BILL ANALYSIS �
-----------------------------------------------------------------
|SENATE RULES COMMITTEE | AB 209|
|Office of Senate Floor Analyses | |
|1020 N Street, Suite 524 | |
|(916) 651-1520 Fax: (916) | |
|327-4478 | |
-----------------------------------------------------------------
THIRD READING
Bill No: AB 209
Author: Pan (D)
Amended: 4/9/13 in Assembly
Vote: 21
SENATE HEALTH COMMITTEE : 9-0, 6/5/13
AYES: Hernandez, Anderson, Beall, De Le�n, DeSaulnier, Monning,
Nielsen, Pavley, Wolk
SENATE APPROPRIATIONS COMMITTEE : 7-0, 6/24/13
AYES: De Le�n, Walters, Gaines, Hill, Lara, Padilla, Steinberg
ASSEMBLY FLOOR : 75-0, 5/9/13 (Consent) - See last page for vote
SUBJECT : Medi-Cal: managed care: quality, accessibility,
and utilization
SOURCE : Author
DIGEST : This bill 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. This
bill requires DHCS to hold public meetings to report on the plan
and to invite public comments. This bill also 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.
CONTINUED
AB 209
Page
2
ANALYSIS :
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.
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
CONTINUED
AB 209
Page
3
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:
The quality of, and access to, primary, specialty,
dental, mental health, behavioral health care services,
and long-term care support and services.
The utilization of primary, specialty, mental
health, and behavioral health care services, inpatient
acute care, emergency services, and long-term care
support and services.
A. 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
B. Coordination with the Department of Managed Health Care
to monitor, survey, and report on network adequacy and
fiscal solvency.
1.Requires DHCS to hold public meetings at least quarterly 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
notify the public of the meetings within a reasonable time
prior to each meeting.
2.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.
3.Requires the responsibilities of the advisory committee to
include, but not be limited to, all of the following:
CONTINUED
AB 209
Page
4
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.
1.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.
Background
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.
In the COHS model, DHCS contracts with a health plan created by
a 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. The third Medi-Cal
managed care model is the Geographic Managed Care (GMC) model,
which serves two counties and has about 600,000 enrollees. In
the GMC model, DHCS contracts with several commercial plans
within those counties.
DHCS is currently 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
CONTINUED
AB 209
Page
5
Services (CMS) that authorized the 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.
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:
1.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. 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.
2.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.
3.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 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.
The auto-assignment program is intended to encourage plans to
CONTINUED
AB 209
Page
6
improve and/or maintain quality of care and services provided
to their members.
4.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.
Medi-Cal Managed Care Dashboard. According to the Senate Health
Committee analysis, 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:
1.To advance understanding among state officials and
stakeholders of the performance of the Medi-Cal managed care
program and participating health plans;
2.To establish a mechanism for ongoing monitoring of the managed
care program and plan performance; and,
3.To assess whether the unique California model of
locally-sponsored health plans are having the impact intended
by state and local officials.
According to the DHCS, the managed care dashboard will allow for
a greater ability to identify program trends, risk areas, and
successes and 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
CONTINUED
AB 209
Page
7
Consulting 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.
Prior Legislation
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.
AB 1467 (Committee on Budget, Chapter 23, Statutes of 2012),
authorizes the expansion of Medi-Cal managed care to 28 mostly
rural counties.
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.
SB 208 (Steinberg, Chapter 714, Statutes of 2010), containes 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.
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), enacts the CCI.
FISCAL EFFECT : Appropriation: No Fiscal Com.: Yes
Local: No
According to the Senate Appropriations Committee, likely ongoing
costs between $40,000 and $75,000 per year to support additional
consultation with stakeholders regarding the development of
performance measures and to support the advisory committee (50%
General Fund and 50% federal funds).
CONTINUED
AB 209
Page
8
SUPPORT : (Verified 6/24/13)
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 Domestic Workers of America/AFSME Local 3930 AFL-CIO
United Ways of California
Western Center on Law & Poverty
ARGUMENTS IN 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 that 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
CONTINUED
AB 209
Page
9
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. 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.
ASSEMBLY FLOOR : 75-0, 5/9/13
AYES: Achadjian, Alejo, Allen, Ammiano, Atkins, Bigelow, Bloom,
Blumenfield, Bocanegra, Bonilla, Bonta, Bradford, Brown,
Buchanan, Ian Calderon, Campos, Chau, Ch�vez, Chesbro, Conway,
Cooley, Dahle, Daly, Dickinson, Eggman, Fong, Fox, Frazier,
Beth Gaines, Garcia, Gatto, Gomez, Gordon, Gorell, Gray,
Grove, Hagman, Hall, Harkey, Roger Hern�ndez, Jones,
Jones-Sawyer, Levine, Linder, Lowenthal, Maienschein, Mansoor,
Medina, Melendez, Mitchell, Morrell, Mullin, Muratsuchi,
Nazarian, Nestande, Olsen, Pan, Patterson, Perea, V. Manuel
P�rez, Quirk, Quirk-Silva, Rendon, Salas, Skinner, Stone,
Ting, Torres, Wagner, Weber, Wieckowski, Wilk, Williams,
Yamada, John A. P�rez
NO VOTE RECORDED: Donnelly, Holden, Logue, Waldron, Vacancy
JL:nl 6/25/13 Senate Floor Analyses
SUPPORT/OPPOSITION: SEE ABOVE
**** END ****
CONTINUED