For more than a decade, California’s 21 public health care systems have been leaders in Medi-Cal transformation, leveraging five-year 1115 Medi-Cal waiver programs and the Medi-Cal managed care rule to help spread innovation and advance high-quality care.
From early coverage expansion efforts to large-scale delivery system reform and value-based care, public health care systems have been on the forefront of the state’s advancements in Medi-Cal. SNI has been a key partner in these efforts, helping systems to implement large scale performance improvement programs.
SNI is currently supporting public health care systems in the key areas below:
Whole Person Care Sets Groundwork for CalAIM
For over six years, public health care systems and their county and community partners led innovative Whole Person Care (WPC) programs to address complex health and social needs. This effort set the groundwork for the State’s largest Medi-Cal reform initiative, CalAIM.
What is Whole Person Care?
Whole Person Care was established as part of the Medi-Cal 2020 waiver. Twenty-five Whole Person Care pilots provided intensive case management and wrap-around services for patients with complex medical and social needs, including individuals experiencing homelessness, severe mental illness, and incarceration, among other hardships.
The program demonstrated the value of cross-sector partnerships to address complex health and social needs and provided a model for how these partnerships can succeed by breaking down longstanding siloes across health care providers, social services agencies, behavioral health providers, and community-based organizations.
Transitioning Whole Person Care Services to CalAIM
In 2022, the Department of Health Care Services launched CalAIM, drawing on the successes of Whole Person Care, to shape the scope and goals of the program. CalAIM is an ambitious multi-year initiative that aims to integrate Medi-Cal health care services with social supports and provide a more holistic approach to care. The critical work of Whole Person Care continues in CalAIM under the Medi-Cal managed care structure, including through the new Enhanced Care Management (ECM) benefit, Community Supports to address the social drivers of health, and efforts to strengthen care for justice-involved individuals.
SNI’s Role in CalAIM Implementation
SNI plays a key role in CalAIM implementation by convening leaders in ECM and Community Supports to work together and troubleshoot as the program rolls out. SNI also identifies and elevates issues to the State for further policy clarification and provides input to ensure that CalAIM policies reflect the realities of work on the front lines.
Global Payment Program
Expanding Primary and Preventive Care for Individuals Without Health Insurance
For over six years, the Global Payment Program (GPP) has helped public health care systems expand primary care and preventive services for individuals without health insurance. GPP restructured how care for this population is financed and created incentives to shift care away from the emergency department and hospital settings to primary care settings.
Strategies to Shift Care
To accomplish this shift in care, public health care systems implemented strategies such as increasing capacity, expanding non-traditional services, improving data collection, and enhancing partnerships. An initial evaluation of the program showed a decrease in emergency and inpatient services (14% and 15% respectively) and a 12% increase in outpatient care, further reinforcing the value of right care at the right time and right place.
GPP Expansion & SNI’s Role
The GPP is now expanding its services to align with CalAIM’s Enhanced Care Management and Community Supports, providing uninsured individuals access to this broader set of Medi-Cal benefits. Working with CAPH, SNI plays an integral in the implementation and evolution of GPP, informing the development of GPP metrics and evaluation approaches and advising members as they expand and offer GPP services to patients, and collect data and report on GPP progress.
Quality Incentive Pool
The Quality Incentive Pool (QIP), a managed care directed payment program, challenges public health care systems to improve equity and quality via ambitious pay-for-performance targets for Medi-Cal managed care enrollees. Incentives are tied to achievement of performance in multiple domains of care, including health equity.
In total, public health care systems report on 40 measures. These measures are selected from a larger group of two measure sets, known as priority and elective measures. Priority measures are closely aligned with the State’s Comprehensive Quality Strategy and assess chronic disease management, preventive care, cancer and depression screenings, and prenatal and post-partum care, among others. Elective measures include additional screening, chronic disease and preventive care measures, as well as measures focused on hospital care and care transitions.
To further advance health equity, public health care systems are required to improve equity on two measures (diabetes management and another measure selected by the system). Systems are also required to report performance data stratified by race and ethnicity for additional priority measures. Learn more about the history of QIP and QIP’s current measurement and reporting requirements.
SNI Assists Members with Performance Measurement
SNI provides ongoing analytic and measure-specific support for members, including webinars where members share successful strategies with each other and receive program updates and measurement guidance from SNI staff. SNI also partners with the State and National Committee for Quality Assurance to provide updated measure specifications, reporting guidance and ongoing performance measurement support.