BILL ANALYSIS �
SENATE COMMITTEE ON HEALTH
Senator Ed Hernandez, O.D., Chair
BILL NO: AB 209
AUTHOR: Pan
AMENDED: April 9, 2013
HEARING DATE: June 5, 2013
CONSULTANT: Bain
SUBJECT : Medi-Cal: managed care: quality, accessibility, and
utilization.
SUMMARY : Requires the Department of Health Care Services (DHCS)
to develop and implement a plan that includes specified
components to monitor, evaluate, and improve the quality,
accessibility, and utilization of health care and dental
services provided through Medi-Cal managed care. Requires DHCS
to hold public meetings to report on performance measures,
utilization levels, quality and access standards, network
adequacy, fiscal solvency, and evaluation standards with regard
to all Medi-Cal managed care services and to invite public
comments. Requires DHCS to appoint an advisory committee for the
purpose of making recommendations to improve quality and access
in the delivery of Medi-Cal managed care services.
Existing law:
1.Establishes the Medi-Cal program, which is administered by
DHCS, under which qualified low-income individuals receive
health care services.
2.Permits the director of DHCS to contract, on a bid or nonbid
basis, with any qualified individual, organization, or entity
to provide services to, arrange for or case manage the care of
Medi-Cal beneficiaries. Permits, at the director's discretion,
the contract to be exclusive or nonexclusive, statewide or on
a more limited geographic basis, and to include provisions to
provide for delivery of services in a manner consistent with
managed care principles, techniques, and practices directed at
ensuring the most cost-effective and appropriate scope,
duration, and level of care.
This bill:
1.Requires DHCS to develop and implement a plan to monitor,
evaluate, and improve the quality, accessibility, and
utilization of health care and dental services provided
through Medi-Cal managed care.
Continued---
AB 209 | Page 2
2.Requires the plan to include all of the following:
a. Nationally recognized quality and access
measures;
b. A process to solicit input from providers,
health care quality experts, consumers, and consumer
representatives for recommendations on supplementing
existing measures and indicators in order to fully
evaluate the quality of, access to, and utilization of
all Medi-Cal benefits, including long-term services
and supports, care coordination, and disease
management, and to perform analysis by race,
ethnicity, primary language, and gender, to the extent
permitted by federal law;
c. Minimum and benchmark performance standards
and contract requirements;
d. Strategies to encourage and reward improvement
and to identify and reduce health disparities among
populations;
e. Sanctions and corrective actions in cases of
deficiencies;
f. A Medi-Cal managed care dashboard that is
publicly available and provides up-to-date information
regarding all of the following:
i. The quality of, and access to,
primary, specialty, dental, mental health,
behavioral health care services, and long-term
care support and services.
ii. The utilization of primary,
specialty, mental health, and behavioral health
care services, inpatient acute care, emergency
services, and long-term care support and
services.
g. Requires the data to be reported, at a
minimum, by eligibility category, plan, county of
residence, age, gender, ethnicity, and primary
language to the extent permitted by federal law,
including federal health privacy law; and,
h. Coordination with the Department of Managed
Health Care to monitor, survey, and report on network
adequacy and fiscal solvency.
3.Requires DHCS to hold public meetings at least quarterly to
AB 209 | Page
3
report on performance measures, utilization levels, quality
and access standards, network adequacy, fiscal solvency, and
evaluation standards with regard to all Medi-Cal managed care
services, and to invite public comments. Requires DHCS to
notify the public of the meetings within a reasonable time
prior to each meeting.
4.Requires DHCS to appoint an advisory committee composed of
providers, plans, researchers, advocates, and enrollees for
the purpose of making recommendations to the DHCS and the
Legislature in order to improve quality and access in the
delivery of Medi-Cal managed care services.
5.Requires the responsibilities of the advisory committee to
include, but not be limited to, all of the following:
a. Reviewing existing performance standards,
quality data, and measures;
b. Developing recommendations to modify, add, or
eliminate measures and collect data, as appropriate;
c. Reviewing managed care plan contract terms and
making recommendations related to improving quality
and access; and,
d. Reviewing rate-setting methodologies and
payment policies.
6.Implements this bill only to the extent that funding is
provided in the annual budget act or federal, private, or
other non-General Fund moneys are available.
FISCAL EFFECT : According to the Assembly Appropriations
Committee, minor costs to DHCS. This bill contains language
making its implementation contingent on funding through the
budget act or federal, private, or other non-General Fund
moneys.
