By Kristen Golden Testa, The Children’s Partnership, and Mike Odeh, Children Now

Our previous post, Making Coverage More Meaningful (Part I): Identifying Challenges in Measuring Access to Care in California described why we have more work to do to make sure that people enrolled in Medi-Cal and Covered California can actually access timely, quality care. In this companion post, we’re going to take a look at some improvements underway in our state to bolster the measurement and monitoring of access to care.

Despite and even possibly because of the problems mentioned in our first post, we are fortunate that California’s officials are recognizing that ensuring network satisfaction in the health care system is not just the role of any one agency or one program. In the past few years there has been a genuine effort to collaborate across agencies and create some efficiencies in our admittedly imperfect health care delivery system and gnarly oversight and regulatory system. As a result, there are several ongoing efforts to help California’s policymakers get a better handle on whether and how consumers are receiving timely access to care through health insurance affordability programs.  Those efforts include:

•  Proposed legislation that would support collecting more meaningful data. Senate Bill 964, which is currently working its way through the state legislative process, aims to provide market-specific reporting for state standards so that health plans can be assessed separately across their Medi-Cal, Covered California Exchange marketplace, and other commercial product lines. Program-specific data will go a long way toward understanding how access to care differs across programs and plans.

• Objective analyses recommended the need for more meaningful network adequacy standards in Medi-Cal. The Legislative Analyst’s Office (LAO) has provided a valuable analysis of and recommendations (beginning on page 25) for improving DHCS’ current monitoring plan, including a more meaningful network adequacy measure than just the state’s standard provider-to-patient ratio. The recommendations also support limiting oversight of fee-for-service Medicaid to services like dental care and focusing the majority of oversight on managed care access, since the majority of people (including nearly all children) in Medi-Cal now have health care services delivered through managed care.

• State officials are working to align differences in state code. As a testament to the complexity of our regulatory system in California, the independently-elected Insurance Commissioner recently launched a process to review the network adequacy provisions in the California Insurance Code in order to align them with provisions in the California Health & Safety Code, which governs most managed health care delivery and Medi-Cal administration. There’s a lot to consider, especially for children, when thinking fresh about network adequacy, so there will definitely be more to come…

• An initial framework will provide a snapshot of access to care. Covered California staff laid out a draft monitoring plan (starting on page 22) for optimizing access under the marketplace Qualified Health Plans, which intends to go beyond simply counting the number of grievances filed with plans by utilizing “secret shopper” and enrollee access satisfaction surveys. For Medi-Cal coverage, the California HealthCare Foundation just released a  valuable report on creating a snapshot or framework of access to care in Medi-Cal. This seminal analysis by researchers from the Urban Institute and Mathematica Policy Research provides an “actionable starting point” to monitor changes in access to care, to identify disparities in access across subgroups (like children) and across regions, and to compare access between Medi-Cal enrollees and other insured populations. Specifically, the report lays out a useful conceptual framework for measuring access based on three dimensions: potential access; realized access and health outcomes. The framework also includes criteria for considering the best measures to use, namely those that can in fact be measured and reported regularly based on existing data sources. We expect the framework will be adopted by officials in California. Although prepared specifically for California’s Medi-Cal program, this analysis and valuable framework can also provide suggestions to other states in their efforts to ensure access to care for their Medicaid populations.

• Stakeholders acknowledge the need to monitor access to care in real-time. While a framework can provide stakeholders, especially legislators, with a snapshot of program progress, Medicaid officials and administrators need to be keeping a constant eye on the program with ongoing, real-time monitoring of access to care. Again, with analytic support from the California HealthCare Foundation, DHCS developed a Medi-Cal managed care dashboard tool to get a bird’s eye view of managed care enrollees and health plans in Medi-Cal. (DHCS is still developing a separate dashboard for dental care.) The managed care dashboard is still in its infancy, and more work is being done to improve its usefulness, especially for children – who make up nearly two-thirds of all Medicaid managed care enrollees in the state. This is important because children have specific types of care, such as the Early Periodic Screening, Diagnostic and Treatment (EPSDT) benefit that warrant their own unique measures (like well-child visits and immunization schedule for example). What will ultimately be important though is whether the dashboard provides data in enough detail to identify problem areas and whether state officials use that information to take specific actionable next steps to rectify problem areas and optimize access to care.

All of these activities are critical steps towards ensuring that California’s health insurance programs translate into meaningful coverage with timely access to appropriate care. And while smart monitoring of access will benefit all populations, we think children should remain front and center in these discussions so that one day we can better answer the question: Are our health insurance affordability programs providing timely care to California’s children?