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
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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 for Medi-Cal managed care plans (MCP) and county behavioral health plans (BHP). DHCS oversees all MCPs to ensure the plans provide members with the best possible care and to increase transparency.
Monetary sanctions are being imposed on MCPs that did not meet or exceed the established minimum performance levels (MPL), meaning the plans failed to provide members with a level of care that reached the quality standards established by DHCS. Today’s actions are the result of the MCP contract, effective January 1, 2024, which significantly strengthened quality and health equity requirements for MCPs.
「加州致力於透過讓計劃合作夥伴對既定基準負責並推動可衡量的改進來提高醫療保健質量，」 DHCS 主任 Michelle Baass說。「透過加強問責制、促進健康公平、加強協作以及與各計劃合作，我們正在提升醫療服務水平，改善所有 Medi-Cal 會員的健康結果。透過這些共同努力，DHCS 旨在支持 Medi-Cal 管理式醫療計劃、縣級行為健康計劃和醫療服務提供者，為所有 Medi-Cal 會員提供更好的健康結果。
WHY THIS IS IMPORTANT: The quality ratings are part of DHCS’ Bold Goals 50×2025 initiative, which targets improvements in children’s health, reproductive care, cancer prevention, maternal health, and behavioral health integration. By releasing these ratings, DHCS encourages MCPs and BHPs to provide improved care, particularly in areas like preventive and primary care services as well as behavioral health services.
WHAT THIS MEANS FOR CALIFORNIANS: Based on the quality ratings, MCPs will take corrective actions, including providing more proactive care to members, such as supporting them in finding a primary care provider and scheduling well-child visits, helping with transportation needs to appointments and picking up prescriptions, assisting them with accessing programs like CalFresh, and screening for eligibility for Enhanced Care Management and Community Supports. MCPs will also ensure their network providers increase evening and weekend appointments and reduce wait times to improve access to care. Additionally, BHPs will focus on improving access to timely and culturally responsive behavioral health services. This includes reaching out to members to connect them with therapy and counseling and supporting them in managing serious mental health conditions and substance use disorders (SUD).
新的製裁措施：在與DHCS簽訂合約的24家醫療管理服務提供者中，有20家（83.3%）因未達到管理式醫療責任制（MCAS）品質指標中合約要求的最低醫療績效指標（MPL）而受到製裁，比2022年衡量年度（MY）的情況還要嚴重。制裁金額從 25,000 美元到 819,000 美元不等，總計 3,069,000 美元，低於 2022 財年。
MCAS 制裁是根據受影響人數、MCP 績效變化以及 MCP 健康場所指數得分等因素確定的。今年制裁的主要原因是兒童局部氟化物（TFL-CH）、兒童和青少年健康檢查以及子宮頸癌篩檢，由於這些措施對大量人口產生影響，因此它們加起來約佔制裁總數的 82%。超過 150 萬名會員未獲得 TFL-CH 服務，導致約 110 萬美元的罰款。醫療照護專業人員 (MCP) 應積極參與改善工作，例如會員和社區參與，以及改善醫療、牙科和行為健康等服務系統之間的健康資訊共享，以改善會員獲得和使用所有所需健康服務的機會。
除了對 MCP 進行品質評級外，DHCS 還發布了第二年的 BHP 行為健康責任制 (BHAS) 品質評分。對於縣級 BHP 而言，71% 的縣在至少一半的心理健康指標上達到或超過了基準。各縣在藥物濫用指標方面的表現類似，80% 的縣在至少一半的藥物濫用指標上達到或超過了基準。雖然今年沒有對必和必拓公司處以罰款，但執法行動將在未來幾年開始。DHCS致力於創建一個透明的系統，擁有可靠的數據，並建立長期的問責機制，以提供更好的行為健康護理。
如需更詳細了解績效指標，請參閱以下內容：
品質改進： DHCS 致力於支持 MCP 透過設定明確的目標、提供及時的數據以及與社區合作來提高預防性服務的可近性，從而改善其績效。DHCS 分享最佳實踐，提供技術援助，並創建區域合作組織，讓 MCP 可以討論挑戰和潛在的解決方案。2024 年，DHCS 啟動了兩項新的全州合作計劃，重點關注兒童預防服務和行為健康整合。
Additionally, DHCS has engaged with BHPs on quality improvement through regular Behavioral Health Regional Collaborative meetings to share best practices and quality improvement strategies. Further, DHCS has partnered with the Institute for Healthcare Improvement (IHI) on a Behavioral Health Demonstration Collaborative designed to enable whole-person care that seamlessly addresses the behavioral, physical, and health-related social needs of Medi-Cal members. Read the Quality Fact Sheet to learn more about how DHCS is working to improve quality of care for members.
ADDITIONAL INFORMATION: DHCS’ Comprehensive Quality Strategy focuses on improving health outcomes through the Bold Goals 50X2025 initiative. Since 2022, DHCS has been publicly releasing annual quality measure ratings for all MCPs and requiring quality improvement actions. Since 2023, DHCS has publicly released annual quality measure ratings for all BHPs and will begin requiring quality improvement actions. These efforts, as well as targeted audits of MCPs and BHPs and enhanced quality improvement and oversight, are aimed at improving health outcomes for millions of Californians. Assembly Bill 1642 (Chapter 465, Statutes of 2019) authorized DHCS to increase sanctions for MCPs that do not meet or exceed required MPLs. The MCP contracts, which became effective on January 1, 2024, promotes a more person-centered, equity-focused, and data-driven Medi-Cal program.
Additionally, in the behavioral health field, the Drug Medi-Cal Organized Delivery System Interagency Agreements and mental health plan contracts require BHPs to establish Quality Improvement Systems and to collect and submit performance measurement data required by DHCS, according to the Comprehensive Quality Strategy. DHCS also released Behavioral Health Information Notice 24-004 in December 2023 to clarify DHCS requirements for the BHPs’ Quality Improvement Systems. DHCS will launch the Behavioral Health Quality Improvement and Health Equity Framework in 2025, which will focus on improving BHAS measure performances.
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