Complex Care in a Complex State: Lessons From California

The unique composition and massive size of California’s population means that health plans and systems in the state have had to explore new ways to improve the delivery of healthcare for those with complex health and social needs, according to panelists at the AHIP Institute & Expo 2018.

The session kicked off with some basic facts about California, where the conference was held: Its 39.5 million residents account for almost $400 billion in healthcare spending per year, and about one-third of those people are enrolled in Medi-Cal, the state’s low-income health coverage program. California has expanded Medi-Cal eligibility for adults under the Affordable Care Act and, separately, for undocumented immigrant children. Due to the fragmentation of care and separate funding streams in the state, there are considerable challenges in coordinating care for those with complex needs.

With those challenges in mind, panelist Greg Buchert, MD, MPH, president and CEO, Blue Shield of California, Care1st Health Plan, suggested that perhaps payers are not the entities best suited to tackling social determinants of health. Instead, a more “humble” approach would involve building relationships with the community organizations that touch members on a day-to-day basis.

A health plan can offer community groups the resources and expertise they need to operate more smoothly, but the groups themselves should take the lead in connecting directly to patients. In this sense, Buchert said, a plan’s relationship with the community is “every bit as important as its relationships with providers, because they touch members more often.”

John F. Grgurina, Jr, explained during his talk that his former work in the state finance department focused on containing the growth in health costs. Now, in his role as CEO of San Francisco Health Plan, he’s learned that the core of care coordination revolves around the coordinators who work with members and the human experience that they enable. No matter the type of plan, he said, each interaction needs to involve caring, trust, and accountability in order for coordinators to make a difference in members’ health outcomes.

Sarita A. Mohanty, MD, MPH, MBA, vice president of care coordination for Medicaid and vulnerable populations at Kaiser Permanente, agreed that insurers and health systems need to do a better job of thinking outside of their 4 walls and instead listening to members. Kaiser’s onboarding process for new members used to be just a checklist, but member engagement specialists are now going out into the field to ask new members about their social needs and connect them to necessary services.

This process, along with other initiatives concerning members’ nonmedical needs, has allowed Kaiser Permanente to have a greater impact on population health by looking upstream to understand the social contexts that contribute to later patterns of disproportionate care utilization. Mohanty described the current atmosphere as “a really exciting time in our space.”

“Medicaid provides an opportunity or a platform for innovation, so we’re excited to partner with everyone on this endeavor,” she concluded.

Lastly, Sarah de Guia, JD, executive director of the California Pan-Ethnic Health Network, provided an alternate perspective from the consumer viewpoint of the consumer, as her organization advocates for multicultural health policy for communities of color. To better address whole-person needs, she said that health services should be integrated so the consumer is at the center and the systems work in the background, meaning there’s “no wrong door” to enter for someone to get the care they need.

She discussed the importance of culturally and linguistically responsive care, which is not uniform across states. California, a racially and ethnically diverse state, requires 24-hour medical interpreter services, but many other states have no such laws. Trauma-informed care and mental health awareness are also key in communities that may experience health disparities due to barriers like lack of transportation and housing or food insecurity.

Health policy makers and delivery systems should think about “centering health equity within care,” de Guia summarized, but they need not try to implement solutions on their own. Her fellow panelist Buchert was right to suggest bringing communities into the discussion, she said, because “communities have a lot of really good ideas about how to meet their needs and they have a lot of great solutions to help us start to address these needs.”