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DATE: |
December 10, 2024 |
14 |
SUBJECT
Authorize Revenue Agreements with Medi-Cal Managed Care Plans, single source procurement, and ACCEPTANCE OF CHILDREN AND YOUTH BEHAVIORAL HEALTH INITIATIVE GRANT FUNDING (DISTRICTS: ALL)
OVERVIEW
On May 23, 2023 (06) the San Diego County Board of Supervisors (Board) approved the San Diego Advancing and Innovating Medi-Cal (SDAIM) Roadmap and recommitted to providing opportunities for Medi-Cal members in San Diego County to achieve better health outcomes and reduce health disparities. The SDAIM Roadmap was developed to align the County of San Diego (County) priorities with the Medi-Cal Transformation Initiative, formerly referred to as California Advancing and Innovating Medi-Cal (CalAIM). Medi-Cal Transformation is the California Department of Health Care Services (DHCS) long-term commitment to improve the quality of life and health outcomes of Medi-Cal members by creating a more coordinated, person-centered, and equitable health system.
Under Medi-Cal Transformation, DHCS is requiring Medi-Cal Managed Care Plans (MCPs) to collaborate with Local Health Departments (LHDs) to create a reimagined Population Needs Assessment (PNA). This new PNA promotes more robust community engagements and greater alignment with MCPs, LHDs, and community stakeholders. This will streamline the separate but related health needs assessments that have historically been conducted by the County, MCPs, and the Hospital Association of San Diego & Imperial Counties (HASD&IC).
Additionally, Medi-Cal Transformation affords an opportunity for the County to provide and bill for care management and community health promotion services through Enhanced Care Management (ECM), Community Supports (CS), and Community Health Worker (CHW) services. Billing for these key services will help address County budget constraints and ensure sustainability, while increasing access to quality services for Medi-Cal members in San Diego County.
Furthermore, to support sustainability and access to services, the County applied for and was awarded $1,500,000 through the DHCS Children and Youth Behavioral Health Initiative (CYBHI) Evidence-Based Practices and Community-Defined Evidence Practices (EBP/CDEP) Grant Program. This funding will support the County’s Healthy Families America program to expand the eligibility criteria for access to early childhood home visiting services focused on prevention, early intervention, and resiliency for children and youth.
Today’s action requests the Board to authorize the following recommendations:
1. Authorize revenue agreement(s) with Medi-Cal MCPs serving San Diego County of up to $3,000,000 for the period of July 1, 2025 through June 30, 2028 to support the PNA.
2. Authorize a single source contract with the HASD&IC to assist with community engagement to support the local comprehensive PNA.
3. Authorize revenue agreement(s) with Medi-Cal MCPs serving San Diego County to allow the County to provide and bill for ECM, CS, and CHW services.
4. Authorize the acceptance of the Children and Youth Behavioral Health Initiative, Healthy Families America grant agreement and funding.
5. Authorize application and acceptance of future funding opportunities to support Medi-Cal Transformation.
This item supports the County vision of a just, sustainable, and resilient future for all, specifically those communities and populations in San Diego County that have been historically left behind, as well as our ongoing commitment to the regional Live Well San Diego vision of healthy, safe, and thriving communities. This will be accomplished by building a better service delivery system that emphasizes quality, equity, sustainability, and transparency.
RECOMMENDATION(S)
CHIEF ADMINISTRATIVE OFFICER
1. Authorize the acceptance of up to $3,000,000 in total funds from Blue Shield of California Promise Health Plan, Community Health Group, Kaiser Foundation Health Plan, Inc., and/or Molina Healthcare of California to meet the California Department of Health Care Services Population Needs Assessment requirements for the period of July 1, 2025 through June 30, 2028, and authorize the Deputy Chief Administrative Officer, Health and Human Services Agency, or designee, to execute revenue agreement(s) as necessary including any extensions, amendments, and/or revisions thereto that do not materially impact or alter either the services or funding level.
2. In accordance with Board Policy A-87, Competitive Procurement, approve and authorize the Director, Department of Purchasing and Contracting, to enter into negotiations with the Hospital Association of San Diego & Imperial Counties and subject to successful negotiations and determination of a fair and reasonable price, award a contract for Community Health Needs Assessment community engagement support for an Initial Term of up to one year, and 2 additional one-year option terms and up to an additional six months, if needed, and to amend the contract as needed to reflect changes to services and funding, subject to the availability of funds and the approval of the Deputy Chief Administrative Officer, Health and Human Services Agency.
