The California Health Care Foundation, working with researchers at the University of California, San Francisco, urged state legislators in a report released Wednesday to take bold steps to improve the quality of Medi-Cal managed care plans.
"For a program as important as Medi-Cal is, we're not getting the kind of quality improvement out of it that we should expect," said Chris Perrone, the foundation's director Improving Access. "No one expects Medi-Cal to be perfect, but they do expect Medi-Cal to improve, and we think the approaches that the department has taken to date to try to improve quality over time are not working as they should."
Researchers and the foundation leaders pointed out that quality measures for for-profit health insurers paled, on average, when compared with those of nonprofit and public carriers, so the foundation advised lawmakers to "reconsider the role" that for-profit insurers play in the Medi-Cal arena.
They called upon legislators to create a path to establish a specific, measurable and time-bound system of quality improvements for not only Medi-Cal managed care plans but also for the Medi-Cal managed care system as a whole. Such a system would drive greater accountability.
The foundation and researchers said data show that competition between carriers doesn't always lead to the highest quality and best value for Medi-Cal enrollees.
Competition may present administrative roadblocks to innovation and access, Perrone said. Say, for instance, that providers want to expand access to telehealth for their patients, but they're in a market with multiple Medi-Cal providers and each provider has a different policy when it comes to offering telehealth services to enrollees.
"If you're a provider, you want to provide the same care to all of your patients, regardless of which plan they have," Perrone said. "This is not just isolated within Medi-Cal. It's across different payer sources, so it's really hard for providers, both in terms of the work flow and in terms of sustaining financially the kinds of services, when each health plan has a different set of policies about what they will or won't cover, or how they will cover it, or who they contract with."
Also, in some cases a Medi-Cal beneficiary needs access to a couple different types of specialists, but the two specialists closest to the beneficiary's home work for two competing plans. In areas with more than one plan, Perrone said, the researchers saw more switching between plans, and they posited that could be a result of beneficiaries looking for the providers that best meet their needs.
Researchers said the state also should work to encourage carriers to meet or exceed quality metrics by offering direct financial rewards to carriers that do so.
"We should be smarter about the way that we pay," Perrone said. "The state relies heavily on sticks, so it sets minimum performance levels and when plans fall below those minimum performance levels, it can penalize or sanction them. Many other states are moving in the direction of having both sticks and carrots, and we think it's time for California to also adopt carrots, so adopt financial incentives that reward plans that are improving quality year over year."
The state's Department of Health Care Services already is collecting much of the data needed to assess whether health plans are making gains on quality, researchers said.
"The department should raise the bar and expect continuous quality improvement from its plans," Perrone said. "They should establish specific and measurable goals for improving access and quality for the program as whole and from each managed care plans."
Now is the time to act, the foundation said, because DHCS is preparing to launch a competitive process to identify the for-profit and nonprofit commercial managed-care plans that the state will contract with serve Medi-Cal enrollees. The issue also has the interest of Gov. Gavin Newsom, they said, since the state auditor reported that millions of children aren't receiving the basic checkups that Medi-Cal requires. And, researchers said, the U.S. Centers for Medicare & Medicaid Services has instituted new regulations requiring states to improve accountability.
In researching the 57-page report, the UCSF team looked at how Medi-Cal managed care plans performed on 41 quality measures and discovered that the performance of 59 percent of the plans had either declined or had remained unchanged. Also on Wednesday, the foundation issued a seven-page report highlighting health plans that made exceptional improvements on quality and how they achieved them. A number of them said they set measurable goals and engaged staff at all levels of their organization in meeting them.
Distributed by Tribune Content Agency, LLC.
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