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CalAIM and Whole Person Care – All right here

The plan is designed to ingrate health care more seamlessly with social services

THE VBP Blog

On December 29, 2021, days before they expired, the Centers for Medicare & Medicaid Services (CMS) approved both the California Department of Health Care Services’ (DHCS’) request for a five-year extension of its Medicaid section 1115 demonstration and a five-year extension of its Medicaid managed care section 1915(b) waiver. The 1915(b) waiver has been renamed and is now known as California Advancing and Innovating Medi-Cal (CalAIM).

Medi-Cal is California’s Medicaid program. It currently covers 1 in 3 Californians, including more than half of school-aged children. With this new federal approval, CalAIM will shift Medi-Cal to a population health approach. This new approach will prioritize prevention and also the incorporation of social determinants of health (SDoH).

CalAIM Focuses on Whole-Person Care, Among Other Goals

Whole-person care is a patient-centered optimal use of healthcare resources to deliver the physical, behavioral, emotional, and social services necessary to improve health outcomes. It requires an expansive care team to deliver services that address the physical health, mental health, and SDoH of each patient. 

Overall, CalAIM strives to transform the Medi-Cal program into a more equitable, coordinated, and person-centered approach to care. The goals, clearly outline below, are designed to maximize the health and life trajectory of beneficiaries receiving care.

These are lofty goals, so how does California get there? By utilizing value-based payment models and working to integrate social services into care plans to ensure that social determinants of health are addressed.

Shared Risk & Shared Savings for CalAIM

CalAIM also utilizes shared risk/savings and incentive payments to provide financial protections that support investments in Community Supports, ECM, and Managed LTSS capacity and infrastructure. DHCS is committed to implementing strategies that limit excessive financial risk, while also supporting initiatives that will result in financial gains that can be shared between the state and federal governments, and Medi-Cal managed care plans.

A Unique Approach to the Management of Managed Care Plans

Another unique aspect of CalAIM is that counties have an opportunity to become involved in the oversight and monitoring of Managed Care Plans (MCPs). Under CalAIM, counties can change the MCP that operates in their county.

There are several types of Managed Care Models. Under CalAIM, a county can transition to a County Organized Health System (COHS). There are also Two-Plan MCPs where there is a Local Initiative and a commercial plan. In this model, the county typically participates as the Local Initiative and will be directly competing with commercial MCPs. 

In order to improve oversight and monitoring of various aspects of Medi-Cal, DHCS started a statewide procurement of commercial Medi-Cal MPCs in 2021. While counties can submit their requests, DHCS maintains the authority to determine which, and how many, MCPs the state contracts with for Medi-Cal in counties. 

DHCS intends for counties to have more oversight and to ensure that programs and initiatives are being implemented properly. This is a unique approach that will require careful attention moving forward. 

Next Steps for CalAIM

The first reforms under CalAIM will start to be implemented in early 2022. Additional reforms will be phased in as they develop through 2027. 

While there are some concerns with CalAIM, including whether new benefits expand the supply of already limited services, whether CalAIM creates new complexities and fragmentation, what the financial risks are, and whether implementation is realistic, DHCS did hold many stakeholder engagement sessions. And the California DHCS is committed to continued stakeholder engagement. On the CalAIM site, they encourage visitors to subscribe to the DHCS’s stakeholder email service to receive updates and information about upcoming stakeholder meetings. 

 As always, you can also expect the XtraGlobex team to provide continued updates as the shift towards a population health approach in California progresses. 

Advocates Perspective

CalAIM will be an interesting transition to watch in the coming months and years. Not only is it moving up the VBP continuum to risk sharing, but it also integrates whole-person care into the Medi-Cal program. Another thing to note is that the California Department of Healthcare Services underwent an extensive public stakeholder process through February 2020 to gather initial input on the proposals. As always, we welcome stakeholder involvement and advocate for continued involvement as the CalAIM reforms roll out through 2027.

Onward!

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About the Author

Fady Sahhar brings over 30 years of senior management experience working with major multinational companies including Sara Lee, Mobil Oil, Tenneco Packaging, Pactiv, Progressive Insurance, Transitions Optical, PPG Industries and Essilor (France).

His corporate responsibilities included new product development, strategic planning, marketing management, and global sales. He has developed a number of global communications networks, launched products in over 45 countries, and managed a number of branded patented products.

mandy sahhar

About the Co-Author

Mandy Sahhar provides experience in digital marketing, event management, and business development. Her background has allowed her to get in on the ground floor of marketing efforts including website design, content marketing, and trade show planning. Through her modern approach, she focuses on bringing businesses into the new digital age of marketing through unique approaches and focused content creation. With a passion for communications, she can bring a fresh perspective to an ever-changing industry. Mandy has an MBA with a marketing concentration from Canisius College.