Report 2018-111 Recommendation 6 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 #6 To: Health Care Services, Department of

To increase access to preventive health services for children in areas where they are needed most, DHCS should identify by September 2019 where more providers who see children are needed and propose to the Legislature funding increases to recruit more providers in these areas.

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: Will Not Implement

DHCS stated in its response to the follow-up audit that it will not implement this recommendation because it asserts that broader workforce recruitment is beyond its purview. However, as the state agency solely responsible for administering Medi-Cal, DHCS has the authority to implement this recommendation. Without a targeted effort by DHCS to increase the number of Medi-Cal providers, children in Medi-Cal will likely continue to face limited access to care.

Annual Follow-Up Agency Response From October 2021

As described in the 2020 Annual Update, DHCS obtained network recruitment strategies from two Regional Model Medi-Cal MCPs, Anthem and California Health & Wellness. The Regional Model MCPs identified their approaches on outreach to expand their networks, such as focused communications to specialists, providers that are contracted with other MCPs, and providers in bordering counties outside the MCPs' counties. They have also encouraged their commercial providers to offer services to Medi-Cal beneficiaries and have used provider incentives to attract new providers in the network, including offering contracts above standard Medi-Cal rates. Further, to promote provider relationships, the MCPs have established designated teams to onboard new providers, address provider concerns, and offer continuous support. Lastly, both MCPs have expanded their use of telehealth services. These strategies aim to improve access to care for their Medi-Cal members.

California State Auditor's Assessment of Annual Follow-Up Status: Will Not Implement

It remains unclear why DHCS disagrees with this recommendation that would proactively address the problem of California children not receiving preventive services in areas where there is a lack of Medi-Cal providers. Instead, DHCS continues to shift responsibility to private managed care plans (MCPs).

Annual Follow-Up Agency Response From November 2020

DHCS continues to disagree with the recommendation. DHCS does agree increasing the number of physicians who practice in Regional Model counties is beneficial for all health care delivery systems.

Specific to Medi-Cal providers, Proposition 56 provided a one-time allocation of $340 million for a loan repayment program for recently graduated physicians and dentists. The selection of physicians and dentists for participation is based on eligibility criteria and prioritizing individuals agreeing to work in geographic shortage areas to increase access to care for Medi-Cal beneficiaries. In October 2019 DHCS provided network analysis data to Physicians for a Healthy California to assist with focusing the loan repayment program efforts on areas with access concerns. Additionally, DHCS will request the health plans conduct an assessment and submit to DHCS a recruitment strategy for areas in the Regional Model not compliant with time and distance standards. The assessment would be due to DHCS three months after the next annual network certification is completed.

California State Auditor's Assessment of Annual Follow-Up Status: Will Not Implement

It remains unclear why DHCS disagrees with this recommendation. DHCS agrees that increasing the number of physicians is beneficial and is implementing the loan repayment program we discuss in the report. Given the extent of the problems we identified, the impact of children not receiving preventive services, and DHCS' inability to improve utilization rates for these services above 50 percent for the past five years, DHCS should pursue multiple approaches to fixing these problems, rather than limiting itself to a single approach.

1-Year Agency Response

DHCS continues to disagree with the recommendation. DHCS does agree increasing the number of physicians who practice in California is beneficial for all health care delivery systems; however, such assessment is not in the purview of DHCS. Other departments such as the Office of Statewide Health Planning and Development are responsible for workforce planning within California. However, DHCS has been actively involved in implementing a physician and dental provider loan repayment program using Proposition 56 funds as authorized and approved in the Budget Act of 2018. These loan repayments will be targeted specifically at newly-practicing providers that agree to see a specific percentage of Medi-Cal patients in their practice (at least 30 percent) and maintain that commitment for at least five years. These loans will be open to both pediatric and adult providers and additional criteria will include providers that are practicing in high-need specialty areas such as child psychiatry or practicing in a medically underserved area.

California State Auditor's Assessment of 1-Year Status: Will Not Implement

It remains unclear why DHCS disagrees with this recommendation. It agrees that increasing the number of physicians is beneficial and is implementing the loan repayment program we discuss in the report. Given the extent of the problems we identified, the impact of children not receiving preventive services, and DHCS' inability to improve utilization rates for these services above 50 percent for the past five years, DHCS should pursue multiple approaches to fixing these problems, rather than limiting itself to a single approach.

6-Month Agency Response

DHCS continues to disagree with the recommendation. DHCS does agree increasing the number of physicians who practice in California is beneficial for all health care delivery systems; however, such assessment is not in the purview of DHCS. However, DHCS has been actively involved in implementing a physician and dental provider loan repayment program using Proposition 56 funds as authorized and approved in the Budget Act of 2018. These loan repayments will be targeted specifically at newly practicing providers that agree to see a specific percentage of Medi-Cal patients in their practice (at least 30 percent) and maintain that commitment for at least five years. These loans will be open to both pediatric and adult providers and additional criteria will include providers that are practicing in high-need specialty areas such as child psychiatry or practicing in a medically underserved area.

California State Auditor's Assessment of 6-Month Status: Will Not Implement

It remains unclear why DHCS disagrees with this recommendation. It agrees that increasing the number of physicians is beneficial and is implementing the loan repayment program we discuss in the report. Given the extent of the problems we identified in the report, the impact of children not receiving preventive services, and DHCS' inability to improve utilization rates for these services above 50 percent for the past five years, DHCS should pursue multiple approaches to fixing these problems, rather than limiting itself to a single approach.

60-Day Agency Response

DHCS continues to disagree with the recommendation. DHCS does agree increasing the number of physicians who practice in California is beneficial for all health care delivery systems; however, such assessment is not in the purview of DHCS. However, DHCS has been actively involved in implementing a physician and dental provider loan repayment program using Proposition 56 funds as authorized and approved in the Budget Act of 2018. These loan repayments will be targeted specifically at newly-practicing providers that agree to see a specific percentage of Medi-Cal patients in their practice (at least 30 percent) and maintain that commitment for at least five years. These loans will be open to both pediatric and adult providers and additional criteria will include providers that are practicing in high-need specialty areas such as child psychiatry or practicing in a medically underserved area.

California State Auditor's Assessment of 60-Day Status: Will Not Implement

It remains unclear why DHCS disagrees with the recommendation. The report acknowledged DHCS' loan repayment program on page 25, however, given the extent of the access problems we identified, the importance of children receiving preventive services, and DHCS' inability to improve the utilization rate for these services, DHCS should adopt more than a single approach, and it should specifically target providers who see children in areas where they are needed most, as stated in the recommendation.

All Recommendations in 2018-111

Agency responses received are posted verbatim.