|
DATE: |
December 10, 2024 |
31 |
SUBJECT
Title
AN ANALYSIS OF BARRIERS TO OPTIMAL MEDI-CAL TRANSFORMATION IMPLEMENTATION, A FEASIBILITY ASSESSMENT FOR A PUBLIC AWARENESS CAMPAIGN, AND DEVELOPMENT OF A HEALTHY SAN DIEGO TASKFORCE (DISTRICTS: ALL)
Body
OVERVIEW
Medi-Cal is a vital government program that provides healthcare coverage to low-income individuals and families throughout the state. Medi-Cal serves nearly a million people in San Diego County and continues to grow with the eligible population doubling over the past decade. Medi-Cal Transformation (formerly known as CalAIM) is an initiative under the Department of Health Care Services (DHCS) that includes broad reforms to the Medi-Cal system. This initiative seeks to advance positive social and health outcomes by addressing the social drivers of health and connecting individuals with community resources and services that support their overall well-being beyond simply access to medical treatment. Several Medi-Cal Transformation programs are targeted at providing specialty services for the most medically complex individuals as 5% of the highest need Medi-Cal members account for nearly half of all Medi-Cal spending.1 The primary programs within Medi-Cal Transformation that will facilitate the connection of these individuals with the services and supports they need are Enhanced Care Management (ECM) and Community Supports (CS). ECM and CS were developed with the intention that these services would be delivered by local providers who have experience and specialized knowledge about their communities and can provide services in the most accessible and culturally appropriate way.
Enhanced Care Management (ECM) supports members with complex clinical or non-clinical needs by connecting them with a lead care manager. ECM is intended to serve individuals from populations of focus including, but not limited to, individuals who are unhoused, have a diagnosis of a serious mental illness or substance use disorder, children and youth involved in the child welfare or foster care system, high utilizers of emergency care, and individuals transitioning to the community from incarceration. ECM services include:
|
• Outreach and Engagement |
• Member and Family Supports |
|
• Comprehensive Assessment and Care Management Plan |
• Health Promotion |
|
• Coordination and Referral to Supportive Services |
• Comprehensive Transitional Care |
|
• Enhanced Coordination of Care |
|
Community Supports (CS) are community-based services that address the social needs of individual Medi-Cal beneficiaries that will allow them to optimize their health. The fourteen Community Supports include:
|
• Housing Navigation• Personal Care Services |
|
|
• Housing Deposits |
• Home Modifications |
|
• Housing Tenancy Services |
• Medically Tailored |
|
• Short-term Post-Hospitalization Housing |
• Nursing Facility Transition/Diversion to Assisted Living |
|
• Recuperative Care |
• Nursing Facility Transition to Home |
|
• Respite Services |
• Sobering Centers |
|
• Day Habilitation Programs |
• Asthma Remediation |
Medi-Cal Transformation presents an opportunity to better serve the most vulnerable residents throughout San Diego County through its focus on shifting to a population health approach that addresses health inequity and the Social Drivers of Health (SDOH). Historically, Medi-Cal beneficiaries have faced more barriers to care, poorer quality of care, and ultimately worse outcomes. These health inequities result in negative impacts on lifespan, healthspan, and overall quality of life. Research has shown that non-medical factors such as income, housing, educational attainment, and access to healthy food, recreational space, reliable transportation, and a clean environment have profound impacts on individual health and well-being. These non-medical factors are collectively known as the SDOH, and research demonstrates they account for as much as 80-90% of an individual’s health outcomes.3
ECM and CS were designed to serve the neediest and most expensive Medi-Cal beneficiaries. DHCS estimates that approximately 3-5% of Medi-Cal membership will be eligible for these services with some variability based on region. According to data from DHCS and the four Medi-Cal Managed Care Plans (MCPs) contracted with DHCS for the County, it is estimated that nearly 50,000 Medi-Cal beneficiaries are eligible for enrollment in ECM and/or CS services in our County. The MCPs report that 26,645 out of the estimated 49,142 (54%) eligible Medi-Cal beneficiaries were enrolled in ECM in quarter two of 2024. MCPs also reported that only 4,101 out of the estimated 49,142 (8%) eligible Medi-Cal beneficiaries were enrolled in Community Supports in quarter two of 2024.6 We are approaching the completion of year three for Medi-Cal transformation implementation and a simple analysis of our current enrollment in CS reveals that over 45,000 of our most vulnerable residents are going without services that would help them improve their health and quality of life. These services include housing navigation, recuperative care, personal care services, sobering centers, and more. All of these services are in need of significant expansions in funding and resources throughout San Diego County.
