BILL ANALYSIS �
AB 209
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Date of Hearing: April 2, 2013
ASSEMBLY COMMITTEE ON HEALTH
Richard Pan, Chair
AB 209 (Pan) - As Amended: March 19, 2013
SUBJECT : Medi-Cal: managed care: quality and accessibility.
SUMMARY : Enacts the Medi-Cal Managed Care Quality and
Transparency Act of 2013 and requires the Department of Health
Care Services (DHCS) to develop and implement a plan to monitor,
evaluate, and improve the quality and accessibility of health
care and dental services provided through Medi-Cal managed care
(MCMC). Specifically, this bill :
1)Requires the quality and accessibility plan to include:
a) Nationally recognized quality and access measures;
b) A process to solicit input from stakeholders on
additional measures to fully evaluate all benefits,
including long term services and supports (LTSS) and to
analyze quality and access by race, ethnicity, gender, and
primary language;
c) Minimum and benchmark standards and contract
requirements;
d) Strategies to encourage and reward improvement and
identify health disparities;
e) Sanctions and corrective actions in cases of deficiency;
f) A publicly available, MCMC dashboard, as specified; and,
g) Coordination with the Department of Managed Health Care
(DMHC) to monitor, survey, and report on network adequacy
and fiscal solvency.
2)Requires DHCS to hold public meetings, at least quarterly, to
report on various performance measures, standards, and metrics
and to invite public comment.
3)Requires DHCS to appoint an advisory committee, as specified,
to make recommendations with regard to improving quality and
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access in the delivery of managed care services. Specifies
the responsibilities of the advisory committee.
4)Provides that implementation is conditioned on available
funding, as specified.
EXISTING LAW :
1)Establishes the Medi-Cal program, to provide various health
and long-term services to low-income women and children,
elderly, and people with disabilities.
2)Authorizes DHCS to enter into contracts with managed care
organizations to provide services to Medi-Cal enrollees.
3)Requires most persons eligible for Medi-Cal to enroll in a
managed care plan (MCP) and establishes a process for
informing enrollees regarding plan selection.
4)Authorizes DHCS to expand MCMC to the 28 mostly rural counties
that are currently in the Medi-Cal fee-for-service (FFS)
program.
FISCAL EFFECT : This bill has not been analyzed by a fiscal
committee.
COMMENTS :
1)PURPOSE OF THIS BILL . According to the author, this bill is
intended to provide an opportunity for public oversight and to
bring transparency to the performance of the MCMC programs
administered by DHCS. The author states this is accomplished
by requiring an open process to allow public review of program
performance measures related to access and quality of care.
In addition, this bill requires DHCS to develop and implement
a monitoring plan, to solicit the input of stakeholders and
health care quality experts, to appoint an advisory body, and
to hold public meetings quarterly with public comment. The
author's particular concern is that while there is a vast
quantity of data available, it is not reported and produced in
a fashion that promotes qualitative assessments of the managed
care programs. For example, the Healthcare Effectiveness Data
and Information Set (HEDIS) scores are reported annually and
the Consumer Assessment of Healthcare Providers and Systems
(CAHPS) is conducted every three years. However the data is
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not reported in a fashion that allows consumers, providers,
advocates, or the Legislature to evaluate or identify
successes or deficiencies. The author's goal is to establish
a public process in which the existing measures can be
presented to the public, stakeholders, and those with research
and quality of care expertise as well as the Legislature and
allow for comment on how these measures could be used to drive
improvements in quality and access.
Another priority of the author, expressed through the provisions
of this bill, is that DHCS has neither sufficiently identified
benchmarks nor acceptable and unacceptable performance levels.
The author's goal is that by requiring DHCS to have public
discussions and consult outside experts, increased
transparency and accountability will be achieved. DHCS has
reported to the Legislature on the development of the Strategy
for Quality Improvement in Health Care (Quality Strategy) as a
blueprint to improve the health of Californians, improve the
quality of all DHCS programs, and reduce DHCS per-capita
health care costs. According to DHCS, the Quality Strategy
and a multi-year implementation plan, currently under
development, will emphasize the use of measures, including
HEDIS and other quality metrics from the Agency for Healthcare
Research and Quality Forum, to guide the establishment and
measurement of quality improvement efforts department wide.
