WE WILL NOW CALL THIS HEARING.
TO BEGIN FOR SIMPLY BUDGET
SUBCOMMITTEE NUMBER ONE. WE CAN
CALL GIRL.
THANK YOU. TODAY WE WILL BE
DISCUSSING SOMETHING THAT WE
OFTENTIMES REFER TO, NOT ONLY IN
THIS COMMITTEE, BUT ON THE FLOOR
AND ALSO IN OUR POLICY
COMMITTEES, WHICH DEALS WITH OUR
MEDI-CAL PROVIDER RATES,
REIMBURSEMENT RATES, AND ALSO
HOW WE CAN START TO THINK
OUTSIDE OF THE BOX IN TERMS OF
HOW WE PAY FOR AND PROVIDE
HEALTH CARE FOR OUR RESIDENTS
HERE IN CALIFORNIA. WE HAVE AN
AMAZING PANEL, AND I WILL ASK
FOR ALL THREE TO COME UP AT THIS
TIME, WE HAVE JASON CONSTANDUROS
FROM THE LEGISLATIVE ANALYST'S
OFFICE, MICHAEL HEITZ HEIFETZ
FROM, INFINITE POLICY SOLUTIONS,
AND MICHELLE BASS FROM THE
DEPARTMENT OF HEALTH CARE
SERVICES, WHO WILL BE HERE TO
JUST PROVIDE ANY QUESTIONS OR
ANY FURTHER, INFORMATION ABOUT
ANYTHING THAT WE HAPPEN TO GO
OVER. SO WE WILL START WITH YOU,
JASON. THANK YOU. CAN YOU HEAR
ME NOW? GREAT. THANK YOU, JASON
CONSTANDUROS, LEGISLATIVE
ANALYST'S OFFICE, MY TESTIMONY
TODAY. I'LL GO THROUGH THIS
HANDOUT HERE THAT SHOULD BE
INCLUDED IN YOUR AGENDA. AND,
WE'LL JUST DIVE RIGHT INTO IT,
STARTING ON PAGE ONE. ON PAGE
ONE, WE PROVIDE A QUICK OVERVIEW
OF THE ORDER OF HOW OUR
PRESENTATION WILL WORK. SO WE'LL
FIRST TALK ABOUT WE'LL PROVIDE
AN OVERVIEW OF HOW TO,
SPECIFICALLY PHYSICIAN RATES
WORK IN MEDI-CAL AND THEN WE
WILL WALK THROUGH FOUR KEY
PRINCIPLES THAT WE DEVELOPED TO
ASSESS PHYSICIAN RATES, JUST AT
THE OUTSET, I WANT TO EMPHASIZE
FOUR KEY POINTS ABOUT OUR
PRESENTATION. THE FIRST IS THAT
THIS WILL FOCUS SPECIFICALLY ON
PHYSICIAN RATES AND MEDI-CAL.
MEDI-CAL HAS MANY DIFFERENT WAYS
OF PAYING DIFFERENT KINDS OF
PROVIDERS. SO THE SYSTEM WORKS A
BIT DIFFERENTLY IF WE'RE TALKING
ABOUT HOSPITALS OR LONG TERM
CARE FACILITIES OR OTHER KINDS
OF PROVIDERS, SECONDLY, EVEN
THOUGH OUR PRESENTATION WILL
FOCUS ON PHYSICIAN PHYSICIAN
RATES, THE FOUR KEY PRINCIPLES
THAT WE DISCUSSED TODAY, WE
THINK APPLY PRETTY BROADLY. SO
YOU COULD APPLY THESE PRINCIPLES
IN THINKING ABOUT OTHER KINDS OF
PROVIDER RATES TO THIRD, YOU
KNOW, THESE FOUR KEY PRINCIPLES