Low enrollment in CS is also unfolding within the context of significant local budget constraints that are hindering the ability of the County to provide needed services for our residents. The Center for Medicare and Medicaid Services (CMS) Federal Agency has approved additional federal funding for Medi-Cal Transformation via section 1115 Waivers as well as CMS approval of "in lieu of” services. This allows Medi-Cal Managed Care Plans to reimburse healthcare providers and community-based organizations (CBOs) for a range of services that are not traditionally available through the Medicaid program. As a consequence of low enrollment, the San Diego region is leaving substantial sums of federal funding on the table that could be utilized by local healthcare providers, CBOs, and the County to optimally serve our most vulnerable residents through ECM and CS.
The County has several analyses currently underway evaluating the Medi-Cal Transformation Landscape as part of the Medicaid Taskforce as well as through contracted efforts undertaken by Partners in Care Foundation, Inc. Today’s item directs the Chief Administrative Officer (CAO) to report back to the Board of Supervisors (Board) with an action plan including staff recommendations for the County to implement based on these analyses. Today’s item also directs the CAO to perform a feasibility assessment regarding a Public Awareness Campaign on Medi-Cal Transformation throughout San Diego County and report back to the Board and directs the Healthy San Diego Joint Consumer and Professional Advisory Committee to establish a taskforce with the goal of increasing Community Supports enrollment.
RECOMMENDATION(S)
SUPERVISOR MONICA MONTGOMERY STEPPE AND SUPERVISOR NORA VARGAS
1. Direct the Chief Administrative Officer to report back to the Board of Supervisors in 90 days on findings from County contract CalAIM Enhanced Care Management (ECM) and Community Supports (CS) Community Capacity Assessment as well as reports that are part of the Medicaid Ad-Hoc Subcommittee.
a. The report back should include, but not be limited to, an analysis of the following factors affecting Medi-Cal Transformation implementation:
i. The impact of reimbursement rates on programmatic viability, sustainability, and staffing.
ii. Administrative and technical challenges including, but not limited to, the processes of contracting, eligibility verification, enrollment, authorization, service documentation, billing, and reimbursement.
iii. Staffing challenges and workforce development needs.
iv. Medi-Cal enrollees’ awareness of and experiences in accessing enhanced care management and community supports services.
v. Data sharing procedures, including participation in the Community Information Exchange.
b. Based on the analysis above, the Chief Administrative Officer should create an action plan which would include staff recommendations for the County of San Diego to implement.
2. Direct the Chief Administrative Officer to perform a feasibility assessment regarding a Public Awareness Campaign on Medi-Cal Transformation throughout San Diego County and report back to the Board of Supervisors in 90 days.
a. The assessment should include an analysis of potential fiscal and programmatic impacts to the County of delivering a public awareness campaign including, but not limited to, the following efforts:
i. Improve eligible Medi-Cal enrollees’ awareness of services available to them through enhanced care management and community supports services and pathways to accessing those services.
ii. Improve healthcare provider and community-based service provider awareness of the following:
1. General knowledge of the Medi-Cal Transformation Initiative.
2. Capacity and Infrastructure Transition, Expansion and Development (CITED) funding.
3. Administrative and technical assistance opportunities including the Technical Assistance Marketplace.
4. Healthy San Diego, SDAIM, and PATH Collaborative Planning and Implementation initiative (CPI).
3. Direct the Healthy San Diego Joint Consumer and Professional Advisory Committee to establish a taskforce with the goal of increasing enrollment in all fourteen Community Supports to 25% of eligible beneficiaries by January 1, 2026; 50% of eligible beneficiaries by January 1, 2027; and 90% of eligible beneficiaries by January 1, 2028.
EQUITY IMPACT STATEMENT
In the United States, health inequities continue to persist based on an individual’s race, ethnicity, sexual orientation, gender identity, and disability. Economic and community level factors such as socioeconomic status, geographic location, access to healthy food and recreational spaces, and transportation have substantial impacts on individual health outcomes. According to the 2022 San Diego County Health Equity Report Series, Black residents have the lowest life expectancy, worse outcomes in terms of physical, behavioral, and perinatal health as well as higher rates of non-communicable disease (heart disease, diabetes, and cancer), communicable disease, and musculoskeletal injury when compared to other racial groups. Improving access to supportive services through Medi-Cal Transformation programming will help address the needs of many vulnerable populations in the County of San Diego.