The author points out that with the exception a few high level
presentations to stakeholder groups, these plans are being
developed without an opportunity for input from consumers,
providers, the Legislature, health care quality and research
experts, or other members of the public.
Finally, the author states that this bill is intended to
preserve some of the best practices that were developed by the
Managed Risk Medical Insurance Board (MRMIB) when it
administered the Healthy Families Program (HFP), now being
transitioned to DHCS as a Medi-Cal program and to apply them
to all MCMC programs. These included public discussions of
MCP contract terms, an active Advisory Committee on Quality
and a Quality, Improvement Work Group that met regularly and
provided specific recommendations on monitoring, measuring,
assessing, and improving quality of care in the program that
were frequently incorporated into plan contracts. In
addition, MRMIB abided by the mandates of the Administrative
Procedures Act (APA) and adopted regulations by means of
public hearings with opportunities for public comment. On the
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other hand, DHCS has regularly requested to be exempt from
these requirements.
2)BACKGROUND . Currently MCMC serves about 5.2 million enrollees
in 30 counties, or about 69% of the total Medi-Cal population.
There are three models of MCPs. The oldest model is the
County Operated Health System (COHS). COHS plans serve about
one million enrollees through six health plans in 14 counties:
Marin, Mendocino, Merced, Monterey, Napa, Orange, San Mateo,
San Luis Obispo, Santa Barbara, Santa Cruz, Solano, Sonoma,
Ventura, and Yolo. In the COHS model, DHCS contracts with a
health plan created by the County Board of Supervisors and all
Medi-Cal enrollees are in the same health plan. The second
model is the two-Plan model in which there is a "Local
Initiative" (LI) and a "commercial plan" (CP). DHCS contracts
with both plans. The Two-Plan model serves about 3.6 million
beneficiaries in Alameda, Contra Costa, Fresno, Kern, Kings,
Los Angeles, Madera, Riverside, San Bernardino, San Francisco,
San Joaquin, Santa Clara, Stanislaus, and Tulare. Thirdly,
two-counties employ the Geographic Managed Care (GMC) model:
Sacramento and San Diego. DHCS contracts with several
commercial plans in those counties and there are about 600,000
enrollees.
DHCS has embarked on an ambitious array of initiatives that
could result in over two million new enrollees into MCPs in
2012 and 2013. These program changes include all age groups
and all geographic regions. For example, DHCS is
transitioning approximately 860,000 HFP children to the
Medi-Cal program in four phases throughout 2013. In November
of 2010, California obtained federal approval for a Section
1115(b) Medicaid Demonstration Waiver from the Centers for
Medicare and Medicaid Services (CMS) entitled "A Bridge to
Reform Waiver." Among other provisions, this waiver
authorized mandatory enrollment into MCPs of over 600,000
low-income seniors and persons with disabilities (SPDs) who
are eligible for Medi-Cal only (not Medicare) in 16 counties.
Enrollment was phased in over a one-year period in the
affected counties; beginning on June 1, 2011. Prior to this,
mandatory enrollment was limited to children and their
families in 30 counties and SPDs in the 14 counties served by
COHS.
DHCS is also participating in a demonstration project authorized
by the 2010 federal Affordable Care Act to improve
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coordination of services for persons who are dually eligible
for state Medicaid programs (Medi-Cal in California) and
Medicare. This Coordinated Care Initiative (CCI) was
authorized by the Legislature as a three-year, eight county
demonstration project. The eight counties are Alameda, Los
Angeles, Orange, Riverside, San Bernardino, San Diego, San
Mateo, and Santa Clara covering 560,000 dual eligible
enrollees. The CCI will combine the continuum of health care,
acute care, behavioral health, and LTSS through MCPs using a
capitated payment model to provide Medicare and Medi-Cal
benefits through existing plans. Los Angeles County will
phase-in enrollment of beneficiaries over 15 months. San
Mateo County will enroll beneficiaries over three months.
Orange, San Diego, San Bernardino, Riverside, Alameda, and
Santa Clara counties will phase-in enrollment over 12 months.
DHCS announced, on March 27, 2013, a Memorandum of
Understanding (MOU) with CMS. As a result of the MOU,
additional modifications were announced. The start date has
been moved to October 1, 2013, the number of enrollees in Los
Angeles is capped at 200,000, which reduces the overall number
by 100,000 and almost half the size called for in the
Governor's 2012-2013 budget. It has been renamed
CalMediConnect.
