The California Department of Health Care Services (DHCS) took an important step to address the health care inequities magnified by the COVID-19 pandemic when it released on December 28 a draft Comprehensive Quality Strategy. In it, DHCS outlines some of the ways in which it intends to improve care and reduce racial and ethnic disparities for 13 million Medi-Cal enrollees, the vast majority of whom are people of color.

The quality strategy is far-reaching and will shape how health care will be provided to almost one in three Californians. Here are some key takeaways from this document:

• DHCS has set bold goals. DHCS goals may be the boldest quality improvement and health equity goals in Medi-Cal’s history and perhaps the most ambitious of any state’s Medicaid agency. California’s goals include reducing racial and ethnic disparities in well-child visits, immunizations, and maternity care for Black and Native American people by 50% in just four years. These specific and ambitious goals will provide Medi-Cal plans and providers a “north star” to work toward together.
• The proposed codesign process for a health equity road map is inclusive and innovative. DHCS has proposed a collaborative process for developing California’s healthy equity road map to “collectively identify gaps, needs, and the work needed to achieve health equity.” The department will engage Medi-Cal members and community-based organizations as well as health plans, counties, providers, and other stakeholders in charting this course. DHCS says it will inform and update the road map while creating vital partnerships.
• Enhancing data collection and monitoring is key to ensuring transparency and accountability. The quality strategy’s focus on data collection and monitoring is key to measuring progress and learning from collective efforts to reduce racial and ethnic disparities. Better data are needed, so we must address many Medi-Cal enrollees’ hesitancy in providing their demographic information because of mistrust and fear that it will be used against them. In 2020 the California Pan-Ethnic Health Network interviewed Medi-Cal enrollees across the state and found that they often experience discrimination in the system because of race, disability, sexual orientation, language, or cultural background. We must all work to increase enrollees’ trust in the system.
• While the principle of paying for value is central to the quality strategy, future decisions will determine how meaningful payment reforms will be. When it comes to driving improvements in quality for Medi-Cal members, the most powerful tools available to DHCS are the incentives and disincentives built into how it pays Medi-Cal managed care plans. It’s encouraging that the quality strategy emphasizes the need to adjust payments to plans based on their performance on quality measures starting in 2023. DHCS, consumer advocates, plans, physician groups, and other stakeholders came together in previous years to examine exactly how to adjust those payments based on quality and equity. They wrestled with many thorny design questions and arrived at recommendations on methodology and quality metrics that should help accelerate implementation by DHCS.

A Framework of Efforts to Improve Medi-Cal

DHCS’s new quality strategy is one of many interrelated steps the state is taking to improve Medi-Cal, including:

• The multiyear CalAIM initiative, which seeks to advance whole-person care and address social determinants of health. Population health management, which focuses Medi-Cal on prospectively keeping enrollees healthy and identifying patients’ risk factors to guide care management, is a cornerstone of both CalAIM and the quality strategy. So, too, is value-based payment, which ties payment to quality of care.
• The competitive process to determine which commercial managed care plans will contract with the state. This year, when the state starts this process (often referred to as “procurement”), it will enable California to require all plans to meet higher standards of quality and to proactively address disparities among their members if they want to be selected. Through procurement, DHCS will vet and select plans based heavily on their ability to achieve the goals of CalAIM and the clinical quality strategy.
• Expansion of Medi-Cal coverage to new provider types, such as community health workers and doulas. Along with many other recent investments in California’s health workforce, these initiatives are designed to improve access, quality, and health outcomes for Medi-Cal enrollees.

Christopher Perrone

Christopher Perrone is director of CHCF’s Improving Access team, which works to improve access to coverage and care for Californians with low incomes. Read More

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