Medi-Cal Insurer CalOptima’s Strategy Includes $100M Tech Investment
CalOptima, which provides healthcare coverage for Orange County, California, residents who are eligible for Medi-Cal, is embarking on a five-year strategy to remove barriers to healthcare access, including a $100 million investment in technology to improve healthcare delivery.
CalOptima serves nearly 880,000 members with a network of more than 10,400 primary care doctors and specialists as well as 41 acute and rehab hospitals. Its board said that the new strategy will change the delivery of healthcare for these residents by implementing same-day treatment authorizations and real-time claims payments for providers, and annually assessing members’ social determinants of health.
A 2021 survey of more than 1,000 doctors, administered by the American Medical Association, showed 93 percent of the treating physicians reported delayed access to necessary care for patients whose treatment required prior authorization. The report also highlighted that physicians and their staff members spend on average almost two business days each week completing prior authorizations.
“The changes articulated in the new vision will help reduce delays and barriers to care for our members, as well as attract more providers to work with CalOptima,” said Supervisor Andrew Do, chair of the CalOptima board of directors, in a statement. “Understanding the life changes in our members will also allow CalOptima to help our members address insecurities in their daily needs that may impact their physical and mental health.”
To achieve this new vision, a $100 million investment in technology advancements will not only allow CalOptima to provide same-day treatment authorizations and process real-time provider claims payments, but it will facilitate sharing critical data with community partners by developing a state-of-the-art health information exchange program to break down silos and enhance care for members.
When the system launches, CalOptima will become the first Medi-Cal plan in the state to implement real-time claims processing. CalOptima’s implementation of a “cloud-first” strategy will also include cybersecurity controls to maintain HIPAA compliance and measures to prevent cyber-attacks.
“As the single largest health plan in Orange County, CalOptima provides care for one in four residents. We take that enormous responsibility seriously, and our members are counting on us to help them access the right care at the right time,” said Michael Hunn, CEO of CalOptima, in a statement. “Automated technology will allow members to receive same-day authorizations, helping them access needed treatments and specialist care on a timely basis.”
In addition, in response to the growing healthcare crisis among the homeless population, CalOptima and other agencies joined to form the Orange County Interagency Council on Homeless Health Care (OCICHHC) in December 2021. In conjunction with this partnership, CalOptima plans to launch a Street Medicine Program to support Medi-Cal members who are experiencing homelessness.
Street Medicine will include health and social services designed to meet individuals where they are to reduce or eliminate barriers to care and follow-up services. Street Medicine providers will work with CalOptima’s current Clinical Field Teams, outreach workers and mobile teams to address the needs of this population, linking them to a medical home in order to prevent emergency department utilization as well as progression of untreated health conditions that may result in mortality.