AB 1467 (Committee on Budget), Chapter 23, Statutes of 2012,
authorized the expansion of MCMC to 28 mostly rural counties.
The stated purpose is to provide a comprehensive program of
MCP services to Medi-Cal recipients residing in these counties
that currently receive Medi-Cal services on a FFS basis:
Alpine, Amador, Butte, Calaveras, Colusa, Del Norte, El
Dorado, Glenn, Humboldt, Imperial, Inyo, Lake, Lassen,
Mariposa, Modoc, Nevada, Mono, Placer, Plumas, San Benito,
Shasta, Sierra, Siskiyou, Sutter, Tehama, Trinity, Tuolumne,
and Yuba. Currently, approximately 365,000 enrollees would
qualify for MCMC. In February 2013, DHCS announced that
Anthem Blue Cross and California Health and Wellness Plan,
received Notices of Intent to Award for the expansion of MCMC
to the counties of Alpine, Amador, Butte, Calaveras, Colusa,
El Dorado, Glenn, Inyo, Mariposa, Mono, Nevada, Placer,
Plumas, Sierra, Sutter, Tehama, Tuolumne, and Yuba. DHCS is
also planning an exclusive MCMC contract with Partnership
HealthPlan of California (PHC) for expansion in Del Norte,
Humboldt, Lassen, Modoc, Shasta, Siskiyou, and Trinity
counties. In addition, Lake and San Benito counties would
become COHS managed care counties served by PHC and Central
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California Alliance for Health, respectively. DHCS is
currently working with Imperial County on its MCP selection
process.
3)CURRENT MEASURES . On October 25, 2012, the Assembly Committee
on Health held an oversight hearing to review the status of
these managed care initiatives, to set the framework for an
evaluation of these various initiatives and to assess the
Brown Administration's plans to evaluate and monitor these
policy changes. The Committee reviewed existing mechanisms
used for monitoring and assessing quality and access in MCMC.
For instance many of the plans meet the licensing and
regulatory standards of the Knox-Keene Health Care Service
Plan Act of 1975 (Knox-Keene Act) and are regulated by DMHC.
However, regulatory and licensing requirements such as the
Knox-Keene Act have limitations with regard to measuring
access and generally do not measure utilization levels and
quality of care. They also do not provide a way to compare
plans with regard to access or quality of care. DHCS reports
on a variety of other measures, some are unique to a specific
population or initiative and others apply more universally.
a) External Accountability Set . CMS requires that states,
through their contracts with MCPs, measure and report on
performance to assess the quality and appropriateness of
care and services provided to members. In response, DHCS
implemented a monitoring system that is intended to provide
an objective, comparative review of health plan
quality-of-care outcomes and performance measures called
the External Accountability Set (EAS). DHCS designates EAS
performance measures on an annual basis and requires plans
to report on them. DHCS uses the HEDIS measures as the
primary tool. The measures are selected after consultation
with the plans and with input from an External Quality
Review Organization (EQRO). All current measures are
applicable across populations. For example, well child
visits, immunizations, comprehensive diabetes care, and
annual monitoring of patients on persistent medications are
just a few of the currently required HEDIS measures that
are applied equally to all MCMC enrollees. In 2011 the EAS
consisted of 11 performance measures. The EAS for 2012
consisted of 13 HEDIS measures and one DHCS developed
measure. DHCS introduced five new measures for the 2012
reporting year and deleted two existing measures.
According to DHCS several of the new measures are to be
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utilized to support performance measurement related to the
implementation of mandatory enrollment of Medi-Cal only
SPDs.
For 2013, DHCS in collaboration with MCPs and the EQRO,
developed a methodology by which to stratify several
measures (comprehensive diabetes care, children and
adolescent access to Primary Care Providers, annual
monitoring for persistent medications, ambulatory care
utilization, and all cause readmissions) into SPD and
non-SPD groups. For 2013, MCPs will be reporting on 14
HEDIS measures. In addition, DHCS is requiring one
customized measure for determining rates of hospital
readmissions within 30 days of discharge.
Plans must meet or exceed the DHCS-established Minimum
Performance Level (MPL) for each required HEDIS measure.
