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Cal AIM: Blue Shield of California Promise Health Plan’s CMO Explains Medi-Cal’s Transformation

Dr. James Cruz talks about the expansion of Medi-Cal to non-medical services and other additions

In January, health plans in California that offer Medi-Cal coverage began to implement the first year of the state’s CalAIM program, an ambitious, multi-year plan to transform the Medi-Cal program and improve health outcomes for Medi-Cal populations. “This transformation has been a long-time coming and is a major shift in the way health care is perceived and delivered. It will make it possible for Medi-Cal enrollees to receive important non-medical services [social services] that complement their regular medical health care and support their well-being,” explained James Cruz, MD and chief medical officer for Blue Shield of California Promise Health Plan. “This transformation will benefit the physical and mental health of our 450,000 Medi-Cal members, and, knowing this, fuels our passion to do everything we can to ensure CalAIM’s success,” he said.

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Dr. James Cruz

In this column, Dr. Cruz answers questions about CalAIM’s comprehensive effort, which will affect Medi-Cal members and health plans alike.

What is CalAIM and why was it created?

California Advancing and Innovating Medi-Cal (CalAIM) is a five-year plan led by the California Department of Health Care Services to transform and strengthen Medi-Cal and improve the health outcomes and overall well-being of Medi-Cal enrollees, especially those with the most complex needs. Our team is deeply committed to ensuring that we meet all the regulatory criteria and deadlines as we roll out additional services for CalAIM over the next few years. We understand the positive outcomes this will produce in our members’ lives and in our role as their Medi-Cal healthcare safety net.

CalAIM was designed as a population-health approach to deliver a streamlined, consistent and coordinated system of preventive, whole-person care, and extends traditional care beyond hospitals and healthcare settings directly into California communities. Simply stated, CalAIM addresses the direct link between a population’s social-needs deficits and the multiple factors that determine healthcare outcomes. The plan expands and incorporates non-medical services into the healthcare system that address social determinants of health such as housing, transportation, nutrition and supportive care.

What complex medical needs of Medi-Cal members will CalAIM address?

We know from first-hand experience that Medi-Cal members have complex needs and are a diverse group. Our teams who work with our Medi-Cal members understand the significant issues they have, and how coordinated medical and social services interventions can help them. These members include those with significant mental illness, substance abuse problems or emotional disturbance; seniors and others living with disabilities; homeless people with complex physical or behavioral health needs; formerly incarcerated people transitioning to the community who have complex physical or behavioral needs; children with complex medical conditions such as cancer, epilepsy and congenital heart disease, and children and youth in foster care.

How long will it take to fully implement CalAIM in California?

The Medi-Cal transformation will occur over five years. The first reforms launched in January this year, and ongoing transformations will be phased in every year through December 2027.

What early changes will Medi-Cal members, healthcare organizations and social services agencies experience?

This year, certain types of non-medical support that used to be provided on an ad-hoc basis for at-risk individuals will now be an integrated part of CalAIM’s system.

There are many examples that demonstrate how important it is to provide holistic support to at-risk members that can significantly improve their outcomes but here’s one:

Under CalAIM, 18 new health codes have been programmed into the Medi-Cal system that now enable community-based organizations who work alongside health plans to provide critically needed non-medical services to Medi-Cal members, such as hotel rooms or travel arrangements for members who need medical procedures that are not located near their home.

What are key challenges that California faces in making CalAIM successful?

There are many challenges our industry faces as we implement CalAIM. To meet them successfully, health plans, physicians, hospitals, state officials and community-based organizations will have to work together closely, with transparency and an open mind. Here are two examples of the challenges in transforming Medi-Cal:

  • A scarcity of resources to provide the social services and support that at-risk people need in their communities: Making the CalAIM vision a reality will take remarkable collaboration among health plans, providers, community-based agencies and the state to develop a strong pipeline of health care professionals – nurses, community health workers and others – who can provide the full access to care required. Innovative approaches are already underway.

One example is California’s Assembly Bill-890, which expands the ability of a nurse practitioner to practice independently once certain specific provisions have been met. With this bill in place, nurses will no longer have to work under the direct supervision of a medical doctor and medical practice. This means they will be able to expand the network of medical professionals available to serve populations who can benefit from a nurse-practitioner’s medical skill set. The California Board of Registered Nursing expects that the implementation of AB 890 will occur on or before January 1, 2023.

  • Timely data about patients: Currently, our healthcare industry doesn’t have enough up-to-date data on patients that allow the sharing of complete patient records across the healthcare system. California lacks a robust, statewide health information exchange that allows information to be safe, securely and quickly shared among hospitals and providers, enabling them to use that data in multiple ways that can benefit patients, especially in life-threatening situations.

How will Blue Shield Promise and other California health plans be impacted by CalAIM?

Overall, I believe the impact will be positive for Blue Shield Promise and other California health plans. We’ll see greater utilization of Medi-Cal healthcare services because people will be identified early on, due to their needs, through the partnerships we have with outside community-based organizations and other participating vendors Importantly, by identifying people with unmet needs through our expanded network of support services, we’ll be able to quickly see where there are inequities. This will help us develop strategies and programs to improve services to those impacted populations, so they don’t lag behind in getting the care they deserve. That’s what CalAIM is all about, in the end.