Existing law establishes the Medi-Cal program, administered by the State Department of Health Care Services, under which health care services are provided to qualified, low-income persons. The Medi-Cal program is, in part, governed and funded by federal Medicaid Program provisions. Under existing law, one of the methods by which Medi-Cal services are provided is pursuant to contracts with various types of managed care health plans, including through a county organized health system and geographic managed care.

This bill would require the State Department of Health Care Services to annually administer the Consumer Assessment of Health Care Providers and Systems (CAHPS) Health Plan surveys, which are developed by the federal Agency for Healthcare Research and Quality, for all Medi-Cal managed care plan populations, and would require the CAHPS survey to be administered for all Medi-Cal managed care plan models, including county organized health systems and geographic managed care. The bill would require the department to translate the CAHPS survey in all Medi-Cal threshold languages, and administer the CAHPS survey in each county in all Medi-Cal threshold languages in that county. The bill would require the department to stratify the results of the CAHPS surveys by specified factors, including geographic region and primary language, as specified. The bill would require the department to annually prepare and make publicly available a report on the results of the CAHPS surveys on the departments Internet Web site, and would require the report to include specified information.

Date of Hearing: April 27, 2016

ASSEMBLY COMMITTEE ON APPROPRIATIONS

Lorena Gonzalez, Chair

ABPCA Bill Id:AB 2670

Author:(Roger Hernández) – As Introduced Ver:February 19, 2016

Urgency: No State Mandated Local Program: No Reimbursable: No

SUMMARY:

This bill requires the Department of Health Care Services (DHCS) to administer, on an annual basis, the Consumer Assessment of Health Care Providers and Systems (CAHPS) Health Plan surveys, as developed by the federal Agency for Healthcare Research and Quality for all Medi-Cal managed care plan (MCP) populations. Specifically, this bill:

1. Requires DHCS to annually administer the CAHPS survey to all MCP models, including county organized health systems (COHS), two-plan models, and geographic managed care plans.
2. Requires DHCS to translate the CAHPS survey in all Medi-Cal threshold languages and requires DHCS to administer the CAHPS survey in all Medi-Cal threshold languages in each county.
3. Requires DHCS to stratify the results in order to identify disparities in the quality of care provided to Medi-Cal managed care enrollees based on all of the following factors:
   1. Geographic region;
   2. Primary language;
   3. Race;
   4. Ethnicity;
   5. Gender; and,
   6. To the extent data is available, sexual orientation and gender identity.
4. Requires DHCS to annually prepare and make publicly available a report on the results of the surveys on the DHCS Website. Provides that the report will include all of the following:
   1. Aggregated data on MCP results compared to national Medicaid data;
   2. Aggregated MCP results stratified by the factors set forth as specified; and,
   3. Plan results at the county level, including results for all MCP models, as specified.

FISCAL EFFECT:

1. Costs, likely in the range of $500,000- $1 million annually to conduct the survey every year in multiple languages. The survey is currently conducted every three years and costs $500,000 to administer in English and Spanish.
2. Unknown, significant one-time costs to translate surveys into thirteen threshold languages. As discussed further below, costs would depend on whether validated translations exist or would have to be developed, and the extent of field testing prior to implementation.
3. Unknown, significant ongoing costs associated with the requirement to stratify by a number of variables. Performing an estimate of the increased sample size needed to ensure the ability to stratify results to identify disparities in care is beyond the scope of this analysis, but costs could be very high if a high level of oversampling is required in order to ensure results can be meaningfully stratified.

COMMENTS:

