Two health plans that serve low-income residents in the Central Valley have consistently failed to meet state standards, recent reports show.
Health Net of San Joaquin and Health Plan San Joaquin, which serve nearly a quarter million Medi-Cal patients combined, failed to meet the state’s minimum performance levels for Medi-Cal health plans since at least 2016.
The state’s performance threshold is 40 percent; on a June quarterly report, Health Net was at 30 percent and Health Plan was at 39 percent. Both plans have been below the performance level for several quarters and have been working with the Department of Health Care Services, which manages Medi-Cal, on improvements.
While health care advocates say the plans must be held accountable for providing the services they promise their members and the state, they acknowledge that a high rate of Medi-Cal enrollment and too few health providers are among the reasons the plans are falling short.
“In the Central Valley there is great demand and real access issues, so the performance reports are not a shock,” said Anthony Wright, executive director of advocacy group Health Access California. “However, meeting the plan obligations is fundamental.”
Both San Joaquin plans have fallen below the minimum performance level since 2016. In particular, the plans have not met targets for childhood immunizations for 2 year olds, adolescent immunizations, prenatal and postpartum care and control of high blood pressure, among other measures.
Both plans are under a quality Corrective Action Plan with the state—Health Net since 2015 and Health Plan in 2016—according to Anthony Cava, a spokesman for the Health Care Services agency. The corrective plans last five years and include increased monitoring of the plans and technical assistance.
Factors that can affect a plan’s performance on quality measures, said Cava, include:
- A plan’s ability to effectively collect data that demonstratesthat the service occurred
- A plan’s ability to accurately report the data
- Beneficiary access issues, such as having enough providers or the ability of plan members to get to appointments
- Providers knowing, they must provide certain services and documenting those services
- Member education on benefits and their own health needs.
Christopher Perrone, director of improving access at the California Health Care Foundation agrees that responsibility lies with the plans to improve quality but points out that a key problem that many plans face is insufficient funding.
“If a health plan invests in services outside of Medi-Cal’s required benefits, and those services successfully lower costs, the plan could essentially be penalized by receiving a lower rate in the future,” wrote Perrone in a recent blog post. “In other words, DHCS has created a financial disincentive for health plans to make investments that could improve the health and well-being of Medi-Cal enrollees and reduce spending.”
In April, the Foundation released a report called Intended Consequences that suggested that the way to improve quality among all Medi-Cal managed care health plans in the state was to change the payment system for health providers.
“By allowing plans to keep some of the money saved … plans are incentivized to keep investing in care improvements and health-related services that generate savings,” said Perrone. “Medi-Cal members get better service and the state makes progress toward bending the program’s long-term cost curve.”
Both San Joaquin health plans said they are addressing social services for their members that they hope will both improve beneficiaries’ lives as well as raise the plans’ performance ratings.
In a statement to the California Health Report, Health Net said new services recently introduced by the plan include home health care visits for some members for such services as post-partum visits, blood tests and eye exams for some members who have diabetes. The plan has also opened a weekend clinic “to broaden access for our members … who are not able to schedule an appointment during the week.”
Lakshmi Dhanvanthari, chief medical officer for Health Plan, said the plan has improved on many measures in the last two years. Dhanvanthari calls the measures “the best available standardized measures, but [they don’t] tell the whole story.” The standards measure preventive healthcare, “but that’s often not a priority for members,” Dhanvanthari said.
Health Plan has made several changes, including monthly reports to providers on which members need to be seen and reminders to patients about upcoming visits. The plan is also working with community partners to address homelessness and literacy, including providing free books for children at providers’ offices.
“We’ve done a lot of things beyond just moving the needle” on the measures, Dhanvanthari said.
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