health conditions or substance use disorders (SUD) were included in State Plan Amendment (SPA) 1 (i.e., Phase 1) and those with severe mental illness (SMI) were included in SPA 2 (i.e., Phase 2). The primary goals of HHP were to improve member outcomes through care coordination and to reduce avoidable health care costs. MCPs were expected to deliver HHP services directly or through contracted community-based care management entities (CB-CMEs), which could include primary care providers (PCPs), Federally Qualified Health Centers (FQHCs), and other service providers. CB-CMEs worked with Community Based Organizations (CBOs) to provide linkages to community and social support services, as needed. HHP Implementation Plan The HHP implementation schedule is displayed in Exhibit 6. The 12 counties implementing HHP were divided into four groups, with Group 1 scheduled to begin implementation on July 1, 2018, and Group 4 to implement the final phase on July 1, 2020. Each Group would first implement HHP for SPA 1 enrollees (those with chronic physical health conditions and/or SUD), followed six months later by implementation for SPA 2 enrollees (those with SMI). UCLA Evaluation | 0BFinal Evaluation of California's Health Homes Program (HHP) 29 UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program Exhibit 6: Timeline of HHP Implementation by Group and SPA Source: Adapted from HHP Implementation Schedule. HHP Managed Care Plans. Note: SPA is State Plan Amendment. A total of 16 MCPs implemented HHP across the 12 counties (Exhibit 7). MCPs were responsible for the overall administration of HHP and were expected to fulfill HHP requirements by leveraging existing infrastructure, communication, and reporting capabilities. MCP responsibilities included (1) performing regular auditing and monitoring activities; (2) training, supporting, and qualifying CB-CMEs; (3) providing CB-CMEs with timely information on admissions, discharges, and other key utilization and health condition information; (4) when possible, providing access to immediate housing post discharge and permanent housing for those experiencing homelessness; and (5) fulfilling HHP care management requirements. 30 0BFinal Evaluation of California's Health Homes Program (HHP) | UCLA Evaluation UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program Exhibit 7: MCPs that Implemented HHP across California, by Group and County Group County Managed Care Plan 1 San Francisco Anthem Blue Cross of California Partnership Plan, Inc. San Francisco Health Plan 2 Riverside Inland Empire Health Plan Molina Healthcare of California Partner Plan, Inc. San Bernardino Inland Empire Health Plan Molina Healthcare of California Partner Plan, Inc. 3 Alameda Alameda Alliance for Health Anthem Blue Cross of California Partnership Plan, Inc. Imperial California Health & Wellness Molina Healthcare of California Partner Plan, Inc. Kern Health Net Community Solutions, Inc. Kern Health Systems Los Angeles Health Net Community Solutions, Inc. L.A. Care Health Plan Sacramento Aetna Better Health of California Anthem Blue Cross of California Partnership Plan, Inc. Health Net Community Solutions, Inc. Kaiser Permanente Molina Healthcare of California Partner Plan, Inc. San Diego Aetna Better Health of California Blue Shield of California Promise Health Plan Community Health Group Partnership Plan Health Net Community Solutions, Inc. Kaiser Permanente Molina Healthcare of California Partner Plan, Inc. United Healthcare Community Plan of California, Inc. Santa Clara Anthem Blue Cross of California Partnership Plan, Inc. Santa Clara Family Health Plan Tulare Anthem Blue Cross of California Partnership Plan, Inc. Health Net Community Solutions, Inc. 4 Orange CalOptima Source: DHCS. Notes: MCP is Managed Care Plan and DHCS is the California Department of Health Care Services. HHP Services The overarching goal of HHP was to achieve the "triple aim" of better care, better health, and lower costs. To achieve these goals, MCPs provided HHP services most often through community-rooted CB-CMEs. These services included (1) comprehensive care management, (2) care coordination, (3) health promotion, (4) comprehensive transitional care, (5) individual and UCLA Evaluation | 0BFinal Evaluation of California's Health Homes Program (HHP) 31 UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program family support services, and (6) referrals to community and social support services. Exhibit 8 displays detailed descriptions of these services. Exhibit 8: HHP Services Provided through MCPs and CB-CMEs Service Description Comprehensive care management • Engage MCP members to participate in HHP • Collaborate with HHP enrollees and their family/support persons to develop a Health Action Plan (HAP) within 90 days of enrollment that is comprehensive and person-centered • Reassess HAP as needed and track referrals • Case conferencing to support continuous and integrated care among all service providers Care coordination • Provide enrollee support to implement HAP and attain enrollee goals • Coordinate referrals and follow-ups, share information to all involved parties, and facilitate communication • Frequent, in-person contact between HHP enrollees and care coordinators • Appointment with primary care physician within 60 days of enrollment encouraged • Identify and address enrollee gaps in care • Maintain an appointment reminder system for enrollees as appropriate • Link eligible enrollees who are experiencing homelessness or housing instability to permanent housing Health promotion • Encourage and support HHP enrollees to make lifestyle choices based on health behavior • Encourage and support health education • Assess and motivate enrollees and family/support person understanding of health condition and motivation to engage in self- management Comprehensive transitional care • Facilitate HHP enrollees' transition from and among treatment facilities • Provide medication information and reconciliation • Plan follow-up appointments and anticipate care or place to stay post-discharge Individual and family support • Ensure HHP enrollees and family/support persons are educated about services the enrollee's conditions to improve treatment and medical adherence Referrals to community and social • Determine appropriate services to meet HHP enrollee's needs support services • Identify and refer enrollees to available community resources Source: Adapted from Health Homes Program Guide. Notes: MCP is Managed Care Plan and CB-CME is Community-Based Care Management Entity. HHP Target Populations The eligibility criteria defined by DHCS for HHP was based on the presence of specific chronic conditions and evidence of high acuity (Exhibit 9). These criteria aimed to identify the Medi-Cal population who may benefit the most from HHP services. DHCS identified a Targeted 32 0BFinal Evaluation of California's Health Homes Program (HHP) | UCLA Evaluation UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program Engagement List (TEL) of Medi-Cal MCP enrollees in the 12 participating counties who were likely to be eligible for HHP services based on specific inclusion and exclusion criteria. The exclusion criteria were designed to limit enrollment to eligible enrollees who were not receiving similar services in other programs and were more likely to benefit from HHP than other interventions, among other reasons. The TEL did not capture the inclusion criteria of chronic homelessness or some exclusion criteria, such as enrollees who would benefit from alternative care management programs, due to data limitations. DHCS delegated this responsibility to MCPs, and allowed MCPs to use other eligibility identification strategies, subject to DHCS approval. Exhibit 9: HHP Eligibility Inclusion and Exclusion Criteria Eligibility Requirement Criteria Details Met at least one chronic condition • At least two of the following: chronic obstructive pulmonary disease, criteria diabetes, traumatic brain injury, chronic or congestive heart failure, coronary artery disease, chronic liver disease, chronic renal (kidney) disease, dementia, substance use disorders • Hypertension and one of the following: chronic obstructive pulmonary disease, diabetes, coronary artery disease, chronic or congestive heart failure • One of the following: major depression disorders, bipolar disorder, psychotic disorders (including schizophrenia) • Asthma Met at least one acuity/complexity • Has at least three or more of the HHP eligible chronic conditions criteria • At least one inpatient hospital stay in the last year • Three or more emergency department (ED) visits in the last year • Chronic homelessness Did not meet one of the exclusion • Hospice recipient or skilled nursing home resident criteria • Enrolled in specialized MCPs (e.g., Program of All-Inclusive Care for the Elderly (PACE), Senior Care Action Network (SCAN) and AIDS Healthcare Foundation (AHF)) • Fee-for-service rather than managed care • Sufficiently well managed through self-management or another program • More appropriate for alternative care management programs • Behavior or environment is unsafe for CB-CME staff Source: Adapted from Health Homes Program Guide. Funding and Payment Methodology Under federal rules, DHCS would receive a 90% enhanced Federal Medical Assistance Percentage (FMAP) for HHP services for the first two years of each phase of implementation. However, the federal portion will revert to the 50% FMAP after this period. DHCS used grant funds provided by The California Endowment to pay for the state's share of HHP services. MCPs received a supplemental per member per month (PMPM) payment for HHP services and reimbursed CB-CMEs based on claims for services under contractual agreements. DHCS also UCLA Evaluation | 0BFinal Evaluation of California's Health Homes Program (HHP) 33 UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program created an HHP-specified Healthcare Common Procedure Coding System (HCPCS) procedure code and modifiers to report HHP services. These codes are described later in this report in the HHP Service Utilization among HHP Enrollees chapter. Transition to New Medi-Cal Services Services provided under HHP were incorporated into new services covered by Medi-Cal under California Advancing and Innovating Medi-Cal (CalAIM). CalAIM is a multi-year initiative by DHCS designed to incorporate HHP approaches in delivery of care to Medi-Cal beneficiaries and to improve their health outcomes. Under CalAIM, Medi-Cal managed care plans were expected to provide Enhanced Care Management (ECM) and Community Supports (CS) through contracts with community-based providers, including CB-CMEs participating in HHP. Members receiving HHP were transitioned to Enhanced Care Management starting with the implementation of CalAIM in January 2022. UCLA HHP Evaluation AB 361 required an independent evaluation of HHP and submission of three reports to the legislature after the first, second, and last years of implementation. This requirement was met by submission of the first and second HHP Evaluation Reports in October 2020 and March 2022. This is the final evaluation report that covers the entire HHP implementation period through December 2021 when HHP ended and members were transitioned to ECM and CS under CalAIM in January 2022. The UCLA Center for Health Policy Research (UCLA) was selected as the evaluator of the HHP program. Conceptual Framework UCLA developed a conceptual framework for the evaluation of HHP (Exhibit 10). Following the HHP program goals and structure, the framework indicated that better care is achieved when MCPs establish the necessary infrastructure and deliver HHP services. Delivery of HHP services will in turn lead to better health indicated by reduced utilization of health care services that are associated with negative health outcomes as well as improvements in population health indicators. Better care and better health will lead to lower overall health care expenditures. 34 0BFinal Evaluation of California's Health Homes Program (HHP) | UCLA Evaluation UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program Exhibit 10: HHP Evaluation Conceptual Framework UCLA Evaluation | 0BFinal Evaluation of California's Health Homes Program (HHP) 35 UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program Evaluation Questions and Data Sources Exhibit 11 displays the evaluation questions and data sources that were used to answer those questions. The evaluation questions were aligned with the components of the conceptual framework. Questions 1-7 examined the infrastructure established by MCPs including the composition of their networks, populations enrolled, and the services delivered. Questions 8-13 examined the impact of HHP service delivery on multiple indicators of health services utilization as well as patient health indicators. Questions 14 and 15 examined the impact of HHP on lowering costs of the Medi-Cal program. Exhibit 11: Health Homes Program Evaluation Questions and Data Sources Evaluation Questions Data Sources Better Care Infrastructure 1. What was the composition of HHP networks? • MCP Readiness Documentation 2. Which HHP network model was employed? • MCP Quarterly HHP Reports 3. When possible, what types of staff provided HHP services? 4. What was the data sharing approach? 5. What was the approach to targeting patients for enrollment per HHP network? Process 6. What were the demographics of program enrollees? • MCP Enrollment Reports What was the acuity level of the enrollees including • MCP Quarterly HHP Reports health and health risk profile indicators, such as • TEL aggregate inpatient, ED, and rehab skilled nursing facility • Medi-Cal Enrollment and Encounter Data (SNF) utilization? What proportion of eligible enrollees were enrolled? How did enrollment patterns change over time? What proportion of enrollees are experiencing homelessness? 7. Were Health Home services provided in-person or telephonically? Were Health Home services provided by clinical or non-clinical staff? How many enrollees received engagement services? How many enrollees experiencing homelessness received housing services? Better Health Health care utilization 8. How did patterns of health care service use among HHP • Medi-Cal Enrollment and Claims Data enrollees change before and after HHP implementation? 9. Did rates of acute care services, length of stay for hospitalizations, nursing home admissions and length of stay decline? 10. Did rates of other services such as substance use treatment or outpatient visits increase? Patient outcomes 36 0BFinal Evaluation of California's Health Homes Program (HHP) | UCLA Evaluation UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program Evaluation Questions Data Sources 11. How did HHP core health quality measures improve • MCP Quarterly HHP Reports before and after HHP implementation? • Medi-Cal Enrollment and Claims Data 12. Did patient outcomes (e.g., controlled blood pressure, screening for clinical depression) improve before and after HHP implementation? 13. How many enrollees experiencing homelessness were housed? Lower Costs Health care expenditures 14. Did Medi-Cal expenditures for health services decline • Medi-Cal Enrollment and Claims Data after HHP implementation? 15. Did Medi-Cal expenditures for needed outpatient services increase? Note: TEL is Targeted Engagement List. Detailed descriptions of the data sources and analytic methods used in the evaluations can be found in Appendix A and Appendix B. UCLA Evaluation | 0BFinal Evaluation of California's Health Homes Program (HHP) 37 UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program HHP Implementation and Infrastructure This section addresses the following HHP evaluation questions: 1. What was the composition of HHP networks? 2. Which HHP network model was employed? 3. When possible, what types of staff provided HHP services? 4. What was the data sharing approach? 5. What was the approach to targeting patients for enrollment per HHP network? UCLA relied on three data sources to address these questions: (1) MCP readiness documents, which outlined MCPs' plans to develop and implement HHP under the guidelines set by DHCS; (2) the MCP Quarterly HHP Reports, which detailed the networks developed by the MCP during each quarter of the program; and (3) a one-time self-report by MCPs in September 2020 to provide additional detail on their CB-CME networks. A total of 16 MCPs implemented HHP across California, submitting both readiness documents and Quarterly HHP Reports. The time period of this report covers data through December 31, 2021. UCLA aimed to answer the HHP evaluation questions by identifying and analyzing the strategies that each MCP planned to implement and by providing selected illustrative examples of these strategies. Since the first interim report, the data available through MCP readiness documents remain the same and UCLA provides a summary of these findings from the first interim report in this section. The HHP Delivery Networks section is updated with new information. Further analytic approach details can be found in Appendix A: Data Sources and Analytic Methods. 38 0BFinal Evaluation of California's Health Homes Program (HHP) | UCLA Evaluation UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program HHP Implementation Exhibit 12 displays the participating HHP counties by their respective implementation groups and the MCPs implementing HHP in each county. Of the 12 counties implementing HHP, four counties were in Northern California, two in Central California, and the remaining six were in Southern California. A total of 16 MCPs were operating across the state with six MCPs (Aetna, Anthem, Health Net, Inland Empire, Kaiser Permanente, and Molina) operating in multiple counties. Exhibit 12: Distribution of California Counties by Health Homes Program Implementation Group and MCPs Implementing Health Homes Program by County Source: Adapted from Health Homes Program Guide. Note: MCP is Managed Care Plan. UCLA Evaluation | 0BFinal Evaluation of California's Health Homes Program (HHP) 39 UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program HHP Delivery Models MCP HHP implementation plans outlined in readiness documents were used to examine MCP intentions at the beginning of HHP, even though the plans may have changed during implementation. These plans indicated that 15 (of 16) MCPs used delivery Model I, where CB- CMEs were typically medical providers that hired and housed HHP staff, including care coordinators. When HHP enrollees' medical providers were not able to take on these responsibilities, MCPs utilized Models II and III to deliver services centrally or regionally. See the first interim evaluation for more details. HHP Delivery Networks HHP delivery networks were composed of CB-CMEs who either used their own staff or sub- contracted with other community-based organization to deliver care management (CM) services. CB-CMEs were certified by the MCPs using DHCS general guidelines and requirements. CB-CMEs were required to maintain a strong and direct connection with the HHP enrollee and their primary care physician, the latter being applicable when CB-CMEs were not medical providers. Goals in developing a MCP's CB-CME network included: (1) ensuring CM delivery at point of care, (2) experience with high utilizing populations and individuals experiencing homelessness, and (3) building upon existing CM infrastructure within the county. Six MCPs indicated that they acted as a CB-CME for a portion of their HHP enrollees; these MCPs included Blue Shield, CalOptima, Inland Empire, Kern, LA Care, and San Francisco Health Plan. In Quarterly HHP Reports, MCPs reported developing contracts with 263 unique CB-CMEs (as identified by organization name per MCP) by December 2021. CB-CMEs by Organization Type In September 2019, HHP delivery networks consisted of 212 unique CB-CMEs; these CB-CMEs were classified based on their primary taxonomy in the National Provider Index (NPI) database in the first interim report. In September 2020, MCPs identified the organization type of their 244 unique CB-CMEs through self-reports to UCLA and these findings were reported in the second interim report. For the final evaluation, UCLA classified the organization type of CB- CMEs added after September 2020 (37 CB-CMEs) based on their primary taxonomy in the NPI database. As of the end of the program, MCPs reported 263 unique CB-CMEs in their delivery networks. Since the second interim report, 18 CB-CMEs were no longer participating. Of the 263 CB-CMEs, they were most commonly acommunity health centers (includes Federally Qualified Health Centers, rural health centers, Indian health centers, and other similar organizations; 41%; 40 0BFinal Evaluation of California's Health Homes Program (HHP) | UCLA Evaluation UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program Exhibit 13). The next most common organizational type of CB-CMEs included community-based social service organizations or local government entities (25%). CB-CMEs were also commonly identified as community based primary care or specialty physicians (17%). Changes in composition of CB-CME organizational type was minimal across time. Exhibit 13: Health Homes Program CB-CME Network by Organization Type as of December 2021 Source: MCP Quarterly HHP Reports up to December 2021, MCP Self-Reports to UCLA in September 2020, and UCLA Classification of CB-CME type. Note: CB-CME is Community-Based Care Management Entity, MCP is Managed Care Plan, and NPI is National Provider Identifier. In September 2020, a total of 244 CB-CMEs were reported and MCPs clarified CB-CME type in self reports to UCLA; 18 CB-CMEs were no longer participating as of December 2021, and UCLA classified 37 CB-CMEs added between September 2020 and December 2021. Community health centers included Federally Qualified Health Centers, rural health centers, Indian health centers, and other similar organizations. CB-CMEs and Projected HHP Capacity MCPs reported the projected number of enrollees each CB-CME would serve under their contracts (referred to as capacity) in MCP Quarterly HHP reports. DHCS required MCPs to report capacity criteria such as the HHP care manager ratios and certification requirements. For example, CB-CMEs had to have the ability to provide appropriate and timely in-person care coordination, telephonic communication, and accompany HHP enrollees to critical appointments. Overall capacity grew significantly from the first interim report (September 2019), where MCPs reported that CB-CMEs had an enrollment capacity of 47,010 enrollees. As of December 2021, MCPs reported 257 CB-CMEs with capacity for a minimum of 11 or more enrollees. These CB- CMEs collectively had a projected capacity for managing the needs of approximately 85,174 HHP enrollees, with a median of 216 enrollees per CB-CME (Exhibit 14). From the second interim report (September 2020), overall capacity grew by 5,804 (from 79,370) and median UCLA Evaluation | 0BFinal Evaluation of California's Health Homes Program (HHP) 41 UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program capacity increased by 36 enrollees, with the addition of 33 CB-CMEs (who had a capacity for a minimum of 11 or more enrollees). Median capacity increased from September 2020 to December 2021 for all groups, except community based primary care or specialty care. The median capacity was largest for hospital or hospital-based physician groups (250 enrollees). Community based social service organizations or local government entities reported the smallest capacity (185 enrollees). An additional six CB-CMEs with less than 11 enrollees were reported, but not included in the analysis below. Exhibit 14: Total Projected CB-CME Capacity for Health Homes Program Enrollment by CB-CME Organization Type as of December 2021 CB-CME Type N Total Capacity Median Projected Capacity Total 257 85,174 216 Community health centers 101 35,411 (42%) 216 Other entity (e.g., community based social 64 16,256 (19%) 185 service organization, homeless service provider) Community based primary care or specialty 45 17,492 (21%) 240 physician Hospital or hospital-based physician group 24 9,520 (11%) 250 Specialty mental health, behavioral health, or 23 6,495 (8%) 240 substance use treatment center Source: MCP Quarterly HHP Reports up to December 2021, MCP Self-Reports to UCLA in September 2020, and UCLA Classification of CB-CME type. Notes: CB-CME is Community-Based Care Management Entity, MCP is Managed Care Plan, and NPI is National Provider Identifier. In September 2020, a total of 244 CB-CMEs were reported and MCPs clarified CB-CME type in self reports to UCLA; 18 CB-CMEs were no longer participating as of December 2021, and UCLA classified 37 CB-CMEs added between September 2020 and December 2021. This analysis does not include six CB-CMEs who has less than 11 enrollees reported. Community health centers included Federally Qualified Health Centers, rural health centers, Indian health centers, and other similar organizations. Community health centers included Federally Qualified Health Centers, rural health centers, Indian health centers, and other similar organizations. CB-CMEs in the "Other" category included community based social service organizations, homeless service providers, and local government entities. HHP Staffing MCPs ensured that CB-CMEs had adequate staffing to deliver HHP services by requiring certain staffing types such as care coordinators, HHP directors, clinical consultants, and housing navigators. In readiness documents, 11 MCPs (of 16), including all of the MCPs that implemented in more than one County, indicated that they planned to hire certain HHP staff internally to improve efficiency and effectiveness. These roles most often included directors, program managers, and housing specialists. See the first interim evaluation for more details. 42 0BFinal Evaluation of California's Health Homes Program (HHP) | UCLA Evaluation UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program HHP Data Sharing Seven MCPs planned to use a SFTP or dedicated email and six MCPs planned to use electronic health records (EHR), care management platforms, or health information exchange (HIE) data sharing technologies. Both CB-CMEs and MCPs planned to use data sharing technologies to provide timely access to information. Eight MCPs (of 16) planned to provide access to a dynamic Health Action Plan (HAP) to allow access to up-to-date information and five MCPs planned to provide real-time and automated notifications of HHP hospital admissions or emergency department visits to CB-CMEs. See the first interim evaluation for more details. Communication with HHP Enrollees MCPs developed plans for identifying and targeting individuals for HHP enrollment including use of predictive modeling and risk grouping of eligible beneficiaries. MCPs most often planned to use newsletters (nine of 16) and websites (nine) to communicate with eligible beneficiaries and developed plans on how often they would outreach to eligible beneficiaries. MCPs planned to use a mix of approaches to target individuals experiencing homelessness. These approaches included collaborating with CB-CMEs or community-based organizations that specialized in working with these individuals and leveraging existing infrastructure developed under Whole Person Care to provide outreach. See the first interim evaluation for more details. UCLA Evaluation | 0BFinal Evaluation of California's Health Homes Program (HHP) 43 UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program HHP and COVID-19 This section addresses the following evaluation questions, included in response to the COVID- 19 pandemic: 1. How did the COVID-19 pandemic impact HHP implementation? 2. How many HHP enrollees had COVID-19 related services? 3. How did healthcare utilization patterns change among HHP enrollees during the COVID- 19 pandemic compared to the year prior to the pandemic? The COVID-19 pandemic began during HHP enrollment. HHP Group 1, Group 2 and Group 3/SPA 1 were implemented between 6 and 18 months prior to the first reports of COVID-19 in the United States in January 2020. HHP Group 3/SPA 2 and Group 4 implemented just as these first cases were reported. In this chapter, UCLA examines the likely impact of the pandemic on HHP implementation. The progress of the pandemic in counties where HHP was implemented was examined using data on COVID-19 cases and hospitalizations from April 2020, when such data were first available, through December 2021, the last month of HHP implementation. These data, along with population counts from the Census Bureau, were used to calculate cases and hospitalizations per 100,000. The impact of COVID on MCP implementation efforts was examined through a COVID-19 Impact Survey (Appendix E) of all participating MCPs (n=16, response rate of 100%) in September 2020. MCPs respondents included HHP program managers and directors who were most informed about HHP implementation at their respective organizations. The impact of COVID-19 on CB- CMEs that had contracted with MCPs was assessed from a survey administered by the Corporation for Supportive Housing (CSH) in August 2020. UCLA submitted survey questions that were similar to those asked from MCPs to CSH who then distributed the survey to all contracted CB-CMEs at the time and collected the data. Further details on these surveys and results are found in the second interim report. UCLA further used Medi-Cal enrollment and claims data to (1) identify HHP enrollees and their controls that have services with COVID-19 as the primary or secondary diagnosis and (2) report changes in overall health care utilization pre- and post-pandemic for HHP enrollees and their controls. COVID-19 cases were identified using the COVID-19 International Classification of Diseases (ICD) diagnosis code, which was first introduced in late March 2020. Therefore, these cases were likely to be underreported early in the pandemic. In addition, counts of state and 44 0BFinal Evaluation of California's Health Homes Program (HHP) | UCLA Evaluation UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program county-wide COVID-19 cases, hospitalizations, and deaths were examined using data reported by the LA Times. MCPs were required to report HHP services to DHCS in Medi-Cal claims data starting on July 1, 2018. Two different procedure codes with unique modifiers that further indicated type and modality of services as well as type of providers were used. UCLA used Medi-Cal claims to identify the proportion of HHP enrollees with these HHP services each month before and during the COVID-19 pandemic, as well as the proportion of HHP services provided through telehealth during the same time period. Progression of COVID-19 Cases and Hospitalizations in HHP Counties UCLA assessed the progression of the COVID-19 cases by examining cumulative case rates and 14-day average hospitalization rates in HHP counties and California overall. Among all Californians, the cumulative case rate of COVID-19 reached 14,118 per 100,000 by the end of December 2021 (Exhibit 15). The cumulative case rate per 100,000 as of December 2021 among HHP counties ranged from a low of 8,192 in San Francisco to a high of 21,483 in Imperial. The cumulative case rates for seven HHP counties, including all Group 2 (Riverside and San Bernardino) counties, were above that of the entire state. Exhibit 15: Cumulative COVID-19 Cases per 100,000, as of December 2021, HHP Counties and California 21,483 18,863 17,010 17,345 15,564 15,889 14,107 14,118 11,654 11,788 8,708 9,271 8,192 Source: UCLA analysis of daily COVID-19 cases reported from March 29, 2020 to December 31, 2021 by the LA Times. State and County population numbers were collected through Census data. Cases per 100,000 were calculated by multiplying cases by 100,000 then dividing by the population. UCLA Evaluation | 0BFinal Evaluation of California's Health Homes Program (HHP) 45 UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program UCLA also assessed COVID-19 hospitalization rates as an indicator of the burden of disease on the healthcare system. From April 2020 to December 2021, the 14-day average hospitalization rate across California first peaked peaked near the end of July 2020 with 18 hospitalizations per 100,000 before returning to around 7 hospitalizations per 100,000 as seen early in the pandemic (Exhibit 16). Two additional peaks occurred in January 2021 and September 2021, with rates reaching 54 and 21 hospitalizations per 100,000, respectively. While most HHP counties had a similar burden of disease, notable exceptions included Imperial County that had an extended peak from May 2020 through August 2020 and an additional peak in late 2021; Los Angeles County with two peaks early in the pandemic in late April 2020 and July 2020; and Tulare and Kern counties with extended peaks in late 2021. Exhibit 16: 14-day Average COVID-19 Hospitalization Rate per 100,000, April 2020 to December 2021, Statewide and Selected HHP Counties 120 100 80 60 40 20 - Imperial Kern Los Angeles Tulare California Source: Daily COVID-19 hospitalizations reported from April 1, 2020 to December 31, 2021 through the California Department of Public Health. State and County population numbers were collected through Census data. Hospitalizations per 100,000 were calculated by multiplying hospitalizations by 100,000 then dividing by the population. Note: Patterns of 14-day average COVID-19 hospitalization rates in other HHP counties were similar to the statewide trends. 46 0BFinal Evaluation of California's Health Homes Program (HHP) | UCLA Evaluation UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program UCLA also assessed the cumulative death rate per 100,000 and new daily deaths from COVID-19 in California, as reported by local public health departments, to estimate the burden of highly resource intensive, severe disease. By the end of December 2021, there were 197 COVID-19 deaths per 100,000 in California (data not shown). The death rate among HHP counties was highest in Imperial (460 deaths per 100,000), followed by San Bernardino (302 per 100,000). The new daily deaths from COVID-19 in California had two peaks in 2020 during April and July. New daily deaths rose rapidly in December 2020 before reaching the highest peak in January 2021. A smaller peak occurred in September 2021. Impact of COVID-19 on HHP Implementation and Infrastructure UCLA assessed the impact of COVID-19 on HHP implementation using MCP and CB-CME surveys. At the time of these surveys, all HHP counties were at or beyond their first peak in COVID-19 hospitalizations as shown in Error! Reference source not found.. MCPs reported that the COVID-19 pandemic had impacted HHP processes, procedures, and/or policies, with the greatest impact on housing and homeless support services, comprehensive transitional care, and delivery of care coordination by frontline staff. MCPs were able to establish effective workflows and infrastructure to support their own and CB-CME's operation by transitioning to telehealth and strategically coordinating with shelters and other short-term housing services. A full description of the findings can be found in the Second Interim Report. Estimated Prevalence of and Trends in COVID-19 among HHP Enrollees and their Controls The diagnosis code for COVID-19 was developed and utilized by providers starting in late March 2020. UCLA analyzed Medi-Cal claims starting in March 2020 and identified services used that had COVID-19 as the primary or secondary diagnosis in order to estimate the prevalence of the disease among HHP enrollees and the control group. Some (19%) of HHP enrollees had at least one COVID-19 related service. A slightly smaller proportion of the control group, 17%, had at least one COVID-19 related service (data not shown). UCLA examined monthly trends in the proportion of enrollees and their controls with at least one COVID-19 related service in that month. Data showed two smaller surges in July 2020 and August 2021, and a larger surge in January 2021 (Exhibit 17). These patterns matched the peaks in COVID-19 hospitalizations seen in California and HHP counties during this timeframe (Exhibit 16). The estimated incidence of COVID-19 was higher for HHP enrollees in every month when compared to their controls for the time frame studied. UCLA Evaluation | 0BFinal Evaluation of California's Health Homes Program (HHP) 47 UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program Exhibit 17: Proportion of HHP Enrollees and their Controls with a COVID-19 Related Service by month, April 2020 to December 2021 7.0% 6.0% 5.0% 4.0% 3.0% 2.0% 1.0% 0.0% HHP Enrollees Control Group Source: UCLA analyses of Medi-Cal enrollment and claims data from April 2020 to December 2021. Notes: COVID-19 diagnosis was identified using ICD code U07.1 in primary or secondary diagnosis per claim. March 2020 was not included because of limited reporting using U07.1 that month. COVID-19–Related Health Service Use of HHP Enrollees and Controls UCLA examined the types of health services for COVID-19–related care utilized by HHP enrollees and their controls with a COVID-19 diagnosis from April 2020 to December 2021. Enrollees and controls had similar rates of COVID-19-related services. They most frequently used hospitalizations (33% and 31%, respectively), followed by primary care services (22% and 20%), emergency department visits (14% and 13%), lab tests (6% and 7%), specialty services (5% and 6%), and stays in long-term care facilities (3% and 6%; Exhibit 18). 48 0BFinal Evaluation of California's Health Homes Program (HHP) | UCLA Evaluation UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program Exhibit 18: Proportion of COVID-19-Related Health Services used among HHP Enrollees and their Controls with a COVID-19 Diagnosis by Service Type 33% Hospitalizations 31% 22% Primary Care Services 20% 14% Emergency Department Visits 13% 6% Lab Tests 7% 5% Specialty Services 6% 3% Long Term Care Stays 6% HHP Enrollees Control Group Source: UCLA analyses of Medi-Cal enrollment and claims data from March 2020 to December 2021. Notes: Services with COVID-19 as primary or secondary diagnosis (identified using ICD code U07.1) only. Emergency department visits only include visits that did not result in hospitalization. Changes in Healthcare Utilization trends before and during the COVID-19 Pandemic UCLA compared trends in service utilization patterns among HHP enrollees and their controls before and during the pandemic, and found similar patterns for both groups. Both enrollees and their controls did not experience large declines in primary care services during the pandemic time period, but had a decline in April 2020 compared to April 2019 for specialty care (Exhibit 19). However, rates of specialty service utilization in December 2020 were similar to those in December 2019. The decline in service use observed in December 2021 for both enrollees and controls maybe due to fewer claims submitted by providers. DHCS reported delays of more than 6 months in receipt of Medi-Cal claims and encounters from some providers to UCLA. UCLA Evaluation | 0BFinal Evaluation of California's Health Homes Program (HHP) 49 UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program Exhibit 19: Monthly Utilization of Primary Care and Specialty Care Services per 1,000 Member Months among HHP Enrollees and their Controls, 2019 Compared to 2020 and 2021 HHP Enrollees Controls 900 900 800 800 700 700 Primary Care Services 600 600 500 500 Pandemic Start 400 400 Pandemic Start 300 300 600 600 500 500 400 400 Specialty Care Services 300 300 200 Pandemic Start 200 Pandemic Start 100 100 0 0 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 2019 Pre-Pandemic 2020 Pre-Pandemic 2020 Pandemic 2021 Pandemic Source: UCLA analysis of Medi-Cal claims data from January 2019 to December 2021. Notes: Member-months were based on Medi-Cal enrollment. 50 0BFinal Evaluation of California's Health Homes Program (HHP) | UCLA Evaluation UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program In contrast to primary care and specialty care, the number of both ED visits and hospitalizations declined in April 2020 relative to April 2019, and the utilization maintained at lower levels throughout the remaining months of 2020 and all of 2021 (Exhibit 20). Exhibit 20: Monthly Utilization of Emergency Department Visits and Hospitalizations per 1,000 Member Months among HHP Enrollees and their Controls, 2019 Compared to 2020 and 2021 HHP Enrollees Controls 200 200 150 150 Emergency 100 100 Department Visits Pa ndemic Start Pa ndemic Start 50 50 0 0 60 60 50 50 40 40 Hospitalizations 30 30 Pa ndemic Start 20 20 Pa ndemic Start 10 10 0 0 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 2019 Pre-Pandemic 2020 Pre-Pandemic 2020 Pandemic 2021 Pandemic Source: UCLA analysis of Medi-Cal claims data from January 2019 to December 2021. Notes: Member-months were based on Medi-Cal enrollment. UCLA Evaluation | 0BFinal Evaluation of California's Health Homes Program (HHP) 51 UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program Further analyses (data not shown) found that less than 0.2% of primary care and specialty services were delivered via telehealth before the pandemic. In response to the pandemic, California's Department of Managed Health Care required that MCPs reimburse telehealth visits at the same rate as in-person visits starting March 18, 2020. UCLA analyses showed that rates of telehealth primary care and specialty care services increased substantially for HHP enrollees starting in March 2020, peaking in April 2020 (Exhibit 21). Exhibit 21: Proportion of Primary Care and Specialty Care Services Provided through Telehealth by HHP Enrollees and Control groups, March 2020 to December 2021 25% 24% 22% 20% 20% 20% 20% 19% 18% 18% 18% 16% 16% 16% 16% 15% 14% 14% 14% 14% 13% 13% 13% 13% 13% 13% 12% 11% 11% 10% 10% 10% 10% 10% 10% 10% 10% 10% 10% 10% 9% 9% 7% 5% Jul-20 Jul-21 Jul-20 Jul-21 Nov-20 Nov-21 Nov-20 Nov-21 May-20 May-21 May-20 May-21 Mar-20 Sep-20 Jan-21 Mar-21 Sep-21 Mar-20 Sep-20 Jan-21 Mar-21 Sep-21 Primary Care Services Specialty Care Services Source: UCLA analyses of Medi-Cal enrollment and claims data from March 2020 to December 2021. 52 0BFinal Evaluation of California's Health Homes Program (HHP) | UCLA Evaluation UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program Changes in HHP Service Utilization before and during the COVID-19 Pandemic UCLA examined the proportion of HHP enrollees that used HHP services each month from July 2018 to December 2021. After some unstable reporting in the initial months, the proportion of enrollees with reported HHP services peaked in October 2018 at 77% (Exhibit 22), before largely declining through the remainder of the program. Slight increases were observed each six months as Group 2 and Group 3 counties began enrolling. There is also a small increase at the start of the COVID-19 pandemic with 42% of enrollees reporting HHP services in April 2020 compared to 37% two months earlier. Starting in June 2020 the proportion declined through the end of the program from 42% to 28%. Exhibit 22: Proportion of HHP Enrollees with Reported HHP Services, July 2018 to December 2021 77% 67% 66% 64% 63% 61% 60% 59% 59% 52% 51% 51% 45% 45% 44% 42% 42% 40% 40% 39% 39% 39% 39% 39% 38% 38% 37% 37% 36% 36% 35% 34% 34% 34% 33% 33% 32% 31% 31% 28% 21% 2% Source: UCLA analyses of Medi-Cal enrollment and claims data from July 2018 to December 2021. Notes: Core HHP services include claims with HCPCS code G0506 (July 1, 2018 to September 30, 2018), HCPCS code G9008 (October 1, 2018 to June 30, 2019), and modifier U1, U2, U4, or U5. HHP engagement service includes claims with HCPCS code G0506 (July 1, 2018 to September 30, 2018), HCPCS code G9008 (October 1, 2018 to June 30, 2019), and modifier U7. Other HHP service includes claims with HCPCS code G0506 (July 1, 2018 to September 30, 2018), HCPCS code G9008 (October 1, 2018 to December 31, 2021), and modifier U3 or U6. Data are based on the number of months during HHP enrollment where HCPCS codes were present. UCLA further examined the proportion of HHP services reported each month that were provided in-person versus telephonic each month from July 2018 to December 2021. HHP outreach services were not reported as either in-person or telephonic, likely resulting in most HHP services not reported as in-person or telephonic during the initial months of the program (Exhibit 23). Prior to the COVID-19 pandemic, the proportion of HHP services provided in- person versus telephone were similar, with slightly more services occurring in-person prior to UCLA Evaluation | 0BFinal Evaluation of California's Health Homes Program (HHP) 53 UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program May 2019. After the start of the pandemic in March 2020, the majority of HHP services were reported as telephonic (66-73%) and the minority were reported as in-person (3-8%). Exhibit 23: Proportion of HHP Services Provided In-Person or Telephonically, July 2018 to December 2021 80% 70% 60% 50% 40% 30% 20% 10% 0% % In-Person % Telephonic Source: UCLA analyses of Medi-Cal enrollment and claims data from July 2018 to December 2021. Notes: Core HHP services include claims with HCPCS code G0506 (July 1, 2018 to September 30, 2018), HCPCS code G9008 (October 1, 2018 to June 30, 2019), and modifier U1, U2, U4, or U5. HHP engagement service includes claims with HCPCS code G0506 (July 1, 2018 to September 30, 2018), HCPCS code G9008 (October 1, 2018 to June 30, 2019), and modifier U7. Other HHP service includes claims with HCPCS code G0506 (July 1, 2018 to September 30, 2018), HCPCS code G9008 (October 1, 2018 to December 31, 2021), and modifier U3 or U6. Data are based on the number of months during HHP enrollment where HCPCS codes were present. 54 0BFinal Evaluation of California's Health Homes Program (HHP)| UCLA Evaluation UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program HHP Enrollment and Enrollment Patterns This section addresses the following HHP evaluation questions: 1. What proportion of eligible enrollees were enrolled? 2. What proportion of enrollees were experiencing homelessness? 