Stakeholders are responding to the California Department of Health Care Services’ draft request for proposals for the upcoming re-procurement of commercial Medicaid managed care plans.
The RFP is the beginning of a three-year process in which the contract goes into effect in 2024. During an Aug. 5 webinar hosted by the California Health Care Foundation, leaders of patient advocacy groups expressed concern that the RFP doesn’t provide enough detail on how the Medicaid managed care organizations would be measured on health equity goals. (The Medicaid program in California is called Medi-Cal.)
Sandra Hernández, M.D., president and CEO of the California Health Care Foundation, kicked off the webinar explaining why the upcoming re-procurement of Medicaid commercial managed care plans is so important.
“The vast majority of Medi-Cal enrollees get their care through a managed care plan. But up until now, the contracts with these plans have failed to ensure that Medicare enrollees get the high-quality care they deserve,” Hernández said. “The rules just aren't written strong enough. Over the last 10 years, quality of care across the Medi-Cal managed care system has either stagnated or declined on many measures. The quality of care received by California Medi-Cal is often much worse than those with other forms of insurance. And even within the Medi-Cal program, there are significant disparities in quality among medical enrollees by race and ethnicity,” she said. “This results in too many medical enrollees going without proper vaccinations, as we're seeing right now with COVID, not receiving timely prenatal care, cervical cancer screenings, or going without adequate care management for chronic diseases such as diabetes, obesity and hypertension.”
She said the procurement process provides a tremendous opportunity to rewrite the rules in Medicare managed care. Many stakeholders shared with CHCF the comments they sent to the state in response to the RFP. During the webinar, several panelists were asked to respond to a summary of those comments.
Kiran Savage-Sangwan, M.P.A., is executive director of the California Pan-Ethnic Health Network, a nonprofit organization created to promote health equity by advocating for public policies and sufficient resources to address the health needs of communities of color. She noted that there were several comments about how the department could have used this opportunity to strengthen accountability for health plans, both through how we pay health plans, but also how we measure what they're accountable for providing beneficiaries. “And for us that, specifically about racial disparities in healthcare, continues to be alarming and should concern all of us. I think this is a missed opportunity for the department to lay out more of a strategy around how we can have a greater level of oversight and accountability, as well as engagement with consumers and communities to determine what's going well and where we need improvement.”
Mike Odeh, M.P.P., director for health or an organization called Children Now, said he was struck by how many of the comments mentioned children. “We know that performance is really bad for kids. I can't put it any other way. I think these comments reflect that the draft RFP doesn't actually change anything in the in the poor performance for kids. I was struck by that kind of cross-cutting issue.”
Savage-Sangwan said she’d like to see a more concrete strategy for eliminating racial disparities in the program. “I think that we know that the disparities are extreme and unacceptable. In the RFP we see a commitment for doing something about it, but what we don't see is a specific strategy,” she said. “I would hope that the final version will outline some of what DHCS can and will do around reforming how we pay health plans, and will also outline our process for getting us to a set of measures on health equity and disparities that will be effective for driving better performance. I understand that those measures shouldn't be set in stone in a contract. But there should be a process that allows us to sort of set forth the domains that we'll be looking at how stakeholders and consumers will be engaged in a process alongside plans and providers to determine what are those things where we are really trying to drive change and how?”
Savage-Sangwan summed up the health equity focus in this procurement as better but not good enough. There is a significant focus on social determinants of health. Other positives include new leadership from the department that is strongly indicating that health equity is a key priority. “There's a new requirement that every plan have a health equity officer; there's a requirement for quality improvement and health equity advisory Committee; there are revamped requirements for annual diversity, equity and inclusion training; there are new reporting requirements around what the plan is doing to provide culturally and linguistically appropriate care,” she explained. There is an acknowledgement about the crucial role of consumer input and local engagement. But she believes the procurement does not go far enough in terms of accountability. “But I will say DHCS has included language to give them the opportunity to go farther on accountability. That's a welcome signal from them.”
Going forward, Odeh said he is going to be looking at the payment rate-setting aspect. “I do think it needs to be tied to some outcomes that we want to see. And right now, what DHCS has proposed hasn't done that yet. It really worries me that the financing payment discussion seems to be completely separate from this goal of quality improvement.”
He noted that there are 5 million kids on Medi-Cal that are enrolled in managed care — that's 92 percent of the kids in managed care in the state. “Everyone knows a kid should go to their annual checkup, and yet only 50 percent of kids in Medi-Cal are getting that annual checkup,” he added, “so that's the most basic thing. If kids are missing out on those basic well-child visits, they're also missing out on their immunizations, on those screenings, on those referrals, both to behavioral health services, but also to dental services. There are just a lot of disconnects. We see things in the contract like medical home — what does that mean? A dental liaison requirement — what does that mean? I don’t know how one would actually begin to operationalize that as part of this contract without more guidance and clarity.”
