BILL ANALYSIS �
SENATE COMMITTEE ON HEALTH
Senator Ed Hernandez, O.D., Chair
BILL NO: AB 411
AUTHOR: Pan
AMENDED: June 6, 2013
HEARING DATE: June 26, 2013
CONSULTANT: Bain
SUBJECT : Medi-Cal: performance measures.
SUMMARY : Requires Medi-Cal managed care plans to link all
individual level data collected as a part of analyzing specified
quality performance measures to patient identifiers in a manner
that allows for an analysis of disparities in medical treatment
by geographic region, primary language, race, ethnicity, gender,
and, to the extent data is available, by sexual orientation and
gender identity. Requires plans to provide that information to
Department of Health Care Services annually, and requires
Department of Health Care Services to develop a report with this
data, and publish the report on the Department of Health Care
Services Internet Web site. Requires plans, if Department of
Health Care Services identifies any disparities, to review their
administrative data to assess whether the disparities identified
exist among the Medi-Cal managed care enrollees enrolled in its
plan, and requires plans that identify the same disparities, to
develop and implement a quality improvement plan to address
those disparities.
Existing law:
1.Establishes the Medi-Cal program, which is administered by
Department of Health Care Services (DHCS), under which
qualified low-income individuals receive health care services.
2.Permits the director of DHCS to contract, on a bid or non-bid
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 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.
3.Requires, under federal regulations, states to require through
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their contracts with managed care plans, that each plan have
an ongoing quality assessment and performance improvement
program for the services it furnishes to its enrollees.
This bill:
1.Requires DHCS to require all Medi-Cal managed care plans,
contracting with DHCS, to link all individual level data
collected as a part of analyzing their Healthcare
Effectiveness Data and Information Set (HEDIS) measures, or
their External Accountability Set (EAS) performance measure
equivalent, to patient identifiers in a manner that allows for
an analysis of disparities in medical treatment by geographic
region, primary language, race, ethnicity, gender, and, to the
extent data is available, by sexual orientation and gender
identity, and to provide that information to DHCS annually.
2.Requires DHCS to make this data available, in a format that
complies with federal privacy requirements, for research
purposes through a data use or business associate agreement.
3.Requires DHCS to stratify, in the aggregate, all HEDIS
measures from Medi-Cal managed care plans by geographic
region, primary language, race, ethnicity, gender, and, to the
extent data is available, by sexual orientation and gender
identity, in order to identify disparities in the quality of
care provided to Medi-Cal managed care enrollees based on
those factors.
4.Requires DHCS to develop a report with this data and publish
the report on DHCS' Internet Web site.
5.Requires DHCS, based upon the data, to identify disparities in
care provided to all Medi-Cal managed care enrollees based
upon these factors, and to notify those plans of any
disparities identified.
6.Requires plans, if DHCS identifies any disparities, to review
their administrative data, including, but not limited to,
encounter and claims data, to assess whether the disparities
identified exist among the Medi-Cal managed care enrollees
enrolled in its plan.
7.Requires a plan, upon review of its administrative data, if
the plan identifies the same disparities identified by DHCS
among the Medi-Cal managed care enrollees enrolled in its
plan, to develop and implement a quality improvement plan to
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address those disparities.
8.Permits the quality improvement plan to be used to meet
existing contractual requirements to develop and implement a
quality improvement plan (QIP).
9.Requires a QIP developed and implemented to be provided to
DHCS, and DHCS to publish that QIP on its Internet Web site.
FISCAL EFFECT : According to the Assembly Appropriations
Committee of the previous version of this bill, minor costs to
DHCS, which currently designates performance measures on an
annual basis and requires Medi-Cal managed care plans to report
on them.
PRIOR VOTES :
Assembly Health: 14- 0
Assembly Appropriations:12- 5
Assembly Floor: 54- 19
COMMENTS :
1.Author's statement. As of April 2013, 5.5 million people were
enrolled in a Medi-Cal managed care plan, the majority of whom
are from communities of color. Beginning in 2014, 1.42
million adults will be newly eligible for Medi-Cal as a result
of the expansion through the federal Affordable Care Act, 67
percent of whom will be from communities of color, and 35
percent will speak English less than very well. Approximately
43 percent of Medi-Cal enrollees speak a language other than
English. Currently, Medi-Cal managed care plans analyze and
report to DHCS on HEDIS measures, a tool used by more than 90
percent of America's health plans to measure performance on
important dimensions of care and service. Additionally,
demographic data, including race, ethnicity, and primary
language, is collected at the time of enrollment for the
Medi-Cal program. Racial and ethnic health disparities are
prevalent and pervasive. In California, African Americans and
Native Americans have at least twice the rate of diabetes as
Whites, and Latinos and African Americans have over twice the
rate of preventable hospital admissions for diabetes with
long-term complications as Whites. Requiring Medi-Cal managed
care plans to analyze utilization, quality, and outcome data
by race, ethnicity, gender and primary language will help
these plans better understand the specific needs of their
members, allowing them to develop culturally and
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linguistically appropriate interventions, enabling them to
allocate resources to more effectively, and ultimately
reducing historic health disparities that communities of color
face.