3. How did enrollment patterns change over time? From July 1, 2018 to July 31, 2019, MCPs reported data on individual-level enrollment in ad hoc Enrollment Reports requested by DHCS. Beginning in the third quarter of 2019, DHCS requested for MCPs to report on member level enrollment data in their Quarterly HHP Reports. Both reports included monthly enrollment status by individual, along with individual level SPA data. Homelessness status was reported by MCPs at the member level in Quarterly HHP Reports beginning in Quarter 3 of 2019. Therefore, enrollment growth and patterns among enrollees experiencing homelessness was not available for enrollees who had disenrolled prior to this time. UCLA used these data from July 1, 2018, to December 31, 2021, to examine how enrollment changed over time for the overall HHP population, by SPA, and for enrollees experiencing homelessness. Data was available for counties in all implementation groups (Groups 1, 2, 3, and 4) at the time of this report. Further details can be found in Appendix A: Data Sources and Methods. A small number of HHP enrollees (1,436) were enrolled for less than 31 days and were excluded from these analyses. MCPs received PMPM payments for one month which allowed MCPs and CB-CMEs to work together to verify HHP eligibility, however MCPs did not receive payments if those individuals could no longer be enrolled in the program. MCPs did not provide other services to this group. Comparison of these enrollees with those enrolled for longer than 30 days indicated the groups had similar demographics, health status, and health care utilization prior to HHP. Further detail about this group can be found in Appendix C: HHP Enrollees Enrolled Less Than 31 Days. DHCS defined inclusion and exclusion eligibility criteria for HHP enrollees and used these criteria to identify eligible Medi-Cal beneficiaries to be included in the TEL, which was then distributed to MCPs in six-month intervals. However, all HHP eligibility criteria were not available in Medi-Cal enrollment and claims data. Specifically, DHCS lacked information on three exclusion criteria including "sufficiently well managed through self-management or another program", "more appropriate for alternative care management programs", and "behavior or environment is unsafe for CB-CME staff". In addition to lack of data, the TEL was UCLA Evaluation | 0BFinal Evaluation of California's Health Homes Program (HHP) 55 UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program based on retrospective claims used to define acuity criteria of "at least one inpatient hospital stay in the last year" and "three or more emergency department (ED) visits in the last year". Nearly all the exclusion criteria were also retrospective and may have changed prior to the enrollment of the individual by the MCPs. For example, individuals in a skilled nursing facility, enrolled in specialized MCPs, or enrolled in fee-for-service Medi-Cal may have been discharged back to the community, disenrolled from a specialized MCP, or enrolled in managed care outside of the TEL defined timeline, respectively. In addition, DHCS issued the TEL every six months based on adjudicated Medi-Cal claims data, while MCPs had and used more recent data on diagnoses and service utilization. MCPs were likely to have access to electronic medical records that contained more comprehensive diagnoses and information on health problems and needs of patients. Furthermore, MCPs had the option to enroll members that were referred by providers that may not have matched the HHP eligibility criteria in Medi-Cal data. Ultimately, MCPs prioritized some TEL enrollees based on severity, complexity, or risk-status using information not available to DHCS. 56 0BFinal Evaluation of California's Health Homes Program (HHP)| UCLA Evaluation UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program Trends in Enrollment Growth in HHP Enrollment Overall and by SPA A total of 90,045 enrollees had ever enrolled in HHP by the end of December 2021 (Exhibit 24). Enrollment in HHP began with Group 1, SPA 1 in San Francisco in July 2018 and expanded rapidly when Groups 2 and 3 began enrollment. The growth in enrollment continued steadily after Group 4 started enrollment. Monthly new enrollment into the program varied between a low of 27 in November 2018 and a high of 3,776 in July 2019, averaging at 2,144 new enrollees per month (data not shown). Total monthly enrollment (new enrollment plus existing enrollment) mainly increased each month through the end of December 2021, ending with 48,861 enrollees actively enrolled at the end of the program. Exhibit 24: Unduplicated Monthly and Cumulative Enrollment in HHP, July 1, 2018 to December 31, 2021 90,045 New Enrollees 78,765 Existing Enrollees 46,293 Enrollees, Cumulative Enrollment Group 4 SPA 2 63,045 Starts 29,912 Enrollees, Group 3 SPA 2 48,861 and Group 4 SPA 1 Start 11,425 Enrollees, Group 2 SPA 2 and Group 3 2,519 Enrollees, SPA 1 Start 69 Group 1 SPA 2 Enrollees, and Group 2 Group 1 SPA 1 Start SPA 1 Starts Nov-18 Nov-19 Nov-20 Nov-21 Feb-19 Feb-20 Feb-21 Aug-18 May-19 Aug-19 May-20 Aug-20 May-21 Aug-21 2018 Q3 2018 Q4 2019 Q1 2019 Q2 2019 Q3 2019 Q4 2020 Q1 2020 Q2 2020 Q3 2020 Q4 2021 Q1 2021 Q2 2021 Q3 2021 Q4 Source: MCP Enrollment Reports from August 2019 and Quarterly HHP Reports from September 2019 to December 2021. Notes: MCP is managed care plan. Groups of MCPs implemented at different time points. Those enrolled for less than 31 days were excluded from this analysis. SPA 1 includes enrollees with chronic conditions and substance use disorders. SPA 2 includes enrollees with severe mental illness. UCLA Evaluation | 0BFinal Evaluation of California's Health Homes Program (HHP) 57 UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program Examining HHP enrollment by SPA revealed a total cumulative enrollment of 66,017 in SPA 1 and 24,028 in SPA 2 as of December 2021 (Exhibit 25). In the first two quarters of the program, MCPs only enrolled in SPA 1 as planned and enrollment grew over time. SPA 2 enrollment as a percentage of total enrollment in HPP was at a minimum of 2.5% in the first quarter (Q1) of 2019 and steadily rose to a maximum of 27% in the last quarter (Q4) of 2021 (data not shown). Exhibit 25: Unduplicated Quarterly Enrollment in HHP by SPA, July 1, 2018 to December 31, 2021 SPA 1 SPA 2 24,028 21,502 19,336 16,559 13,578 11,187 8,008 1,697 4,898 62,030 66,017 1,021 52,078 56,962 46,682 159 35,931 40,367 30,500 121 24,599 188 295 16,485 4,650 7,490 Source: MCP Enrollment Reports from August 2019 and Quarterly HHP Reports from September 2019 to December 2021. Notes: MCP is managed care plan. Those enrolled for less than 31 days were excluded from this analysis. SPA 1 includes enrollees with chronic conditions and substance use disorders. SPA 2 includes enrollees with severe mental illness. In x-axis label, Q stands for quarter. 58 0BFinal Evaluation of California's Health Homes Program (HHP)| UCLA Evaluation UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program Growth in HHP Enrollment among Enrollees Experiencing Homelessness by SPA MCPs began reporting homelessness data per enrollee in Quarter 3 of 2019 through HHP Quarterly Reports. UCLA used the identifier indicating enrollees who were ever experiencing homelessness or at risk of homelessness during each quarter to show the patterns of enrollment over time. However, these data underestimate the number of enrollees in HHP experience homelessness because they excluded enrollees experiencing homelessness that disenrolled prior to July 2019 and did not reenroll in HHP. During the fourth quarter of 2021, 5,252 SPA 1 and 2,561 SPA 2 enrollees were experiencing homelessness or at risk of homelessness (Exhibit 26). Enrollees experiencing homelessness or at risk of homelessness represented 8.2% of HHP enrollees overall by December 2019, 9.4% by December 2020, and 8.7% by December 2021 (data not shown). Exhibit 26: Enrollment of Individuals Reported as Experiencing Homelessness or At-Risk of Homelessness each Quarter in HHP by SPA, January 1, 2019 to December 31, 2021 SPA 1 SPA 2 2,561 2,414 2,202 1,931 1,616 5,252 5,054 1,352 4,718 4,417 913 4,040 172 3,627 549 3,096 94 2,531 628 1,976 387 1,336 Source: Quarterly HHP Reports from July 2019 to December 2021. Enrollees experiencing homelessness that disenrolled prior to July 2019 are not included. Notes: MCP is Managed Care Plan. Those enrolled for less than 31 days were excluded from this analysis. SPA 1 includes enrollees with chronic conditions and substance use disorders. SPA 2 includes enrollees with severe mental illness. Monthly enrollment of less than 11 was recorded as 11. Excludes HHP enrollees that were designated as experiencing homelessness and were disenrolled prior to Q3. Includes enrollees experiencing homelessness that were included in Q3 HHP Quarterly Reports. In x-axis label, Q stands for quarter. Enrollment Size by Group and County UCLA Evaluation | 0BFinal Evaluation of California's Health Homes Program (HHP) 59 UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program Exhibit 27 shows cumulative enrollment by group and county as of December 2021. Enrollment varied by county. Los Angeles (Group 3) had the largest enrollment, reaching 38,819 cumulative enrollments in December 2021. Other counties with large enrollment included Riverside (11,773) and San Bernardino (9,732) from Group 2, and San Diego (8.914) from Group 3. Exhibit 27: Unduplicated Cumulative HHP Enrollment by Group and County as of December 31, 2021 38,819 11,773 9,732 8,914 5,914 4,798 1,568 1,097 2,308 1,596 1,975 1,551 SAN FRANCISCO LOS ANGELES ORANGE SACRAMENTO SANTA CLARA RIVERSIDE SAN DIEGO ALAMEDA SAN BERNARDINO KERN TULARE IMPERIAL Group 1 Group 2 Group 3 Group 4 Source: MCP Enrollment Reports from August 2019 and Quarterly HHP Reports from September 2019 to December 2021. Notes: MCP is Managed Care Plan. Those enrolled for less than 31 days were excluded from this analysis. Group 1 implemented HHP on July 1, 2018, Group 2 implemented HHP on January 1, 2019, Group 3 implemented HHP on July 1, 2019, and Group 4 implemented HHP on January 1, 2020 (SPA1) and June 1, 2020 (SPA2). 60 0BFinal Evaluation of California's Health Homes Program (HHP)| UCLA Evaluation UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program Enrollment from the Target Engagement List UCLA assessed the concordance between Medi-Cal enrollees identified by DHCS as eligible for HHP, based on their claims prior to HHP enrollment and communicated to MCPs biannually in the TEL, and Medi-Cal beneficiaries enrolled in HHP. The analyses showed that 79% of HHP enrollees were identified in the TEL and this proportion varied by MCP (Exhibit 28). The proportion of enrollees identified in the TEL did not differ by SPA (data not shown). Exhibit 28: Proportion of HHP Enrollees that were identified in the Target Engagement List (TEL), Overall and by MCP Total Enrollment Proportion Identified in TEL Overall 90,045 79% Anthem Blue Cross of California Partnership Plan, Inc. 4,254 68% San Francisco Health Plan 1,219 92% Inland Empire Health Plan 18,632 82% Molina Healthcare of California Partner Plan, Inc. 8,367 79% Alameda Alliance for Health 749 79% California Health & Wellness 1,518 83% Health Net Community Solutions, Inc. 11,934 90% Kern Health Systems 5,306 74% L.A. Care Health Plan 29,216 72% Aetna Better Health of California 442 68% Kaiser Permanente 893 86% Blue Shield of California Promise Health Plan 1,842 75% Community Health Group Partnership Plan 2,219 98% United Healthcare Community Plan of California, Inc. 260 67% Santa Clara Family Health Plan 1,493 82% CalOptima 1,551 95% Source: MCP Enrollment Reports from August 2019 and Quarterly HHP Reports from September 2019 to December 2021. Target Engagement Lists from May 2018 to May 2021. Notes: Those enrolled for less than 31 days were excluded from this analysis. Group 1 implemented HHP on July 1, 2018, Group 2 implemented HHP on January 1, 2019, Group 3 implemented HHP on July 1, 2019, and Group 4 implemented HHP on January 1, 2020. Individuals identified on the TEL supplemental list were not included as part of TEL. UCLA Evaluation | 0BFinal Evaluation of California's Health Homes Program (HHP) 61 UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program Enrollment Patterns Enrollment Churn Slightly more than half of HHP enrollees (53%) remained continuously enrolled from enrollment date to December 2021, with a higher share for SPA 2 enrollees (58%) than SPA 1 enrollees (51%; Exhibit 29). Disenrollment rates increased since September 2019 for each of the two SPAs (data not shown). Overall, nearly half of enrollees (45%) have disenrolled once and stayed disenrolled from the program. Re-enrollment rates were low across both SPA 1 (2.4%) and SPA 2 (1.5%). Exhibit 29: Enrollment and Disenrollment Patterns in HHP as of December 31, 2021 Total Enrollment Continuously Enrolled Disenrolled Once Enrolled Multiple Times Overall 90,045 53.0% 44.8% 2.1% SPA 1 66,017 51.2% 46.4% 2.4% SPA 2 24,028 58.1% 40.4% 1.5% Source: MCP Enrollment Reports from August 2019 and Quarterly HHP Reports from September 2019 to December 2021. Notes: MCP is Managed Care Plan. Those enrolled for less than 31 days were excluded from this analysis. SPA 1 includes enrollees with chronic conditions and substance use disorders. SPA 2 includes enrollees with severe mental illness. 62 0BFinal Evaluation of California's Health Homes Program (HHP)| UCLA Evaluation UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program Enrollment Length Average length of enrollment was measured given the date first enrolled in HHP per enrollee and was calculated by Group and SPA. The length of enrollment was shorter for Groups 3 and 4 relative to Group 1. Group 2 had a longer average length of enrollment compared to all other groups. Length of enrollment was shorter for SPA 2 than for SPA 1, commensurate with the later start date of SPA 2 (Exhibit 30). Exhibit 30: Average Length of Enrollment in Months in HHP by Group as of December 31, 2021 Overall 11.7 Group 1 SPA 1 12.7 SPA 2 10.1 Overall 12.6 Group 2 SPA 1 13.5 SPA 2 10.1 Overall 11.0 Group 3 SPA 1 11.5 SPA 2 9.5 Overall 9.2 Group 4 SPA 1 9.8 SPA 2 7.5 Source: MCP Enrollment Reports from August 2019 and Quarterly HHP Reports from September 2019 to December 2021. Notes: MCP is managed care plan. Those enrolled for less than 31 days were excluded from this analysis. SPA 1 includes enrollees with chronic conditions and substance use disorders. SPA 2 includes enrollees with severe mental illness. MCP Exclusions of Specific HHP Eligible Populations MCPs were able to use standardized criteria to exclude some of the eligible beneficiaries identified in their respective TELs and were required to report the reason for such exclusions in their Quarterly HHP Reports in the aggregate and for the first year of implementation. Ten MCPs reported this data only for the first three quarters of implementation and one MCP did not report at all. Exhibit 31 displays the percent of eligible beneficiaries in the TEL that were excluded by reasons for such exclusions. For Groups 2 and 3 the most common reason was that an eligible beneficiary was not an MCP member. At the time the TEL was constructed, these individuals may have been members of the MCP, but were no longer members when the MCP began enrollment either due to enrollment in another MCP or disenrollment from Medi-Cal. UCLA Evaluation | 0BFinal Evaluation of California's Health Homes Program (HHP) 63 UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program Other most common reasons for exclusion were eligible enrollee declined to participate (Group 1) and eligible enrollee was already well managed (Group 4). Exhibit 31: Percent of Eligible Beneficiaries Excluded by MCPs by Reason for Exclusion in the First Year of HHP Implementation Group Exclusion Rationale 1 2 3 4 Excluded because well-managed 0.4% 0.5% 0.4% 7.2% Excluded because declined to participate 3.1% 1.9% 2.2% 2.2% Excluded because of unsuccessful engagement 0.9% 3.0% 2.5% 4.8% Excluded because duplicative program 0.5% 0.3% 1.0% 0.6% Excluded because unsafe behavior or environment n/a <0.0% <0.0% n/a Excluded because not enrolled in Medi-Cal at MCP 0.3% 7.4% 3.1% 1.8% Externally referred but excluded <0.0% 0.1% <0.0% n/a Source: MCP Quarterly HHP Reports from September 1, 2018 to September 30, 2019. Groups 1 and 2 reported excluded beneficiaries for the first year of implementation. Group 3 MCPs reported 3 or 4 quarters of excluded beneficiaries. Group 4 only reported 3 quarters of excluded beneficiaries. HealthNet counties (Kern, Los Angeles, Sacramento, San Diego and Tulare) were excluded from analysis due to insufficient reporting. Eligible beneficiaries were identified on the targeted engagement lists created prior to the last quarter of reporting for each MCP and County. Notes: MCP is Managed Care Plan and TEL is Targeted Engagement List. n/a indicates small cell size. 64 0BFinal Evaluation of California's Health Homes Program (HHP)| UCLA Evaluation UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program HHP Enrollee Demographics and Health Status This section addresses the following HHP evaluation questions: 1. What were the demographics of program enrollees? 2. What was the acuity level of the enrollees including health and health risk profile indicators, such as aggregate inpatient, ED, and rehab SNF utilization? 3. What proportion of enrollees were experiencing homelessness? UCLA used demographic information from the Medi-Cal enrollment data, homelessness status from MCP Quarterly HHP Reports, and Medi-Cal claims data to construct measures of health status and healthcare utilization prior to enrollment in HHP. Medi-Cal data included both managed care and fee-for-service encounters. UCLA used a look-back period of 24 months for these measures in line with the HHP Program Guide. The exception to this was description of enrollee demographics, which was based on an enrollee's HHP enrollment date. Measures of chronic conditions and acuity eligibility criteria were created based on definitions in the HHP Program Guide and the Centers for Medicare and Medicaid Service's Chronic Condition Warehouse condition categories, using primary and secondary diagnosis codes in each Medi-Cal claim. Further details can be found in Appendix A: Data Sources and Methods. UCLA reported demographics and health status for (1) all enrollees, (2) SPA 1 enrollees, and (3) SPA 2 enrollees. Of the 90,609 HHP enrollees (see HHP Enrollment and Enrollment Patterns), seven enrollees were missing Medi-Cal data prior to HHP enrollment and were not included in these analyses. DHCS defined inclusion and exclusion eligibility criteria for HHP enrollees and used these criteria to identify eligible Medi-Cal beneficiaries to be included in the TEL, which was then distributed to MCPs in six-month intervals. However, DHCS did not have access to all eligibility criteria in Medi-Cal enrollment and claims data (see Introduction: HHP Target Populations). Specifically, DHCS lacked information on the "chronic homelessness" acuity criteria. UCLA Evaluation | 65 UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program Demographics of HHP Enrollees at Time of Enrollment By the end of HHP, MCPs had enrolled 90,609 individuals, with 66,241 in SPA 1 and 24,368 in SPA 2. Overall, HHP enrollees were most often 50 to 64 years old, female and Latinx. When comparing SPA 1 and SPA 2 enrollees, the former group were more often older, less likely to be White, and less likely to speak English. Some (8%) of HHP enrollees were reported as experiencing homelessness at any point during HHP enrollment, and rates varied by SPA with 8% for SPA 1 and 10% for SPA 2 (Exhibit 32). The overall demographics of enrollees as of December 2021 did not differ greatly from the demographics of enrollees reported in the second interim evaluation (data not shown), indicating that the demographics of new enrollees remained similar throughout the program. Exhibit 32: HHP Enrollee Demographics, Overall, and by SPA, at the Time of HHP Enrollment as of December 30, 2021 SPA 1 SPA 2 Total Enrollee Enrollee s s Enrollment N 90,60 66,241 24,368 9 Age (at time % 0-17 7% 7%% 5% of % 18-34 15% 11% 24% enrollment) % 35-49 22% 21% 27% % 50-64 48% 50% 41% % 65+ 8% 10% 4% Gender % male 41% 43% 35% Race/Ethnicit % White 20% 18% 25% y % Latinx 47% 49% 42% % African American 17% 18% 17% % Alaskan Native or American Indian <1% <1% <1% % Asian 4% 5% 3% % Hawaiian, Guamanian, Samoan, Other Asian or Pacific 1% 1% 1% Islander % other 5% 4% 7% % unknown 5% 5% 5% Language % English proficient 71% 68% 78% Enrolled in Average number of months 12 12 12 Medi-Cal full- scope during the year prior to enrollment Homelessnes Experienced homelessness during enrollment 8% 8% 10% s 66 | UCLA Evaluation UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program Source: MCP Enrollment Reports from August 2019 and Quarterly HHP Reports from September 2019 – December 2021. HHP enrollment was limited to available data for the period between July 1, 2018 and September 30, 2020, and homelessness is only reported for enrollees who were active as of July 2019. Demographics at the time of HHP enrollment were obtained from Medi- Cal enrollment data from July 1, 2016 to December 31, 2021. Notes: MCP is Managed Care Plan. SPA 1 includes enrollees with chronic conditions and substance use disorders. SPA 2 includes enrollees with severe mental illness. Homeless data was not reported for 720 enrollees. Health Status of HHP Enrollees Prior to Enrollment UCLA examined the proportion of enrollees with the top ten most frequent physical health and mental health conditions in the 24 months prior to enrollment overall and by SPA. Data showed high rates of hypertension (65%) and diabetes (49%) among HHP enrollees (Exhibit 33). When comparing SPA 1 and SPA 2, SPA 2 enrollees were more likely to have mental health conditions, including depression (73%), anxiety (54%), and bipolar disorder (30%) compared to SPA 1. Exhibit 33: Top Ten Most Frequent Physical and Mental Health Conditions among HHP Enrollees, 24 Months Prior to HHP Enrollment Total SPA 1 Enrollees SPA 2 Enrollees N=90,609 N=66,241 N=24,368 Hypertension (65%) Hypertension (71%) Depression (73%) Diabetes (49%) Diabetes (56%) Depressive Disorders (69%) Depression (40%) Chronic Kidney Disease (45%) Anxiety (54%) Chronic Kidney Disease (39%) Hyperlipidemia (40%) Hypertension (50%) Hyperlipidemia (38%) Obesity (35%) Obesity (33%) Depressive Disorders (38%) Asthma (31%) Hyperlipidemia (32%) Obesity (34%) Rheumatoid Arthritis / Fibromyalgia, Chronic Pain and Osteoarthritis (30%) Fatigue (31%) Anxiety (33%) Depression (27%) Bipolar (30%) Rheumatoid Arthritis / Fibromyalgia, Chronic Pain and Diabetes (30%) Osteoarthritis (29%) Fatigue (27%) Fibromyalgia, Chronic Pain and Depressive Disorders (26%) Rheumatoid Arthritis / Fatigue (28%) Osteoarthritis (28%) Source: MCP Enrollment Reports from August 2019 and Quarterly HHP Reports from December 2021. HHP enrollment was limited to available data for the period between July 1, 2018 and September 30, 2020. Chronic and other chronic health, mental health, and potentially disabling condition categories were identified using the Chronic Condition Warehouse methodology using Medi-Cal claims data from July 1, 2016 to September 30, 2020. Notes: MCP is managed care plan. SPA 1 includes enrollees with chronic conditions and substance use disorders. SPA 2 includes enrollees with severe mental illness. In order to further examine the level of complexity of health status of HHP enrollees, UCLA examined the proportion of HHP enrollees that met each of the four HHP eligibility criteria outlined in the HHP Program Guide in the 24 months prior to enrollment. Overall, 93% of HHP enrollees met at least one of these criteria. Exhibit 34 shows that 53% of HHP enrollees had hypertension along with chronic obstructive pulmonary disease, diabetes, coronary artery disease, or chronic or congestive heart failure (Criteria 2). Similar proportions of enrollees had serious mental health conditions (45%; Criteria 3) compared to those with a combination of very complex conditions such as chronic renal (kidney) disease, chronic liver disease, traumatic UCLA Evaluation | 67 UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program brain injury and a more common condition (44%; Criteria 1). A smaller proportion of HHP enrollees (27%) had asthma (Criteria 4). Consistent with HHP program goals, more SPA 2 enrollees had major depression disorder, bipolar disorder, or psychotic disorders (Criteria 3) than SPA 1 enrollees (83% versus 30%). The composition of enrollees by eligibility criteria did not differ greatly as of December 2021 compared to September 2020 (data not shown). Exhibit 34: Complexity of HHP Enrollees' Health Status by SPA, 24 Months Prior to HHP Enrollment as of September 30, 2020 Total SPA 1 Enrollees SPA 2 Enrollees Number of HHP Enrollees N=90,609 N=66,241 N=24,368 Two specific conditions (Criteria 1) 44% 50% 27% Hypertension and another specific condition (Criteria 2) 53% 61% 30% Serious mental health conditions (Criteria 3) 45% 30% 83% Asthma (Criteria 4) 27% 31% 16% Any Criteria (1-4) 93% 93% 93% Source: MCP Enrollment Reports from August 2019 and Quarterly HHP Reports from September 2019 – December 2021. HHP enrollment was limited to available data for the period between July 1, 2018 and September 30, 2020. Utilization data was calculated using Medi-Cal claims data from July 1, 2016 to September 30, 2020. Chronic condition categories were based on definitions from the HHP Program Guide. Notes: Criteria 1 includes any two of the following conditions: chronic obstructive pulmonary disease, diabetes, traumatic brain injury, chronic or congestive heart failure, coronary artery disease, chronic liver disease, chronic renal (kidney) disease, dementia, substance use disorders. Criteria 2 includes hypertension and one of the following: chronic obstructive pulmonary disease, diabetes, coronary artery disease, chronic or congestive heart failure. Criteria 3 includes one of the following: major depression disorders, bipolar disorder, psychotic disorders including schizophrenia. Criteria 4 includes asthma. HHP enrollees may meet multiple criteria. 68 | UCLA Evaluation UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program HHP Service Utilization among HHP Enrollees This section addresses the following HHP evaluation questions: 1. Were HHP services provided in-person or telephonically? 2. Were HHP services provided by clinical or non-clinical staff? 3. How many enrollees experiencing homelessness received housing services? MCPs were required to report HHP services to DHCS in Medi-Cal claims data starting on July 1, 2018. Two different procedure codes with unique modifiers that further indicated type and modality of services as well as type of providers were used. DHCS required HCPCS code G0506 from July 1, 2018 to September 30, 2018, but discontinued it because it led to denial of claims where a provider had submitted more than one unit of service per date of service. Therefore, DHCS adopted HCPCS code G9008 starting on October 1, 2018. Both codes were used to report HHP services in this report. Prior to Q3 2019, MCPs reported on the number of HHP enrollees experiencing or at risk of homelessness and the provision of housing services to these beneficiaries in the aggregate and per quarter. This data could not be used to assess trends since it lacked information on each individual member and changes in their status. MCPs began reporting this data at the member level starting in Q3 2019, representing July 1 through September 30, 2019, and reported homelessness status during each quarter, receipt of housing services during each quarter, and whether a person was no longer experiencing homelessness by the end of each quarter. Therefore, this report describes the homelessness status and receipt of housing services for beneficiaries experiencing or at risk of homelessness for each quarter from Q3 2019 to Q4 2021. UCLA used all available data to examine the type and frequency of HHP services received by enrollees at the SPA level. Further details can be found in Appendix A: Data Sources and Analytic Methods. HHP enrollees enrolled for less than 31 days (2,758 enrollees) were excluded from these analyses (Appendix C: HHP Enrollees Enrolled Less Than 31 Days). UCLA Evaluation | 69 UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program HHP Services MCPs were required to report HHP services under HCPCS code G9008, defined as "coordinated care fee, physician coordinated care oversight services." MCPs were required to use HCPCS code modifiers (U1 – U7) to identify three unique service types, service provider, and service modality (Exhibit 35). MCPs were expected to use at least one modifier per claim to define an HHP service. For example, a single visit where an enrollee receives HHP core services in-person by both clinical and non-clinical staff would use two modifiers (U1 and U4). Multiple units of service (UOS) were allowed, where one UOS was equivalent to 15 minutes of time to provide the service. Clinical staff included licensed medical professionals such as physicians, nurse practitioners, LCSWs, and medical assistants, while non-clinical staff included employees working in administrative or technical roles. In-person visits could occur at a variety of locations (e.g., home, office, or clinic). Telehealth allowed for remote patient monitoring (e.g., vitals and blood pressure), allowing enrollee care, reminders, and education to occur through telephone and electronic communications. 70 | UCLA Evaluation UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program Exhibit 35: HHP Services HCPCS Provider Type Modality Definition Modifier Engagement Services Provider Type Not U7 Not specified Active outreach such as direct communications with Specified member (e.g., face-to-face, mail, electronic, and telephone), follow-up if the member presents to another partner in the HHP network or using claims data to contact providers the member is known to use. Providers must show active, meaningful, and progressive attempts at member engagement each month until the member is engaged. Examples of acceptable engagement include: (1) letter to member followed by phone call to member; (2) phone call to member, outreach to care delivery partners and social service partners; (3) and street level outreach, including, but not limited to, where the member lives or is accessible. Core Services Provided by U1 In-person Comprehensive care management, care coordination, Clinical Staff health promotion, comprehensive transitional care, U2 Telehealth individual and family support services, and referral to community and social supports Provided by Non- U4 In-person Clinical Staff U5 Telehealth Other Services Provided by U3 Not specified Case notes, case conferences, tenant supportive services, Clinical Staff and driving to appointments Provided by Non- U6 Not specified Clinical Staff Source: Adapted from Health Homes Program Guide issued November 1, 2019. Notes: HCPCS is Healthcare Common Procedure Coding System, MCP is Managed Care Plan, and UOS is Unit of Service. Service use was reported by MCPs in claims data. Each service (UOS) represented a 15-minute interaction between HHP staff and HHP enrollee. Multiple UOS' were allowed within a single visit. Modifiers U1-U7 accompanied both HCPCS code G0506 (July 1, 2018 to September 30, 2018) and HCPCS code G9008 (October 1, 2018 to December 31, 2021) to specify the service. Telehealth includes phone and other forms of remote communication. UCLA Evaluation | 71 UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program UCLA's examination of claims data revealed that HHP-specific HCPCS codes were never reported for 25% of HHP enrollees and that enrollees without these codes came from all 16 MCPs (data not shown). DHCS reported identifying deficiencies in reporting of HHP services both in claims and in MCP reports. MCPs reported to DHCS that CB-CMEs had challenges in reporting of HHP services that were included in claims. DHCS provided technical support to MCPs to address these problems. MCPs also reported to DHCS that they were providing technical assistance to CB-CMEs to improve reporting for all data. An examination of the extent of this under-reporting showed that 25% of HHP enrollees lacked any HHP-specific HCPCS modifier codes and 26% of HHP enrollees lacked HCPCS codes for some months during their enrollment (data not shown). The proportion of enrollees that lacked codes for some months declined from 38% in September 2020. Further analysis showed that the rate of under-reporting varied by type of service with a higher rate for engagement services and a lower rate for core services. Therefore, UCLA calculated the average number of HHP services during months when HHP-specific HCPCS codes were present for each enrollee rather than calculating HHP services across all months of enrollment. The latter methodology would have been based on the incorrect assumption that HHP enrollees did not receive HHP services when HCPCS modifier codes were missing. Due to the limitations of data on HHP services and the methodology employed by UCLA, the data presented in this chapter are considered estimates of HHP services received by enrollees. Estimated Overall HHP Service Delivery to HHP Enrollees Exhibit 36 shows estimated service utilization for any HHP service (HCPCS modifiers U1-U7), regardless of provider type and modality between July 1, 2018 and December 31, 2021. Available data showed that a total of 1,819,484 UOS (in 15-minute increments) were received during this time period, averaging to 3.1 UOS per enrollee per month in months where services were received. Comparison of services received by HHP enrollees by SPA showed a higher number of total UOS delivered to SPA 1 enrollees corresponding to more enrollees in this SPA. However, SPA 2 enrollees had a slightly higher average number of UOS than SPA 1 enrollees (3.2 UOS versus 3.1 UOS per month per enrollee in months that HHP services were received). The median UOS per enrollee was similar between SPAs. 72 | UCLA Evaluation UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program Exhibit 36: Estimated Overall HHP Units of Service Received by HHP Enrollees by SPA, July 1, 2018 to December 31, 2021 All HHP Enrollees SPA 1 Enrollees SPA 2 Enrollees (n=90,045) (n=66,017) (n=24,028) Total number of units of service received 1,819,484 1,403,357 416,128 Average number of units of service per enrollee per month in months where HHP services were received 3.1 3.1 3.2 Median number of units of service per enrollee per month in months where HHP services were received 2.0 2.0 2.0 Source: Medi-Cal Claims data from June 1, 2018 to December 31, 2021. Notes: HCPCS is Healthcare Common Procedure Coding System, MCP is Managed Care Plan. Service use was under-reported by MCPs in claims data. Each unit of service (UOS) represented a 15-minute interaction between HHP staff and HHP enrollee. Multiple UOS' were allowed within a single visit. Modifiers U1-U7 accompanied both HCPCS code G0506 (July 1, 2018 to September 30, 2018) and HCPCS code G9008 (October 1, 2018 to December 31, 2021) to specify the service. Data are based on the number of months during HHP enrollment where HCPCS codes were present. UCLA Evaluation | 73 UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program Estimated Types of HHP Services Received Exhibit 37 shows estimated average number of UOS per enrollee per month in months where HHP services were received by type of service from July 1, 2018 to December 31, 2021. The average number of UOS received was higher for core HHP services (2.8) than engagement services (1.7) or other HHP services (2.5). Also, the average number of UOS for core HHP services was higher for SPA 2 than SPA 1 enrollees, while for other HHP services it was higher for SPA 1 than SPA 2. Exhibit 37: Estimated Average Number of HHP Units of Service Provided to HHP Enrollees in Months HHP Services were Received by Service Type and SPA, July 1, 2018 to December 31, 2021 Service Type All HHP Enrollees SPA 1 Enrollees SPA 2 Enrollees (n=90,045) (n=66,017) (n=24,028) Engagement Services (U7) 1.7 1.7 1.7 Core HHP Services (U1, U2, U4, or U5) 2.8 2.7 2.9 Other Health Homes Services (U3 or U6) 2.5 2.5 2.4 Source: Medi-Cal Claims data from July 1, 2018 to December 31, 2021. Notes: Data show estimated average number of units of services (UOS) per enrollee during months that specific service was received. HCPCS is Healthcare Common Procedure Coding System, MCP is Managed Care Plan. Service use is under-reported by MCPs in claims data. Each UOS represented a 15-minute interaction between HHP staff and HHP enrollee. Multiple UOS' were allowed within a single visit. Core HHP services include claims with HCPCS code G0506 (July 1, 2018 to September 30, 2018), HCPCS code G9008 (October 1, 2018 to June 30, 2019), and modifier U1, U2, U4, or U5. HHP engagement service includes claims with HCPCS code G0506 (July 1, 2018 to September 30, 2018), HCPCS code G9008 (October 1, 2018 to June 30, 2019), and modifier U7. Other HHP service includes claims with HCPCS code G0506 (July 1, 2018 to September 30, 2018), HCPCS code G9008 (October 1, 2018 to December 31, 2021), and modifier U3 or U6. Data are based on the number of months during HHP enrollment where HCPCS codes were present. 74 | UCLA Evaluation UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program Estimated HHP Core Services by Modality and Staff Type MCPs were required to report the modality of HHP core services including in-person or through telehealth. However, DHCS did not require reporting modality for other HHP services or engagement services. Exhibit 38 shows the average number of in-person UOS received per enrollee during months that in-person services were received (3.1 UOS) was higher than the average number of telehealth services received per enrollee (2.5 UOS). However, as shown in Chapter 3: Changes in HHP Service Utilization before and during the COVID-19 Pandemic, the use of telehealth services increased greatly after the pandemic with the proportion of HHP services provided telephonically peaking at 73% (data not shown). MCPs were required to report the types of staff that provided core and other HHP services. The average number of services received from non-clinical staff (3.1 UOS) were higher than clinical staff (2.6 UOS). Exhibit 38: Estimated Average Number of HHP Core Units of Service Provided to HHP Enrollees in Months those HHP Services were received by Modality and SPA, July 1, 2018 to December 31, 2021 All HHP Enrollees SPA 1 Enrollees SPA 2 Enrollees (n=90,045) (n=66,017) (n=24,028) Modality In-Person UOS (U1 or U4) 3.1 3.1 3.1 Telehealth UOS (U2 or U5) 2.5 2.5 2.8 Staff Types Who Delivered the Service Clinical Staff UOS (U1, U2, or U3) 2.6 2.6 2.7 Non-Clinical Staff UOS (U4, U5, or U6) 3.1 3.0 3.1 Source: Medi-Cal Claims data from July 1, 2018 to December 31, 2021. Notes: Data show estimated average number of units of services per enrollee during months that service was received. HCPCS is Healthcare Common Procedure Coding System, MCP is Managed Care Plan, and UOS is Unit of Service. Service use was under-reported by MCPs in claims data. Each service (UOS) represented a 15-minute interaction between HHP staff and HHP enrollee. Multiple UOS' were allowed within a single visit. Modifiers U1-U7 accompanied both HCPCS code G0506 (July 1, 2018 to September 30, 2018) and HCPCS code G9008 (October 1, 2018 to December 31, 2021) to specify the service. Data are based on the number of months during HHP enrollment where HCPCS codes were present. UCLA Evaluation | 75 UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program HHP Housing Services Housing navigation and transition services included activities such as conducting tenant screenings, developing an individualized housing plan, assisting with move-in, and assisting with the housing search and application process. MCPs began reporting enrollee level data on homeless status and delivery of housing services in Q3 2019 (July 1 through September 30, 2019). In this period and onward, MCPs reported on enrollees who were experiencing homelessness or at risk for homelessness during each quarter, those who were no longer experiencing homelessness by the end of the quarter, and those who received housing services during the quarter. They also reported on whether an enrollee had experienced homelessness during HHP, although this measure was not examined due to data inconsistencies. MCPs communicated challenges in reporting for provision of housing services. DHCS provided technical support to MCPs to address these problems, and MCPs reported to DHCS that they were providing technical assistance to CB-CMEs to improve reporting for all data. The table below is considered an estimation of homeless status and receipt of housing services due to inconsistent reporting across these variables. Inconsistencies were present when an enrollee was reported as no longer experiencing homelessness while that enrollee was never reported as having experienced homelessness or at risk; an enrollee was reported as receiving housing services although they were never reported as experiencing homelessness or at risk; and an enrollee was not reported as having experienced homelessness or at risk during the same quarter when they first reported as experiencing homelessness at some point during the program. One reason for such discrepancies may have been that CB-CMEs had 90 days to assess an enrollee's homeless status and may not have done so when the quarterly report had to be submitted 60 days after the end the quarter. Using data from the MCP Quarterly Reports, UCLA estimated that the percentage of enrollees who were experiencing homelessness or at risk for homelessness in a given quarter grew during HHP, from 4% of the population in Q3 2019 to 10% of the population in Q1 2021 and then declined to 8% of the population in Q4 2021 (Exhibit 39). The percentage of enrollees experiencing homelessness or at-risk enrollees who received housing services also increased over time, starting at 38% in Q3 2019 and peaked at 75% in Q1 2021. Of those who were experiencing homelessness or at-risk during a given quarter, 3% were no longer experiencing homelessness by the end of Q3 2019, and this number peaked in Q2 2020 at 10%. 76 | UCLA Evaluation UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program Exhibit 39: Homelessness Status and Receipt of Housing Services by HHP Enrollees, July 1, 2019 to December 31, 2021 Percentage of Enrollees Percentage of Enrollees Percentage of Enrollees Experiencing Homeless or Experiencing Homeless or Experiencing Homelessness were at Risk who Received were at Risk who were No or were at Risk During Housing Services During Longer Homeless by End of Quarter Quarter Quarter Q3 2019 4% 38% 3% Q4 2019 6% 44% -- Q1 2020 7% 47% 4% Q2 2020 8% 54% 10% Q3 2020 9% 68% 7% Q4 2020 9% 70% 7% Q1 2021 10% 75% 4% Q2 2021 9% 72% 6% Q3 2021 9% 68% 8% Q4 2021 8% 62% 6% Source: MCP Quarterly Reports from July 1, 2019 to December 31, 2021. Notes: "--" indicates samples of less than 11 enrollees. Housing services data is shown only for enrollees who were reported as experiencing homelessness or at risk for homelessness. UCLA Evaluation | 77 UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program HHP Outcomes This section addresses the following HHP evaluation questions: 1. How did patterns of health care service use among HHP enrollees change before and during HHP implementation? 2. Did rates of acute care services, length of stay for hospitalizations, nursing home admissions and length of stay decline? 3. Did rates of other services such as substance use treatment or outpatient visits increase? 4. How did HHP core health quality measures improve before and after HHP implementation? 5. Did patient outcomes (e.g., controlled blood pressure, screening for clinical depression) improve before and after HHP implementation? UCLA used Medi-Cal claims data, which included both managed care and fee-for-service encounters, to construct HHP metrics per the HHP Technical Specifications. UCLA measured trends before and during HHP for each metric based on the date of an individual HHP enrollee's enrollment. UCLA did not examine trends through the second year of HHP enrollment because as of the end of the program in December 2021, only 33% of SPA 1 enrollees and 6% of SPA 2 enrollees had enrollment longer than 24 months (further details can be found in Appendix D: Enrollees with More than Two Year of HHP Enrollment). UCLA restricted the sample to enrollees with a minimum 1 month of HHP enrollment and calculated all metrics by SPA and overall. UCLA examined trends for all HHP metrics for SPA 1 and SPA 2 per HHP metric specifications and further created and examined the trend for seven optional measures to further describe changes in utilization of services during HHP. UCLA examined changes in trends before and during HHP using a difference-in-difference (DD) analysis. The DD analyses differed for HHP specified metrics that required one year of observation from metrics that did not require one year of observation and for optional measures. For HHP specified metrics with a one-year requirement, the DD analyses measured changes from Pre-HHP Year 2 to Pre-HHP Year 1 for both HHP enrollees and the control group; the change from HHP Year 1 to HHP Year 2 for both HHP enrollees and the control group; and the difference between the changes for HHP enrollees vs. the control group. For the remaining metrics and measures, UCLA examined changes in six month increments up to 24 months (1-6, 7-12, 13-18, and 19-24) before HHP enrollment and up to 24 months (1-6, 7- 12, 13-18, and 19-24) during HHP. For these, the DD analysis measured the change from 19-24 vs. 1-6 months before HHP for both HHP enrollees and the control group; the change during 138 | UCLA Evaluation UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program HHP from 1-6 to 19-24 months for both HHP enrollees and the control group; and the difference between the changes in HHP enrollees vs. the control group. The shorter timeframe for examining metrics allowed for a clearer assessment of changes during the early phase of HHP implementation. The findings were not subject to potential seasonality in service utilization due to rolling enrollment throughout the year and measuring change following the date of enrollment per beneficiary. Further details can be found in Appendix A: Data Sources and Analytic Methods. UCLA Evaluation | 139 UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program HHP Utilization Metrics Trends in two HHP specified metrics and all seven optional measures were examined on a semi- annual basis. Outpatient Utilization Primary Care Services UCLA calculated the number of primary care services per 1,000 beneficiaries per year as an optional measure of service utilization under HHP. Primary care services are likely to increase due to unmet need and increased access, but this use is likely to decrease once health needs are addressed. Exhibit 40 shows an increase in the number of primary care services before HHP by 434 services per 1,000 beneficiaries per year for SPA 1 enrollees. The rate of primary care services increased from 8,047 to 10,277 services per 1,000 beneficiaries per year from the six months before enrollment to first six month of enrollment. Following the first six months, this rate declined by 854 services per 1,000 beneficiaries per year. Rates of primary care service utilization remained higher than the rates seen before HHP for the first 18 months compared to controls that had rates below those observed before HHP. The decline from before to during HHP was significantly greater for HHP enrollees than the control group by 778 (DD). A similar trend was observed for SPA 2 enrollees. 138 | UCLA Evaluation UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program Exhibit 40: Trends in Primary Care Services per 1,000 Beneficiaries per Year Before and During HHP by SPA as of December 31, 2021 10,277 9,820 8,799 8,444 8,212 8,047 7,809 7,746 7,728 7,714 7,292 7,252 7,210 6,746 6,625 6,536 6,377 6,295 6,144 6,061 5,936 5,914 5,908 5,708 5,685 5,674 5,554 5,476 5,324 5,276 5,101 4,938 19-24 13-18 7-12 1-6 1-6 7-12 13-18 19-24 19-24 13-18 7-12 1-6 1-6 7-12 13-18 19-24 Before HHP (months) During HHP (months) Before HHP (months) During HHP (months) SPA 1 SPA 2 HHP Enrollees Control Group Difference Change Change Difference-in- Between Before HHP During HHP Difference (DD) Changes SPA 1 HHP Enrollees 434* -854* -1,288* Control Group 357* -153* -510* -778* SPA 2 HHP Enrollees 555* -843* -1,398* Control Group 452* -191* -643* -755* Overall HHP Enrollees 464* -851* -1,315* Control Group 381* -162* -543* -772* Source: Medi-Cal claims data from July 1, 2016 through December 31, 2021. Notes: * Denotes p≤0.05, a statistically significant difference. Primary care services were identified as services with a primary care physician, physician assistant, or nurse practitioner per NUCC's Taxonomy code set. SPA 1 includes enrollees with chronic conditions and substance use disorders. SPA 2 includes enrollees with severe mental illness. Change Before HHP is calculated as: (1 – 6 months before HHP minus 19 – 24 months before HHP divided by 3). Change During HHP is calculated as: (19-24 months during HHP minus 1 – 6 months during HHP). Difference between changes is calculated as: (Change During HHP – Change Before HHP). Difference-in-difference is calculated as: (Difference between changes for HHP enrollees – Difference between changes for control group). UCLA Evaluation | 139 UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program Specialty Care Services UCLA calculated the number of specialty care services per 1,000 beneficiaries per year as an optional measure of service utilization under HHP. Specialty care services are likely to increase due to unmet need and increased access, but this use is likely to decrease once health needs are addressed. Exhibit 41 shows an increase in the number of specialty care services before HHP by 428 services per 1,000 beneficiaries per year for SPA 1 enrollees. The rate of specialty care services increased from 6,226 to 6,501 services per 1,000 beneficiaries per year from the six months before enrollment to first six month of enrollment. Following the first six months, the rate declined by 763 services per 1,000 beneficiaries pear year. The decline from before to during HHP was significantly greater for HHP enrollees than the control group by 239 (DD). A similar trend was observed for SPA 2 enrollees. Exhibit 41: Trends in Specialty Services per 1,000 Beneficiaries per Year Before and During HHP by SPA as of December 31, 2021 6,226 6,501 6,065 5,798 5,674 5,509 5,498 5,454 5,284 5,253 5,232 5,230 5,079 5,046 4,966 4,942 4,875 4,846 4,787 4,673 4,628 4,509 4,434 4,329 4,209 4,192 4,170 4,142 3,947 3,847 3,806 3,553 19-24 13-18 7-12 1-6 1-6 7-12 13-18 19-24 19-24 13-18 7-12 1-6 1-6 7-12 13-18 19-24 Before HHP (months) During HHP (months) Before HHP (months) During HHP (months) SPA 1 SPA 2 HHP Enrollees Control Group Difference Change Change Difference-in- Between Before HHP During HHP Difference (DD) Changes SPA 1 HHP Enrollees 428* -334* -763* Control Group 375* -148* -523* -239* SPA 2 HHP Enrollees 348* -279* -627* Control Group 294* -108* -402* -225* Overall HHP Enrollees 408* -321* -729* Control Group 355* -138* -493* -236* 138 | UCLA Evaluation UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program Source: Medi-Cal claims data from July 1, 2016 through December 31, 2021. Notes: * Denotes p≤0.05, a statistically significant difference. Specialty care services were identified as services with a specialty physician, physician assistant, or nurse practitioner per NUCC's Taxonomy code set. SPA 1 includes enrollees with chronic conditions and substance use disorders. SPA 2 includes enrollees with severe mental illness. Change Before HHP is calculated as: (1 – 6 months before HHP minus 19 – 24 months before HHP divided by 3). Change During HHP is calculated as: (19-24 months during HHP minus 1 – 6 months during HHP). Difference between changes is calculated as: (Change During HHP – Change Before HHP). Difference-in-difference is calculated as: (Difference between changes for HHP enrollees – Difference between changes for control group). UCLA Evaluation | 139 UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program Mental Health Services UCLA calculated the number of mental health services per 1,000 beneficiaries per year as an optional measure of service utilization under HHP. Mental health services are likely to increase due to unmet need and increased access, but this use is likely to decrease once health needs are addressed. 