Report 2018-111 Recommendation 14 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 #14 To: Health Care Services, Department of

To mitigate health disparities for children of differing ethnic backgrounds and language needs, DHCS should revise by September 2019 the methodology for its EQRO's health disparity study to enable it to better make demographic comparisons, and it should use the findings to drive targeted interventions within plan service areas. It should publish this study annually.

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 revised the methodology for its EQRO's health disparity study to enable it to better make demographic comparisons. DHCS plans to fully implement this recommendation by January 2023.

Annual Follow-Up Agency Response From October 2021

Leveraging data from our health disparities reports, DHCS is currently working on a study to determine potential metrics that experience the highest disparities for our managed care Medi-Cal population not only based on race/ethnicity, age, gender, and language but also by geographical location. These identified metrics will potentially be the focus for a state driven project to improve these disparities. MCP's will need to improve disparities in a specified timeframe and by a predetermined quantifiable amount. Additionally, the health disparities report is undergoing a few methodological updates to allow for better reporting, accuracy, and fluidity of the reports. The reports will continue to be published annually.

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

Full implementation will require DHCS to show that the study it describes allows for demographic and that its findings are used to drive targeted interventions.

Annual Follow-Up Agency Response From November 2020

PNA submissions have been received and are being reviewed by DHCS. Analysis and reporting of PNAs, including MCP-identified health disparities, will be included in DHCS' Plan Specific Evaluation Report included in DHCS' April 2021 Technical Report as previously reported. DHCS fully intends to continue to publish the Health Disparities Report, based on the annual quality metrics when possible. Due to the COVID-19 pandemic, MCPs were given flexibilities in reporting annual quality metrics for Reporting Year 2020, aligning with flexibilities given by CMS and the National Committee for Quality Assurance. Please see Supplement to APL 19-017 for more information regarding reporting flexibilities, which can be found here: https://www.dhcs.ca.gov/formsandpubs/Documents/MMCDAPLsandPolicyLetters/APL2019/APL19-017QISupp.pdf. The methodologies used in previous reports are not appropriate to apply to the Reporting Year 2020 quality metrics. Therefore, the annual report cannot be produced using the same data source or methodology as previous years.

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

Full implementation of this recommendation will require DHCS to demonstrate that it's methodology for its EQRO's health disparity study enables it to make demographic comparisons, and that it uses findings from the study to drive targeted interventions within plan service areas and that it publishes the study annually.

1-Year Agency Response

DHCS has continued to move forward with the annual Health Disparities Reports, utilizing the improved methodology and identifying opportunities to expand the measures and stratifications included in future iterations of the report. DHCS has also continued to move forward with policy initiatives that will require the MCPs to utilize data from this report for purposes of identifying health disparities. APL "Health Education and Cultural and Linguistic Population Needs Assessment" was published September 30, 2019, (DHCS notes that the GNA was renamed Population Needs Assessment (PNA) to clarify the policy applied to the entire MCP member population as opposed to particular groups, but the substance of the requirement was not impacted by the name change). On November 7, 2019, DHCS conducted a webinar for MCP Health Education Consultants to review the submission requirements and timeframe of the PNA. PNA submissions are due to DHCS June 30, 2020. DHCS informed the MCPs that the health disparities data is required to be utilized for their submission. On December 17, 2019, DHCS informed MCPs the health disparities data from measurement years 2017 and 2018 was available to MCPs by the EQRO. DHCS requires PNA submissions to utilize available data to describe and identify health disparities within the MCP member population. Analysis and reporting of PNAs, including MCP-identified health disparities, will be included in DHCS' Plan Specific Evaluation Report included in DHCS' April 2021 Technical Report.

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

DHCS submitted an updated All Plan Letter and documentation of the webinar described in its response. Full implementation of this recommendation will require DHCS to demonstrate that it uses findings from the study to drive targeted interventions within plan service areas and that it publishes the study annually.

6-Month Agency Response

DHCS has continued to move forward with the annual Health Disparities Reports, utilizing the improved methodology and identifying opportunities to expand the measures and stratifications included in future iterations of the report. DHCS has also continued to move forward with policy initiatives that will require the MCPs to utilize data from this report for purposes of identifying health disparities, developing an action plan to address the health disparity, and reporting back to DHCS on the progress and impact of the action plan as part of the Group Needs Assessment (GNA). The second Disparities Report was posted before June. The date for completion has been modified to September 2019 to account for the submission of two additional methodologies which detail the upcoming evolution of the report.

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

DHCS' revised EQRO methodology now allows for demographic comparisons in ways the previous methodology did not. However, DHCS has not addressed other aspects of this recommendation, specifically demonstrating that it uses the enhanced demographic comparisons from the EQRO to drive targeted interventions within plan service areas.

60-Day Agency Response

The second health disparities report (measurement year 2016) methodology has been revised to allow for additional metrics and demographic comparisons and will be released in Spring 2019. The EQRO will continue to produce this report on an annual basis and each iteration will continue to evolve as DHCS identifies opportunities to improve methodologies, expand the metrics being analyzed, and drive targeted interventions within MCP service areas.

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

We reviewed DHCS' revised EQRO methodology, and it allows for demographic comparisons in ways the previous methodology did not. We look forward to seeing future updates from DHCS in which it demonstrates that it uses the enhanced demographic comparisons from the EQRO to drive targeted interventions within particular service areas.

All Recommendations in 2018-111

Agency responses received are posted verbatim.