Medi-Cal Hopes to Deliver Better Care to Kids: Will it Work?

By Health Team

March 25, 2024

Top image via iStock from DragonImages

Imagine a world where kids have seamless access to health care. If your child needs eyeglasses, they get them promptly. If your toddler is struggling with developmental milestones, you are warmly supported in figuring out which early intervention services they may benefit from. If your child has asthma, your health care team helps find all the ways to keep it under control. And if your teenager is seeking support with their mental health, the health care system helps connect them with the right provider without delay.  

For far too long, that has not been the case for millions of families with Medi-Cal for Kids & Teens. Children and youth with Medi-Cal continue to struggle to get the most basic preventive health services, as highlighted in a recent LA Times article. And the State’s own performance data once again reflect just how poorly health plans are delivering care for children and youth. Only half of kids in Medi-Cal received any preventive care at all, and many also face challenges accessing behavioral health appointments in a timely way, the State Auditor recently found. .  

Fortunately, health plans (insurers) are now going to be held more accountable by the State for addressing and improving the health of children and youth through the set of multi-year reforms – called CalAIM – intended to transform how Medi-Cal delivers care. As part of CalAIM, each Medi-Cal must ensure, through its Population Health Management (PHM) program, that their members have access to a comprehensive set of health care and social services based on their individual or family needs and preferences.  

A PHM program looks not just at whether a health screening happens, but that there is follow-up and support so that children and families get connected to the services, supports, and interventions that they need (read more about the policy on Closed Loop Referrals). Through PHM requirements, Medi-Cal managed care plans will now be required to assess and understand the health risks of particular groups of children & youth under their care AND address all drivers of health – including clinical, social, behavioral, and environmental factors.  

Each health plan may do things a bit differently to meet the needs of their members, but with new formalized PHM Programs, all health plans will be “on the hook” for better engaging families in their care. This can encompass many activities like innovative community outreach, novel collaborations with local agencies, the roll out of new benefits and providers, and fresh partnerships with community groups.  

Monitoring the Health of Children and Youth Populations 

Among the new CalAIM changes in 2024, the State will be regularly monitoring data on PHM programs to hold health plans accountable for meeting the diverse health and social needs of their members. The State will use the data to compare health plans to one another, look for individual health plan improvement each year, and ensure all health plans are meeting the goals that the State has set.   

The State will begin by looking at data on established performance and quality measures for all health plans, as well as consumer satisfaction data. It will then also check to see if health plans are ensuring children’s basic access needs to primary care by looking at:  

  • How many kids had no preventive care visits? Which racial and ethnic communities are they from? 
  • How many kids had at least one preventive care visit? Which racial and ethnic communities are they from? 
  • How many kids went to the emergency room more than they went to their primary care provider? Which racial and ethnic communities are they from? 

Beyond providing basic preventive care, health plans must ensure all children and youth populations receive the appropriate level of support with care coordination. To accomplish this, the State will now be monitoring PHM programs for the following: 

  • The percentage of children receiving Care Management programs, like Complex Care Management or the new Enhanced Care Management (ECM) benefit, which went live for children and youth in July 2023 to address the underlying social drivers of health (read more about the ECM benefit here) 
  • The percentage of health plan members receiving support from the Community Health Worker (CHW) benefit, since CHWs have been found to offer effective care management for diverse populations. 
PHM Program Quality Measures for Children and Youth  PHM Program Key Performance Indicators (KPI) for Children and Youth 
Early Childhood  

  • Well-Child Visits in the First 30 Months of Life – 0 to 15 Months – Six or More Well-Child Visits ^ 
  • Well-Child Visits in the First 30 Months of Life – 15 to 30 Months – Two or More Well-Child Visits ^  
  • Developmental Screening for the First Three Years of Life  
  • Lead Screening for Children  
  • Childhood Immunization Status: Combination 10 ^  
  • Topical Fluoride for Children  

Children and Adolescents  

  • Child and Adolescent Well-Care Visits ^  
  • Immunizations for Adolescents: Combination 2  
  • Depression Screening and Follow-Up for Adolescents and Adults^ 
  • Depression Remission or Response for Adolescents and Adults  
  • Follow-Up Care for Children Prescribed ADHD Medication: Initiation Phase  
  • Follow-Up Care for Children Prescribed ADHD Medication: Continuation and Maintenance Phase 
  • Asthma Medication Ratio (Note: not child/youth specific) 

All Children and Youth 

  • Ambulatory Care: Emergency Department (ED) Visits 
  • CAHPS: Getting Needed Care (Adult and Child)  
  • CAHPS: Getting Care Quickly (Adult and Child) 
Basic and Complex Care Management 

  • Percentage of members who had more ED visits than primary care visits within a 12-month period^ 
  • Percentage of members who had at least one primary care visit within a 12-month period^ 
  • Percentage of members with no ambulatory or preventive visit within a 12-month period^ 
  • Percentage of members who received CHW benefit (Note: not child/youth specific) 
  • Percentage of members eligible for Complex Care Management (CCM) who are successfully enrolled in the CCM program^ 

Enhanced Care Management 

  • Percentage of members enrolled in all Enhanced Care Management (ECM) Children and Youth POFs 
  • Percentage of members enrolled in ECM “Homeless Families or Unaccompanied Children/Youth Experiencing Homelessness” POF 
  • Percentage of members enrolled in ECM “Children and Youth At Risk for Avoidable Hospital or ED Utilization” POF 
  • Percentage of members enrolled in ECM “Children and Youth with Serious Mental Health and/or SUD Needs” POF  
  • Percentage of members enrolled in ECM “Children and Youth Transitioning from Incarceration” POF 
  • Percentage of members enrolled in ECM “Children and Youth Enrolled in California Children’s Services (CCS) or CCS Whole Child Model (WCM) with Additional Needs Beyond the CCS Condition” POF 
  • Percentage of members enrolled in ECM “Children and Youth Involved in Child Welfare” POF  
^ = Stratified by race/ethnicity per NCQA categorizations  ^ = Stratified by race, ethnicity, language, and age on a plan-level based on technical specifications 

California’s future is literally at stake if Medi-Cal investments do not improve the health and well-being of children and youth populations.

Looking Ahead: Accountability for Improving Children’s Health 

The State will use data from the monitoring metrics described above to hold plans accountable by requiring corrective actions from health plans to address areas that need improvement. The State may also use the PHM program data to inform future policy changes and/or additional implementation supports.  

Furthermore, each year all health plans will be required to review their data on utilization of children’s preventive health visits and developmental screenings, then outline their PHM program strategies for improving access to those services and ensure that any follow-up and care coordination needs identified from screenings are delivered. This requirement will help keep child health improvement top of mind for health plans, providers, and communities as CalAIM transformations roll out locally. 

We are eager to see the first wave of public reporting of PHM program data (expected to be published here) and accountability actions around PHM programs for children and youth. We also applaud the State for taking this transformational new direction to improve outcomes for children and youth.  

However, in the future, we expect the State to add other measures of important PHM program components for children and youth, especially ones that reflect the realms of well-being for youth. While more discussion and review are needed about what processes and outcomes should be prioritized for measurement (and how) to ensure the health of children and youth, there are already some areas ripe for future consideration in PHM program measurement and accountability. These areas include: oral and vision health; mental and behavioral health; asthma management; school-based health care; and care coordination and planning.