THAT WE DEVELOPED HERE. YOU CAN
SEE THE ACCESS AND QUALITY,
ECONOMY AND EFFICIENCY, EQUITY
AND SIMPLICITY AND TRANSPARENCY,
THESE ARE CONCEPTS THAT WE
DEVELOPED, BUT WE DEVELOPED THEM
LOOKING AT MANY DIFFERENT
SOURCES. WE CONSIDERED EXISTING
FEDERAL POLICY AND LAW. WE ALSO
MET WITH POLICY EXPERTS AND
STAKEHOLDERS, AND THAT'S HOW WE
DEVELOPED OUR PRINCIPLES. AND
THEN FOURTH, WELL, A LOT OF OUR
PRESENTATION WILL FOCUS ON HOW
PHYSICIAN RATES HAVE WORKED
HISTORICALLY, AS WE'VE TALKED
ABOUT IN PREVIOUS COMMITTEE
HEARINGS, THE ADMINISTRATION'S
PROPOSING TO, NOTABLY CHANGE THE
WAY PHYSICIANS ARE PAID IN
MEDI-CAL AS PART OF THE MCO TAX
PACKAGE. WE'LL ALSO TOUCH ON
THOSE CHANGES, TOO, BUT THAT
WILL BE IMPORTANT TO CONSIDER
WHEN YOU'RE THINKING ABOUT HOW
IT'S WORKED HISTORICALLY. A LOT
OF THESE WILL BE WILL BE
CHANGING, SO TURNING TO PAGE TWO
OF YOUR AGENDA. WE PROVIDE WE
WILL FIRST PROVIDE AN OVERVIEW
OF PHYSICIAN RATES AND MEDI-CAL.
MEDI-CAL HAS TWO MAJOR DELIVERY
SYSTEMS. THERE'S FEE FOR SERVICE
AND MANAGED CARE. SO WE'LL START
WITH FEE FOR SERVICE FEE FOR
SERVICE IS THE HISTORICAL SORT
OF SYSTEM IN IN MEDI-CAL TODAY.
IT'S A RELATIVELY SMALL PART OF
MEDI-CAL. ABOUT 5% OF
BENEFICIARIES ARE IN THE FEE FOR
SERVICE SYSTEM, BUT WE FIND IT'S
A HELPFUL PLACE TO START. IT IS
SORT OF THE HISTORICAL WAY THE
STATE HAS PAID FOR SERVICES. AND
ALSO IT IS THESE ARE THE RATES
THAT THE STATE HAS THE MOST
DIRECT SORT OF CONTROL OVER AND
THE WAY PHYSICIANS ARE PAID IN
MEDI-CAL GENERALLY, THE WAY IT
WORKS IS A PHYSICIAN RENDERS A
SERVICE TO A BENEFICIARY AND
THEN SUBMITS A CLAIM FOR THAT
SERVICE. THERE ARE THOUSANDS OF
CODES ASSOCIATED WITH DIFFERENT
PROCEDURES, LIKE HAVING A VISIT
AT THE OFFICE OR A SURGERY, AND
THOSE CODES HAVE A RATE
ASSOCIATED WITH THEM. NOW,
HISTORICALLY, THE SYSTEM WAS
DEVELOPED IN THE 1960S, AND IT
WAS, YOU KNOW, OUR UNDERSTANDING
IS IT WAS PRIMARILY DEVELOPED TO
CONSIDER THE RELATIVE COST OF
PROVIDING A SERVICE. SO, FOR
EXAMPLE, IF A PROCEDURE WAS
RELATIVELY EXPENSIVE, IT WOULD
GET MUCH MORE PAYMENT THAN A
PROCEDURE THAT WAS RELATIVELY
SIMPLE AND LESS EXPENSIVE.