138 | UCLA Evaluation UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program Exhibit 42 shows that mental health service use was increasing prior to enrollment for SPA 1 enrollees (379 services per 1,000 beneficiaries per year) and continued to increase in the first six months of enrollment. Use of these services than declined during HHP by 320 services per 1,000 beneficiaries per year. Compared to controls, rates of mental health services declined an additional 272 services per 1,000 beneficiaries per year (DD) from before to during HHP. For SPA 2 enrollees, data show overall higher rates of mental health service utilization compared to SPA 1. Rates increased by 1,163 services per 1,000 beneficiaries per year prior to HHP and then declined by 1,152 services per 1,000 beneficiaries per year after enrollment. SPA 2 enrollees had a significantly greater decline from before to during HHP compared to the control group by 823 services per 1,000 beneficiaries per year (DD). UCLA Evaluation | 139 UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program Exhibit 42: Trends in Mental Health Services per 1,000 Beneficiaries per Year Before and During HHP by SPA as of December 31, 2021 13,203 12,362 12,282 11,193 10,900 9,723 9,713 9,357 9,104 8,843 8,825 8,243 8,092 7,543 7,153 6,935 4,865 4,762 4,611 4,410 4,126 3,982 3,906 3,652 3,639 3,626 3,559 3,408 3,296 3,210 2,976 2,710 19-24 13-18 7-12 1-6 1-6 7-12 13-18 19-24 19-24 13-18 7-12 1-6 1-6 7-12 13-18 19-24 Before HHP (months) During HHP (months) Before HHP (months) During HHP (months) SPA 1 SPA 2 HHP Enrollees Control Group Change Difference Difference-in- Change Before Between Difference During HHP HHP Changes (DD) SPA 1 HHP Enrollees 379* -320* -698* Control Group 283* -143* -426* -272* SPA 2 HHP Enrollees 1,163* -1,152* -2,315* Control Group 857* -636* -1,493* -823* Overall HHP Enrollees 574* -527* -1,101* Control Group 426* -266* -692* -409* Source: Medi-Cal claims data from July 1, 2016 through December 31, 2021. Notes: * Denotes p≤0.05, a statistically significant difference. Mental health services were identified as services with a mental health procedure code. SPA 1 includes enrollees with chronic conditions and substance use disorders. SPA 2 includes enrollees with severe mental illness. Change Before HHP is calculated as: (1 – 6 months before HHP minus 19 – 24 months before HHP divided by 3). Change During HHP is calculated as: (19-24 months during HHP minus 1 – 6 months during HHP). Difference between changes is calculated as: (Change During HHP –Change Before HHP). Difference-in-difference is calculated as: (Difference between changes for HHP enrollees – Difference between changes for control group). 138 | UCLA Evaluation UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program Substance Use Disorder Services UCLA calculated the number of substance use disorder (SUD) services per 1,000 beneficiaries per year as an optional measure of service utilization under HHP. SUD services are likely to increase due to unmet need and increased access, but this use is likely to decrease once health needs are addressed. UCLA Evaluation | 139 UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program Exhibit 43 shows a significant increasing trend in SUD services before HHP for SPA 1 enrollees (219 services per 1,000 beneficiaries per year). During HHP this rate declined significantly by 212 services per 1,000 beneficiaries per year, and SPA 1 enrollees had a significantly greater decline from before to during HHP compared to the control group by 175 services per 1,000 beneficiaries per year (DD). A similar pattern was observed for SPA 2 enrollees, though the number of SUD services provided was greater overall and the magnitude of change before and during HHP was greater. There was a significant increasing trend in SUD services before HHP (429 services per 1,000 beneficiaries per year), followed by a significant decrease (210 services per 1,000 beneficiaries per year). The SPA 2 enrollees had a significantly greater decline from before to during HHP compared to the control group by 345 services per 1,000 beneficiaries per year (DD). 138 | UCLA Evaluation UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program Exhibit 43: Trends in Substance Use Disorder Services per 1,000 Beneficiaries per Year Before and During HHP by SPA as of December 31, 2021 7,263 7,535 7,291 6,688 6,591 6,248 5,985 5,959 5,584 5,430 5,383 5,229 5,119 4,956 4,799 4,630 4,128 4,101 4,037 3,877 3,857 3,690 3,491 3,443 3,012 2,972 2,968 2,926 2,878 2,810 2,719 2,495 19-24 13-18 7-12 1-6 1-6 7-12 13-18 19-24 19-24 13-18 7-12 1-6 1-6 7-12 13-18 19-24 Before HHP (months) During HHP (months) Before HHP (months) During HHP (months) SPA 1 SPA 2 HHP Enrollees Control Group Difference Difference-in- Change Change Between Difference Before HHP During HHP Changes (DD) SPA 1 HHP Enrollees 219* -212* -432* Control Group 159* -98* -257* -175* SPA 2 HHP Enrollees 429* -444* -873* Control Group 318* -210* -528* -345* Overall HHP Enrollees 272* -270* -542* Control Group 199* -126* -324* -217* Source: Medi-Cal claims data from July 1, 2016 through December 31, 2021. Notes: * Denotes p≤0.05, a statistically significant difference. SUD services were identified as services with a SUD treatment procedure code or an NDC for pharmacotherapy. SPA 1 includes enrollees with chronic conditions and substance use disorders. SPA 2 includes enrollees with severe mental illness. Change Before HHP is calculated as: (1 – 6 months before HHP minus 19 – 24 months before HHP divided by 3). Change During HHP is calculated as: (19-24 months during HHP minus 1 – 6 months during HHP). Difference between changes is calculated as: (Change During HHP –Change Before HHP). Difference-in-difference is calculated as: (Difference between changes for HHP enrollees – Difference between changes for control group). UCLA Evaluation | 139 UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program Emergency Department Utilization Ambulatory Care: Emergency Department Visits Ambulatory Care: Emergency Department Visits is an HHP core metric that measures the rate of emergency department (ED) visits that do not result in hospitalization per 1,000 beneficiaries per year. The intended direction of the metric and DD is decrease. Exhibit 44 shows an increase in the number of ED visits before HHP by 27 visits per 1,000 beneficiaries per year for SPA 1 enrollees. This rate declined during HHP by 72 visits and the decline from before to during HHP was significantly greater than the control group by 23 visits (DD). A similar trend was observed for SPA 2 enrollees with a greater decline compared to the control group (56 visits, DD). During the first year of HHP, there was a faster decline in the rate of ED visits for SPA 1 enrollees compared to SPA 2 enrollees. Exhibit 44: Trends in Ambulatory Care: Emergency Department Visits per 1,000 Beneficiaries per Year Before and During HHP by SPA as of December 31, 2021 2,144 2,179 2,374 2,259 2,259 2,149 2,079 2,073 2,051 2,040 2,003 1,954 1,944 1,908 1,901 1,898 1,872 1,843 1,839 1,828 1,805 1,804 1,749 1,747 1,731 1,670 1,533 1,523 1,501 1,500 1,494 1,483 19-24 13-18 7-12 1-6 1-6 7-12 13-18 19-24 19-24 13-18 7-12 1-6 1-6 7-12 13-18 19-24 Before HHP (months) During HHP (months) Before HHP (months) During HHP (months) SPA 1 SPA 2 HHP Enrollees Control Group Change Change Difference Difference-in- Before During Between Difference (DD) HHP HHP Changes SPA 1 HHP Enrollees 27* -72* -99* Control Group 27* -49* -76* -23* SPA 2 HHP Enrollees 38* -111* -149* Control Group 36* -56* -93* -56* Overall HHP Enrollees 30* -82* -111* Control Group 29* -51* -80* -31* 138 | UCLA Evaluation UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program Source: Medi-Cal claims data from July 1, 2016 through December 31, 2021. Notes: Includes ED visits that do not result in hospitalization. * Denotes p≤0.05, a statistically significant difference. SPA 1 includes enrollees with chronic conditions and substance use disorders. SPA 2 includes enrollees with severe mental illness. Change Before HHP is calculated as: (1 – 6 months before HHP minus 19 – 24 months before HHP divided by 3). Change During HHP is calculated as: (19-24 months during HHP minus 1 – 6 months during HHP). Difference between changes is calculated as: (Change During HHP –Change Before HHP). Difference-in-difference is calculated as: (Difference between changes for HHP enrollees – Difference between changes for control group). Any Emergency Department Visit UCLA created a second measure of ED utilization that assessed the likelihood of any ED visit during each six-month period, which is distinct from the HHP core metric of number of ED visits. Exhibit 45 shows a significant decline in the proportion of enrollees with any ED visit during HHP for SPA 1 (-1.6%) and SPA 2 (-1.7%). For SPA 1 enrollees, the decline in this proportion compared to before HHP was greater than that of the control group by 0.5% (DD). A similar trend was observed for SPA 2 enrollees, with a greater decline in this proportion compared to the control group by 0.7% (DD). Exhibit 45: Trends in Percentage of Patients with Any ED Visits Before and During HHP by SPA as of December 31, 2021 40.6% 39.9% 42.2% 41.6% 40.4% 41.2% 40.2% 41.9% 40.9% 45.3% 44.3% 43.0% 42.1% 39.7% 39.5% 38.4% 37.8% 37.0% 36.9% 36.2% 36.1% 35.1% 34.9% 34.8% 34.3% 33.8% 32.4% 32.1% 32.0% 31.9% 31.6% 31.4% 19-24 13-18 7-12 1-6 1-6 7-12 13-18 19-24 19-24 13-18 7-12 1-6 1-6 7-12 13-18 19-24 Before HHP (months) During HHP (months) Before HHP (months) During HHP (months) SPA 1 SPA 2 HHP Enrollees Control Group Change Change Difference Difference-in- During Before HHP Between Changes Difference (DD) HHP SPA 1 HHP Enrollees 0.6%* -1.6%* -2.2%* Control Group 0.6%* -1.1%* -1.7%* -0.5%* SPA 2 HHP Enrollees 0.6%* -1.7%* -2.4%* Control Group 0.6%* -1.1%* -1.7%* -0.7%* Overall HHP Enrollees 0.6%* -1.6%* -2.3%* Control Group 0.6%* -1.1%* -1.7%* -0.5%* UCLA Evaluation | 139 UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program Source: Medi-Cal claims data from July 1, 2016 through December 31, 2021. Notes: Includes ED visits that do not result in hospitalization. * Denotes p≤0.05, a statistically significant difference. SPA 1 includes enrollees with chronic conditions and substance use disorders. SPA 2 includes enrollees with severe mental illness. Change Before HHP is calculated as: (1 – 6 months before HHP minus 19 – 24 months before HHP divided by 3). Change During HHP is calculated as: (19-24 months during HHP minus 1 – 6 months during HHP). Difference between changes is calculated as: (Change During HHP –Change Before HHP). Difference-in-difference is calculated as: (Difference between changes for HHP enrollees – Difference between changes for control group). 138 | UCLA Evaluation UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program Hospital Utilization Inpatient Utilization Inpatient Utilization is an HHP core metric that measures the rate of acute inpatient care and services per 1,000 beneficiaries per year. The intended direction of the metric and DD is decrease. Exhibit 46 shows an increase in the number of hospitalizations before HHP by 56 stays per 1,000 beneficiaries per year for SPA 1 enrollees. During HHP, this rate declined by 58 stays and the decline from before to during HHP was significantly greater for HHP enrollees as compared to the control group, by 46 stays per year (DD). A similar trend was observed for SPA 2 enrollees; the decline from before to during HHP was significantly greater for HHP enrollees as compared to the control group, by 30 stays per year (DD). Exhibit 46: Trends in Inpatient Utilization per 1,000 Beneficiaries per Year Before and During HHP by SPA as of December 31, 2021 671 661 632 623 614 577 567 554 531 527 518 515 511 503 495 478 474 468 458 449 436 433 433 429 420 416 409 391 391 387 382 351 19-24 13-18 7-12 1-6 1-6 7-12 13-18 19-24 19-24 13-18 7-12 1-6 1-6 7-12 13-18 19-24 Before HHP (months) During HHP (months) Before HHP (months) During HHP (months) SPA 1 SPA 2 HHP Enrollees Control Group Difference Change Change Difference-in- Between Before HHP During HHP Difference (DD) Changes SPA 1 HHP Enrollees 56* -58* -114* Control Group 52* -16* -68* -46* SPA 2 HHP Enrollees 40* -48* -88* Control Group 36* -22* -58* -30* Overall HHP Enrollees 52* -56* -107* Control Group 48* -18* -66* -42* UCLA Evaluation | 139 UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program Source: Medi-Cal claims data from July 1, 2016 through December 31, 2021. Notes: * Denotes p≤0.05, a statistically significant difference. SPA 1 includes enrollees with chronic conditions and substance use disorders. SPA 2 includes enrollees with severe mental illness. Change Before HHP is calculated as: (1 – 6 months before HHP minus 19 – 24 months before HHP divided by 3). Change During HHP is calculated as: (19-24 months during HHP minus 1 – 6 months during HHP). Difference between changes is calculated as: (Change During HHP –Change Before HHP). Difference-in- difference is calculated as: (Difference between changes for HHP enrollees – Difference between changes for control group). Any Hospitalization UCLA created a second measure of inpatient care utilization that assessed the likelihood of any hospitalization during each six-month period, which is distinct from the HHP core metric of the rate of hospitalizations. Exhibit 47 shows a significant decline in the proportion of enrollees with any hospitalization during HHP for SPA 1 (-1.3%) and SPA 2 (-1.3%). The decline in this proportion compared to before HHP was greater than that of the control group by 1.0% (DD) for SPA 1 and 0.8% for SPA 2 enrollees. Exhibit 47: Trends in Percentage of Patients with Any Hospitalization Before and During HHP by SPA as of December 31, 2021 20.0% 19.9% 18.9% 18.7% 17.6% 17.4% 17.3% 16.8% 16.5% 16.2% 15.8% 15.2% 14.9% 14.3% 14.2% 14.1% 14.0% 13.8% 13.4% 13.2% 13.2% 13.1% 12.7% 12.5% 12.3% 12.3% 12.2% 11.6% 11.6% 11.3% 11.1% 10.7% 19-24 13-18 7-12 1-6 1-6 7-12 13-18 19-24 19-24 13-18 7-12 1-6 1-6 7-12 13-18 19-24 Before HHP (months) During HHP (months) Before HHP (months) During HHP (months) SPA 1 SPA 2 HHP Enrollees Control Group Difference Change Change Difference-in- Between Before HHP During HHP Difference (DD) Changes SPA 1 HHP Enrollees 1.6%* -1.3%* -2.9%* Control Group 1.5%* -0.4%* -1.9%* -1.0%* SPA 2 HHP Enrollees 1.4%* -1.3%* -2.7%* Control Group 1.3%* -0.5%* -1.8%* -0.8%* Overall HHP Enrollees 1.5%* -1.3%* -2.8%* Control Group 1.4%* -0.4%* -1.9%* -1.0%* Source: Medi-Cal claims data from July 1, 2016 through December 31, 2021. Notes: * Denotes p≤0.05, a statistically significant difference. SPA 1 includes enrollees with chronic conditions and substance use disorders. SPA 2 includes enrollees with severe mental illness. Change Before HHP is calculated as: (1 – 6 months before HHP minus 19 – 24 months before HHP divided by 3). Change During HHP is calculated as: (19-24 months during HHP minus 1 – 138 | UCLA Evaluation UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program 6 months during HHP). Difference between changes is calculated as: (Change During HHP –Change Before HHP). Difference-in- difference is calculated as: (Difference between changes for HHP enrollees – Difference between changes for control group). UCLA Evaluation | 139 UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program Inpatient Length of Stay Inpatient Length of Stay is an HHP core metric that measures the average length of stay per hospitalization. The intended direction of the metric and DD is decrease. Exhibit 48 shows that lengths of stay were increasing during HHP for both SPA 1 and SPA 2, but the trends were similar with the control group. Exhibit 48: Trends in Average Inpatient Length of Stay in Days Before and During HHP by SPA as of December 31, 2021 6.0 6.0 5.9 5.9 5.8 5.7 5.6 5.6 5.5 5.5 5.4 5.3 5.3 5.2 5.2 5.2 5.2 5.1 5.1 5.1 5.1 5.0 5.0 4.9 4.9 4.9 4.8 4.8 4.7 4.6 4.6 4.5 19-24 13-18 7-12 1-6 1-6 7-12 13-18 19-24 19-24 13-18 7-12 1-6 1-6 7-12 13-18 19-24 Before HHP (months) During HHP (months) Before HHP (months) During HHP (months) SPA 1 SPA 2 HHP Enrollees Control Group Difference- Difference Change Change in- Between Before HHP During HHP Difference Changes (DD) SPA 1 HHP Enrollees 0 3* 3* Control Group 0 2* 2* 0 SPA 2 HHP Enrollees 1 3* 3 Control Group 1 1 0 2 Overall HHP Enrollees 0 3* 3* Control Group 0 2* 2* 1 Source: Medi-Cal claims data from July 1, 2016 through December 31, 2021. Notes: * Denotes p≤0.05, a statistically significant difference. SPA 1 includes enrollees with chronic conditions and substance use disorders. SPA 2 includes enrollees with severe mental illness. Change Before HHP is calculated as: (1 – 6 months before HHP minus 19 – 24 months before HHP divided by 3). Change During HHP is calculated as: (7 – 12 months of HHP minus 1 – 6 months of HHP). Difference between changes is calculated as: (Change During HHP –Change Before HHP). Difference-in- difference is calculated as: (Difference between changes for HHP enrollees – Difference between changes for control group). 138 | UCLA Evaluation UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program Institution Utilization Admission to an Institution from the Community Admission to an Institution from the Community is an HHP core metric that measures the number of admissions per 1,000 beneficiaries per year to an institutional facility among individuals of age 18 and older residing in the community for at least one month. The rate is reported for short stays (<20 days), medium stays (21-100 days) and long stays (>100 days). The criteria that determine whether admissions come from the community requires a full year of data. The intended direction of the metric and DD is decrease. UCLA Evaluation | 139 UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program Short Term Exhibit 49 shows no significant change in short-term admissions before or during HHP for either SPA 1 or SPA 2 enrollees or for their respective control groups. Exhibit 49: Trends in Admissions to an Institution from the Community (Short-Term Stay) Before and During HHP by SPA as of December 31, 2021 12 11 10 9 9 7 8 8 8 8 8 7 6 6 6 4 Pre-Year 2 Pre-Year 1 Year 1 Year 2 Pre-Year 2 Pre-Year 1 Year 1 Year 2 Before HHP During HHP Before HHP During HHP SPA 1 SPA 2 HHP Enrollees Compairson Group Change Change Pre- Difference Difference-in- Before Year 1 to HHP Between Difference (DD) HHP Year 1 Changes SPA 1 HHP Enrollees 2 0 -2 Control Group 1 0 -1 -1 SPA 2 HHP Enrollees 3 0 -3 Control Group 2 -1 -2 -1 Overall HHP Enrollees 2 0 -3 Control Group 1 0 -2 -1 Source: Medi-Cal claims data from July 1, 2016 through December 31, 2021. Notes: * Denotes p≤0.05, a statistically significant difference. SPA 1 includes enrollees with chronic conditions and substance use disorders. SPA 2 includes enrollees with severe mental illness. Change Before HHP is calculated as: (Pre-Year 1 – Pre-Year 2). Change Pre-Year 1 to HHP Year 1 is calculated as: (Year 1 – Pre-Year 1). Difference between changes is calculated as: (Change Pre-Year 1 to HHP Year 1 –Change Before HHP). Difference-in-difference is calculated as: (Difference between changes for HHP enrollees – Difference between changes for control group). Admission to an Institution from the Community is an HHP core metric that measures the number of admissions per 1,000 beneficiaries per year to an institutional facility among individuals of age 18 and older residing in the community for at least one month. The rate is reported for short stays (<20 days), medium stays (21-100 days) and long stays (>100 days). 138 | UCLA Evaluation UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program Medium Term Exhibit 50 shows no significant changes in medium-term admissions before or during HHP for either SPA 1 or SPA 2 enrollees or for their respective control groups. Exhibit 50: Trends in Admissions to an Institution from the Community (Medium-Term Stay) Before and During HHP by SPA as of December 31, 2021 13 13 13 13 11 12 11 10 10 9 9 9 8 8 7 6 Pre-Year 2 Pre-Year 1 Year 1 Year 2 Pre-Year 2 Pre-Year 1 Year 1 Year 2 Before HHP During HHP Before HHP During HHP SPA 1 SPA 2 HHP Enrollees Compairson Group Change Change Pre- Difference Difference-in- Before Year 1 to HHP Between Difference HHP Year 1 Changes (DD) SPA 1 HHP Enrollees 2 0 -2 Control Group 1 -1 -2 0 SPA 2 HHP Enrollees 2 2 1 Control Group 1 -1 -2 3 Overall HHP Enrollees 2 0 -1 Control Group 1 -1 -2 1 Source: Medi-Cal claims data from July 1, 2016 through December 31, 2021. Notes: * Denotes p≤0.05, a statistically significant difference. SPA 1 includes enrollees with chronic conditions and substance use disorders. SPA 2 includes enrollees with severe mental illness. Change Before HHP is calculated as: (Pre-Year 1 – Pre-Year 2). Change Pre-Year 1 to HHP Year 1 is calculated as: (Year 1 – Pre-Year 1). Difference between changes is calculated as: (Change Pre-Year 1 to HHP Year 1 –Change Before HHP). Difference-in-difference is calculated as: (Difference between changes for HHP enrollees – Difference between changes for control group). Admission to an Institution from the Community is an HHP core metric that measures the number of admissions per 1,000 beneficiaries per year to an institutional facility among individuals of age 18 and older residing in the community for at least one month. The rate is reported for short stays (<20 days), medium stays (21-100 days) and long stays (>100 days). UCLA Evaluation | 139 UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program Long term Exhibit 51 shows that HHP enrollees had a significantly increasing rate of long-term admissions before HHP, but no change in this rate during HHP. However, among the controls the rate of long-term admission declined during HHP by 2 admissions per 1,000 beneficiaries per year. As a result, compared to control groups, HHP enrollees had a significant increasing rate in long-term admissions from before to during HHP (1, DD). Exhibit 51: Trends in Admissions to an Institution from the Community (Long-Term Stay) Before and During HHP by SPA as of December 31, 2021 9 7 7 7 7 7 7 6 6 6 6 6 6 5 5 5 Pre-Year 2 Pre-Year 1 Year 1 Year 2 Pre-Year 2 Pre-Year 1 Year 1 Year 2 Before HHP During HHP Before HHP During HHP SPA 1 SPA 2 HHP Enrollees Compairson Group Change Difference Difference-in- Change Pre-Year Before Between Difference 1 to HHP Year 1 HHP Changes (DD) SPA 1 HHP Enrollees 1* 0 -1 Control Group 1* -2* -3* 1 SPA 2 HHP Enrollees 1* 0 -1 Control Group 1* -1 -3* 2 Overall HHP Enrollees 1* 0 -1 Control Group 1* -2* -3* 1* Source: Medi-Cal claims data from July 1, 2016 through December 31, 2021. Notes: * Denotes p≤0.05, a statistically significant difference. SPA 1 includes enrollees with chronic conditions and substance use disorders. SPA 2 includes enrollees with severe mental illness. Change Before HHP is calculated as: (Pre-Year 1 – Pre-Year 2). Change Pre-Year 1 to HHP Year 1 is calculated as: (Year 1 – Pre-Year 1). Difference between changes is calculated as: (Change Pre-Year 1 to HHP Year 1 –Change Before HHP). Difference-in-difference is calculated as: (Difference between changes for HHP enrollees – Difference between changes for control group). Admission to an Institution from the Community is an HHP core metric that measures the number of admissions per 1,000 beneficiaries per year to an institutional facility among individuals of age 18 and older residing in the community for at least one month. The rate is reported for short stays (<20 days), medium stays (21-100 days) and long stays (>100 days). 138 | UCLA Evaluation UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program Utilization of Long-Term Care UCLA created an additional measure of long-term care facility utilization that examined rate of any long-term care stay regardless of the whether the admission came from the community or another inpatient setting and length of stay. This measure includes all of the stays that were used to estimate the cost of long-term care stays presented in Chapter 8. Exhibit 52 shows the rate of long-term care stays was decreasing significantly before HHP for both SPA 1 (-2 stays per 1,000 beneficiaries per year) and SPA 2 (-3) enrollees. During HHP, this measure increased significantly for SPA 1 (7) enrollees but did not change significantly for SPA 2 enrollees. The changes in long-term care stays for SPA 1 and SPA 2 enrollees from before to during HHP were not significantly greater when compared to the changes in their respective control groups. The overall increase in this metric for HHP enrollees was significantly greater than that of the control groups overall, by 2 stays per 1,000 beneficiaries per year (DD). UCLA Evaluation | 139 UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program Exhibit 52: Trends in Number of Long-Term Care Stays per 1,000 Beneficiaries per Year Before and During HHP by SPA as of December 31, 2021 123 121 116 112 110 106 105 100 99 94 90 89 89 88 84 80 77 72 70 70 68 67 65 64 63 62 62 61 60 60 56 55 19-24 13-18 7-12 1-6 1-6 7-12 13-18 19-24 19-24 13-18 7-12 1-6 1-6 7-12 13-18 19-24 Before HHP (months) During HHP (months) Before HHP (months) During HHP (months) SPA 1 SPA 2 HHP Enrollees Control Group Difference Change Change Difference-in- Between Before HHP During HHP Difference (DD) Changes SPA 1 HHP Enrollees -2* 7* 9* Control Group -2* 5* 7* 2 SPA 2 HHP Enrollees -3* 3 6* Control Group -2* 1 3* 2 Overall HHP Enrollees -2* 6* 8* Control Group -2* 4* 6* 2* Source: Medi-Cal claims data from July 1, 2016 through December 31, 2021. Notes: * Denotes p≤0.05, a statistically significant difference. SPA 1 includes enrollees with chronic conditions and substance use disorders. SPA 2 includes enrollees with severe mental illness. Change Before HHP is calculated as: (1 – 6 months before HHP minus 19 – 24 months before HHP divided by 3). Change During HHP is calculated as: (19-24 months during HHP minus 1 – 6 months during HHP). Difference between changes is calculated as: (Change During HHP –Change Before HHP). Difference-in- difference is calculated as: (Difference between changes for HHP enrollees – Difference between changes for control group). 138 | UCLA Evaluation UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program HHP Process Metrics Trends in six HHP specified metrics were examined on an annual basis. Adult Body Mass Index Assessment Adult Body Mass Index Assessment is an HHP core metric that measures the percentage of beneficiaries between the ages of 18 and 74 who had an outpatient visit and whose body mass index (BMI) was documented during the measurement year or the year prior to the measurement year. The intended direction of this metric and DD is increase. Exhibit 53 shows a significant decrease in documented BMI from HHP Year 1 to HHP Year 2 for HHP SPA 1 enrollees (-4.6%) and SPA 2 enrollees (-5.1%). For SPA 1 HHP enrollees, the decline in documented BMI was significantly smaller than the declined observed in the control group (1.2%, DD). The same pattern was observed for SPA 2 enrollees (2.2%, DD). Exhibit 53: Trends in Adult Body Mass Index Assessment Before and During HHP by SPA for HHP Enrollees and the Control group as of December 31, 2021 70.5% 70.4% 69.0% 66.6% 64.4% 68.1% 68.2% 64.1% 62.6% 62.5% 62.2% 62.1% 61.2% 60.8% 58.9% 53.8% Pre-Year 2 Pre-Year 1 Year 1 Year 2 Pre-Year 2 Pre-Year 1 Year 1 Year 2 Before HHP During HHP Before HHP During HHP SPA 1 SPA 2 HHP Enrollees Control Group Difference Difference-in- Change Change Between Difference Before HHP During HHP Changes (DD) SPA 1 HHP Enrollees 7.9%* -4.6%* -12.5%* Control Group 7.9%* -5.8%* -13.7%* 1.2%* SPA 2 HHP Enrollees 6.0%* -5.1%* -11.2%* Control Group 6.0%* -7.3%* -13.3%* 2.2%* Overall HHP Enrollees 7.4%* -4.7%* -12.2%* Control Group 7.4%* -6.2%* -13.6%* 1.4%* UCLA Evaluation | 139 UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program Source: Medi-Cal claims data from July 1, 2016 through December 31, 2021. Notes: * Denotes p≤0.05, a statistically significant difference. SPA 1 includes enrollees with chronic conditions and substance use disorders. SPA 2 includes enrollees with severe mental illness. Change Before HHP is calculated as: (Pre-Year 1 – Pre-Year 2). Change During HHP is calculated as: (Year 2 – Year 1). Difference between changes is calculated as: (Change During HHP – Change Before HHP). Difference-in-difference is calculated as: (Difference between changes for HHP enrollees – Difference between changes for control group). Adult Body Mass Index Assessment is an HHP core metric that measures the percentage of beneficiaries between the ages of 18 and 74 who had an outpatient visit and whose body mass index (BMI) was documented during the measurement year or the year prior to the measurement year. 138 | UCLA Evaluation UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program Screening for Depression and Follow-Up Plan Screening for Depression and Follow-Up Plan is an HHP core metric that measures the percentage of beneficiaries aged 12 and older with an outpatient visit in the measurement year who were screened for depression and had a documented follow-up plan on the date of the positive screen. This metric was not reported for SPA 2 because the metric specifications exclude enrollees with an active diagnosis of depression or bipolar disorder, which were very common conditions among the SPA 2 enrollees. An increase in this metric and DD is intended. Exhibit 54 shows a significant increase in this metric before HHP for SPA 1 enrollees (3.8%) and the control group (3.6%). During HHP there was no significant change in this metric for either SPA 1 or the control group. The change in trend from before to during HHP was not significantly different for HHP enrollees compared to their controls. Exhibit 54: Trends in Screening for Depression and Follow-Up Plan Before and During HHP for SPA 1 HHP Enrollees and the Control group as of December 31, 2021 12.3% 11.6% 12.7% 12.6% 11.2% 11.4% 8.6% 8.0% Pre-Year 2 Pre-Year 1 Year 1 Year 2 Before HHP During HHP SPA 1 HHP Enrollees Compairson Group Change Change Difference Difference-in- Before HHP During HHP Between Changes Difference (DD) SPA 1 HHP Enrollees 3.8%* -0.1% -3.9%* Control Group 3.6%* 0.2% -3.3%* -0.5% Source: Medi-Cal claims data from July 1, 2016 through December 31, 2021. Notes: * Denotes p≤0.05, a statistically significant difference. SPA 1 includes enrollees with chronic conditions and substance use disorders. SPA 2 includes enrollees with severe mental illness. Change Before HHP is calculated as: (Pre-Year 1 – Pre-Year 2). Change During HHP is calculated as: (Year 2 – Year 1). Difference between changes is calculated as: (Change During HHP – Change Before HHP). Difference-in-difference is calculated as: (Difference between changes for HHP enrollees – Difference between changes for control group). Screening for Depression and Follow-Up Plan is an HHP core metric that measures the percentage of beneficiaries aged 12 and older with an outpatient visit in the measurement year who were screened for depression and had a documented follow-up plan on the date of the positive screen. UCLA Evaluation | 139 UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program Follow-Up After Hospitalization for Mental Illness Follow-Up After Hospitalization for Mental Illness is an HHP core metric that measures the percentage of beneficiaries aged 6 and older who were hospitalized for treatment of selected mental illness in the measurement year and who had a follow-up visit within 7 and 30 days with a mental health practitioner. The intended direction of the metric and DD is increase. Exhibit 55 shows that the trends for 7-day follow-up did not change significantly for SPA 1 or SPA 2 enrollees during HHP or between HHP enrollees and the control group. Exhibit 55: Trends in Follow-Up After Hospitalization for Mental Illness within 7 Days Before and During HHP by SPA for HHP Enrollees and the Control group as of December 31, 2021 51.2% 51.2% 54.8% 50.8% 50.5% 50.4% 48.7% 48.6% 48.4% 48.0% 47.3% 46.6% 46.3% 46.1% 42.1% 42.0% Pre-Year 2 Pre-Year 1 Year 1 Year 2 Pre-Year 2 Pre-Year 1 Year 1 Year 2 Before HHP During HHP Before HHP During HHP SPA 1 SPA 2 HHP Enrollees Compairson Group Change Difference-in- Change Difference During Difference Before HHP Between Changes HHP (DD) SPA 1 HHP Enrollees 0.1% -0.7% -0.8% -0.6% Control Group 0.1% -0.1% -0.3% SPA 2 HHP Enrollees 2.8% 3.5% 0.7% 3.7% Control Group 2.8% -0.2% -3.0% Overall HHP Enrollees 1.7% 1.8% 0.1% 2.0% Control Group 1.7% -0.2% -1.9% Source: Medi-Cal claims data from July 1, 2016 through December 31, 2021. Notes: * Denotes p≤0.05, a statistically significant difference. SPA 1 includes enrollees with chronic conditions and substance use disorders. SPA 2 includes enrollees with severe mental illness. Change Before HHP is calculated as: (Pre-Year 1 – Pre-Year 2). Change During HHP is calculated as: (Year 2 – Year 1). Difference between changes is calculated as: (Change During HHP – Change Before HHP). Difference-in-difference is calculated as: (Difference between changes for HHP enrollees – Difference 138 | UCLA Evaluation UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program between changes for control group). Follow-Up After Hospitalization for Mental Illness is an HHP core metric that measures the percentage of beneficiaries aged 6 and older who were hospitalized for treatment of selected mental illness in the measurement year and who had a follow-up visit within 7 and 30 days with a mental health practitioner. Exhibit 56 shows that that the trends for 30-day follow-up also did not change significantly for SPA 1 or SPA 2 enrollees during HHP or between HHP enrollees and the control group. Before HHP, this metric was increasing significantly for SPA 1 HHP enrollees (5.0%). Exhibit 56: Trends in Follow-Up After Hospitalization for Mental Illness within 30 Days Before and During HHP by SPA for HHP Enrollees and the Control group as of December 31, 2021 76.6% 75.8% 75.3% 75.4% 75.6% 74.6% 73.8% 73.7% 73.5% 71.6% 71.6% 71.1% 70.9% 69.7% 66.1% 65.3% Pre-Year 2 Pre-Year 1 Year 1 Year 2 Pre-Year 2 Pre-Year 1 Year 1 Year 2 Before HHP During HHP Before HHP During HHP SPA 1 SPA 2 HHP Enrollees Compairson Group Change Difference Difference-in- Change During Between Difference Before HHP HHP Changes (DD) SPA 1 HHP Enrollees 5.0%* -2.4% -7.4% Control Group 4.9%* -0.8% -5.7% -1.7% SPA 2 HHP Enrollees 1.6% -4.5% -6.1% Control Group 1.6% -0.8% -2.4% -3.7% Overall HHP Enrollees 3.0%* -3.6% -6.6% Control Group 2.9%* -0.8% -3.7% -2.9% Source: Medi-Cal claims data from July 1, 2016 through December 31, 2021. Notes: * Denotes p≤0.05, a statistically significant difference. SPA 1 includes enrollees with chronic conditions and substance use disorders. SPA 2 includes enrollees with severe mental illness. Change Before HHP is calculated as: (Pre-Year 1 – Pre-Year 2). Change During HHP is calculated as: (Year 2 – Year 1). Difference between changes is calculated as: (Change During HHP – Change Before HHP). Difference-in-difference is calculated as: (Difference between changes for HHP enrollees – Difference between changes for control group). Follow-Up After Hospitalization for Mental Illness is an HHP core metric that measures the percentage of beneficiaries aged 6 and older who were hospitalized for treatment of selected mental illness in the measurement year and who had a follow-up visit within 7 and 30 days with a mental health practitioner. UCLA Evaluation | 139 UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program Follow-Up After Emergency Department Visit for Alcohol and Other Drug Abuse or Dependence Follow-Up after Emergency Department Visit for Alcohol and Other Drug Abuse or Dependence is an HHP core metric that measures the percentage of emergency department (ED) visits in the measurement year among individuals aged 13 and older with a principal diagnosis of alcohol and other drug (AOD) abuse or dependence who had a follow-up visit for AOD abuse or dependence. The measure is reported for follow-up within 7 days and within 30 days. The intended direction of the metric and DD is increase. 138 | UCLA Evaluation UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program Exhibit 57 shows that for SPA 1, during HHP, there was a significant decrease by 2.7% in follow- ups after ED visits for AOD abuse or dependence within 7 days. For SPA 2 enrollees, no significant trends were observed for this metric during HHP. There were no significant differences in trends for SPA 1 or SPA 2 enrollees when compared to their control groups; however, HHP enrollees overall had a larger decrease in this metric from before to during HHP when compared to the control groups overall (2.23%, DD). UCLA Evaluation | 139 UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program Exhibit 57: Trends in Follow-Up After ED Visit for Alcohol and Other Drug Abuse and Dependence within 7 Days Before and During HHP by SPA for HHP Enrollees and the Control Group as of December 31, 2021 8.4% 7.9% 7.6% 7.5% 7.1% 6.9% 6.8% 6.5% 6.5% 6.3% 6.1% 6.1% 6.0% 5.7% 5.1% 4.9% Pre-Year 2 Pre-Year 1 Year 1 Year 2 Pre-Year 2 Pre-Year 1 Year 1 Year 2 Before HHP During HHP Before HHP During HHP SPA 1 SPA 2 HHP Enrollees Compairson Group Difference Difference- Change Change Between in-Difference Before HHP During HHP Changes (DD) SPA 1 HHP Enrollees 0.6% -2.7%* -3.3%* Control Group 0.6% -1.2% -1.7% -1.6% SPA 2 HHP Enrollees 1.6%* -1.7% -3.3% Control Group 1.4%* 1.2% -0.2% -3.1% Overall HHP Enrollees 1.0%* -2.3%* -3.3%* Control Group 0.9%* -0.2% -1.1% -2.2%* Source: Medi-Cal claims data from July 1, 2016 through December 31, 2021. Notes: * Denotes p≤0.05, a statistically significant difference. SPA 1 includes enrollees with chronic conditions and substance use disorders. SPA 2 includes enrollees with severe mental illness. Change Before HHP is calculated as: (Pre-Year 1 – Pre-Year 2). Change During HHP is calculated as: (Year 2 – Year 1). Difference between changes is calculated as: (Change During HHP – Change Before HHP). Difference-in-difference is calculated as: (Difference between changes for HHP enrollees – Difference between changes for control group). Follow-Up after Emergency Department Visit for Alcohol and Other Drug Abuse or Dependence is an HHP core metric that measures the percentage of emergency department (ED) visits in the measurement year among individuals aged 13 and older with a principal diagnosis of alcohol and other drug (AOD) abuse or dependence who had a follow-up visit for AOD abuse or dependence. 138 | UCLA Evaluation UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program Exhibit 58 shows that for SPA 1, during HHP, there was a significant decrease (3.4%) in follow- ups after ED visits for AOD abuse or dependence within 30 days. For SPA 2 enrollees, no significant trends were observed for this metric during HHP. There were no significant differences in trends for SPA 1 or SPA 2 enrollees when compared to their control groups. Exhibit 58: Trends in Follow-Up After ED Visit for Alcohol and Other Drug Abuse and Dependence within 30 Days Before and During HHP by SPA for HHP Enrollees and the Control Group as of December 31, 2021 16.8% 15.9% 15.2% 14.3% 13.5% 13.5% 12.8% 12.6% 12.6% 12.5% 12.2% 11.5% 11.3% 11.0% 10.9% 10.7% Pre-Year 2 Pre-Year 1 Year 1 Year 2 Pre-Year 2 Pre-Year 1 Year 1 Year 2 Before HHP During HHP Before HHP During HHP SPA 1 SPA 2 HHP Enrollees Compairson Group Difference- Difference Change Before Change During in- Between HHP HHP Difference Changes (DD) SPA 1 HHP Enrollees 1.3% -3.6%* -4.9%* Control Group 1.3% -1.5% -2.8%* -2.1% SPA 2 HHP Enrollees 4.1%* -2.4% -6.5%* Control Group 3.7%* 0.9% -2.8% -3.7% Overall HHP Enrollees 2.5%* -3.1%* -5.6%* Control Group 2.3%* -0.5% -2.8%* -2.8% Source: Medi-Cal claims data from July 1, 2016 through December 31, 2021. Notes: * Denotes p≤0.05, a statistically significant difference. SPA 1 includes enrollees with chronic conditions and substance use disorders. SPA 2 includes enrollees with severe mental illness. Change Before HHP is calculated as: (Pre-Year 1 – Pre-Year 2). Change During HHP is calculated as: (Year 2 – Year 1). Difference between changes is calculated as: (Change During HHP – Change Before HHP). Difference-in-difference is calculated as: (Difference between changes for HHP enrollees – Difference between changes for control group). Follow-Up after Emergency Department Visit for Alcohol and Other Drug Abuse or Dependence is an HHP core metric that measures the percentage of emergency department (ED) visits in the measurement year among individuals aged 13 and older with a principal diagnosis of alcohol and other drug (AOD) abuse or dependence who had a follow-up visit for AOD abuse or dependence. UCLA Evaluation | 139 UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program Initiation and Engagement of Alcohol and Other Drug Abuse or Dependence Treatment Initiation of AOD Abuse or Dependence Treatment is an HHP core metric that measures the percentage of individuals aged 13 and older with a new episode of AOD abuse or dependence in the measurement year who received initiation of treatment within 14 days of the diagnosis. The intended direction of this metric and DD is increase. Exhibit 59 shows that for SPA 1 enrollees, initiation of AOD treatment was significantly increasing prior to HHP (1.2%), but the change in this metric during HHP was not significant. For SPA 2 enrollees, there were no significant changes in this metric before or during HHP, and compared to control groups, neither SPA 1 nor SPA 2 had any significant changes in this metric. Exhibit 59: Trends in Initiation of Alcohol and Other Drug Abuse or Dependence Treatment Before and During HHP by SPA for HHP Enrollees and the Control Group as of December 31, 2021 26.3% 26.3% 25.6% 25.6% 25.5% 25.0% 22.4% 22.4% 20.9% 20.7% 20.7% 20.0% 19.8% 19.5% 18.1% 16.9% Pre-Year 2 Pre-Year 1 Year 1 Year 2 Pre-Year 2 Pre-Year 1 Year 1 Year 2 Before HHP During HHP Before HHP During HHP SPA 1 SPA 2 HHP Enrollees Control Group Difference Difference- Change Change During Between in-Difference Before HHP HHP Changes (DD) SPA 1 HHP Enrollees 1.2%* -1.2% -2.3%* Control Group 1.2%* -0.7% -1.8%* -0.5% SPA 2 HHP Enrollees -0.7% -2.6% -1.8% Control Group -0.7% -3.1%* -2.3%* 0.5% Overall HHP Enrollees 0.5% -1.6%* -2.2%* Control Group 0.5% -1.5%* -2.0%* -0.2% 138 | UCLA Evaluation UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program Source: Medi-Cal claims data from July 1, 2016 through December 31, 2021. Notes: * Denotes p≤0.05, a statistically significant difference. SPA 1 includes enrollees with chronic conditions and substance use disorders. SPA 2 includes enrollees with severe mental illness. Change Before HHP is calculated as: (Pre-Year 1 – Pre-Year 2). Change During HHP is calculated as: (Year 2 – Year 1). Difference between changes is calculated as: (Change During HHP – Change Before HHP). Difference-in-difference is calculated as: (Difference between changes for HHP enrollees – Difference between changes for control group). Initiation of AOD Abuse or Dependence Treatment is an HHP core metric that measures the percentage of individuals aged 13 and older with a new episode of AOD abuse or dependence in the measurement year who received initiation of treatment within 14 days of the diagnosis. UCLA Evaluation | 139 UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program Engagement of AOD Abuse or Dependence Treatment is an HHP core metric that measures the percentage of beneficiaries aged 13 and older that initiated AOD abuse or dependence treatment and who were engaged in ongoing treatment within 34 days of the initiation visit. The intended direction of the metric and DD is increase. Exhibit 60 shows that for SPA 1 enrollees, engagement in AOD treatment was significantly increasing prior to HHP (1.4%), but the change in this metric during HHP was not significant. For SPA 2 enrollees, there were no significant changes in this metric before or during HHP, and compared to control groups, neither SPA 1 nor SPA 2 had any significant changes in this metric. Exhibit 60: Trends in Engagement of Alcohol and Other Drug Abuse or Dependence Treatment Before and During HHP by SPA for HHP Enrollees and the Control Group as of December 31, 2021 21.4% 25.3% 25.5% 26.2% 26.3% 25.6% 26.9% 23.4% 23.4% 21.1% 21.0% 19.9% 19.7% 19.5% 18.5% 17.6% Pre-Year 2 Pre-Year 1 Year 1 Year 2 Pre-Year 2 Pre-Year 1 Year 1 Year 2 Before HHP During HHP Before HHP During HHP SPA 1 SPA 2 HHP Enrollees Control Group Difference Change Change During Difference-in- Between Before HHP HHP Difference (DD) Changes SPA 1 HHP Enrollees 1.4%* -0.9% -2.3%* Control Group 1.4%* -1.5%* -2.9%* 0.6% SPA 2 HHP Enrollees 0.8% -2.2% -3.1%* Control Group 0.9% -3.4%* -4.3%* 1.2% Overall HHP Enrollees 1.2%* -1.3% -2.6%* Control Group 1.2%* -2.2%* -3.4%* 0.8% Source: Medi-Cal claims data from July 1, 2016 through December 31, 2021. Notes: * Denotes p≤0.05, a statistically significant difference. SPA 1 includes enrollees with chronic conditions and substance use disorders. SPA 2 includes enrollees with severe mental illness. Change Before HHP is calculated as: (Pre-Year 1 – Pre-Year 2). Change During HHP is calculated as: (Year 2 – Year 1). Difference between changes is calculated as: (Change During HHP – Change Before HHP). Difference-in-difference is calculated as: (Difference between changes for HHP enrollees – Difference between changes for control group). Initiation of AOD Abuse or Dependence Treatment is an HHP core metric that measures the percentage of individuals aged 13 and older with a new episode of AOD abuse or dependence in the measurement year who received initiation of treatment within 14 days of the diagnosis. 