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Equity in CalAIM: How to Identify Patients Who Will Benefit Most

Perspectives from the Field

About the Perspectives from the Field Series

As California’s Department of Health Care Services administers changes to the Medi-Cal program, especially those that are part of the CalAIM initiative, CHCF is intermittently publishing short reports that highlight the perspectives of those implementing the changes. These “Perspectives from the Field” seek to inform policymakers and other health care leaders about insights and experiences from people on the ground who work directly with patients.

California’s recently launched CalAIM initiative is an ambitious effort to transform the state’s Medi-Cal program with a focus on equity and whole-person care. With most enrollees now receiving benefits through managed care, the Department of Health Care Services (DHCS) enlisted managed care plans to carry out much of this work, including providing a range of care management and supportive services for people with complex needs. The question then becomes how best to identify patients with the greatest need of these services.

This perspective explores the unintended consequences of one commonly used approach for identifying people with complex needs — relying on utilization and cost data from inpatient and emergency department visits. Yet studies show that Black, Latino/x, American Indian and Alaska Native, and members of other underserved groups may not access health care as much as they need to due to factors such as mistrust of health care providers and lack of available health care services in underresourced communities. Organizations that rely on utilization data to identify patients risk missing people who might benefit from more comprehensive services.

DHCS has included utilization in eligibility criteria in only a few instances and has given managed care plans discretion to offer services to people based on other criteria. Managed care plans are now refining their approaches for determining eligibility. In developing this brief, a team from the Center for Health Care Strategies spoke to national and local experts about their experiences pursuing high-need identification strategies. The paper offers insights for ensuring that services provided are both equitable and impactful.

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