HOWEVER, IT'S OUR UNDERSTANDING
THAT OVER TIME THE STATE, YOU
KNOW, DIDN'T SORT OF ADJUST
THESE RATES TO ACCOUNT FOR
EMPIRICAL EVIDENCE AND THE
CHANGES OF COST AND CARE AND
INSTEAD, THE STATE KIND OF
DIDN'T HAVE A VERY SPECIFIC OR A
WELL DEFINED SORT OF SYSTEM TO
ADJUST RATES IN THE ABSENCE OF
THAT, RATES OFTEN WENT FOR MANY
YEARS, NOT BEING ADJUSTED FOR
THINGS LIKE INFLATION OR IF THEY
WERE ADJUSTED, IT WAS OFTEN
DEPENDENT ON RESOURCES IN THE
BUDGET. SO, FOR EXAMPLE, IF THE
BUDGET HAD WAS A PARTICULARLY
STRONG YEAR IN TERMS OF
REVENUES, THE STATE ENACTED RATE
INCREASES. AND IN YEARS WHERE
THERE WERE RECESSIONS, THE STATE
ENACTED, REDUCTIONS TO RATES AS
A PART OF A BUDGET SOLUTION, IN
ADDITION TO THAT SORT OF RATE
SYSTEM, WE DID ALSO WANT TO NOTE
THAT THERE IS A SUPPLEMENTAL
PAYMENT SYSTEM FOR PHYSICIANS.
IT'S FUNDED BY PROPOSITION 56,
WHICH IS A WHICH IS PART OF THE
STATE'S TOBACCO TAX REVENUES,
THE WAY THIS WORKS IS IN
ADDITION TO THE SORT OF BASE
RATE THAT'S PROVIDED, THEY GET A
SORT OF SUPPLEMENTAL RATE ON TOP
OF THAT, TURNING TO PAGE THREE
OF YOUR AGENDA, WE THEN TALK
ABOUT HOW RATES WORK IN THE
MANAGED CARE SYSTEM. SO MEDI-CAL
MANAGED CARE IS A BIT OF A
DIFFERENT SYSTEM THAN FEE FOR
SERVICE, AND THIS IS THE PRIMARY
DELIVERY SYSTEM. MOST
BENEFICIARIES ARE IN MEDI-CAL
MANAGED CARE. THE WAY IT
PRIMARILY WORKS IS THE STATE
CONTRACTS WITH MANAGED CARE
PLANS, AND MANAGED CARE PLANS
ARE THEN RESPONSIBLE FOR
OVERSEEING THE DELIVERY OF CARE
FOR BENEFICIARIES IN THIS
SYSTEM. MANAGED CARE PLANS
HISTORICALLY HAVE HAD A LOT OF
FLEXIBILITY OVER DETERMINING THE
LEVEL OF PAYMENT AND ALSO HOW TO
STRUCTURE THEIR PAYMENTS TO
PROVIDERS, AND SO HISTORICALLY,
THERE'S BEEN A LOT OF VARIATION
ACROSS THE STATE IN TERMS OF HOW
THIS WORKS. IT'S HARD TO MAKE
GENERAL STATEMENTS ABOUT THE
MANAGED CARE SYSTEM FOR THAT
REASON. BUT GENERALLY, SOME
MANAGED CARE PLANS PAY USING A
FEE FOR SERVICE SYSTEM, MUCH
LIKE THE STATE DOES, SO THAT
EVERY TIME A PHYSICIAN RENDERS A
SERVICE IT, THEY SUBMIT A CLAIM
AND THEY GET PAID FOR THAT
SERVICE. OTHER PLANS HAVE MORE
COMPLEX ARRANGEMENTS. FOR
EXAMPLE, THEY HAVE THEIR OWN
MANAGED CARE ARRANGEMENTS WITH
PROVIDERS WHERE THEY PAY THEM
MONTHLY FOR A SET OF
BENEFICIARIES, AND THEN THAT
PAYMENT PAYS FOR THE SERVICES
UNDER THAT CONTRACT. SO THERE'S
JUST A LOT OF VARIATION THERE.
THE STATE ALSO DOES DIRECT SOME
PAYMENTS TO PROVIDERS IN THE
MANAGED CARE SYSTEM. THE STATE
REFERS TO THOSE AS DIRECTED
PAYMENTS. AND THERE ARE SOME
SPECIFICALLY FOR PHYSICIANS.
