Report 2018-111 Recommendation 11 Responses

Report 2018-111: Department of Health Care Services: Millions of Children in Medi-Cal Are Not Receiving Preventive Health Services (Release Date: March 2019)

Recommendation #11 To: Health Care Services, Department of

To ensure that plans address underutilization of children's preventive services, DHCS should require plans by September 2019 to use their utilization management programs to identify barriers to usage specifically for these services and hold the plans accountable to address the barriers they identify.

Annual Follow-Up Agency Response From September 2022

There is no agency response for this update. Government Code section 8546.1(d) authorizes the California State Auditor to conduct follow-up audit work on statutorily mandated or legislatively required financial and performance audits. Our office followed up on this March 2019 audit to assess DHCS's status regarding implementation of the eight outstanding recommendations from this report. Below is our assessment of the status of this recommendation based on work we performed during the follow-up audit. All future updates for this recommendation will be posted under the follow-up audit (2022-502).

California State Auditor's Assessment of Annual Follow-Up Status: Partially Implemented

DHCS has not required health plans to identify barriers to usage of children's preventive services and develop strategies to address those barriers as we recommended. DHCS plans to fully implement this recommendation by July 2023.

Annual Follow-Up Agency Response From October 2021

On September 29, 2020, DHCS issued APL 20-016: Blood Lead Screening of Young Children. This APL informs MCPs of their updated Blood Lead Screening requirements as part of the revisions made in the Welfare and Institutions Code (W&I) by AB 2276. On November 3, 2020, DHCS issued a revised version of APL 20-016 which included additional clarifications to the requirements. To ensure MCP compliance with the new requirements in W&I that were incorporated as Department's new policy by way of APL 20-016, DHCS reviewed managed care plan policies and procedures which outlined the plans' updated approach in the provision and reporting of blood lead screening as specified in the new legislation. In February 2021, DHCS published an Addendum to the PSR, which focused on reporting and analysis of blood lead screening across California for children in Medi-Cal managed care. The PSR Addendum provided blood lead screening rates calculated in accordance with California Title 17 requirements, as well as following the national Medicaid Healthcare Effectiveness Data and Information Set (HEDIS) technical specifications by MCP. Data from the PSR Addendum was provided to each MCP to inform their improvement efforts in Basic Life Support. This same process will be repeated annually with the publication of the PSR.

California State Auditor's Assessment of Annual Follow-Up Status: Pending

DHCS' response does not address this recommendation. As we state in the recommendation and in our previous assessments for this recommendation, full implementation of this recommendation will require DHCS to provide documentation of a requirement for plans to identify barriers to usage specifically for preventive services. We also will look for documentation of DHCS' mechanism for holding plans accountable to address the barriers they identify.

Annual Follow-Up Agency Response From November 2020

DHCS continues to work with stakeholders towards the PSR. The first version is on track to be issued in December 2020 and will include program wide data. The second version, which is on track to be issued in February 2021, will include plan specific information. Once the PSR is completed, DHCS will instruct the MCPs to use the PSR findings in conjunction with plan information, including the MCP's utilization management program, to identify and address barriers to usage. The instruction will be issued in the form of an APL.

California State Auditor's Assessment of Annual Follow-Up Status: Pending

1-Year Agency Response

DHCS continues to work with stakeholders towards the PSR which is on track to be issued in 2020. Once the report is completed, DHCS will instruct the MCPs to use the PSR findings in conjunction with plan information, including the MCP's utilization management program, to identify and address barriers to usage. The instruction will be issued in the form of an APL.

California State Auditor's Assessment of 1-Year Status: Pending

6-Month Agency Response

DHCS continues to work towards the PSR which will be issued in 2020. As part of the preparation for the PSR, DHCS is in the process of engaging stakeholders to comment on aspects, metrics, and the content of the report. Once the report is completed, DHCS will instruct the MCPs to use the PSR findings in conjunction with plan information, including the MCP's utilization management program, to identify and address barriers to usage.

California State Auditor's Assessment of 6-Month Status: Pending

We look forward to reviewing documentation in the form of all-plan letters, contract language, or other enforceable notice that DHCS is requiring plans to identify barriers to usage specifically for preventive services. We also will look for documentation of DHCS' mechanism for holding plans accountable to address the barriers they identify.

60-Day Agency Response

DHCS has initiated changes with its EQRO to develop a Preventive Services Report which will utilize available data to calculate metrics of appropriate utilization of preventive services for children and adults. DHCS and the EQRO will look to align with existing quality metrics where available and will investigate the development of metrics where appropriate. The report is expected to be issued in 2020.

California State Auditor's Assessment of 60-Day Status: Pending

DHCS' response does not appear to include a requirement for plans to use their utilization management programs to identify barriers to usage, or to hold the plans accountable to address those barriers, but we will review the report it is initiating and the alignment and development of its metrics to determine the extent to which they implement this recommendation.

All Recommendations in 2018-111

Agency responses received are posted verbatim.