138 | UCLA Evaluation UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program Use of Pharmacotherapy for Opioid Use Disorder Use of Pharmacotherapy for Opioid Use Disorder is an HHP core metric that measures the percentage of beneficiaries aged 18 to 64 with an opioid use disorder (OUD) who filled a prescription or were administered a medication for the disorder during the measurement year. The intended direction of the metric and DD is increase. Exhibit 61 does not show a change in this metric for SPA 1 or SPA 2 enrollees and their control groups during HHP. There were also no significant differences in changes for SPA 1 and SPA 2 enrollees when compared with their control groups. Exhibit 61: Trends in Use of Pharmacotherapy for Opioid Use Disorder Before and During HHP by SPA for HHP Enrollees and the Control Group as of December 31, 2021 31.1% 30.6% 34.1% 33.6% 32.0% 32.4% 30.6% 32.1% 26.8% 26.6% 26.3% 26.1% 25.7% 25.5% 25.3% 25.3% Pre-Year 2 Pre-Year 1 Year 1 Year 2 Pre-Year 2 Pre-Year 1 Year 1 Year 2 Before HHP During HHP Before HHP During HHP SPA 1 SPA 2 HHP Enrollees Control Group Difference Difference- Change Change Between in-Difference Before HHP During HHP Changes (DD) SPA 1 HHP Enrollees 0.9%* -1.3% -2.2%* Control Group 0.9%* -1.1%* -1.9%* -0.3% SPA 2 HHP Enrollees 3.0%* -1.4% -4.4%* Control Group 3.0%* -0.3% -3.3%* -1.1% Overall HHP Enrollees 1.5%* -1.4%* -2.9%* Control Group 1.5%* -0.8% -2.4%* -0.5% Source: Medi-Cal claims data from July 1, 2016 through December 31, 2021. Notes: * Denotes p≤0.05, a statistically significant difference. SPA 1 includes enrollees with chronic conditions and substance use disorders. SPA 2 includes enrollees with severe mental illness. Change Before HHP is calculated as: (Pre-Year 1 – Pre-Year 2). Change During HHP is calculated as: (Year 2 – Year 1). Difference between changes is calculated as: (Change During HHP – Change Before HHP). Difference-in-difference is calculated as: (Difference between changes for HHP enrollees – Difference between changes for control group). Use of Pharmacotherapy for Opioid Use Disorder is an HHP core metric that measures the percentage of beneficiaries aged 18 to 64 with an opioid use disorder (OUD) who filled a prescription or were administered a medication for the disorder during the measurement year. UCLA Evaluation | 139 UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program HHP Outcome Metrics Trends in three HHP specified metrics were examined on an annual basis. Controlling High Blood Pressure Controlling High Blood Pressure is an HHP core metric that measures the percentage of beneficiaries aged 18 to 85 who had a diagnosis of hypertension and whose blood pressure was adequately controlled during the measurement year. The intended direction is increase. Exhibit 62 shows that there was a significant increase in SPA 1 HHP enrollees with controlled high blood pressure both before HHP (1.0%) and from Pre-Year 1 to HHP Year 1 (1.9%). Similar trends were observed for SPA 2 for whom there was a significant increase in this metric from Pre-Year 1 to HHP Year 1 (6.2%). Both SPA 1 and SPA 2 enrollees showed an increase in this metric that was significantly greater than that of the control groups, by 2.5% and 4.8% respectively (DD). Exhibit 62: Trends in Controlling High Blood Pressure Before and During HHP by SPA for HHP Enrollees and the Control Group as of December 31, 2021 21.3% 27.4% 21.2% 20.4% 19.9% 19.7% 19.4% 19.3% 19.1% 18.1% 17.9% 17.6% 17.0% 16.9% 16.3% 16.3% Pre-Year 2 Pre-Year 1 Year 1 Year 2 Pre-Year 2 Pre-Year 1 Year 1 Year 2 Before HHP During HHP Before HHP During HHP SPA 1 SPA 2 HHP Enrollees Control Group Difference Difference- Change Change Between in-Difference Before HHP During HHP Changes (DD) SPA 1 HHP Enrollees 1.0%* 1.9%* 1.0%* Control Group 0.9%* -0.6%* -1.5%* 2.5%* SPA 2 HHP Enrollees 0.6% 6.2%* 5.6%* Control Group 0.6% 1.3%* 0.7% 4.8%* Overall HHP Enrollees 0.9%* 2.7%* 1.8%* Control Group 0.9%* -0.2% -1.1%* 2.9%* Source: Medi-Cal claims data from July 1, 2016 through December 31, 2021. Notes: * Denotes p≤0.05, a statistically significant difference. SPA 1 includes enrollees with chronic conditions and substance use disorders. SPA 2 includes enrollees with severe mental illness. Change Before HHP is calculated as: (Pre-Year 1 – Pre-Year 2). Change During HHP is calculated as: (Year 2 – Year 1). Difference between changes is calculated as: (Change During HHP – 138 | UCLA Evaluation UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program Change Before HHP). Difference-in-difference is calculated as: (Difference between changes for HHP enrollees – Difference between changes for control group). Controlling High Blood Pressure is an HHP core metric that measures the percentage of beneficiaries aged 18 to 85 who had a diagnosis of hypertension and whose blood pressure was adequately controlled during the measurement year. UCLA Evaluation | 139 UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program Plan All-Cause Readmission Plan All-Cause Readmission is an HHP core metric that measures the percentage of acute inpatient and observation stays during the measurement year that were followed by an unplanned acute readmission for any diagnosis within 30 days for beneficiaries ages 18 to 64. The intended direction is decrease. Exhibit 63 shows that readmission rates did not significantly change during HHP and the change in rate from before HHP was only significantly different for SPA 1 enrollees (-1.56%). Neither SPA 1 nor SPA 2 enrollees had significantly greater changes in the rates from before to during HHP when compared to the control group. Exhibit 63: Trends in Plan All-Cause Readmission Before and During HHP by SPA for HHP Enrollees and the Control Group as of December 31, 2021 10.0% 10.1% 10.3% 10.2% 10.0% 9.9% 9.9% 9.8% 9.8% 9.6% 9.6% 9.5% 9.0% 9.0% 8.8% 8.3% Pre-Year 2 Pre-Year 1 Year 1 Year 2 Pre-Year 2 Pre-Year 1 Year 1 Year 2 Before HHP During HHP Before HHP During HHP SPA 1 SPA 2 HHP Enrollees Compairson Group Difference- Difference Change Change During in- Between Before HHP HHP Difference Changes (DD) SPA 1 HHP Enrollees 1.1%* -0.5% -1.6%* Control Group 1.1%* -0.3% -1.4%* -0.2% SPA 2 HHP Enrollees 0% -1.2% -1.2% Control Group 0% -1.3%* -1.3%* 0.1% Overall HHP Enrollees 0.8%* -0.7% -1.5%* Control Group 0.8%* -0.6%* -1.4%* -0.1% Source: Medi-Cal claims data from July 1, 2016 through December 31, 2021. Notes: * Denotes p≤0.05, a statistically significant difference. SPA 1 includes enrollees with chronic conditions and substance use disorders. SPA 2 includes enrollees with severe mental illness. Change Before HHP is calculated as: (Pre-Year 1 – Pre-Year 2). Change During HHP is calculated as: (Year 2 – Year 1). Difference between changes is calculated as: (Change During HHP – Change Before HHP). Difference-in-difference is calculated as: (Difference between changes for HHP enrollees – Difference between changes for control group). Plan All-Cause Readmission is an HHP core metric that measures the percentage of acute 138 | UCLA Evaluation UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program inpatient and observation stays during the measurement year that were followed by an unplanned acute readmission for any diagnosis within 30 days for beneficiaries ages 18 to 64. Prevention Quality Indicator (PQI) 92: Chronic Conditions Composite PQI 92 is an HHP core metric that measures the number of inpatient hospital admissions for ambulatory care sensitive chronic conditions per 100,000 member months for individuals aged 18 and older. The intended direction of the metric and DD is decrease. Exhibit 64 shows that PQI was significantly increasing before HHP for SPA 1 and SPA 2 enrollees. The rates then declined significantly during HHP for both SPA 1 and SPA 2 enrollees. SPA 1 rates declined significantly from before to during HHP compared to the control group (-90, DD), but SPA 2 rates did not decline more compared to the control group. Exhibit 64: Trends in Prevention Quality Indicator (PQI) 92: Chronic Conditions Composite Before and During HHP by SPA for HHP Enrollees and the Control Group as of December 31, 2021 1027 867 831 770 737 650 636 592 420 398 379 357 339 324 313 299 Pre-Year 2 Pre-Year 1 Year 1 Year 2 Pre-Year 2 Pre-Year 1 Year 1 Year 2 Before HHP During HHP Before HHP During HHP SPA 1 SPA 2 HHP Enrollees Compairson Group Difference Difference- Change Change During Between in-Difference Before HHP HHP Changes (DD) SPA 1 HHP Enrollees 257* -95* -351* Control Group 217* -44* -261* -90* SPA 2 HHP Enrollees 63* -65* -128* Control Group 59* -25 -85* -43 Overall HHP Enrollees 209* -87* -296* Control Group 178* -39* -217* -79* Source: Medi-Cal claims data from July 1, 2016 through December 31, 2021. Notes: * Denotes p≤0.05, a statistically significant difference. SPA 1 includes enrollees with chronic conditions and substance use disorders. SPA 2 includes enrollees with severe mental illness. Change Before HHP is calculated as: (Pre-Year 1 – Pre-Year 2). Change During HHP is calculated as: (Year 2 – Year 1). Difference between changes is calculated as: (Change During HHP – Change Before HHP). Difference-in-difference is calculated as: (Difference between changes for HHP enrollees – Difference between changes for control group). PQI 92 is an HHP core metric that measures the number of inpatient hospital admissions for ambulatory care sensitive chronic conditions per 100,000 member months for individuals aged 18 and older. UCLA Evaluation | 139 UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program Estimated Medi-Cal Payments among HHP Enrollees and HHP Costs This section addresses the following HHP evaluation questions: 1. Did Medi-Cal expenditures for health services decline after HHP implementation? 2. Did Medi-Cal expenditures for needed outpatient services increase? UCLA calculated estimated payments for all services provided to HHP enrollees and the control group before HHP and during HHP using Medi-Cal claims and encounter data. Payments were estimated by creating mutually exclusive categories of service and attributing a fee to each Medi-Cal claim in that category (Appendix A: Attributing Estimated Medi-Cal Payments to Claims). This methodology allowed UCLA to estimate payments for HHP enrollees and the control group before each enrollee's HHP enrollment and during HHP and assess if payments for HHP enrollees declined more than for the control group using the DD methodology. UCLA developed DD models to measure changes in total estimated payments and in specific categories of services including ED visits, hospitalizations, outpatient medication, and outpatient services. UCLA examined changes in six month increments up to 24 months (1-6, 7-12, 13-18, and 19-24) before HHP enrollment and up to 24 months (1-6, 7-12, 13-18, and 19-24) during HHP. The DD analysis measured the change from 19-24 vs. 1-6 months before HHP for both HHP enrollees and the control group; the change during HHP from 1-6 to 19-24 months for both HHP enrollees and the control group; and the difference between the changes in HHP enrollees vs. the control group. The shorter timeframe for examining payments allowed for a clearer assessment of change during the early phase of HHP implementation. The findings were not subject to potential seasonality in service utilization due to rolling enrollment throughout the year and measuring change following the date of enrollment per beneficiary. The payment amounts reported in this section are estimates and are not equivalent to overall Medi-Cal expenditures for multiple reasons, including significant differences between this attribution methodology vs. per member per month payments to managed care plans for enrolled beneficiaries. These estimated payments are primarily intended to compare change in trends between HHP enrollees and the control group. See (Appendix A: Data Sources and Methods) for further detail and limitations. 120 UCLA Evaluation | UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program Estimated Payments for HHP Services Total Estimated Medi-Cal Payments UCLA measured total estimated Medi-Cal payments before and during HHP. The payment estimates were generated using the methodology described above and detailed further in the Appendix A. These estimates are intended for measuring whether HHP led to efficiencies and do not represent actual Medi-Cal expenditures for HHP enrollees. Examples of Medi-Cal expenditures include inpatient and outpatient services, pharmaceuticals, imaging and laboratory services, behavioral health services, and long-term care stays. UCLA Evaluation | 121 UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program Exhibit 65 shows that total estimated payments were significantly increasing for SPA 1 ($1,484 per beneficiary per year) and for SPA 2 ($1,390) before HHP. The total estimated payments declined during HHP by $1,017 and $1,113 per beneficiary per year for SPA 1 and SPA 2 enrollees, respectively. Compared to control groups, the decrease in payments from before HHP to during HHP was significantly greater for both SPA 1 and SPA 2, by $1,074 (DD) and $1,232 (DD) per beneficiary per year, respectively. 122 UCLA Evaluation | UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program Exhibit 65: Trends in Total Estimated Payments per Beneficiary per Year Before and During HHP by SPA as of December 2021 $24,158 $25,251 $25,480 $24,122 $23,444 $23,304 $23,071 $22,568 $22,429 $21,978 $21,899 $20,800 $20,718 $20,582 $20,361 $20,105 $19,822 $19,497 $19,167 $19,134 $18,886 $18,867 $18,673 $18,084 $18,033 $17,957 $17,945 $17,721 $17,472 $17,066 $16,315 $15,332 19-24 13-18 7-12 1-6 1-6 7-12 13-18 19-24 19-24 13-18 7-12 1-6 1-6 7-12 13-18 19-24 Before HHP (months) During HHP (months) Before HHP (months) During HHP (months) SPA 1 SPA 2 HHP Enrollees Control Group Difference- Difference Change Change During in- Between Before HHP HHP Difference Changes (DD) SPA 1 HHP Enrollees $1,484* -$1,017* -$2,501* -$1,074* Control Group $1,217* -$210* -$1,427* SPA 2 HHP Enrollees $1,390* -$1,113* -$2,503* -$1,232* Control Group $1,114* -$158* -$1,271* Overall HHP Enrollees $1,460* -$1,041* -$2,501* -$1,113* Control Group $1,191* -$197* -$1,388* Source: Medi-Cal claims data from July 1, 2016, through December 31, 2021. Notes: * Denotes p≤0.05, a statistically significant difference. SPA 1 includes enrollees with chronic conditions and substance use disorders. SPA 2 includes enrollees with severe mental illness. Change Before HHP is calculated as: (1 – 6 months before HHP minus 19 – 24 months before HHP divided by 3). Change During HHP is calculated as: (19 – 24 months during HHP minus 1 – 6 months during HHP divided by 3). Difference between changes is calculated as: (Change During HHP –Change Before HHP). Difference-in-difference is calculated as: (Difference between changes for HHP enrollees – Difference between changes for control group). Estimated Payments for Outpatient Services UCLA estimated Medi-Cal payments for outpatient services. Payments for outpatient services are likely to increase due to unmet need and increased access to these services, but payments are likely to decrease once health needs are addressed and service use declines. Exhibit 66 shows that after an initial increase at the start of HHP, estimated payments decreased significantly for SPA 1 and SPA 2 enrollees during HHP. Compared to control groups, the UCLA Evaluation | 123 UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program decrease in payments from before HHP to during HHP was significantly greater for both SPA 1 and SPA 2, by $490 (DD) and $718 (DD) per beneficiary per year, respectively. Exhibit 66: Trends in Payments per Beneficiary per Year for Outpatient Services Before and During HHP by SPA as of December 2021 $9,712 $9,459 $9,428 $9,155 $9,098 $8,826 $8,582 $8,517 $8,461 $8,106 $7,921 $7,794 $7,783 $7,387 $7,343 $7,126 $6,746 $6,662 $6,622 $6,455 $6,303 $6,211 $6,162 $6,158 $6,133 $6,005 $5,869 $5,725 $5,665 $5,495 $5,344 $5,025 19-24 13-18 7-12 1-6 1-6 7-12 13-18 19-24 19-24 13-18 7-12 1-6 1-6 7-12 13-18 19-24 Before HHP (months) During HHP (months) Before HHP (months) During HHP (months) SPA 1 SPA 2 HHP Enrollees Control Group Change Difference Change Difference-in- Before Between During HHP Difference (DD) HHP Changes SPA 1 HHP Enrollees $585* -$535* -$1,120* -$490* Control Group $426* -$204* -$630* SPA 2 HHP Enrollees $676* -$680* -$1,356* -$718* Control Group $477* -$162* -$639* Overall HHP Enrollees $608* -$572* -$1,179* -$547* Control Group $99* $322* -$427* Source: Medi-Cal claims data from July 1, 2016, through December 31, 2021. Notes: * Denotes p≤0.05, a statistically significant difference. SPA 1 includes enrollees with chronic conditions and substance use disorders. SPA 2 includes enrollees with severe mental illness. Change Before HHP is calculated as: (1 – 6 months before HHP minus 19 – 24 months before HHP divided by 3). Change During HHP is calculated as: (19 – 24 months during HHP minus 1 – 6 months during HHP divided by 3). Difference between changes is calculated as: (Change During HHP –Change Before HHP). Difference-in-difference is calculated as: (Difference between changes for HHP enrollees – Difference between changes for control group). 124 UCLA Evaluation | UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program Estimated Payments for Outpatient Medication UCLA estimated Medi-Cal payments for outpatient medication. Payments for outpatient medication are likely to increase due to unmet need and increased access to these medications, but payments are likely to stabilize or decrease once health needs are addressed. Exhibit 67 shows a significant increase in estimated payments during the first 6 months of HHP for both SPA 1 and SPA 2, followed by a decrease in payments for the remainder of HHP implementation. Compared to control groups, the decrease in payments from before HHP to during HHP was significantly greater for both SPA 1 and SPA 2, by $134 (DD) and $100 (DD) per HHP enrollee per year, respectively. Exhibit 67: Trends in Outpatient Medication Payments per Beneficiary per Year Before and During HHP by SPA as of December 2021 $4,950 $4,866 $4,809 $4,662 $4,593 $4,582 $4,395 $4,375 $4,356 $4,167 $4,162 $4,159 $4,113 $4,111 $4,035 $3,998 $3,979 $3,962 $3,929 $3,897 $3,804 $3,776 $3,732 $3,725 $3,590 $3,582 $3,575 $3,469 $3,451 $3,444 $3,406 $3,364 19-24 13-18 7-12 1-6 1-6 7-12 13-18 19-24 19-24 13-18 7-12 1-6 1-6 7-12 13-18 19-24 Before HHP (months) During HHP (months) Before HHP (months) During HHP (months) SPA 1 SPA 2 HHP Enrollees Control Group Change Difference Difference-in- Change Before Between Difference During HHP HHP Changes (DD) SPA 1 HHP Enrollees $170* -$192* -$362* -$134* Control Group $146* -$82* -$228* SPA 2 HHP Enrollees $66* -$166* -$232* -$100* Control Group $56* -$75* -$132* Overall HHP Enrollees $144* -$185* -$329* -$126* Control Group $22* $109* -$256* UCLA Evaluation | 125 UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program Source: Medi-Cal claims data from July 1, 2016, through December 31, 2021. Notes: * Denotes p≤0.05, a statistically significant difference. SPA 1 includes enrollees with chronic conditions and substance use disorders. SPA 2 includes enrollees with severe mental illness. Change Before HHP is calculated as: (1 – 6 months before HHP minus 19 – 24 months before HHP divided by 3). Change During HHP is calculated as: (19 – 24 months during HHP minus 1 – 6 months during HHP divided by 3). Difference between changes is calculated as: (Change During HHP –Change Before HHP). Difference-in-difference is calculated as: (Difference between changes for HHP enrollees – Difference between changes for control group). 126 UCLA Evaluation | UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program Estimated Payments for Emergency Department Visits UCLA estimated Medi-Cal payments for emergency department (ED) visits. Exhibit 68 shows that these estimated payments were increasing significantly before HHP for both SPA 1 (by $39 per beneficiary per year) and for SPA 2 ($50). During HHP, the estimated payments for ED visits decreased by $42 and $54 per SPA 1 and SPA 2 enrollee per year, respectively. For one six- month period, estimated payments for ED visits increased for SPA 1, after which they continued to decline. Compared to control groups, the decrease in payments from before HHP to during HHP was significantly greater for both SPA 1 and SPA 2, by $25 (DD) and $43 (DD) per beneficiary per year, respectively. Exhibit 68: Trends in Payments for Emergency Department Visits per Beneficiary per Year Before and During HHP by SPA as of December 2021 $1,172 $1,163 $1,088 $1,071 $1,043 $1,035 $1,022 $1,008 $1,005 $969 $953 $938 $934 $933 $927 $923 $920 $913 $909 $889 $877 $862 $855 $852 $832 $826 $814 $807 $807 $775 $772 $746 19-24 13-18 7-12 1-6 1-6 7-12 13-18 19-24 19-24 13-18 7-12 1-6 1-6 7-12 13-18 19-24 Before HHP (months) During HHP (months) Before HHP (months) During HHP (months) SPA 1 SPA 2 HHP Enrollees Control Group Difference Change Change Difference-in- Between Before HHP During HHP Difference (DD) Changes SPA 1 HHP Enrollees $39* -$42* -$81* -$25* Control Group $36* -$20* -$56* SPA 2 HHP Enrollees $50* -$54* -$104* -$43* Control Group $45* -$17* -$61* Overall HHP Enrollees $42* -$45* -$87* -$30* Control Group $4* $34* -$65* Source: Medi-Cal claims data from July 1, 2016, through December 31, 2021. Notes: * Denotes p≤0.05, a statistically significant difference. SPA 1 includes enrollees with chronic conditions and substance UCLA Evaluation | 127 UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program use disorders. SPA 2 includes enrollees with severe mental illness. Change Before HHP is calculated as: (1 – 6 months before HHP minus 19 – 24 months before HHP divided by 3). Change During HHP is calculated as: (19 – 24 months during HHP minus 1 – 6 months during HHP divided by 3). Difference between changes is calculated as: (Change During HHP –Change Before HHP). Difference-in-difference is calculated as: (Difference between changes for HHP enrollees – Difference between changes for control group). Estimated Payments for Hospitalizations UCLA estimated Medi-Cal payments for hospitalizations. Exhibit 69 shows that the estimated payments for hospitalization declined significantly for SPA 1 (by $1,478 per beneficiary per year) and for SPA 2 ($1,157) enrollees from before HHP to during HHP. Compared to control groups, the decrease in payments from before HHP to during HHP was significantly greater for both SPA 1 and SPA 2, by $606 (DD) and $503 (DD) per HHP enrollee per year, respectively. Exhibit 69: Trends in Payments for Hospitalizations per Beneficiary per Year Before and During HHP by SPA as of December 2021 $8,596 $8,177 $8,150 $7,458 $7,084 $7,071 $6,993 $6,893 $6,674 $6,653 $6,481 $6,271 $6,167 $6,067 $5,982 $5,905 $5,866 $5,790 $5,745 $5,732 $5,644 $5,571 $5,383 $5,317 $5,264 $5,090 $4,989 $4,984 $4,950 $4,914 $4,766 $4,490 19-24 13-18 7-12 1-6 1-6 7-12 13-18 19-24 19-24 13-18 7-12 1-6 1-6 7-12 13-18 19-24 Before HHP (months) During HHP (months) Before HHP (months) During HHP (months) SPA 1 SPA 2 HHP Enrollees Control Group Difference Change Change Difference-in- Between Before HHP During HHP Difference (DD) Changes SPA 1 HHP Enrollees $843* -$635* -$1,478* -$606* Control Group $731* -$141* -$872* SPA 2 HHP Enrollees $589* -$568* -$1,157* -$503* Control Group $497* -$156* -$654* Overall HHP Enrollees $780* -$618* -$1,398* -$580* Control Group $673* -$145* -$817* 128 UCLA Evaluation | UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program Source: Medi-Cal claims data from July 1, 2016, through December 31, 2021. Notes: * Denotes p≤0.05, a statistically significant difference. SPA 1 includes enrollees with chronic conditions and substance use disorders. SPA 2 includes enrollees with severe mental illness. Change Before HHP is calculated as: (1 – 6 months before HHP minus 19 – 24 months before HHP divided by 3). Change During HHP is calculated as: (19 – 24 months during HHP minus 1 – 6 months during HHP divided by 3). Difference between changes is calculated as: (Change During HHP –Change Before HHP). Difference-in-difference is calculated as: (Difference between changes for HHP enrollees – Difference between changes for control group). UCLA Evaluation | 129 UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program Estimated Payments for Long Term Care UCLA estimated Medi-Cal payments for long term care services. Exhibit 70 shows that before HHP the estimated payments for long term care were decreasing for both SPA 1 (by $39 per beneficiary per year) and SPA 2 ($7). About a year before HHP implementation, payments began to increase for both SPA 1 and SPA 2. Payments continued to increase after HHP implementation for SPA 1 (by $76 per beneficiary per year) and SPA 2 ($129). Compared to control groups, the increase in payments from before HHP to during HHP was significantly greater for SPA 1 (by $26, DD) and significantly less for SPA 2 (by $14, DD) per beneficiary per year, respectively. Exhibit 70: Trends in Payments for Long Term Care per Beneficiary per Year Before and During HHP by SPA as of December 2021 $901 $809 $749 $727 $701 $674 $663 $653 $630 $617 $616 $568 $565 $559 $544 $499 $484 $475 $460 $436 $427 $426 $406 $401 $391 $366 $352 $343 $321 $321 $314 $281 19-24 13-18 7-12 1-6 1-6 7-12 13-18 19-24 19-24 13-18 7-12 1-6 1-6 7-12 13-18 19-24 Before HHP (months) During HHP (months) Before HHP (months) During HHP (months) SPA 1 SPA 2 HHP Enrollees Control Group Difference Change Change Difference-in- Between Before HHP During HHP Difference (DD) Changes SPA 1 HHP Enrollees -$39* $76* $115* Control Group -$44* $44* $89* $26* SPA 2 HHP Enrollees -$7* $129* $136* Control Group -$8* $142* $150* -$14* Overall HHP Enrollees -$31* $89* $120* Control Group -$35* $69* $104* $16* 130 UCLA Evaluation | UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program Source: Medi-Cal claims data from July 1, 2016, through December 31, 2021. Notes: * Denotes p≤0.05, a statistically significant difference. SPA 1 includes enrollees with chronic conditions and substance use disorders. SPA 2 includes enrollees with severe mental illness. Change Before HHP is calculated as: (1 – 6 months before HHP minus 19 – 24 months before HHP divided by 3). Change During HHP is calculated as: (19 – 24 months during HHP minus 1 – 6 months during HHP divided by 3). Difference between changes is calculated as: (Change During HHP –Change Before HHP). Difference-in-difference is calculated as: (Difference between changes for HHP enrollees – Difference between changes for control group). Estimated Payments for Residual Costs UCLA estimated Medi-Cal payments for residual costs. UCLA Evaluation | 131 UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program Exhibit 71 shows that for both SPA 1 and SPA 2 estimated payments for residual costs were increasing in the years leading up to HHP and continued to increase for a year after HHP implementation. One year after HHP implementation, payments decreased and subsequently increased again. Overall, payments for residual costs increased before HHP for both SPA 1 (by 68$ per beneficiary per year) and SPA 2 ($102), and also increased after HHP for both SPA 1 (by 19$ per beneficiary per year) and SPA 2 ($4). Despite this, compared to control groups, the increase in payments from before HHP to during HHP was significantly lower for both SPA 1 and SPA 2 by $6 (DD) and $38 (DD) per beneficiary per year, respectively. 132 UCLA Evaluation | UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program Exhibit 71: Trends in Residual Costs per Beneficiary per Year Before and During HHP by SPA as of December 2021 $1,725 $1,631 $1,629 $1,607 $1,597 $1,572 $1,566 $1,512 $1,475 $1,474 $1,428 $1,416 $1,399 $1,361 $1,348 $1,326 $1,308 $1,284 $1,277 $1,271 $1,245 $1,243 $1,211 $1,205 $1,148 $1,140 $1,076 $1,050 $1,026 $1,018 $989 $909 19-24 13-18 7-12 1-6 1-6 7-12 13-18 19-24 19-24 13-18 7-12 1-6 1-6 7-12 13-18 19-24 Before HHP (months) During HHP (months) Before HHP (months) During HHP (months) SPA 1 SPA 2 HHP Enrollees Control Group Difference Change Change Difference-in- Between Before HHP During HHP Difference (DD) Changes SPA 1 HHP Enrollees $68* $19* -$49* Control Group $53* $11* -$42* -$6* SPA 2 HHP Enrollees $102* $4* -$99* Control Group $77* $16* -$61* -$38* Overall HHP Enrollees $77* $15* -$61* Control Group $59* $12* -$47* -$14* Source: Medi-Cal claims data from July 1, 2016, through December 31, 2021. Notes: * Denotes p≤0.05, a statistically significant difference. SPA 1 includes enrollees with chronic conditions and substance use disorders. SPA 2 includes enrollees with severe mental illness. Change Before HHP is calculated as: (1 – 6 months before HHP minus 19 – 24 months before HHP divided by 3). Change During HHP is calculated as: (19 – 24 months during HHP minus 1 – 6 months during HHP divided by 3). Difference between changes is calculated as: (Change During HHP –Change Before HHP). Difference-in-difference is calculated as: (Difference between changes for HHP enrollees – Difference between changes for control group). HHP Program Expenditures UCLA examined HHP supplemental payments based on per-member per-month (PMPM) rates to participating MCPs and calculated the estimated total and average per-enrollee HHP expenditures per month from July 1, 2018, to December 31, 2021. PMPM payments varied by MCP and county and were changed each fiscal year. PMPM rates were higher at the start of the UCLA Evaluation | 133 UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program program to account for anticipated start-up costs and were lowered as the program went on. Rates were consistently lower for enrollees covered by both Medicare and Medi-Cal (Duals) compared to those covered by Medi-Cal only. Exhibit 72 shows that by December 2021 estimated HHP expenditures totaled $403,910,020 and the average expenditure per enrollee per month was $383. The overall estimated expenditures for duals were lower ($9,532,186) than those covered by Medi-Cal only ($394,377,834), and the average monthly per person expenditures were lower as well ($106 for duals, $409 for Medi-Cal only). Group 4 had the highest average expenditure per enrollee per month ($483), while Group 1 had the lowest ($315). Exhibit 72: Estimated HHP Supplemental Expenditures by Enrollees Type and Implementation Group, as of December 31, 2021 Total Cumulative Average Expenditure per Expenditures Enrollee per Month Overall $403,910,020 $383 Group 1 $5,973,141 $315 Total HHP Group 2 $90,479,958 $323 Group 3 $300,208,947 $405 Group 4 $7,247,975 $483 Overall $9,532,186 $106 Group 1 $191,940 $89 Duals Group 2 $1,144,353 $102 Group 3 $8,126,738 $107 Group 4 $69,156 $116 Overall $394,377,834 $409 Group 1 $5,781,201 $344 Medi-Cal Group 2 $89,335,605 $333 only Group 3 $292,082,209 $439 Group 4 $7,178,819 $499 Source: UCLA Analysis of MCP Enrollment Reports from August 2019 and Quarterly HHP Reports from September 2019 to December 2021. Per-member, per-month rates by MCP and dual-status were provided by the California Department of Health Care Services. 134 UCLA Evaluation | UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program Conclusions and Implications Conclusions The findings in this report build on the earlier progress under HHP included in the first interim and second interim evaluation reports. The earlier reports described MCP implementation plans and approaches to creation of CB-CME networks by MCPs; delivery of HHP services; enrollment size; health and utilization profile of HHP enrollees prior to enrollment; and initial utilization, process, outcome, and cost outcomes. This final summative report highlighted the status of HHP as of December 30, 2021 when the program was transitioned to Enhanced Care Management (ECM) and Community Supports (CS) programs under the California Advancing and Innovating Medi-Cal (CalAIM) initiative. HHP Implementation and Infrastructure The first interim report highlighted evidence that MCPs in all HHP counties participated and had developed comprehensive plans to build the needed infrastructure and deliver HHP services as required by HHP. MCPs further built a diverse network of CB-CMEs using mainly primary care providers as CB-CMEs as preferred by HHP. The second interim report and this final report further indicated a substantial growth in CB-CME networks over time to increase capacity commensurate with growth in enrollment. Assessment of the composition of CB-CME networks and patterns of growth suggested inclusion of organizations that were likely to be responsive to the needs of enrollees. HHP and COVID-19 The second interim report indicated that the onset of the COVID-19 pandemic and subsequent statewide shelter in place order in mid-March 2020 led to programmatic and enrollment changes. The assessment of the impact of the pandemic on HHP in that report highlighted the changes in the ability of MCPs to enroll and their contracted CB-CMEs to provide HHP services. However, some of this impact was mitigated by MCP efforts to adapt workflows and increase telehealth capacity. Analysis of claims data in this report indicated that providers continued to provide services through telehealth and the burden of COVID-19 diagnosis on service use was similar between HHP enrollees and the control group, allowing for an unbiased measurement of the role of HHP in health care delivery and outcomes of care. HHP Enrollment and Enrollment Patterns UCLA Evaluation | 135 UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program MCPs collectively succeeded in enrolling a substantial number of high-need high-cost beneficiaries in HHP, commensurate with the service delivery capacity of the CB-CMEs in their network. The greater enrollment in SPA 1, which represented enrollees with a medically complex profile and a subset with substance use disorders, reflected in part the phased approach to enrollment by SPA and lower prevalence of enrollees with serious mental health conditions that were eligible for SPA 2 enrollment. Nevertheless, MCPs succeeded in enrolling significantly more SPA 2 enrollees as well as beneficiaries experiencing homelessness over time. Examining how enrollees were identified indicated that while MCPs used the TEL for most enrollees, they also used other methods for identifying eligible beneficiaries that were not in the TEL. This approach was consistent with DHCS expectations as there was a six-month lag in availability of TEL and MCPs were more likely to have more recent utilization data or electronic medical records that included more comprehensive demographic and health status data. The continuous enrollment of most HHP enrollees likely reflected the continuous need for HHP services as well as the success of MCPs or CB-CMEs in engaging HHP enrollees in care. This was consistent with the sustained growth among both enrollees with multiple chronic conditions and substance use disorders in SPA 1, and those with serious mental illness in SPA 2. The complex nature of many HHP enrollees likely required continuous delivery of HHP services to maintain their health through coordination of their care and supportive services that prevent use of acute care. HHP Enrollee Demographics and Health Status The health status of HHP enrollees was consistent with the chronic condition criteria set by the program in order to target high-need high-cost beneficiaries. The demographic differences between SPA 1 and SPA 2 enrollees were also consistent with prevalence of medical complexity, substance use disorders, and serious mental illness given age and gender. Further assessment of health conditions of enrollees confirmed higher prevalence of a complex combination of medical conditions such as chronic renal disease, chronic liver disease, and traumatic brain injury among SPA 1 and higher prevalence of depression among SPA 2 enrollees, consistent with the aims of the program. Overall data indicated that MCPs successfully enrolled high-need Medi-Cal beneficiaries who may have benefited the most from HHP services. HHP Service Utilization among HHP Enrollees There were gaps in availability of data on HHP service use associated with challenges of CB- CMEs in reporting services they provided to MCPs and an improvement in reporting by the end 136 UCLA Evaluation | UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program of HHP. The higher frequency of delivery of HHP core services in-person likely reflected the needs of HHP enrollees who may have been home-bound, had transportation and mobility barriers, or required assessment of their home environment. The more frequent use of non- clinical staff likely reflected the higher need for navigation services, care coordination, transportation, or health education for better self-care. The successes reported by MCPs in linking enrollees experiencing homelessness and housing some of them may also have been due to the use of non-clinical staff to help engage these enrollees. HHP Outcomes Core Performance Metrics Assessment of core metrics showed success in one process (Adult BMI screening) and one outcome (controlling high blood pressure) overall, with greater gains among SPA 2 enrollees. Information on the mechanisms by which MCP or CB/CMEs succeeded to improve these metrics is not available in the existing evaluation data. Likely mechanisms to promoting process and outcome metrics by MCPs may have been financial incentives in contractual agreements by CB/CMEs, which may have resulted in increasing quality improvement efforts by these organization that included identifying champions to train and encourage providers to follow practice guidelines or included community health workers in provider teams to engage enrollees in self-care. Gains were reported for some other core process metrics associated with mental illness and substance use treatment; however, they were not greater than that of the control group. Therefore, gains could not be attributed to HHP but progress had occurred. The reasons for lack of greater gains or lack of change in these metrics may have been because of general challenges of engaging these populations in treatment, particularly for those who also have SMI. Lack of greater gains in other outcome metrics such as readmissions and long-term admissions from the community may have been due to the continuing decline in health of the most complex beneficiaries that were not responsive to HHP or other medical interventions. Health Care Utilization and Associated Payments Despite the mixed findings in core metrics described above, ED visits and hospitalizations, two important core metrics of HHP, improved consistent with the goals of the program. These declines further extended to nearly all service categories suggesting that HHP enrollees were utilizing more care than was appropriate and provision of non-clinical HHP services reduced the need for avoidable outpatient and ED visits and hospitalization. This may have been accomplished by better assessment of patients medical, behavioral, and social needs soon after enrollment and directing patients to appropriate providers who could provide the needed care UCLA Evaluation | 137 UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program sooner. These assertions were consistent with early increases in utilization of most services, particularly primary care, in the first 6 months of enrollment and a decline in most service use categories afterwards. These conclusions are also aligned with differences in the patterns of change by SPA, where HHP services addressed the different needs of SPA 1 and SPA 2 enrollees. For example, the greater declines in mental health and substance use disorders services among SPA 2 enrollees may have been due to improvements in their status that reduced the need for more frequent visits. The assessment of the payments associated with service categories above further suggested that decline in service utilization may have been accompanied by a reduction in intensity of care needed or received by HHP enrollees. The greater decline in payments for outpatient services, outpatient medications, and hospitalizations may have been because of better management of care avoided more serious consequences of undiagnosed or untreated conditions. Implications Overall, the evaluation findings highlighted the potential impact of providing non-clinical services to high-cost high-need Medi-Cal beneficiaries and what outcomes may be expected as a consequence of this approach to population health management. The findings implied that assessment of enrollees with complex conditions and high utilization of care is likely to result in initial increase of utilization and costs in the short term but a greater reduction over time. HHP enrollees were transitioned to ECM and CS programs under the CalAIM initiative. The provision of ECM benefit and CS services was delegated to MCPs that were required to build and maintain a provider network to deliver these non-clinical services and report performance metrics to DHCS. The HHP evaluation did not include a detailed assessment of how MCPs implemented the program and how CB-CMEs delivered care. Despite this limitation, HHP evaluation findings have implications for ECM and CS based on important elements of the program including relatively standard criteria for identification of high-need high-cost eligible beneficiaries and delivery of HHP services by primary care providers and other organization with knowledge and expertise in how to address complexities such as serious mental illness and homelessness. Further research is required to fully understand whether MCPs set CB-CMEs performance criteria and what incentives they used; what were MCP responses and course corrections to high and low CB- CME performance; what were CB-CME approaches to delivery of HHP services to enrollees and associated challenges and successes; and what types of CB-CMEs that achieved greater success in outcomes than others. 138 UCLA Evaluation | UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program In the context of ECM and CS programs, it is important to obtain a greater understanding of MCP contracting arrangements, incentives to providers, and MCP responses to low performance. It is also important to ensure reporting and subsequent availability of information on how providers delivery ECM including intensity of the effort depending on enrollee complexity. Given the complexity of the populations eligible for these programs, it is essential to consider less traditional outcomes such as quality of life and wellbeing, particularly when disease progression can mask other less tangible benefits of better managing patient care. UCLA Evaluation | 139 UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program Appendix A: Data Sources and Analytic Methods Readiness Documents UCLA used the readiness documents from 16 MCPs submitted to DHCS to report on MCP implementation of HHP. In these readiness documents, MCPs reported on topics including organizational model, staffing, health information technology, HHP services, HHP network, and HHP operations. Analytic Methods UCLA reviewed all readiness documents to answer the UCLA evaluation questions detailed in Exhibit 73Error! Reference source not found.. MCPs varied in the level of detail in their documents. UCLA identified and tabulated relevant information to the extent possible given this variation by MCP. Information from readiness documents were cross-checked with other data including MPC Quarterly HHP Reports to improve accuracy when possible. Exhibit 73: Evaluation Questions and Data Sources Evaluation Question Location in Readiness Documents 1. Which HHP network model was employed? Organizational Model 2. What was the composition of HHP networks? Organizational Model MCP Duties/Responsibilities 3. What types of staff provide HHP services? Organizational Model Staffing 4. What was the data sharing approach? Health Information Technology/Data and Information Sharing 5. What was the approach to targeting patients for enrollment into HHP? Member Engagement Member Notices Risk Grouping Housing Services Source: UCLA Health Homes Program Evaluation Design, 2019. Limitations The MCP readiness documents represented MCP plans for HHP implementation and may not reflect the final implementation approach by MCPs. Several MCPs submitted periodically revised readiness documents during HHP implementation. These documents included drafts, revisions, and communications with DHCS regarding further revisions and/or clarifications. In addition, MCPs provided variable amounts of detail on planned implementation, which may have led to a limited understanding of MCPs' final approach. 140 UCLA Evaluation | UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program The MCPs maximum estimated HHP enrollment overall and by CB-CME in readiness documents and their responsibilities are unlikely to align with actual quarterly enrollment data. Enrollment Reports and MCP Quarterly Reports UCLA used MCP Enrollment Reports and Quarterly HHP Reports to analyze HHP enrollment. Enrollee-level HHP enrollment data was only available in MCP Enrollment Reports prior to July 2019. All four MCPs (Anthem Blue Cross of California Partnership Plan, San Francisco Health Plan, Inland Empire Health Plan, and Molina Healthcare of California Partner Plan) that implemented HHP by July 2019 submitted an Enrollment Report to DHCS in August 2019, covering the period of July 1, 2018 to June 30, 2019. All MCPs submitted Quarterly HHP Reports during the time they had implemented HHP from July 1, 2018 to December 31, 2021. Starting in July 2019, MCP Quarterly HHP Reports included enrollee-level data on both enrollment, homelessness, and housing status. These two data sources had some differences, which resulted in UCLA only being able to analyze enrollment at a monthly level. Staggered implementation of the program by county resulted in MCPs with different reporting lengths. Homeless and housing statuses on an enrollee-level were examined quarterly, from July 1, 2019 when enrollee-level homeless data was first reported, through December 31, 2021. Analytic Methods Exhibit 74 shows the enrollment data obtained from these reports. Monthly enrollment data from the MCP Enrollment Reports and Quarterly HHP Reports were combined to determine monthly enrollment status by individual enrollee. If there were conflicting data for individual enrollees between the two data sources, UCLA used the more recent data from the Quarterly HHP Reports. Forty-three enrollees that switched counties or plans during their enrollment were excluded from further analysis. Beneficiaries who were enrolled on any date during a given month were considered enrolled for the whole month. Beneficiaries that were disenrolled for less than 30 days in between enrolled months were considered enrolled in the program for that month. However, 1,439 beneficiaries who were only enrolled for less than 31 days were excluded from the analyses of enrollment patterns. UCLA Evaluation | 141 UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program UCLA used the MCP Quarterly HHP Reports to analyze data on enrollee's housing status and housing service utilization. Enrollee-level housing services data were included in the Quarterly HHP Reports starting in July 2019, which limited the analysis of housing services to July 1, 2019 through December 31, 2021. Exhibit 74: Beneficiary-Level Variables Data Elements Definitions SPA Enrolled in SPA 1 vs. SPA 2. Dual Status Ever enrollee in both Medicare and Medi-Cal during HHP enrollment. County County in which enrollee is enrolled. Monthly Enrollment Status Indicator for HHP enrollment status for a particular month. Enrollment Date The date an enrollee starts to enroll in HHP. Enrollment date reported prior to 2019 Quarter 3 always begins on the first day of the initially enrolled month. Enrollment date reported after June 30, 2019 is the exact date. Disenrollment Date The date an enrollee disenrolled from HHP. Disenrollment date reported prior to July 1, 2019 is the last day of the month. Disenrollment date reported after June 30, 2019 is an exact date. Number of Times The number of times each enrollee disenrolled from the MCP throughout their Disenrolled enrollment. Length of Enrollment The differences between disenrollment date and enrollment date. If an enrollee enrolls in and disenrolls from HHP on the same date, the length of enrollment will be one day. Day count was divided by 30 to estimate length of enrollment in months. Ever Homeless during HHP Data only available from Quarterly HHP Reports. Indicates whether enrollee was ever homeless during HHP enrollment. Homeless or at Risk for Data only available from Quarterly HHP Reports. Enrollee is homeless or at risk Homelessness for homelessness from July 1, 2019 to September 30, 2020. Received Housing Services Data only available from Quarterly HHP Reports. Enrollee received housing services from July 1, 2019 to September 30, 2020. Housed by September 2019 Data only available from Quarterly HHP Reports. Indicator of whether enrollee was housed by September 30, 2020. Notes: Data from MCP Enrollment Reports from July 1, 2018 to September 30, 2020 and MCP Quarterly HHP Reports from July 1, 2019 to December 31, 2021. From the MCP Quarterly HHP Reports, UCLA reported on CB-CMEs by organization type as of December 2021. MCPs reported individual CB-CMEs, identified by the National Plan and Provider Enumeration System (NPPES) NPI, serving HHP enrollees and the projected capacity of each CB-CME. UCLA used the NPI Registry to identify characteristics of unique CB-CMEs in MCP networks. In addition, UCLA reported on the percentage of eligible beneficiaries by implementation group excluded from HHP for seven exclusion rationales defined by DHCS and reported in the MCP Quarterly Reports. 142 UCLA Evaluation | UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program Limitations UCLA analyzed the enrollment data provided by MCPs. Given that enrollee-level data in the MCP Quarterly Report were not required until July 2019, UCLA had to combine these data with MCP Enrollment Reports from July 1, 2018 to June 30, 2019 to examine enrollment and enrollment patterns. These two data sources had some differences, which resulted in UCLA only being able to analyze enrollment at a monthly level. Staggered implementation of the program by county resulted in MCPs with different reporting lengths. Medi-Cal Enrollment and Claims Data UCLA used Medi-Cal enrollment and claims data from July 1, 2016 to December 31, 2021 to create demographic health status indicators, health care utilization indicators, and preliminary metrics used in this report. Claims data included both managed care and fee-for-service encounters. Analytic Methods HHP Services HHP services were reported for all MCPs, although reporting varied by MCP. Kaiser reported that none of their enrollees received services while Alameda Alliance reported that 98% of their enrollees received services. All MCPs reported that less than 100% of their enrollees received any HHP service, although every HHP enrollee should have received at least one service. Exhibit 75 displays indicators of utilization of HHP services reported by MCPs in Medi-Cal claims data. Exhibit 75: HHP Service Utilization Indicators Indicators Definitions Proportion of enrollees that ever received an HHP The percent of enrollees that ever received the service service. Proportion of enrolled months that services were The percent months with services received out of the provided per enrollee number of months enrolled in HHP among HHP enrollees that have ever received the service. Average number of units of service per enrollee per The average of each HHP enrollee's monthly average month during months that services were provided number of service units for the received service each month among HHP enrollees that have ever received the service. Units of service are defined as 15-minutes of service; multiple units of service are possible. Median number of units of service per enrollee during The median of each HHP enrollee's monthly number months that service was provided of service units for the received service each month among HHP enrollees that have ever received the service. Units of service are defined as 15-minutes of service; multiple units of service are possible. UCLA Evaluation | 143 UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program UCLA used the HHP designated HCPCS codes and modifiers to identify encounters that included HHP services, defined in Exhibit 76. HCPCS code G0506 and modifier codes U1 to U7 were used July 1, 2018 through September 30, 2018, and HCPCS code G9008 and modifier codes U1 to U7 were used October 1, 2018 through December 31, 2021. Exhibit 76: HHP Services Provider Type Modifier Modality Definition Engagement Services Provider Type Not U7 Not specified Active outreach such as direct communications with Specified member (e.g., face-to-face, mail, electronic, and telephone), follow-up if the member presents to another partner in the HHP network or using claims data to contact providers the member is known to use. Providers must show active, meaningful, and progressive attempts at member engagement each month until the member is engaged. Examples of acceptable engagement include: (1) letter to member followed by phone call to member; (2) phone call to member, outreach to care delivery partners and social service partners; (3) and street level outreach, including, but not limited to, where the member lives or is accessible. Core Services Provided by U1 In-person Comprehensive care management, care coordination, Clinical Staff health promotion, comprehensive transitional care, U2 Telehealth individual and family support services, and referral to community and social supports Provided by Non- U4 In-person Clinical Staff U5 Telehealth Other Services Provided by U3 Not specified Case notes, case conferences, tenant supportive services, Clinical Staff and driving to appointments Provided by Non- U6 Not specified Clinical Staff Demographic Indicators Exhibit 77 displays demographic indicators created by UCLA using Medi-Cal monthly enrollment data. UCLA calculated age based on an enrollee's HHP enrollment date. On the rare occasion enrollment data included more than one birthday for an enrollee, UCLA used the latest birthday reported. While not common, if the Medi-Cal enrollment data contained conflicting data for gender, race, or language for an HHP enrollee, UCLA used the most frequently reported category. 