PRIOR VOTES :
Assembly Health: 17- 0
Assembly Appropriations:17- 0
Assembly Floor: 75- 0
COMMENTS :
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1.Author's statement. This bill enacts the Medi-Cal Managed Care
Health Care Quality and Transparency Act of 2013 to improve health
and dental services provided through Medi-Cal managed care plans.
This bill is intended to provide an opportunity for public
oversight and to bring transparency to the performance of the
Medi-Cal managed care programs administered by the DHCS. This bill
does this by requiring an open process that will allow public
review of program performance measures related to access and
quality of care. This bill further 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. In
addition, DHCS is required to develop a plan to improve the
quality, accessibility and use of services provided by their
contracted managed care plans. The improvement plan is to be based
on input from consumers, providers and other stakeholders, and
requires continually monitoring of performance using nationally
recognized quality and access measures. This bill requires DHCS to
implement transparency standards that the Managed Risk Medical
Insurance Board has proven to be effective in the administration
of its health coverage programs. DHCS would implement the Medi-Cal
Managed Care Dashboard to provide the public with up-to-date
information on the quality and overall use of services including
primary care, specialists and mental health services.
Additionally, the bill requires the plan to include rewards for
improvements and reductions in health care disparities, as well as
sanctions and corrective actions in cases of deficiencies.
2.Medi-Cal managed care. Medi-Cal managed care provides coverage to
approximately 5.2 million enrollees in 30 counties, or about 69
percent of the total Medi-Cal population. There are three models
of Medi-Cal managed care plans. 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 in the county are in the health plan.
The second Medi-Cal managed care model is the two-plan model in
which DHCS contracts with a local initiative (LI) and a commercial
plan (CP). The two-plan model serves approximately 3.6 million
beneficiaries in 14 counties (Alameda, Contra Costa, Fresno, Kern,
Kings, Los Angeles, Madera, Riverside, San Bernardino, San
Francisco, San Joaquin, Santa Clara, Stanislaus, and Tulare). The
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third Medi-Cal managed care model is the Geographic Managed Care
(GMC) model, which consists of two counties (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 Medi-Cal managed
care plans. For example, DHCS is transitioning approximately
860,000 Healthy Families Program 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 federal Centers for Medicare and
Medicaid Services (CMS) that authorized the mandatory enrollment
into Medi-Cal managed care plans of over 600,000 low-income
seniors and persons with disabilities (SPDs) who are eligible for
Medi-Cal only. Prior to this, mandatory enrollment in Medi-Cal 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 coordination of
services for persons who are dually eligible for state Medicaid
programs, (Medi-Cal in California) and Medicare. The Coordinated
Care Initiative (CCI) was authorized by the Legislature as a
three-year demonstration project. The eight counties selected for
the project are Alameda, Los Angeles, Orange, Riverside, San
Bernardino, San Diego, San Mateo, and Santa Clara covering
approximately 456,000 dual eligible enrollees. The CCI will
combine the continuum of health care, acute care, behavioral
health, and long term services and support (LTSS) through Medi-Cal
managed care plans using a capitated payment model to provide
Medicare and Medi-Cal benefits through existing plans.
AB 1467 (Committee on Budget), Chapter 23, Statutes of 2012,
authorized the expansion of Medi-Cal managed care to 28 mostly
rural counties. The purpose of the rural expansion is to provide a
comprehensive program of Medi-Cal program services to the
approximately 470,000 Medi-Cal recipients. 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 Medi-Cal managed care 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 Medi-Cal
Managed Care contract with Partnership HealthPlan of California
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(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 California Alliance for Health, respectively. DHCS is
currently working with Imperial County on its Medi-Cal plan
selection process.
3.Current quality measures. Federal regulations require states,
through their contracts with Medicaid managed care plans, to have
an ongoing quality assessment and performance improvement program
for the services it furnishes to its enrollees. DHCS reports on a
variety of measures, some of which are unique to a specific
population or initiative and others that apply more generally.
a) External Accountability Set . CMS requires that states,
through their contracts with Medi-Cal managed care plans,
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 Healthcare
Effectiveness Data and Information Set (HEDIS) measures as
the primary tool (HEDIS is described below). 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.
Currently required HEDIS measures include well child
visits, immunizations, comprehensive diabetes care, and
annual monitoring of patients on persistent medications. 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 utilized to support performance measurement
related to the implementation of mandatory enrollment of
Medi-Cal only SPDs.