DHCS adjusts the MPL each year to reflect the national
Medicaid averages reported in the most current version of
National Committee for Quality Assurance (NCQA) Audit
Means, Percentiles, and Ratios. Currently, the MPL is the
25th percentile of the national Medicaid rates. For each
measure that a plan does not meet the established MPL or is
reported as "Not Reportable" due to an unacceptable error
rate, a plan must submit a HEDIS Improvement Plan to DHCS
within the specified timeframe that describes steps to be
taken for improvement during the subsequent year. DHCS
also establishes a High Performance Level for each required
measure, which is currently at the 90th percentile of the
national Medicaid average. DHCS publically reports audited
HEDIS results for each contracted health plan as well as
the program average for MCMC, national Medicaid, and
commercial plan averages for each measure. However the
reports are only available on the DHCS website and total
hundreds of pages.
b) HEDIS . HEDIS, developed by NCQA, a private not-for
profit, is a standardized set of performance measures used
to provide health care purchasers, consumers, and others
with a reliable comparison among health plans. HEDIS data
are often used to produce health plan "report cards,"
analyze quality improvement activities, and benchmark
performance. NCQA classifies the broad range of HEDIS
measures across eight domains of care:
i) Effectiveness of Care;
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ii) Access/Availability of Care;
iii) Satisfaction With the Experience of Care;
iv) Use of Services;
v) Cost of Care;
vi) Health Plan Descriptive Information;
vii) Health Plan Stability; and,
viii) Informed Health Care Choices.
According to the DHCS EQRO contractor, Health Services
Advisory Group, Inc. (HSAG), performance measures within
these domains provide information about a plan's
performance in such areas as providing timely access to
preventive services, management of members with chronic
disease, and appropriate treatment for members with select
conditions. HSAG also states the while HEDIS data provide
an opportunity to compare plans based on some aspects of
health care delivered to members, the intent of the data is
not to provide an overall, comprehensive assessment of
health care quality for a plan. Rather, DHCS uses HEDIS
data as one component of its overall quality monitoring
strategy. Both DHCS and plans use plan-specific data,
aggregate data, and comparisons to state and national
benchmarks to identify opportunities for improvement,
analyze performance, and assess whether previously
implemented interventions were effective.
c) Auto-assignment program . In 2005, DHCS also began using
HEDIS performance measures as one factor in the algorithm
that is used to assign a MCMC enrollee who does not select
a plan. Previously, it was based solely on the MCPs use of
safety net providers. It is currently based on a mix of
five HEDIS measures and two factors based on use of safety
net providers. Points are assigned based on a comparison
of the plans in the county and for improvement or
exceptionally strong performance. DHCS awards more default
enrollment to Two-Plan and GMC MCPs that score high on
these measures and achieve improvement over time. The
auto-assignment program is intended to encourage plans to
improve and/or maintain quality of care and services
provided to their members.
d) Enrollment and complaint data . DHCS collects and
reports data that comes in through the MCMC ombudsman
office. However, the data is reported as raw numbers and
is not analyzed for patterns or trends. It is also sorted
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by categories that are so broadly described as to be
meaningless. The same can be said for enrollment,
disenrollment, and requests for medical exemptions. By
contrast, at monthly public MRMIB meetings, enrollment data
is publicly released and public comment is allowed. A
particular example is the MRMIB administrative vendor
performance report that includes a description of specific
performance standards, such as what percentage of calls
were returned within two days, how many and what percentage
of calls were answered in 25 seconds and how long it took
to make eligibility determinations.
e) Pediatric dental . HFP had been providing comprehensive
dental coverage and evaluating dental plan performance
since 1998. MRMIB monitors the quality of services
provided to children in the program by annually collecting
and reporting data on dental performance measures from the
dental plans. HFP is one of the few programs in the
country that measures dental quality and MRMIB has been at
the forefront of developing quality measures. MRMIB
revised its HFP dental measures in 2007. Reports are made
annually at the Board meetings. In addition to collecting
data on the quality of dental services, MRMIB has also
administered the Dental-CAHPS survey to assess members'
satisfaction with the dental care that they received.
Families receive the results in enrollment materials,
including the program handbook, and can use the information
to compare dental plans. Reports are also available to the
public on the MRMIB website. DHCS has committed to
continuing to monitor these metrics. According to DHCS,
both the Dental Managed Care (DMC) plans and Dental FFS
(Denti-Cal) program will be required to report on 11
performance measures. The DMC plans will provide encounter
data and Denti-Cal will provide claims data. The data will
be monitored on a monthly basis and publicly reported
quarterly, but there are no current plans for public
comment. An annual report will be produced to represent
the findings, similar to the current Healthy Families
Quality Report.
