California’s Advancing and Innovating Medi-Cal (CalAIM) seeks to transform the Medi-Cal (California Medicaid) delivery system for more than 14 million Californians, taking a population health approach that prioritizes prevention and to the care of the whole person and addresses Medi-Cal members’ physical, behavioral, developmental, dental and long-term care needs across the continuum of care.
As a key part of CalAIM, the California Department of Health Care Services (DHCS) is launching the Population Health Management (PHM) program in January 2023.1 The PHM program establishes a standardized, data-driven approach statewide to ensure that all Medi-Cal Managed Care members can access services based on their needs and preferences, ranging from good from prevention to managed care for the most needy Medi-Cal members. . In conjunction with the PHM program, DHCS is also launching a statewide “PHM Service” solution in July 2023, which will provide access to current and historical data currently available in disparate ways, and support the PHM program. through its statewide standardized risk stratification and segmentation (RSS), algorithm, analytics, and other features. The PHM service is part of a larger statewide effort to accelerate and expand access to health and human services information among health care entities, government agencies, and health care organizations. social services under the California Data Exchange Framework (DxF).
A critical goal of the PHM program and the PHM service is to address the large health disparities in the Medi-Cal program for people of color compared to the general population, which have been further exacerbated by the COVID-19 pandemic. .
Under the PHM, Medi-Cal’s Managed Care Plans (MCPs) will work within a common set of core expectations while meeting the individual needs of members within local communities. PHM program requirements apply specifically to MCPs. However, PHM is a statewide undertaking that interacts with other separate delivery systems and services, including California’s specialty mental health system, which is county-based, and therefore requires a commitment meaningful between MCPs and other stakeholders, as well as with the members themselves. .
Under the new PHM program, the DHCS establishes comprehensive requirements for MCPs in each of the four domains of the PHM framework (see Figure 1 below):
Figure 1: MPS Framework
- MPS strategy and population needs assessment: The foundation for successful MPS implementation is a comprehensive, data-driven strategy that prioritizes collaboration with community partners. Today in California, MCPs are required to measure health disparities and identify priority health and social needs of its members through the Population Needs Assessment (PNA). Beginning in January 2023, DHCS will revamp the PNA process to include greater community engagement and align with other processes such as hospital community health needs assessments and community health improvement plans. local health services. The PNA will also support the development of a new annual PHM strategy, which will detail each component of an MCP’s PHM approach, prioritize strong connections in the community, and incorporate cross-sectoral strategies to improve neighborhood health. and communities with poor health outcomes.
- Collection of member information: The PHM program also emphasizes the collection, sharing and evaluation of timely and accurate data at the individual level in order to identify effective and efficient intervention opportunities. The DHCS will require each MCP to collect and use a wide variety of data to carry out the PHM program, including data generated within the MCP and outside, including, but not limited to, vendor credentials, member demographics (e.g., race, ethnicity, preferred language), and information about screenings and assessments. When the PHM service goes live, it will enhance and consolidate the information available to MCPs outside of the managed care delivery system and provider practices, including members’ medical histories, needs and risks by leveraging administrative, medical, behavioral, dental and social services data. and other program information from disparate sources. The MPS service will also use the data to support the assessment and selection processes.
- Understanding the risk: Before the PHM service goes live in July 2023, MCPs should have their own data-driven RSS approaches that consider all information to avoid and reduce bias and prevent the exacerbation of health disparities. Once the PHM service is live, it will use the collected data to support a statewide standardized RSS algorithm and risk prioritization process that will be developed with input from stakeholders and a group of national experts. Specifically, the PHM service will employ a risk prioritization process that will use standardized criteria to place all individuals served by Medi-Cal into a risk level (i.e. systems into account. MCPs will be required to use the service’s risk levels PHM as the baseline standard to identify and assess member-level risks and needs and, when needed, connect members to services MCPs can also use local data sources (i.e. clinical data or postcode-level social health data factors) or real-time data that may supplement these PHM service results for the purpose of identifying additional members for further assessments and services.
- Provide services and supports: One of the primary goals of MPS is to connect MCP members to the right services and supports at the right time and in the right setting based on their needs and preferences. DHCS will require each MCP to provide the supports and programs members need and want across the continuum of care, which will include Basic Population Health Management (BPHM) for all members ; care management programs, including Enhanced Care Management (ECM) or Complex Care Management (CCM) for high-risk members and some medium-risk members; and transitional care services for members in care transition (see Figure 2 below). Through the analysis and reporting capabilities of the PHM service, DHCS will have the enhanced ability to understand population health trends and the effectiveness of various PHM interventions as well as strengthen surveillance.
Figure 2: PHM care management continuum
PHM is a journey rather than a destination. Over time, the PHM program will evolve to support greater integration between delivery systems, going beyond the current requirements for MCPs.
The launch of the PHM program and rollout of the PHM service is part of a larger arc of change aimed at improving health outcomes that began with CalAIM and is further articulated within DHCS’ overall quality strategy. Through these collective efforts, California is making great strides in improving holistic care for Medi-Cal members, reducing health disparities, and achieving significant advances in quality and health. , all with the aim of combining quality and health equity efforts with prevention.