SUSTAINABILITY IMPACT STATEMENT
With the adoption of these recommendations, the County of San Diego will support Sustainability Goal #2 to provide just and equitable access to services and resources, and Sustainability Goal #4 to protect the health and well-being of everyone in the region. These actions will improve access to critical housing navigation services, behavioral healthcare, recuperative care, personal care, medically tailored meals, and beyond. Access to this array of services will help address the needs of many vulnerable populations in the County of San Diego.
FISCAL IMPACT
There is no fiscal impact associated with this action. There will be no change in net General Fund cost and no additional staff years.
BUSINESS IMPACT STATEMENT
N/A
Details
ADVISORY BOARD STATEMENT
N/A
BACKGROUND
Medi-Cal is a vital government program that provides healthcare coverage to low-income individuals and families throughout the state. The program is administered by the Department of Health Care Services (DHCS) and ensures beneficiaries have access to services, including doctor visits, hospital care, prescription drugs, and preventive care. Medi-Cal serves nearly a million people in San Diego County (County) and continues to grow with the eligible population doubling over the past decade.
Medi-Cal Transformation (formerly known as CalAIM) is an initiative under DHCS that includes broad reforms to the Medi-Cal system. Medi-Cal Transformation shifts Medi-Cal to a population health approach with the goals of improving access, quality, and outcomes for beneficiaries. This initiative seeks to advance positive social and health outcomes by addressing the social drivers of health and connecting individuals with community resources and services that support their overall well-being beyond access to medical treatment. The initiative also has programs targeted at providing specialty services for the most medically complex individuals as 5% of the highest need Medi-Cal members account for nearly half of all Medi-Cal spending.1 The primary programs within Medi-Cal Transformation that will facilitate the connection of these individuals with the services and supports they need are Enhanced Care Management (ECM) and Community Supports (CS). ECM and CS were developed with the intention that these services would be delivered by local providers who have experience and specialized knowledge about their communities and can provide services in the most accessible and culturally appropriate way.
Enhanced Care Management (ECM) supports members with complex clinical or non-clinical needs by connecting them with a lead care manager. ECM focuses on serving individuals from populations of focus including, but not limited to, individuals who are unhoused, have a diagnosis of a serious mental illness or substance use disorder, children and youth involved in the child welfare or foster care system, high utilizers of emergency care, and individuals transitioning to the community from incarceration. The lead care manager coordinates with the individual to ensure they can access the health and social services they need.
ECM services include:
|
• Outreach and Engagement • Member and Family Supports |
|
|
• Comprehensive Assessment and Care Management Plan |
• Health Promotion |
|
• Coordination and Referral to Supportive Services |
• Comprehensive Transitional Care |
|
• Enhanced Coordination of Care |
|
Community Supports (CS) are community-based services that address the social needs of individual Medi-Cal beneficiaries that will allow them to optimize their health. The fourteen Community Supports include:
|
• Housing Navigation• Personal Care Services |
|
|
• Housing Deposits |
• Home Modifications |
|
• Housing Tenancy Services |
• Medically Tailored |
|
• Short-term Post-Hospitalization Housing |
• Nursing Facility Transition/Diversion to Assisted Living |
|
• Recuperative Care |
• Nursing Facility Transition to Home |
|
• Respite Services |
• Sobering Centers |
|
• Day Programs |
• Asthma Remediation |
Medi-Cal Transformation presents an opportunity to better serve the most vulnerable residents throughout the County through its focus on shifting to a population health approach that addresses health inequity and the Social Drivers of Health (SDOH). Historically, Medi-Cal beneficiaries have faced more barriers to care, poorer quality of care, and ultimately worse outcomes. These health inequities result in negative impacts on lifespan, healthspan, and overall quality of life. Additionally, our current healthcare system continues to fail to address persistent health inequities resulting in significant negative fiscal impacts. A 2022 analysis found that health inequities in the United States account for roughly $320 billion in excess health spending annually and that this number could surpass $1 trillion by the year 2040 if changes are not made.2
Over the past several decades, research has highlighted how non-medical factors such as income, housing, educational attainment, and access to healthy food, recreational space, reliable transportation, and a clean environment have profound impacts on individual health and well-being. These non-medical factors are collectively known as SDOH and encompass the conditions in which people are born, grow, live, work and age. Research has shown that SDOH account for as much as 80-90% of an individual’s health outcomes.3 County Based Health Rankings and Roadmaps were developed to illustrate this interaction between health outcomes, the SDOH, and policies and programs.