3. Authorize the acceptance of up to $1,000,000 in total funds for the period of July 1, 2025 through June 30, 2026 and up to $2,000,000 in total funds for the period of July 1, 2026 through June 30, 2027 from Blue Shield of California Promise Health Plan, Community Health Group, Kaiser Foundation Health Plan, Inc., and/or Molina Healthcare of California for delivering Enhanced Care Management, Community Supports, and Community Health Worker services to eligible Medi-Cal members and authorize the Deputy Chief Administrative Officer, Health and Human Services Agency, or designee, to execute revenue agreement(s) as necessary including any extensions, amendments, and/or revisions thereto that do not materially impact or alter the services or funding level.
4. Authorize the acceptance of $1,500,000 in grant funds from the Department of Health Care Services for the Children and Youth Behavioral Health Initiative to support Healthy Families America for the period of July 1, 2024 through June 30, 2026 and authorize the Deputy Chief Administrative Officer, Health and Human Services Agency, or designee, to execute grant documents as necessary including any extensions, amendments, and/or revisions thereto that do not materially impact or alter the services or funding level.
5. Authorize the Deputy Chief Administrative Officer, Health and Human Services Agency, or designee, to apply for and accept future funding opportunities to support implementation of Medi-Cal Transformation in San Diego County.
EQUITY IMPACT STATEMENT
Medi-Cal is the Medicaid program for California, a public health insurance program that provides needed health care services to eligible individuals. As of July 2024, 952,452 individuals were enrolled in Medi-Cal in San Diego County, representing roughly one-third of the county population and the second largest Medi-Cal population in California. Medi-Cal members represent various demographic backgrounds and those who have been historically underserved including Black, Indigenous, and People of Color (BIPOC), women, persons with disabilities, immigrants, youth, and the LGBTQ+ community. Local data indicates that as of July 2024, individuals between 19 to 44 years old represent the largest Medi-Cal population in San Diego County (38%), followed by children 0 to 18 years old (32%), adults 45 to 64 years old (20%), and adults 65 years of age and older (10%). Among Medi-Cal members with a reported race/ethnicity, approximately 61% were Hispanic, 22% were White, 10% were Asian, 7% were Black, and under 1% were American Indian and Alaska Native.
Medi-Cal members face significant disparities in terms of access, quality of care, and health outcomes. Healthcare Payments Data indicates that Medi-Cal members in San Diego County had higher prevalence rates of Diabetes, Ischemic Heart Disease, COPD, Asthma, Dementia, and Stroke compared to those enrolled in commercial health plans. Medi-Cal members are also more likely to experience higher rates of emergency care use compared to commercial members. In 2023, Black/African Americans were found to experience the highest rates of emergency room visits (61.5 per 1,000 members) and have the highest rate of emergency room visits resulting in hospitalization (5.9 per 1,000 members) among Medi-Cal Managed Care Plan members. According to State and local data, Black infants in San Diego County are nearly three times more likely to die during their first year, 60% more likely to be born prematurely, and almost two times more likely to be born with low birth weight. Recognizing the intersectionality of race, socioeconomic status, and health outcomes is essential to fostering a healthcare system that is truly inclusive and just. As a major source of healthcare coverage, Medi-Cal can help advance equity goals and reduce disparities by increasing access to health care, social services, and identifying new and innovative approaches to service delivery.
SUSTAINABILITY IMPACT STATEMENT
Today’s proposed actions support the County of San Diego Sustainability Goal #2 to provide just and equitable access to County services and Sustainability Goal #4 to protect the health and well-being of everyone in the region. These goals will be accomplished by increasing access and providing critical services to Medi-Cal members and supporting a collaborative and comprehensive assessment of health and social care needs among San Diego County population.
FISCAL IMPACT
Recommendations #1 & #2: Authorize Revenue Agreement(s) to receive funding to support a Population Needs Assessment & Authorize Single Source Procurement
Funds for these requests are not included in the Fiscal Year (FY) 2024-26 Operational Plan in the Health and Human Services Agency. If approved, this request will have no fiscal impact in FY 2024-25 and will result in estimated annual costs and revenue of up to $1,000,000 from FY 2025-26 through FY 2027-28 for a total of $3,000,000 to support the Population Needs Assessment. Approximately $111,000 of this funding will be allocated for the procurement of Community Health Needs Assessment community engagement support. The funding sources are Medi-Cal Managed Care Plans. Funds for subsequent years will be included in future operational plans. There will be no change in net General Fund cost and no additional staff years.
