加州要求加州醫療補助健康保健計劃負責確保會員獲得高品質、公平的護理​​ 

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.​​ 

"加州在改善醫療照護提供方式方面持續領先。DHCS 主任 Michelle Baass 表示：「我們要求 Medi-Cal 計劃合作夥伴負責，同時也與他們密切合作，以改善他們的評等。「透過這些共同努力，DHCS 尋求賦予計劃能力並支援服務提供者，為所有 Medi-Cal 會員實現整體更好的健康成果」。​​ 

重要原因：DHCS 將發布所有 MCP 和縣行為健康計劃 2022 衡量年度 (MY) 的品質衡量評級，以幫助推動改進，支持 DHCS 的50×2025 大膽目標。隨著 DHCS 繼續與 Medi-Cal 計劃合作改善品質，Medi-Cal 會員可望看到更多的計劃參與和外展活動，以確保他們的醫療需求得到優先處理，特別是促進 Medi-Cal 會員健康和福祉的預防性護理和基本護理服務。​​ 

DHCS 致力於改善 Medi-Cal 的品質、可及性和健康公平性，並要求 Medi-Cal 計劃對改善數百萬加州人的健康結果負責。​​   

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.​​ 

所有未能達到 MPL 的 MCP 必須：​​ 

• 提交修訂後的全面品質策略，包括旨在達到或超過 2023 年所需里程碑的新干預措施。​​ 
• 詳細說明該計劃如何將足夠的資源和員工投入質量改善。​​ 
• 與 DHCS 的品質團隊密切合作，進行資料驅動的改善工作，持續解決全州所經歷的差異問題。​​ 

今年是 DHCS 首次公布縣行為健康計劃的品質評分，但沒有對這些計劃進行制裁。將於未來幾年開始對各縣採取執法行動。​​ 

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.​​ 
• 通過區域學習合作和參與 CMS 嬰兒健康兒童訪問學習協作，提供持續的技術協助和提供質量改善工具的教程。​​ 
• 為所有 MCP 創建新的區域合作夥伴，以討論區域障礙、差異和潛在社區合作夥伴（這些基於區域的方法在 2023 年是新的）。​​ 
• 於 2023 年主辦 DHCS 品質與健康公平會議，作為計劃分享和網路品質和公平改進成功策略的論壇。​​ 
• 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.​​ 

計劃的績效：根據與 DHCS 簽訂的合約，所有計劃（包括 MCP 和縣行為健康計劃）都必須達到 DHCS 為每項 Medi-Cal 管理性護理責任集 (MCAS) 績效測量設定的 MPL。就 MCP 而言，與 2021 MY 相比，雖然大多數措施中符合 MPL 的報告單位百分比有所增加，但某些措施中符合 MPL 的報告單位數量有所減少。​​ 

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.​​ 

在兒童健康領域中，雖然大多數衡量指標顯示整體改善，達到 MPL 的報告單位百分比增加，但大多數 MCP 在半數兒童健康衡量指標上仍難以達到 MPL。此外，與 2021 財政年度相比，2022 財政年度的兒童和青少年健康照護門診的強制性供款（MPL）增加了 3.62%。如果 MPL 與 2021 MY 相同，則會有額外 27% 的報告單位符合 MPL 基準。這是很重要的，因為兒童和青少年健康照護就診計畫包括一些人數最多的會員。與 2021 MY 比率相比，52% 的報告單位在此項指標上有所改善。​​ 

精神疾病急診室就診後的後續追蹤是另一個焦點，約有 70% 的報告單位低於 MPL，不過整體而言，符合 MPL 的報告單位數目比 2021 年度提高了約 20%。MCP 在急診室就診後的後續藥物使用量測中表現優異，幾乎有 90% 的報告單位符合 MPL。​​ 

就縣級行為健康計劃而言，縣級在心理健康品質評量方面整體表現良好，71% 的縣至少有一半的心理健康評量符合強制性邊界值，這些心理健康評量與急診室就診後的追蹤、與精神疾病有關的住院，以及抗憂鬱藥物的管理有關（16% 的縣至少有四分之三的心理健康評量符合強制性邊界值）。各縣在藥物使用障礙 (SUD) 措施方面的表現類似，80% 的縣在至少一半的 SUD 急診室就診後追蹤、阿片類藥物使用障礙的藥物治療，以及 SUD 治療的開始和參與等相關措施方面達到 MPL，但沒有縣在至少四分之三的 SUD 措施方面達到 MPL。​​ 

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.​​ 

作為提高 MCPs 透明度和問責性承諾的一部分，DHCS 去年首次公開發佈了所有 MCPs 的品質評量評級，並要求 MCPs 立即採取具體行動以改善其品質評級。這些努力，以及針對 MCP 的稽核和強化的品質指標，都是為了改善數百萬加州人的健康成果。州長 Newsom 頒佈了第1642 號議會法案（2019 年法規第 465 章），賦予 DHCS 對 MCP 未達到特定績效水平提高金錢制裁的權力。新的 MCP 合約於 1 月1,2024 生效，以提供一個更以人為中心、更注重公平和資料驅動的 Medi-Cal 計劃。​​ 

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