As CalAIM continues through year three of implementation, Enhanced Care Management (ECM), Community Health Workers (CHWs) and Community Supports (CS) continue to scale. These services are increasing integration with primary care provider organizations, whether an in-house service, contracted or a referral partner, who are ultimately accountable to managed care plans (MCPs) and the State for quality, member experience, clinical outcomes and total cost of care.

Bringing ECM, CHW and CS providers into the integrated care team is not only enabling these primary care provider organizations, whether FQHCs, medical groups, IPAs, health systems, hospitals or private practice physicians, to better address Health Related Social Needs (HRSNs), it is providing an extension into the community to better engage members, impact care and generate more meaningful data.

As ECM, CHW and CS providers continue expand members served and digitize documentation and billing, share care plans and increase the volume of data through increased patient interactions, there is a wealth of new information flowing to the newly formed Qualified Health Information Organizations, MCPs and Management Services Organizations (MSOs) as noted in our recent article, “The Importance of Integrated Claims and Electronic Medical Record Data for a Successful Value-Based Contract.”

Those primary care providers and CalAIM service providers who are able to capture this data, interpret trends, and translate this information to delivery enhancements, quality & social gap closure, and care team feedback loops will be positioned to come out of the CalAIM waiver ahead of the curve, as reimbursement models through MCPs will likely place a greater emphasis on value and outcomes, as well as overall integration into a more comprehensive premium dollar for health and health-related services, which will inherently require closer integration & coordination across the continuum or care, as well as selection of partners based on outcomes and value-add.

Key Considerations for Provider Data Strategies & Value Prop
1. What data do you need to generate a clear value proposition?
Process measures (leading indicators): Whether contracting with a health plan, risk-bearing primary provider group or conversely selecting a CalAIM service provider, understanding Key Performance Indicators (KPIs) for operations and delivery will be table stakes for partner selection. That said, these KPIs are foundational to internal performance management, as well as contractual performance evaluation and management, which should be documented and defined in service level agreements (SLAs).

Outcome measures (lagging indicators) to understand performance across teams and sites by service or program, which can be benchmarked against peers relative to HEDIS quality measures, utilization, member experience, member retention (or opt-outs), total cost of care. The State’s increased focus on HEDIS measures, which includes stronger financial penalties and greater transparency, continues to drive the need to document and demonstrate performance in this area, with a particular focus emphasis on the relatively new subset of Managed Care Accountability Sets (MCAS). These measures include minimum performance levels and cascade from DHCS, to MCPs, to providers.

Whether directly accountable or indirectly supporting these measures, developing systems to manage and analytics & reporting to understand and track performance is essential for providers of any service as they plan to scale and demonstrate value to risk-bearing provider partners and MCPs looking to refine their networks to attain the highest outcomes and quality for their members.

Numerous MCP CalAIM contracts already have quality and performance incentives, and the trajectory is clear, greater weight will be placed on outcomes as a portion of total compensation, and these measures likely become a threshold (minimum requirements) for participation in networks of care.

2. How to fund infrastructure to keep pace with these requirements?
Collecting, validating and normalizing the data from the growing breadth of sources requires a significant investment in infrastructure and/or third-party solutions to facilitate this process. Translating this data into actionable reports for management, as well as operational & clinical teams at the point of care is an additional layer of investment.

CalAIM provides a range of financial support to fund these investments, including Capacity and Infrastructure Transition, Expansion, and Development (CITED) funding which is typically awarded twice a year, and Incentive Payment Program (IPP) funds, which vary by MCP and county, but may offer more flexibility based on organizational maturity and ability to address specific performance gaps highlighted by the MCP for their markets and attributed populations.¹

These funds are complimented by Providing Access and Transforming Health (PATH) Technical Assistance Marketplace, which funds a range of planning and advisory support on behalf of providers to engage qualified vendors to complete gap assessments, business planning, operational readiness & configuration, training and more. The Marketplace is accessible to current providers of CalAIM services or those intending to provide services, providing a relatively flexible and low-barrier entry into infrastructure planning.

How we can help
COPE Health Solutions is a national, tech-enabled value-based advisory & operations firm, with decades of experience translating data into actionable insights, medical management & quality strategies. As a state approved technical advisor in the CalAIM PATH Marketplace for all seven domains, including “building data capacity,” with an in-house population health management platform that was built specifically for success in value-based payment arrangements & population health management, currently ingesting claims and clinical encounter data for some of the state’s largest health plan carriers and provider organizations, we understand the value & drivers of getting data right, making it easy to use and driving change at the point of care.

Whether practice transformation support to improve clinical workflows & pre-visit planning to optimize the new level of patient engagement afforded by the range of CalAIM benefits, implementing risk stratification models to align members to best-fit services & interventions, configuring performance dashboards, or developing automated data-exchange solutions to reduce administrative burden for patient-facing teams while providing more timely, complete understanding of quality and social care gaps, we can assist organizations along the continuum of their value-based data journey.

Contact us today at info@copehealthsolutions.com or (213) 259-0245.

Footnotes:

¹PATH Funding: https://www.dhcs.ca.gov/CalAIM/Pages/CalAIM-PATH