Today, the Department of Health Care Services (DHCS) is releasing new data on how Cal MediConnect health plans are performing in six areas related to care coordination, quality, and service utilization.
The metrics in this new Cal MediConnect Performance Dashboard are: 1) Health Risk Assessments, 2) Appeals by Determination, 3) Hospital Discharge, 4) Emergency Utilization, 5) Long Term Care Services and Supports (LTSS) Utilization, and 6) Case Management. The Dashboard can be found here.
The Dashboard shows that, on average, Cal MediConnect health plans are performing well on measures related to care coordination. During the reporting period and across all Cal MediConnect health plans, 88 percent of reachable and willing beneficiaries received on-time Health Risk Assessments and 88 percent of beneficiaries with a case manager/care coordinator were contacted by their case manager/care coordinator or care team. The Dashboard also shows that, on average, 61 percent of hospital discharges during the reporting period resulted in outpatient follow up visits within 30 days, which can lead to better health outcomes for beneficiaries.
As part of ongoing quality-monitoring efforts, DHCS and the Centers for Medicare & Medicaid Services (CMS) work with Cal MediConnect health plans to track certain performance data. Where Cal MediConnect health plans have reported data that is below average, information on steps the plans are taking to improve their performance is included in the Dashboard. DHCS and CMS will continue to work with all Cal MediConnect health plans to measure, sustain, and improve performance on all reporting measures in order to ensure beneficiaries are receiving high quality, coordinated care.
Of the six measures in the March Cal MediConnect Performance Dashboard, three are “quality withhold” measures for Cal MediConnect health plans. This means that for each measure, a portion of a plan’s payment is withheld, which can be earned back if they meet the required threshold for the measure.
- Health Risk Assessments (HRAs): An HRA is a survey tool that assesses the full range of a beneficiary’s needs, such as medical and behavioral health, chronic conditions, and disabilities. A beneficiary’s HRA serves as the foundation for an individualized care plan and helps the Cal MediConnect health plan connect a beneficiary to the care and services they need. Cal MediConnect health plans are required to conduct the HRA within 45 days for beneficiaries that are identified as high-risk, and 90 days for low-risk beneficiaries (see Duals Plan Letter 15-005 for additional information). This metric shows the HRA completion rates across plans, which is a quality withhold measure. Across plans, from April 2014 to September 2015, HRAs were completed for 88 percent of beneficiaries who were reachable and willing to participate in the process. More information on HRAs and previous data can be found here.
- Appeals by Determinations: All beneficiaries in Cal MediConnect health plans have the right to appeal their plan’s denial (in part or whole) of a service or item. This metric measures the number of appeal determinations per plan, as well as the outcome of the appeal. Across plans, an average of nearly 1 appeal per 1000 members was resolved during the reporting period, with 86 percent resolved fully favorably.
- Hospital Discharge: When patients receive proper and timely follow up care after being discharged from a hospital, it reduces the likelihood that they will need to be readmitted and it improves their health outcomes. This metric measures the percent of hospital discharges that resulted in ambulatory follow up visits within 30 days of being discharged. Ambulatory care includes medical services received in an outpatient setting without admission to a hospital or other facility. Across plans, the average was 61 percent during the reporting period. This measure is a quality withhold measure.
- Emergency Utilization: Cal MediConnect health plans are responsible for coordinating a beneficiary’s complete needs – including behavioral health needs (with serious mental illness coordinated with county providers). This metric measures emergency department visits by Cal MediConnect beneficiaries for behavioral health-related diagnoses. The reduction in emergency room use for beneficiaries with serious mental illness and substance use disorders is a quality withhold measure.
- LTSS Utilization: Beneficiaries in Cal MediConnect health plans can access long-term services and supports, including Community Based Adult Services (CBAS), In-Home Supportive Services (IHSS), the Multi-Purpose Senior Services Program (MSSP), and nursing facility services. This metric measures the total number of beneficiaries in Cal MediConnect health plans receiving these different services. For all Cal MediConnect health plans, IHSS was the most accessed LTSS benefit.
- Case Management: Care coordination is a major benefit of Cal MediConnect. Beneficiaries in Cal MediConnect health plans have access to a care coordinator, an experienced person who helps them with their health care, as well as a care team that includes their doctors and other providers. This metric measures the percentage of members with a case manager/care coordinator who were contacted by their case manager/care coordinator or care team. Across plans, 88 percent of beneficiaries were contacted by their case manager or care team in 2014. This measure is a quality withhold measure.
All data included in this dashboard is reported to DHCS by the Cal MediConnect health plans. A new Cal MediConnect Performance Dashboard will be released quarterly. If you have any questions, please e-mail info@calduals.org. Thank you for your continued interest in the Cal MediConnect program.