The Evolution of Medi-Cal

Nobody knew the blockbuster news of Friday that Toby Douglas deciding to step down as head of te California Department of Health Care Services and for Medi-Cal–but one day before the Medi-Cal Stakeholder Advisory Committee was still noteworthy for the news and information it did provide.

The main topics were a deeper discussion on network adequacy and timely access in the Medi-Cal program; and a broader discussion on the negotiations for a new 1115 waiver. These are both parts of a evolution of Medi-Cal–not just expanding coverage, but to a different way of providing care.

TIMELY ACCESS: With regard to timely access, it seemed after that presentation even more urgent that the Governor sign SB964 (Hernandez), to improve network adequacy, which is now on his desk.

Many of the Committee’s participants had requested this briefing. DHCS (Department of Health Care Services, which administers Medi-Cal) and DMHC (over commercial markets and  most Medi-Cal managed care) are taking additional steps to determine ongoing compliance with network adequacy and timely access requirements, including a new timely access verification study announced by DHCS, public posting (for the first time ever) of DHCS medical audits, and annual reporting of network adequacy by DMHC as well as geoaccess mapping at the plan/provider level which is being used by both departments. SB964 would provide structure and support for this increased oversight.

The promise of Medi-Cal managed care is that Californians in managed care will have the same consumer protections whether they are enrolled in Medi-Cal managed care or through coverage on the job or coverage they buy as an individual. The Brown Administration has pointed to these California consumer protections like timely access to care as they worked to expand Medi-Cal managed care, moving almost a million kids from Healthy Families to Medi-Cal, imposing mandatory enrollment of managed care on hundreds of thousands of seniors and persons with disabilities, expanding managed care into rural areas, and now embarking on a “pilot project” that will affect 800,000 Californians covered by both Medi-Cal and Medicare. But if health plans use different networks for Medi-Cal than for commercial coverage, those networks should be surveyed separately. The Administration is taking some steps to provide more effective oversight but given the decades of complaints about lack of access in Medi-Cal managed care, more needs to be done.

WAIVER: The provider access discussion set the tone and helped to frame the main topic and purpose for yesterday’s gathering: the Medi-Cal waiver renewal process, which is about to move at a very fast clip.  The state is entering into negotiations with CMS on its Medi-Cal waiver renewal: lots of new ideas about expanding access to the remaining uninsured, as well as ideas about care delivery and payment methodologies will be tested over the next five years, with everything at stake for beneficiaries.

The state can certainly take pride in the many successes of the current “Bridge to Reform” waiver: the Low Income Health Programs that were an early Medicaid expansion, Delivery System Reform Incentive Pool (DSRIP), among others.  The waiver renewal will build on these successes and on lessons from any missteps.

Lots of unknowns and pitfalls here, particularly when DHCS starts looking at shared savings models where the savings achieved through any delivery system reforms or efficiencies would be shared with the Feds. Is California poised to become the next “accountable care state?” Some advocates express concern–since in the wrong hands or under certain state fiscal conditions, large scale accountable care arrangements can easily devolve into Medicaid block grants or per capita caps that take an already starved base of funding and constrain it into the future.

Like New York’s recent waiver and consistent with California’s grant application for system transformation (CalSIM), California expects to focus its waiver to emphasize payment and delivery system reform and re-aligned incentives for providers to coordinate care more efficiently. There was some discussion about new delivery models in order to improve access though this was long on aspirational vision and short on specifics.

Other advocates continued to raise issues around increasing access to care and coverage, and ensuring that the safety net survives and thrives–most notably the public hospitals, which they note put up the money to draw down the federal matching funds.

The state hopes to submit its waiver renewal request by mid-February (!) and technical advisory groups are forming now (track the process here).

OTHER UPDATES: The state is about to transition more seniors and people with disabilities into managed care as part of the Coordinated Care Initiative—but will beneficiaries have the access to coordinated care they need to manage chronic conditions? Gary Passmore of the Congress of California Seniors notes there’s a cost to not sorting this out early on—for care delivered too late, in the wrong settings for this population the costs can add up quickly.

In related news, DHCS also announced that it may delay the implementation of the pregnancy wrap and the wrap for recent lawful immigrants who are low-income, childless adults. This is not good news for pregnant women: once the pregnancy wrap is implemented, pregnant women up to 138%FPL will be eligible for no-cost, full-scope Medi-Cal (instead of pregnancy-only coverage) and pregnant women 139%FPL-208%FPL will remain in Covered California but with zero premiums and zero cost sharing. For recent lawful immigrants who are low-income childless adults, it is better news: they stay on state-only, zero-cost Medi-Cal but once the wrap is implemented they will be covered through Covered California but with zero premiums, zero copays and continued coverage for adult dental. Implementation of these coverage “wraps” was set for January 1 but may be delayed. More to follow on this.

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