2.Health care disparities. The Institute of Medicine (IOM), in a
2002 report entitled "Unequal Treatment: Confronting Racial
and Ethnic Disparities in Health Care," found that a
consistent body of research demonstrates significant variation
in the rates of medical procedures by race, even when
insurance status, income, age, and severity of conditions are
comparable. This research indicates that U.S. racial and
ethnic minorities are less likely to receive even routine
medical procedures and experience a lower quality of health
services. The IOM report says a large body of research
underscores the existence of disparities. For example,
minorities are less likely to be given appropriate cardiac
medications or to undergo bypass surgery, and are less likely
to receive kidney dialysis or transplants. By contrast, they
are more likely to receive certain less-desirable procedures,
such as lower limb amputations for diabetes and other
conditions.
3.Current quality measures. DHCS reports on a variety of
measures, some of which are unique to a specific population or
initiative and others that apply more generally. Two of the
quality measures referenced in this bill are EAS and HEDIS.
a. External Accountability Set . The federal Centers for
Medicare and Medicaid Services (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 EAS. DHCS designates EAS performance
measures on an annual basis and requires plans to report on
them. DHCS uses HEDIS measures as the primary tool (HEDIS
is described below). Currently required HEDIS measures
include well child visits, immunizations, comprehensive
diabetes care, and annual monitoring of patients on
persistent medications. 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.
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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. 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.
4.Managed Risk Medical Insurance Board (MRMIB) monitoring of
plans. MRMIB administers the Healthy Families Program (HFP),
and requires its HFP-health and dental plans to ensure that
access to quality health care was shared by all of its
members. Analysis of HEDIS data was performed for measures
that use administrative data where all eligible members are
counted. Data groupings used by MRMIB for its HEDIS report are
health plan, region, income level, language spoken in the
home, ethnicity, and age. For example MRMIB reported in the
2011 HFP HEDIS Report that 88 percent of white children saw a
Primary Care Physician at least once; for Black/African
American children the rate was 85 percent; and, for
Asian/Pacific Islander children it was 86 percent. The HEDIS
measure for appropriate medications for asthma, there was a
range of 95 percent for Vietnamese speaking to 88 percent for
English speaking. MRMIB was able to accomplish this analysis
by requiring the plans to provide patient identifiers with the
individual HEDIS measure. MRMIB matched the information
through a contractor, with demographic information reported by
the enrollee. This allows demographic analysis, comparison,
and reporting without breaching patient confidentiality.
Medi-Cal does not analyze and report the HEDIS data from its
contracting plans in the same way and does not require the
plans to report the data in a way that would allow similar
analysis.
5.Related legislation. AB 209 (Pan) requires DHCS to develop and
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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. In addition, AB 209 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. Finally, AB 209 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.
6.Prior legislation.
a. 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 (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.
b. 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.
c. AB 1467 (Committee on Budget), Chapter 23, Statutes of
2012, authorized the expansion of Medi-Cal managed care to
28 mostly rural counties.
d. 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
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not choose a plan. AB 2002 was held in the Assembly
Appropriations Committee.
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 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.
f. 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
Coordinated Care Initiative.
7.Support. The California-Pan Ethnic Health Network (CPEHN),
sponsor of this bill writes in support that even though 73
percent of Medi-Cal enrollees are from communities of color,
there exists no requirement for Medi-Cal managed care plans to
analyze quality data by race, ethnicity, and primary language.
CPEHN points out racial and ethnic health disparities are
prevalent and pervasive. For example in California, African
Americans and Native Americans have at least twice the rate of
diabetes as whites, and Latinos and African Americans have
over twice the rate of preventable hospital admissions for
diabetes with long-term complications as whites. According to
CPEHN, data also show that African Americans have almost four
times the rate of preventable hospital admissions among
children with asthma compared to whites, and three times the
rate of preventable hospital admission for congestive heart
failure. CPEHN points to a UCSF study that found there were
average deviances from a health plan's overall performance
among racial and ethnic subpopulations on each of the HEDIS
measures they analyzed. CPEHN argues the experience of such
stark racial and ethnic health disparities among communities
of color necessitates Medi-Cal managed care plans to begin to
seriously and systematically identify and address the
disparities of its diverse enrollee population. CPEHN
concludes that this bill will help inform DHCS and Medi-Cal
managed care plans of health disparities among enrollees and
develop strategies to address them.
8.Technical amendment. This bill uses the acronym "EAS" but does
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not define the acronym.
SUPPORT AND OPPOSITION :
Support: California Pan-Ethnic Health Network (sponsor)
Access to Healthcare Momentum Team
American Cancer Society Cancer Action Network
American Federation of State, County and Municipal
Employees, AFL-CIO
Binational Center for the Development of Oaxaca
Indigenous Communities
Cal-Islanders Humanitarian Association
California Black Health Network
California Center for Research on Women and Families
California Council of Community Mental Health Agencies
California National Organization for Women
California Primary Care Association
California School Health Centers Association
Greenlining Institute
Guam Communications Network
Health Access California
Health Officers Association of California
March of Dimes California Chapter
Mental Health America of California
National Association of Social Workers, California
Chapter
National Health Law Program
Public Health Institute
Street Level Health Project
Transgender Law Center
14 Individuals
Oppose: None received.
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