Recommendation #3: Authorize Revenue Agreement(s) to receive funding for Enhanced Care Management, Community Supports, and Community Health Worker services delivered by the County of San Diego
Funds for this request are not included in the FY 2024-26 Operational Plan in the Health and Human Services Agency (HHSA). If approved, this request will have no fiscal impact in FY 2024-25 and will allow for revenue of up to $1,000,000 to be received in FY 2025-26 and potentially up to $2,000,000 in FY 2026-27 to offset operational costs for identified programs that may qualify for reimbursement as Enhanced Care Management, Community Supports, and Community Health Worker services based on successful negotiations with local Medi-Cal Managed Care Plans. The actual amount of revenue and timing of receipts will depend on recommendations received from the contractor analysis anticipated in January as to what services are most feasible to begin implementation first. Any funds that are received will be applied toward existing ongoing costs within HHSA. The funding sources are Medi-Cal Managed Care Plans. Funds for subsequent years will be included in future operational plans. There will be no change in net General Fund cost and no additional staff years.
Recommendation #4: Authorize to accept grant funding from the California Department of Health Care Services for the Children and Youth Behavioral Health Initiative to support Healthy Families America
Funds for this request are included in the FY 2024-26 Operational Plan in the Health and Human Services Agency. If approved, this request will result in costs and revenue of $355,243 in FY 2024-25 and costs and revenue of $1,144,757 in FY 2025-26. The funding source is an award from the California Department of Health Care Services. There will be no change in net General Fund cost and no additional staff years.
Recommendation #5: Authorize to apply for funding opportunities to support Medi-Cal Transformation
There is no fiscal impact related to this recommendation. There will be no change in net General Fund cost and no additional staff years.
BUSINESS IMPACT STATEMENT
N/A
Details
ADVISORY BOARD STATEMENT
The Health Services Advisory Board voted to support these recommendations at its meeting on November 5, 2024.
BACKGROUND
Medi-Cal, California’s Medicaid program, is a public health insurance program that provides needed health and social care services to nearly one million San Diego County residents. In San Diego County, there are four Medi-Cal Managed Care Plans (MCPs) contracted with the California Department of Health Care Services (DHCS) to administer the delivery of Medi-Cal benefits to members. In January 2022, DHCS began implementing the Medi-Cal Transformation Initiative, formerly referred to as California Advancing and Innovating Medi-Cal (CalAIM), which is DHCS’ long-term commitment to improve the quality of life and health outcomes of Medi-Cal members by creating a more coordinated, person-centered, and equitable health system.
The County of San Diego (County) is a key partner in the Medi-Cal program locally, playing a role through Healthy San Diego, the organizational structure created in the implementation of San Diego County’s Managed Care Model. Through this collaborative partnership, local MCPs enter into Memorandums of Understanding (MOU) with the Health and Human Services Agency (HHSA) and individual departments to ensure care coordination on behalf of Medi-Cal members. Through Healthy San Diego, HHSA and MCPs participate in and share results from community health and Population Needs Assessments (PNA) to identify needs and inform current and future services provided to Medi-Cal members in the community.
In July 2022, the San Diego Advancing and Innovating Medi-Cal (SDAIM) Unit was established within the County Medical Care Services Department to support the local Medi-Cal Transformation implementation. Shortly after, the SDAIM Roadmap was developed to facilitate alignment of County and regional priorities with the Medi-Cal Transformation initiative, and foster coordination and collaboration between County departments, MCPs, health and social care providers, community organizations, consumers, and advocates. The SDAIM Roadmap clarifies the role of SDAIM based on stakeholder input and outlines key priority areas. Each of these priorities are linked to strategic actions that are supported by today’s recommendations.
Recommendation #1: Authorize Revenue Agreement(s) to Support the Population Needs Assessment
Under Medi-Cal Transformation, DHCS launched the Population Health Management Initiative in 2023 to proactively assess and address the care needs of Medi-Cal members with tailored interventions to improve health outcomes across the State. Thus, DHCS reimagined the Population Needs Assessment (PNA), a mechanism for MCPs to identify the priority needs of their local communities and members and to identify health disparities. DHCS introduced new requirements for the PNA to promote the MCPs to meaningfully participate in Community Health Assessments (CHA) and Community Health Improvement Plans (CHIP), conducted by Local Health Jurisdictions. This includes a central requirement that MCPs collaborate with Local Health Departments (LHDs), which is the County Public Health Services Department (PHS), instead of each conducting their own assessment. Additionally, it requires local MCPs to contribute resources to PHS in the form of funding and/or in-kind staffing, starting on January 1, 2025.
