California Holds Medi-Cal Plans Accountable for Ensuring Members Have Access to High Quality, Equitable Care

SACRAMENTO — The Department of Health Care Services (DHCS) today published quality ratings and imposed monetary sanctions on Medi-Cal managed care plans (MCP) that do not meet required performance levels. These actions are bolstered by the new MCP model contract that took effect on January 1, 2024, and significantly strengthens quality and health equity requirements for MCPs. Additionally, for the first time, DHCS is releasing quality ratings for county behavioral health plans, based upon performance.

“California continues to be a leader in improving how health care is delivered. We are holding our Medi-Cal plan partners accountable while also working closely with them to improve their ratings," said DHCS Director Michelle Baass. “Through these combined efforts, DHCS seeks to empower plans and support providers in achieving overall better health outcomes for all Medi-Cal members."

WHY THIS IS IMPORTANT: DHCS is issuing quality measure ratings for Measurement Year (MY) 2022 for all MCPs and county behavioral health plans to help drive improvement in support of DHCS' Bold Goals 50x2025. As DHCS continues working with Medi-Cal plans on quality improvement, Medi-Cal members can expect to see more plan engagement and outreach to ensure their medical needs are prioritized, especially preventive care and primary care services that promote the health and well-being of Medi-Cal members.

DHCS is committed to improving quality, accessibility, and health equity in Medi-Cal and is holding Medi-Cal plans accountable for improving health outcomes for millions of Californians.

WHAT THIS MEANS FOR CALIFORNIANS: Medi-Cal members should expect better care coordination across all of their services, so the health care delivery system works for the member, rather than having to bear the burden of health care fragmentation. For example, the parents of child and adolescent members should expect their providers and plans to proactively reach out to them to schedule well-child visits and address barriers to accessing care, such as arranging transportation, supporting enrollment in programs like CalFresh, and screening for eligibility in Enhanced Care Management. Additionally, women of reproductive age should expect their providers and plans to contact them for services, such as breast and cervical cancer screening, in a manner convenient for them.

NEW SANCTIONS: Eighteen of the 25 MCPs will be fined due to performance rates below designated Minimum Performance Levels (MPLs), which is down from 22 plans in MY 2021. For MY 2022, MCP sanctions ranged from $25,000 to $890,000 based upon factors that include the eligible population impacted, the degree to which a plan fell below MPLs, the degree of improvement or decline from the previous MY, and the plan's Healthy Places Index (HPI) score for assigned membership to that plan.

All MCPs failing to meet MPLs are required to:

Submit a revised comprehensive quality strategy, including new interventions designed to meet or exceed the required 2023 milestones.
Detail how the plan intends to devote adequate resources and staff to quality improvements.
Work closely with DHCS' quality team on data-driven improvement efforts that will address disparities experienced throughout the state on an ongoing basis.

This is the first year DHCS is releasing quality scores for county behavioral health plans, but there are no sanctions being issued to these plans. Enforcement actions will begin for counties in future years.

SUPPORTING QUALITY: DHCS is committed to working closely with MCPs to improve performance ratings by taking the following actions to support plans and statewide quality efforts:

Setting improvement goals for all MCPs on children's and reproductive health/cancer preventive services to be achieved annually and working toward providing real-time data to assess the effectiveness of quality improvement efforts.
Partnering with communities to improve well-infant visits by sharing best practices to assist improvement efforts, in collaboration with plan partners and the Centers for Medicare & Medicaid Services (CMS), as a part of the broader Bold Goals 50x2025 initiative.
Providing ongoing technical assistance and tutorials for quality improvement tools through regional learning collaboratives and participation in the CMS Infant Well-Child Visit Learning Collaborative.
Creating new regional collaboratives for all MCPs to discuss regional barriers, disparities, and potential community partners (these regional-based approaches were new in 2023).
Hosting the DHCS Quality & Health Equity Conference in 2023 as a forum for plans to share and network successful strategies in quality and equity improvement.
Launching two new statewide learning collaboratives in 2024, one focused on improving and scaling children's preventive services and the other focused on behavioral health integration and improved collaboration between MCPs and county behavioral health plans.

PLAN PERFORMANCE: Under their contract with DHCS, all plans (both MCPs and county behavioral health plans) are required to meet the DHCS established MPLs for each Medi-Cal Managed Care Accountability Set (MCAS) performance measure. For MCPs, while the percentage of reporting units meeting MPLs increased for most measures when compared to MY 2021, some measures had a decrease in the number of reporting units meeting MPLs.

Reporting units are defined as the smallest geographic boundary from which network adequacy ratios are determined and MCP quality performance measure rates and incentive programs are based. A reporting unit may be a single county or an aggregate of counties with less populated areas. For MY 2022, there are a total of 56 MCP reporting units across 25 MCPs.

Additionally, DHCS held MCPs accountable to more measures in 2022 than in 2021. As a result, the total sanction amount across all plans increased significantly, which was driven by large population-impacted numbers for two measures (well-child visits and cervical cancer screening). These two measures account for more than 70 percent of the total sanction amount.

In the children's health domain, while most of the measures showed overall improvement with an increase in the percentage of reporting units meeting MPLs, most MCPs continue to struggle to meet MPLs on half of the children's health measures. In addition, the MPL for the child and adolescent well-care visits measure increased for MY 2022 compared to MY 2021 by 3.62 percent. If the MPL remained the same as in MY 2021, an additional 27 percent of reporting units would have met MPL benchmarks. This is significant since the child and adolescent well-care visits measure includes some of the highest number of members. When compared to their MY 2021 rates, 52 percent of reporting units improved on this measure.

The follow up after emergency department visit for mental illness measure is another area of focus, with about 70 percent of reporting units falling below MPL, although overall, the number of reporting units meeting MPL improved by about 20 percent compared to MY 2021. MCPs demonstrated strong performance in the follow up after emergency department visit for substance use measure, with almost 90 percent of reporting units meeting MPL.

For county behavioral health plans, counties overall performed well on mental health quality measures, with 71 percent of counties meeting MPLs on at least half of the mental health measures related to follow up after emergency department visits and hospitalizations related to mental illness, and management of antidepressant medications (and 16 percent of counties meeting MPLs on at least three-quarters of these mental health measures). County performance was similar on substance use disorder (SUD) measures, with 80 percent of counties meeting MPLs for at least half of the measures related to follow up after emergency department visits for SUD, use of pharmacotherapy for opioid use disorder, and initiation and engagement with SUD treatment, but no counties met MPLs on at least three-quarters of these SUD measures.

ADDITIONAL INFORMATION: DHCS' Comprehensive Quality Strategy outlines the pathway for achieving improvement through the Bold Goals 50X2025 initiative, which will enhance quality measures across children's and women's preventive services, maternal health care outcomes, and behavioral health integration, as well as maintaining strong performance in adult chronic disease outcomes. DHCS evaluates quality scores annually and imposes financial sanctions on MCPs that do not meet required performance targets.

As part of a pledge to increase transparency and accountability for MCPs, DHCS last year publicly issued quality measure ratings for all MCPs for the first time and required immediate and concrete action from MCPs to improve their quality ratings. These efforts, as well as targeted audits of MCPs and enhanced quality metrics, are aimed at improving health outcomes for millions of Californians. Governor Newsom enacted Assembly Bill 1642 (Chapter 465, Statues of 2019) to provide DHCS with the authority to increase monetary sanctions for MCPs' failure to meet certain performance levels. On January 1, 2024, the new MCP contract went into effect to deliver a more person-centered, equity-focused, and data-driven Medi-Cal program.

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