California Advancing and Innovating Medi-Cal (CalAIM) seeks to transform the Medi-Cal (California Medicaid) delivery system for more than 14 million Californians by adopting a population health approach that prioritizes prevention and care for 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 Services (DHCS) launched the Population Health Management (PHM) Program in January 2023.1 The PHM program establishes a statewide, standardized, data-driven approach to ensure that all Medi-Cal managed care members have access to services based on their needs and preferences, ranging from wellness and prevention to hospice care management are Medi-Cal members. Along with the PHM program, DHCS is also launching a statewide PHM Service solution in July 2023 that will provide access to current and historical data that is currently disparate and support the PHM program through its standardized stratification and segmentation of the risk to the whole country (RSS) algorithm, analytics and other functionalities. The PHM service is part of a broader, statewide effort to accelerate and expand access to health and social services information among health care institutions, government agencies and social service organizations under the California Data Exchange Framework (DxF).
A critical goal of both the PHM program and the PHM service is to address the large health disparities in the Medi-Cal program for people of color relative 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 operate within a common set of core expectations while meeting the individual needs of members within their local communities. PHM program requirements apply specifically to MCPs. However, PHM is a statewide endeavor that interacts with other delivery systems and individual services—notably the California Special Mental Health System, which is county-based—and thus requires significant engagement between MCPs and other stakeholders, such as and with the members themselves.
Under the new PHM program, DHCS sets out comprehensive MCP requirements within each of the four domains of the PHM framework (see Figure 1 below):
Figure 1: PHM framework
- PHM Strategy and Population Needs Assessment: At the core of PHM implementation success is a comprehensive data-driven strategy that prioritizes collaboration with community partners. Today in California, MCPs are required to measure health disparities and identify the priority health and social needs of their members through the Population Needs Assessment (PNA). Beginning in January 2023, DHCS will redesign the PNA process to include greater community engagement and align with other processes such as hospitals’ community health needs assessments and local health departments’ plans for improving community health. The PNA will also support the development of a new annual PHM strategy that will detail each component of the MCP approach to PHM, prioritize strong community connections, and incorporate cross-sectoral strategies to improve health in neighborhoods 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 to identify effective and efficient opportunities for interventions. DHCS will require each MCP to collect and use a wide variety of data to conduct the PHM program, including data generated within the MCP and externally, including but not limited to referrals, member demographics (eg, race, ethnicity , preferred language), and screening and assessment information. When the PHM service goes online, it will enhance and consolidate information available to MCPs outside of the managed care delivery system and provider practices, including members’ health history, needs and risks, using administrative, medical, behavioral, dental and social data to services and other program information from various sources. The PHM Service will also use data to support assessment and screening processes.
- Understanding Risk: Before the PHM service goes live in July 2023, MCPs are expected to have their own data-driven RSS approaches that take all information into account to avoid and reduce bias and prevent exacerbating health disparities. Once the PHM service is live, it will use the collected data to support a state-standardized RSS algorithm and risk ranking process that will be developed with stakeholder input and a panel of national experts. Specifically, the PHM service will use a risk-stratification process that will use standardized criteria to place all individuals served by Medi-Cal into a risk level (ie, high, medium-increasing, or low) by taking information from all Medi-Cal delivery systems considered. MCPs will be required to use the PHM Service risk levels as the primary standard to identify and assess member-level risks and needs and, if necessary, link members to services. MCPs may also use local data sources (ie, clinical data or zip code-level social drivers of health data) or real-time data that could supplement these PHM service results to identify additional members for additional assessments and services.
- Provision of services and support: One of PHM’s primary goals is to connect MCP members with the right services and support at the right time and in the right setting based on their needs and preferences. DHCS will require each MCP to offer supports and programs that members need and want throughout the continuum of care, which will include basic population health management (BPHM) for all members; care management programs, including enhanced care management (ECM) or comprehensive care management (CCM) for high-risk members and selected moderate-risk members; and transitional care services for members in care transition (see Figure 2 below). With the analytics and reporting functionalities of the PHM service, DHCS will have the enhanced ability to understand population health trends and the efficacy of various PHM interventions, as well as strengthen oversight.
Figure 2: PHM care management continuum
PHM is more of a journey than a destination. Over time, the PHM program will evolve to support greater integration between delivery systems, going beyond current MCP requirements.
The launch of the PHM program and implementation of the PHM service are part of a broader arc of change to improve health outcomes that began with CalAIM and is further articulated in DHCS’s overall quality strategy. Through these collective efforts, California is making important strides in improving whole-person care for Medi-Cal members, reducing health care disparities, and making significant advances in quality and health outcomes, all with the goal of combining quality and equity efforts in health care with prevention.