How Medi-Cal Payers Can Strategically Meet CalAIM’s Guiding Principles for Success

March 31, 2021

The California Department of Health Care Services (DHCS) redoubled their focus and recently updated the California Advancing and Innovating Medi-Cal or CalAIM framework. This framework was designed with an eye toward improving care for the whole person and is leveraging the upcoming waiver renewals to address broader delivery system, program and payment reform across the Medi-Cal program.

Two key drivers behind the development of CalAIM include:

  • Widespread adoption of Medi-Cal managed care plans. DHCS has increased the number of beneficiaries that receive most of their physical health care through Medi-Cal managed care plans. Managed care plans offer more complete care coordination and care management than fee-for-service systems.
  • Increased need for care coordination. More intensive care coordination is needed as system fragmentation increases, clinical complexity grows, and patients’ capacity for coordinating their own care decreases. Depending on their needs, some beneficiaries need access to six or more separate delivery systems, such as managed care, fee-for-service, mental health, substance use disorder, dental, developmental, and in-home supportive systems.

As part of CalAIM, all Medi-Cal managed care plans must develop and maintain a patient-centered population health strategy. This means focusing on preventive and wellness services to keep members healthy; assessing member risks and needs on an ongoing basis; using effective care coordination to manage member safety and outcomes during transitions across delivery systems or care settings; and identifying and mitigating social determinants of health (SDoH) to reduce health disparities or inequities.

Taking a Whole-Person Approach to Fulfill CalAIM Objectives

California DHCS has identified ten guiding principles to guide the CalAIM initiative. Six out of these ten principles are directly related to population health management (PHM) and providing whole-person care.

Here are several essential tactics that Medi-Cal managed care providers can implement to meet these objectives:

  1. Improve the member experience. The first step to improving the member experience is understanding the plan’s membership. This means gathering and understanding data from the population-level down to individual members. When organizations have access to in-depth, member-level risk analytics, including SDoH data, they can predict which individuals have rising risk and engage them through proactive educational outreach. They can also increase the contact rate for members at risk.
  2. Deliver person-centered care that meets the behavioral, developmental, physical and oral health needs of all members. To achieve this goal, organizations need insights about the whole person that are generated through the claim, lab, clinical and Social Determinants of Health (SDoH) data. With this complete picture of member data, Medi-Cal plans can determine each member’s needs and enroll them in tailored outreach programs or care plans.
  3. Build a data-driven population health management strategy to achieve full system alignment. Data-driven population health starts when plans understand the populations they serve. Finding a trusted partner that uses self-trained algorithms, artificial intelligence and machine learning within their population risk analytics solution is crucial. This is a highly effective way to generate insights into the risk levels of different populations. This approach also ensures that the partner can provide monthly updates for key performance indicators and regular updates for risk stratification models.
  4. Identify and mitigate social determinants of health and reduce disparities or inequities. Plans should look for a partner that recognizes the importance of SDoH data and has built it into its algorithms and recommendations. A focus on SDoH ensures that plans are working with a holistic view of their population. They can then focus on building strategies to reduce the health disparities.
  5. Support community activation and engagement. Plans emphasize tailored outreach and custom educational programs in conjunction with insights gained from comprehensive risk analytics. This can further member engagement and education about available community programs.
  6. Reduce the per-capita cost over time through iterative system transformation. By utilizing a solution that identifies rising risk to inform and improve whole-person care, managed care plans can further reduce per-capital costs. In addition, receiving monthly updates such as year-over-year/month-over-month KPI dashboards is vital for evaluating performance and trends. With these analytics, plans can continuously iterate on their approach to whole-person care over time.

In addition to addressing these guiding principles, managed care plans under CalAIM must also submit local population health management plans, account for SDoH, and implement “in lieu of” services (such as housing navigation, supporting services, respite, and sober centers). This work aligns directly with what HMS does best – tracking members, managing cases, identifying issues, and communicating with and creating member engagement, all while simplifying the underlying processes.

By combining the capabilities of Elli, HMS’ risk analytics solution, and Eliza, HMS’ member engagement solution, Medi-Cal managed care providers will be well-positioned to meet the CalAIM objectives. To learn more about how HMS solutions like Elli and Eliza can help your organization conform to the goals and principles of CalAIM, feel free to contact us.

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