1. Purpose. The author states that this bill gives us the opportunity to assess California’s most diverse populations and different health care needs. Furthermore, the author states that Medi-Cal’s quality measures must be consistent and reflect everyone’s health care experience, as one in three Californians is now enrolled in Medi-Cal.
2. Background. The CAHPS survey assesses both patient satisfaction and perceptions of access to care, and the survey exists for hospitals, managed care plans, and other providers. In Medi-Cal managed care, CAHPS measures assess the experiences of surveyed managed care plan members in the prior six months. Members are asked questions like, "How often was it easy to get necessary care, tests, or treatment?" or "How would you rate your health plan?" Currently, DHCS conducts the CAHPS survey once every three years in two languages, English and Spanish. DHCS publishes the results on its website and uses results as part of its Medi-Cal Managed Care Program Quality Strategy and to recognize plan quality improvement.
3. Staff Comments. Data collection can provide valuable insight into program operation, but does come with a cost. The requirements of this bill address several items:
4. This bill increases the frequency of the CAHPS survey. This is consistent with LAO recommendations and appears warranted given significant changes in enrollment, networks, and overall impacts on Medi-Cal managed care plan operations.
5. This bill also requires the survey to be translated into all Medi-Cal threshold languages, and administered in each county in all Medi-Cal threshold languages in that county. This is beneficial because it allows the opinion of Medi-Cal enrollees who do not speak English or Spanish to be counted in the poll. However, it is unclear whether validated translations exist in languages other than in Spanish. Survey instruments must be validated through psychometric testing, and surveys such as CAHPS have been very well-tested. The agency for Healthcare Research and Quality, which houses CAHPS, offers guidelines for translating CAHPS surveys into other languages. These include the use of two simultaneous translators and a translation review to ensure the quality and cultural appropriateness of the translated instrument, as well as subject the translated instrument to qualitative analysis and psychometric testing to gauge the reliability, validity, and equivalence of the instrument in measuring the health needs of various subgroups. Thus, while translation is certainly possible, translating a survey is quite involved. Questions and responses translated into each threshold languages are not guaranteed to directly map to the English version without significant effort to carefully translate and test the surveys. It should be noted a small number of Medi-Cal enrollees would be sampled for any CAHPS survey, making the chances small that some languages would be represented.
6. Finally, this bill requires stratification of results in order to identify disparities in the quality of care provided to Medi-Cal managed care enrollees based on the factors: geographic region, primary language, race, ethnicity, and gender, as well as sexual orientation and gender identity to the extent data is available. Stratification is different than simply including a diverse population in the sample, as addressed in (b) above. Stratification would theoretically allow one to measure, for example, how persons of a particular ethnic group perceive care in a particular plan.

CAHPS is designed to measure enrollees' recent experiences with health plans and their service, to support consumers in choosing a plan, and identify areas of quality improvement for plans. However, the LAO report notes that DHCS has not even been able to stratify by health plan given the sample size they've used, let alone by subpopulations within a plan. Depending on the goals, stratification by these sub-categories may likewise either be impossible due to limited sample size or, if sample size was increased in order to collect enough data to allow stratification for the many variables of interest, data collection could become prohibitively expensive. For example, to compare perceptions about the timeliness of care between Fresno County Hmong-speaking individuals and persons speaking other languages, the survey would need to include a sufficient number of Hmong speakers from Fresno County. Without oversampling small populations of interest, it is difficult to collect enough data to report anything meaningful about members of these small populations.

For comparison's sake, the California Health Interview Survey is conducted in English, Spanish, two Chinese dialects, Korean, and Vietnamese. Other languages can be added on a pilot basis, and Korean and Vietnamese, as smaller language groups, are oversampled.

Given the potentially high cost of requiring sufficient sample sizes to be able to stratify by the listed variables, staff recommends the author consider clarifying that stratification is only required if the sample size is large enough to report meaningful results. Special one-time surveys could be conducted whereby certain populations of interest are oversampled, allowing for stratification if there are particular areas of concern, instead of requiring a costly level of data collection on an ongoing basis.

Analysis Prepared by: Lisa Murawski / APPR. / (916) 319-2081

Date of Hearing: April 19, 2016

ASSEMBLY COMMITTEE ON HEALTH

Jim Wood, Chair

ABPCA Bill Id:AB 2670 (

Author:Roger Hernández) – As Introduced Ver:February 19, 2016

SUBJECT: Medi-Cal: managed care health plans: Consumer Assessment of Health Care Providers and Systems (CAHPS) Health Plan surveys.

SUMMARY: Requires the Department of Health Care Services (DHCS) to administer, on an annual basis, the Consumer Assessment of Health Care Providers and Systems (CAHPS) Health Plan surveys, as developed by the federal Agency for Healthcare research and Quality for all Medi-Cal managed care plan (MCP) populations. Specifically, this bill:

1. Requires DHCS to annually administer the CAHPS survey to all MCP models, including county organized health systems (COHS), two-plan models, and geographic managed care plans.
2. Requires DHCS to translate the CAHPS survey in all Medi-Cal threshold languages and requires DHCS to administer the CAHPS survey in all Medi-Cal threshold languages in each county.
3. Requires DHCS to stratify the results in order to identify disparities in the quality of care provided to Medi-Cal managed care enrollees based on all of the following factors:
   1. Geographic region;
   2. Primary language;
   3. Race;
   4. Ethnicity;
   5. Gender; and,
   6. To the extent data is available, sexual orientation and gender identity.
4. Requires DHCS to annually prepare and make publicly available a report on the results of the surveys on the DHCS Website. Provides that the report will include all of the following:
   1. Aggregated data on MCP results compared to national Medicaid data;
   2. Aggregated MCP results stratified by the factors set forth as specified; and,
   3. Plan results at the county level, including results for all MCP models, as specified.

