加州要求 Medi-Cal 计划负责确保会员获得高质量、公平的医疗服务​​ 

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.​​ 

"加利福尼亚州在改善医疗服务方式方面一直处于领先地位。DHCS 主任 Michelle Baass 说："我们正在对 Medi-Cal 计划合作伙伴进行问责，同时也在与他们密切合作，以提高他们的评级。"通过这些共同努力，DHCS 力求增强计划的能力，支持医疗服务提供者为 Medi-Cal 所有成员实现更好的整体健康成果"。​​ 

重要意义：DHCS 正在为所有 MCP 和县行为健康计划发布 2022 衡量年 (MY) 的质量衡量评级，以帮助推动改进工作，支持 DHCS 的大胆目标50×2025。随着 DHCS 继续与 Medi-Cal 计划合作提高质量，Medi-Cal 会员可以期待看到更多的计划参与和外联活动，以确保他们的医疗需求得到优先考虑，特别是预防性护理和促进 Medi-Cal 会员健康和福祉的初级护理服务。​​ 

DHCS 致力于提高 Medi-Cal 的质量、可及性和健康公平性，并要求 Medi-Cal 计划对改善数百万加州人的健康状况负责。​​   

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.​​ 

所有未达到 MPL 要求的多边协商程序必须​​ 

• 提交修订后的综合质量战略，包括旨在达到或超过 2023 年里程碑要求的新干预措施。​​ 
• 详细说明该计划打算如何投入足够的资源和人员来提高质量。​​ 
• 与 DHCS 的质量团队密切合作，开展以数据为导向的改进工作，持续解决全州出现的不均衡问题。​​ 

今年是 DHCS 首次公布县行为健康计划的质量分数，但没有对这些计划进行处罚。今后几年将开始对各县采取执法行动。​​ 

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 50×2025 initiative.​​ 
• 通过区域学习协作和参与 CMS 婴儿健康儿童访问学习协作，为质量改进工具提供持续的技术援助和教程。​​ 
• 为所有 MCP 创建新的区域合作，以讨论区域障碍、差异和潜在的社区伙伴（这些基于区域的方法是 2023 年的新方法）。​​ 
• 主办 2023 年 DHCS 质量与健康公平会议，作为分享和交流质量与公平改进成功策略的论坛。​​ 
• 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.​​ 

计划绩效：根据与 DHCS 签订的合同，所有计划（包括 MCP 和县行为健康计划）都必须达到 DHCS 为每项 Medi-Cal 管理式医疗问责组合（MCAS）绩效衡量设定的 MPL。就多指标类集方案而言，虽然与 2021 多年期相比，大多数措施中达到多指标类集方案要求的报告单位比例有所上升，但一些措施中达到多指标类集方案要求的报告单位数量有所下降。​​ 

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.​​ 

在儿童健康领域，虽然大多数指标都有整体改善，达到 MPL 要求的报告单位百分比有所增加，但在半数儿童健康指标上，大多数多边协商进程仍难以达到 MPL 要求。此外，与 2021 财政年度相比，2022 财政年度儿童和青少年保健就诊措施的 MPL 增加了 3.62%。如果 MPL 与 2021 MY 保持一致，将有另外 27% 的报告单位达到 MPL 基准。这一点意义重大，因为儿童和青少年健康护理就诊量包括了一些就诊人数最多的成员。与 2021 年度的比率相比，52%的报告单位在这一指标上有所改进。​​ 

精神疾病急诊室就诊后的随访是另一个重点领域，约有 70% 的报告单位低于 MPL，但总体而言，与 2021 年相比，达到 MPL 的报告单位数量增加了约 20%。在急诊室就诊后的药物使用随访方面，医保计划表现突出，近 90% 的报告单位达到了 MPL。​​ 

就县级行为健康计划而言，各县在精神健康质量衡量标准方面总体表现良好，71% 的县在至少一半的精神健康衡量标准上达到了 MPL 要求，这些衡量标准涉及急诊室就诊后的随访、与精神疾病有关的住院治疗以及抗抑郁药物的管理（16% 的县在至少四分之三的精神健康衡量标准上达到了 MPL 要求）。各县在药物使用障碍（SUD）衡量标准方面的表现类似，80% 的县至少有一半的衡量标准达到了 MPL 要求，这些衡量标准涉及急诊室就诊后的药物使用障碍随访、阿片类药物使用障碍药物疗法的使用以及药物使用障碍治疗的启动和参与，但没有一个县至少有四分之三的药物使用障碍衡量标准达到了 MPL 要求。​​ 

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.​​ 

作为提高多边合作中心透明度和问责制承诺的一部分，健康与社会服务部去年首次公开发布了所有多边合作中心的质量衡量评级，并要求多边合作中心立即采取具体行动来提高其质量评级。这些努力以及有针对性的多级保健计划审计和强化质量指标，旨在改善数百万加州人的健康状况。纽森州长颁布了第1642 号议会议案（2019 年法规，第 465 章），授权 DHCS 对未能达到特定绩效水平的多方合作伙伴计划（MCPs）加大罚款力度。1,2024 ，新的 Medi-Cal Medi-Cal 合同生效，以提供一个更加以人为本、注重公平和数据驱动的 Medi-Cal 计划。​​ 

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