Community Health Assessment (CHA) and Community Health Improvement Plan (CHIP)
Every three years, PHS publishes the Live Well San Diego CHA, which captures health and demographic data. The CHA identifies health and well-being concerns and is a “living document” used to identify emerging issues, develop and guide priorities, determine additional data needs, and plan projects. The CHIP then utilizes the results of CHA activities and the community health improvement process to create a plan, not limited to issues clarified within traditional public health or health services categories, but may include environmental, business, economic, housing, land use, and other community issues indirectly affecting the public's health. The CHIP planning process involves an ongoing collaborative, community-wide effort to identify, analyze, and address health problems; assess applicable data; develop measurable health objectives and indicators; inventory community assets and resources; identify community perceptions; develop and implement coordinated strategies; identify accountable entities; and cultivate community ownership of the process. PHS conducts CHAs and CHIPs in collaboration with a broad array of community stakeholders. Completion of the CHA and CHIP are necessary to obtain and maintain Public Health Accreditation Board accreditation.
DHCS’ vision for the reimagined PNA promotes closer collaboration with PHS, as well as with hospitals, tribal partners, community clinics, community-based organizations, Medi-Cal members, and other community stakeholders to deepen each MCP’s understanding of its members and strengthen its relationship with the community.
The goals for the PNA include ensuring a clear understanding of the health needs, health disparities, and social needs of members, identifying available resources and gaps in resources that affect members’ health and social needs, promoting strong engagement with local communities, and creating a comprehensive strategy for addressing the specific disparities and gaps in care and resources identified in the PNA. This strategy will streamline the separate but related health needs assessments conducted by the County, MCPs, and the Hospital Association of San Diego & Imperial Counties (HASD&IC).
Today’s action requests the San Diego County Board of Supervisors (Board) authorize revenue agreement(s) with Medi-Cal MCPs serving San Diego County of up to $3,000,000 for the period of July 1, 2025 through June 30, 2028 to support the PNA.
Recommendation #2: Authorize Single Source Contract to Support the Population Needs Assessment
Through HASD&IC’s role as the representative for hospital systems in San Diego County, they facilitate the local Community Health Needs Assessment (CHNA), which is an IRS regulatory requirement that private, not-for-profit (tax-exempt) hospitals must conduct once every three years. In 2022, HASD&IC expanded their CHNA process to include every private hospital, health system, health district, and behavioral health hospital in San Diego County in a collective effort to better understand the health and social needs of San Diego communities.
Today’s action requests the Board authorize a single-source contract with HASD&IC for the procurement of new CHNA community engagement strategies to support the PNA for an Initial Term of up to one year, and 2 additional one-year option terms and up to an additional six months, if needed. These new and enhanced strategies include gathering community input through focus groups, key informant interviews, field interviews, online surveys, and providing incentives to community members for their participation. HASD&IC’s annual price of up to $111,000 is deemed fair and reasonable based on a comparative analysis of County contracts with similar deliverables and services.
This request is an exception to Board Policy A-87 Competitive Procurement, under Section D-3 as this procurement is for services from a provider with unique knowledge, skill, or ability not available from other sources. As the only association that represents local health systems, HASD&IC is uniquely positioned to conduct the assessment in accordance with the new State PNA requirements based on their experience as the longtime lead of the collaborative CHNA and their existing, long-standing relationships with health systems, hospitals, tribal partners, community clinics, community-based organizations, Medi-Cal members, and other community stakeholders in San Diego County. In addition to possessing the experience, tools, and capacity to perform the assessment, through these partnerships, HASD&IC represents the 38 hospitals and integrated health systems in San Diego and Imperial County and through this partnership with local health systems, they have a unique level of access to community members to engage stakeholders and people with lived experience in focus groups, key informant interviews, field interviews, and surveys that will provide the information needed to meet the new PNA requirements.
Recommendation #3: Authorize Revenue Agreement(s) for Enhanced Care Management, Community Supports, and Community Health Worker Services
Enhanced Care Management (ECM), Community Supports (CS), and Community Health Workers (CHWs) are major components of Medi-Cal Transformation. ECM is person-centered care management provided primarily through in-person engagement where members live, seek care, and choose to access services. ECM is part of the broader Population Health Management system design through which MCPs offer care management interventions at different levels of intensity based on member need and for the most vulnerable Medi-Cal members. CS, also known as “In-Lieu of Services,” are new services offered to eligible Medi-Cal members as cost effective alternatives to traditional medical services or settings. There are 14 CS services designed to address social drivers of health, including Housing Navigation, Housing Deposits, Recuperative Care, Medically Tailored Meals, Asthma Remediations, among others, and these services are provided by community-based organizations and other social care providers through contracts with MCPs. CHW services are a new Medi-Cal benefit and an integral part of ECM and CS services. CHW services are preventive health services to prevent disease, disability, and other health conditions or their progression; to prolong life; and promote physical and mental health and well-being. CHWs may include individuals known by a variety of job titles, including promotores, community health representatives, navigators, and other non-licensed public health workers, including violence prevention professionals.