THEY'RE FUNDED BY PROPOSITION
56, JUST LIKE THE SUPPLEMENTAL
PAYMENTS. AND THEY WORK VERY
SIMILARLY. THEY PROVIDE
ADDITIONAL PAYMENT ABOVE WHAT
THE MANAGED CARE PLANS, PAY IN
THEIR BASE RATES. TURNING TO
PAGE FOUR OF YOUR AGENDA, WE
PROVIDE AN OVERVIEW OF HOW,
THINGS WOULD CHANGE UNDER THE
MCO TAX PACKAGE. AND I KNOW THE
COMMITTEE HAS DISCUSSED THIS
BEFORE, AND YOU HAVE A LOT OF
GROUND TO COVER TODAY, SO I
WON'T I WON'T SPEND TOO MUCH
TIME ON ALL THE SPECIFICS, BUT I
DO WANT TO EMPHASIZE FOUR KEY
CHANGES THAT KIND OF START ON
THE TOWARDS THE BOTTOM OF PAGE
FOUR. THE FIRST KEY CHANGE IS
THAT THE ADMINISTRATION IS
PROPOSING TO REALLY BENCHMARK
PHYSICIAN RATES AND RATES TO
OTHER PROVIDERS, AS WELL TO WHAT
IS PAID IN MEDICARE. AND RATES
WOULD BE AT BETWEEN 80 AND 100%
OF MEDICARE, DEPENDING ON THE
KIND OF PROCEDURE. AND THEN
CRITICALLY, THIS WOULD NOT BE A
ONE TIME INCREASE. THE STATE
WOULD MAINTAIN THIS BENCHMARK.
SO EVERY TIME THE MEDICARE RATES
CHANGE, THE RATES WOULD BE
ACCORDINGLY CHANGED IN MEDI-CAL
FEE FOR SERVICE SO THAT THEY
STAY AT THAT BENCHMARKED RATE.
SECONDLY, THE STATE IS THE
ADMINISTRATION IS PROPOSING TO
HAVE A REGIONAL VARIATION IN
RATES. AND SO THERE WOULD BE A
DIFFERENT RATES FOR DIFFERENT
PARTS OF THE STATE, REFLECTING
THE VARIATION IN THE COST OF
CARE. RATHER THAN HAVING A
STATEWIDE RATE SCHEDULE, WHICH
IS THE APPROACH TODAY. TURNING
TO PAGE FIVE. THE THIRD KEY
CHANGE THE ADMINISTRATION'S
PROPOSING TO CREATE, WHAT IT
CALLS AN EQUITY BASED
ADJUSTMENT. THIS WOULD PROVIDE
AN ADDITIONAL BOOST IN RATES IN
CERTAIN REGIONS OF THE STATE
WHERE THERE ARE SORT OF EQUITY
ISSUES, THIS MEANS THAT FOR SOME
IN SOME AREAS OF THE STATE, THE
RATES WOULD BE MORE THAN 100% OF
MEDICARE. THE DEPARTMENT HAS
TOLD US THAT IT IS STILL WORKING
WITH STAKEHOLDERS TO DESIGN THE
SYSTEM. SO THE DETAILS HAVEN'T
FULLY BEEN, FINISHED YET. BUT
THIS IS SORT OF THE PROPOSAL AND
CONCEPT. AND THEN FINALLY, YOU
KNOW, THE CHANGES WE TALKED
ABOUT ARE IN MEDI-CAL FEE FOR
SERVICE. BUT THE ADMINISTRATION
ALSO IS PROPOSING TO REQUIRE
MANAGED CARE PLANS TO PAY AT
LEAST THAT FEE FOR SERVICE LEVEL
WHEN THEY PAY FOR THESE
SERVICES. SO THAT WOULD
BASICALLY BECOME A FLOOR THAT
WOULD WOULD DETERMINE RATES FOR
IN THE MANAGED CARE SYSTEM.