For 2013, DHCS in collaboration with Medi-Cal managed care
plans 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
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care utilization, and all cause readmissions) into SPD and
non-SPD groups. For 2013, Medi-Cal managed care plans 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.
b) HEDIS . HEDIS is a standardized set of performance
measures used to provide health care purchasers, consumers,
and others with a reliable comparison between 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: effectiveness
of care; access/availability of care; satisfaction with the
experience of care; use of services; cost of care; health
plan descriptive information; health plan stability; and,
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 states the HEDIS data provides 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. DHCS publicly
reports audited HEDIS results for each contracted health
plan as well as the program average for Medi-Cal managed
care, national Medicaid, and commercial plan averages for
each measure. However, the reports are only available on
the DHCS website and total hundreds of pages.
c) Auto-assignment program . In 2005, DHCS also began using
HEDIS performance measures as one factor in the algorithm
that is used to assign Medi-Cal beneficiaries who do not
affirmatively select a health plan. The algorithm was
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previously based on the Medi-Cal managed care plan's use of
safety net providers. The algorithm is currently based on a
mix of five HEDIS measures selected in consultation with
plans, 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
plans 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 come in through the Medi-Cal managed care
Ombudsman's office. However, the data is reported as raw
numbers in broad categories and is not analyzed for
patterns or trends.
e) Pediatric dental . 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.
1.Medi-Cal Managed Care Dashboard. DHCS currently consults with
Medi-Cal managed care plans 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 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 its first meeting on
March 13, 2013. The project objectives are:
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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. DHCS
indicates 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.
2.Related legislation. AB 411 (Pan) requires DHCS to require all
Medi-Cal managed care plans to analyze their HEDIS measures,
or their External Accountability Set performance measure
equivalent, by geographic region, primary language, race,
ethnicity, and, to the extent data is available, by sexual
orientation and gender identity in order to identify
disparities in medical treatment between Medi-Cal managed care
members from different regions, with different primary
languages, and of different races, ethnicities, sexual
orientations, and gender identities, and to implement
strategies to reduce those disparities.
3.Prior legislation.
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
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2012, authorized the expansion of Medi-Cal managed care to
28 mostly rural counties.
c) AB 2002 (Cedillo) of 2012 would have defined "safety net
provider" for the purpose of determining which Medi-Cal
managed care a beneficiary will be assigned to if they do
not choose a plan. AB 2002 was held in the Assembly
Appropriations Committee.
d) 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 Medi-Cal managed care
plans of over 600,000 low-income seniors and persons with
disabilities who are eligible for Medi-Cal only (not
Medicare) in 16 counties.
e) 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.
4.Support. The California Black Health Network (CBHN), the
California Commission on Aging, and the California Coverage &
Health Initiatives write that this bill ensures meaningful
standards and a formalized process in which stakeholders and
outside experts can assess and comment on how DHCS is
delivering care in the Medi-Cal managed care program, and this
bill will institute a transparent, easy to access process for
obtaining and understanding the quality, access and
comparability of Medi-Cal managed care plans. CBHN further
states in support that data that provides a mechanism to
measure quality and access is needed if the state is to reduce
the current disparities.
The March of Dimes, California Chapter, 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, and it supports this
bill because it creates an opportunity to advocate for the use
of additional quality measures by Medi-Cal that will lead to
improvements in maternal and child health. The March of Dimes
indicates Medi-Cal currently reports on four of the 12
identified priority pediatric and perinatal quality measures.
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Health Access California writes in support that the Medi-Cal
program operates Medi-Cal with little public oversight, and
that although the Medi-Cal managed care Ombudsman provides
good information, there is only one person in that office for
every million enrollees and it is very difficult to reach the
office on the phone.
SUPPORT AND OPPOSITION :
Support: AARP
American Academy of Pediatrics, California
American Federation of State, County and Municipal
Employees, AFL-CIO
California Academy of Physician Assistants
California Association for Health Services at Home
California Association of Physician Groups
California Black Health Network
California Chiropractic Association
California Commission on Aging
California Coverage & Health Initiatives
California Medical Association
California Pan-Ethnic Health Network
California Primary Care Association
California School Employees Association
Children Now
Children's Defense Fund California
Community Clinic Association of Los Angeles County
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
Oppose: None received.
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