EXISTING LAW:

1. Regulates health plans through the Department of Managed Health Care under the Knox-Keene Act and health insurance policies through the California Department of Insurance under the Insurance Code.
   
2. Establishes the Medi-Cal program, administered by DHCS, under which qualified low-income persons receive health care benefits and, in part, governed and funded by federal Medicaid program provisions.
3. Provides that Medi-Cal services are provided pursuant to contracts with various types of managed care health plans, including through a COHS, two plan, and geographic managed care plan model.
4. Requires DHCS to monitor, evaluate, and improve the quality of care provided by MCPs.

FISCAL EFFECT: This bill has not yet been analyzed by a fiscal committee.

COMMENTS:

1. PURPOSE OF THIS BILL. The author states that this bill gives us the opportunity to assess California’s most diverse populations and different health care needs. Futhermore, the author states that Medi-Cal’s quality measures must be consistent and reflect everyone’s health care experience. One in three Californians is now enrolled in Medi-Cal. The author states that it is time for us to make sure everyone is receiving quality coverage and care.
2. BACKGROUND. According to California Pan-Ethnic Health Network, the sponsor of this bill, California’s Medi-Cal program has grown tremendously in enrollment since implementation of the Patient Protection and Affordable Care Act (ACA). Medi-Cal covers approximately 12 million enrollees, up from 7 million in 2013. Approximately 78% of enrollees belong to a community of color, and more than a third of the beneficiaries’ primary language is not English. Many communities of color face disproportionate rates of chronic disease. With these groups comprising a majority of Medi-Cal enrollees, the long term success of the ACA rests on how the health system will improve the care experience of California’s diverse population.
   1. CAHPS Survey – DHCS is charged with monitoring, evaluating, and improving the quality of care provided by MCPs. The CAHPS survey is a federally developed consumer assessment tool that polls patients on their actual experience receiving care. The CAHPS survey assesses both patient satisfaction and perceptions of access to care. In the context of managed care, CAHPS measures assess the experiences of surveyed managed care plan members in the prior six months. The members are asked about their experiences with getting the care they felt they needed, getting care as quickly as they felt they needed to receive the care, and other perceptions about their experiences with care through their health plan. Currently, DHCS conducts the CAHPS survey once every three years, and only in two languages, English and Spanish. DHCS publishes the results on its website and uses results as part of its Medi-Cal Managed Care Program Quality Strategy. In addition to reporting the performance measurement data for each health plan on its website, DHCS presents annual quality awards to high–performing plans based on performance as assessed by HEDIS (Healthcare Effectiveness Data and Information Set - widely used set of performance measures in the managed care industry, developed and maintained by the National Committee for Quality Assurance) and CAHPS measures. Achievement awards are presented by DHCS at an annual quality conference to the plans with the highest performance on HEDIS measures, the plans with the highest performance on CAHPS measures, and the plan with the most improved performance on HEDIS measures.
   2. Standards for Determining Threshold Languages – DHCS is responsible for promulgating the standards that MCPs must apply to determine which language, at a minimum, they must use to provide translated materials to their enrollees. As required by state and federal law, DHCS must identify non-English languages spoken by enrollees and potential enrollees through the state based on a significant number or percentage of persons who speak each language; provide member informing materials in each prevalent non-English language; and require each MCP to make its written information available in the prevalent non-English languages in its particular service area. DHCS then implements requirements through its MCP contracts.
   3. Legislative Analyst Office Report – A Legislative Analyst Office (LAO) Report (Report) on Improving Medi-Cal Managed Care Plan Quality dated May 5, 2015, analyzed the quality of MCPs and current DHCS efforts to improve MCPs plan quality, and considered additional steps and alternative approaches, such as pay-for-performance programs (that provide financial incentives to plans for meeting specified quality performance standards), the state could take to monitor plans and stimulate quality improvement in MCPs. The Report recommended that the Legislature direct DHCS to expand the collection of the CAHPS survey from once every three years to annually to improve current manage care quality monitoring and incentive programs implemented by DHCS. This bill is consistent with the LAO’s recommendation.
   4. Other states - Michigan, Colorado, and Connecticut require annual CAHPS reporting.
3. SUPPORT. The California Pan-Ethnic Health Network (CPEHN) contends that DHCS only conducts the CAHPS survey once every three years and the most recent CAHPS survey data are from 2013, prior to the Medi-Cal expansion in 2014. Additionally, CPEHN notes that this bill will be able to assess whether DHCS is meeting its obligation to ensure all Medi-Cal beneficiaries have access to quality healthcare by translating the CAHPS survey in all of the Medi-Cal threshold languages. Health Access California states that some or even most MCPs voluntarily conduct CAHPS surveys annually. Additionally, Health Access states that conducting consumer satisfaction surveys in Medi-Cal threshold languages is an important step toward assuring that all Californians are able to express satisfaction or dissatisfaction with the care and coverage they receive. Consumers Union state that consumers benefit when validated surveys, such as CAHPS, are used to illuminate the quality of products available, to identify disparities, and to guide improvements. Since DHCS only conducts the CAHPS survey once every three years, it does not fully reflect the views and experiences of California’s diverse enrollees.