MANAGED CARE PLANS COULD STILL
PAY MORE THAN THAT RATE, BUT
THEY COULDN'T PAY LESS THAN THAT
RATE. TURNING TO PAGE SIX. WE
START WITH OUR SORT OF
ASSESSMENT OF PHYSICIAN RATES,
AND I'LL WALK THROUGH EACH OF
OUR CORE PRINCIPLES THAT WE
DEVELOPED, THE FIRST PRINCIPLE
WE DEVELOPED IS ACCESS AND
QUALITY. THAT PROBABLY DOESN'T
SEEM TOO SURPRISING IF YOU
CONSIDER THAT MEDI-CAL IS A
SYSTEM THAT IS INTENDED TO
PROVIDE ACCESS TO QUALITY CARE
FOR LOW INCOME PATIENTS IN THE
CONTEXT OF RATES, WHEN WE TALK
ABOUT ACCESS AND QUALITY, WE'RE
PRIMARILY THINKING ABOUT
SUFFICIENCY. SO OUR RATE
SUFFICIENT TO ATTRACT PROVIDERS
TO ENSURE THAT THERE IS ACCESS
TO QUALITY CARE FOR
BENEFICIARIES. THE WAY WHEN WE
REVIEWED THE LITERATURE AND MET
WITH STAKEHOLDERS, THE WAY WE
SAW IT WAS GAUGED WAS KIND OF 1
IN 2 WAYS. THE FIRST WAS, WE SAW
LITERATURE OFTEN MAKES
COMPARISONS TO WHAT IS PAID BY
OTHER PAYERS. SO THAT COULD BE
MEDICARE'S TYPICALLY THE
THRESHOLD THAT'S USED, BUT
SOMETIMES, FOLKS, ALSO COMPARED
TO WHAT'S PAID IN THE PRIVATE
SECTOR AS WELL. AND THE IDEA
THERE IS THAT THE RATES SHOULD
BE SORT OF COMPETITIVE, WITH,
WITH OTHER PAYERS. AND THEN THE
SECOND APPROACH WE ALSO SAW WAS
THAT SOMETIMES RATES ARE
COMPARED TO THE COST OF CARE.
THAT SECOND APPROACH TENDS TO BE
MORE COMMON FOR FACILITY BASED
PROVIDERS, WHERE THERE'S KIND OF
MORE READILY AVAILABLE
INFORMATION ON COSTS. BUT WE
ALSO HEARD FROM FROM
STAKEHOLDERS CONCERNS AROUND
RATES AND WHETHER OR NOT THEY'RE
COVERING THE COSTS. FOR EXAMPLE,
FOR PHYSICIAN SERVICES. AND WHAT
WE FOUND IS GENERALLY SUMMARIZED
ON PAGES SIX AND SEVEN OF YOUR
HANDOUT, YOU KNOW, GENERALLY,
RESEARCH HAS FOUND THAT THAT,
YOU KNOW, MEDI-CAL FEE FOR
SERVICE TENDS TO PAY LESS THAN
WHAT IS PAID IN MEDICARE, AND
MEDICARE TENDS TO PAY LESS THAN
WHAT IS PAID IN THE PRIVATE
SECTOR. SO MEDI-CAL TENDS TO BE
THE LOWEST OF THE THREE PAYERS.
WE FOUND RESEARCH LOOKING AT
RESEARCH THAT THE RATE TENDED TO
BE ABOUT 70% OF WHAT MEDICARE
PAYS. THERE IS A LOT OF
VARIATION, THOUGH RESEARCH HAS
FOUND THAT, YOU KNOW, THE
MEDICARE FOR MATERNITY CARE, FOR
EXAMPLE, THE RATIO TO MEDICARE
IS AS LOW AS 60, AS WE NOTE ON
THE TOP OF PAGE SEVEN, THE
DEPARTMENT ALSO HAS DONE SOME
EXPLORATION INTO WHAT IS WHAT
MANAGED CARE PLANS PAY PROVIDERS
. AND GENERALLY THEY FOUND THAT
MANAGED CARE. MANAGED CARE PLANS
TEND TO PAY A BIT MORE THAN
WHAT'S PAID IN FEE FOR SERVICE.
THAT CORRESPONDS WITH WHAT WE'VE
HEARD FROM MANAGED CARE PLANS.