144 UCLA Evaluation | UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program Exhibit 77: Demographic Indicators Indicators Definitions Age Enrollee's final age in years at the time of HHP enrollment. Gender Indicates whether an enrollee is male or female. Race The race label for an enrollee: White, Hispanic, African American, Asian American and Pacific Islander, American Indian and Alaska Native, other, or unknown. English as Primary Indicating whether an enrollee's primary language is English or not. Language Number of Months Full scope coverage is defined as at enrollment in at least one dental MCP and another with Full Scope non-dental MCP during the eligible date period. The number of months that an enrollee Coverage is full scope is reported for the year prior to the enrollee's initial enrollment in HHP. Health Status Indicators UCLA used Medi-Cal claims data from July 1, 2016 to December 31, 2021 to assess health status of HHP enrollees prior to their enrollment in HHP. UCLA followed chronic condition and acuity eligibility criteria developed by DHCS for HHP as described in the HHP Program Guide (Exhibit 78). According to these criteria, chronic conditions were present if an enrollee had two or more services on different dates for the specified condition during the two years prior to HHP enrollment. UCLA also used the criteria set by CMS's Chronic Condition Warehouse to obtain a complete list of chronic condition and potentially chronic or disabling condition categories. Exhibit 78: Health Status Indicators Indicators Definition Chronic Conditions Chronic Condition The percentage of enrollees that meet chronic condition criteria 1. An enrollee satisfies Criteria 1: Two chronic condition criteria 1 if the enrollee has at least two of the following HHP eligible specific chronic conditions: chronic obstructive pulmonary disease (COPD), chronic kidney disease conditions and (CKD), diabetes, traumatic brain injury, chronic or congestive heart failure, coronary artery SUD disease, chronic liver disease, dementia, substance use disorder. Chronic Condition The percentage of enrollees that meet chronic condition criteria 2. An enrollee satisfies Criteria 2: chronic condition criteria 2 if the enrollee has hypertension and one of the following HHP Hypertension and eligible chronic conditions: chronic obstructive pulmonary disease, diabetes, coronary another specific artery disease, chronic or congestive heart failure. comorbidity Chronic Condition The percentage of enrollees that meet chronic condition criteria 3. An enrollee satisfies Criteria 3: Serious chronic condition criteria 3 if the enrollee has one of the following HHP eligible chronic Mental Illness conditions: major depression disorders, bipolar disorder, psychotic disorders (including (SMI) schizophrenia. Chronic Condition The percentage of enrollees that meet chronic condition criteria 4. An enrollee satisfies Criteria 4: Asthma chronic condition criteria 4 if the enrollee has the HHP eligible chronic condition asthma. Acuity Acuity Criteria 1: The percentage of enrollees that meet acuity criteria 1. An enrollee satisfies acuity criteria Three or more 1 if the enrollee has at least three of the following HHP eligible chronic conditions: chronic chronic obstructive pulmonary disease (COPD), chronic kidney disease (CKD), diabetes, traumatic conditions brain injury, chronic or congestive heart failure, coronary artery disease, chronic liver disease, dementia, substance use disorder. UCLA Evaluation | 145 UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program Indicators Definition Acuity Criteria 2: The percentage of enrollees that meet acuity criteria 2. An enrollee satisfies acuity criteria One or more 2 if the enrollee has at least one inpatient hospital stay during one year prior to HHP Hospitalizations enrollment. Acuity Criteria 3: The percentage of enrollees that meet acuity criteria 3. An enrollee satisfies acuity criteria Three or more ED 3 if the enrollee has at least three or more emergency department visits during one year Visits prior to HHP enrollment. Chronic Condition The percentage of enrollees meeting each of the CCW condition category criteria in the Warehouse period prior to HHP enrollment. (CCW) Conditions CDPS (Chronic The mean, median, and standard deviation of CDPS among all enrollees. The CDPS is Illness and calculated based on the International Classification of Diseases (ICD) diagnosis codes in Disability Medi-Cal claims data. Payment System Risk Score) 146 UCLA Evaluation | UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program Healthcare Utilization Indicators UCLA also created healthcare utilization indicators using Healthcare Effectiveness Data and Information Set (HEDIS) 2019 Volume 2 definitions, National Uniform Claim Committee taxonomy designations, the Chronic Conditions Warehouse, and the American Medical Association's Current Procedure Terminology (CPT) Codebook. Exhibit 79 displays these indicators. Exhibit 79: Healthcare Utilization Indicators Indicators Definitions Number of Hospitalizations per 1,000 Member The number of inpatient hospitalization visits during the Months service month. Length of hospitalization (days) The total lengths measured in number of total days of all hospitalizations during the service month. Percentage of Enrollees with Any The percentage of enrollees who ever had at least one Hospitalizations hospitalization Number of ED Visits resulting in Discharge per The number of ED visits resulting in discharge during the 1,000 Member Months service month. Percentage of Enrollees with Any ED Visits The percentage of enrollees who ever had at least one ED visit Resulting in Discharge resulting in discharge Number of Primary Care Services per 1,000 The number primary care provider services during the service Member Months month. Number of Specialty Services per 1,000 The number of specialty services during the service month. Member Months Number of Mental Health Services per 1,000 The number of mental health services during the service Member Months month. Number of Substance Use Disorder Services The number of substance use disorder services during the per 1,000 Member Months service month. Number of Long-Term Care Stays per 1,000 The number of long-term care stays during the service month. Member Months UCLA Evaluation | 147 UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program HHP Metrics and Additional Mesures HHP metrics were calculated based on HHP metric specifications in CMS's Core Set of Health Care Quality Measures for Medicaid Health Home Programs. HHP metrics were grouped by whether they measured process of care delivery or patient outcomes. All metrics were reported in the aggregate and included data for two years prior to and one year following each individual's enrollment in HHP when possible. UCLA assessed any length of enrollment or required number of months of enrollment on Medi-Cal enrollment rather than HHP enrollment in order to be consistent between HHP enrollees and the control group. A limited number of metrics were reported semi-annually rather than annually in order to calculate the change in the measure during HHP when there was only one year of data. Exhibit 80 includes descriptions of all HHP metrics and how changes in the metric are to be interpreted. Exhibit 80: HHP Core Metrics, Definitions, and Reporting Status Improvement Measured by Metric Description Increase or Decrease Adult Body Mass Percentage of Health Home enrollees ages 18 to 74 who Increase Index (BMI) had an outpatient visit and whose body mass index Assessment (BMI) was documented during the measurement year or the year prior to the measurement year. Follow-Up After Percentage of discharges for Health Home enrollees age Increase Hospitalization for 6 and older who were hospitalized for treatment of Mental Illness within selected mental illness diagnoses and who had a follow- 30 days up visit with a mental health practitioner within 30 days. Follow-Up After Percentage of discharges for Health Home enrollees age Increase Hospitalization for 6 and older who were hospitalized for treatment of Mental Illness within selected mental illness diagnoses and who had a follow- 7 days up visit with a mental health practitioner within 7 days. Follow-Up After ED Percentage of ED visits for Health Home enrollees age Increase Visit for Alcohol and 13 and older with a principal diagnosis of alcohol or Other Drug Abuse or other drug (AOD) abuse or dependence who had a Dependence within 7 follow-up visit for AOD abuse or dependence with 7 days days. Follow-Up After ED Percentage of ED visits for Health Home enrollees age Increase Visit for Alcohol and 13 and older with a principal diagnosis of alcohol or Other Drug Abuse or other drug (AOD) abuse or dependence who had a Dependence within follow-up visit for AOD abuse or dependence with 30 30 days days. 148 UCLA Evaluation | UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program Improvement Measured by Metric Description Increase or Decrease Screening for Percentage of Health Home enrollees age 12 and older Increase Depression and screened for clinical depression on the date of the Follow-Up Plan encounter, and if positive, a follow-up plan is documented on the date of the positive screen. Initiation of Alcohol Percentage of enrollees who initiate treatment through Increase and Other Drug Abuse within 14 days of the diagnosis. or Dependence Treatment Engagement of Percentage of enrollees who initiate treatment and who Increase Alcohol and Other had two or more additional AOD services or MAT within Drug Abuse or 34 days of the initiation visit. Dependence Treatment Controlling High Blood Percentage of Health Home enrollees ages 18 to 85 who Increase Pressure had a diagnosis of hypertension (HTN) and whose blood pressure (BP) was adequately controlled during the measurement year. Plan All-Cause For Health Home enrollees ages 18 to 64, the number of Decrease Readmissions acute inpatient stays during the measurement year that were followed by an unplanned acute readmission for any diagnosis within 30 days and the predicted probability of an acute readmission. Prevention Quality Number of inpatient hospital admissions for ambulatory Decrease Indicator (PQI) 92: care sensitive chronic conditions per 100,000 member Chronic Conditions months for Health Home enrollees age 18 and older. Composite This measure includes adult hospital admissions for diabetes with short-term complications, diabetes with long-term complications, uncontrolled diabetes without complications, diabetes with lower extremity amputation, chronic obstructive pulmonary disease, asthma, hypertension, or heart failure without a cardiac procedure. Ambulatory Care: Rate of emergency department (ED) visits resulting in Decrease Emergency discharge per 1,000 member months among Health Department (ED) Home enrollees. Visits UCLA Evaluation | 149 UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program Improvement Measured by Metric Description Increase or Decrease Inpatient Utilization Rate of acute inpatient care and services (total, Decrease maternity, mental and behavioral disorders, surgery, and medicine) per 1,000 member months among Health Home enrollees Inpatient Length of All approved days from admission to discharge. Decrease Stay Use of Percentage of enrollees ages 18 to 64 with an opioid Increase Pharmacotherapy for use disorder who received buprenorphine, oral Opioid Use Disorder naltrexone, long-acting injectable naltrexone, or methadone for the disorder. Admission to an The number of admissions to an institutional facility Decrease Institution from the (skilled nursing facility or intermediate care facility) Community (Short- from the community that result in a short-term stay (1 Term Stay) to 20 days) during the measurement year per 1,000 member months. Admission to an The number of admissions to an institutional facility Decrease Institution from the (skilled nursing facility or intermediate care facility) Community (Medium- from the community that result in a medium-term stay Term Stay) (21 to 100 days) during the measurement year per 1,000 member months. Admission to an The number of admissions to an institutional facility Decrease Institution from the (skilled nursing facility or intermediate care facility) Community (Long- from the community that result in a long-term stay Term Stay) (more than 100 days) during the measurement year per 1,000 member months. Source: Detailed information for each metric is available in HHP Metric Specifications. Control Group Construction UCLA obtained administrative Medi-Cal monthly enrollment and claims data from July 2016 to December 2021 for 90,038 individuals reported as enrolled into HHP and for 1,089,792 individuals that were potentially eligible for HHP based on their inclusion on the targeted engagement list (TEL). The TEL was produced bi-annually and UCLA used all TELs through May 2021. These data included two years prior to the start of HHP enrollment (July 2016 to June 2018) and up through the end of HHP enrollment (July 2018 to December 2021). 150 UCLA Evaluation | UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program UCLA used 46 indicators and variables describing beneficiaries' demographic, health status, service utilization, and cost characteristics to select the control group (Exhibit 81). Demographic variables were constructed from Medi-Cal enrollment data. Health status variables were constructed from claims data and reflected the HHP chronic condition eligibility criteria and measures of illness burden (e.g., CDPS risk score). The chronic condition eligibility criteria and indicators were constructed following the specifications developed to create the TEL by DHCS (HHP Program Guide). UCLA created and included a measure of acute care utilization by grouping enrollees based on their number of ED visits and hospitalizations. Exhibit 81: Variables Used to Select the Control Group Indicator Description Demographics and Baseline Description (9 indicators and variables) Age Group Age at the start of HHP enrollment (0-17, 18-34, 35-49, 50-64, or 65+ years) Gender Reported Gender in Medi-Cal Enrollment (Male or Female) Race/Ethnicity Reported Race/Ethnicity in Medi-Cal (White, Hispanic, Black, Asian or Pacific Islander, or Native American/Other/Unknown) Language English as the preferred language Homelessness UCLA developed indicator that uses address-based and claim-based indicators to predict homelessness WPC enrollment Indicator of whether or not individual was ever enrolled in Whole Person Care County County of residence Number of Baseline Years Count of baseline years with Medi-Cal enrollment Full Scope Months in Medi-Cal Number of months in the reported as having full-scope Medi-Cal coverage Health Status (5 indicators) HHP Chronic Condition At least two of the following: Chronic Obstructive Pulmonary Disease (COPD), Eligibility Criteria 1 Chronic Kidney Disease (CKD), Diabetes, Traumatic Brain Injury, Chronic or Congestive Heart Failure, Coronary Artery Disease, Chronic Liver Disease, Dementia, Substance Use Disorder. HHP Chronic Condition Hypertension and one of the following: COPD, Diabetes, Coronary Artery Eligibility Criteria 2 Disease, Chronic or Congestive Heart Failure. HHP Chronic Condition One of the following: Major Depression Disorders, Bipolar Disorder, or Eligibility Criteria 3 Psychotic Disorders (including Schizophrenia). HHP Chronic Condition Asthma Eligibility Criteria 4 CDPS Risk Score Risk score that measures illness burden Service Utilization (18 indicators and variables) Acute Care Utilization Group UCLA created indicators that groups individuals by their baseline emergency department and hospital utilization: super utilization, high utilization, moderate utilization, low utilization or at-risk-for high utilization Utilization Slopes (7 variables)* Slope of monthly service utilization in the baseline period for emergency department visits, hospitalizations, primary care services, specialty care UCLA Evaluation | 151 UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program services, long-term care stays, mental health services, and substance use disorder services. Utilization Intercepts (7 Intercept of monthly service utilization in the baseline period for emergency variables)* department visits, hospitalizations, primary care services, specialty care services, long-term care stays, mental health services, and substance use disorder services. Primary Care Organization type Number of primary care services by organization type: health centers, group (3 variables) organizations, and individual practices Cost (14 variables) Estimated Payment Slopes (7 Slope of monthly estimated Medi-Cal payments in the baseline period for variables) total costs, emergency department visits, hospitalizations, outpatient services, outpatient prescriptions, long term care stays, and residual services. Estimated Payment Intercepts Intercept of monthly estimated Medi-Cal payments in the baseline period for (7 variables) total costs, emergency department visits, hospitalizations, outpatient services, outpatient prescriptions, long term care stays, and residual services. Using the above variables, the control group was first identified by developing a propensity score that indicated the similarity between an enrollee and a beneficiary on the TEL. Due to the phased implementation of HHP, UCLA grouped HHP enrollees into 14 cohorts based on the quarter in which they enrolled and selected control beneficiaries for each cohort. This method ensured that the control group beneficiaries had a similar baseline period to their matched enrollee. UCLA constructed two separate control groups for analysis of utilization and cost measures, because of limited sample sizes for individuals with similar levels and trends in utilization of services and estimated payments prior to HHP enrollment. The control group selection generalized additive models were set to require an exact match for chronic condition eligibility criteria and acute care utilization categories and the closest possible match for the pre-year 1 and pre-year 2 difference in utilization or cost in addition to the propensity score developed as described above. UCLA aimed to create a matched sample with a 1:2 ratio (1 HHP enrollee to 2 control beneficiaries) by MCP and county, allowing for sampling with replacement. The sampling with replacement approach was because of unavailability of similar matches per MCP and led to the final control group to HHP enrollee ratio of 1.6. To balance the sample, each control group beneficiary was matched to multiple HHP enrollees. Exhibit 82 shows the characteristics of the final utilization-based control group for the largest HHP SPA 1 enrollee cohort (cohort 5; n=6,184), which consisted of those enrolled from July to September 2019 from Groups 1, 2, and 3 for SPA 1. Data show that the control group was similar to the HHP enrollees for all indicators and measures. 152 UCLA Evaluation | UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program Exhibit 82: Comparison of Select Characteristics of HHP SPA 1 Cohort 5 Enrollees (Enrolled July to September 2019) and Matched Control Beneficiaries SPA 1 HHP Before Match After Match Enrollees in Control Group Control Group Cohort 5 Age (at time of % 0-17 6% 19% 9% enrollment) % 18-34 12% 18% 14% % 35-49 23% 16% 19% % 50-64 51% 31% 42% % 65+ 8% 16% 16% Gender % Male 41% 43% 42% Race/Ethnicity % White 21% 21% 24% % Latinx 44% 43% 42% % African American 20% 13% 15% % Asian 6% 11% 8% % Other or Unknown 9% 12% 10% Language % English proficient 73% 67% 70% Medi-Cal full-scope Average number of months 11.5 11.2 11.4 months in the year prior to enrollment Homelessness UCLA-constructed indicator 20% 14% 16% WPC enrollment Enrollment in WPC 7% 6% 7% Two specific conditions 51% 24% 51% (Criteria 1) Hypertension and another 61% 34% 61% HHP Chronic Condition specific condition (Criteria 2) Criteria Serious mental health 42% 30% 41% conditions (Criteria 3) Asthma (Criteria 4) 31% 23% 31% Hypertension 72% 44% 68% Select Chronic Diabetes 57% 34% 53% Conditions Major Depressive Disorders 36% 25% 34% Substance Use Disorders 12% 8% 12% Emergency Department ED Intercept 0.185 0.114 0.178 Utilization ED Slope 0.001 -0.001 0.002 Hospitalization Intercept 0.047 0.024 0.039 Inpatient Utilization Hospitalization Slope 0.005 0.000 0.002 PCP slope 0.063 0.013 0.023 Outpatient Services PCP intercept 0.565 0.352 0.451 Utilization Specialty slope 0.051 0.020 0.027 Specialty intercept 0.432 0.240 0.303 At-Risk 14% 33% 14% Low Utilization 33% 40% 33% Acute Care Utilization Moderate Utilization 35% 20% 35% Categories High Utilization 13% 6% 13% Super Utilization 5% 2% 5% UCLA Evaluation | 153 UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program Additionally, UCLA developed unique matched control groups for those HHP core metrics that restricted the sample to specific subpopulations. For example, for follow-up after hospitalization for mental illness, UCLA developed a control group within groups based on whether individuals met the denominator criteria (i.e., hospitalized for mental illness) before HHP, during HHP or is both time periods. The same methodology described above was employed to create these metric-specific matches. Difference-in-Difference Models UCLA assessed changes in the outcomes of interest before and during HHP, and in contrast to the control group in difference-in-difference (DD) models. UCLA assessed the impact of HHP for the overall HHP enrollees and for SPA 1 and SPA 2 enrollees in DD models using an interaction term for SPA. All models were controlled for demographics (gender, age, race/ethnicity, primary language, months of Medi-Cal enrollment), utilization indicators (acute care utilization group), and health status indicators (baseline CDPS risk scores and HHP chronic condition eligibility criteria). The models additionally included an indicator for having at least one primary or secondary diagnosis of COVID-19 in the claims data and the number of months spent enrolled in HHP during the pandemic. The baseline and enrollment periods for each HHP enrollee and their matched controls were based on the beneficiaries' date of enrollment, and the enrollee sample included only HHP enrollees with at least one year of baseline data and at least one month of enrollment in HHP per year. UCLA used logistic regression models for binary metrics (e.g., Controlling High Blood Pressure) and count models with Poisson distribution for count metrics (e.g., Primary Care Visits per 1,000 Member-Months, Specialty Care Visits per 1,000 Members-Months) and estimated Medi- Cal payments (outpatient payments per member per year). The exposure option within a Generalized Linear Model (GLM) was used to adjust for different number of months of Medi-Cal enrollment and the subsequent different lengths of exposure to HHP. All analyses of individual- level metrics were analyzed based on Medi-Cal member months. The DD analyses differed for HHP specified metrics that required one year of observation from metrics that did not require one year of observation and for optional measures. For HHP specified metrics that required one year of observation, the DD analyses measured changes from the Pre-HHP Year 2 to Pre-HHP Year 1 for both HHP enrollees and the control group; the change from HHP Year 1 to the HHP Year 2 for both HHP enrollees and the control group; and the difference between the changes for HHP enrollees vs. the control group. For the remaining metrics and measures, UCLA examined changes in six month increments up to 24 months (1-6, 7-12, 13-18, and 19-24) before HHP enrollment and up to 24 months (1-6, 7- 154 UCLA Evaluation | UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program 12, 13-18, and 19-24) during HHP. For these, the DD analysis measured the change from 19-24 vs. 1-6 months before HHP for both HHP enrollees and the control group; the change during HHP from 19-24 vs. 1-6 months for both HHP enrollees and the control group; and the difference between the changes in HHP enrollees vs. the control group. The shorter timeframe for examining metrics allowed for a clearer assessment of change during the early phase of HHP implementation. The findings were not subject to potential seasonality in service utilization due to rolling enrollment throughout the year and measuring change following the date of enrollment per beneficiary. Limitations One of the acuity criteria set by DHCS in the HHP Program Guide was chronic homelessness. However, Medi-Cal Enrollment and Claims data do not include an indicator of chronic homelessness. As a result, UCLA created an indicator of homelessness based on Medi-Cal eligibility and claims data, which is likely subject to estimation error. The identification of chronic conditions relied on the primary and secondary diagnoses associated with each service. Any error in original reporting of these diagnoses by providers may have resulted in under- or over-reporting of chronic conditions. HHP services may have been underreported due to missing HCPCS code modifiers by MCPs. As a result, the HHP services analysis reflects an estimation of HHP service use and was likely to under-report the actual number of HHP services delivered. Using separate control groups for measurement of utilization and payments was not optimal and may have led to discrepancies in between these findings. Attributing Estimated Medi-Cal Payments to Claims Background The great majority of services under Medi-Cal are provided by managed care plans that receive a specific capitation amount per member per month and do not bill for individual services received by Medi-Cal beneficiaries. While managed care plans are required to submit claims to Medi-Cal, these claims frequently include payment amounts of unclear origin that are different from the Medi-Cal fee schedule. A small and unique subset of Medi-Cal beneficiaries are not enrolled in managed care and receive care under the fee-for-service (FFS) reimbursement methodology and have claims with actual charges and paid values. FFS claims are reimbursed primarily using fee schedules developed by Medi-Cal. The capitation amounts for managed care plans are developed using the same fee schedules by Mercer annually, using complex algorithms and other data not included in claims. UCLA Evaluation | 155 UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program To address the gaps in reliable and consistent payment data for all claims, UCLA estimated the amount of payment per Medi-Cal claim under HHP using various Medi-Cal fee schedules for services covered under the program. The methodology included (1) specifying categories of service observed in the claims data, (2) classifying all adjudicated claims into these service categories, (3) attributing a dollar payment value to each claim using available fee schedules and drug costs, and (4) examining differences between these and available external estimates. UCLA estimated payments for both managed care and FFS claims to promote consistency in payments across groups and to avoid discrepancies due to different methodologies. The payment estimates generated using this methodology are not actual Medi-Cal expenditures for health care services delivered during HHP. Rather, they represent the estimated amount of payment for services and are intended for measuring whether HHP led to efficiencies by reducing the total payments for HHP enrollees before and after the program, and in comparison, to a group of comparison patients in the same timeframe. 156 UCLA Evaluation | UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program Service Category Specifications Data Sources UCLA used definitions from multiple sources to categorize and define different types of services. These sources included Medi-Cal provider manuals, HEDIS value set, DHCS 35C File, American Medical Association's CPT Codebook, National Uniform Code Committee's taxonomy code set, and other available sources. • DHCS's Medi-Cal provider manuals included billing and coding guidelines for provider categories and some services. • The HEDIS Value Set by the National Committee for Quality Assurance used procedure codes (CPT and HCPCS), revenue codes (UBREV), place of service codes (POS), and Systematized Nomenclature of Medicine-Clinical Terms (SNOMED CT) to define value sets that measure performance in health care. For example, the HEDIS value set "ED" is a combination of procedure codes that describe emergency department services and revenue codes specifying that services were provided in the emergency room. • DHCS Paid Claims and Encounters Standard 35C File (DHCS 35C File) provided specifications to managed care plans on how claims must be submitted and contained detailed information about claims variables and their meaning and utility, such as vendor codes describing the location of services and taxonomy codes describing the type of provider and their specializations. • The American Medical Association's Current Procedure Terminology (CPT) Codebook contained a list of all current procedural terminology (CPT) codes and descriptions that are used by providers to bill for services. • The National Uniform Claim Committee's (NUCC's) Health Care Provider Taxonomy code set identified provider types such as Allopathic and Osteopathic Physician and medical specialties such as Addiction Medicine defined by taxonomy codes. UCLA also used other resources to address gaps in definitions. For example, hospice codes that were used in claims submitted before 2016 were not included in the Medi-Cal provider manual, but UCLA collected the pre-2016 hospice codes from other DHCS guidelines. UCLA Evaluation | 157 UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program Methods UCLA constructed eighteen mutually exclusive categories of service (Exhibit 83). Available claims data included managed care, fee-for-service, and Short-Doyle. Some categories were defined using complementary definitions from more than one source. UCLA assigned claims to only one of the eighteen service categories to avoid duplication when calculating total estimated HHP payments. The outpatient services category may include claims included in other categories and therefore is not included in calculation of the total estimated payment in this report. UCLA assigned claims to the first service category a claim meets the criteria for as ordered in Error! Reference source not found.. All services, apart from primary care visits, provided on the day of an ED visit were grouped as part of the ED visit to represent the total cost of the visit. For example, patients may have received transportation to an emergency department and laboratory tests during the emergency department visit, and these services were included in the ED category rather than the transportation or laboratory services categories. This approach may have included lab or transportation services in the ED category that were not part of the ED visit, and may have undercounted lab and transportation in their respective categories. However, this was necessary because claims data lacked information on the specific time of day when services were rendered. Similarly, all claims for services received during a hospitalization were counted as part of the same stay and were excluded from other categories of service, except for primary care visits on the day of admission. Other categories were identified solely by the procedure code or place of service and were not bundled with other services occurring on the same day, such as long-term care, home health/ home and community-based services, community-based adult services, FQHC services, labs, imaging, outpatient medication, transportation, and urgent care. Some claims lacked the information necessary to be categorized and were classified under an "Other Services" category. These frequently included physician claims without a defined provider taxonomy and durable medical equipment codes that were billed separately and could not be associated with an existing category. Exhibit 83: Description of Mutually Exclusive Categories of Service* Order Service category Definition Description source 1 Emergency HEDIS Place of service is hospital emergency Department Visits room and procedure code is emergency (ED) service 158 UCLA Evaluation | UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program Order Service category Definition Description source 2 Hospitalizations DHCS 35C File Place of service is inpatient and admission and discharge dates are present and are on different days 3 Hospice Care DHCS 35C File, Provider is hospice or procedure code is HEDIS, and hospice service DHCS Medi-Cal Provider Manuals 4 Long-Term Care DHCS 35C File Claim is identified as LTC or provider is (LTC) Stays LTC organization; stays one day apart are counted as one visit, stays two or more days apart are separate stays 5 Home Health and DHCS 35C File Provider is a home health agency or Home and and DHCS Medi- home and community-based service Community-Based Cal Provider waiver provider, procedure is home Services (HH/HCBS) Manuals health or home and community-based service 6 Community-Based DHCS 35C File Provider is adult day health care center or Adult Services and DHCS Medi- procedure code is community-based (CBAS) Cal Provider adult service, which are health, Manuals therapeutic and social services in a community-based day health care program 7 Federally Qualified DHCS 35C File Provider is an FQHC or RHC (FQHC) and Rural Health Center (RHC) Services 8 Laboratory Services DHCS 35C File Claim is identified as clinical laboratory, laboratory & pathology services, or laboratory tests 9 Imaging Services DHCS 35C File Claim is identified as portable x-ray services or imaging/ nuclear medicine services 10 Outpatient DHCS 35C File Claim is identified as pharmacy Medication 11 Transportation DHCS 35C File Claim is identified as medically required Services transportation 12 Primary Care National Provider is allopathic and osteopathic Services Uniform Claim physician (with specialization in adult Committee medicine, adolescent medicine, or geriatric medicine, family medicine, UCLA Evaluation | 159 UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program Order Service category Definition Description source internal medicine, pediatrics, or general practice), or physician assistant or nurse practitioner (with specialization in medical, adult health, family, pediatrics, or primary care) 13 Specialty Care National Provider is allopathic and osteopathic Services Uniform Claim physician or physician assistant or nurse Committee practitioner (with all specializations not captured in the Primary Care Services category) 14 Outpatient Facility DHCS 35C File Claim is identified as outpatient facility Services 15 Dialysis Services DHCS 35C File Provider is a dialysis center and and CPT procedure is dialysis Codebook 16 Therapy Services DHCS Medi-Cal Procedure code is occupational, physical, Provider Manual speech, or respiratory therapy 17 Urgent Care National Provider is ambulatory urgent care facility Services Uniform Claim Committee 18 Other Services N/A Provider, procedure, or place of service is not captured above N/A Outpatient Services HEDIS Claim type is outpatient and procedure code, revenue code, or place of service code is outpatient Source: UCLA Methodology. Notes: * indicates categories are mutually exclusive except for outpatient services category UCLA examined the above categories and found that four of these categories, outpatient services, hospitalizations, outpatient medications, and emergency department visits, accounted for 93% of total payments for HHP claims in 2019 (Exhibit 84). Exhibit 84: Percentage of 2019 Total Estimated Payments by Category of Service for HHP Medi- Cal Claims Percentage of Total Category of Service Estimated Payment All Categories 100% Outpatient Services 35% Outpatient Medication 21% 160 UCLA Evaluation | UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program Emergency Department Visits 5% Hospitalizations 32% All other categories 7% Source: UCLA analysis of Medi-Cal Claims data from July 1, 2018 to September 30, 2020 UCLA Evaluation | 161 UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program Attributing Payments to Specific Services To attribute payments to each category of service, UCLA developed methods to calculate an estimated payment for each category based on available data. Exhibit 85 displays the categories of service and what is included in the calculation of estimated payments for each category. Exhibit 85: Category of Service and Payment Descriptions Category of Service Calculation of Estimated Payment Emergency Department Payments for all services taking place in the emergency Visits (ED) department of a hospital, including services on the same day of the ED visit, excluding services by PCPs and FQHCs and RHCs. Two sub-categories are reported: ED visits followed by hospitalizations and all other ED visits that are followed by discharge. Hospitalizations Payments for all services that take place during a hospitalization, excluding visits with primary care providers on the first or last day of the stay, FQHC visits on the first or last day of the stay, or ED visits that preceded hospitalization Hospice Care Payments for hospice services in an LTC facility or Home Health setting, excluding hospice services rendered during a hospitalization Long-Term Care (LTC) Institutional fees billed by LTC facilities; the per diem rate Stays includes supplies, drugs, equipment, and services such as therapy Home Health and Home Payments for services provided by a home health agency (HHA) and Community-Based and services provided through the home and community-based Services (HH/HCBS) services (HCBS) waiver Community-Based Adult Payments for community-based adult services and for services Services /(CBAS) rendered at an adult day health care center Federally Qualified (FQHC) Payments for all services provided in an FQHC or RHC and Rural Health Center (RHC) Services Laboratory Services Payments for laboratory services, except those provided during a hospitalization or ED visit Imaging Services Payment for imaging services, except those provided during a hospitalization, ED visit, or LTC stay 162 UCLA Evaluation | UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program Category of Service Calculation of Estimated Payment Outpatient Medication Payments for outpatient drug claims, excluding prescriptions filled on the same day as an ED visit or on the day of discharge from a hospitalization Transportation Services Payments for medically required transportation, excluding transportation on the same day as an inpatient admission or an emergency department visit Primary Care Services Payments for services provided by a primary care physician Specialty Care Services Payments for services provided by a specialist, excluding services provided during an inpatient stay or an emergency department visit, and excluding facility fees Outpatient Facility Services Facility fees paid to hospital outpatient departments and ambulatory surgical centers Dialysis Services Payments for dialysis services rendered in a dialysis center Therapy Services Payments for occupational, speech, physical, and respiratory therapy services Urgent Care Services Payments for services provided in an urgent care setting Other Services Payments for services not captured above Outpatient Services Payments for all services delivered in an outpatient setting Source: UCLA Methodology. UCLA used all available Medi-Cal fee schedules and supplemented this data with other data sources as needed. Payment data sources, brief descriptions, and the related categories of services they were attributed to are provided in Exhibit 86. Exhibit 86: Payment Data Sources Source Description Applicable Service Categories Medi-Cal Physician Fee Contains rates set by DHCS for all Level I ED, Hospitalizations, Schedule procedure codes that are reimbursable Hospice, LTC, HH/HCBS, Annual files 2013 to by Medi-Cal for services and procedures CBAS, Imaging, 2020 inflated/ deflated rendered by physicians and other Transportation, Primary to 2019 providers Care, Specialty Care, Dialysis, Urgent Care, Other, and Outpatient Services UCLA Evaluation | 163 UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program Source Description Applicable Service Categories Durable Medical Contains rates set by CMS for Level II ED, Hospitalizations, Equipment (DME) Fee procedure codes for durable medical Hospice, LTC, HH/HCBS, Schedule equipment such as hospital beds and CBAS, Transportation, Annual files 2017 to accessories, oxygen and related Primary Care, Specialty 2020 inflated/ deflated respiratory equipment, and wheelchairs Care, Dialysis, Urgent to 2019 Care, and Other Medical Supplies Fee Contains rates set by DHCS for supplies ED, Hospitalizations, Schedules such as needles, bandages, and diabetic Hospice, LTC, HH/HCBS, October 2019 test strips CBAS, Transportation, Primary Care, Specialty Care, Dialysis, Urgent Care, and Other Average Sales Price Contains rates set by CMS for procedure ED, Hospitalizations, Data (ASP) for Medicare codes for physician-administered drugs Hospice, LTC, Primary Part B Drugs covered by Medicare Part B Care, Specialty Care, Annual files 2014 to and Other 2020 inflated/ deflated to 2019 CMS MS-DRG grouping Contains Diagnostic Related Grouping Hospitalizations, LTC software, DHCS's APR- (DRG) codes used for hospitalizations DRG Pricing Calculator (CMS), base rate per DRG (DHCS) and 12/1/2019 DRG weights (CMS) FQHC and RHC Rates Contains rates set by DHCS for services FQHC and RHC 12/19/2018 provided by FQHCs and RHCs inflated to 2019 Hospice per diem rates Contains rates set by DHCS for hospice Hospice 9/28/2020 stays and services deflated to 2019 Nursing Facility Level A Contains per diem rates set by DHCS per LTC, Hospice per diem rates county for Freestanding Level A Nursing 8/1/2019 Facilities Distinct Part Nursing Contains per diem rates set by DHCS for LTC, Hospice Facilities, Level B nursing facilities that are distinct parts 8/1/2019 of acute care hospitals 164 UCLA Evaluation | UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program Source Description Applicable Service Categories Home Health Services Contains billing codes and Home health Rates reimbursement rates set by DHCS for 8/1/2020 procedure codes reimbursable by home deflated to 2019 health agencies Home and Community- Contains billing codes and Home and community- Based Services Rates reimbursement rates set by DHCS for based services 8/1/2020 the home and community-based deflated to 2019 services program Community-Based Contains billing codes and Community-based adult Adult Services Rates reimbursement rates set by DHCS for services 8/1/2020 community-based adult services deflated to 2019 National Average Drug Contains per unit prices for drugs Outpatient medication Acquisition Cost dispensed through an outpatient (NADAC) File pharmacy setting based on the 12/30/2019 approximate price paid by pharmacies, calculated by CMS Clinical Laboratory Fee Contains rates set by CMS for clinical lab Laboratory Schedule services 12/30/2019 Therapy Rates Contains billing codes and Therapy 8/1/2020 reimbursement rates set by DHCS for deflated to 2019 physical, occupational, speech, and respiratory therapy Ambulatory Surgical Contains billing codes and ED, Hospitalizations, Center (ASC) Fee reimbursement rates set by CMS for Outpatient Facility Schedule facility fees for ASCs January 2019 Outpatient Prospective Contains billing codes and ED, Hospitalizations, Payment System (OPPS) reimbursement rates set by CMS for Outpatient Facility File facility fees for hospital outpatient October 2019 departments Payments were attributed based on available service and procedures codes included in each claim. A specific visit may have included a physician claim from the providers for their medical UCLA Evaluation | 165 UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program services and a facility claim for use of the facility and resources (e.g., medical/ surgical supplies and devices) where service was provided. The Medi-Cal Physician Fee Schedule contained monthly updated rates for all procedures that were reimbursable by Medi-Cal to providers and hospital outpatient departments. Each procedure code had multiple rates that varied based on provider type (e.g. physician, podiatrist, hospital outpatient department, ED, community clinic) and patient age. UCLA distinguished between these rates, but the paid amount for FFS still varied within the same procedure code, likely due to the directly negotiated rates between the providers and DHCS. For the purpose of HHP cost evaluation, UCLA used the procedure code with the most expensive rate when adequate information was lacking. UCLA also included a payment augmentation of 43.44% for claims for physician services provided in county and community hospital outpatient departments following DHCS guidelines. UCLA did not include any other reductions or augmentations that may have been applied by Medi-Cal due to limited information in claims data. Some procedures such as those performed by a qualified physical therapist in the home health or hospice setting did not have a fee in the Medi-Cal physician fee schedule but had fees in the Medi-Cal Provider Manual and UCLA used these fees when applicable. A number of claims lacked procedure codes but had a revenue code such as "Emergency Room- General" or "Freestanding Clinic- Clinic visit by member to RHC/FQHC". UCLA obtained documentation from DHCS that enabled identification of a price using outpatient revenue codes alone. CMS's Durable Medical Equipment (DME) Fee Schedule included billing codes that are reimbursable by Medi-Cal for DMEs such as hospital beds and accessories, oxygen and related respiratory equipment, and wheelchairs. Rates for other medical supplies such as needles, bandages, and diabetic test strips were found in DHCS's Medical Supplies Fee Schedules. FQHCs and RHCs consist of a parent organization with one or more clinic sites and are paid a bundled rate for all services during a visit. DHCS publishes FQHC and RHC Rates for each clinic within the parent organization. Payments for outpatient medication claims were calculated using the national drug acquisition cost (NADAC), which contains unit prices for drugs. UCLA calculated the drug cost by multiplying the unit price by the number of units seen on the claim. Drugs administered by physicians were priced using CMS's Average Sales Price Data (ASP) for Medicare Part B drugs. 