Project

Medi-Cal Beneficiaries with Disabilities: Performance Standards and Measures for Managed Care

Background

Approximately one million people with disabilities are enrolled in Medi-Cal. Compared to other Medi-Cal beneficiaries, those with a physical or mental impairment or other disabling condition are five times more likely to have two or more chronic conditions. They also use more health care goods and services (such as prescription drugs, physician services, and inpatient hospital care) and many rely on goods and services not commonly used by other beneficiaries (such as personal care services, community mental health services, and durable medical equipment). For these reasons, people with disabilities account for 40% of Medi-Cal expenditures, although they constitute only 14% of the program's beneficiaries.

Despite the importance of Medi-Cal coverage to this population and its impact on the Medi-Cal budget, very little information is available to determine how well the program serves these beneficiaries.

In September 2004, the California HealthCare Foundation (CHCF) funded a five-month project to study the feasibility of developing performance standards and measures for health plans serving people with disabilities. The project team examined Medicaid contracts in California and other states and consulted with a 21-member advisory group of state officials, consumer representatives, health plan executives, and medical professionals to identify opportunities for improvement and assess whether those with diverse interests could support such improvements and find common ground.

In January 2005, during the course of this feasibility study, the Governor submitted a plan for Medi-Cal Redesign to the legislature. The Governor's proposal would have required disabled Medi-Cal beneficiaries in the 35 most-populous counties to enroll in a managed care health plan. This plan would have reduced Medi-Cal spending by tripling the number of beneficiaries enrolled in managed care (from 200,000 to 620,000).

In February 2005, the advisory group recommended that an investment be made to develop and implement better health plan performance standards and measures for this population and to develop a tool to assess the readiness of health plans to enroll large numbers of people with disabilities and chronic illness. And in April the CHCF board of directors approved funding to pursue these objectives. This project was a collaborative effort between CHCF, which provided funding and technical assistance, and the California Department of Health Services (DHS), which contracts with Medi-Cal managed care plans. An overview of the project at the outset is available under Document Downloads below.

Phase 1: Develop Recommendations

The goal of this project was to enhance California's Medi-Cal managed care program to support a health care service delivery system that provides quality care for people with disabilities and chronic illness. The project laid the foundation for efforts to evaluate and to improve how well the Medi-Cal managed care program serves this population.

In Phase 1, the project team developed a set of recommendations to DHS for health plan contract performance standards (also called operating standards or contract specifications) and measures that can foster improvements in quality of care for people with disabilities and chronic illness. These recommendations may also be used by DHS to enhance its policies. Another set of recommended strategies for DHS addressed cross-agency issues that affect quality of care for people with disabilities and chronic illness (such as care coordination and information sharing).

The recommendations are based on an extensive review of federal and California Medicaid managed care regulations, contract requirements, and policies; an examination of best practices of other state Medicaid managed care programs; and a review of Medicare Advantage program rules. The consultant team also analyzed Medi-Cal fee-for-service claims data and consulted with national experts. In addition, the report reflects feedback gathered through an extensive public input process involving eight workgroups and over 100 participants representing consumer organizations, health plans, health care providers, DHS, and other state agencies serving people with disabilities.

The final report provides specific recommendations to strengthen existing standards in managed care (while recognizing that similar requirements do not exist in Medi-Cal fee-for-service); to ensure that limited state resources are used most effectively; and to improve the quality of care provided to people with disabilities. The recommendations encompass new standards in the areas of enrollment and members services, network capacity and accessibility, benefit management, care management, quality improvement, performance measurement, and coordination of carve-out services.

Upon completion of Phase 1, DHS conducted internal analysis of the recommended performance standards and measures, prepared a draft response in which it concurred with most of the recommendations, and solicited public comment on its draft response. DHS is currently taking steps to adopt many of the recommendations.

The complete recommendations and a summary presentation are available under Document Downloads below, as is the response to the recommendations from DHS.

Phase 2: Develop Health Plan Readiness Tool

In Phase 2 of the project, the project team worked with DHS to create a set of recommended strategies for DHS to monitor health plan contract compliance on an ongoing basis as well as a tool to assess the readiness of health plans to serve a large influx of new beneficiaries with disabilities and chronic illnesses. It is intended to supplement the tools and activities the state already uses to assess the readiness of a health plan to serve Medi-Cal beneficiaries. This tool is not designed to be used alone, as it does not reflect existing performance standards and measures used in Medi-Cal managed care.

The Medi-Cal Health Plan Readiness Assessment Tool has several potential uses. It can be used to help evaluate health plans that already enroll a large number of people with disabilities, such as current County Organized Health System (COHS) plans and certain local initiative and commercial plans in large counties. Also, in counties where enrollment in managed care becomes mandatory for Medi-Cal beneficiaries with disabilities -- either because the county adopts a COHS or because the legislature approves an expansion of mandatory managed care for disabled beneficiaries in Two-Plan Model or Geographic Managed Care counties -- this tool can be used to help assess the readiness of plans that must prepare to serve a large influx of new members with disabilities. In addition, the tool can be used by health plans or other stakeholders to assess the capacity to serve members with disabilities and to identify areas for operational enhancement, regardless of which of the recommended performance standards the state might adopt.

The complete readiness tool is available under Document downloads below.

Advisory Group and Project Team

The project team consisted of three organizations that collaborated to conduct research on current and best practices, develop recommendations, and facilitate workgroup and advisory group discussions: the Center for Health Care Strategies, The Lewin Group, and the Center for Disability Issues and the Health Professions at Western University of the Health Sciences.

The advisory group, consisting of representatives from health plans, consumer groups, health care providers, state officials, and national experts, worked to review and provide feedback on the proposed recommendations before they were finalized.