Report 2022-502 Recommendation 2 Responses

Report 2022-502: Follow-Up: Children in Medi‑Cal: The Department of Health Care Services Is Still Not Doing Enough to Ensure That Children in Medi‑Cal Receive Preventive Health Services (Release Date: September 2022)

Recommendation #2 To: Health Care Services, Department of

To ensure that health plans address underutilization of children's preventive services, DHCS should require plans 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 October 2024

DHCS continues monitoring evidence-based QI and Health Equity projects with hands-on technical assistance to help MCPs drive data-driven approaches. To better understand underutilization, DHCS launched reporting on Population Health Key Performance Indicators (KPIs), including measurement of primary care engagement in the last 12 months. KPI 3 assesses the percentage of members with no ambulatory or preventive visits within 12 months (refer to pages 123 through 126 of the Population Health Management (PHM) Policy Guide). All KPI data submitted by plans was stratified by age, race, ethnicity, and language. Additionally, within the PHM requirements, MCPs must review the utilization of children's preventive health visits and developmental screenings and outline their strategies for improving access to those services, as well as articulate and track how Basic Population Health Management (BPHM) may be deployed to ensure any follow-up and care coordination needs identified from screenings are delivered. For example, BPHM ensures all children with abnormal vision screenings receive glasses or all children with an abnormal developmental screen receive additional required testing. As part of BPHM, MCPs are required to meet all EPSDT requirements related to timely access to services. In addition, to support children enrolled in Medi-Cal in accessing and receiving wellness and prevention programs, MCPs must also enter into Memorandums of Understandings (MOUs) with Women, Infants, and Children (WIC) providers. DHCS further shared data on peer performance with MCPs to increase awareness of and attention to relative performance on primary care engagement. MCPs are required to review Member utilization reports to identify Members not using Primary Care; stratify such reports, at minimum, by race and ethnicity to identify Health Disparities resulting from differences in utilization of outpatient and preventive services and develop strategies to address differences in utilization.

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

DHCS provided evidence that it fully implemented the recommendation.

Annual Follow-Up Agency Response From December 2023

The Population Health Management (PHM) program has begun monitoring various Key Performance Indicators (KPIs) assessing utilization of services to include hospitalization admissions, behavioral health services, and primary care access. Additionally, the PHM program has launched a dashboard which tracks KPIs to better determine areas requiring additional improvement efforts to address underutilized services. Page 35 of the CalAIM: Population Health Management (PHM) Policy Guide outlines the monitoring program. Additionally, page 41 identifies how KPIs are attributed to specific populations and page 46 includes more on the framework. The KPIs will be further stratified by age to better monitor Medi-Cal Members under 21 years-of-age. Lastly, DHCS issued quality sanctions for poor performance, which can be found here.

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

DHCS did not provide evidence to substantiate that it had fully implemented this recommendation.

1-Year Agency Response

The Population Health Management (PHM) program has begun monitoring various measures Key Performance Indicators (KPIs) that assess utilization of services to include hospitalization admissions, behavioral health services, and primary care access. Additionally, the PHM program has launched a dashboard that is tracking KPIs to better determine areas that require additional improvement efforts of underutilized services.

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

DHCS did not provide evidence to substantiate that it had fully implemented this recommendation.

6-Month Agency Response

Tracking underutilization data is underway with the Population Health Management requirements and the new contract language. However, the HEDIS rate data is currently undergoing the auditing process. When DHCS receives the rates in July 2023, DHCS will pair the rates with the Population Health Management services and MCP underutilization data to see what quality improvement (QI) efforts can be developed. DHCS is beginning to incorporate underutilization data as a focus for the MCPs which struggle on multiple lower performing measures; DHCS will have the plans take a closer look at this data and develop QI methods to engagement and connect the members to Primary Care Provider.

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

Per DHCS's response, it will not implement this recommendation until July 2023.

60-Day Agency Response

On January 1, 2023, the MCP new contract begins, which requires MCPs to monitor and address underutilization. Also, CalAIM Population Health Management Program launches and requires plans to monitor underutilization of children's services and stratification of data.

In July 2023, DHCS will receive HEDIS results. DHCS will monitor MCP performance rates and track services of children's utilization and delivery. On July 1, 2023, DHCS will begin the focus study with EQRO and assess MCPs methods for addressing barriers resulting in underutilization.

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

Per DHCS's response, it will not implement this recommendation until July 2023.

All Recommendations in 2022-502

Agency responses received are posted verbatim.