The California Telehealth Resource Center (CTRC), a federally funded nonprofit, is dedicated to the successful implementation of virtual care within California. Our mission goes beyond simply supporting the adoption of evidence-based digital health tools into clinical practice (telehealth, remote patient monitoring, and eConsults, for example); it’s about helping providers and patients navigate the complexities of the rapidly evolving delivery and payment landscape—particularly for patients in underinvested and rural communities. By offering free, on-demand online digital health resources and organizing monthly learning events, we aim to assist providers and their patients in overcoming barriers to effective care by leveraging high-tech and high-touch solutions as delivery models undergo rapid changes.
Our focus is to provide a blueprint for the use of digital health tools to drive sustainable delivery transformation called for by Medi-Cal and Medicare.
Background
While the COVID-19 public health emergency accelerated the use of an array of digital health modalities—telehealth in particular, there is a new impetus for effectively deploying the full range of digital health tools: the movement to new delivery and payment models by Medi-Cal (through CalAIM and other initiatives), Medicare, and commercial payers. For example, Medicare has the goal of moving all beneficiaries to value-based delivery and payment models by 2030. California has been a national pacesetter in laying the groundwork for Medi-Cal delivery and payment transformation through a range of initiatives, but most notably through CalAIM. Many of the delivery transformation priorities advanced by Medicare and Medi-Cal align and lend themselves well to the deployment of high touch/high tech solutions that expand provider capacity, center care where the patient is located, and offer the promise of improved care coordination and communication.
Medi-Cal’s transformation goals include:
“build[ing] a more coordinated, person-centered, and accessible health system that works for everyone. Members will have access to new and improved services and receive well-rounded care that goes beyond the doctor’s office or hospital and addresses all of their physical and mental health needs.”
CalAIM Priority Areas
- Behavioral health initiative: This initiative aims to enhance Medi-Cal beneficiaries’ health and quality of life through integrated, whole-person care. It focuses on comprehensive preventive and personalized care that spans the physical and mental health needs of Californians, including strengthening mental health and substance use disorder services and better integrating them with physical health care. It simplifies the administration of Medi-Cal’s behavioral health services for consistency and reduced complexity while introducing innovative policies and payment reforms.
- Community supports: Community support encompasses services addressing members’ health-related social needs (also known as social drivers of health) to promote healthier living and deter more expensive care. These services range from assistance with housing and provision of medically tailored meals for short-term recovery to other diverse community-based offerings.
- Dental initiative: This initiative aims to enhance Medi-Cal dental services accessibility and oral health outcomes for Californian children and adults. Key features of the initiative comprise expanded pay-for-performance measures, a Caries Risk Assessment Bundle, and Silver Diamine Fluoride treatments for youth and certain high-risk groups.
- Enhanced care management: This initiative targets members with intricate needs. It offers a dedicated Lead Care Manager to oversee comprehensive care and ensures members receive quality care across various settings, whether it’s with a doctor, dentist, social worker, or at a community center.
- Integrated care for dual eligible members: Starting January 2023, the majority of dual eligible beneficiaries not previously enrolled in Medi-Cal managed care were enrolled into Medi-Cal plans. These plans offer wraparound services and enhanced care coordination, especially for Long-Term Services and Supports.
- Justice-involved initiative: This initiative enables incarcerated Californians to enroll in Medi-Cal, offering specific services 90 days prior to release. This ensures seamless health care continuity from incarceration to release, providing necessary medications, durable medical equipment, and support programs for their transition.
- Population health management initiative: This initiative aims for a unified, statewide approach ensuring Medi-Cal members have comprehensive programs for improved health outcomes and equity. With some elements pre-existing in Medi-Cal, the initiative mandates plan to build trust with members, utilize data-driven approaches for tailored interventions, focus on preventative care, ensure seamless care management across various systems, and address social determinants to minimize disparities.
- Providing access and transforming health (PATH): This initiative is a five-year project with a $1.85 billion investment to enhance the infrastructure and capacity of local partners, such as community-based organizations and public hospitals. Drawing from previous successes, PATH aims to bridge organizational gaps, enabling partners to amplify their services for Medi-Cal beneficiaries. Through increased resources, these partners can integrate more seamlessly with managed care organizations, driving health equity and fostering a more coordinated Medi-Cal system.
- Statewide managed long-term care: Starting in 2023, Medi-Cal managed care plans (MCPs) coordinated institutional Long-Term Care (LTC) across all counties, aiming for consistent care across California. This integration seeks to bridge care across both institutional and community-based settings. With this system, MCPs can deliver comprehensive care management, encompassing services like Enhanced Care Management and Community Supports. LTC covers facilities such as skilled nursing and intermediate care.
