CalAIM’s Population Health Management (PHM) program is slated to launch in January 2023. The Department of Health Care Services (DHCS) says the program will be a statewide approach that ensures Medi-Cal members lead “longer, healthier, and happier lives, improved health outcomes, and health equity.”
Stay one step ahead. Join our email list for the latest news.Subscribe
The PHM program will be focused around proactively assessing and addressing the care needs of Medi-Cal beneficiaries with tailored interventions.
The program will require Medi-Cal managed care plans to implement person-centered strategies focused on wellness and prevention. According to DHCS, the broad requirements of Medi-Cal managed care plans under the PHM program are as follows:
- “Build trust and meaningfully engage with members;
- Gather, share, and assess timely and accurate data on member preferences and needs to identify efficient and effective opportunities for intervention through data-driven risk stratification processes, predictive analytics, identification of gaps in care, and standardized assessment processes;
- Focus on upstream approaches that link to public health and social services and supports members staying healthy through wellness and prevention services;
- Provide care management, care coordination and care transitions across delivery systems, settings, and life circumstances; and
- Identify and mitigate social drivers of health to reduce disparities.”
To support DHCS’s vision for PHM, the department is also developing a statewide PHM Service designed to collect and integrate data for enhanced data sharing between Medi-Cal enrollees, their providers, and social service programs. According to DHCS, the PHM Service will:
- “Provide plans, providers, counties, Medi-Cal members and other authorized users access to more timely, accurate, and comprehensive data on members’ health history and needs, to help improve care, and avoid duplicative processes.
- Support risk stratification and segmentation and risk tiering functions.
- Promote trusting relationships between members and their care team by making it easier for members to update their information and providing members with access to health education, their rights and applicable benefits, and information on how their data are being used, among other features.
- Improve DHCS’ ability to understand population health trends and support oversight.”
DHCS notes that in 2023, health plans will be required to meet the National Committee for Quality Assurance’s standards for PHM as well as additional DHCS statewide PHM standards.
The PHM program involves DHCS setting various new requirements for Medi-Cal managed care plans. Two notable components of the program include improving processes related to the gathering of member information and improving the PHM Strategy and Population Needs Assessment (PNA).
For improving the existing PHM Strategy and PNA, DHCS says the PNA process will require less frequent data collection and greater engagement with communities, including local stakeholders such as members and families, Medi-Cal providers, local health departments and governmental agencies, and county mental health plans.
In early 2023, DHCS says it will release guidance and a template for the new comprehensive PHM Strategy and new PNA structure to help Medi-Cal managed care plans work with their community partners to develop a focused strategy for their PHM programs, and to improve decision-making and track progress toward PHM goals.
According to DHCS, Medi-Cal managed care plans will be required to submit this comprehensive PHM Strategy annually starting in October 2023. The PHM Strategy must include details about the plan’s PHM program, including prevention and wellness strategies and interventions.
In July 2025, Medi-Cal managed care plans will be required to submit their PNA and produce a report made available to the public.
For gathering member information, DHCS expects each Medi-Cal managed care plan to gather and use a wide variety of data, including data collected from within the managed care plan as well as information from provider referrals and member screening and assessments.
DHCS notes that existing mechanisms for data gathering in Medi-Cal managed care plans do not always maintain member trust, lack timeliness and accuracy, do not effectively share data across the member’s care team, and often lack data on the social determinants of health.
“An effective PHM approach begins with gathering accurate and robust information to understand each member’s health and social needs to ensure that they receive the right services at the right time and right place,” the department states in its PHM strategy document.
DHCS also notes that it will be retiring existing requirements that Medi-Cal managed care plans ensure that members complete the Individual Health Education and Behavior Assessment /Staying Healthy Assessment at initial primary care visits, due to stakeholder feedback claiming that state prescription of the exact health behavior questions to ask patients during visits is burdensome, not evidence-based, and unnecessary.