In December 2023, through a competitive procurement process, a contractor was selected to assess County infrastructure including staffing, case management and outreach systems, data sharing capability, billing systems, and referral processes for County delivered services that are similar to ECM, CS, and CHW services. The goal of this assessment is to assess the County’s readiness and provide recommendations to contract with local MCPs to provide ECM, CS and/or CHW services. Final recommendations are anticipated to be received in January 2025. The contract is funded through the DHCS Providing Access and Transforming Health Capacity and Infrastructure Transition, Expansion and Development Initiative. The results of the assessment will be used to create a more integrated and coordinated system, ensure the sustainability of various County programs, expand ECM, CS, and CHW capacity in the community, and increase local utilization of ECM, CS, and CHW services. Billing for ECM, CS, and CHW services provides an opportunity to receive revenue for services provided by the County to community members, which is vital to offset forecasted budget deficits in Fiscal Year 2025-2026 and future years. Implementation would utilize a phased approach that prioritizes billing for existing services where the results of the assessment indicate current infrastructure capabilities are adequate to move forward.
Today’s action requests the Board to authorize revenue agreement(s) with Medi-Cal MCPs serving San Diego County to allow the County to provide and bill for ECM, CS, and/or CHW services.
Recommendation #4: Authorize to Accept Children and Youth Behavioral Health Initiative Grant Funding
DHCS is awarding a total of $56,000,000 across the state to expand the eligibility criteria for early childhood wraparound services that provide preventive mental health services to children, youth, and families in California as part of the Children and Youth Behavioral Health Initiative (CYBHI) Evidence-Based Practices and Community-Defined Evidence Practices (EBP/CDEP) Grant Program. The County was awarded $1,500,000 to support the Healthy Families America program to expand the eligibility criteria for access to early childhood services focused on prevention, early intervention, and resiliency for children and youth, with a specific focus on children and youth from the following groups: Black, Indigenous, and People of Color (BIPOC), and the LGBTQIA+ community. The CYBHI is a cornerstone of the State’s Master Plan for Kids’ Mental Health and the CYBHI funding will be used locally to accomplish the following:
• Increase access to home visiting and consultation services that are culturally and linguistically centered and responsive to the needs of the communities they serve by building a strong, diverse home-visiting workforce.
• Improve coordination of services for pregnant and parenting people and their families by enhancing communication and collaboration between service providers.
• Strengthen child/caregiver relationships and family dynamics through positive parenting trainings on proven, effective skills and strategies that support the healthy development of children.
• Improve caregiver well-being, as well as newborn, child, and maternal health, by reducing emotional and behavioral challenges and increasing early identification of developmental concerns.
• Reduce health disparities by ensuring equitable access to services for parents, caregivers, and children in California.
Today’s action requests the Board to authorize the acceptance of the CYBHI grant agreement and funding. This funding will be used to drive transformative system changes and use ongoing learnings as the basis for change and improvement in outcomes for children and youth.
Recommendation #5: Authorize to Apply for Future Funding Opportunities
The County is continuing to explore current and future funding opportunities to support ongoing implementation of Medi-Cal Transformation in San Diego County. This includes, but is not limited to, funding that may become available through future rounds of the California Department of Health Care Services Providing Access and Transforming Health (PATH) Capacity and Infrastructure Transition, Expansion, and Development (CITED) grant and the Incentive Payment Program (IPP), which provides funding through local Medi-Cal Managed Care Plans. PATH CITED and IPP are funding opportunities intended to support the provision of ECMs and CS services to Medi-Cal members and are designed to help organizations strengthen their ability to participate in the Medi-Cal delivery system by providing whole-person care to Medi-Cal members.
Today’s action requests the Board to authorize the County to apply for and accept future funding opportunities to support Medi-Cal Transformation. Future funding opportunities will help build capacity to expand quality services for Medi-Cal members in San Diego County.
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 Equity (Health) and Community (Quality of Life) as well as the regional Live Well San Diego
vision. This is accomplished by reducing disparities and disproportionality for individuals enrolled in Medi-Cal and ensuring access to care for San Diego County’s most vulnerable residents.
Respectfully submitted,
ebony n. shelton
Chief Administrative Officer
ATTACHMENT(S)
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