- Supporting health and opportunity for children and families: This initiative aims to enhance the health and well-being of California’s children. The strategy, rooted in principles like health equity, integrated care, and family-focused approaches, consolidates existing and new child and family health initiatives. It emphasizes eight action areas, including stronger pediatric care, integrated behavioral health investments, and an improved foster care model.
Why Value-Based Delivery Transformation and Payment Matters Now More Than Ever
Value-based delivery transformation and associated changes to payment that prioritize access (particularly for rural and underinvested communities), strengthen primary care, care coordination with specialists, enhanced care management, and measures to address health-related social needs (HRSN) are more likely to drive improved patient-level health outcomes as well as overall population health while bending the cost curve. When properly designed models are constructed and implemented, a more integrated, holistic approach to patient care not only improves health outcomes but advances other components of the quadruple aim.
The Role of Digital Health in Value-Based Pay
Digital health tools are critical to delivery transformation as shortages of primary care clinicians and specialists deepen, given the large geographic mismatch between where patients are and the clinicians who can meet their needs are located. These tools provide a robust framework for achieving the goals set by VBP.
- Accessing Integrated Specialty Care
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- eConsults: Addressing the challenge of accessing specialty care is paramount in a VBP model. eConsults pave the way by allowing primary care providers to consult with specialists in a streamlined manner, ensuring patients get the expert advice they need without the traditional wait times.
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- Telehealth and Specialty Referrals: By leveraging telehealth for referrals, providers can ensure that patients get timely care, reducing the lag between diagnosis and treatment. With the enhanced capability of virtual visits, geographical barriers diminish, and patients can access specialized care irrespective of their location.
- Managing Chronic Conditions
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- Remote Patient Monitoring (RPM): For chronic conditions, continuous monitoring can significantly improve outcomes. RPM allows providers to keep a close watch on patients’ health metrics, intervening promptly when anomalies arise. This proactive approach aligns perfectly with VBP’s emphasis on quality outcomes.
- Addressing Health-Related Social Needs
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- Patient Portals and SDOH: Social Determinants of Health (SDOH) play a pivotal role in patient outcomes. By using patient portals, health care providers can screen for SDOH, ensuring that non-medical factors affecting health, like housing or food security, are addressed.
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- Screening Utilizing Telehealth: The use of telehealth as part of the delivery of health care services means that clinicians and staff are able to conduct HRSN screening. As Medicare moves to compensate for SDOH screenings, telehealth offers a valuable avenue for these evaluations, further solidifying its place in the VBP model.
These digital tools, when combined, provide a holistic approach to care that fits seamlessly with the objectives of value-based pay.
Accessibility to Care in California – Now and in the Future
California, often considered a microcosm of the United States, provides a unique lens into the health care challenges we face. Home to a vast, diverse population, the Golden State is no stranger to health care disparities and systemic issues that run deep. We also face systemic challenges that do not have immediate-term solutions:
- Provider Shortages: One of the most pressing concerns within the state is the provider shortage. While California boasts some of the country’s most renowned medical institutions, many regions, especially in the rural and underinvested parts of the state, suffer from a dearth of health care providers. This shortage is prevalent across the board and falls disparately on rural and underinvested communities, where patients often endure extended wait times or travel long distances to access care.
- Rural Disparities: Rural communities in California face a distinct set of challenges. In areas like the Central Valley and far northern counties, residents grapple with barriers that go beyond just provider shortages. Limited access to advanced medical facilities, lower economic stability, and a higher burden of chronic diseases create a perfect storm, leading to significant disparities in health outcomes compared to urban regions.
- Growing Need for Cultural, Community, and Language Competency: While California’s rich diversity fuels growth and innovation, it also presents challenges to connecting providers with the needed cultural, language, and community competencies to meet patient needs.
Opportunities in Value-Based Care
The evolution towards value-based care presents a tapestry of benefits, promising to reshape our health care ecosystem. At its core, this model propels a patient-centric approach. As care models become more transparent and are driven relentlessly by quality metrics, patients and health care stakeholders find themselves better positioned to make decisions that resonate with positive incentives. These transparent systems are not just theoretical constructs; they actively drive quality improvement. By fostering a culture of proactivity, health care providers are equipped to better impact metrics, thereby enhancing patient outcomes.
Furthermore, a significant boon of a properly constructed value-based approach lies in its potential to efficiently utilize resources. The goal is to deliver care in the prevention or early disease progression stage, reducing cost and driving care into lower sites of care. (For example, primary care – even with enhanced payments, results in lower costs to the broader system than hospitalization.)