REGISTERED SUPPORT / OPPOSITION:

Support

California Pan-Ethnic Health Network (sponsor)

Asian Law Alliance

Consumers Union

Having Our Say

Health Access California

Inland Empire Immigrant Youth Coalition

SEIU California

Western Center on Law and Poverty

Opposition

None on file.

Analysis Prepared by: Kristene Mapile / HEALTH / (916) 319-2097

Date of Hearing: April 12, 2016

ASSEMBLY COMMITTEE ON HEALTH

Jim Wood, Chair

ABPCA Bill Id:AB 2670 (

Author:Roger Hernández) – As Introduced Ver:February 19, 2016

SUBJECT: Medi-Cal: managed care health plans: Consumer Assessment of Health Care Providers and Systems (CAHPS) Health Plan surveys.

SUMMARY: Requires the Department of Health Care Services (DHCS) to administer, on an annual basis, the Consumer Assessment of Health Care Providers and Systems (CAHPS) Health Plan surveys, as developed by the federal Agency for Healthcare research and Quality for all Medi-Cal managed care plan (MCP) populations. Specifically, this bill:

1. Requires DHCS to annually administer the CAHPS survey to all MCP models, including county organized health systems (COHS), two-plan models, and geographic managed care plans.
2. Requires DHCS to translate the CAHPS survey in all Medi-Cal threshold languages and requires DHCS to administer the CAHPS survey in all Medi-Cal threshold languages in each county.
3. Requires DHCS to stratify the results in order to identify disparities in the quality of care provided to Medi-Cal managed care enrollees based on all of the following factors:
   1. Geographic region;
   2. Primary language;
   3. Race;
   4. Ethnicity;
   5. Gender; and,
   6. To the extent data is available, sexual orientation and gender identity.
4. Requires DHCS to annually prepare and make publicly available a report on the results of the surveys on the DHCS Website. Provides that the report will include all of the following:
   1. Aggregated data on MCP results compared to national Medicaid data;
   2. Aggregated MCP results stratified by the factors set forth as specified; and,
   3. Plan results at the county level, including results for all MCP models, as specified.

EXISTING LAW:

1. Regulates health plans through the Department of Managed Health Care under the Knox-Keene Act and health insurance policies through the California Department of Insurance under the Insurance Code.
   
2. Establishes the Medi-Cal program, administered by DHCS, under which qualified low-income persons receive health care benefits and, in part, governed and funded by federal Medicaid program provisions.
3. Provides that Medi-Cal services are provided pursuant to contracts with various types of managed care health plans, including through a COHS, two plan, and geographic managed care plan model.
4. Requires DHCS to monitor, evaluate, and improve the quality of care provided by MCPs.

FISCAL EFFECT: This bill has not yet been analyzed by a fiscal committee.