County Health Rankings Model:
Homelessness represents one of the most significant social issues and injustices within our county and there is a substantial body of research demonstrating the long-term negative impacts of homelessness on individual health and wellbeing.4 The reasons homelessness has such negative impacts include high levels of psychological distress, sleep deprivation, exposure to violence and communicable disease, transportation challenges, lack of identification, difficulty obtaining and storing medications, and avoidance of the health care system due to previous experiences with stigma and discrimination.5
ECM and CS were designed to serve the neediest and most expensive Medi-Cal beneficiaries. DHCS estimates that approximately 3-5% of Medi-Cal membership will be eligible for these services with some variability based on region. According to data provided by DHCS and the four Medi-Cal Managed Care Plans (MCPs) contracted with DHCS for the County, it is estimated that nearly 50,000 Medi-Cal beneficiaries are eligible for enrollment in ECM and/or CS services in our County. The MCPs report that 26,645 out of the estimated 49,142 (54%) eligible Medi-Cal beneficiaries were enrolled in ECM in quarter two of 2024. MCPs also reported that only 4,101 out of the estimated 49,142 (8%) eligible Medi-Cal beneficiaries were enrolled in Community Supports in quarter two of 2024.6
We are nearing the completion of year three for Medi-Cal transformation implementation and simple analysis of our current enrollment in CS reveals that over 45,000 of our most vulnerable residents are going without services that would help them improve their health and quality of life, including services such as housing navigation, recuperative care, sobering centers, personal care services, and more. All of these service areas are in need of expansions in funding and resources in throughout San Diego County.
Low enrollment in CS is also unfolding within the context of significant local budget constraints that are hindering the ability of the County to provide needed services for our residents. The Center for Medicare and Medicaid Services (CMS) Federal Agency has approved additional federal funding for Medi-Cal Transformation via section 1115 Waivers as well as CMS approval of "in lieu of” services. This allows Medi-Cal Managed Care Plans to reimburse healthcare providers and community-based organizations (CBOs) for a range of services that are not traditionally available through the Medicaid program. As a consequence of low enrollment, the San Diego region is leaving substantial sums of federal funding on the table that could be utilized by local healthcare providers, CBOs, and the County to optimally serve our most vulnerable residents through ECM and CS.
The County has several analyses currently underway evaluating the Medi-Cal Transformation landscape as part of the Medicaid Taskforce as well as through contracted efforts undertaken by Partners in Care Foundation, Inc. Today’s item directs the Chief Administrative Officer (CAO) to report back to the Board of Supervisors with an action plan including staff recommendations for the County to implement based on these analyses. Today’s item also directs the CAO to perform a feasibility assessment regarding a Public Awareness Campaign on Medi-Cal Transformation throughout the County and report back to the Board of Supervisors. It also directs the Healthy San Diego Joint Consumer and Professional Advisory Committee to establish a taskforce with the goal of increasing Community Supports enrollment.
Optimal implementation of Medi-Cal Transformation throughout San Diego County represents a significant opportunity to better serve our most vulnerable residents. A brief review of the listed populations of focus and services available through ECM and CS reveals the scale of this opportunity as we see supports to address all of the major social challenges we face including homelessness, lack of recuperative care and sobering center beds, transitional supports for foster youth and individuals exiting the criminal justice system, and beyond. Medi-Cal Transformation presents a generational opportunity to build a more effective healthcare system that bolsters health equity, expands access to preventative care, and advances innovative care models that emphasize whole-person wellness. Such a system will best support San Diego’s diverse population, enhancing quality of life, and optimizing health outcomes across the state.
LINKAGE TO THE COUNTY OF SAN DIEGO STRATEGIC PLAN
Today’s proposed actions support the County of San Diego 2024-2029 Strategic Plan initiatives of Sustainability (Resiliency), Equity (Economic Opportunity), and Community (Quality of Life) by expanding access to support services for at-risk populations including, but not limited to, individuals who are unhoused, have a diagnosis of a serious mental illness or substance use disorder, children and youth involved in the child welfare or foster care system, high utilizers of emergency care, and individuals transitioning to the community from incarceration.
Respectfully submitted,
Monica Montgomery steppe nORA E. VARGAS
Supervisor, Fourth District Supervisor, First District
ATTACHMENT(S)
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