Reflections on the first year of CalAIM

Valerie Andrews, head of the community organization The JUDAHH Project (Just Us Delivering a Helping Hand), hands out backpacks at a back-to-school event in South Sacramento. The project conducts home visits to address asthma triggers such as mold or dust mites as part of CalAIM’s Community Support Program. Photo: José Luis Villegas

As 2023 begins, it’s hard to believe that it’s only been a year since the federal government approved California’s ambitious plan to transform the Medi-Cal program. The initiative, CalAIM (California Advancing and Improving Medi-Cal), is a multiyear effort to advance holistic person-centered care for people with complex needs while pursuing population health goals to make care more fair for all in Medi-Cal. Cal.

CalAIM is so important and far-reaching that it forces all of us to work together in new ways to fulfill its promise. So, let’s review what CalAIM has already undertaken and peer over the horizon at what is yet to come.

First, the achievements. Countless individuals in the California Department of Health Care Services (DHCS), health systems, provider groups, health plans, community-based organizations, and county health departments have come together to ensure a smooth transition for tens of thousands of Medi -Cal which were supported by CalAIM’s precursor programs, known as Whole Person Care and Health Homes. That alone was a huge lift.

Additionally, California achieved the following:

And this is only a partial list.

The primary strategy that CalAIM employs to move a fragmented care system into a person-centered system, and to do so with sustainable funding, is managed care. Managed care isn’t perfect and comes with an extra layer of administrative requirements. But given all the trade-offs, it’s probably the best tool we have for ensuring that the all-person care Californians need can be delivered fairly.

It is important to remember that CalAIM inherently required everyone involved to build the bridge during the crossing. It involves countless new partnerships, myriad new data sharing needs, uncertain reporting volume, and cash flow constraints introduced by retrospective payments, all at the same time. Getting to this point has been a huge step forward for the entire Medi-Cal system. And all of this change has come in the wake of a once-in-a-century pandemic.

Yet we have to keep our eyes on the mountain top in the distance. CalAIM offers an unprecedented opportunity to make Medi-Cal and other safety net programs work better for Californians who depend on them. It’s an opportunity to make care more equitable and easier to access. Beyond that, it enables the transformation of healthcare delivery to meet the needs of the whole person wherever people go for care. For example, a person having a stroke needs their immediate health crisis addressed, but may also need paid home care to make a full recovery. Much of Californians’ ultimate well-being depends on factors outside the health care system, and many programs in CalAIM are designed to help meet these societal needs, particularly for individuals with complex physical and behavioral health conditions.

And for the millions of people with less complex healthcare needs, CalAIM raises the bar for quality, access, satisfaction and equity (PDF). DHCS is making changes in quality metrics (PDFs) more transparent and imposing fines on managed care plans that fail to comply with key measures.

What to expect in 2023

CalAIM brings a host of new possibilities and challenges into 2023. Across the state, individuals will work to establish:

Again, this is only a partial list. There’s also news on the way to additional waiver requests: the California Behavioral Health Community-Based Continuum Demonstration and “pre-release services” for people leaving jails and jails.

What do all these policy changes have in common? They support a deepening of engagement with people who have not been well served – or not understood – by the system for too long. The goals of these changes are to improve health equity for all Californians. The changes support a more streamlined and consistent delivery of Medi-Cal services to enrollees in every corner of the state. And they support more reliable funding streams for service providers.

From a patient or consumer perspective, CalAIM should streamline the system to make it easier for people to get the care they need. Initially, it may not seem like an improvement for providers, health plans, county health departments, and other health system stakeholders. Indeed, the operational complexities of moving from an established system to a new way of doing business should not be underestimated. And it takes time to cultivate collaboration, trust and cross-industry relationships.

Building the infrastructure for people-centered care

It would be almost impossible to implement CalAIM successfully without making other improvements to the system. That’s why CalAIM makes key investments in data exchange, healthcare personnel and infrastructure to support new partnerships. Exchanging data between health systems and social services agencies is truly the only efficient way for different providers to obtain a unified view of the patient as a whole person with complex and interconnected health needs. The state has set a 2024 deadline for most health care providers to share health information. This year’s state budget includes $250 million to support the adoption of data exchange.

Much of CalAIM relies on managed care organizations, but their key partners on the ground — community-based organizations, hospitals, clinics, county agencies, tribes and other providers — need to hire and train staff and build infrastructure if they are to participate with success. Of course, all of this requires money. DHCS has committed $1.85 billion in a new program called Providing Access and Transforming Health for these organizations to build their workforce and community-based systems to be effective partners with managed care organizations in reaching the people who too often they have been left behind. DHCS announced in late December that it will contract with five commercial health plans in California. This move defines which health plans will operate in each county starting January 2024 so plans and providers can continue to work together to implement CalAIM programs.

CHCF is proud to partner with everyone across the state working to make CalAIM’s vision a success. Dramatic changes like this take time. Other challenges California has encountered are worth mentioning. Ten years ago, 22% of Californians were uninsured. Today it is less than 6%, thanks to California’s enthusiastic adherence to the Affordable Care Act and further expansions of Medi-Cal coverage. In 10 years, we hope to see a statewide health care system that is responsive to all in a person-centered and equal way. If there’s one place that can do it, it’s California.

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