What keeps Jacey Cooper, California’s state Medicaid director, up at night? The change management challenge of scaling up whole-person care pilot projects into systemwide managed care transformation involving paying for non-medical community supports. “This is true delivery system transformation,” she says.
Cooper was speaking during an April 6 webinar put on by Manatt Health to describe California’s experience working with the Center for Medicare and Medicaid Services on ways the state could identify and mitigate social drivers of health in a comprehensive way.
The California Advancing and Innovating Medi-Cal (CalAIM) program launched on Jan. 1, 2022. The goal is to align all elements of Medi-Cal into a standardized, simplified, and focused system that helps enrollees live healthier lives. Its programs are designed to create an easier pathway to support care for people outside of traditional healthcare settings and help address enrollees’ health-related social needs. CalAIM will provide $4.3 billion in total funding for the state’s home and community-based services (HCBS) program.
“We implemented what we call enhanced care management and community support, taking advantage of our learnings from what we call the Whole Person Care pilots in California, which were tested in 25 counties, really looking at how you bring medical services and social needs together in an integrated, comprehensive way to meet the needs of populations who are unfortunately often falling through the cracks,” Cooper said. “People who are experiencing serious mental illness or substance use disorder services, and medically complex, both children or aging populations, the core of our justice populations, and then, of course, those experiencing homelessness. How do we build a better continuum for them in a way that really addresses the services and supports in a way that we historically had never done?”
California came up with a list of 14 community supports to help address the needs of Medicaid beneficiaries in California.
Cooper said there had to be conversations around how to invest in non-medical services that ultimately improve someone's health outcomes. “How do you demonstrate that clear connection between the two, while still investing in what some may call social services within the Medicaid program? We wanted to make sure that we could have the preventive lens — how do you use these services to get more upstream to prevent utilization of inpatient, skilled nursing facility, institutional levels of care? That was really critical. With the variety of services that we have, some are more upstream, some have that preventative lens.”
California had to demonstrate to CMS that the community supports were medically appropriate and that they were actually cost-effective. The state built standardized criteria for each of the community supports that clearly demonstrated the impact it could have on medical health outcomes. “That helped frame up the medical appropriateness part,” Cooper said. “Then from a cost-effectiveness standpoint, we pulled in a number of evaluations demonstrating how each of these items was not just medically appropriate but had demonstrated improvement in health outcomes, reduction of ED visits or inpatient stays, or skilled nursing facility stays, preventing institutionalization, or just genuinely improving health outcomes. We had a number that were able to demonstrate reduction of blood pressure and more compliance with diabetes care.”
Asthma remediation is a great example, Cooper said. “In California, especially in certain parts of the Central Valley of California, we have really high rates of asthma. There are various triggers within our environment or in someone's home. Asthma remediation was added in as an ‘in lieu of service.’ And it's really upstream. If you make modifications in someone's home, you're really preventing kids showing up in the emergency room, or even worse being admitted. By those small investments, we're making changes in someone's home or investing in an air purifier or removing mold, it's really allowing us to get more upstream.”
Cooper was joined on the webinar by Daniel Tsai, deputy administrator and director of the Center for Medicaid and CHIP services at CMS. He said that what was groundbreaking about the work that CMS and California have done was that it moved some of this innovative work out of the Section 1115 demonstration construct into managed care.
He said CMS is working to develop a clear, consistent framework and set of expectations around the role of health plans in screening for housing, nutrition and other instabilities — and not only screening, but incorporating that into care planning and making referrals to a range of community-based organizations that have expertise in housing or connecting people into other state agencies.
“That care delivery expectation is a starting point, before we even get into what Medicaid can or can't finance,” Tsai said. “Many states have been exploring this and figuring out managed care contracts. We want to be able to get to a more consistent way of actually measuring how successfully folks are being connected to services,” he said. Another important question is: What does Medicaid pay for or not? That is linked to policy goals from a care delivery and equity standpoint, but also fundamentally to the statutory framework of what Medicaid can and can't cover and other guardrails that are important to the discussion, Tsai added. “I want to make sure even as we're expressing great excitement and encouragement about this, folks understand there are guardrails and limitations that are an important part of the discussion around what Medicaid covers.”
Cooper was asked what excites her and worries her the most about implementation and moving forward.
“It is a huge change to take components of a pilot, standardize them and scale them up across a state as large as California. It is a massive change management project, fundamentally, within a delivery system, where you are creating new partnerships, new relationships,” she said. “Trust has to be built over time. The piece that keeps me up at night a little bit is that this is true delivery system transformation. The thing we're spending a lot of time on is how do we pivot the policy and tweak it as we go? Because there are probably many things we don't know and that we will learn along this way. I joke with my team by saying if we are not uncomfortable, then we probably didn't change enough, right? But it's really exciting, to be honest with you. The impact it could have on people's lives is remarkable. And we're really excited to see it scale up, move out to more counties and all of our managed care plans.”
