Modern Healthcare reporters take a deep dive with leaders in the industry who are standing out and making a difference in their organization or their field. We hear from John Baackes, CEO of LA Care Health Plan, a publicly operated plan serving more than 2.5 million people in Los Angeles County, about what the organization has learned following the launch of California Advancing and Innovating Medi-Cal in January 2022.
California has an ambitious plan to transform its Medicaid program by providing the sickest and costliest patients with non-medical benefits. The first wave of reforms began last year, with an initial focus on enhanced care management, dental care and behavioral health support. What has changed with LA Care Health Plan since then? And what difficulties have you faced?
This was a massive undertaking, and I want to applaud the state for pushing this initiative and getting all the approvals it needed from the Centers for Medicare and Medicaid Services to do it. Those of us in the field and on the street have been saying for years that we need to begin to incorporate social services into the care management of our
most vulnerable patients, but to do it in a more coordinated fashion so we get more synergistic results.
We were [already] using our own reserves to pay for [some of the elements of this program], like [providing] medically tailored meals and recuperative care, so we have the data to know they worked. It’s been a great step forward to have [those services] included as part of our reimbursement and resources.
The difficulty has been [with] the size of the program and doing it so quickly, on the heels of two demonstrations that preceded it. We had 30,000 to 40,000 people in those other programs. Transitioning those people into a program with different rules and regulations was a big challenge. And we [at LA Care Health Plan] probably had the most people in the state who had to make that transition.
I think the first year went as well as it could. Everybody is still learning how we exercise this new set of benefits in the most efficient way possible. But we’re doing it, people are getting services, and every month that goes by, we and the providers in our network are getting more comfortable with it. There’s a great amount of learning that has to be done across the healthcare system, by the providers and by the administrators of the various agencies we cross paths with.
You mentioned you’ve already provided care management in some capacity. How many more people does this program bring on?
For the enhanced care management program, the state is looking for a level of member involvement exceeding what we previously did through a program called complex care management. The state is estimating that 3% to 5% of the Medicaid population are probably eligible for it. For us, with 2.5 million Medi-Cal members, we’re talking about 75,000 to 125,000 people.
We’re not going to be able to absorb that many people in one year into this elevated program. So to accomplish that, the state required that we contract with community-based organizations that can provide some of those additional services. We have contracts with 59 vendors helping us with [services] over and above what we were doing in complex care management ourselves. Those vendors include federally qualified health centers; specialty vendors that have people doing street medicine; and [companies with] nurses and home health workers, who will go into the home to provide additional services.
We, as the plans, are responsible for organizing and developing the contract vendor management portion of this, which is the behind-the scenes stuff that the member doesn’t see. To that degree, we had our providers all in place and ready to go a year ago.
LA Care also has 11 community resource centers, which are storefront facilities. We will have 14 by July. We do health education programming out of those sites for the community. They are also where we place our community health workers, to encourage more face-to-face contact with our most vulnerable members. We find that an in-home visit is way more helpful than probably 10 visits in the doctor’s exam room because you can observe things the patient might not think are relevant to their health status, which are very instrumental in crafting a care management program for them.
How do you decide whether to seek a vendor partner for these services addressing social determinants, as opposed to providing them in-house?
The state required us to use a vendor because it wanted community-based organizations [to provide services]. We will be revisiting this with the state because we do home visits with our own complex care management team. We think we can extend [their services] to include enhanced care management.
Right now, the enhanced care management is all done by the vendors, but we have the capacity. And again, the community resource centers on the ground across the county give us an opportunity to be more innovative and have options other than just vendors.