4)MANAGED CARE DASHBOARD . Currently, DHCS consults with MCPs
and a number of stakeholder groups with regard to performance
standards and measures regarding quality and access, however
there is no formalized process for the public, stakeholders,
or outside experts to comment on how DHCS is assessing plan
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performance. In addition, although the results are generally
posted on the DHCS website, they are not displayed in a
fashion that allows for comparative analysis. DHCS, with
support from the California HealthCare Foundation (CHCF) is
developing a mechanism for ongoing monitoring of the managed
care program and participating health plans. CHCF has
contracted with Navigant Consulting for this project. DHCS is
consulting with a Technical Assistance Workgroup in the
development of the dashboard and held the first meeting on
March 13, 2013. The project objectives were described as: a)
to advance understanding among state officials and
stakeholders of the performance of the Medi-Cal managed care
program and participating health plans; b) to establish a
mechanism for ongoing monitoring of the managed care program
and plan performance; and, c) to assess whether the unique
California model of locally-sponsored health plans are having
the impact intended by state and local officials. The managed
care dashboard will allow for a greater ability to identify
program trends, risk areas, and successes. As DHCS states,
this will be critical to ensuring successful managed care
expansion and ongoing program operations. DHCS is soliciting
input from the workgroup on the selection of measures and the
program goals. The project will also include a comparative
study of LIs and CPs. Navigant will develop the
specifications for a tool to monitor the performance of the
managed care program as a whole and compare the performance of
participating health plans. These specifications will
identify the measures, sources of data, frequency of
reporting, benchmarks and thresholds, and key comparative
indicators. This bill codifies the requirement that DHCS
implement a tool such as this managed care dashboard.
5)SUPPORT . Supporters such as the California Black Health
Network (CBHN), the California Commission on Aging, and the
California Coverage & Health Initiatives support this bill
because of the importance of ensuring meaningful standards and
a formalized process in which stakeholders and outside experts
can assess and comment on how DHCS is delivering care in the
new MCMC programs. According to these supporters, this bill
will institute a transparent, easy to access process for
obtaining and understanding the quality, access and
comparability of MCMC programs. CBHN further states in
support that data that provides a mechanism to measure quality
and access is needed if we are to lessen the current
disparities. The March of Dimes, California Chapter (MOD),
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writes in support that improving the quality of health care
services provided by Medi-Cal is aligned with its mission to
improve the health of women, infants and children by reducing
birth defects, premature birth, and infant mortality. The
March of Dimes is in support because this bill creates an
opportunity to advocate for use of additional quality measures
by Medi-Cal that will lead to improvements in maternal and
child health. According to MOD, currently, Medi-Cal reports
on four of the 12 identified priority pediatric and perinatal
quality measures. The California Chiropractic Association,
also in support expresses appreciation for the inclusion of
providers on the advisory committee in addition to plans,
researchers, advocates, and enrollees. Health Access
California writes in support that the Medi-Cal program
operates Medi-Cal with little public oversight and that
although the MCMC Ombudsman provides good accurate information
there is only one person for every million enrollees and it is
very difficult to get through on the phone. The Greenlining
Institute writes in support that since the intended outcome of
this bill is to improve quality of care and accessibility
among MCMC enrollees, this bill can contribute to a healthier
and more productive workforce by improving the quality of care
of and access to MCPs through evidence-based strategies.
6)REQUEST FOR AMENDMENTS . The California Chapter of the
American College of Emergency Physicians (Cal/ACEP) writes
that it agrees with the goal of this bill, however as
currently drafted this bill leaves out an important part of
the healthcare delivery system: emergency care. As a result,
Cal/ACEP is requesting an amendment to include "emergency
care" to the list of healthcare services.
7)RELATED LEGISLATION . AB 411 (Pan) requires DHCS to require
all MCMC plans to analyze HEDIS measures, or EAS performance
measure equivalents, by race, ethnicity and primary language
to identify disparities in medical treatment and to implement
strategies to reduce disparities. Provides that MCPs shall be
required to link individual level data to patient identifiers
in order to allow for an analysis of disparities in medical
treatment by race, ethnicity, and primary language and provide
the information annually to DHCS. Requires DHCS to make the
data available for research in a method that complies with the
Health Insurance Portability and Accountability Act of 1996.