COMMENTS:

1. PURPOSE OF THIS BILL. The author states that this bill gives us the opportunity to assess California’s most diverse populations and different health care needs. Futhermore, the author states that Medi-Cal’s quality measures must be consistent and reflect everyone’s health care experience. One in three Californians is now enrolled in Medi-Cal. The author states that it is time for us to make sure everyone is receiving quality coverage and care.
2. BACKGROUND. According to California Pan-Ethnic Health Network, the sponsor of this bill, California’s Medi-Cal program has grown tremendously in enrollment since implementation of the Patient Protection and Affordable Care Act (ACA). Medi-Cal covers approximately 12 million enrollees, up from 7 million in 2013. Approximately 78% of enrollees belong to a community of color, and more than a third of the beneficiaries’ primary language is not English. Many communities of color face disproportionate rates of chronic disease. With these groups comprising a majority of Medi-Cal enrollees, the long term success of the ACA rests on how the health system will improve the care experience of California’s diverse population.
   1. CAHPS Survey – DHCS is charged with monitoring, evaluating, and improving the quality of care provided by MCPs. The CAHPS survey is a federally developed consumer assessment tool that polls patients on their actual experience receiving care. The CAHPS survey assesses both patient satisfaction and perceptions of access to care. In the context of managed care, CAHPS measures assess the experiences of surveyed managed care plan members in the prior six months. The members are asked about their experiences with getting the care they felt they needed, getting care as quickly as they felt they needed to receive the care, and other perceptions about their experiences with care through their health plan. Currently, DHCS conducts the CAHPS survey once every three years, and only in two languages, English and Spanish. DHCS publishes the results on its website and uses results as part of its Medi-Cal Managed Care Program Quality Strategy. In addition to reporting the performance measurement data for each health plan on its website, DHCS presents annual quality awards to high–performing plans based on performance as assessed by HEDIS (Healthcare Effectiveness Data and Information Set - widely used set of performance measures in the managed care industry, developed and maintained by the National Committee for Quality Assurance) and CAHPS measures. Achievement awards are presented by DHCS at an annual quality conference to the plans with the highest performance on HEDIS measures, the plans with the highest performance on CAHPS measures, and the plan with the most improved performance on HEDIS measures.
   2. Standards for Determining Threshold Languages – DHCS is responsible for promulgating the standards that MCPs must apply to determine which language, at a minimum, they must use to provide translated materials to their enrollees. As required by state and federal law, DHCS must identify non-English languages spoken by enrollees and potential enrollees through the state based on a significant number or percentage of persons who speak each language; provide member informing materials in each prevalent non-English language; and require each MCP to make its written information available in the prevalent non-English languages in its particular service area. DHCS then implements requirements through its MCP contracts.
   3. Legislative Analyst Office Report – A Legislative Analyst Office (LAO) Report (Report) on Improving Medi-Cal Managed Care Plan Quality dated May 5, 2015, analyzed the quality of MCPs and current DHCS efforts to improve MCPs plan quality, and considered additional steps and alternative approaches, such as pay-for-performance programs (that provide financial incentives to plans for meeting specified quality performance standards), the state could take to monitor plans and stimulate quality improvement in MCPs. The Report recommended that the Legislature direct DHCS to expand the collection of the CAHPS survey from once every three years to annually to improve current manage care quality monitoring and incentive programs implemented by DHCS. This bill is consistent with the LAO’s recommendation.
   4. Other states - Michigan, Colorado, and Connecticut require annual CAHPS reporting.
3. SUPPORT. The California Pan-Ethnic Health Network (CPEHN) contends that DHCS only conducts the CAHPS survey once every three years and the most recent CAHPS survey data are from 2013, prior to the Medi-Cal expansion in 2014. Additionally, CPEHN notes that this bill will be able to assess whether DHCS is meeting its obligation to ensure all Medi-Cal beneficiaries have access to quality healthcare by translating the CAHPS survey in all of the Medi-Cal threshold languages. Health Access California states that some or even most MCPs voluntarily conduct CAHPS surveys annually. Additionally, Health Access states that conducting consumer satisfaction surveys in Medi-Cal threshold languages is an important step toward assuring that all Californians are able to express satisfaction or dissatisfaction with the care and coverage they receive. Consumers Union state that consumers benefit when validated surveys, such as CAHPS, are used to illuminate the quality of products available, to identify disparities, and to guide improvements. Since DHCS only conducts the CAHPS survey once every three years, it does not fully reflect the views and experiences of California’s diverse enrollees.

REGISTERED SUPPORT / OPPOSITION:

Support

California Pan-Ethnic Health Network (sponsor)

Asian Law Alliance

Consumers Union

Having Our Say

Health Access California

Inland Empire Immigrant Youth Coalition

SEIU California

Western Center on Law and Poverty

Opposition

None on file.

Analysis Prepared by: Kristene Mapile / HEALTH / (916) 319-2097