California’s Bold Experiment with Whole-Person Centered Care: Has it Worked?

This article highlights California Medi-Cal Program’s whole person centered care initiative, payable through Medi-Cal for services such as enhanced primary care management, meal delivery, in home support, transitional care, and more.

Introduction

CalAIM is an initiative of the California Department of Health Care Services (the Department) to improve the quality of life and health outcomes of Medi-Cal members by implementing delivery system, program, and payment reforms across the Medi-Cal Program. CalAIM is a 10-year vision of the Department to prevent illness, support healthcare needs, address health disparities, and reduce the impact of poor health.

A key feature of CalAIM was the 2022 Statewide introduction of Enhanced Care Management (ECM) and Community Supports (CS) services, which at the option of the Medi-Cal managed care plan (MCP) and member, may substitute for traditional Medi-Cal services. As of January 1, 2023, all Medi-Cal members were covered by a managed care plan in California.

ECM and CS Services are focused on: (i) Breaking down the traditional walls of health care, extending beyond hospitals and health care settings and into communities; (ii) Introducing a better way to coordinate care across the physical, behavioral, and dental health delivery systems; and (iii) Providing high-need members with in-person care management where they live, seek care, or prefer to access services.

Whole Person Centered Care moves away from traditional fee for services payment to a quality-of-care approach that acknowledges the whole person. Members are the drivers of care and may appoint someone as their care “navigator.” Members may receive services in-person or via telehealth, with no impact on provider reimbursement.

Why is this needed?

California stakeholders acknowledge that care transitions are key to preventing frequent hospitalization and poor health outcomes. In providing housing, delivering meals or groceries, and providing updates or changes to the home environment, California hoped to mitigate the negative Social Determinants of Health and promote positive ones. Much of the work is based on the Whole Person Care Pilot Program that began on January 1, 2016 and ended on December 31, 2021 and included 25 pilot programs representing a majority of counties in California. UCLA Center for Health Policy Research released a report in 2023 showing that the program resulted in an overall reduction in emergency department visits and hospitalizations and had a reduction in overall estimated Medi-Cal costs compared to the control group. Since this report was released, no third-party comprehensive study has looked at the quality improvements or health outcomes of the program, as a whole, but there are positive trends in the data monitored by the Department and set forth in more detail below.

ECM Explained

ECM is a whole-person interdisciplinary approach to care that addresses the clinical and non-clinical needs of members with the most complex medical and social needs. ECM is designed to be delivered by community-based ECM providers that enter into contracts with managed care plans. ECM is the highest level of comprehensive care management involving a Lead Care Manager for each member. California has suggested types of ECM providers for each Population of Focus covered by the program. Examples of target populations include Adults At risk for Institutionalization and Eligible for Long Term Care and Children Involved in Child Welfare.

Community Supports (CS) or In Lieu of Services (ILOS) Explained

CS Services are wraparound services designed to address a member’s health-related social needs, to live healthier lives and avoid higher, costlier levels of care. CS Services emanate from ILOS services at the federal level, and are statutorily authorized under 42 C.F.R. §§ 438.3(e)(2) and 438.16. CS services are available regardless of whether a Member qualifies for ECM. Managed care plans may select and offer any CS services that have been pre-approved as medically-appropriate and cost-effective substitutes for Covered Services or settings under the State Plan. There are 14 pre-approved medically appropriate and cost effective Community Supports. All members are eligible for the services as long as they meet the established criteria for referral, and managed care plans may not restrict the eligibility criteria.

Quality and Outcomes Data Available Today

The Department engages in multiple quality Population Health Management and Operational Programs activities, including working directly with health plans, counties, providers, and programs on quality improvement programs and monitoring health outcomes using key performance indicators. There are various dashboards containing health outcomes published quarterly or annually with respect to the following: (i) plan enrollment, health care utilization, member grievances, network adequacy, and quality of care; (ii) California Children’s Services and pediatric health and demographics; and (iii) dental performance. Also, a drug organized delivery system dashboard is under development.  

The data is somewhat granular but there are clear improvements across the monitored categories of health outcomes. For example, emergency room visits have declined overall as have emergency room visits with an inpatient admission. Child well care visits, developmental screenings, and weight assessment counseling are steadily increasing. For both adults and children, preventative dental services which dipped in 2020 during the COVID-19 pandemic appear to have fully rebounded and be on an upward trajectory. The data is promising.

The data collection is extensive, uniform, ongoing, and ripe for data analysis to determine if these improvements are statistically significant and lasting. Without objective research, it is difficult to render a positive report card, particularly when it comes to overall cost reduction of program spending or happier, heathier members. Although it may be too soon to confirm that California’s whole person centered care model has worked, it is functioning as intended and is only three years into the statewide implementation of the program.

Kate Bowles is a Director in Fennemore’s Business Litigation practice group in Orange County and Fresno. Her experience encompasses all aspects of healthcare, including traditional healthcare systems and emerging groups in the outpatient sector, such as managed care health plans, Medi-Cal enrolled health plans and community support providers, ERISA health plans, surgery centers, telehealth providers, outpatient mental health, home health, infusion pharmacy, physical therapy and rehabilitation, hospital and anesthesia support, care management support, medical, and nursing provider groups. Kate can be reached at kbowles@fennemorelaw.com for insightful guidance and strategic advice on healthcare disputes and compliance issues.