166 UCLA Evaluation | UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program Facility fees were priced based on the ambulatory surgical center (ASC) fee schedule or the outpatient prospective payment system (OPPS) depending on whether the billing facility was an ASC or an outpatient department. Medi-Cal paid most LTC institutions such as nursing and intermediate care facilities for the developmentally disabled on a per-diem rate, while long-term care hospital stays were reimbursed via diagnosis related group (DRG) payments. Per diem rates for LTC facilities were obtained directly from DHCS's long-term care reimbursement webpage, and these rates varied by type of facility. Rates for hospice services were based on DHCS's hospice care site and hospice room and board rates were based on the Nursing Facility/ Intermediate Care facility fee schedule. UCLA lacked some variables in claims data that were needed to calculate some LTC and hospice payments, such as accommodation code which specifies different rates for each nursing facility depending on the type of program including the "nursing facility level B special treatment program for the mentally disordered" or "nursing facility level B rural swing bed program". In these cases, UCLA used the rates associated with accommodation code 1: "nursing facility level B regular", which were higher than other accommodation code rates. Hospitalizations are paid based on diagnosis related groups (DRGs), a bundled prospective payment methodology that is inclusive of all services provided during a hospitalization, except for physician services. Identification and pricing of DRGs varies by payers such as Medi-Cal and Medicare. In California, DHCS uses 3M's proprietary APR-DRG Core Grouping Software to assign DRGs and 3M's APR-DRG Pricing Calculator to calculate prices for Medi-Cal DRG hospitals. APR- DRGs have more specific DRGs for Medicaid populations such as pediatric patients and services such as labor and delivery, and incorporate four levels of illness severity. However, UCLA did not have access to this software and used 3M's publicly available CMS MS- DRG grouping software for the Medicare population, which includes Medicare-Severity DRGs (MS-DRGs) and their corresponding weights. MS-DRGs only include two levels of severity of illness, with complications or without complications. UCLA used this software to assign a DRG to each hospitalization based on procedure code, diagnosis, length of stay, payer type, patient discharge status, and patient age and gender. Although CMS uses the Inpatient Prospective Payment System to assign hospital prices based on the MS-DRGs, UCLA used available data and publicly available prices for DHCS's APR-DRG Pricing Calculator to calculate payments for each DRG. DHCS's APR-DRG Pricing Calculator used multiple hospital and patient-level variables to calculate the final payment for hospitals, and UCLA incorporated some of these variables into the estimated payment (such as patient age and hospital status of rural vs. urban) but could not incorporate other modifiers due to data limitations (such as other health coverage and whether or not the hospital was an NICU facility). UCLA Evaluation | 167 UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program UCLA calculated the estimated payment by starting with the base rate from DHCS's APR-DRG Calculator, which was $12,832 for rural hospitals and $6,507 for urban hospitals. This base rate was multiplied by the weight assigned to each MS-DRG, which modified the base rate to account for resources needs for a given DRG. For example, more severe hospitalizations such as "Heart Transplant or Implant of Heart Assist System with major complications" had a high weight of 25.4241 but "Poisoning and Toxic Effects of Drugs without major complication" had a lower weight of 0.7502. This rate was further modified by one available policy adjuster, which increased the payment amount by patient age and was higher for those under 21 (1.25) than those 21 and older (1). Overall payment for a hospitalization was calculated by adding the estimated payments for physician specialist services that occurred during the hospitalization. When no fees were found for procedure codes in any payment data sources, UCLA used the most frequent paid amount seen in fee-for-service claims for the procedure code. These included procedures such as tattooing/ intradermal introduction of pigment to correct color defects of skin and excision of excessive skin. When outlying units of service were found on the claim, UCLA used the 90th percentile value of units for the procedure code rather than the observed units. All claims were included in a category of service and were assigned a price. For dual beneficiaries, Medi-Cal is the secondary payer (payer of last resort) and covers a portion of the costs of the service. However, UCLA lacked information on percentage of services paid for by Medi-Cal for dual managed care beneficiaries. Therefore, UCLA used Medi-Cal claims data to calculate payments for these dual beneficiaries using the same methodology as non-dual managed care beneficiaries. Dual beneficiaries made up 7% of the HHP enrollee population. For the purpose of evaluation, all payments were calculated using the 2019 fee schedules when available. In the absence of 2019 data, UCLA inflated or deflated payment amounts using the paid amounts for similar FFS claims in available data. Using the 2019 fees removed the impact of inflation and pricing changes in subsequent analyses. Comparison of Estimated Payments with Medi-Cal Paid Amounts UCLA examined the potential bias that may have resulted due to the methodology used to estimate payments by comparing the estimated FFS payments with Medi-Cal paid amounts in FFS claims. Exhibit 87 shows that the estimated FFS payments were 5% higher than paid amounts for all services. There was underlying variation by category of services. For example, estimated ED payments were 8% higher, estimated payments for hospitalizations were 10% higher, and estimated payments for outpatient medication were 8% lower. 168 UCLA Evaluation | UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program Exhibit 87: Comparison of Estimated Fee-for Service Payments and Paid Amounts for 2019 HHP Medi-Cal Claims Difference Between Estimated Category of Service Payment and Medi-Cal Payment All Categories 5% Outpatient Services 13% Outpatient Medication -8% Emergency Department Visits 8% Hospitalizations 10% All other categories -13% Source: UCLA analysis of Medi-Cal Claims data from July 1, 2018 to September 30, 2020 UCLA further compared the difference in estimated payments for FFS and managed care claims and found that managed care payments were 3% lower than the FFS claims ($194 vs $188; Exhibit 88). Exhibit 88: Comparison of Average Fee- for-Service and Managed Care Payments per Claim for 2019 HHP Medi-Cal Claims Average Estimated Payment Estimated Payment Average Medi-Cal Payment per Claim for Managed Care Compared to Medi-Cal per Claim for FFS Claims Claims Payment $194 $188 -3% Source: UCLA analysis of Medi-Cal Claims data from July 1, 2018 to September 30, 2020 Limitations There were three types of limitations associated with UCLA's cost analysis including the availability of needed variables in the claims data and access to fee schedules and other pricing resources. The goal of the cost analysis was not to calculate exactly what DHCS paid for claims, but rather to calculate estimated payments and measure the impact of HHP by comparing changes in estimated payments over time. The limitations below describe why UCLA results may be different from DHCS reimbursements for certain services and categories. The first limitation was related to estimating payments for hospitalizations. First, the MS-DRG relative weights reflected Medicare payments, which were higher than Medi-Cal. This likely led to higher estimated payments for hospitalization. Second, MS-DRG only identified those levels of severity, with and without complication, but APR-DRG includes four severity levels. Third, DHCS uses multiple criteria to adjust hospital payments but UCLA was only able to adjust for urban and rural rates. UCLA Evaluation | 169 UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program A second limitation was related to availability of fee schedules for accurate pricing. The HHP evaluation required analysis of multiple years of claims data and UCLA used all available fee schedules to price procedures, supplies, and facilities from multiple years and inflated prices to 2019 dollars whenever necessary. UCLA always used the most recent rate for a procedure. The inflation rates used were based on medical care Consumer Price Index provided by US Bureau of Labor Statistics without adjusting for regional-specific inflation rates. Not all procedures that appeared in the claims data had corresponding rates in all the available fee schedules. Procedures that required Treatment Authorization Requests (TARs) lacked a fee-schedule and are frequently more expensive than covered services. Some specific procedures had no fees in the Medi-Cal fee-schedule. When fee schedules were missing, UCLA attributed the most frequently observed price from the paid amount for a similar FFS claim. If the procedure did not appear in any FFS claims, UCLA assigned the median allowed amount from all managed care claims for the given procedure code. A third limitation was related to outlier values for service units, some of which were extremely high. UCLA attributed the 95th percentile value instead of the original value in the claim, potentially underestimating payments for some claims. HHP Rates UCLA used the Medi-Cal Health Homes Program Rate Range Summary, which provided per member per month (PMPM) HHP rates, to calculate total expenditures per quarter and average per enrollee expenditures. Rates varied by MCP and County, and whether the enrollee was dual (covered by Medi-Cal and Medicare) or non-dual (covered only by Medi-Cal). 170 UCLA Evaluation | UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program Appendix B: UCLA HHP Evaluation Design Introduction The Health Homes Program (HHP) is created and implemented under the statutory authority of California AB 361. The legislation authorizes the California Department of Health Care Services (DHCS) to create HHP under the Section 2703 of the 2010 Patient Protection and Affordable Care Act. Section 2703 allows states to create Medicaid health homes to coordinate the full range of physical health, behavioral health, and community-based long-term services and supports needed by members with chronic conditions. The program is subject to cost-neutrality requirements regarding the State General Funds and federal financial participation. AB 361 requires an evaluation of the program. AB 361 also required that DHCS submit a report to the Legislature within two years after implementation of the program. The overarching goal of HHP is to achieve the Triple Aim of Better Care, Better Health, and Lower Costs. These goals are to be achieved by providing (1) comprehensive care management, (2) care coordination, (3) health promotion, (4) comprehensive transitional care, (5) individual and family support services, and (6) referrals to community and social support services. The program is implemented by Medi-Cal managed care plans (MCPs) to their members. MCPs form contractual or non-contractual relationships with Community-Based organizations or entities, forming an HHP network for delivery of services. HHP is scheduled to be implemented in 14 California counties, with four groups of counties implanting HHP in five consecutive time periods. In addition to staggered implementation by county, MCPs incorporate the subset of patients with serious mental illness (SMI) and serious emotional disturbance (SED) six months after the program start date (phase 2) for other eligible populations with program criterion of physical health/substance use disorder (SUD) (phase 1). The first county has implemented the first phase of the program in July 2018 and the last counties will implement the second phase in July 2020. The target population of the program is a small subset (3-5%) of the state's Medi-Cal population. This subset requires an intensive set of services and the highest levels of care coordination. Eligibility for HHP includes having chronic conditions that fit one of several predetermined categories and evidence of high acuity/complexity. There are program exclusions criteria for those receiving care management such as: (1) hospice recipients and skilled nursing home residents, (2) enrollees in specialized MCPs (e.g., Program of All-Inclusive Care for the Elderly (PACE), Senior Care Action Network (SCAN) and AIDS Healthcare Foundation (AHF)), (3) MCP members sufficiently well managed through self-management or UCLA Evaluation | 171 UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program another program, and (4) members determined to be more appropriate for alternative care management programs, etc. HHP Evaluation Conceptual Framework and Questions The UCLA Center for Health Policy Research (UCLA) is the evaluator of the HHP program. UCLA has developed a conceptual framework for the evaluation of HHP (Exhibit 89). According to the framework, better care is achieved when HHP network providers establish the necessary infrastructure and deliver HHP services. Delivery of HHP services will in turn lead to better health indicated by reduced utilization of health care services that are associated with negative health outcomes as well as improvements in population health indicators. Better care and better health will lead to lower overall health care expenditures. Exhibit 89: Evaluation Conceptual Framework •Infrastructure: HHP network composition, organization model of community-based care management, care coordination staffing, HIT and data sharing approach, patient enrollment approach •Process: provide comprehensive care management, coordinate care, deliver health promotion services, provide comprehensive transitional care, provide individual and family support Better Care services, refer to community and social support services •Health care utilization: reduce emergency department visits, reduce inpatient hospitalizations, reduce length of stay, increase outpatient follow-up care post admission, reduce nursing facility admissions, increase use of substance use treatment Better •Patient outcomes: control blood pressure, screen for depression, assess BMI, reduce all-cause readmissions, reduce inpatient admission for ambulatory care sensitive chronic conditions Health •Health care expenditures: reduce overall expenditures by lower spending on acute care services and higher spending on needed outpatient services •Cost neutrality: maintain cost neutrality by insuring HHP service expenditures do not lead to higher overall expenditures Lower Costs •Return on investment: show return on investment due to HHP program implementation Exhibit 90 displays the evaluation questions and data sources that will be used to answer those questions. The evaluation questions are aligned with the components of the conceptual framework. Questions 1-7 examine the infrastructure established by HHP networks, population enrolled, and the services delivered. Questions 8-13 examine the impact of HHP service delivery 172 UCLA Evaluation | UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program on multiple indicators of healthcare service utilization as well as patient health indicators. Question 14-17 examine the impact of HHP on lowering costs or cost savings for the Medi-Cal program. Exhibit 90: Evaluation Questions and Data Sources Evaluation Questions Data Sources Better Care Infrastructure 16. What was the composition of HHP networks? MCP Reports 17. Which HHP network model was employed? 18. When possible, what types of staff provided HHP services? 19. What was the data sharing approach? 20. What was the approach to targeting patients for enrollment per HHP network? Process 21. What were the demographics of program enrollees? MCP Reports What was the acuity level of the enrollees including TEL: demographic and eligibility criteria of health and health risk profile indicators, such as targeted MCP members aggregate inpatient, ED, and rehab SNF utilization? What Medi-Cal Claims and Encounter Data: proportion of eligible enrollees were enrolled? How did demographics and service use enrollment patterns change over time? What proportion Quarterly HHP Enrolled CIN File: HHP enrollees of enrollees are homeless? 22. Were Health Home services provided in-person or telephonically? Were Health Home services provided by clinical or non-clinical staff? How many enrollees received engagement services? How many homeless enrollees received housing services? Better Health Health care utilization 23. How did patterns of health care service use among HHP TEL: demographic and eligibility criteria of enrollees change before and after HHP implementation? targeted MCP members 24. Did rates of acute care services, length of stay for Medi-Cal Claims and Encounter Data: hospitalizations, nursing home admissions and length of demographics and service use stay decline? 25. Did rates of other services such as substance use treatment or outpatient visits increase? Patient outcomes 26. How did HHP core health quality measures improve MCP Reports: core measures before and after HHP implementation? Medi-Cal Claims and Encounter Data: 27. Did patient outcomes (e.g., controlled blood pressure, conditions and service use screening for clinical depression) improve before and after HHP implementation? 28. How many homeless enrollees were housed? Lower Costs Health care expenditures UCLA Evaluation | 173 UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program Evaluation Questions Data Sources 29. Did Medi-Cal expenditures for health services decline Medi-Cal Claims and Encounter Data: after HHP implementation? conditions and service use 30. Did Medi-Cal expenditures for needed outpatient services HHP Payment Files: HHP services and increase? payments for those services Cost neutrality 31. When possible, did HHP have the opportunity during the Medi-Cal Claims and Encounter Data: Service time period studied to achieve cost neutrality in the use and expenditures delivery of HHP services, in that the overall Medi-Cal HHP Payment Files: HHP services and expenditures after HHP implementation remained in line payments for those services with the expected patterns of growth in utilization and cost prior to HHP program implementation? Return on Investment 32. When possible, did HHP program operations lead to cost Medi-Cal Claims and Encounter Data: Service savings? What was the ratio of program expenditures to use and expenditures cost savings? HHP Payment Files: HHP services and payments for those services Notes: TEL is Targeted Engagement List. Data Sources As indicated in Exhibit 90, UCLA will receive four data sources from DHCS including (1) reports filed by each MCP, (2) TEL (Targeted Engagement List) created every six months by DHCS, (3) Medi-Cal Claims and Encounter Data for all program beneficiaries and comparison group, and (4) monthly HHP payments files submitted by MCPs. These data sources allow for a qualitative and quantitative approach to the HHP evaluation. The ability of UCLA to address the evaluation questions is dependent on the content of these datasets and the type of analyses will be dependent on availability of data. MCP reports include the readiness deliverables and required quarterly reporting. The readiness deliverables include HHP policies and procedures describing infrastructure, services, network and operations, engagement plans, and HHP network composition. The quarterly reporting will include aggregate semi-annual and annual health outcome measures. The quarterly reports will also identify enrollees that are experiencing homelessness and whether or not they received housing services and were successfully housed. TEL is created every six months by DHCS to identify enrollees of participating MCPs who are potentially eligible for enrollment in HHP based on the HHP inclusion and exclusion criteria. These data include patient demographics and health status indicators. 174 UCLA Evaluation | UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program Medi-Cal fee-for-service (FFS) claims and managed care encounter data include comprehensive information on use of services by eligible and enrolled HHP patients. UCLA will receive two years of data prior to implementation of HHP to establish baseline trends, and a minimum of one year of data during HHP implementation. These data include diagnoses, service use, and provider payments for fee-for-service (FFS) claims. HHP payment files will be submitted monthly by the MCPs to DHCS. They are expected to include enrollment lists, the enrollee's State Plan Amendment (SPA) assignment, enrollee's status as a dual-enrollee and monthly DHCS payments to MCPs. UCLA will maintain all data in a secure environment. UCLA anticipates receiving a preliminary enrollment and encounter data from DHCS within six months of program implementation to evaluate the data for completeness and accuracy and to conduct preliminary analyses. The final and complete data for the first year of the program are anticipated no later than six months after the end of the first year of program implementation. Methods UCLA will analyze all available data to evaluate HHP impact. The evaluation will include a quantitative assessment of program impact on enrollment, health care utilization, and cost indicators. In addition, the evaluation will also include a qualitative assessment of HHP infrastructure and implementation process through analysis of the HHP readiness deliverables. The quantitative analyzes will range from more descriptive analyses of enrollees, enrollment trends, self-reported metrics, and health outcomes, to advanced methods to assess changes in utilization and costs. The descriptive analyses will use descriptive statistics to examine basic enrollee demographics, health conditions and acuity, and healthcare utilization both historically and during the period of the program. The advanced methods include use of regression models and quasi-experimental analytic design including pre-post, intervention-comparison group design and difference-in-difference (DD) methodology when possible. The quasi-experimental design is desirable due to its rigor in isolating the impact of HHP services. In order to study the impact of the HHP by county and MCP, the evaluation will use small area estimation to stratify all relevant outcomes by county and MCP combinations. This will be accomplished by including MCP and county as random effects in the models, thereby allowing for the measurement of these factors on the overall estimate even among small counties and MCPs. The final measures will be presented for the overall program and stratified by these groups. Selection of the comparison group is necessary for the quasi-experimental design and allows for elimination of the impact of contextual determinants of health care utilization and costs. UCLA has identified two possible methods of identifying a comparison group including: 1) UCLA Evaluation | 175 UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program participating MCP members that are on the TEL but either were not targeted or yet to be targeted by MCPs or did not opt-in; and 2) MCP members in counties not implementing HHP that fit the TEL criteria. As enrollment in HHP will change over the course of the program and inclusion on the TEL will also change over time, the comparison group will have to be created during multiple time points during the course of the evaluation. If needed to create a sufficiently large enough group, the comparison group may be composed of individuals from both methods. Both methods to identify the comparison group have significant limitations. HHP enrollment among the eligible beneficiaries is not random as MCPs target beneficiaries based on additional criteria and their knowledge of patient utilization and costs. In addition, HHP enrollees have to choose to opt-in and those who do not are likely to have different characteristics. Therefore, the first comparison group is subject to selection bias. UCLA will be unable to identify which members on the TEL chose not to opt-in versus those that were not contacted. The second comparison group is not subject to selection bias, but there are potential differences in health system characteristics, population demographics, and patterns of health care utilization in other counties. For both comparison groups, HHP eligible patients may be enrolled in the Whole Person Care pilot programs which provides a number of similar services to HHP. Enrollment in WPC will not be known among either the treatment or comparison group members. UCLA will create these comparison groups and will closely examine the size and characteristics of each group to assess the utility of each group for the DD analyses, in addition to exploring modeling tools that account for selection bias. If an appropriate comparison group is not possible, an alternative strategy to assess the impact of HHP is to compare pre- and post-trends in health care utilization and expenditures for HHP enrollees, using regression models to project trends in the post period assuming no HHP services are provided (counterfactual trends), and measure the change between the observed and projected trends in the post period. The difference in these trends will estimate the potential reduction in utilization or expenditures that can be attributed to HHP. The Medi-Cal managed care encounter data used for assessing HHP impact does not have enough information on expenditures, which will be needed to demonstrate potential savings, cost neutrality and return-on-investment. Possible methods that UCLA will use to attribute expenditures to managed care encounters include using FFS expenditure data and the Medi-Cal Fee Schedule. If possible, the Medi-Cal fee schedule will be used to attribute a fee to each service provided during managed care encounters. UCLA will also compare the fee schedule to the FFS claims to assess the accuracy of using the fee schedule. If the fee schedule does not have sufficient information, ULCA will examine the patterns of care among FFS beneficiaries and managed care HHP enrollees to assess whether the FFS claims will be suitable for 176 UCLA Evaluation | UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program estimating expenditures. UCLA anticipates population and health care use differences between the two groups. UCLA's ability to estimate cost neutrality and return-on-investment is dependent on being able to estimate expenditures for managed care encounters. If the FFS data and fee schedule do not provide all necessary estimated expenditures, UCLA will calculate the individual acuity factors over time based on the prospective Medicaid Rx model for the HHP enrollees and derive change over time to draw inference on how HHP works. UCLA will collaborate with DHCS to examine the HHP encounter submissions. UCLA will use the DD analytic technique when available to measure potential reduction in total expenditures that can be attributed to HHP. Total expenditures will include the HHP payments. The potential reduction in expenditures will represent the savings associated with delivery of HHP services. UCLA will then calculate the return on investment by assessing the amount of savings per each dollar spent on the HHP program. In addition to calculating changes in HHP enrollee utilization and expenditures, UCLA will independently assess changes in self-reported HHP metrics during the program when possible. UCLA will also independently assess the CMS recommended Core Set of health care quality measures for HHP using Medi-Cal data whenever possible. These measures include both health outcome and utilizations measures that are endorsed by organizations such as National Quality Forum (NQF), Agency for Healthcare Research and Quality (AHRQ), National Committee for Quality Assurance (NCQA), and/or CMS that have detailed measure specifications. The evaluation will further focus on creating metrics and utilization measures that are likely to be the outcome of HHP services. For example, care coordination and wrap around services are likely to reduce hospital and emergency department visits because of availability of timely and appropriate outpatient care. Therefore, UCLA will assess the changes in the annual rates of emergency department and hospital visits in the pre- and post-periods and compare these changes to the comparison groups or the counterfactual trends. Alternatively, care coordination services are likely to increase use of outpatient medical and substance use services for some enrollees. Therefore, UCLA will examine the change in delivery of these services using the same methodology. HHP interventions to improve care transitions are expected to increase the rate of post-admission outpatient follow up and reduce readmissions. Thus, UCLA will assess the delivery of outpatient follow up post-discharge, number of hospital readmissions, and potential association of outpatient follow ups on readmissions. UCLA will also create additional measures that are specific to common subpopulations in HHP when possible. For example, many of the HHP enrollees will have common chronic conditions such as diabetes or asthma or will be homeless. UCLA will use Medi-Cal data to create measures that evaluate the program impact on subgroups with conditions such as asthma or diabetes or UCLA Evaluation | 177 UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program the homeless. Examples of the measures may include frequency of HbA1c lab tests among patients with diabetes and the rate of asthma prescriptions filled among patients with asthma. UCLA will also create metrics and measures for homeless patients including the most common conditions and service use patterns among the homeless. Other subpopulations of interest may include pediatric patients, SPA groups and recent Medi-Cal enrollees. Limitations External contextual factors may impact individual MCP results, such as other local or state initiatives that were ongoing or newly embarked on in the geographic areas that are served by HHP networks. These challenges will be met through use of DD analyses and comparing the HHP enrollee results with selected comparison groups or the counterfactual trends. There are limitations to UCLA's ability to independently assess all HHP self-reported metrics. UCLA anticipates that metrics such as all-cause hospitalizations and emergency department visits can be independently assessed using Medi-Cal enrollment and claims data. However, measures of use of some services such as screening for clinical depression are only available in self-reported data. Similarly, information on implementation of care coordination policies and procedures are limited to self-reported data. UCLA anticipated some error in attributing expenditures to managed care encounters due to anticipated differences in characteristics of FFS and managed care enrollees, systematic differences in health care delivery, and potential lack of detailed encounter data or fee schedule data. These limitations will lead to under or overestimates of actual expenditures attributed to encounter data but do not negatively impact estimates of changes in utilizations or savings. This is because the error in attributing expenditures is consistently and systematically applied to all encounters. Due to the staggered rollout of the program, with the majority of counties implementing SPA 2 in January 2020, UCLA anticipates that enrollment numbers will be low for the initial June 2020 report and that there will be insufficient time to observe the comprehensive impact of the program. Furthermore, due to a lag of at least six months in adjudicated Medi-Cal claims data, the data available for the first evaluation report will be limited to the first county to implement the program, San Francisco County. Two additional reports will follow this first report (Exhibit 91), which allows for all counties to implement HHP and an adequate time period to observe an impact of HHP on health and utilization trends and outcomes. For some of the outcomes of interest, UCLA anticipates that HHP's impact may not be realized during the evaluation timeframe. 178 UCLA Evaluation | UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program Timeline Exhibit 91 indicates the evaluation deliverables and anticipated dates. Exhibit 91: Evaluation Timeline and Deliverables Deliverable Description Due Date(s) Draft evaluation design Draft evaluation methodology for managed care September 30, 2018 and methods plan/stakeholder review and comment Revised evaluation design Revised evaluation methodology November 16, 2018 and methods Final evaluation design Final evaluation methodology December 31, 2018 and methods First draft interim First draft interim evaluation report to be completed after May 22, 2020 evaluation report the first 18 months of HHP implementation Final first interim Final first interim evaluation report June 20, 2020 evaluation report Second draft interim Second draft interim evaluation report to be completed August 22, 2021 evaluation report after 30 months of HHP implementation Final second interim Final second interim evaluation report September 30, 2021 evaluation report Draft Final Evaluation Draft final evaluation report May 1, 2023 Report Final Evaluation Report Final evaluation report June 23, 2023 UCLA Evaluation | 179 UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program Appendix C: HHP Enrollees Enrolled Less Than 31 Days There were 2,758 HHP enrollees enrolled for less than 31 days due to unsuccessful engagement among other unknown factors. This group was reported exclusively in this appendix. MCPs received PMPM payments for one month for these enrollees, but payments ceased when those individuals were no longer be enrolled in the program. MCPs did not provide other services to this group. Comparison of these enrollees with those enrolled for longer than 30 days during the first interim evaluation report indicated these groups had similar demographics, health status, and health care utilization prior to HHP (data not shown). Of the 2,758 HHP enrollees enrolled for less than 31 days, 1,900 came from SPA 1 and 858 came from SPA 2. 180 | UCLA Evaluation UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program Appendix D: Enrollees with More than One Year of HHP Enrollment UCLA restricted analysis of HHP metrics and measure during HHP for the final report to two years of enrollment due to the limited number of enrollees with more than two year of enrollment. Exhibit 92 shows that 8,777 (13%) of SPA 1 enrollees had 25 or more months of enrollment. Of that 8,777, 61% have less than six months of enrollment in the second year. Exhibit 92: Count of SPA 1 Enrollees by Number of Months of HHP Enrollment as of December 2021 4,063 4,494 3,753 3,639 3,559 3,514 3,177 2,823 2,761 2,595 2,537 2,505 2,351 2,222 1,900 1,763 1,516 1,483 1,401 1,314 1,270 1,201 1,180 1,172 1,115 1,042 1,020 1,016 958 930 574 315 313 309 229 180 52 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37+ Number of Months of Enrollment Source: MCP Enrollment Reports from August 2019 and Quarterly HHP Reports from September 2019 to December 2021. Exhibit 93 shows that 449 (2%) of SPA 2 enrollees had 25 or more months of enrollment. Of that 449, 85% had less than six months of enrollment in the second year. Appendix C: HHP Enrollees Enrolled Less Than 31 Days| UCLA Evaluation 181 UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program Exhibit 93: Count of SPA 2 Enrollees by Number of Months of HHP Enrollment as of September 2020 2,005 1,789 1,718 1,619 1,496 1,448 1,288 1,244 1,227 1,002 1,000 858 799 722 702 682 677 669 600 563 463 458 446 444 96 83 78 63 63 50 16 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31+ Number of Months of Enrollment Source: MCP Enrollment Reports from August 2019 and Quarterly HHP Reports from September 2019 to December 2021. 182 | UCLA Evaluation UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program Appendix E: Survey: COVID-19 Impact on the Health Homes Program (HHP) In the late fall of 2020, the UCLA Center for Health Policy Research conducted the following survey on HHP MCPs. The brief survey focused on (1) how HHP infrastructure and integrated care delivery approaches may have helped with local response to COVID-19, and (2) the potential impact of the COVID-19 pandemic on HHP. The survey instrument is included in this appendix. | UCLA Evaluation 183 UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program 1) On a scale of 0-10, please rate the impact of the COVID-19 pandemic on your organization's (or your contracted CB-CME's) ability to perform the following HHP-related activities. Please briefly describe the changes and impact. Process/Procedure/ Process/procedure/ Degree of Impact Briefly describe the Policy policy changed? changes and impact 0 = Not at 5= 10 = all 1 2 3 4 Somewhat 6 7 8 9 Extremely Impacted Impacted Impacted a. Identifying eligible HHP SPA 1 – Yes / No enrollees (e.g., ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ administrative SPA 2 – Yes / No data, referrals) b. Engagement and enrollment of SPA 1 – Yes / No eligible ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ beneficiaries SPA 2 – Yes / No into HHP (e.g., outreach) c. Communications with HHP SPA 1 – Yes / No enrollees (e.g., ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ telephonic, SPA 2 – Yes / No telehealth, in- person) d. Frontline staffing SPA 1 – Yes / No ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ policies and procedures (e.g., 184 | UCLA Evaluation UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program Process/Procedure/ Process/procedure/ Degree of Impact Briefly describe the Policy policy changed? changes and impact 0 = Not at 5= 10 = all 1 2 3 4 Somewhat 6 7 8 9 Extremely Impacted Impacted Impacted shift to telework, SPA 2 – Yes / No protocols for in- person visits and use of PPE, recruitment or retention policies and practices) e. Delivery of comprehensive care management by SPA 1 – Yes / No frontline staff ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ (e.g., frequency, SPA 2 – Yes / No modality, location in which provided) f. Delivery of care coordination by SPA 1 – Yes / No frontline staff ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ (e.g., SPA 2 – Yes / No implementation of Health Action | UCLA Evaluation 185 UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program Process/Procedure/ Process/procedure/ Degree of Impact Briefly describe the Policy policy changed? changes and impact 0 = Not at 5= 10 = all 1 2 3 4 Somewhat 6 7 8 9 Extremely Impacted Impacted Impacted Plan, case conferences) g. Ability to provide health promotion and individual/family support services SPA 1 – Yes / No (e.g., effective ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ health SPA 2 – Yes / No education, referrals to resources such as smoking cessation) h. Comprehensive transitional care (e.g., admission notifications, SPA 1 – Yes / No coordinating ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ with hospital SPA 2 – Yes / No discharge planners, transportation) 186 | UCLA Evaluation UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program Process/Procedure/ Process/procedure/ Degree of Impact Briefly describe the Policy policy changed? changes and impact 0 = Not at 5= 10 = all 1 2 3 4 Somewhat 6 7 8 9 Extremely Impacted Impacted Impacted i. Housing and SPA 1 – Yes / No homeless ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ support services SPA 2 – Yes / No j. Referral by MCP and/or CB-CMEs to community SPA 1 – Yes / No and social ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ supports (e.g., SPA 2 – Yes / No housing, food resources) k. Contracts with CB-CMEs (e.g., challenges contracting with new CB-CMEs, SPA 1 – Yes / No revisions to ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ existing CB-CME SPA 2 – Yes / No contracts in response to policy/process changes) l. Reporting (e.g., SPA 1 – Yes / No ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ delays in receiving data | UCLA Evaluation 187 UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program Process/Procedure/ Process/procedure/ Degree of Impact Briefly describe the Policy policy changed? changes and impact 0 = Not at 5= 10 = all 1 2 3 4 Somewhat 6 7 8 9 Extremely Impacted Impacted Impacted from CB-CMEs, SPA 2 – Yes / No accuracy or comprehensiven ess of data) m. MCP monitoring SPA 1 – Yes / No and oversight of ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ CB-CMEs SPA 2 – Yes / No n. Other (please SPA 1 – Yes / No specify: ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ _______) SPA 2 – Yes / No 188 | UCLA Evaluation UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program 2) Did COVID-19 impacts on HHP processes, procedures, and/or policies vary by County? ☐Yes ☐No ☐Not applicable If yes, please briefly explain: 3) Briefly describe COVID-19 impact on your plan's ability to achieve desired HHP outcomes. 4) Please comment on if and how HHP helped with your plan's overall COVID-19 response and in what ways. 5) Are you using telehealth to deliver HHP services in response to COVID-19? ☐Yes ☐No Please describe the type of services telehealth is used for and the effectiveness of these strategies. | UCLA Evaluation 189 UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program 190 | UCLA Evaluation UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program 6) In addition to telehealth, what other mitigation strategies (e.g., street medicine) has your organization used to respond to COVID-19? Please list and briefly describe the effectiveness of any strategies used. 7) Have there been any unexpected positive impacts due to COVID-19 (e.g., ability to use telehealth or other mitigation strategies, changing utilization patterns, or changes to your policies or your arrangements with CB-CMEs)? Please describe. 8) Are there any mitigation strategies or other changes that you are considering maintaining after the COVID-19 emergency ends? (e.g., increased use of telehealth, etc.) Please describe. 9) Is there anything we haven't asked that you think is important to know about your experience with the COVID-19 pandemic? Please denote N/A if not applicable. | UCLA Evaluation 191 UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program 192 | UCLA Evaluation UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program Appendix F: MCP-Level Descriptives and Unadjusted HHP Core Metrics UCLA used HHP Quarterly Reports from July 1, 2018, to December 31, 2021 and Medi-Cal enrollment and claims data from July 1, 2016 to December 31, 2021 to create descriptives and outcomes by MCP at the County- and SPA-level in the following areas: • HHP Implementation and Enrollee Demographics • Health Status and Utilization • HHP Metric Trends • Estimated Medi-Cal Payment Trends The following exhibits are broken up by MCP: • Exhibits 94 - 97: Aetna, Alameda Alliance, Blue Shield, and CA Health and Wellness • Exhibits 98 - 101: Anthem Blue Cross • Exhibits 102 - 105: LA Care, Community Health Group, Kern Health Systems, and CalOptima • Exhibits 106 - 109: Inland Empire Health Plan and Kaiser • Exhibits 110 - 113: Molina Healthcare Plan • Exhibits 114 - 117: Health Net • Exhibits 118 - 121: San Francisco Health Plan, Santa Clara Family Health Plan, and United Healthcare | UCLA Evaluation 193 UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program Exhibit 94: HHP Implementation and Enrollee Demographics for Aetna, Alameda Alliance, Blue Shield, and CA Health and Wellness as of December 31, 2021 California Health MCP Aetna Alameda Alliance Blue Shield & Wellness Group Group 3 Group 3 Group 3 Group 3 County Sacramento San Diego Alameda San Diego Imperial SPA 1 2 1 2 1 2 1 2 1 2 Program Implementation and Enrollment Implementation Date 7/1/19 1/1/20 7/1/19 1/1/20 7/1/19 1/1/20 7/1/19 1/1/20 7/1/19 1/1/20 Total Enrollment (12/2021) 148 27 184 69 696 63 1403 470 1328 200 % Of enrollees from TEL 79% 64% 78% 74% 83% Avg Length of Enrollment (Months) 12 15 11 13 15 11 11 9 7 9 Enrollee Demographics % 0-17 -- -- 10% -- 0% 0% 3% 3% 9% 6% % 18-34 10% -- 15% 33% 8% -- 10% 25% 12% 26% % 34-49 28% -- 23% 29% 21% 29% 16% 27% 19% 28% % 49-64 51% 44% 43% 29% 50% 52% 47% 37% 53% 36% % 65+ -- -- 9% -- 22% -- 24% 8% 7% -- % Male 49% -- 46% 46% 49% 35% 47% 38% 36% 23% % White 31% 44% 24% 19% 10% 17% 33% 35% 4% -- % Hispanic 12% -- 28% 26% 20% 21% 28% 20% 91% 90% % African American 20% -- 10% -- 37% 27% 11% 10% 1% -- % Asian American and Pacific Islander 11% 0% 8% -- 16% -- 5% 3% -- -- % American Indian and Alaskan Native -- 0% 0% 0% -- 0% -- -- -- -- % Other 19% -- 29% 41% 14% 24% 17% 28% -- 0% % Unknown -- -- -- -- 4% -- 5% 4% 3% -- % Speak English 86% 100% 80% 88% 76% 87% 74% 85% 37% 52% Medi-Cal full-scope months baseline year 1 12 12 12 12 12 12 12 12 12 12 # Enrollees with Homeless Information Available 148 27 184 69 696 63 1403 470 1328 200 Proportion ever homeless during HHP enrollment -- -- -- -- 21% 21% 19% 23% 1% -- Source: MCP Enrollment Reports from August 2019, Quarterly HHP Reports from September 2019 to December 2021, and Medi-Cal Claims data from July 1, 2016 to December 31, 2021. Notes: -- indicates data is not reported due to small cell size. N/A indicates there are no enrollees to report. 