By OPEN MINDS Circle
On September 6, 2022, the California Department of Health Care Services (DHCS) announced plans to award a $340 million contract for population health management (PHM) services to Gainwell Technologies as part of the stateās California Advancing and Innovating Medi-Cal (CalAIM) initiative. A key goal is to improve DHCSā ability to understand Medicaid population health trends and to support oversight. The contract will run for three years through June 30, 2025, followed by one three-year renewal options.
DHCS had released the Invitation for Proposal (IFP 21-10375) for the PHM services on May 9, 2022. Responses were due on June 6, 2022. DHCS has not disclosed the number of bids received or the names of the unsuccessful bidders.
Scope Of Population Health Management Program
The PHM Service will support the recently announced Medi-Cal managed care plan (MCP) procurement and the new, enhanced MCP contract to provide services to members beginning on January 1, 2024. The PHM Program will establish a cohesive, statewide approach that ensures all Medi-Cal (Californiaās Medicaid program) managed care members have access to a comprehensive program. The PHM service will support Medi-Cal by integrating beneficiary data from multiple sources including medical, behavioral, and social services, and performing core population health management functions. It will provide authorized entities within provider organizations with comprehensive, whole-person information about beneficiaries. This information will include member health history and needs. The service will support risk stratification and segmentation, and risk tiering functions. Additionally, the PHM service will make it easier for members to update their information. It will provide members with access to health education, their rights and applicable benefits, and information on how their data are being used.
Determinants Of Health Plan Readiness For PHM Program
The PHM service will test launch in January 2023 with selected Medi-Cal MCPs. The statewide launch is slated for June 2023. In preparation for the January 2023 test launch, the stateās Medi-Cal managed care plans (MCPs) were required to submit readiness attestations by October 7, 2022 for DHCS review and approval. According to the final āCalAIM Population Health Management Policy Guideā released on September 2, 2022, MCP readiness for PHM was determined based on the following:
- Attestation of National Committee for Quality Assurance (NCQA) PHM accreditation or equivalent.
- Readiness to use diverse data sources to guide Risk Stratification and Segmentation (RSS).
- Approach to screening and assessment within revised 2023 requirements.
- Approach to assessing beneficiaries for care management within revised 2023 requirements.
- Approach to basic PHM, Complex Care Management (CCM), and Transitional Care Services (TCS). CCM is a service for MCP members who need extra support to avoid adverse outcomes but who are not in the highest risk group designated for enhanced care management (ECM). TCS is for MCP members transferring from one setting or level of care to another, such as a discharge from a hospital.
Before the launch of the PHM Service and any requirements to use it, DHCS will not require MCPs to develop new infrastructure that would subsequently be replaced by the PHM Service. DHCS is working with stakeholders to identify the priorities and capabilities that the PHM Service will support.
The PHM Service is part of the stateās effort under its Data Exchange Framework to expand access to health and social services information among health care entities, government agencies, and social services organizations. The framework is intended to improve how health information is shared across health and human services organizations, improve care delivery, and guide policies aimed at caring for the whole person while maintaining consumer privacy and data security, and promoting equity.
About the Medi-Cal Program
Currently, over 14 million California residents are enrolled in Medi-Cal, and about 85% are enrolled in a Medi-Cal MCP. About 1.6 million Medi-Cal beneficiaries are dually eligible for Medicare and are enrolled in Medicare Advantage or similar Medicare managed care plans in addition to Medi-Cal MCPs, which provide their Medi-Cal services. Specialty mental health and substance use disorder treatment services are carved out of Medi-Cal managed care and are administered through county behavioral health plans. Pharmacy benefits are carved out of managed care and transitioned to a fee-for-service (FFS) program.
About Gainwell Technologies
Gainwell Technologies provides technology solutions to help states administer and operate health and human services programs. Its service lines include Medicaid management, cost containment and care quality, human services and public health, pharmacy solutions for Medicaid prescription drug program administration, systems integration, and interoperability to enhance data exchange between platforms and devices, and data analytics,
For more information, contact:
- Paul Saleh, President and Chief Executive Officer, Gainwell Technologies, 1250 Camp Hill Bypass, Camp Hill, Pennsylvania 17011; Email: info@gainwelltechnologies.com; Website: https://www.gainwelltechnologies.com/
- Michelle Baass, Director, California Department of Health Care Services, 1501 Capitol Avenue, MS 0000, Post Office Box 997413, Sacramento, California 95899; Email: dhcspress@dhcs.ca.gov; Website: https://www.dhcs.ca.gov/CalAIM/Pages/PopulationHealthManagement.aspx