Report 2018-111 Recommendation 9 Responses

Report 2018-111: Department of Health Care Services: Millions of Children in Medi-Cal Are Not Receiving Preventive Health Services (Release Date: March 2019)

Recommendation #9 To: Health Care Services, Department of

To improve access and utilization rates, DHCS should establish by March 2020 performance measures that cover Bright Futures services through well-child visits for all age groups, and require plans to track and report the utilization rates on those measures.

Annual Follow-Up Agency Response From October 2021

As described above, NCQA has formally amended the well-child measures: "Child and Adolescent Well-Care Visits" measure amended the existing "Well Child Visits in the 3rd-6th Years of Life (W34)," adding new four new age groups: 3-6, 7 11, 12-18, and 19-21 years old. The existing Well-Child Visits measure for the first 15 months of life was replaced with a revised metric, to include services in the first 30 months of life. The rates for the new measure will have two age groups: children who turn 15- or 30-months old during the measure year. Because the well-child metrics are part of DHCS' Managed Care Accountability Set (MCAS), DHCS is in full compliance with CSA's recommendation to track and report the utilization rates on those measures.

California State Auditor's Assessment of Annual Follow-Up Status: Fully Implemented

Annual Follow-Up Agency Response From November 2020

DHCS continues to work with stakeholders towards the PSR. DHCS plans to issue the first version in December 2020 and the second version in February 2021. The first will add program wide data, the second will add plan specific data. Once the PSR is completed, DHCS will instruct the MCPs, using an APL, to use the PSR findings along with plan information, including the MCP's utilization management program, to identify and address barriers to usage.

DHCS will use the PSR as a monitoring and reporting tool to assess appropriate utilization of children's preventative services in Medi-Cal. The PSR will include two revised National Committee for Quality Assurance Well-Child measures being adopted into the formal Managed Care Accountability Set and will be reported by the MCPs starting with Reporting Year 2021.

The new "Child and Adolescent Well-Care Visits" measure amends the existing "Well Child Visits in the 3rd-6th Years of Life (W34)," adding new four new age groups: 3-6, 7 11, 12-18, and 19-21 years old.

The existing Will-Child Visits measure for the first 15 months of life will be replaced with a revised metric, to include services in the first 30 months of life. The rates for the new measure will have two age groups: children who turn 15- or 30-months old during the measure year.

The revised measures will allow DHCS to improve the monitoring of MCPs' provision of well-child visits from birth through age 21 and will fill in existing gaps in capturing information using the prior Well-Child Visit measures. Additional measures are planned for inclusion in the PSR capturing other preventative services recommended by the Bright Futures Periodicity Schedule. DHCS will use the PSR to identify regional, demographic, and other factors potentially causing disparities in the rates. Findings from the PSR will inform DHCS' actions with the MCPs to drive targeted interventions and improvement in the provision of preventive services for children in Medi-Cal.

California State Auditor's Assessment of Annual Follow-Up Status: Pending

Full implementation of this recommendation will require DHCS to establish performance measures that cover Bright Futures services through well-child visits for all age groups, and to require plans to track and report the utilization rates on those measures.

1-Year Agency Response

DHCS released the draft proposed measures for the 2020 PSR for public comment on January 17, 2020. The public comment period ended on February 3, 2020. DHCS will review the comments received, finalize the performance measures for the report with the EQRO, and continue moving forward with production of the report.

California State Auditor's Assessment of 1-Year Status: Pending

6-Month Agency Response

DHCS implemented the requirement that MCPs report annually on the applicable CMS adult and child CSMs beginning with the current measurement year (2019). DHCS has established the minimum benchmark as the 50th percentile of Medicaid plans nationally where national performance information is available. Many CMS child CSMs align with AAP Bright Futures.

DHCS implemented the VBP Program which provides MCPs with an incentive payment for the provision of specified services starting July 1, 2019, including an enhanced incentive amount when those services are provided to individuals who are homeless, have serious mental illness, or have substance use disorders. Metrics in the VBP Program that align with AAP Bright Futures include well-child visits in the first 15 months and third through sixth years of life, childhood vaccines for two-year-olds, blood lead screening, and dental fluoride varnish. The VBP Program is located here: https://www.dhcs.ca.gov/provgovpart/Pages/VBP_Measures_19.aspx

DHCS is working on implementing the first annual PSR, and expects to complete it in 2020. DHCS is instructing EQRO to utilize encounter data to determine the rates of provision of appropriate preventive services in accordance with AAP Bright Futures, including frequency of well-visits occurring at the recommended ages/intervals and healthcare visits. Currently the EQRO is evaluating the AAP Bright Futures recommendations to determine the measures that are possible to calculate from encounter data. DHCS plans to evaluate alternative data sources for future iterations of the annual report to expand the measures that can be included.

California State Auditor's Assessment of 6-Month Status: Pending

This recommendation specifically includes the establishment of performance measures that cover well-child visits for all age groups. DHCS's response indicates that it has begun requiring reporting from plans on certain core set measures, but that it has not yet implemented performance measures for well-child visits for all age groups. We look forward to reviewing its implementation of its reporting requirements in the context of the performance measures for well-child visits for all age groups.

60-Day Agency Response

DHCS has announced that MCPs will report on applicable CMS adult and child core set measures for reporting year 2020 (measurement year 2019) and that MCPs will be required to meet the minimum benchmark of the 50th percentile (up from the 25th percentile) of Medicaid plans nationally where that national performance information is available. DHCS also announced that failure to meet this minimum performance level will lead to immediate sanctions and MCPs may also be placed under a CAP.

Additionally, DHCS has released proposed metrics for the Governor's proposed 2019-20 budget regarding Value Based Payments for public comment. The proposal includes metrics for early childhood development including those related to completion of well child visits, immunizations, and other preventive services such as lead screenings and dental fluoride varnish application.

These metrics are in alignment with AAP/Bright Futures recommended preventive services for children. Furthermore, DHCS has begun working with its EQRO to develop a Preventive Services Report which will utilize available data to calculate metrics of appropriate utilization of preventive services for children and adults. DHCS and the EQRO will look to align with existing quality metrics where available and will investigate the development of metrics where appropriate. The report continues to be expected to be issued in 2020.

California State Auditor's Assessment of 60-Day Status: Pending

DHCS did not provide evidence that it will adopt performance measures that cover Bright Futures services though well-child visits for children of all age groups in its response, or in response to a specific follow-up request. We will look for evidence that it intends to implement this recommendation in DHCS' 6-month response.

All Recommendations in 2018-111

Agency responses received are posted verbatim.