194 | UCLA Evaluation UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program Exhibit 95: HHP Enrollee Health Status and Utilization Prior to Enrollment and Service Delivery for Aetna, Alameda Alliance, Blue Shield, and CA Health and Wellness as of December 31, 2021 California Health MCP Aetna Alameda Alliance Blue Shield & Wellness Group Group 3 Group 3 Group 3 Group 3 County Sacramento San Diego Alameda San Diego Imperial SPA 1 2 1 2 1 2 1 2 1 2 Health Status and Utilization Prior to Enrollment Two specific conditions (criteria 1) 42% -- 41% 23% 67% 60% 60% 33% 39% 22% Hypertension and another specific condition (criteria 2) 58% -- 39% -- 71% 57% 57% 25% 64% 26% Serious mental health condition (criteria 3) 51% 96% 47% 90% 39% 92% 45% 90% 27% 92% Asthma (criteria 4) 26% -- 27% -- 25% 40% 24% 16% 29% 18% Average number of ED visits 5.1 3.4 4.3 2.9 9.3 9.5 4.9 5.5 3.4 4.5 Average number of hospitalizations 0.9 0.5 1.0 0.4 2.4 1.8 1.3 1.1 0.4 0.4 HHP Services Delivered to HHP Enrollees Total number of units of service provided 3,735 939 3,478 1,305 45,899 1,604 56,960 19,659 1,765 379 Average number of units of service per enrollee 2.0 2.0 1.4 1.4 2.8 3.1 2.7 3.6 2.6 2.4 Median number of units of service per enrollee 1.0 1.0 1.0 1.0 2.0 3.0 2.0 3.0 2.0 2.0 Average number of engagement services provided 1.1 1.1 1.4 1.3 1.3 1.7 1.4 1.3 1.4 1.8 Average number of core services provided 1.9 1.8 1.3 1.2 2.5 3.1 1.9 2.4 2.4 2.2 Average number of other HHP services provided 1.6 1.4 1.1 1.2 3.0 2.4 2.2 2.6 1.7 1.8 Average number of in-person services provided 1.1 1.3 1.2 1.0 1.6 1.9 1.2 1.2 1.3 1.2 Average number of phone/ telehealth services provided 1.8 1.8 1.3 1.2 2.4 2.9 1.9 2.4 2.3 2.1 Average number of services provided by clinical staff 1.0 1.1 1.0 1.0 2.7 0.0 1.9 1.8 1.0 0.0 Average number of services provided by non-clinical staff 2.0 1.9 1.3 1.3 2.6 3.1 2.5 3.5 2.5 2.4 Source: UCLA analysis of Medi-Cal Claims data from July 1, 2016 to December 31, 2021. Notes: -- indicates data is not reported due to small cell size. N/A indicates there are no enrollees to report. At risk for high utilization is defined as no ED utilization or hospitalizations 24 months prior to enrollment, low utilization is less than 2 ED visits and less than 1 hospitalizations per year, moderate utilization is 2 or more ED visits or 1 or more hospitalizations per year, high utilization is 5 or more ED visits or 2 or more hospitalizations per year, and super utilization is 10 or more ED visits or 4 or more hospitalizations per year. | UCLA Evaluation 195 UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program Exhibit 96: Trends in HHP Metrics for Aetna, Alameda Alliance, Blue Shield, and CA Health and Wellness as of December 31, 2021 Alameda California Health MCP Aetna Alliance Blue Shield & Wellness Group Group 3 Group 3 Group 3 Group 3 County Sacramento San Diego Alameda San Diego Imperial SPA 1 2 1 2 1 2 1 2 1 2 Adult BMI Assessment Baseline year 1 53% 32% 59% 44% 33% 45% 55% 48% 89% 91% Baseline year 2 70% 64% 63% 58% 39% 66% 60% 53% 88% 90% HHP year 1 70% 74% 61% 52% 40% 52% 59% 49% 72% 80% HHP year 2 68% 58% 59% 50% 34% 37% 56% 43% 64% 56% Follow-Up After Hospitalization for Mental Illness within 30 Days Baseline year 1 100% -- 100% -- 56% -- 90% 71% 100% 0% Baseline year 2 100% 0% 100% 67% 90% 100% 86% 80% 100% 100% HHP year 1 100% -- 100% -- 67% -- 65% 92% -- -- HHP year 2 -- 0% -- 100% 60% 75% 90% 50% -- -- Follow-Up After Hospitalization for Mental Illness within 7 Days Baseline year 1 100% -- 57% -- 33% -- 64% 54% 100% 0% Baseline year 2 0% 0% 67% 33% 60% 100% 53% 61% 100% 80% HHP year 1 0% -- 50% -- 33% -- 43% 83% -- -- HHP year 2 -- 0% -- 100% 60% 75% 60% 50% -- -- Screening for Depression and Follow-Up Plan Baseline year 1 2% 0% 3% 4% 0% 0% 4% 6% 0% 0% Baseline year 2 2% 0% 14% 0% 0% 0% 11% 5% 0% 0% HHP year 1 3% 0% 2% 0% 0% -- 17% 30% 0% 0% HHP year 2 0% -- 16% 0% 0% -- 19% 33% 0% 0% Follow-Up After ED Visit for Alcohol and Other Drug Abuse or Dependence within 7 days Baseline year 1 25% -- 0% 0% 8% 0% 15% 7% 7% 0% Baseline year 2 0% 0% 33% 0% 15% 0% 1% 12% 20% 57% HHP year 1 25% -- 0% 0% 24% 0% 14% 11% 25% 100% HHP year 2 -- 0% -- 0% 9% 0% 6% 0% 0% 0% Follow-Up After ED Visit for Alcohol and Other Drug Abuse or Dependence within 30 days Baseline year 1 38% -- 0% 33% 17% 0% 23% 22% 13% 0% Baseline year 2 0% 0% 44% 0% 21% 0% 7% 22% 30% 57% HHP year 1 25% -- 25% 0% 37% 17% 27% 11% 25% 100% HHP year 2 -- 0% -- 0% 18% 0% 11% 0% 0% 0% Initiation of Alcohol and Other Drug Dependence Treatment Baseline year 1 32% 0% 34% 42% 25% 33% 24% 31% 28% 47% Baseline year 2 25% 0% 34% 50% 25% 60% 25% 27% 34% 41% HHP year 1 21% 100% 11% 25% 30% 20% 26% 18% 29% 53% HHP year 2 10% 50% 27% 25% 29% 67% 20% 24% 25% 0% Engagement of Alcohol and Other Drug Dependence Treatment Baseline year 1 50% -- 50% 60% 30% 25% 38% 44% 57% 47% Baseline year 2 33% -- 58% 20% 17% 50% 32% 42% 46% 56% HHP year 1 50% 0% 0% 50% 26% 67% 38% 40% 18% 30% HHP year 2 100% 0% 33% 100% 22% 50% 50% 33% 0% -- Use of Pharmacotherapy for Opioid Use Disorder Baseline year 1 70% 100% 67% 0% 58% 55% 35% 44% 34% 25% 196 | UCLA Evaluation UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program Alameda California Health MCP Aetna Alliance Blue Shield & Wellness Group Group 3 Group 3 Group 3 Group 3 County Sacramento San Diego Alameda San Diego Imperial SPA 1 2 1 2 1 2 1 2 1 2 Baseline year 2 88% 100% 56% 50% 65% 71% 32% 40% 38% 45% HHP year 1 63% 50% 50% 40% 72% 36% 34% 45% 42% 45% HHP year 2 67% 100% 20% 100% 85% 33% 35% 29% 50% 33% All-Cause Readmission Baseline year 1 13% 0% 30% 33% 12% 6% 11% 7% 6% 6% Baseline year 2 16% 0% 14% 0% 13% 13% 6% 6% 9% 13% HHP year 1 10% -- 14% 14% 15% 10% 11% 9% 8% 0% HHP year 2 0% 0% 9% 0% 13% 22% 13% 7% 17% 0% Controlling High Blood Pressure Baseline year 1 20% 14% 7% 13% 0% 0% 11% 9% 8% 3% Baseline year 2 18% 29% 6% 15% 0% 0% 22% 20% 7% 6% HHP year 1 32% 14% 5% 0% 0% 0% 31% 38% 6% 8% HHP year 2 28% 33% 11% 0% 0% 0% 38% 40% 3% 0% Outpatient Services: Primary Care per 1,000 Beneficiaries per Year Baseline year 1 4,927 3,811 4,703 3,827 7,515 7,885 6,689 7,106 9,456 8,973 Baseline year 2 6,417 6,000 6,508 6,808 10,163 12,468 8,838 10,328 10,699 10,435 HHP year 1 7,628 5,492 9,434 9,147 15,311 15,811 10,632 10,954 12,766 12,071 HHP year 2 5,604 5,702 8,951 7,027 12,430 12,978 9,869 10,464 11,290 7,887 Outpatient Services: Specialty Care per 1,000 Beneficiaries per Year Baseline year 1 2,839 2,068 4,061 2,958 4,575 3,151 6,439 5,453 4,510 3,699 Baseline year 2 2,399 2,886 5,070 3,886 5,842 5,475 7,327 6,831 4,784 3,789 HHP year 1 3,168 3,649 6,624 4,543 6,947 5,331 7,432 6,537 4,841 3,269 HHP year 2 3,518 4,840 7,599 3,532 5,873 5,543 7,327 5,825 5,938 3,849 Outpatient Services: Mental Health per 1,000 Beneficiaries per Year Baseline year 1 4,935 6,851 4,850 6,508 5,915 12,671 4,640 10,464 3,661 10,560 Baseline year 2 4,278 10,747 5,983 8,811 5,750 18,040 5,044 12,816 3,940 13,409 HHP year 1 4,755 6,809 5,091 7,240 7,045 20,870 5,895 11,689 3,832 12,143 HHP year 2 3,227 8,884 3,770 8,613 6,021 20,348 4,830 11,418 2,794 10,113 Outpatient Services: Substance Use Disorder per 1,000 Beneficiaries per Year Baseline year 1 9,120 2,554 2,263 4,179 15,480 26,359 3,579 5,897 3,434 8,458 Baseline year 2 9,027 3,570 3,981 3,189 14,689 23,758 3,129 6,792 4,516 10,335 HHP year 1 9,471 3,009 3,156 3,008 14,374 14,132 3,040 5,025 4,848 7,181 HHP year 2 6,722 5,635 2,628 3,748 11,726 7,696 2,898 4,228 5,957 6,151 Emergency Department Visits per 1,000 Beneficiaries per Year Baseline year 1 2,385 1,662 2,182 1,498 3,412 2,600 1,957 2,303 1,674 2,516 Baseline year 2 2,173 1,671 1,861 1,350 3,833 5,314 1,912 2,535 1,345 1,701 HHP year 1 1,436 940 1,790 1,101 3,297 3,289 1,378 1,768 1,354 1,399 HHP year 2 1,293 2,718 1,186 649 2,462 3,391 1,142 1,381 1,449 1,849 Inpatient Stays per 1,000 Beneficiaries per Year Baseline year 1 487 243 612 203 875 499 633 525 237 217 Baseline year 2 540 266 558 267 1,639 1,341 693 643 184 206 HHP year 1 471 75 437 372 1,429 1,225 516 446 170 86 HHP year 2 198 133 511 180 989 848 333 256 218 75 PQI 92 (per 1,000 Beneficiaries per Year) Baseline year 1 117 -- 67 -- 264 138 82 39 24 5 | UCLA Evaluation 197 UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program Alameda California Health MCP Aetna Alliance Blue Shield & Wellness Group Group 3 Group 3 Group 3 Group 3 County Sacramento San Diego Alameda San Diego Imperial SPA 1 2 1 2 1 2 1 2 1 2 Baseline year 2 103 -- 107 30 455 210 104 30 20 -- HHP year 1 112 -- 55 -- 388 227 73 53 17 -- HHP year 2 70 -- 75 -- 223 -- 41 23 19 -- Admission to an Institution from the Community - Short (per 1,000 Beneficiaries per Year) Baseline year 1 -- 41 15 -- 21 34 22 10 5 -- Baseline year 2 -- -- 17 15 41 48 27 19 1 -- HHP year 1 8 -- 7 16 24 45 18 18 1 -- HHP year 2 -- -- 30 -- 26 -- 24 8 9 -- Admission to an Institution from the Community - Medium (per 1,000 Beneficiaries per Year) Baseline year 1 17 -- -- -- 19 17 23 10 2 10 Baseline year 2 7 -- 6 -- 44 65 31 13 2 -- HHP year 1 8 -- -- -- 40 91 14 15 3 -- HHP year 2 -- -- 30 -- 41 130 19 39 -- -- Admission to an Institution from the Community - Long (per 1,000 Beneficiaries per Year) Baseline year 1 17 -- 7 -- 11 -- 9 2 1 -- Baseline year 2 -- -- -- 15 19 32 10 9 1 -- HHP year 1 -- -- 7 -- 29 23 12 -- 3 -- HHP year 2 -- -- -- -- 3 -- 10 8 -- -- Source: UCLA analysis of Medi-Cal Claims data from July 1, 2016 to December 31, 2021. Notes: -- indicates data is not reported due to small cell size. N/A indicates there are no enrollees to report. 198 | UCLA Evaluation UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program Exhibit 97: Trends in Estimated Payments for Aetna, Alameda Alliance, Blue Shield, and CA Health and Wellness as of December 31, 2021 MCP Aetna Alameda Alliance Blue Shield CA H&W Group Group 3 Group 3 Group 3 Group 3 County Sacramento San Diego Alameda San Diego Imperial SPA 1 2 1 2 1 2 1 2 1 2 Total Estimated Medi-Cal Payment per Beneficiary per Year Baseline year 1 $17,424 $ 8,943 $24,670 $19,436 $30,053 $20,570 $24,100 $24,768 $18,448 $21,143 Baseline year 2 $16,978 $11,998 $21,193 $22,313 $42,520 $43,794 $27,188 $29,358 $18,619 $17,371 HHP year 1 $16,432 $13,560 $19,388 $17,651 $49,599 $40,786 $27,047 $23,791 $17,404 $16,910 HHP year 2 $10,844 $12,143 $18,867 $14,180 $38,064 $49,473 $23,263 $20,474 $18,333 $12,202 % Change Year 1* -3% 13% -9% -21% 17% -7% -1% -19% -7% -3% % Change Year 2* -36% 1% -11% -36% -10% 13% -14% -30% -2% -30% Estimated Medi-Cal Payment for Emergency Department Visits per Beneficiary per Year Baseline year 1 $1,092 $488 $1,186 $977 $2,127 $2,676 $1,236 $1,191 $881 $1,519 Baseline year 2 $1,188 $598 $1,224 $631 $2,370 $3,352 $1,136 $1,487 $727 $895 HHP year 1 $728 $368 $1,058 $819 $2,576 $1,945 $931 $944 $687 $725 HHP year 2 $559 $866 $991 $627 $1,987 $2,897 $805 $614 $790 $1,037 % Change Year 1* -39% -38% -14% 30% 9% -42% -18% -37% -6% -19% % Change Year 2* -53% 45% -19% -1% -16% -14% -29% -59% 9% 16% Estimated Medi-Cal Payment for Inpatient Stays per Beneficiary per Year Baseline year 1 $6,767 $1,743 $13,902 $7,840 $9,408 $4,118 $7,968 $7,577 $3,823 $4,153 Baseline year 2 $6,281 $3,552 $7,888 $5,044 $18,349 $17,475 $9,937 $8,346 $3,467 $2,904 HHP year 1 $5,441 $1,332 $5,251 $5,154 $16,046 $15,708 $7,450 $5,755 $3,052 $1,753 HHP year 2 $2,564 $1,274 $5,417 $2,251 $11,049 $12,832 $4,481 $2,719 $3,664 $1,585 % Change Year 1* -13% -63% -33% 2% -13% -10% -25% -31% -12% -40% % Change Year 2* -59% -64% -31% -55% -40% -27% -55% -67% 6% -45% Estimated Medi-Cal Payment for Long-Term Care Stays per Beneficiary per Year Baseline year 1 $768 $9 $88 -- $434 $398 $1,655 $560 $77 $85 | UCLA Evaluation 199 UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program MCP Aetna Alameda Alliance Blue Shield CA H&W Group Group 3 Group 3 Group 3 Group 3 County Sacramento San Diego Alameda San Diego Imperial SPA 1 2 1 2 1 2 1 2 1 2 Baseline year 2 $417 -- $173 $191 $664 $551 $1,681 $957 $23 -- HHP year 1 $275 -- $56 $4 $2,056 $1,460 $1,875 $573 $59 -- HHP year 2 -- -- $277 -- $3,219 $1,055 $1,922 $1,190 $86 -- % Change Year 1* -34% - -68% -98% 210% 165% 12% -40% 154% - % Change Year 2* - - 60% - 385% 91% 14% 24% 273% - Estimated Medi-Cal Payment for Outpatient Services per Beneficiary per Year Baseline year 1 $3,938 $3,680 $5,115 $7,509 $11,638 $7,486 $7,176 $9,616 $5,672 $9,445 Baseline year 2 $4,395 $6,020 $6,465 $12,507 $14,222 $14,544 $8,412 $12,407 $6,958 $7,699 HHP year 1 $4,516 $10,648 $7,536 $7,268 $20,538 $12,649 $10,176 $10,799 $6,350 $8,435 HHP year 2 $3,095 $7,989 $5,902 $6,743 $14,079 $22,898 $9,186 $8,123 $6,198 $6,117 % Change Year 1* 3% 77% 17% -42% 44% -13% 21% -13% -9% 10% % Change Year 2* -30% 33% -9% -46% -1% 57% 9% -35% -11% -21% Estimated Medi-Cal Payment for Outpatient Pharmacy per Beneficiary per Year Baseline year 1 $3,959 $2,753 $3,358 $2,214 $4,839 $4,320 $4,826 $4,544 $6,999 $5,013 Baseline year 2 $4,075 $1,321 $4,236 $3,031 $5,153 $5,031 $4,930 $4,508 $6,280 $4,430 HHP year 1 $4,618 $891 $3,457 $3,275 $6,057 $6,553 $5,324 $4,551 $6,003 $4,773 HHP year 2 $3,887 $1,413 $3,287 $2,145 $5,676 $5,854 $5,752 $6,043 $5,732 $2,613 % Change Year 1* 13% -33% -18% 8% 18% 30% 8% 1% -4% 8% % Change Year 2* -5% 7% -22% -29% 10% 16% 17% 34% -9% -41% Estimated Medi-Cal Payment for Residual Services per Beneficiary per Year Baseline year 1 $778 $246 $822 $689 $1,335 $1,389 $1,039 $1,094 $864 $852 Baseline year 2 $470 $476 $1,043 $835 $1,278 $2,350 $882 $1,405 $1,033 $1,281 HHP year 1 $780 $296 $1,940 $906 $1,848 $1,997 $1,147 $1,063 $1,171 $1,138 HHP year 2 $699 $574 $2,861 $2,396 $1,729 $3,638 $1,025 $1,691 $1,702 $824 % Change Year 1* 66% -38% 86% 9% 45% -15% 30% -24% 13% -11% 200 | UCLA Evaluation UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program MCP Aetna Alameda Alliance Blue Shield CA H&W Group Group 3 Group 3 Group 3 Group 3 County Sacramento San Diego Alameda San Diego Imperial SPA 1 2 1 2 1 2 1 2 1 2 % Change Year 2* 49% 21% 174% 187% 35% 55% 16% 20% 65% -36% Source: UCLA analysis of Medi-Cal Claims data from July 1, 2016 to December 31, 2021. Notes: -- indicates data is not reported due to small cell size. N/A indicates there are no enrollees to report. *The percentage changes for Year 1 and 2 are calculated using Baseline Year 2 as the reference. | UCLA Evaluation 201 UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program Exhibit 98: HHP Implementation and Enrollee Demographics for Anthem Blue Cross as of December 31, 2021 MCP Anthem Blue Cross Partnership Plan Group Group 1 Group 3 County San Francisco Alameda Sacramento Santa Clara Tulare SPA 1 2 1 2 1 2 1 2 1 2 Program Implementation and Enrollment Implementation Date 7/1/19 1/1/20 7/1/19 1/1/20 7/1/19 1/1/20 7/1/19 1/1/20 7/1/19 1/1/20 Total Enrollment (12/2021) 211 61 282 79 1145 590 511 296 794 330 % of enrollees from TEL 59% 70% 71% 58% 70% Avg Length of Enrollment (Months) 12 9 10 9 13 11 15 12 17 14 Enrollee Demographics % 0-17 -- -- 6% -- 8% 1% 10% 6% 8% -- % 18-34 <13% 33% 11% 34% 21% 28% 19% 30% 17% 22% % 34-49 21% 18% 22% 24% 26% 30% 18% 21% 25% 32% % 49-64 44% 38% 47% 29% 36% 35% 32% 33% 39% 40% % 65+ 23% -- 14% -- 9% 5% 22% 11% 11% -- % Male 57% 49% 54% 42% 38% 33% 42% 36% 36% 25% % White 22% 21% 12% -- 25% 41% 18% 34% 28% 29% % Hispanic 12% -- 17% 14% 19% 12% 45% 33% 60% 55% % African American 29% 26% 48% 43% 27% 22% 7% 6% 3% 4% % Asian American and Pacific Islander 15% -- 6% -- 7% 3% 19% 8% 1% -- % American Indian and Alaskan Native -- 0% -- -- -- -- -- -- -- -- % Other 18% 26% 12% 22% 16% 16% 9% 14% 5% 8% % Unknown -- -- <5% -- 4% 4% 3% 4% <5% -- % Speak English 79% 92% 88% 89% 85% 93% 68% 86% 71% 74% Medi-Cal full-scope months baseline year 1 12 12 12 12 12 12 12 12 12 12 # Enrollees with Homeless Information Available 197 61 282 79 1145 590 511 296 794 330 Proportion ever homeless during HHP enrollment 8% -- 17% 16% 6% 11% 8% 10% 10% 8% Source: MCP Enrollment Reports from August 2019, Quarterly HHP Reports from September 2019 to September 2020, and Medi-Cal Claims data from July 1, 2016 to December 31, 2021. Notes: -- indicates data is not reported due to small cell size. N/A indicates there are no enrollees to report. 202 | UCLA Evaluation UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program Exhibit 99: HHP Enrollee Health Status and Utilization Prior to Enrollment and Service Delivery for Anthem Blue Cross as of December 31, 2021 MCP Anthem Blue Cross Partnership Plan Group Group 1 Group 3 County San Francisco Alameda Sacramento Santa Clara Tulare SPA 1 2 1 2 1 2 1 2 1 2 Health Status and Utilization 24 Months Prior to Enrollment Two specific conditions (criteria 1) 48% 16% 49% 20% 39% 28% 36% 24% 48% 31% Hypertension and another specific condition (criteria 2) 49% 15% 49% 19% 39% 28% 42% 22% 55% 39% Serious mental health condition (criteria 3) 31% 79% 29% 70% 35% 77% 20% 71% 26% 72% Asthma (criteria 4) 22% -- 26% -- 33% 19% 26% 8% 31% 19% Average number of ED visits 4.9 5.8 6.4 4.6 6.8 7.9 4.3 5.0 4.7 5.3 Average number of hospitalizations 1.4 1.2 1.8 1.1 1.3 0.9 0.9 0.7 1.1 1.2 HHP Services Delivered to HHP Enrollees Total number of units of service provided 2,375 606 2,341 535 8,950 5,523 4,391 2,518 22,681 6,302 Average number of units of service per enrollee 1.1 1.1 1.1 1.0 1.1 1.1 1.0 1.0 1.0 1.0 Median number of units of service per enrollee 1.0 1.0 1.0 1.0 1.0 1.0 1.0 1.0 1.0 1.0 Average number of engagement services provided 1.0 1.2 1.0 1.0 1.0 1.0 1.0 1.0 1.0 1.0 Average number of core services provided 1.0 1.0 1.0 1.0 1.0 1.0 1.0 1.0 1.0 1.0 Average number of other HHP services provided 1.1 1.1 1.1 1.1 1.0 1.0 1.0 1.0 1.0 1.0 Average number of in-person services provided 1.1 1.0 1.0 1.0 1.0 1.0 1.0 1.0 1.0 1.0 Average number of phone/ telehealth services provided 1.0 1.0 1.0 1.0 1.0 1.0 1.0 1.0 1.0 1.0 Average number of services provided by clinical staff 1.0 1.0 1.0 1.0 1.0 1.0 1.0 1.0 1.0 1.0 Average number of services provided by non-clinical staff 1.1 1.1 1.1 1.0 1.0 1.0 1.0 1.0 1.0 1.0 Source: UCLA analysis of Medi-Cal Claims data from July 1, 2016 to December 31, 2021. Notes: -- indicates data is not reported due to small cell size. N/A indicates there are no enrollees to report. At risk for high utilization is defined as no ED utilization or hospitalizations 24 months prior to enrollment, low utilization is less than 2 ED visits and less than 1 hospitalizations per year, moderate utilization is 2 or more ED visits or 1 or more hospitalizations per year, high utilization is 5 or more ED visits or 2 or more hospitalizations per year, and super utilization is 10 or more ED visits or 4 or more hospitalizations per year. | UCLA Evaluation 203 UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program Exhibit 100: Trends in HHP Metrics for Anthem Blue Cross as of December 31, 2021 MCP Anthem Blue Cross Partnership Plan Group Group 1 Group 3 County San Francisco Alameda Sacramento Santa Clara Tulare SPA 1 2 1 2 1 2 1 2 1 2 Adult BMI Assessment Baseline year 1 16% 8% 31% 23% 51% 55% 31% 29% 53% 53% Baseline year 2 23% 8% 34% 17% 73% 71% 40% 35% 66% 73% HHP year 1 23% 6% 32% 15% 79% 68% 43% 37% 78% 77% HHP year 2 24% 14% 28% 35% 77% 66% 40% 42% 79% 77% Follow-Up After Hospitalization for Mental Illness within 30 Days Baseline year 1 100% 50% -- 100% 33% 100% 100% 89% 83% 77% Baseline year 2 100% 100% 100% 100% 100% 85% 100% 88% 86% 69% HHP year 1 100% -- -- 100% 83% 100% 100% 67% 86% 91% HHP year 2 -- 100% -- -- 100% 67% 100% -- 86% 100% Follow-Up After Hospitalization for Mental Illness within 7 Days Baseline year 1 60% 50% -- 75% 22% 75% 80% 67% 33% 46% Baseline year 2 80% 100% 100% 80% 50% 54% 100% 63% 50% 63% HHP year 1 100% -- -- 100% 33% 80% 0% 67% 57% 73% HHP year 2 -- 0% -- -- 100% 67% 100% -- 29% 0% Screening for Depression and Follow-Up Plan Baseline year 1 1% 0% 0% 0% 1% 0% 0% 0% 0% 0% Baseline year 2 0% 0% 0% 0% 2% 0% 3% 0% 0% 0% HHP year 1 1% 0% 1% 0% 1% 0% 6% 0% 0% 0% HHP year 2 0% -- 0% -- 0% 0% 4% 0% 0% 0% Follow-Up After ED Visit for Alcohol and Other Drug Abuse or Dependence within 7 days Baseline year 1 31% 40% 4% 33% 9% 9% 6% 10% 14% 20% Baseline year 2 13% 14% 10% -- 11% 7% 8% 0% 13% 0% HHP year 1 33% 50% 0% 0% 8% 5% 0% 0% 25% 11% HHP year 2 0% 0% 0% -- 0% 0% 0% -- 0% 0% Follow-Up After ED Visit for Alcohol and Other Drug Abuse or Dependence within 30 days Baseline year 1 50% 60% 15% 67% 18% 24% 19% 25% 23% 20% Baseline year 2 50% 43% 10% -- 19% 7% 15% 7% 13% 8% HHP year 1 40% 50% 0% 0% 17% 8% 17% 11% 42% 11% HHP year 2 9% 50% 50% -- 18% 9% 0% -- 0% 0% Initiation of Alcohol and Other Drug Dependence Treatment Baseline year 1 18% 13% 21% 22% 26% 24% 24% 35% 25% 15% Baseline year 2 16% 13% 22% 43% 20% 18% 23% 29% 17% 25% HHP year 1 34% 22% 13% 40% 16% 30% 17% 36% 16% 41% HHP year 2 15% 33% 27% 100% 13% 25% 15% 11% 18% 29% Engagement of Alcohol and Other Drug Dependence Treatment Baseline year 1 50% 0% 67% 0% 37% 32% 33% 65% 40% 40% Baseline year 2 43% 0% 36% 0% 34% 52% 25% 41% 46% 30% HHP year 1 45% 50% 20% 0% 29% 42% 29% 44% 33% 15% HHP year 2 0% 0% 0% 100% 20% 44% 0% 100% 0% 0% Use of Pharmacotherapy for Opioid Use Disorder Baseline year 1 56% 90% 58% 50% 56% 69% 29% 77% 72% 64% Baseline year 2 63% 100% 51% 40% 56% 61% 22% 50% 59% 44% HHP year 1 80% 75% 56% 0% 60% 80% 20% 50% 58% 50% 204 | UCLA Evaluation UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program MCP Anthem Blue Cross Partnership Plan Group Group 1 Group 3 County San Francisco Alameda Sacramento Santa Clara Tulare SPA 1 2 1 2 1 2 1 2 1 2 HHP year 2 56% 100% 75% -- 58% 69% 25% 71% 55% 45% All-Cause Readmission Baseline year 1 12% 0% 14% 7% 9% 6% 14% 3% 12% 20% Baseline year 2 10% 0% 13% 0% 13% 5% 6% 10% 8% 10% HHP year 1 14% 0% 23% 25% 12% 10% 10% 6% 13% 15% HHP year 2 0% 0% 9% 0% 13% 6% 16% 20% 6% 25% Controlling High Blood Pressure Baseline year 1 0% 0% 1% 0% 10% 12% 5% 3% 2% 0% Baseline year 2 1% 7% 1% 0% 23% 29% 7% 3% 8% 7% HHP year 1 8% 13% 1% 0% 29% 25% 16% 19% 28% 48% HHP year 2 2% 17% 3% 0% 25% 32% 18% 28% 54% 61% Outpatient Services: Primary Care per 1,000 Beneficiaries per Year Baseline year 1 5,120 5,320 6,015 4,908 5,228 6,208 3,995 5,311 8,166 9,240 Baseline year 2 5,928 6,402 8,301 7,182 6,807 7,388 5,263 5,879 9,852 10,586 HHP year 1 7,258 7,736 11,353 9,917 7,155 8,922 6,115 5,730 10,975 11,641 HHP year 2 7,078 9,260 10,183 8,643 6,508 7,406 5,704 5,159 10,107 11,478 Outpatient Services: Specialty Care per 1,000 Beneficiaries per Year Baseline year 1 2,781 2,297 3,952 2,779 3,659 3,778 2,770 2,414 2,978 3,239 Baseline year 2 3,287 5,187 4,738 3,353 4,707 4,222 3,415 2,924 3,691 4,045 HHP year 1 3,478 4,681 4,859 4,032 4,992 4,614 2,971 3,226 4,116 3,928 HHP year 2 2,939 4,346 5,415 2,434 4,843 4,970 2,934 3,316 3,506 3,171 Outpatient Services: Mental Health per 1,000 Beneficiaries per Year Baseline year 1 6,951 11,470 4,606 11,253 3,248 7,458 2,545 9,914 1,375 3,427 Baseline year 2 7,627 13,773 6,059 14,544 3,740 8,803 3,772 12,484 1,724 3,690 HHP year 1 7,228 14,198 7,230 13,510 3,741 8,911 5,088 11,875 2,351 4,081 HHP year 2 5,633 13,606 6,063 9,734 3,797 7,162 3,681 7,038 2,285 3,081 Outpatient Services: Substance Use Disorder per 1,000 Beneficiaries per Year Baseline year 1 18,473 24,053 12,413 2,751 9,110 16,181 1,435 6,080 7,411 7,892 Baseline year 2 14,679 17,237 11,679 2,904 9,646 16,397 1,900 5,976 7,939 7,570 HHP year 1 10,813 9,802 9,352 2,561 8,992 16,866 2,086 6,823 8,424 8,095 HHP year 2 8,939 10,110 8,996 2,266 8,980 11,161 2,796 3,955 6,114 5,349 Emergency Department Visits per 1,000 Beneficiaries per Year Baseline year 1 2,105 2,474 2,382 1,935 2,865 3,540 1,707 2,357 1,732 2,182 Baseline year 2 1,689 2,298 2,460 1,889 2,792 3,608 1,791 2,333 2,000 1,967 HHP year 1 1,680 1,385 2,388 1,643 1,934 3,258 1,363 1,875 1,467 1,492 HHP year 2 1,469 3,213 1,313 587 1,745 2,440 1,484 1,535 1,147 1,792 Inpatient Stays per 1,000 Beneficiaries per Year Baseline year 1 656 619 688 484 658 496 416 301 521 629 Baseline year 2 823 640 1,132 617 728 470 563 422 639 630 HHP year 1 558 571 989 325 451 377 414 347 427 449 HHP year 2 380 189 630 168 397 313 444 184 320 290 PQI 92 (per 1,000 Beneficiaries per Year) Baseline year 1 132 35 90 41 124 59 81 30 52 125 Baseline year 2 129 49 196 116 155 74 99 24 71 76 HHP year 1 89 -- 188 38 73 39 83 24 60 73 | UCLA Evaluation 205 UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program MCP Anthem Blue Cross Partnership Plan Group Group 1 Group 3 County San Francisco Alameda Sacramento Santa Clara Tulare SPA 1 2 1 2 1 2 1 2 1 2 HHP year 2 159 -- 90 -- 67 30 73 61 46 26 Admission to an Institution from the Community - Short (per 1,000 Beneficiaries per Year) Baseline year 1 -- -- 26 14 11 12 9 4 -- 10 Baseline year 2 5 -- 46 -- 15 7 16 10 6 21 HHP year 1 18 -- 22 38 8 14 23 8 8 -- HHP year 2 12 -- 72 -- 14 9 13 -- 2 6 Admission to an Institution from the Community - Medium (per 1,000 Beneficiaries per Year) Baseline year 1 15 -- 15 14 12 18 13 27 15 13 Baseline year 2 24 -- 21 -- 11 14 32 21 23 9 HHP year 1 12 -- 28 19 5 6 14 -- 15 13 HHP year 2 24 -- 36 -- 11 4 17 25 9 -- Admission to an Institution from the Community - Long (per 1,000 Beneficiaries per Year) Baseline year 1 10 -- 4 -- 6 -- 9 4 1 -- Baseline year 2 10 -- 11 -- 4 3 4 7 5 6 HHP year 1 6 -- 17 -- 5 2 11 8 4 7 HHP year 2 -- -- -- -- 1 4 9 -- 6 -- Source: UCLA analysis of Medi-Cal Claims data from July 1, 2016 to December 31, 2021. Notes: -- indicates data is not reported due to small cell size. N/A indicates there are no enrollees to report. 206 | UCLA Evaluation UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program Exhibit 101: Trends in Estimated Payments for Anthem Blue Cross as of December 31, 2021 MCP Anthem Blue Cross Partnership Plan Group Group 1 Group 3 County San Francisco Alameda Sacramento Santa Clara Tulare SPA 1 2 1 2 1 2 1 2 1 2 Total Estimated Medi-Cal Payment per Beneficiary per Year Baseline year 1 $33,034 $26,116 $36,191 $21,052 $20,470 $20,062 $16,083 $16,992 $20,291 $23,259 Baseline year 2 $35,362 $26,478 $46,322 $30,128 $24,292 $21,217 $21,446 $21,469 $23,489 $22,110 HHP year 1 $34,680 $28,964 $43,949 $19,562 $21,113 $22,363 $18,952 $19,471 $23,123 $22,600 HHP year 2 $18,344 $20,801 $25,471 $30,022 $21,439 $23,427 $18,289 $15,658 $22,962 $18,357 % Change Year 1* -2% 9% -5% -35% -13% 5% -12% -9% -2% 2% % Change Year 2* -48% -21% -45% 0% -12% 10% -15% -27% -2% -17% Estimated Medi-Cal Payment for Emergency Department Visits per Beneficiary per Year Baseline year 1 $1,142 $1,169 $1,238 $1,066 $1,334 $1,510 $616 $995 $879 $1,145 Baseline year 2 $800 $1,747 $1,103 $1,212 $1,361 $1,605 $647 $924 $987 $1,215 HHP year 1 $1,038 $916 $1,200 $846 $1,006 $1,493 $480 $894 $866 $896 HHP year 2 $513 $1,759 $592 $1,420 $931 $1,287 $621 $501 $816 $796 % Change Year 1* 30% -48% 9% -30% -26% -7% -26% -3% -12% -26% % Change Year 2* -36% 1% -46% 17% -32% -20% -4% -46% -17% -35% Estimated Medi-Cal Payment for Inpatient Stays per Beneficiary per Year Baseline year 1 $9,408 $6,875 $9,464 $8,471 $8,641 $6,478 $4,846 $3,750 $6,742 $7,964 Baseline year 2 $11,559 $6,981 $15,157 $13,769 $9,859 $6,343 $6,515 $4,500 $10,174 $7,679 HHP year 1 $8,961 $7,867 $14,013 $3,807 $6,361 $4,694 $4,838 $3,429 $6,044 $5,904 HHP year 2 $4,636 $1,842 $8,500 $6,635 $5,843 $4,586 $4,716 $2,288 $5,824 $3,542 % Change Year 1* -22% 13% -8% -72% -35% -26% -26% -24% -41% -23% % Change Year 2* -60% -74% -44% -52% -41% -28% -28% -49% -43% -54% Estimated Medi-Cal Payment for Long-Term Care Stays per Beneficiary per Year Baseline year 1 $292 -- $370 $112 $360 $207 $519 $978 $184 $380 Baseline year 2 $252 -- $562 $187 $365 $256 $587 $802 $321 $226 | UCLA Evaluation 207 UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program MCP Anthem Blue Cross Partnership Plan Group Group 1 Group 3 County San Francisco Alameda Sacramento Santa Clara Tulare SPA 1 2 1 2 1 2 1 2 1 2 HHP year 1 $589 -- $872 $204 $239 $198 $743 $598 $452 $403 HHP year 2 $309 -- $2,365 -- $571 $457 $587 $299 $600 $123 % Change Year 1* 134% - 55% 9% -35% -22% 27% -25% 41% 78% % Change Year 2* 23% - 321% -100% 56% 79% 0% -63% 87% -46% Estimated Medi-Cal Payment for Outpatient Services per Beneficiary per Year Baseline year 1 $18,102 $10,832 $12,077 $8,222 $5,853 $6,833 $6,821 $7,781 $8,195 $9,368 Baseline year 2 $17,948 $9,671 $18,403 $9,954 $7,924 $7,852 $8,848 $11,290 $7,183 $8,444 HHP year 1 $17,894 $13,273 $19,110 $10,920 $8,281 $10,832 $8,322 $9,947 $10,218 $10,413 HHP year 2 $7,796 $13,120 $8,493 $10,852 $8,225 $11,849 $8,372 $8,690 $10,200 $9,286 % Change Year 1* 0% 37% 4% 10% 5% 38% -6% -12% 42% 23% % Change Year 2* -57% 36% -54% 9% 4% 51% -5% -23% 42% 10% Estimated Medi-Cal Payment for Outpatient Pharmacy per Beneficiary per Year Baseline year 1 $3,064 $6,711 $4,078 $2,464 $3,137 $4,078 $2,353 $2,753 $3,421 $3,415 Baseline year 2 $3,663 $7,119 $3,632 $2,939 $3,556 $4,108 $2,762 $2,382 $3,761 $3,560 HHP year 1 $4,638 $5,763 $4,297 $1,827 $3,758 $4,167 $2,789 $3,053 $4,402 $3,890 HHP year 2 $3,661 $2,642 $4,205 $2,165 $3,878 $4,217 $2,675 $2,912 $4,260 $3,675 % Change Year 1* 27% -19% 18% -38% 6% 1% 1% 28% 17% 9% % Change Year 2* 0% -63% 16% -26% 9% 3% -3% 22% 13% 3% Estimated Medi-Cal Payment for Residual Services per Beneficiary per Year Baseline year 1 $848 $433 $8,754 $540 $924 $789 $815 $658 $698 $712 Baseline year 2 $924 $723 $7,104 $1,887 $977 $885 $1,897 $1,446 $869 $753 HHP year 1 $1,392 $1,021 $4,147 $1,814 $1,316 $873 $1,678 $1,464 $1,006 $953 HHP year 2 $1,247 $1,216 $1,113 $8,854 $1,901 $914 $1,211 $935 $1,168 $836 % Change Year 1* 51% 41% -42% -4% 35% -1% -12% 1% 16% 27% % Change Year 2* 35% 68% -84% 369% 95% 3% -36% -35% 34% 11% 208 | UCLA Evaluation UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program Source: UCLA analysis of Medi-Cal Claims data from July 1, 2016 to December 31, 2021. Notes: -- indicates data is not reported due to small cell size. N/A indicates there are no enrollees to report. *The percentage changes for Year 1 and 2 are calculated using Baseline Year 2 as the reference. | UCLA Evaluation 209 UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program Exhibit 102: HHP Implementation and Enrollee Demographics for LA Care, Community Health Group, Kern Health Systems, and CalOptima as of December 31, 2021 MCP LA Care Community Health Group Kern Health Systems CalOptima Group Group 3 Group 3 Group 3 Group 4 County Los Angeles San Diego Kern Orange SPA 1 2 1 2 1 2 1 2 Program Implementation and Enrollment Implementation Date 7/1/19 1/1/20 7/1/19 1/1/20 7/1/19 1/1/20 7/1/19 1/1/20 Total Enrollment (12/2021) 22361 7715 1768 509 4663 670 1194 411 % of TEL enrolled 70% 98% 74% 92% Avg Length of Enrollment (Months) 11 10 12 10 16 9 10 8 Enrollee Demographics % 0-17 8% 4% 7% 7% 3% 3% 7% 12% % 18-34 11% 21% 8% 22% 13% 29% 10% 33% % 34-49 18% 24% 22% 26% 27% 30% 24% 29% % 49-64 49% 44% 57% 42% 50% 36% 55% 26% % 65+ 14% 7% 7% 4% 7% 2% 5% -- % Male 44% 37% 35% 33% 36% 29% 51% 36% % White 11% 16% 22% 29% 28% 30% 31% 30% % Hispanic 54% 52% 38% 33% 54% 55% 44% 42% % African American 22% 21% 10% 7% 11% 9% 4% 7% % Asian American and Pacific Islander 7% 4% 6% 5% 2% -- 6% <5% % American Indian and Alaskan Native -- -- -- -- -- -- 0% -- % Other 2% 2% 20% 22% 1% 0% 9% 9% % Unknown 4% 5% 4% 3% 5% 4% 6% 5% % Speak English 61% 72% 64% 75% 72% 78% 73% 83% Medi-Cal full-scope months baseline year 1 12 12 12 12 12 12 12 12 # Enrollees with Homeless Information Available 22361 7715 1768 509 4663 670 1194 411 Proportion ever homeless during HHP enrollment 6% 9% 6% 10% 2% 2% 23% 21% Source: MCP Enrollment Reports from August 2019, Quarterly HHP Reports from September 2019 to September 2020, and Medi-Cal Claims data from July 1, 2016 to December 31, 2021. Notes: -- indicates data is not reported due to small cell size. N/A indicates there are no enrollees to report. 210 | UCLA Evaluation UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program Exhibit 103: HHP Enrollee Health Status and Utilization Prior to Enrollment and Service Delivery for LA Care, Community Health Group, Kern Health Systems, and CalOptima as of December 31, 2021 MCP LA Care Community Health Group Kern Health Systems CalOptima Group Group 3 Group 3 Group 3 Group 4 County Los Angeles San Diego Kern Orange SPA 1 2 1 2 1 2 1 2 Health Status and Utilization 24 Months Prior to Enrollment Two specific conditions (criteria 1) 47% 27% 57% 40% 52% 29% 67% 19% Hypertension and another specific condition (criteria 2) 62% 36% 61% 34% 63% 40% 67% 8% Serious mental health condition (criteria 3) 26% 80% 53% 83% 40% 79% 45% 96% Asthma (criteria 4) 29% 16% 32% 22% 29% 22% 37% 10% Average number of ED visits 4.3 5.0 4.7 4.6 4.6 4.2 9.7 7.5 Average number of hospitalizations 1.1 1.1 1.1 0.9 0.9 0.9 2.7 1.4 HHP Services Delivered to HHP Enrollees Total number of units of service provided 540,600 3,736 36,138 9,493 104,039 8,973 50,277 8,748 Average number of units of service per enrollee 1.7 1.7 1.0 1.0 1.5 1.5 2.2 2.0 Median number of units of service per enrollee 1.0 1.0 1.0 1.0 1.0 1.0 2.0 2.0 Average number of engagement services provided 1.1 1.2 1.0 1.0 1.2 1.1 0.0 0.0 Average number of core services provided 1.5 1.6 1.0 1.0 1.5 1.5 1.8 1.6 Average number of other HHP services provided 1.6 1.5 1.0 1.0 1.1 1.1 2.1 2.0 Average number of in-person services provided 1.1 1.1 1.0 1.0 1.2 1.2 1.8 1.5 Average number of phone/ telehealth services provided 1.5 1.6 1.0 1.0 1.3 1.3 1.7 1.6 Average number of services provided by clinical staff 1.5 1.5 1.0 1.0 1.4 1.5 1.5 1.6 Average number of services provided by non-clinical staff 1.7 1.7 1.0 1.0 1.2 1.1 2.2 2.1 Source: UCLA analysis of Medi-Cal Claims data from July 1, 2016 to December 31, 2021. Notes: -- indicates data is not reported due to small cell size. N/A indicates there are no enrollees to report. At risk for high utilization is defined as no ED utilization or hospitalizations 24 months prior to enrollment, low utilization is less than 2 ED visits and less than 1 hospitalizations per year, moderate utilization is 2 or more ED visits or 1 or more hospitalizations per year, high utilization is 5 or more ED visits or 2 or more hospitalizations per year, and super utilization is 10 or more ED visits or 4 or more hospitalizations per year. | UCLA Evaluation 211 UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program Exhibit 104: Trends in HHP Metrics for LA Care, Community Health Group, Kern Health Systems, and CalOptima as of December 31, 2021 Community Health Kern Health MCP LA Care Group Systems CalOptima Group Group 3 Group 3 Group 3 Group 4 County Los Angeles San Diego Kern Orange SPA 1 2 1 2 1 2 1 2 Adult BMI Assessment Baseline year 1 72% 69% 78% 75% 51% 49% 74% 63% Baseline year 2 75% 73% 78% 72% 60% 60% 77% 62% HHP year 1 71% 70% 71% 65% 60% 62% 71% 60% HHP year 2 67% 65% 67% 58% 60% 60% 63% 55% Follow-Up After Hospitalization for Mental Illness within 30 Days Baseline year 1 69% 71% 84% 82% 86% 82% 67% 85% Baseline year 2 77% 75% 86% 73% 96% 87% 72% 80% HHP year 1 71% 72% 82% 88% 100% 89% 75% 61% HHP year 2 59% 63% 60% 100% 100% -- 69% 67% Follow-Up After Hospitalization for Mental Illness within 7 Days Baseline year 1 49% 42% 67% 64% 57% 45% 52% 54% Baseline year 2 52% 51% 68% 53% 78% 70% 61% 48% HHP year 1 42% 45% 64% 69% 87% 56% 48% 45% HHP year 2 43% 48% 40% 100% 83% -- 31% 33% Screening for Depression and Follow-Up Plan Baseline year 1 5% 5% 3% 4% 0% 0% 7% 9% Baseline year 2 5% 5% 17% 17% 1% 0% 9% 0% HHP year 1 5% 6% 20% 23% 3% 5% 7% 0% HHP year 2 7% 10% 14% 64% 2% 0% 2% 0% Follow-Up After ED Visit for Alcohol and Other Drug Abuse or Dependence within 7 days Baseline year 1 5% 3% 9% 0% 6% 0% 3% 0% Baseline year 2 8% 7% 11% 9% 19% 0% 4% 4% HHP year 1 3% 8% 5% 20% 7% 0% 4% 9% HHP year 2 7% 5% 0% 0% 7% 50% 9% 0% Follow-Up After ED Visit for Alcohol and Other Drug Abuse or Dependence within 30 days Baseline year 1 8% 7% 20% 0% 13% 13% 6% 0% Baseline year 2 12% 12% 13% 31% 30% 20% 11% 11% HHP year 1 7% 14% 14% 28% 12% 0% 15% 16% HHP year 2 11% 8% 33% 50% 18% 100% 9% 0% Initiation of Alcohol and Other Drug Dependence Treatment Baseline year 1 19% 24% 28% 28% 16% 20% 25% 36% Baseline year 2 20% 23% 25% 25% 16% 27% 27% 38% HHP year 1 16% 24% 21% 18% 15% 26% 28% 33% HHP year 2 17% 23% 15% 21% 11% 41% 21% 23% Engagement of Alcohol and Other Drug Dependence Treatment Baseline year 1 37% 47% 44% 37% 41% 31% 25% 45% Baseline year 2 33% 40% 33% 52% 32% 55% 41% 51% HHP year 1 34% 39% 41% 62% 41% 50% 41% 45% 212 | UCLA Evaluation UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program Community Health Kern Health MCP LA Care Group Systems CalOptima Group Group 3 Group 3 Group 3 Group 4 County Los Angeles San Diego Kern Orange SPA 1 2 1 2 1 2 1 2 HHP year 2 29% 31% 18% 50% 29% 36% 52% 60% Use of Pharmacotherapy for Opioid Use Disorder Baseline year 1 38% 37% 43% 42% 34% 41% 23% 38% Baseline year 2 37% 41% 45% 49% 38% 42% 27% 42% HHP year 1 34% 42% 44% 54% 46% 56% 35% 35% HHP year 2 32% 41% 39% 70% 44% 44% 31% 47% All-Cause Readmission Baseline year 1 8% 10% 10% 7% 8% 11% 12% 13% Baseline year 2 9% 10% 8% 6% 12% 11% 12% 10% HHP year 1 10% 11% 12% 11% 13% 17% 13% 6% HHP year 2 12% 10% 9% 0% 13% 21% 12% 8% Controlling High Blood Pressure Baseline year 1 19% 21% 6% 4% 4% 6% 23% 16% Baseline year 2 22% 23% 11% 12% 3% 4% 34% 19% HHP year 1 23% 24% 21% 20% 2% 1% 29% 24% HHP year 2 28% 32% 21% 10% 2% 2% 20% 25% Outpatient Services: Primary Care per 1,000 Beneficiaries per Year Baseline year 1 6,210 6,304 8,917 8,536 8,760 7,557 6,175 4,093 Baseline year 2 7,587 7,554 10,559 10,443 10,568 10,751 7,917 5,897 HHP year 1 8,845 8,763 15,256 14,589 15,148 14,012 7,936 6,005 HHP year 2 7,509 7,437 13,128 12,639 14,066 10,753 6,923 4,797 Outpatient Services: Specialty Care per 1,000 Beneficiaries per Year Baseline year 1 4,043 3,771 7,714 5,933 7,418 5,210 7,291 4,972 Baseline year 2 4,967 4,426 9,229 7,586 8,380 6,603 9,463 5,558 HHP year 1 5,123 4,789 9,836 8,269 10,170 9,976 9,659 5,992 HHP year 2 5,127 4,550 9,084 8,401 8,760 7,614 9,606 5,229 Outpatient Services: Mental Health per 1,000 Beneficiaries per Year Baseline year 1 3,398 9,753 4,976 8,380 4,018 5,760 4,374 14,010 Baseline year 2 4,071 11,864 5,902 10,533 5,267 8,585 5,080 17,077 HHP year 1 4,055 11,161 5,911 9,918 5,837 8,797 5,224 13,549 HHP year 2 4,166 8,369 5,527 6,560 5,381 7,075 3,949 11,342 Outpatient Services: Substance Use Disorder per 1,000 Beneficiaries per Year Baseline year 1 2,799 5,255 2,529 4,053 5,796 5,741 6,712 12,679 Baseline year 2 2,962 6,101 2,832 4,197 6,324 6,736 7,545 12,747 HHP year 1 2,611 5,989 2,755 3,954 6,909 6,960 5,130 6,405 HHP year 2 2,560 4,306 2,421 2,753 6,230 6,266 1,869 6,701 Emergency Department Visits per 1,000 Beneficiaries per Year Baseline year 1 1,723 2,065 1,880 1,809 1,971 1,713 3,545 2,781 Baseline year 2 1,806 2,154 1,833 2,084 1,981 2,078 3,667 3,549 HHP year 1 1,313 1,626 1,564 1,637 1,629 1,411 2,555 2,592 HHP year 2 1,163 1,477 1,441 1,385 1,559 1,253 2,453 3,186 | UCLA Evaluation 213 UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program Community Health Kern Health MCP LA Care Group Systems CalOptima Group Group 3 Group 3 Group 3 Group 4 County Los Angeles San Diego Kern Orange SPA 1 2 1 2 1 2 1 2 Inpatient Stays per 1,000 Beneficiaries per Year Baseline year 1 492 511 528 395 421 318 1,308 571 Baseline year 2 621 593 656 550 466 595 1,523 911 HHP year 1 468 396 489 477 440 309 1,025 627 HHP year 2 369 353 476 240 399 288 816 554 PQI 92 (per 1,000 Beneficiaries per Year) Baseline year 1 82 45 71 38 60 34 223 8 Baseline year 2 107 49 80 51 61 37 249 25 HHP year 1 83 42 80 59 54 31 148 12 HHP year 2 66 46 94 50 54 50 150 -- Admission to an Institution from the Community - Short (per 1,000 Beneficiaries per Year) Baseline year 1 5 6 7 13 6 2 28 10 Baseline year 2 6 7 19 12 7 12 35 5 HHP year 1 4 5 19 12 8 6 17 6 HHP year 2 7 10 20 17 12 -- 29 -- Admission to an Institution from the Community - Medium (per 1,000 Beneficiaries per Year) Baseline year 1 8 7 5 4 5 10 30 3 Baseline year 2 9 9 8 10 8 8 40 15 HHP year 1 8 7 11 7 11 -- 24 19 HHP year 2 10 10 17 -- 8 6 20 17 Admission to an Institution from the Community - Long (per 1,000 Beneficiaries per Year) Baseline year 1 4 4 1 2 3 -- 9 5 Baseline year 2 4 6 5 6 3 6 12 5 HHP year 1 5 7 7 2 3 2 13 6 HHP year 2 7 7 3 -- 5 6 18 -- Source: UCLA analysis of Medi-Cal Claims data from July 1, 2016 to December 31, 2021. Notes: -- indicates data is not reported due to small cell size. N/A indicates there are no enrollees to report. 214 | UCLA Evaluation UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program Exhibit 105: Trends in Estimated Payments for LA Care, Community Health Group, Kern Health Systems, and CalOptima as of December 31, 2021 Community Health Kern Health MCP LA Care Group Systems CalOptima Group Group 3 Group 3 Group 3 Group 4 County Los Angeles San Diego Kern Orange SPA 1 2 1 2 1 2 1 2 Total Estimated Medi-Cal Payment per Beneficiary per Year Baseline year 1 $18,746 $19,328 $24,580 $20,057 $23,244 $14,341 $36,285 $20,834 Baseline year 2 $22,256 $22,495 $29,631 $27,031 $26,162 $20,615 $47,740 $29,480 HHP year 1 $21,637 $20,918 $27,681 $24,991 $26,400 $18,297 $41,167 $32,482 HHP year 2 $20,394 $19,283 $26,603 $20,147 $24,916 $17,042 $41,586 $23,317 % Change Year 1* -3% -7% -7% -8% 1% -11% -14% 10% % Change Year 2* -8% -14% -10% -25% -5% -17% -13% -21% Estimated Medi-Cal Payment for Emergency Department Visits per Beneficiary per Year Baseline year 1 $747 $929 $872 $875 $1,224 $1,058 $2,027 $1,367 Baseline year 2 $806 $965 $1,042 $1,144 $1,322 $1,389 $2,453 $1,791 HHP year 1 $620 $767 $911 $1,095 $1,201 $1,016 $1,854 $1,893 HHP year 2 $585 $710 $879 $1,014 $1,199 $888 $1,926 $1,415 % Change Year 1* -23% -21% -13% -4% -9% -27% -24% 6% % Change Year 2* -27% -26% -16% -11% -9% -36% -21% -21% Estimated Medi-Cal Payment for Inpatient Stays per Beneficiary per Year Baseline year 1 $5,493 $5,686 $6,476 $4,415 $4,697 $4,151 $13,165 $5,805 Baseline year 2 $7,811 $7,262 $7,793 $6,830 $6,313 $7,953 $17,464 $9,239 HHP year 1 $6,509 $5,182 $5,197 $5,195 $6,137 $4,214 $11,431 $6,457 HHP year 2 $5,270 $4,532 $5,558 $2,468 $5,389 $4,443 $9,664 $5,525 % Change Year 1* -17% -29% -33% -24% -3% -47% -35% -30% % Change Year 2* -33% -38% -29% -64% -15% -44% -45% -40% Estimated Medi-Cal Payment for Long-Term Care Stays per Beneficiary per Year Baseline year 1 $305 $237 $92 $71 $177 $69 $651 $624 Baseline year 2 $345 $319 $260 $213 $149 $151 $904 $285 HHP year 1 $472 $443 $484 $257 $174 $45 $1,190 $496 HHP year 2 $896 $972 $672 $139 $207 $32 $2,586 $867 % Change Year 1* 37% 39% 86% 21% 17% -70% 32% 74% % Change Year 2* 160% 205% 159% -35% 39% -79% 186% 204% Estimated Medi-Cal Payment for Outpatient Services per Beneficiary per Year Baseline year 1 $6,600 $6,507 $9,367 $8,116 $11,339 $5,120 $11,369 $7,935 Baseline year 2 $7,505 $7,880 $11,579 $11,763 $11,828 $6,978 $16,181 $11,440 HHP year 1 $8,198 $8,454 $11,799 $10,640 $12,484 $8,177 $15,963 $10,723 HHP year 2 $7,854 $7,151 $10,832 $8,440 $12,194 $7,286 $15,502 $5,756 % Change Year 1* 9% 7% 2% -10% 6% 17% -1% -6% | UCLA Evaluation 215 UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program Community Health Kern Health MCP LA Care Group Systems CalOptima Group Group 3 Group 3 Group 3 Group 4 County Los Angeles San Diego Kern Orange SPA 1 2 1 2 1 2 1 2 % Change Year 2* 5% -9% -6% -28% 3% 4% -4% -50% Estimated Medi-Cal Payment for Outpatient Pharmacy per Beneficiary per Year Baseline year 1 $4,366 $4,721 $6,884 $5,534 $4,865 $3,238 $7,340 $3,186 Baseline year 2 $4,267 $4,484 $7,899 $6,074 $5,347 $3,171 $7,841 $4,334 HHP year 1 $4,009 $4,258 $8,244 $6,808 $5,146 $3,964 $8,310 $4,095 HHP year 2 $3,803 $4,122 $7,510 $7,304 $4,519 $3,022 $7,994 $5,077 % Change Year 1* -6% -5% 4% 12% -4% 25% 6% -6% % Change Year 2* -11% -8% -5% 20% -15% -5% 2% 17% Estimated Medi-Cal Payment for Residual Services per Beneficiary per Year Baseline year 1 $1,108 $1,092 $706 $911 $813 $599 $1,327 $1,738 Baseline year 2 $1,376 $1,395 $840 $847 $1,076 $816 $2,484 $2,101 HHP year 1 $1,728 $1,702 $860 $805 $1,134 $805 $2,073 $8,627 HHP year 2 $1,895 $1,712 $957 $696 $1,297 $1,284 $3,676 $4,549 % Change Year 1* 26% 22% 2% -5% 5% -1% -17% 311% % Change Year 2* 38% 23% 14% -18% 21% 57% 48% 117% Source: UCLA analysis of Medi-Cal Claims data from July 1, 2016 to December 31, 2021. Notes: -- indicates data is not reported due to small cell size. N/A indicates there are no enrollees to report. *The percentage changes for Year 1 and 2 are calculated using Baseline Year 2 as the reference. 216 | UCLA Evaluation UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program Exhibit 106: HHP Implementation and Enrollee Demographics for Inland Empire Health Plan and Kaiser as of December 31, 2021 MCP Inland Empire Health Plan Kaiser Group Group 2 Group 3 County Riverside San Bernardino Sacramento San Diego SPA 1 2 1 2 1 2 1 2 Program Implementation and Enrollment Implementation Date 7/1/19 1/1/20 7/1/19 1/1/20 7/1/19 1/1/20 7/1/19 1/1/20 Total Enrollment (12/2021) 7204 2596 6240 2065 546 317 <30 N/A % of TEL enrolled 84% 85% 86% 73% Avg Length of Enrollment (Months) 15 10 15 11 11 10 9 N/A Enrollee Demographics % 0-17 2% 1% 5% 2% 15% 10% 0% N/A % 18-34 12% 25% 12% 24% 19% 28% -- N/A % 34-49 23% 29% 25% 31% 24% 24% -- N/A % 49-64 59% 43% 54% 41% 36% 35% 56% N/A % 65+ 5% 2% 4% 2% 6% -- -- N/A % Male 42% 33% 39% 32% 42% 30% -- N/A % White 29% 34% 24% 31% 26% 32% -- N/A % Hispanic 49% 45% 49% 43% 13% 16% -- N/A % African American 12% 11% 18% 18% 38% 28% -- N/A % Asian American and Pacific Islander 3% 2% 3% 1% 8% <5% -- N/A % American Indian and Alaskan Native -- -- -- -- -- -- -- N/A % Other 1% 1% 1% 1% 11% 12% -- N/A % Unknown 6% 7% 5% 5% 4% 6% 0% N/A % Speak English 77% 83% 81% 88% 93% 93% 85% N/A Medi-Cal full-scope months baseline year 1 12 12 12 12 12 12 12 N/A # Enrollees with Homeless Information Available 6987 2596 6038 2065 546 317 27 N/A Proportion ever homeless during HHP enrollment 9% 12% 9% 13% 28% 34% -- N/A Source: MCP Enrollment Reports from August 2019, Quarterly HHP Reports from September 2019 to September 2020, and Medi-Cal Claims data from July 1, 2016 to December 31, 2021. Notes: -- indicates data is not reported due to small cell size. N/A indicates there are no enrollees to report. Exhibit 107: HHP Enrollee Health Status and Utilization Prior to Enrollment and Service Delivery for Inland Empire Health Plan and Kaiser as of December 31, 2021 MCP Inland Empire Health Plan Kaiser | UCLA Evaluation 217 UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program Group Group 2 Group 3 County Riverside San Bernardino Sacramento San Diego SPA 1 2 1 2 1 2 1 2 Health Status and Utilization 24 Months Prior to Enrollment Two specific conditions (criteria 1) 55% 24% 55% 25% 34% 24% 70% N/A Hypertension and another specific condition (criteria 2) 66% 26% 65% 27% 35% 25% 78% N/A Serious mental health condition (criteria 3) 38% 85% 37% 83% 17% 90% 67% N/A Asthma (criteria 4) 26% 13% 33% 16% 50% 30% -- N/A Average number of ED visits 5.5 5.1 6.7 5.5 7.7 7.5 6.0 N/A Average number of hospitalizations 1.3 1.0 1.6 1.0 1.0 1.2 1.6 N/A HHP Services Delivered to HHP Enrollees Total number of units of service provided 174,966 48,006 177,563 53,157 378 165 145 N/A Average number of units of service per enrollee 1.6 1.7 1.7 1.8 1.2 1.2 1.4 N/A Median number of units of service per enrollee 1.0 1.0 1.0 1.0 1.0 1.0 1.0 N/A Average number of engagement services provided 1.1 1.2 1.2 1.3 1.0 0.0 0.0 N/A Average number of core services provided 1.6 1.6 1.6 1.7 1.0 0.0 1.4 N/A Average number of other HHP services provided 1.2 1.3 1.3 1.3 1.2 1.2 0.0 N/A Average number of in-person services provided 1.2 1.2 1.2 1.1 0.0 0.0 0.0 N/A Average number of phone/ telehealth services provided 1.6 1.6 1.6 1.7 1.0 0.0 1.4 N/A Average number of services provided by clinical staff 1.6 1.6 1.6 1.7 1.1 1.1 1.4 N/A Average number of services provided by non-clinical staff 1.5 1.5 1.5 1.6 1.0 1.1 0.0 N/A Source: UCLA analysis of Medi-Cal Claims data from July 1, 2016 to December 31, 2021. Notes: -- indicates data is not reported due to small cell size. N/A indicates there are no enrollees to report. At risk for high utilization is defined as no ED utilization or hospitalizations 24 months prior to enrollment, low utilization is less than 2 ED visits and less than 1 hospitalizations per year, moderate utilization is 2 or more ED visits or 1 or more hospitalizations per year, high utilization is 5 or more ED visits or 2 or more hospitalizations per year, and super utilization is 10 or more ED visits or 4 or more hospitalizations per year. 218 | UCLA Evaluation UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program Exhibit 108: Trends in HHP Metrics for Inland Empire Health Plan and Kaiser as of December 31, 2021 MCP Inland Empire Health Plan Kaiser Group Group 2 Group 3 County Riverside San Bernardino Sacramento San Diego SPA 1 2 1 2 1 2 1 2 Adult BMI Assessment Baseline year 1 54% 60% 61% 61% 44% 37% 57% N/A Baseline year 2 67% 72% 72% 71% 48% 45% 58% N/A HHP year 1 75% 69% 75% 68% 42% 41% 63% N/A HHP year 2 74% 65% 71% 62% 38% 30% 64% N/A Follow-Up After Hospitalization for Mental Illness within 30 Days Baseline year 1 81% 62% 76% 72% 100% 68% 100% N/A Baseline year 2 80% 86% 83% 73% 79% 54% 40% N/A HHP year 1 70% 86% 72% 73% 80% 63% 50% N/A HHP year 2 58% 67% 82% 88% 0% 57% -- N/A Follow-Up After Hospitalization for Mental Illness within 7 Days Baseline year 1 46% 42% 45% 41% 57% 39% 0% N/A Baseline year 2 56% 52% 48% 51% 50% 29% 20% N/A HHP year 1 49% 57% 33% 52% 20% 31% 0% N/A HHP year 2 33% 33% 43% 63% 0% 43% -- N/A Screening for Depression and Follow-Up Plan Baseline year 1 16% 23% 18% 20% 0% 0% 0% N/A Baseline year 2 42% 30% 37% 25% 0% 0% 0% N/A HHP year 1 48% 34% 46% 37% 0% 0% 0% N/A HHP year 2 38% 25% 46% 32% 0% 0% 0% N/A Follow-Up After ED Visit for Alcohol and Other Drug Abuse or Dependence within 7 days Baseline year 1 5% 4% 5% 6% 10% 11% 0% N/A Baseline year 2 6% 7% 4% 6% 29% 21% 0% N/A HHP year 1 9% 5% 3% 1% 0% 0% 0% N/A HHP year 2 8% 13% 0% 0% 0% 0% -- N/A Follow-Up After ED Visit for Alcohol and Other Drug Abuse or Dependence within 30 days Baseline year 1 8% 12% 9% 12% 30% 16% 0% N/A Baseline year 2 12% 15% 7% 10% 35% 29% 0% N/A HHP year 1 16% 10% 8% 8% 0% 0% 0% N/A HHP year 2 17% 21% 3% 0% 0% 0% -- N/A Initiation of Alcohol and Other Drug Dependence Treatment Baseline year 1 18% 25% 18% 23% 20% 30% 25% N/A Baseline year 2 22% 33% 18% 22% 22% 38% 33% N/A HHP year 1 18% 27% 15% 22% 19% 16% 0% N/A HHP year 2 20% 25% 17% 15% 20% 29% 0% N/A Engagement of Alcohol and Other Drug Dependence Treatment Baseline year 1 42% 41% 29% 41% 0% 33% 0% N/A Baseline year 2 37% 51% 27% 24% 21% 27% 0% N/A HHP year 1 38% 49% 30% 45% 33% 50% -- N/A | UCLA Evaluation 219 UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program MCP Inland Empire Health Plan Kaiser Group Group 2 Group 3 County Riverside San Bernardino Sacramento San Diego SPA 1 2 1 2 1 2 1 2 HHP year 2 34% 45% 20% 27% 40% 33% -- N/A Use of Pharmacotherapy for Opioid Use Disorder Baseline year 1 22% 25% 19% 27% 53% 60% -- N/A Baseline year 2 22% 30% 18% 29% 48% 32% 0% N/A HHP year 1 23% 30% 18% 32% 50% 31% 0% N/A HHP year 2 24% 29% 18% 41% 70% 29% -- N/A All-Cause Readmission Baseline year 1 9% 10% 10% 9% 8% 11% 0% N/A Baseline year 2 10% 9% 11% 11% 10% 13% 14% N/A HHP year 1 11% 11% 13% 9% 14% 15% 50% N/A HHP year 2 13% 13% 11% 12% 13% 20% 0% N/A Controlling High Blood Pressure Baseline year 1 9% 20% 16% 26% 1% 0% 0% N/A Baseline year 2 13% 21% 21% 27% 3% 1% 11% N/A HHP year 1 16% 26% 26% 34% 10% 25% 20% N/A HHP year 2 25% 31% 30% 39% 37% 44% 0% N/A Outpatient Services: Primary Care per 1,000 Beneficiaries per Year Baseline year 1 6,880 5,891 6,715 5,285 4,703 4,908 9,592 N/A Baseline year 2 7,367 7,529 7,435 6,328 4,956 4,585 10,345 N/A HHP year 1 11,549 13,304 13,466 13,223 4,787 4,968 9,540 N/A HHP year 2 10,914 11,259 11,558 10,929 4,210 4,699 7,469 N/A Outpatient Services: Specialty Care per 1,000 Beneficiaries per Year Baseline year 1 6,343 6,463 5,221 4,693 4,973 7,561 7,264 N/A Baseline year 2 8,568 7,975 6,731 6,022 5,621 7,399 8,389 N/A HHP year 1 9,454 8,492 7,841 8,188 5,164 7,440 7,732 N/A HHP year 2 8,136 7,610 6,696 6,942 5,536 7,801 8,327 N/A Outpatient Services: Mental Health per 1,000 Beneficiaries per Year Baseline year 1 3,860 9,120 3,582 9,060 1,179 4,494 1,686 N/A Baseline year 2 5,404 11,585 4,988 12,267 1,613 4,709 3,724 N/A HHP year 1 6,177 11,180 6,038 13,612 1,339 5,338 3,715 N/A HHP year 2 5,053 9,050 5,470 12,239 1,034 4,244 2,939 N/A Outpatient Services: Substance Use Disorder per 1,000 Beneficiaries per Year Baseline year 1 4,391 6,372 3,940 6,093 5,357 4,290 1,284 N/A Baseline year 2 4,658 7,078 3,883 6,811 5,166 4,321 3,197 N/A HHP year 1 5,116 7,087 3,793 6,607 4,567 2,552 6,075 N/A HHP year 2 4,290 5,995 3,009 6,060 3,795 917 122 N/A Emergency Department Visits per 1,000 Beneficiaries per Year Baseline year 1 2,202 2,095 2,565 2,185 3,324 3,206 2,488 N/A Baseline year 2 2,219 2,290 2,580 2,372 3,806 3,291 2,520 N/A HHP year 1 1,903 1,915 2,230 2,062 3,039 3,124 2,460 N/A HHP year 2 1,436 1,521 1,783 1,770 2,789 2,532 1,469 N/A Inpatient Stays per 1,000 Beneficiaries per Year 220 | UCLA Evaluation UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program MCP Inland Empire Health Plan Kaiser Group Group 2 Group 3 County Riverside San Bernardino Sacramento San Diego SPA 1 2 1 2 1 2 1 2 Baseline year 1 538 426 717 448 437 463 682 N/A Baseline year 2 790 588 952 636 554 706 978 N/A HHP year 1 787 627 935 641 515 502 502 N/A HHP year 2 525 469 612 388 373 308 122 N/A PQI 92 (per 1,000 Beneficiaries per Year) Baseline year 1 80 22 117 44 83 49 201 N/A Baseline year 2 148 50 179 58 87 29 263 N/A HHP year 1 109 41 142 45 88 35 -- N/A HHP year 2 78 27 108 35 31 26 -- N/A Admission to an Institution from the Community - Short (per 1,000 Beneficiaries per Year) Baseline year 1 17 10 13 6 4 3 40 N/A Baseline year 2 22 11 14 11 8 6 38 N/A HHP year 1 15 9 13 8 10 14 -- N/A HHP year 2 8 5 9 5 9 -- -- N/A Admission to an Institution from the Community - Medium (per 1,000 Beneficiaries per Year) Baseline year 1 13 10 15 10 6 3 -- N/A Baseline year 2 22 15 24 21 9 3 -- N/A HHP year 1 25 19 24 24 4 7 50 N/A HHP year 2 15 20 18 20 9 -- -- N/A Admission to an Institution from the Community - Long (per 1,000 Beneficiaries per Year) Baseline year 1 6 9 5 5 2 -- -- N/A Baseline year 2 12 11 13 12 4 -- - N/A HHP year 1 11 11 13 10 10 -- -- N/A HHP year 2 13 16 12 12 -- -- -- N/A Source: UCLA analysis of Medi-Cal Claims data from July 1, 2016 to December 31, 2021. Notes: -- indicates data is not reported due to small cell size. N/A indicates there are no enrollees to report. | UCLA Evaluation 221 UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program Exhibit 109: Trends in Estimated Payments for Inland Empire Health Plan and Kaiser as of December 31, 2021 MCP Inland Empire Health Plan Kaiser Group Group 2 Group 3 County Riverside San Bernardino Sacramento San Diego SPA 1 2 1 2 1 2 1 2 Total Estimated Medi-Cal Payment per Beneficiary per Year Baseline year 1 $23,758 $19,776 $24,344 $20,174 $15,347 $18,246 $24,503 $15,809 Baseline year 2 $33,221 $27,258 $33,819 $25,932 $21,892 $23,923 $35,284 $29,640 HHP year 1 $36,169 $29,313 $37,529 $29,121 $23,451 $25,560 $34,695 $16,741 HHP year 2 $30,045 $24,077 $30,604 $22,526 $24,119 $29,671 $17,380 -- % Change Year 1* 9% 8% 11% 12% 7% 7% -2% -44% % Change Year 2* -10% -12% -10% -13% 10% 24% -51% - Estimated Medi-Cal Payment for Emergency Department Visits per Beneficiary per Year Baseline year 1 $983 $929 $1,136 $1,004 $1,282 $1,167 $2,141 $429 Baseline year 2 $1,180 $1,158 $1,356 $1,321 $1,875 $1,732 $2,103 $6,976 HHP year 1 $1,075 $1,089 $1,318 $1,237 $1,967 $2,244 $1,591 $396 HHP year 2 $886 $830 $1,085 $1,179 $2,059 $2,105 $937 -- % Change Year 1* -9% -6% -3% -6% 5% 30% -24% -94% % Change Year 2* -25% -28% -20% -11% 10% 22% -55% - Estimated Medi-Cal Payment for Inpatient Stays per Beneficiary per Year Baseline year 1 $6,892 $5,486 $8,593 $5,727 $5,197 $4,489 $7,892 -- Baseline year 2 $10,753 $8,415 $12,812 $8,802 $8,849 $7,653 $13,696 $5,852 HHP year 1 $10,946 $9,146 $12,571 $8,731 $6,516 $6,123 $8,652 -- HHP year 2 $7,455 $6,999 $8,604 $5,436 $6,166 $5,853 $1,794 -- % Change Year 1* 2% 9% -2% -1% -26% -20% -37% - % Change Year 2* -31% -17% -33% -38% -30% -24% -87% - Estimated Medi-Cal Payment for Long-Term Care Stays per Beneficiary per Year Baseline year 1 $334 $375 $238 $328 $123 $269 $73 -- Baseline year 2 $494 $465 $558 $462 $282 $195 $111 -- HHP year 1 $585 $442 $683 $487 $470 $128 $402 -- HHP year 2 $732 $826 $758 $806 $758 $437 -- -- % Change Year 1* 18% -5% 22% 5% 67% -34% 262% - % Change Year 2* 48% 78% 36% 74% 169% 124% - - Estimated Medi-Cal Payment for Outpatient Services per Beneficiary per Year Baseline year 1 $7,858 $6,792 $7,064 $7,060 $4,911 $8,210 $9,837 $7,171 Baseline year 2 $12,040 $10,135 $10,409 $8,452 $6,549 $10,587 $14,023 $9,075 HHP year 1 $14,104 $10,294 $13,595 $10,924 $9,049 $12,937 $19,736 $6,379 HHP year 2 $12,173 $8,380 $11,392 $8,388 $9,232 $16,770 $10,704 -- % Change Year 1* 17% 2% 31% 29% 38% 22% 41% -30% % Change Year 2* 1% -17% 9% -1% 41% 58% -24% - 222 | UCLA Evaluation UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program MCP Inland Empire Health Plan Kaiser Group Group 2 Group 3 County Riverside San Bernardino Sacramento San Diego SPA 1 2 1 2 1 2 1 2 Estimated Medi-Cal Payment for Outpatient Pharmacy per Beneficiary per Year Baseline year 1 $5,819 $4,191 $5,526 $4,174 $3,218 $3,123 $2,830 $7,867 Baseline year 2 $6,420 $4,753 $6,366 $4,564 $3,331 $2,485 $3,341 $5,462 HHP year 1 $6,880 $5,670 $6,772 $5,333 $3,859 $2,617 $2,649 $9,732 HHP year 2 $6,578 $4,780 $6,171 $4,796 $4,048 $3,351 $3,280 -- % Change Year 1* 7% 19% 6% 17% 16% 5% -21% 78% % Change Year 2* 2% 1% -3% 5% 22% 35% -2% - Estimated Medi-Cal Payment for Residual Services per Beneficiary per Year Baseline year 1 $1,721 $1,854 $1,562 $1,746 $515 $878 $1,478 $342 Baseline year 2 $2,066 $2,099 $1,969 $2,083 $852 $1,045 $1,882 $2,196 HHP year 1 $2,311 $2,407 $2,267 $2,189 $1,419 $1,334 $1,521 $233 HHP year 2 $2,037 $2,073 $2,393 $1,764 $1,089 $1,079 $664 -- % Change Year 1* 12% 15% 15% 5% 67% 28% -19% -89% % Change Year 2* -1% -1% 22% -15% 28% 3% -65% - Source: UCLA analysis of Medi-Cal Claims data from July 1, 2016 to December 31, 2021. Notes: -- indicates data is not reported due to small cell size. N/A indicates there are no enrollees to report. *The percentage changes for Year 1 and 2 are calculated using Baseline Year 2 as the reference. | UCLA Evaluation 223 UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program Exhibit 110: HHP Implementation and Enrollee Demographics for Molina Healthcare Plan as of December 31, 2021 MCP Molina Healthcare Plan of California Group Group 2 Group 3 County Riverside San Bernardino Imperial Sacramento San Diego SPA 1 2 1 2 1 2 1 2 1 2 Program Implementation and Enrollment Implementation Date 1/1/19 7/1/19 1/1/19 7/1/19 7/1/19 1/1/20 7/1/19 1/1/20 7/1/19 1/1/20 Total Enrollment (12/2021) 945 674 807 447 239 218 605 609 1651 2172 % of TEL enrolled 76% 75% 82% 85% 83% Avg Length of Enrollment (Months) 12 11 12 11 11 7 12 11 10 9 Enrollee Demographics % 0-17 20% 10% 17% 7% 8% -- 10% 2% 19% 5% % 18-34 10% 26% 12% 26% 8% 23% 9% 22% 9% 18% % 34-49 20% 30% 20% 23% 24% 25% 22% 27% 16% 26% % 49-64 44% 32% 44% 42% 52% 47% 53% 47% 47% 48% % 65+ 6% 2% 8% 2% 8% -- 6% 2% 9% 4% % Male 53% 36% 50% 42% 52% 32% 52% 42% 51% 36% % White 22% 30% 15% 20% 3% 11% 25% 30% 21% 33% % Hispanic 46% 42% 52% 53% 92% 77% 17% 12% 35% 23% % African American 14% 13% 18% 18% -- 7% 29% 36% 8% 9% % Asian American and Pacific Islander <10% -- 8% 3% -- 0% 10% 4% 7% 3% % American Indian and Alaskan Native 0% -- 0% -- -- -- -- 2% -- -- % Other -- -- -- -- -- 0% 13% 12% 25% 27% % Unknown 10% 12% 6% 6% -- -- -- 5% 4% 4% % Speak English 74% 84% 71% 79% 40% 58% 82% 91% 59% 71% Medi-Cal full-scope months baseline year 1 12 12 12 12 12 12 12 12 12 12 # Enrollees with Homeless Information Available 847 648 739 443 242 219 604 610 1640 2159 Proportion ever homeless during HHP enrollment 2% -- 3% -- -- 6% 11% 16% 6% 6% Source: MCP Enrollment Reports from August 2019, Quarterly HHP Reports from September 2019 to September 2020, and Medi-Cal Claims data from July 1, 2016 to December 31, 2021. Notes: -- indicates data is not reported due to small cell size. N/A indicates there are no enrollees to report. 