AGAIN, THERE'S A LOT OF
VARIATION THERE. FOR SOME
SERVICES, IT WAS JUST A JUST A
BIT MORE, JUST A BIT HIGHER. IN
OTHER CASES, IT WAS CONSIDERABLY
HIGHER. FOR EXAMPLE, THE
DEPARTMENT FOUND THAT, YOU KNOW,
THE RATIO TO MEDICARE FOR, YOU
KNOW, PRIMARY CARE WAS, WAS
CLOSE TO 90. THAT WAS QUITE A
BIT HIGHER THAN WHAT IS PAID IN
FEE FOR SERVICE. AND GENERALLY
THIS IS AN AREA THAT WOULD
DIRECTLY CHANGE UNDER THE
ADMINISTRATION'S PROPOSAL. THE
ADMINISTRATION'S PROPOSING TO
SET THESE RATES AT A MUCH HIGHER
RATIO, 80 TO 100% OF MEDICARE.
AND THEN THERE WOULD BE
ADDITIONAL PAYMENTS ON TOP OF
THAT, FOR EXAMPLE, EQUITY BASED
PAYMENTS. ONE OF THE THINGS WE
CAN WE LOOKED AT WHEN WE WHEN WE
UNDERTOOK THIS PROJECT IS WE
LOOKED AT WHAT RESEARCH SAYS
ABOUT RATE INCREASES. WHAT DOES
THAT MEAN IN TERMS OF ACCESS TO
QUALITY CARE AND GENERALLY THE
RESEARCH DOES FIND AN
ASSOCIATION BETWEEN RATE
INCREASES AND ACCESS TO CARE,
CERTAIN MEASURES OF ACCESS TEND
TO IMPROVE WITH RATE INCREASES
LIKE HAVING A USUAL SOURCE FOR
CARE, HAVING LOWER WAIT TIMES
FOR APPOINTMENTS, HAVING
INCREASED UTILIZATION AND
SERVICES. THE EVIDENCE TENDS TO
BE A BIT MORE MIXED WHEN WE'RE
TALKING ABOUT THE IMPACT OF
RATES ON, GETTING MORE PROVIDERS
INTO THE INTO MEDI-CAL. AND
THERE COULD BE MANY REASONS FOR
THAT. BUT ONE LIKELY REASON IS
THAT RATE INCREASES TEND TO
STILL MEAN THAT THE RATES ARE
BELOW WHAT IS PAID IN THE
PRIVATE MARKET. SO IF YOU HAVE
PROVIDERS WHO RELY PRIMARILY ON
PRIVATE INSURANCE FOR PAYMENT,
THEY THEY MIGHT NEED EVEN MORE
FINANCIAL INCENTIVE TO, TO ENTER
INTO THE MEDI-CAL SYSTEM.
TURNING TO PAGE EIGHT. WE TALK,
WE GO. I'LL GO THROUGH OUR
SECOND CORE PRINCIPLE THAT WE
DEVELOPED. AND THAT'S ECONOMY
AND EFFICIENCY. AND THESE ARE
PRINCIPLES THAT ARE PART OF
FEDERAL POLICY. AND IN
DISCUSSIONS WITH STAKEHOLDERS
AND POLICY EXPERTS, OUR
UNDERSTANDING IS YOU COULD THINK
OF THESE, AT LEAST IN THE
CONTEXT OF RATE SETTING, AS
REFERRING TO COST EFFECTIVENESS.
SO KEEPING COSTS AS LOW AS THEY
CAN WHILE STILL ACHIEVING THE
POLICY OBJECTIVES OF THE
PROGRAM, WHILE ALSO MAXIMIZING
OUTCOMES FOR BENEFICIARIES, AND
THAT THAT INVOLVES BOTH SORT OF
THE LEVEL OF PAYMENT, BUT ALSO
HOW HOW PAYMENTS ARE STRUCTURED.
AND, YOU KNOW, IN THE CONTEXT OF
PHYSICIAN RATES, YOU KNOW, THERE
ARE WE THINK THERE ARE A COUPLE
ISSUES TO CONSIDER HERE. THE
FIRST IS THAT, YOU KNOW, WE
THINK THAT WE THINK YOU COULD
MAKE A REASONABLE CASE THAT THE
PHYSICIAN FEE SCHEDULE TODAY IS,
IS SOMEWHAT OUTDATED, YOU KNOW,
IN THE 1960S, AS OUR
UNDERSTANDING THAT THAT SCHEDULE
WAS INTENDED TO REFLECT,
EMPIRICAL EVIDENCE ON THE
RELATIVE COST OF CARE, BUT THAT
HASN'T SEEMED TO HAVE BEEN A
MAJOR FACTOR IN MANY DECADES.
