A Close Look at Medi-Cal Managed Care: Stories of Quality Improvement Success

With more than 80% of Medi-Cal enrollees (greater than 10 million Californians) in managed care, assessing and monitoring the quality of care delivered by managed care plans (MCPs) is critical to ensuring all enrollees receive high-quality, timely care. A 2019 study by the University of California, San Francisco, found that between 2009 and 2018, quality of care varied significantly across MCPs and regions and that, over this 10-year period, quality declined or did not improve for more than half of the measures studied.

However, there are still many examples of significant progress by individual MCPs on specific measures. The California Health Care Foundation commissioned Chapman Consulting to examine the experiences of a subset of successful MCPs.

Among the most important criteria to be included in this study, an MCP had to have improved HEDIS quality scores by at least 10 percentage points between 2009 and 2018, the MCP’s most recent score (2018) had to be at or above the statewide average, and the MCP had to have demonstrated significant improvement across a minimum of three HEDIS measures in a given service area. Also, measures had to have been reported on for at least five years to qualify.

Structured interviews with multiple MCPs that met these criteria revealed several common, interconnected strategies for success, including:

• Leadership commitment
• Effective data analysis
• Real-time data exchange
• Collaborating with providers at the point of service
• Increasing member access to care and education
• Targeted financial incentives

These strategies are discussed further in the issue brief. The brief also includes several concrete success stories including:

• CalViva Health used data analysis as well as training and education of staff at a few high-volume, low-performing clinics to improve blood pressure control among diabetic patients, which rose from 53% in 2013 to 68% in 2018.  Also, the rate of eye exams among diabetic patients rose from 49% to 59% during the same period.
• Health Plan of San Mateo (HPSM) improved its outreach to women who had just given birth to ensure that they were scheduling follow-up care with a provider. HPSM’s score on the percentage of women receiving appropriate postpartum care improved from 60% in 2009 to 75% in 2018, 11 percentage points above the statewide average.
• Through targeted outreach to clinics and providers as well as through patient education, L.A. Care’s score on monitoring patients using ACE inhibitors improved from 73% in 2012 to 89% in 2018. Similarly, the MCP’s score on monitoring patients using diuretics improved from 72% to 88% during this period.

See the full paper for more success stories as well as common challenges the MCPs voiced in regards to quality improvement.