A closer look at CalAIM: Innovations in California’s Medicaid program

While the picturesque image of California is a dream for some, there’s an unsettling reality that not all residents have equal access to health and well-being. Amidst these challenges, there is a beacon of hope in a new program called CalAIM, California Advancing and Innovating Medi-Cal. The multi-year initiative was designed to reform and improve California’s Medicaid program – which provides healthcare coverage to low-income individuals and families in the state. The program’s primary goal is to support whole-person care by improving health outcomes and addressing health disparities. To meet this goal, beneficiaries’ care will be coordinated across the multiple providers and services they receive. State initiatives like CalAIM are forging a path toward a country where health is truly within reach for every resident, regardless of the shadows cast by their SDOH. 

Key Components of CalAIM 

Over 13 million Californians – one in three – rely on Medi-Cal for health coverage. With the complex nature of Medicaid beneficiaries, the CalAIM program is significant because it is designed to transform Medi-Cal to better meet the needs of its beneficiaries. 

Most spending in health care goes to direct medical services rather than services focused on disease prevention, health promotion, and removing barriers to care. Despite this lack of focus, social determinants of health (SDOH), like food insecurity and lack of access to affordable nutritious food, still have a significant impact on health outcomes. SDOH can increase the risk for chronic illnesses, such as diabetes, heart disease, and mental health disorders. Similarly, patients with insurance coverage often face restrictions that inhibit access to behavioral health care. CalAIM is designed to acknowledge the impact of these barriers and redirect spending to adequately address them and improve the quality of life for Medicaid patients. 

CalAIM builds on prior initiatives focused on whole-person care and coordinated care and introduces a statewide population health management plan. Under the program, managed care plans must implement a person-centered strategy that focuses on upstream approaches to addressing member needs. For example, managed care plans will be required to identify and mitigate health-related social needs and provide care management and coordination across different settings. To support these initiatives, Medi-Cal establishes an Incentive Payment Program for managed care plans that build sustainable infrastructure to promote quality and have measurable impacts on utilization.

CalAIM also contains a $1.85 billion initiative for non-traditional health care organizations. The Providing Access and Transforming Health (PATH) initiative provides investments to community-based organizations to improve infrastructure for Medicaid beneficiaries to access social services like affordable housing and medically tailored meals. This element ensures that all aspects of a beneficiary’s care—not just medical services—are financially sustainable and supported. 

Tools for Success

With the lofty goals of CalAIM, technology is required to support the initiative. 

Care management and coordination tools are vital for the success of programs like CalAIM, especially for Medicaid patients, as they promote better communication among providers and support patient engagement. The tools assist in conducting comprehensive patient assessments, which help identify an individual’s unique healthcare needs and develop personalized care plans. By leveraging these tools, providers can ensure a patient-centered approach driven by data insights to achieve a more equitable and efficient experience for beneficiaries in the Medicaid program. 

Social needs screenings are the first step in addressing a patient’s whole health. However, once a patient is referred to a community-based organization for social services, there needs to be a clear responsibility of who follows up to make sure the patient receives the service. Oftentimes, in the lack of clear directions, this responsibility falls to providers who have little time or capabilities to track these referrals. Given that Medicaid covers over 13 million Californians, it is even more difficult to expect providers to follow up with every patient. Closed-loop solutions – like Medecision’s Aerial Social Care Coordinator – are vital to supporting providers or empowering payers to facilitate this process and ensure patients receive the services they require. 

Measuring Impact on Beneficiaries 

While technology can help facilitate more equitable and higher quality care, outcomes must be analyzed to ensure investments directly impact patients. CalAIM identifies several ways to measure the impact of plans’ strategies and assess whether California Medicaid beneficiaries’ experiences are improving. To start, as part of the population health management strategy, all managed care plans are required to meet the National Committee for Quality Assurance’s (NCQA) standards for Population Health Management.

To truly meet the goal of keeping all beneficiaries healthy, access and disparities must be analyzed.

• Access
  • Geographic data to help identify areas with limited access to services
  • Utilization rates of preventative care, screenings, and social services
• Disparities
  • Disease prevalence, mortality rates, and health status indicators
  • Assessing outcomes by race, ethnicity, gender, and income status

These measures provide a clear target for managed care organizations to improve upon, and may be implemented around the U.S. Closing the loop on referrals, providing quality care to prevent readmissions, and facilitating data exchange for care management all play a vital role in reimagining all Medicaid programs, not just California’s. 

Takeaways 

CalAIM is an ambitious proposal that if successful, will positively impact the health of California Medicaid beneficiaries. However, one state action is not enough to combat the problems in the health care system. Other states and health organizations must take lessons about the importance of coordinated, whole-person care from CalAIM and begin to implement them in order to make true on the promise of equitable health. Focusing on whole-person health, rather than strictly paying for medical care, is a good place to start to achieve this goal. Thoughtful implementation of data and coordination solutions is the path to successfully following through.

Acknowledgments

We extend our thanks to Maverick Health Policy’s Julie Barnes and Eric Schiavone. Their expertise and insight have been critical in our effort to turn complex federal policy into practical, innovative solutions, helping Medecision’s customers confidently navigate the ever-changing healthcare landscape.