AND SO LIKELY ISN'T ISN'T SORT
OF FOLLOWING THAT UNDER THE
ADMINISTRATION'S PROPOSAL, RATES
WOULD BE TIED TO MEDICARE AND
THE MEDICARE PHYSICIAN FEE
SCHEDULE IS A BIT MORE UPDATED
AND IS TENDS TO BE MORE UPDATED
BASED ON STAKEHOLDER FEEDBACK.
SO IN THAT SENSE THAT THAT THAT
COULD BE AN IMPROVEMENT TO SOME
EXTENT. BUT THERE ARE
LIMITATIONS TO THAT. AND
GENERALLY WE WOULD ALSO
EMPHASIZE THAT, YOU KNOW, THE
MEDICARE PROGRAM IS SET BY, YOU
KNOW, FEDERAL POLICY. AND SO
THAT WOULD MEAN RATES AND THEIR
ADJUSTMENTS TO RATES WOULD BE
SUBJECT TO CHANGES IN FEDERAL
POLICY, WHICH CAN BE UNCERTAIN,
TURNING TO PAGE NINE, THE OTHER,
AREA IN TERMS OF EFFICIENCY THAT
POLICYMAKERS HAVE LONG
CONSIDERED ARE THINGS CALLED
ALTERNATIVE PAYMENT MODELS.
THESE ARE PAYMENT MODELS THAT
CONSIDER APPROACHES OTHER THAN
JUST PAYING FOR THE VOLUME OF
SERVICES. SO THEY, FOR EXAMPLE,
MIGHT PAY FOR AN EPISODE OF
CARE, OR THEY MIGHT, YOU KNOW,
PAY FOR A BROADER SUITE OF
SERVICES OR THEY MIGHT TIE, YOU
KNOW, PAYMENT TO MEETING CERTAIN
PERFORMANCE OBJECTIVES. IT'S A
VERY BROAD CATEGORY AND CAN
INCLUDE LOTS OF DIFFERENT
STRATEGIES. BUT THE AIM IS TO
INCENTIVIZE PROVIDERS TO
MINIMIZE COSTS AND INCREASE
OUTCOMES FOR, FOR PATIENTS. AND
WHAT WE WOULD SAY HERE IS THAT
ALTERNATIVE PAYMENT MODELS, AS A
CONCEPT, THEY HAVE PROMISE FOR
THE MEDI-CAL SYSTEM AND THE
STATE HAS EXPLORED ALTERNATIVE
PAYMENT MODELS IN MANY WAYS,
INCLUDING IN THE MANAGED CARE
SYSTEM FOR PHYSICIAN SERVICES,
YOU KNOW, IT IS AN AREA THAT
REQUIRES MORE STUDY AS A
LEGISLATURE CONSIDERS IT. THERE
CAN BE TRADE OFFS WHEN THINKING
ABOUT ALTERNATIVE PAYMENT
MODELS, AND THE DETAILS DO
MATTER TO ENSURE THAT THE MODELS
PROVIDE THE INTENDED INCENTIVES,
MOVING TO PAGE TEN, OUR THIRD
PRINCIPLE THAT WE DEVELOPED IS
EQUITY. AND EQUITY IS SOMETHING
THAT THE LEGISLATURE HAS BEEN
FOCUSED ON FOR SEVERAL YEARS.
AND, YOU KNOW, IT'S ARGUABLY A
KEY GOAL OF THE MEDI-CAL PROGRAM
BECAUSE MEDI-CAL AIMS TO
MITIGATE DISPARITIES IN ACCESS
TO CARE FOR LOW INCOME,
BENEFICIARIES. AND THERE ARE
DOCUMENTED HEALTH DISPARITIES.