224 | UCLA Evaluation UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program Exhibit 111: HHP Enrollee Health Status and Utilization Prior to Enrollment and Service Delivery for Molina Healthcare Plan as of December 31, 2021 MCP Molina Healthcare Plan of California Group Group 2 Group 3 County Riverside San Bernardino Imperial Sacramento San Diego SPA 1 2 1 2 1 2 1 2 1 2 Health Status and Utilization 24 Months Prior to Enrollment Two specific conditions (criteria 1) 43% 22% 46% 25% 48% 27% 50% 35% 48% 37% Hypertension and another specific condition (criteria 2) 51% 27% 56% 32% 64% 32% 60% 36% 56% 39% Serious mental health condition (criteria 3) 6% 84% 8% 79% 7% 77% 12% 85% 8% 82% Asthma (criteria 4) 40% 16% 37% 17% 25% 23% 36% 20% 37% 21% Average number of ED visits 4.6 5.5 4.2 5.5 3.4 3.2 6.1 7.6 3.8 4.8 Average number of hospitalizations 0.9 0.9 0.9 1.2 0.5 0.3 1.3 1.3 0.9 0.9 HHP Services Delivered to HHP Enrollees Total number of units of service provided 5,355 2,134 9,905 3,864 592 -- 2,421 10 865 105 Average number of units of service per enrollee 1.9 2.1 2.2 2.4 3.1 0.0 2.5 1.3 1.8 1.4 Median number of units of service per enrollee 1.0 2.0 2.0 2.0 2.0 0.0 2.0 1.0 1.0 1.0 Average number of engagement services provided 1.2 1.1 1.2 1.2 1.3 0.0 1.5 0.0 1.4 1.5 Average number of core services provided 1.9 2.0 2.1 2.4 3.0 0.0 2.2 1.0 1.8 1.2 Average number of other HHP services provided 1.0 1.0 1.0 1.0 1.0 0.0 1.3 0.0 1.2 1.3 Average number of in-person services provided 1.1 1.4 1.1 1.6 1.4 0.0 1.3 0.0 2.0 0.0 Average number of phone/ telehealth services provided 1.9 2.0 2.1 2.4 2.9 0.0 2.0 1.0 1.6 1.2 Average number of services provided by clinical staff 2.3 2.2 2.4 2.7 2.3 0.0 2.5 0.0 2.1 1.5 Average number of services provided by non-clinical staff 1.7 1.8 1.7 1.9 2.5 0.0 2.2 1.0 1.8 1.3 Source: UCLA analysis of Medi-Cal Claims data from July 1, 2016 to December 31, 2021. Notes: -- indicates data is not reported due to small cell size. N/A indicates there are no enrollees to report. At risk for high utilization is defined as no ED utilization or hospitalizations 24 months prior to enrollment, low utilization is less than 2 ED visits and less than 1 hospitalizations per year, moderate utilization is 2 or more ED visits or 1 or more hospitalizations per year, high utilization is 5 or more ED visits or 2 or more hospitalizations per year, and super utilization is 10 or more ED visits or 4 or more hospitalizations per year. | UCLA Evaluation 225 UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program Exhibit 112: Trends in HHP Metrics for Molina Healthcare Plan as of December 31, 2021 MCP Molina Healthcare Plan of California Group Group 2 Group 3 San County Riverside Bernardino Imperial Sacramento San Diego SPA 1 2 1 2 1 2 1 2 1 2 Adult BMI Assessment Baseline year 1 55% 59% 62% 68% 80% 85% 58% 56% 75% 75% Baseline year 2 74% 76% 77% 77% 80% 80% 73% 71% 75% 72% HHP year 1 76% 73% 80% 77% 81% 70% 74% 70% 69% 65% HHP year 2 70% 68% 76% 73% 91% 74% 72% 64% 64% 61% Follow-Up After Hospitalization for Mental Illness within 30 Days Baseline year 1 -- 79% -- 84% -- -- -- 69% 80% 79% Baseline year 2 -- 73% 100% 70% -- -- 0% 70% 67% 78% HHP year 1 100% 56% 100% 83% -- -- 0% 67% 83% 80% HHP year 2 -- 22% -- 75% -- -- -- 100% 100% 50% Follow-Up After Hospitalization for Mental Illness within 7 Days Baseline year 1 -- 41% -- 64% -- -- -- 31% 60% 52% Baseline year 2 -- 33% 100% 48% -- -- 0% 52% 33% 57% HHP year 1 0% 38% 50% 56% -- -- 0% 42% 67% 63% HHP year 2 -- 22% -- 63% -- -- -- 100% 50% 40% Screening for Depression and Follow-Up Plan Baseline year 1 11% 10% 8% 8% 0% 0% 1% 2% 10% 10% Baseline year 2 20% 19% 20% 20% 1% 0% 2% 0% 15% 15% HHP year 1 24% 47% 30% 38% 0% 0% 1% 0% 15% 20% HHP year 2 29% 13% 34% 18% 0% -- 1% 0% 19% 20% Follow-Up After ED Visit for Alcohol and Other Drug Abuse or Dependence within 7 days Baseline year 1 0% 0% 0% 0% 0% 20% 0% 4% 0% 9% Baseline year 2 4% 4% 0% 0% -- 0% 0% 13% 4% 12% HHP year 1 6% 0% 0% 0% 33% -- 13% 4% 17% 13% HHP year 2 14% 0% 0% 0% 100% -- 0% 6% 0% 19% Follow-Up After ED Visit for Alcohol and Other Drug Abuse or Dependence within 30 days Baseline year 1 0% 0% 0% 0% 0% 20% 7% 5% 5% 21% Baseline year 2 4% 4% 0% 6% -- 0% 0% 22% 7% 24% HHP year 1 12% 14% 0% 7% 33% -- 13% 16% 33% 26% HHP year 2 14% 0% 0% 0% 100% -- 17% 11% 0% 38% Initiation of Alcohol and Other Drug Dependence Treatment Baseline year 1 16% 22% 15% 27% 25% 21% 28% 15% 13% 28% Baseline year 2 27% 36% 13% 24% 36% 31% 20% 22% 19% 26% HHP year 1 24% 34% 21% 19% 0% 23% 15% 24% 17% 24% HHP year 2 23% 14% 9% 25% 0% 0% 17% 23% 22% 12% Engagement of Alcohol and Other Drug Dependence Treatment Baseline year 1 46% 48% 13% 35% 67% 67% 15% 28% 17% 49% Baseline year 2 24% 43% 30% 32% 25% 64% 20% 27% 27% 35% HHP year 1 44% 42% 0% 36% -- 67% 18% 25% 33% 42% HHP year 2 11% 63% 33% 30% -- -- 25% 33% 27% 67% 226 | UCLA Evaluation UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program MCP Molina Healthcare Plan of California Group Group 2 Group 3 San County Riverside Bernardino Imperial Sacramento San Diego SPA 1 2 1 2 1 2 1 2 1 2 Use of Pharmacotherapy for Opioid Use Disorder Baseline year 1 24% 13% 19% 21% 48% 18% 65% 58% 56% 43% Baseline year 2 26% 22% 21% 19% 40% 18% 48% 56% 52% 50% HHP year 1 30% 19% 24% 27% 40% 18% 70% 57% 56% 59% HHP year 2 42% 23% 25% 11% 57% 33% 55% 69% 54% 64% All-Cause Readmission Baseline year 1 7% 10% 7% 11% 7% 5% 10% 10% 13% 10% Baseline year 2 12% 11% 10% 6% 9% 13% 13% 10% 9% 12% HHP year 1 14% 14% 9% 6% 10% 17% 18% 12% 16% 15% HHP year 2 14% 4% 11% 15% 0% 0% 12% 22% 10% 7% Controlling High Blood Pressure Baseline year 1 15% 18% 21% 24% 4% 9% 20% 20% 14% 13% Baseline year 2 25% 28% 32% 36% 8% 11% 35% 36% 13% 13% HHP year 1 28% 19% 34% 32% 20% 7% 31% 27% 16% 17% HHP year 2 27% 17% 27% 32% 29% 13% 29% 29% 19% 23% Outpatient Services: Primary Care per 1,000 Beneficiaries per Year Baseline year 1 4,805 5,002 4,622 4,303 6,742 7,060 3,611 4,431 5,658 7,567 Baseline year 2 5,541 6,076 5,247 5,690 8,103 7,694 5,015 6,659 6,035 8,555 HHP year 1 6,292 6,703 7,336 7,377 10,139 9,074 7,255 7,843 5,825 8,799 HHP year 2 5,257 5,607 5,800 6,470 10,769 10,168 5,893 7,575 6,068 7,902 Outpatient Services: Specialty Care per 1,000 Beneficiaries per Year Baseline year 1 3,883 4,084 3,995 3,739 6,372 5,144 3,428 2,974 5,601 5,952 Baseline year 2 4,748 4,643 4,764 4,497 6,777 6,212 3,656 3,385 6,710 6,582 HHP year 1 5,235 4,856 5,228 4,854 7,642 6,264 4,650 4,461 6,847 6,972 HHP year 2 4,296 4,345 4,781 4,328 6,453 6,600 4,786 4,318 6,551 6,654 Outpatient Services: Mental Health per 1,000 Beneficiaries per Year Baseline year 1 1,036 8,507 1,158 6,271 1,557 8,356 1,556 7,441 1,139 8,968 Baseline year 2 1,637 11,248 1,330 7,695 1,755 8,797 1,726 9,202 1,566 9,860 HHP year 1 2,207 9,704 1,877 8,222 2,457 9,099 1,913 10,171 2,051 9,289 HHP year 2 2,869 7,869 1,979 7,852 2,448 7,768 2,388 8,984 2,301 7,651 Outpatient Services: Substance Use Disorder per 1,000 Beneficiaries per Year Baseline year 1 1,746 4,317 3,299 3,598 5,772 4,944 6,927 12,481 875 4,820 Baseline year 2 2,476 5,851 3,218 4,802 6,227 6,023 7,234 13,198 1,188 4,868 HHP year 1 3,182 5,733 2,984 4,311 8,682 9,000 6,264 14,139 1,029 4,394 HHP year 2 3,567 5,652 1,548 3,512 18,184 12,189 6,116 14,268 1,455 4,235 Emergency Department Visits per 1,000 Beneficiaries per Year Baseline year 1 1,819 2,360 1,706 2,004 1,363 1,855 2,262 3,029 1,498 1,983 Baseline year 2 2,051 2,332 1,775 2,317 1,705 1,237 2,653 3,261 1,500 2,016 HHP year 1 1,493 1,803 1,300 2,060 1,245 1,372 2,207 2,942 1,078 1,840 HHP year 2 1,200 1,585 971 1,514 1,175 1,137 1,920 2,642 1,122 1,971 Inpatient Stays per 1,000 Beneficiaries per Year | UCLA Evaluation 227 UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program MCP Molina Healthcare Plan of California Group Group 2 Group 3 San County Riverside Bernardino Imperial Sacramento San Diego SPA 1 2 1 2 1 2 1 2 1 2 Baseline year 1 390 404 353 590 226 119 505 536 426 464 Baseline year 2 585 558 573 692 288 138 820 762 513 470 HHP year 1 478 531 528 666 272 83 921 939 444 484 HHP year 2 337 387 300 382 113 126 624 599 498 494 PQI 92 (per 1,000 Beneficiaries per Year) Baseline year 1 75 45 81 56 27 9 128 96 65 44 Baseline year 2 135 56 99 105 46 14 237 188 75 45 HHP year 1 68 37 96 72 33 8 207 184 65 51 HHP year 2 78 40 80 94 14 32 165 122 89 46 Admission to an Institution from the Community - Short (per 1,000 Beneficiaries per Year) Baseline year 1 8 5 3 7 -- -- 9 22 14 16 Baseline year 2 18 8 18 9 8 5 18 40 14 27 HHP year 1 5 6 4 11 13 -- 23 17 22 19 HHP year 2 7 3 2 -- -- -- 15 11 17 24 Admission to an Institution from the Community - Medium (per 1,000 Beneficiaries per Year) Baseline year 1 13 12 -- 2 -- -- 11 21 8 12 Baseline year 2 16 8 5 11 8 5 17 10 9 8 HHP year 1 14 13 10 5 13 -- 23 21 13 9 HHP year 2 11 6 7 4 14 -- 25 34 15 17 Admission to an Institution from the Community - Long (per 1,000 Beneficiaries per Year) Baseline year 1 8 -- 3 7 -- -- 5 9 3 9 Baseline year 2 4 5 3 2 4 -- 7 12 4 5 HHP year 1 12 7 4 8 -- -- 17 23 7 10 HHP year 2 -- 3 2 4 -- -- -- -- 6 7 Source: UCLA analysis of Medi-Cal Claims data from July 1, 2016 to December 31, 2021. Notes: -- indicates data is not reported due to small cell size. N/A indicates there are no enrollees to report. 228 | UCLA Evaluation UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program Exhibit 113: Trends in Estimated Payments for Molina Healthcare Plan as of December 31, 2021 MCP Molina Healthcare Plan of California Group Group 2 Group 3 County Riverside San Bernardino Imperial Sacramento San Diego SPA 1 2 1 2 1 2 1 2 1 2 Total Estimated Medi-Cal Payment per Beneficiary per Year Baseline year 1 $15,526 $16,392 $14,590 $19,254 $18,006 $16,199 $15,952 $18,295 $18,913 $22,970 Baseline year 2 $19,338 $19,455 $19,738 $19,964 $19,925 $15,723 $23,794 $22,515 $23,682 $24,858 HHP year 1 $20,609 $21,421 $19,712 $23,616 $26,978 $18,773 $27,086 $29,864 $25,866 $27,105 HHP year 2 $17,319 $21,442 $15,174 $15,821 $19,561 $17,609 $21,595 $22,346 $23,698 $25,618 % Change Year 1* 7% 10% 0% 18% 35% 19% 14% 33% 9% 9% % Change Year 2* -10% 10% -23% -21% -2% 12% -9% -1% 0% 3% Estimated Medi-Cal Payment for Emergency Department Visits per Beneficiary per Year Baseline year 1 $679 $1,195 $668 $1,004 $595 $1,258 $1,042 $1,469 $643 $1,112 Baseline year 2 $830 $1,135 $816 $1,101 $683 $684 $1,173 $1,857 $737 $1,323 HHP year 1 $718 $1,044 $579 $1,139 $682 $1,080 $1,173 $2,046 $764 $1,190 HHP year 2 $624 $1,120 $533 $769 $569 $429 $1,208 $1,878 $535 $1,103 % Change Year 1* -13% -8% -29% 3% 0% 58% 0% 10% 4% -10% % Change Year 2* -25% -1% -35% -30% -17% -37% 3% 1% -27% -17% Estimated Medi-Cal Payment for Inpatient Stays per Beneficiary per Year Baseline year 1 $5,058 $5,092 $4,410 $7,520 $4,172 $2,395 $5,911 $6,101 $6,161 $5,846 Baseline year 2 $7,901 $6,298 $8,433 $8,451 $5,307 $1,952 $11,421 $8,395 $6,831 $6,421 HHP year 1 $8,040 $6,671 $7,196 $11,939 $3,906 $1,218 $12,344 $12,187 $6,412 $6,562 HHP year 2 $5,230 $4,821 $4,592 $4,649 $2,100 $2,020 $8,427 $6,851 $7,143 $6,032 % Change Year 1* 2% 6% -15% 41% -26% -38% 8% 45% -6% 2% % Change Year 2* -34% -23% -46% -45% -60% 3% -26% -18% 5% -6% Estimated Medi-Cal Payment for Long-Term Care Stays per Beneficiary per Year Baseline year 1 $215 $116 $89 $155 -- $45 $409 $479 $161 $351 Baseline year 2 $195 $122 $132 $119 $134 $2 $263 $299 $183 $279 | UCLA Evaluation 229 UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program MCP Molina Healthcare Plan of California Group Group 2 Group 3 County Riverside San Bernardino Imperial Sacramento San Diego SPA 1 2 1 2 1 2 1 2 1 2 HHP year 1 $441 $270 $403 $299 $129 -- $1,412 $1,281 $573 $648 HHP year 2 $221 $351 $324 $198 $116 -- $897 $1,081 $844 $955 % Change Year 1* 126% 122% 206% 152% -4% - 438% 328% 214% 132% % Change Year 2* 13% 188% 146% 66% -13% - 241% 261% 362% 242% Estimated Medi-Cal Payment for Outpatient Services per Beneficiary per Year Baseline year 1 $5,079 $5,336 $5,661 $5,749 $6,298 $7,177 $4,612 $5,095 $6,675 $8,587 Baseline year 2 $5,681 $6,896 $6,025 $5,542 $8,632 $6,616 $6,736 $7,121 $9,789 $9,403 HHP year 1 $6,508 $8,242 $6,956 $5,115 $16,013 $7,338 $7,161 $8,653 $11,892 $11,178 HHP year 2 $6,283 $10,212 $5,454 $4,940 $9,532 $5,790 $7,018 $7,200 $9,257 $10,407 % Change Year 1* 15% 20% 15% -8% 86% 11% 6% 22% 21% 19% % Change Year 2* 11% 48% -9% -11% 10% -12% 4% 1% -5% 11% Estimated Medi-Cal Payment for Outpatient Pharmacy per Beneficiary per Year Baseline year 1 $3,466 $3,565 $3,168 $3,665 $4,433 $4,632 $3,361 $4,446 $4,134 $5,295 Baseline year 2 $3,464 $3,498 $3,443 $3,263 $4,410 $5,784 $2,966 $3,756 $4,287 $5,409 HHP year 1 $3,297 $3,786 $3,400 $3,480 $5,391 $7,424 $3,572 $4,376 $4,463 $5,395 HHP year 2 $3,457 $3,713 $3,047 $3,099 $5,954 $8,021 $3,009 $4,392 $4,122 $5,080 % Change Year 1* -5% 8% -1% 7% 22% 28% 20% 17% 4% 0% % Change Year 2* 0% 6% -12% -5% 35% 39% 1% 17% -4% -6% Estimated Medi-Cal Payment for Residual Services per Beneficiary per Year Baseline year 1 $890 $930 $459 $974 $2,408 $566 $481 $500 $1,016 $1,614 Baseline year 2 $1,073 $1,327 $709 $1,264 $619 $593 $950 $814 $1,707 $1,856 HHP year 1 $1,454 $1,175 $1,051 $1,424 $805 $1,672 $1,141 $1,046 $1,630 $1,969 HHP year 2 $1,413 $1,060 $1,149 $2,036 $1,268 $1,311 $890 $752 $1,666 $1,875 % Change Year 1* 36% -11% 48% 13% 30% 182% 20% 28% -5% 6% % Change Year 2* 32% -20% 62% 61% 105% 121% -6% -8% -2% 1% 230 | UCLA Evaluation UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program Source: UCLA analysis of Medi-Cal Claims data from July 1, 2016 to December 31, 2021. Notes: -- indicates data is not reported due to small cell size. N/A indicates there are no enrollees to report. *The percentage changes for Year 1 and 2 are calculated using Baseline Year 2 as the reference. | UCLA Evaluation 231 UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program Exhibit 114: HHP Implementation and Enrollee Demographics for Health Net as of December 31, 2021 MCP Health Net Group Group 3 County Kern Los Angeles Sacramento San Diego Tulare SPA 1 2 1 2 1 2 1 2 1 2 Program Implementation and Enrollment Implementation Date 7/1/19 1/1/20 7/1/19 1/1/20 7/1/19 1/1/20 7/1/19 1/1/20 7/1/19 1/1/20 Total Enrollment (12/2021) 447 163 7893 1849 584 258 285 130 377 123 % of TEL enrolled 95% 87% 96% 82% 94% Avg Length of Enrollment (Months) 12 11 12 8 12 11 9 9 13 11 Enrollee Demographics % 0-17 8% -- 12% 9% 4% -- 16% -- 8% -- % 18-34 11% 29% 11% 30% 14% 33% 12% 35% 10% 34% % 34-49 24% 29% 19% 27% 24% 33% 20% 21% 26% 37% % 49-64 53% 35% 49% 32% 53% 31% 46% 35% 49% 24% % 65+ 5% -- 9% 2% 4% -- 5% -- 7% -- % Male 40% 29% 42% 35% 39% 28% 49% 41% 36% 20% % White 28% 44% 10% 16% 26% 37% 19% 28% 20% 24% % Hispanic 50% 36% 53% 53% 20% 14% 40% 27% 69% 64% % African American 15% 13% 23% 19% 32% 23% 7% 12% 3% -- % Asian American and Pacific Islander -- -- 8% 5% 5% -- 6% -- 1% -- % American Indian and Alaskan Native 0% -- -- -- -- -- -- 0% -- -- % Other 0% -- 2% 2% 12% 17% 25% 27% 5% -- % Unknown 5% -- 4% 5% 3% -- -- -- -- -- % Speak English 77% 90% 64% 75% 89% 95% 67% 85% 59% 72% Medi-Cal full-scope months baseline year 1 12 12 12 12 12 12 12 12 12 12 # Enrollees with Homeless Information Available 447 163 7893 1849 584 258 285 130 377 123 Proportion ever homeless during HHP enrollment 3% -- 8% 9% 14% 22% 7% 11% 29% 52% Source: MCP Enrollment Reports from August 2019, Quarterly HHP Reports from September 2019 to September 2020, and Medi-Cal Claims data from July 1, 2016 to December 31, 2021. Notes: -- indicates data is not reported due to small cell size. N/A indicates there are no enrollees to report. 232 | UCLA Evaluation UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program Exhibit 115: HHP Enrollee Health Status and Utilization Prior to Enrollment and Service Delivery for Health Net as of December 31, 2021 MCP Health Net Group Group 3 County Kern Los Angeles Sacramento San Diego Tulare SPA 1 2 1 2 1 2 1 2 1 2 Health Status and Utilization 24 Months Prior to Enrollment Two specific conditions (criteria 1) 50% 15% 48% 18% 54% 18% 48% 16% 54% 24% Hypertension and another specific condition (criteria 2) 66% 12% 63% 19% 61% 9% 51% 10% 67% 16% Serious mental health condition (criteria 3) 38% 93% 32% 88% 40% 94% 26% 92% 36% 95% Asthma (criteria 4) 40% 13% 37% 11% 38% 12% 40% 12% 43% 15% Average number of ED visits 5.2 5.2 5.1 5.1 7.4 6.9 4.8 4.9 5.6 8.3 Average number of hospitalizations 1.0 0.6 1.3 1.1 1.3 0.6 1.2 1.2 1.5 1.2 HHP Services Delivered to HHP Enrollees Total number of units of service provided 19 -- 43,734 5,483 56 14 1,313 730 34 -- Average number of units of service per enrollee 1.0 0.0 1.5 1.6 1.2 1.2 3.0 3.5 1.0 0.0 Median number of units of service per enrollee 1.0 0.0 1.0 1.0 1.0 1.0 2.0 3.0 1.0 0.0 Average number of engagement services provided 0.0 0.0 1.1 1.2 1.0 1.0 1.3 1.4 1.0 0.0 Average number of core services provided 1.0 0.0 1.4 1.4 1.1 1.2 2.6 3.2 1.0 0.0 Average number of other HHP services provided 1.0 0.0 1.6 1.6 1.2 1.0 2.3 2.2 0.0 0.0 Average number of in-person services provided 0.0 0.0 1.1 1.0 1.0 1.0 1.4 1.9 0.0 0.0 Average number of phone/ telehealth services provided 1.0 0.0 1.4 1.4 1.2 1.1 2.5 3.0 1.0 0.0 Average number of services provided by clinical staff 1.0 0.0 1.2 1.2 1.0 0.0 1.3 1.0 1.0 0.0 Average number of services provided by non-clinical staff 1.0 0.0 2.0 2.0 1.1 1.2 3.0 3.6 1.0 0.0 Source: UCLA analysis of Medi-Cal Claims data from July 1, 2016 to December 31, 2021. Notes: -- indicates data is not reported due to small cell size. N/A indicates there are no enrollees to report. At risk for high utilization is defined as no ED utilization or hospitalizations 24 months prior to enrollment, low utilization is less than 2 ED visits and less than 1 hospitalizations per year, moderate utilization is 2 or more ED visits or 1 or more hospitalizations per year, high utilization is 5 or more ED visits or 2 or more hospitalizations per year, and super utilization is 10 or more ED visits or 4 or more hospitalizations per year. | UCLA Evaluation 233 UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program Exhibit 116: Trends in HHP Metrics for Health Net as of December 31, 2021 MCP Health Net Group Group 3 County Kern Los Angeles Sacramento San Diego Tulare SPA 1 2 1 2 1 2 1 2 1 2 Adult BMI Assessment Baseline year 1 60% 42% 75% 70% 59% 42% 77% 65% 65% 53% Baseline year 2 59% 43% 78% 71% 73% 58% 77% 69% 76% 70% HHP year 1 58% 38% 73% 64% 74% 59% 72% 62% 85% 77% HHP year 2 52% 35% 65% 58% 67% 50% 68% 52% 82% 71% Follow-Up After Hospitalization for Mental Illness within 30 Days Baseline year 1 100% 80% 60% 74% 67% 67% 86% 58% 75% 63% Baseline year 2 100% 78% 66% 74% 83% 89% 100% 63% 100% 88% HHP year 1 67% 0% 72% 67% 67% 100% 100% 33% 100% 89% HHP year 2 100% -- 71% 64% 0% 67% -- 0% 100% 100% Follow-Up After Hospitalization for Mental Illness within 7 Days Baseline year 1 100% 50% 43% 49% 33% 53% 86% 33% 63% 31% Baseline year 2 50% 44% 43% 49% 67% 33% 100% 42% 71% 65% HHP year 1 67% 0% 51% 46% 33% 50% 100% 11% 100% 89% HHP year 2 100% -- 49% 45% 0% 67% -- 0% 0% 67% Screening for Depression and Follow-Up Plan Baseline year 1 0% 0% 7% 6% 0% 0% 16% 9% 0% 0% Baseline year 2 0% 0% 7% 2% 0% 0% 19% 11% 0% 0% HHP year 1 0% 0% 6% 0% 0% 0% 14% 0% 0% 0% HHP year 2 0% 0% 7% 0% 0% 0% 23% -- 0% 0% Follow-Up After ED Visit for Alcohol and Other Drug Abuse or Dependence within 7 days Baseline year 1 0% 0% 7% 6% 5% 9% 8% 10% 0% 0% Baseline year 2 0% 0% 2% 5% 7% 9% 0% 0% 25% 0% HHP year 1 14% 0% 5% 10% 13% 6% 13% 33% 14% 11% HHP year 2 0% -- 9% 0% 0% 0% 0% 0% -- 0% Follow-Up After ED Visit for Alcohol and Other Drug Abuse or Dependence within 30 days Baseline year 1 11% 18% 11% 10% 13% 20% 15% 20% 17% 33% Baseline year 2 11% 0% 6% 9% 7% 18% 7% 8% 33% 14% HHP year 1 43% 0% 8% 18% 25% 6% 13% 33% 43% 22% HHP year 2 0% -- 18% 0% 0% 0% 33% 0% -- 25% Initiation of Alcohol and Other Drug Dependence Treatment Baseline year 1 18% 31% 21% 26% 23% 23% 17% 45% 28% 36% Baseline year 2 14% 24% 22% 25% 18% 31% 32% 37% 17% 20% HHP year 1 17% 22% 17% 25% 27% 33% 41% 16% 26% 19% HHP year 2 17% 0% 14% 17% 21% 15% 20% 36% 25% 25% Engagement of Alcohol and Other Drug Dependence Treatment Baseline year 1 20% 70% 31% 44% 48% 45% 14% 22% 20% 20% Baseline year 2 17% 22% 31% 32% 25% 40% 19% 35% 60% 67% HHP year 1 17% 25% 25% 43% 25% 43% 18% 50% 20% 33% HHP year 2 0% -- 54% 57% 14% 67% 0% 40% 67% 100% 234 | UCLA Evaluation UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program MCP Health Net Group Group 3 County Kern Los Angeles Sacramento San Diego Tulare SPA 1 2 1 2 1 2 1 2 1 2 Use of Pharmacotherapy for Opioid Use Disorder Baseline year 1 23% 42% 35% 27% 61% 53% 57% 14% 55% 17% Baseline year 2 33% 55% 39% 39% 59% 71% 57% 45% 42% 13% HHP year 1 33% 45% 43% 38% 53% 71% 71% 29% 50% 25% HHP year 2 30% 63% 46% 73% 74% 77% 100% 0% 83% 25% All-Cause Readmission Baseline year 1 8% 8% 9% 10% 10% 6% 0% 21% 8% 13% Baseline year 2 12% 3% 8% 11% 8% 12% 8% 0% 6% 13% HHP year 1 13% 7% 11% 15% 11% 0% 11% 14% 7% 17% HHP year 2 7% 0% 10% 10% 18% 16% 38% 0% 5% 7% Controlling High Blood Pressure Baseline year 1 5% 2% 27% 26% 9% 3% 19% 29% 2% 0% Baseline year 2 3% 2% 27% 24% 28% 49% 16% 13% 11% 17% HHP year 1 6% 11% 25% 19% 28% 28% 15% 5% 50% 55% HHP year 2 19% 16% 22% 20% 34% 37% 10% 11% 57% 54% Outpatient Services: Primary Care per 1,000 Beneficiaries per Year Baseline year 1 7,805 7,051 6,751 5,518 6,735 6,595 5,640 5,967 11,270 11,923 Baseline year 2 8,456 7,928 6,903 5,888 7,443 7,671 7,177 6,709 12,048 11,870 HHP year 1 9,162 8,205 6,624 5,879 8,128 7,674 11,209 11,645 11,965 12,856 HHP year 2 8,998 7,694 6,132 5,543 6,918 6,136 6,646 7,376 11,425 11,136 Outpatient Services: Specialty Care per 1,000 Beneficiaries per Year Baseline year 1 5,685 3,500 4,405 3,071 4,770 4,134 5,078 4,053 3,765 3,004 Baseline year 2 6,082 4,294 5,148 3,984 4,108 4,212 6,836 4,406 4,174 3,672 HHP year 1 6,598 4,323 5,513 3,968 4,527 4,454 7,840 4,946 4,546 3,252 HHP year 2 7,338 3,919 5,284 3,910 4,711 3,904 5,510 3,518 3,517 2,861 Outpatient Services: Mental Health per 1,000 Beneficiaries per Year Baseline year 1 3,273 8,696 4,617 15,182 5,081 9,165 3,479 9,936 1,876 7,311 Baseline year 2 3,535 10,257 5,249 17,101 4,375 10,932 3,973 14,472 2,453 8,727 HHP year 1 4,108 9,881 5,366 15,408 4,585 10,328 3,821 13,784 2,719 10,874 HHP year 2 3,068 7,790 5,705 11,451 4,504 9,233 3,051 7,177 2,460 7,968 Outpatient Services: Substance Use Disorder per 1,000 Beneficiaries per Year Baseline year 1 3,053 12,614 3,560 6,351 9,882 12,735 1,434 4,479 4,145 3,251 Baseline year 2 3,797 11,920 3,800 7,217 9,542 14,683 1,839 6,778 3,648 3,761 HHP year 1 3,930 12,913 3,984 7,266 9,067 13,126 1,875 5,885 3,563 6,216 HHP year 2 2,072 12,984 3,994 6,333 9,300 12,395 1,494 3,631 3,839 6,278 Emergency Department Visits per 1,000 Beneficiaries per Year Baseline year 1 2,366 2,652 2,148 2,134 3,463 3,622 1,872 2,006 2,212 3,379 Baseline year 2 2,012 2,125 1,889 2,020 2,723 2,943 2,041 1,979 1,998 3,867 HHP year 1 1,761 2,126 1,436 1,587 2,246 2,086 1,733 1,753 1,324 2,901 HHP year 2 1,766 1,677 1,272 1,494 2,188 1,828 1,323 1,645 1,075 3,245 Inpatient Stays per 1,000 Beneficiaries per Year Baseline year 1 520 304 664 564 707 370 534 643 831 698 | UCLA Evaluation 235 UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program MCP Health Net Group Group 3 County Kern Los Angeles Sacramento San Diego Tulare SPA 1 2 1 2 1 2 1 2 1 2 Baseline year 2 500 351 667 552 668 268 741 570 675 578 HHP year 1 514 228 547 384 558 247 512 637 438 405 HHP year 2 511 226 503 354 460 272 420 369 299 288 PQI 92 (per 1,000 Beneficiaries per Year) Baseline year 1 87 -- 98 23 172 12 92 25 194 17 Baseline year 2 76 18 111 26 183 16 103 -- 162 24 HHP year 1 85 7 89 13 138 9 117 31 99 18 HHP year 2 113 -- 94 11 92 -- 62 -- 57 19 Admission to an Institution from the Community - Short (per 1,000 Beneficiaries per Year) Baseline year 1 5 13 5 2 13 8 4 8 -- -- Baseline year 2 -- -- 10 4 14 4 14 -- 3 8 HHP year 1 8 -- 9 3 4 -- 10 10 6 9 HHP year 2 7 -- 4 4 10 -- -- -- -- -- Admission to an Institution from the Community - Medium (per 1,000 Beneficiaries per Year) Baseline year 1 5 -- 7 6 16 4 12 17 11 -- Baseline year 2 9 6 8 4 10 -- 18 15 8 8 HHP year 1 5 -- 6 4 15 4 15 10 6 -- HHP year 2 7 -- 9 4 30 8 16 -- 11 -- Admission to an Institution from the Community - Long (per 1,000 Beneficiaries per Year) Baseline year 1 7 -- 3 2 5 -- -- 8 -- 9 Baseline year 2 -- -- 5 2 5 -- 11 -- 5 -- HHP year 1 -- -- 5 2 -- -- -- 21 6 9 HHP year 2 7 -- 5 -- -- -- -- -- -- -- Source: UCLA analysis of Medi-Cal Claims data from July 1, 2016 to December 31, 2021. Notes: -- indicates data is not reported due to small cell size. N/A indicates there are no enrollees to report. 236 | UCLA Evaluation UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program Exhibit 117: Trends in Estimated Payments for Health Net as of December 31, 2021 MCP Health Net Group Group 3 County Kern Los Angeles Sacramento San Diego Tulare SPA 1 2 1 2 1 2 1 2 1 2 Total Estimated Medi-Cal Payment per Beneficiary per Year Baseline year 1 $21,128 $13,471 $20,663 $17,797 $25,244 $18,896 $20,459 $29,366 $ 32,397 $ 24,900 Baseline year 2 $22,057 $16,870 $22,791 $19,768 $24,983 $16,325 $29,418 $29,225 $ 30,375 $ 25,826 HHP year 1 $21,558 $12,754 $22,776 $18,268 $25,917 $14,848 $26,490 $26,360 $ 29,520 $ 18,811 HHP year 2 $22,881 $11,110 $21,875 $17,344 $22,595 $13,770 $20,403 $16,516 $ 19,742 $ 18,733 % Change Year 1* -2% -24% 0% -8% 4% -9% -10% -10% -3% -27% % Change Year 2* 4% -34% -4% -12% -10% -16% -31% -43% -35% -27% Estimated Medi-Cal Payment for Emergency Department Visits per Beneficiary per Year Baseline year 1 $1,136 $1,083 $856 $822 $1,754 $1,516 $872 $1,121 $1,015 $1,562 Baseline year 2 $941 $902 $829 $907 $1,411 $1,327 $1,012 $1,340 $1,510 $1,798 HHP year 1 $771 $879 $713 $741 $1,232 $1,062 $1,146 $1,142 $913 $1,451 HHP year 2 $587 $560 $654 $568 $1,357 $924 $763 $870 $660 $1,686 % Change Year 1* -18% -2% -14% -18% -13% -20% 13% -15% -40% -19% % Change Year 2* -38% -38% -21% -37% -4% -30% -25% -35% -56% -6% Estimated Medi-Cal Payment for Inpatient Stays per Beneficiary per Year Baseline year 1 $6,319 $3,061 $7,481 $6,192 $8,403 $4,493 $8,245 $9,196 $12,952 $6,755 Baseline year 2 $8,058 $4,277 $7,761 $6,479 $7,914 $2,976 $11,563 $7,256 $9,982 $7,688 HHP year 1 $6,072 $2,239 $7,014 $4,610 $9,351 $3,186 $7,190 $8,656 $6,744 $5,123 HHP year 2 $6,429 $2,649 $7,117 $4,839 $6,939 $2,872 $6,112 $3,796 $4,079 $3,880 % Change Year 1* -25% -48% -10% -29% 18% 7% -38% 19% -32% -33% % Change Year 2* -20% -38% -8% -25% -12% -4% -47% -48% -59% -50% Estimated Medi-Cal Payment for Long-Term Care Stays per Beneficiary per Year Baseline year 1 $349 $136 $289 $130 $322 $125 $188 $235 $130 $55 Baseline year 2 $284 $49 $363 $139 $211 $76 $551 $358 $193 $74 | UCLA Evaluation 237 UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program MCP Health Net Group Group 3 County Kern Los Angeles Sacramento San Diego Tulare SPA 1 2 1 2 1 2 1 2 1 2 HHP year 1 $74 $21 $484 $233 $166 $92 $244 $637 $377 $186 HHP year 2 $241 $112 $612 $233 $328 $85 $65 $1,213 $187 -- % Change Year 1* -74% -58% 33% 68% -22% 20% -56% 78% 95% 150% % Change Year 2* -15% 127% 69% 68% 55% 11% -88% 239% -4% - Estimated Medi-Cal Payment for Outpatient Services per Beneficiary per Year Baseline year 1 $6,067 $5,323 $5,707 $6,374 $7,178 $9,295 $6,898 $13,194 $11,650 $12,228 Baseline year 2 $5,321 $7,425 $7,227 $7,795 $7,471 $7,609 $10,626 $14,228 $11,171 $10,949 HHP year 1 $7,006 $6,077 $7,886 $8,332 $7,898 $6,045 $12,373 $9,537 $13,102 $7,109 HHP year 2 $9,606 $5,374 $7,680 $7,138 $6,510 $5,433 $8,095 $4,214 $7,748 $8,581 % Change Year 1* 32% -18% 9% 7% 6% -21% 16% -33% 17% -35% % Change Year 2* 81% -28% 6% -8% -13% -29% -24% -70% -31% -22% Estimated Medi-Cal Payment for Outpatient Pharmacy per Beneficiary per Year Baseline year 1 $6,235 $3,024 $5,357 $3,224 $6,552 $2,597 $3,517 $3,784 $5,541 $3,285 Baseline year 2 $6,435 $3,353 $5,344 $3,077 $6,875 $3,187 $4,567 $3,965 $6,290 $4,045 HHP year 1 $6,360 $2,364 $5,116 $2,896 $6,115 $3,575 $4,448 $4,089 $6,646 $3,400 HHP year 2 $4,810 $1,962 $4,196 $3,404 $6,170 $3,577 $3,959 $4,423 $5,900 $2,673 % Change Year 1* -1% -30% -4% -6% -11% 12% -3% 3% 6% -16% % Change Year 2* -25% -41% -21% 11% -10% 12% -13% 12% -6% -34% Estimated Medi-Cal Payment for Residual Services per Beneficiary per Year Baseline year 1 $894 $787 $789 $848 $852 $769 $619 $1,671 $840 $730 Baseline year 2 $934 $777 $1,092 $1,172 $935 $1,069 $908 $1,930 $1,020 $1,025 HHP year 1 $1,162 $1,106 $1,420 $1,322 $960 $836 $965 $2,075 $1,613 $1,359 HHP year 2 $1,070 $384 $1,474 $1,047 $1,181 $753 $1,307 $1,952 $1,092 $1,746 % Change Year 1* 24% 42% 30% 13% 3% -22% 6% 8% 58% 32% % Change Year 2* 15% -51% 35% -11% 26% -30% 44% 1% 7% 70% 238 | UCLA Evaluation UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program Source: UCLA analysis of Medi-Cal Claims data from July 1, 2016 to December 31, 2021. Notes: -- indicates data is not reported due to small cell size. N/A indicates there are no enrollees to report. *The percentage changes for Year 1 and 2 are calculated using Baseline Year 2 as the reference. | UCLA Evaluation 239 UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program Exhibit 118: HHP Implementation and Enrollee Demographics for San Francisco Health Plan, Santa Clara Family Health Plan, and United Healthcare as of December 31, 2021 MCP San Francisco Health Plan Santa Clara Family Health Plan United Healthcare Group Group 1 Group 3 Group 3 County San Francisco Santa Clara San Diego SPA 1 2 1 2 1 2 Program Implementation and Enrollment Implementation Date 7/1/19 1/1/20 7/1/19 1/1/20 7/1/19 1/1/20 Total Enrollment (12/2021) 764 512 879 662 143 121 % of enrollees from TEL 94% 79% 66% Avg Length of Enrollment (Months) 13 11 13 11 8 8 Enrollee Demographics % 0-17 10% 2% 7% <21% -- 0% % 18-34 6% 13% 10% 33% 16% 25% % 34-49 13% 25% 22% 23% 23% 38% % 49-64 56% 54% 44% 24% 51% 32% % 65+ 14% 6% 16% -- -- -- % Male 59% 49% 49% 39% 55% 42% % White 9% 22% 17% 19% 22% 24% % Hispanic 15% 16% 39% 45% 23% 19% % African American 23% 21% 6% 7% 10% 17% % Asian American and Pacific Islander 34% 18% 24% 8% 13% -- % American Indian and Alaskan Native -- -- -- -- -- -- % Other 16% 19% 10% 13% 28% 30% % Unknown 2% 4% <5% 7% -- -- % Speak English 57% 73% 69% 80% 79% 83% Medi-Cal full-scope months baseline year 1 12 12 12 12 11 11 # Enrollees with Homeless Information Available 645 495 879 662 143 121 Proportion ever homeless during HHP enrollment 6% 10% 14% 13% -- 9% Source: MCP Enrollment Reports from August 2019, Quarterly HHP Reports from September 2019 to September 2020, and Medi-Cal Claims data from July 1, 2016 to December 31, 2021. Notes: -- indicates data is not reported due to small cell size. N/A indicates there are no enrollees to report. 240 | UCLA Evaluation UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program Exhibit 119: HHP Enrollee Health Status and Utilization Prior to Enrollment and Service Delivery for San Francisco Health Plan, Santa Clara Family Health Plan, and United Healthcare as of December 31, 2021 MCP San Francisco Health Plan Santa Clara Family Health Plan United Healthcare Group Group 1 Group 3 Group 3 County San Francisco Santa Clara San Diego SPA 1 2 1 2 1 2 Health Status and Utilization 24 Months Prior to Enrollment Two specific conditions (criteria 1) 65% 44% 55% 32% 57% 24% Hypertension and another specific condition (criteria 2) 63% 36% 63% 21% 55% 21% Serious mental health condition (criteria 3) 16% 97% 13% 92% 25% 86% Asthma (criteria 4) 35% 19% 33% 18% 21% -- Average number of ED visits 7.1 9.7 5.0 6.0 4.3 4.5 Average number of hospitalizations 2.3 1.7 1.3 1.4 1.3 0.8 HHP Services Delivered to HHP Enrollees Total number of units of service provided 31,801 21,706 19,727 12,909 2,950 2,798 Average number of units of service per enrollee 2.3 2.7 1.7 1.7 1.8 1.8 Median number of units of service per enrollee 1.0 1.0 1.0 1.0 1.0 1.0 Average number of engagement services provided 1.6 1.7 1.1 1.0 1.2 1.3 Average number of core services provided 2.0 2.5 1.4 1.5 1.5 1.5 Average number of other HHP services provided 1.8 1.7 1.4 1.4 1.7 1.7 Average number of in-person services provided 1.6 1.5 1.1 1.1 1.1 1.0 Average number of phone/ telehealth services provided 1.9 2.4 1.4 1.5 1.6 1.5 Average number of services provided by clinical staff 1.8 2.2 1.1 1.2 1.3 1.4 Average number of services provided by non-clinical staff 2.1 2.4 1.6 1.6 1.9 1.8 Source: UCLA analysis of Medi-Cal Claims data from July 1, 2016 to December 31, 2021. Notes: -- indicates data is not reported due to small cell size. N/A indicates there are no enrollees to report. At risk for high utilization is defined as no ED utilization or hospitalizations 24 months prior to enrollment, low utilization is less than 2 ED visits and less than 1 hospitalizations per year, moderate utilization is 2 or more ED visits or 1 or more hospitalizations per year, high utilization is 5 or more ED visits or 2 or more hospitalizations per year, and super utilization is 10 or more ED visits or 4 or more hospitalizations per year. | UCLA Evaluation 241 UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program Exhibit 120: Trends in HHP Metrics for San Francisco Health Plan, Santa Clara Family Health Plan, and United Healthcare as of December 31, 2021 San Francisco Health Santa Clara Family MCP Plan Health Plan United Healthcare Group Group 1 Group 3 Group 3 County San Francisco Santa Clara San Diego SPA 1 2 1 2 1 2 Adult BMI Assessment Baseline year 1 18% 18% 31% 35% 51% 47% Baseline year 2 29% 24% 38% 41% 63% 50% HHP year 1 34% 27% 36% 37% 60% 50% HHP year 2 40% 29% 34% 36% 60% 47% Follow-Up After Hospitalization for Mental Illness within 30 Days Baseline year 1 -- 79% 75% 92% 100% 50% Baseline year 2 100% 91% 100% 92% 100% 86% HHP year 1 100% 83% 50% 86% 100% 67% HHP year 2 100% 88% 100% 63% 100% 50% Follow-Up After Hospitalization for Mental Illness within 7 Days Baseline year 1 -- 50% 25% 71% 80% 0% Baseline year 2 100% 79% 100% 77% 0% 50% HHP year 1 50% 67% 50% 70% 100% 67% HHP year 2 100% 75% 100% 63% 0% 50% Screening for Depression and Follow-Up Plan Baseline year 1 0% 0% 0% 0% 5% 2% Baseline year 2 3% 2% 1% 0% 7% 14% HHP year 1 11% 9% 3% 0% 8% 0% HHP year 2 17% 19% 4% 0% 13% 0% Follow-Up After ED Visit for Alcohol and Other Drug Abuse or Dependence within 7 days Baseline year 1 2% 13% 8% 6% 17% 27% Baseline year 2 7% 15% 17% 22% 14% 10% HHP year 1 5% 13% 17% 18% 33% 33% HHP year 2 4% 9% 10% 25% 0% 0% Follow-Up After ED Visit for Alcohol and Other Drug Abuse or Dependence within 30 days Baseline year 1 9% 22% 8% 19% 33% 27% Baseline year 2 13% 31% 22% 41% 29% 20% HHP year 1 5% 33% 17% 24% 33% 50% HHP year 2 12% 24% 10% 25% 0% 100% Initiation of Alcohol and Other Drug Dependence Treatment Baseline year 1 27% 26% 20% 24% 38% 31% Baseline year 2 30% 23% 22% 23% 19% 21% HHP year 1 23% 27% 17% 28% 21% 31% HHP year 2 12% 40% 20% 23% 11% 0% Engagement of Alcohol and Other Drug Dependence Treatment Baseline year 1 17% 26% 20% 26% 38% 56% Baseline year 2 22% 50% 39% 68% 67% 50% HHP year 1 24% 46% 36% 48% 0% 40% 242 | UCLA Evaluation UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program San Francisco Health Santa Clara Family MCP Plan Health Plan United Healthcare Group Group 1 Group 3 Group 3 County San Francisco Santa Clara San Diego SPA 1 2 1 2 1 2 HHP year 2 13% 38% 33% 43% 0% -- Use of Pharmacotherapy for Opioid Use Disorder Baseline year 1 64% 62% 43% 59% 25% 38% Baseline year 2 70% 72% 50% 47% 36% 53% HHP year 1 71% 71% 67% 39% 18% 62% HHP year 2 71% 65% 62% 40% 50% 57% All-Cause Readmission Baseline year 1 11% 13% 11% 13% 19% 13% Baseline year 2 12% 7% 10% 15% 13% 16% HHP year 1 15% 11% 11% 10% 19% 0% HHP year 2 11% 10% 20% 17% 20% 22% Controlling High Blood Pressure Baseline year 1 6% 2% 2% 1% 0% 0% Baseline year 2 15% 9% 9% 4% 0% 3% HHP year 1 26% 14% 11% 15% 8% 3% HHP year 2 23% 16% 23% 9% 22% 25% Outpatient Services: Primary Care per 1,000 Beneficiaries per Year Baseline year 1 7,999 8,171 6,012 6,177 5,187 5,029 Baseline year 2 10,441 10,520 7,005 7,824 8,230 9,873 HHP year 1 10,777 11,559 10,299 11,237 20,722 24,257 HHP year 2 8,411 8,867 8,574 8,376 13,961 18,022 Outpatient Services: Specialty Care per 1,000 Beneficiaries per Year Baseline year 1 2,816 2,493 3,905 2,426 3,008 2,902 Baseline year 2 3,292 2,706 5,165 2,941 4,007 5,085 HHP year 1 3,381 2,892 5,392 2,878 5,847 4,972 HHP year 2 3,081 2,568 5,335 2,130 4,680 3,101 Outpatient Services: Mental Health per 1,000 Beneficiaries per Year Baseline year 1 2,259 21,531 1,811 18,805 2,615 6,960 Baseline year 2 2,997 25,775 2,206 24,394 6,382 13,672 HHP year 1 3,270 23,129 3,026 23,417 6,650 18,026 HHP year 2 3,182 19,079 3,443 19,637 5,699 8,899 Outpatient Services: Substance Use Disorder per 1,000 Beneficiaries per Year Baseline year 1 17,458 27,615 2,123 5,159 1,339 4,289 Baseline year 2 17,081 31,232 2,485 6,674 2,041 6,372 HHP year 1 15,015 29,785 2,145 6,733 2,929 7,901 HHP year 2 14,200 25,964 2,571 4,091 2,327 8,180 Emergency Department Visits per 1,000 Beneficiaries per Year Baseline year 1 2,306 4,024 1,940 2,486 1,796 1,931 Baseline year 2 2,684 4,109 2,240 2,550 2,056 2,608 HHP year 1 1,974 3,234 1,577 1,993 2,093 2,351 HHP year 2 1,616 2,846 1,614 1,702 2,379 1,573 Inpatient Stays per 1,000 Beneficiaries per Year 243 Appendix G: Enrollees with More than One Year of HHP | UCLA Evaluation UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program San Francisco Health Santa Clara Family MCP Plan Health Plan United Healthcare Group Group 1 Group 3 Group 3 County San Francisco Santa Clara San Diego SPA 1 2 1 2 1 2 Baseline year 1 977 722 498 628 531 266 Baseline year 2 1,395 1,033 831 850 1,009 604 HHP year 1 1,065 695 575 483 793 334 HHP year 2 846 567 498 341 471 494 PQI 92 (per 1,000 Beneficiaries per Year) Baseline year 1 267 64 118 43 85 12 Baseline year 2 321 87 199 40 163 35 HHP year 1 287 77 100 24 95 -- HHP year 2 238 31 102 22 26 -- Admission to an Institution from the Community - Short (per 1,000 Beneficiaries per Year) Baseline year 1 7 4 4 5 -- 12 Baseline year 2 4 12 8 6 -- 18 HHP year 1 3 4 5 5 11 -- HHP year 2 6 12 6 9 -- 45 Admission to an Institution from the Community - Medium (per 1,000 Beneficiaries per Year) Baseline year 1 4 6 9 2 11 -- Baseline year 2 3 6 14 8 30 -- HHP year 1 4 7 14 11 32 -- HHP year 2 6 25 6 4 26 -- Admission to an Institution from the Community - Long (per 1,000 Beneficiaries per Year) Baseline year 1 6 4 1 -- -- -- Baseline year 2 4 2 3 3 -- -- HHP year 1 3 2 4 7 -- -- HHP year 2 6 -- 2 4 -- -- Source: UCLA analysis of Medi-Cal Claims data from July 1, 2016 to December 31, 2021. Notes: -- indicates data is not reported due to small cell size. N/A indicates there are no enrollees to report. 244 | UCLA Evaluation UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program Exhibit 121: Trends in Estimated Payments for San Francisco Health Plan, Santa Clara Family Health Plan, and United Healthcare as of December 31, 2021 Santa Clara Family Health MCP San Francisco Health Plan Plan United Healthcare Group Group 1 Group 3 Group 3 County San Francisco Santa Clara San Diego SPA 1 2 1 2 1 2 Total Estimated Medi-Cal Payment per Beneficiary per Year Baseline year 1 $24,985 $34,109 $20,110 $27,899 $19,318 $22,821 Baseline year 2 $35,552 $38,518 $28,520 $37,901 $26,286 $27,958 HHP year 1 $32,454 $33,016 $28,203 $36,329 $26,206 $22,916 HHP year 2 $28,474 $29,418 $26,738 $29,828 $18,232 $20,357 % Change Year 1* -9% -14% -1% -4% 0% -18% % Change Year 2* -20% -24% -6% -21% -31% -27% Estimated Medi-Cal Payment for Emergency Department Visits per Beneficiary per Year Baseline year 1 $1,121 $2,536 $740 $1,231 $932 $905 Baseline year 2 $1,403 $2,455 $1,116 $1,331 $1,036 $1,531 HHP year 1 $1,105 $2,031 $814 $1,095 $1,107 $1,600 HHP year 2 $1,094 $1,703 $907 $879 $1,343 $718 % Change Year 1* -21% -17% -27% -18% 7% 4% % Change Year 2* -22% -31% -19% -34% 30% -53% Estimated Medi-Cal Payment for Inpatient Stays per Beneficiary per Year Baseline year 1 $10,318 $7,751 $7,175 $7,367 $6,750 $3,882 Baseline year 2 $16,017 $11,262 $10,419 $10,122 $14,272 $7,487 HHP year 1 $13,087 $8,756 $7,517 $5,816 $12,437 $3,556 HHP year 2 $10,978 $8,002 $6,315 $4,173 $5,149 $5,490 % Change Year 1* -18% -22% -28% -43% -13% -53% % Change Year 2* -31% -29% -39% -59% -64% -27% Estimated Medi-Cal Payment for Long-Term Care Stays per Beneficiary per Year Baseline year 1 $212 $169 $108 $69 $290 $39 Baseline year 2 $234 $73 $114 $152 $454 $296 HHP year 1 $269 $333 $168 $160 $303 -- HHP year 2 $1,006 $1,105 $364 $688 $376 $130 % Change Year 1* 15% 358% 47% 5% -33% - % Change Year 2* 329% 1419% 220% 352% -17% -56% Estimated Medi-Cal Payment for Outpatient Services per Beneficiary per Year Baseline year 1 $6,726 $16,361 $7,320 $13,644 $8,501 $14,735 Baseline year 2 $9,902 $16,964 $10,857 $19,382 $6,399 $13,890 HHP year 1 $10,011 $14,260 $13,268 $22,492 $7,457 $10,304 HHP year 2 $7,484 $11,907 $13,518 $19,758 $5,720 $7,272 % Change Year 1* 1% -16% 22% 16% 17% -26% % Change Year 2* -24% -30% 25% 2% -11% -48% 245 Appendix G: Enrollees with More than One Year of HHP | UCLA Evaluation UCLA Center for Health Policy Research July 2023 Health Economics and Evaluation Research Program Estimated Medi-Cal Payment for Outpatient Pharmacy per Beneficiary per Year Baseline year 1 $5,838 $6,067 $4,092 $4,080 $1,811 $1,789 Baseline year 2 $7,002 $6,329 $4,960 $4,995 $2,367 $2,820 HHP year 1 $6,774 $6,090 $5,078 $4,592 $2,834 $3,890 HHP year 2 $6,763 $5,033 $4,347 $3,096 $4,073 $5,059 % Change Year 1* -3% -4% 2% -8% 20% 38% % Change Year 2* -3% -20% -12% -38% 72% 79% Estimated Medi-Cal Payment for Residual Services per Beneficiary per Year Baseline year 1 $551 $857 $535 $1,344 $909 $1,362 Baseline year 2 $656 $1,041 $822 $1,688 $1,492 $1,759 HHP year 1 $905 $1,292 $1,195 $1,986 $1,900 $3,405 HHP year 2 $860 $1,506 $1,114 $1,142 $1,414 $1,565 % Change Year 1* 38% 24% 45% 18% 27% 94% % Change Year 2* 31% 45% 35% -32% -5% -11% Source: UCLA analysis of Medi-Cal Claims data from July 1, 2016 to December 31, 2021. Notes: -- indicates data is not reported due to small cell size. N/A indicates there are no enrollees to report. *The percentage changes for Year 1 and 2 are calculated using Baseline Year 2 as the reference. 246 | UCLA Evaluation The views expressed in this report are those of the authors and do not necessarily represent the UCLA Center for Health Policy Research, the Regents of the University of California, or collaborating organizations or funders. Copyright © 2020 by the Regents of the University of California. All Rights Reserved. The UCLA Center for Health Policy Research is affiliated with the UCLA Fielding School of Public Health and the UCLA School of Public Affairs. Phone: 310-794-0909 Fax: 310-794-2686 Email: chpr@ucla.edu www.healthpolicy.ucla.edu