8)PREVIOUS LEGISLATION.
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a) AB 1494 (Committee on Budget), Chapter 28, Statutes of
2012, provides for the transition of children from HFP to
Medi-Cal starting no earlier than January 1, 2013.
b) AB 1467 (Committee on Budget), Chapter 23, Statutes of
2012, authorized the expansion of MCMC to 28 mostly rural
counties.
c) AB 2002 (Cedillo) of 2012 would have defined "safety net
provider" for the purpose of determining which MCMC plan a
beneficiary will be assigned to if they do not choose a
plan. AB 2002 was held in Assembly Appropriations at the
author's request.
d) SB 1008 (Committee on Budget and Fiscal Review), Chapter
33, Statutes of 2012, and SB 1036 (Committee on Budget and
Fiscal Review), Chapter 45, Statutes of 2012, enacted the
CCI.
e) SB 208 (Steinberg), Chapter 714, Statutes of 2010,
contained the provisions implementing Section 1115(b)
Medicaid Demonstration Waiver from CMS entitled "A Bridge
to Reform Waiver." Among the provisions, this waiver
authorized mandatory enrollment into MCMC plans of over
600,000 low-income seniors and persons with disabilities
(SPDs) who are eligible for Medi-Cal only (not Medicare) in
16 counties.
9)POLICY COMMENTS.
a) Data availability . While DHCS, as required by federal
and state law and regulation, contracts for annual HEDIS
audits and Health Performance Evaluation Reports, now
posted online, they are for all intents and purposes of no
value in assessing the program unless one spends hours
reviewing them individually. Furthermore, it appears to be
driven by the federal minimum requirements. This bill
would require this useful and valuable information to be
discussed and in a public fashion, reported in a more
accessible way and bring greater transparency to plan
performance. Examples of the information that could be
highlighted are as follows:
i) With regard to Plan A, a large commercial plan, it
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was reported in the 2010 Plan Performance Evaluation
Report (Report) that it continues to struggle with
prenatal and postpartum care performance measure rates,
similar to the prior year's findings. The plan had rates
below the MPL for prenatal care in 2009 in two counties.
For postpartum care, four counties in 2009 required an
improvement plan. The Report goes on to describe the
activities undertaken to improve prenatal care. The
Report found that the prenatal care interventions were
effective in one county, which reported a 2010 rate that
exceeded the MPL, but another county, had a slight
decline between 2009 and 2010 rates. The plan identified
that a major barrier to improvement was early
identification of a pregnant member. With regard to
postpartum care, none of the counties with improvement
plans in 2009 reported rates that exceeded the MPL in
2010, and one county experienced a statistically
significant decline.
ii) With regard to Plan B, a COHS plan, the Report found
it had a strong HEDIS 2010 performance; nine measures
outperformed the national Medicaid 90th percentile. In
2010, 13 out of the 15 (87%) possible measures had
statistically significant increases in performance from
2009. The Report also found that In the Reducing
Avoidable Emergency Room (ER) Visits QIP, Plan B reported
a decrease in the percentage of avoidable ER visits. The
decrease was statistically significant and probably not
due to chance. According to the Report, a decrease for
this measure reflects an improvement in performance.
Plan B implemented several plan-specific interventions
including reports to primary care providers regarding
their members' ER usage and a Web-based reporting system
that allows providers to check their members' ER usage in
real time. Additionally, the plan had a financial
incentive program that rewards primary care providers for
providing preventive care and services to their members.
iii) With regard to Plan C, a large LI plan, the Report
found below average to average performance in the
timeliness domain of care based on 2010 performance
measure rates for providing timely care, medical
performance and member rights reviews related to
timeliness, and member satisfaction results related to
timeliness. Member satisfaction results showed that the
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plan had poor performance in the global and composite
ratings related to timeliness for both adult and child
populations, suggesting that members perceive that they
do not always receive timely care. Plan C performed
better, however, in the customer service area in the
child survey results, suggesting that the plan had
sufficient mechanisms to address and promptly resolve
member inquiries. Plan C also demonstrated deficiencies
related to sending notice of action letters which
exceeded the allowable time frame for grievances and
contained incorrect time frame requirements within the
letters for filing an appeal. However, the Report also
found that Plan C demonstrated above average performance,
with no performance measure results below the MPL, and
one measure exceeding the HPL. Four of the plan's
measures achieved a statistically significant
improvement, and no statistically significant declines
were noted.
a) Existing advisory bodies and stakeholder groups . Most
of the legislation authorizing DHCS to expand MCMC or
enroll new populations included broad grants of authority.
