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Medi-Cal Healthier California for All: Integrated Health Services
Broader delivery system, program and payment reforms & consolidating health and social services

Article Scott Gruendl, BHRS Assistant Director
A mother and father with their baby

The most vulnerable California residents need access to various services spanning from behavioral and physical health services to substance use disorder treatment, In-Home Services and developmental help. When the care is hard to coordinate, patients struggle to navigate it on their own and might end up not accessing it at all. 

To meet all the various health needs,the Department of Health Care Services (DHCS) created a multi-year initiative for integrating the many care programs and systems, aligning their funding, data reporting, as well as the quality and infrastructure of the services to improve the quality of life and health outcomes. 

The initiative will guide the discussion for a new waiver (agreements that allow California to operate a Medicaid and/or Medicare program differently than what is required) to replace the waivers slated to expire at the close of 2020, including 1115 which allows for early implementation of health care reform and 1915b which “carves out” behavioral health services for the severely mentally ill for County Mental Health Plans. 

Medi-Cal Healthier California for All 

This initiative dubbed “Medi-Cal Healthier California for All” (formerly known as CalAIM) encompasses a broader delivery system program and payment reform across the Medi-Cal program, and includes a series of proposals.  These proposals, which support the goals below include: standardizing the managed care benefit and managed care enrollment, annual open enrollment, NCQA accreditation of managed care plans, regional rates, payment reform for behavioral health, as well as changing medical necessity, administration integration, enhancing County oversight and monitoring, and improving data quality.

The “Medi-Cal Healthier California for All” initiative has three basic goals:  

  1. To manage member risk and need through Whole Person Care approaches and address the social determinants of health; 
  2. To improve quality outcomes and drive delivery system transformation through value-based initiatives, modernization of systems and payment reform;
  3. To move Medi-Cal to a more consistent and seamless system by reducing complexity and increasing flexibility.

Behavioral Health Components of “Medi-Cal Healthier California for All” 

The initiative contains several components that help increase access to behavioral health. 

  1. Population health management: health strategy to address various health needs based on data analysis from multiple resources. Such an approach can help the patient to receive integrated services according to their combination of needs. In turn, care providers will be able to improve the quality of their services.  
  2. Enhanced care management benefit: the benefit meant to addresses the clinical and non-clinical needs of high-need Medi-Cal beneficiaries.  It is an interdisciplinary approach to provide intensive and comprehensive care. 
  3. Mandatory coordination between the Medi-Cal application and behavioral health: a proposal to require counties to implement an inmate pre-release Medi-Cal application process.  
  4. In lieu of services: services that address medical and social determinants of health needs and aim to substitute a higher level of care such as hospitals and nursing facilities. An example of in lieu services can be housing navigation services, recuperative care, respite or sobering center. 
  5. Incentive Payments: payments that are meant to drive change all the way down to the provider level. 
  6. Mental Health Institutes of Mental Disease (IMD) waiver: a proposal to allow states to receive federal matching funds for services provided to Medicaid beneficiaries during short-term stays for acute care in psychiatric hospitals or residential treatment settings that qualify as an institution for mental disease.
  7. Full integration plans: a proposal to test full integration of physical health, behavioral health, and oral health under one contracted entity.  
  8. Long-term plan for Foster Care: an idea to gather a workgroup to decide whether a new model of care should be implemented for children and youth in foster care. 

Another exciting improvement the initiative can help achieve is Behavioral Health Integration. First, this means administrative consolidation of specialty mental health and substance use disorder services. The next step of the process is integration across Health Divisions, which may be represented by integrated teams where a client has their primary care, behavioral health care, case management, peer support, housing and income stability provided through one dedicated team. 

BHRS is currently working on freeing up resources to have the capacity to begin planning for an organization that thrives in the framework created by “Medi-Cal Healthier California for All.” Case and care management services at BHRS will expand under the initiative as we become more long-term and holistically focused on our clients while paying close attention to the health of the entire population.  

Other benefits of the initiative  

Besides Behavioral Health, “Medi-Cal Healthier California for All” includes initiatives and reforms for Medi-Cal Managed Care, Dental and other County programs and services.  

Overall, the initiative aims to help investments and programs to integrate, to support other issues such as the homelessness crisis and to move toward reforming our justice systems for youth and adults who have significant health issues. The framework can also be a platform for vastly more integrated systems of care while standardizing and streamlining administration so that it can support single-payer principles.  

Besides, the initiative advances key priorities of the Newsom Administration such as: 

  • “Health for All”: an initiative that focuses on identifying high and emerging risk/need patients and providing a comprehensive set of services for them over time, including preventative, health, social and wellness services.
  • Managing high utilizers: providing frequent hospital or emergency room visitors with services that address their clinical and non-clinical needs.
  • Initiating a fundamental shift in how Californians access specialty mental health and substance use disorder services;  
  • Aligning behavioral health funding with physical health, allowing flexibility to innovate and enter value-based payment systems that improve quality and access to care;  
  • Enhancing care management for vulnerable youth, the justice-involved and the aging populations. 

“Medi-Cal Healthier California for All” is a continuation of existing initiatives and builds upon successes of pilots from previous waivers, including but not limited to Whole Person Care, Health Homes and Coordinated Care Initiative. It improves the entire continuum of care across Medi-Cal, so that the system manages patients over time through a comprehensive array of health and social services spanning all levels of intensity of care, from cradle to grave, resulting in a better quality of life for Medi-Cal members as well as long-term cost savings.  

Learn more about the Medi-Cal Healthier California for All initiative here