In addition, properly constructed delivery and transformation models ensure stakeholders—from payers to providers and technology developers—synchronize their efforts, fostering a seamless flow of both clinical and operational data. This confluence of data and collaboration eventually improves care coordination, strengthens public health, and supports value for patients and the broader health care system.
Equity and Practice Transformation Payments Program: $700 million for Primary Care Provider Practice Transformation in the State of California
The California Department of Health Care Services is launching the “Equity and Practice Transformation Payments Program,” a monumental $700 million initiative to revolutionize primary care in the state. This program’s core objective is to bridge the disparities in care exacerbated by the COVID-19 pandemic, champion health equity, and pivot towards upstream care models that address comprehensive health and wellness. A substantial portion of this fund is devoted to ushering in value-based payment models, enabling Medi-Cal providers to cater more effectively to California’s diverse Medi-Cal enrollees. This strategy aligns with the DHCS’s Comprehensive Quality Strategy and Equity Roadmap. The funds will be allocated to enhance primary care sectors like pediatrics, family practice, adult medicine, primary care OB/GYN, and behavioral health within primary care settings. The “50 by 2025: Bold Goals” Initiative stands as the cornerstone of these equity endeavors, preparing providers for alternative payment paradigms. The funding is segmented into three distinct pathways:
- Medi-Cal Managed Care Plan (MCP) Initial Provider Planning Incentive Payments will allocate $25 million over a year, incentivizing MCPs to collaborate with small to medium independent practices. The pmhCAT standardized assessment tool will aid practices in formulating transformation strategies.
- EPT Provider Directed Payment Program dedicates $650 million over five years to fortify delivery system transformation. Special focus will be on core primary care disciplines and integrating behavioral health within them. Notably, $200 million from this allocation will streamline practices for value-based care, fostering infrastructure enhancement like electronic health record systems, advanced data recording, and care management systems. The application deadline is set for October 23, 2023.
- The Statewide Learning Collaborative, with a $25 million budget over five years, is designed to support practices in their transformative journey, promoting best practices and achieving stipulated quality and equity targets.
Challenges En Route to Value-Based Care
Yet, the road to achieving a holistic value-based care model is interspersed with challenges. One significant hurdle is the evident reluctance among both providers and patients to adopt this model. Providers often find themselves at a crossroads, grappling with resource constraints, staffing issues, or the lack of technical prowess required to collect, report, and meaningfully elevate quality performance. Concurrently, patients, especially those hailing from historically marginalized communities, face apprehensions. This is compounded by factors like low health literacy or past experiences that have seeded mistrust.
Systemic biases, too, cast a shadow over the value-based model. The absence of essential infrastructure, such as nuanced data analytics and tools for population health management, can cripple the effective management of risks, particularly for specific population segments. This is further exacerbated by challenges in patient attribution, which can result in a lack of consistent accountability. Such inconsistencies could inadvertently deter providers from embracing the model, fearing repercussions for outcomes beyond their control.
Further complexities arise due to the lack of a cohesive national framework for patient identification. Misidentifications, ranging from duplicate records to overlaid ones, pose formidable challenges, especially when ensuring interoperability across EHR systems. Moreover, the metamorphosis to value-based care is not an overnight phenomenon. Achieving tangible outcomes, marked by enhancements in key cost and quality metrics, might span years, necessitating stakeholders to persistently refine policies, optimize resources, and assimilate learnings from previous endeavors.
Digital Health as the Path Forward
In the aftermath of the global COVID-19 pandemic, the value and potential of digital health tools have been thrust into the limelight. Terms like “telehealth,” “remote patient monitoring,” and “mHealth” have become mainstays, capturing the essence of a digitally transformed health care landscape. The remarkable adoption of these digital tools, especially during the challenging pandemic times, serves as a testament to their efficacy. One pivotal observation was the catalytic role policy interventions played. By eliminating financial, administrative, and regulatory obstacles, we witnessed an accelerated shift toward digital health, transcending traditional barriers.
When we speak of digital health, it’s not just about tools; it’s about data and intelligence. Merging health data with AI tools unfolds a panorama of opportunities for enhancing value-based care, spanning research, administration, health operations, and direct clinical care.
The California Telehealth Resource Center: Your Resource for Digital Health Success
The journey towards achieving value-based care, fortified by digital health, is both challenging and promising. The California Telehealth Resource Center remains unwavering in its commitment to guide and support this transition in California. By harnessing collective efforts, devising streamlined policies, and leveraging the immense potential of technology, we envision a health care system that promises better outcomes at more sustainable costs. We invite you to explore our free resources and register for our monthly events, joining hands in this transformative journey towards ensuring unparalleled virtual care success in California.
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