In some cases, such as the transition of SPDs into
mandatory managed care or the CCI initiative, details could
not be adopted in legislation because they would not be
known until further negotiations with CMS. In other cases,
such as the rural expansion, DHCS desired flexibility in
order to accommodate the potential variety in the types of
anticipated responses to the request for proposal. In all
cases, DHCS demanded exemptions from the APA and requested
authorization to implement the program by use of All Plan
Letters, provider bulletins, County Welfare Directors
Letters, or other similar letters of instruction. In
response, the Legislature required DHCS to hold stakeholder
meetings and submit reports to the Legislature providing
some level of transparency and accountability. DHCS is
also required to post information on its website. A number
of issues have been raised regarding these substitutes.
For instance the Administration has established a
stakeholder group or work group for each initiative and one
that began as the waiver advisory committee is now a
broader stakeholder advisory committee (SAC). There is
also a separate group that is meeting on the CCI and the
HFP transition. Not all the meetings are open to the
public. Those that are, allow for limited or minimal
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public comment. Most of the meeting time is used for
presentations by DHCS staff or outside consultants and
response from the members of the group is limited to
questions. At the request of DHCS, the Pacific Health
Consulting Group conducted a survey of the SAC with funding
from the Blue Shield Foundation. Responses about the
benefits of participating indicate that many SAC members
receive benefit from a better understanding of the issues
and information from various points of view and from
staying current on the waiver process. However other
comments indicated that members felt the updates were
sanitized with not enough detail to fully understand what
is going on. Some commented that the updates were the
least helpful and that there should be more time for
discussion. Others suggested recommendations for change
including allowing public comment during the meeting, not
just at the end, more feedback from DHCS on what input is
taken forward, what is not and why and that it felt like
the input was meaningless.
b) Program accountability . Much of the data and reports
specified in this bill are currently available. However,
the intent of this bill is to add requirements such as
public hearings and solicitation of input to increase
oversight and accountability. Such a process would open up
the State's managed care performance assessment process to
a wider range of stakeholders than those chosen or
designated by DHCS. For instance, with regard to the
choice of EAS measures, currently it is decided by DHCS
with input only from the EQRO contractor and the MCPs. The
development of dental performance measures in the HFP was
nationally recognized as innovative and unique. It was
accomplished by means of a Quality Advisory Body and open
discussions at Board meetings. Currently, DHCS is
developing quality standards to be used in the CCI. DHCS
will use the existing Medi-Cal access standards, plus the
LTSS network adequacy standards currently under
development. The LTSS standards are being developed
through a stakeholder review process. The quality
standards for the CCI will reflect medical, LTSS, and
behavioral health quality measures. DHCS posted a list of
over 90 measures for consideration, and is reviewing the
stakeholder comments for those measures. Measures include
HEDIS, CAHPS, Health Outcomes Survey, administrative data,
as well as, new measures for LTSS and behavioral health
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that will be developed in consultation with CMS, other
state agencies, and stakeholders. The development of these
measures could further benefit from a more public
discussion in which DHCS is required to respond to
stakeholder comments and suggestions. This would ensure
that stakeholders do not feel that their input was ignored
as was the case with the SAC. Should this bill become law,
DHCS could benefit from program efficiencies. For instance
the public meetings could reduce the need for many of the
existing reports and advisory bodies and these multiple
meetings could be eliminated or combined. The many reports
now required could be consolidated and presented as meeting
materials.
REGISTERED SUPPORT / OPPOSITION :
Support
American Federation of State, County and Municipal Employees,
AFL-CIO
California Association for Health Services at Home
California Black Health Network
California Chiropractic Association
California Commission on Aging
California Coverage & Health Initiatives
California Coverage & Health Initiatives
California Medical Association
California Primary Care Association
Children Now
Children's Defense Fund California
Greenlining Institute
Health Access California
March of Dimes, California Chapter
PICO California
The Children's Partnership
United Ways of California
Western Center on Law & Poverty
Opposition
None on file.
Analysis Prepared by : Marjorie Swartz / HEALTH / (916)
AB 209
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319-2097