AND THOSE DISPARITIES IMPACT THE
MEDI-CAL PROGRAM TO, YOU KNOW,
GENERALLY, HISTORICALLY, THE
MEDI-CAL FEE FOR SERVICE RATE
SYSTEM HASN'T HAD A DIRECT FOCUS
ON EQUITY, AND THE
ADMINISTRATION'S PROPOSAL
APPEARS TO BE INTENDED TO
ADDRESS THAT AND A NUMBER OF
WAYS, BY VARYING RATES
REGIONALLY, BY HAVING A MORE
CONSISTENT APPROACH TO ADJUSTING
RATES OVER TIME, AND MORE MOST
DIRECTLY BY HAVING AN EQUITY
ADJUSTMENT, THESE CHANGES COULD
IMPROVE EQUITY, BUT, YOU KNOW,
SOME OF THESE THINGS WILL
MATTER. FOR EXAMPLE, HOW THAT
EQUITY ADJUSTMENT ULTIMATELY IS
DETERMINED. SO SOME OF THAT IT'S
A LITTLE HARD TO ASSESS AT THE
MOMENT WHAT THE IMPACT OF THAT
WOULD BE. TURNING TO PAGE 11, WE
PROVIDE OUR SORT OF FINAL
PRINCIPLE HERE, WHICH IS
SIMPLICITY AND TRANSPARENCY. AND
FROM OUR PERSPECTIVE, YOU KNOW,
AN IDEAL RATE SYSTEM, IS
ACCESSIBLE AND TRANSPARENT, AND
THAT PROVIDERS AND POLICYMAKERS
CAN UNDERSTAND HOW HOW THE
SYSTEM WORKS AND WHAT IT TAKES
TO GET PAID. AND ALSO THAT
PROVIDERS DON'T FACE UNNECESSARY
BURDENS TO GET PAID FOR
DELIVERING SERVICES. AND WE
WOULD EMPHASIZE GENERALLY
MEDI-CAL IS A COMPLICATED
PROGRAM, AND THERE CAN BE
LIMITATIONS TO GETTING MAKING
RATES SIMPLER AND MORE
TRANSPARENT. STATES DO HAVE
CHOICES, THOUGH, AND WE WOULD
EMPHASIZE HERE THAT THE THAT THE
ADMINISTRATION'S PROPOSAL, IT'S
A LITTLE HARD TO PROJECT WHAT
THE, YOU KNOW, IMPACTS WOULD BE.
SOME PARTS OF IT APPEAR TO BE
FOCUSED ON IMPROVING SIMPLICITY
IN THE RATE SYSTEM, IN PART
BECAUSE AS A CONSEQUENCE OF THE
ADMINISTRATION'S PROPOSAL, YOU
KNOW, MANY OF THESE ADJUSTMENTS,
LIKE THE SUPPLEMENTAL PAYMENTS,
SOME, SOME REDUCTIONS THAT HAD
BEEN IN THE SYSTEM, THOSE WOULD
BE SORT OF FOLDED INTO THESE NEW
RATE INCREASES, WHICH WOULD JUST
BE SORT OF BASE RATES. AND THAT
COULD BETTER SIGNAL TO PROVIDERS
WHAT THE PAYMENT FOR SERVICES
IS, AND IN THAT SENSE COULD MAKE
THINGS SIMPLER. AS WE'VE NOTED
IN PREVIOUS HEARINGS, TOO, THE
ADMINISTRATION IS ALSO PROPOSING
QUITE AN EXPANSIVE CHANGE IN A
NUMBER OF DIFFERENT PROVIDER
PAYMENT SYSTEMS. AND SO THERE
COULD BE IMPLEMENTATION
CHALLENGES THERE, AT LEAST IN
THE SHORT RUN. AND SO THAT COULD
AT LEAST ADD SOME COMPLEXITY, AT
LEAST AS THE STATE AND MANAGED
CARE PLANS AND PROVIDERS ADJUST
TO THE NEW SYSTEM. TURNING TO
PAGE 12. WE ALSO WANTED TO NOTE
THAT THE FEDERAL GOVERNMENT
RECENTLY ADOPTED A PACKAGE OF
RULE CHANGES AND THOSE RULE
CHANGES AIM TO DO SEVERAL
THINGS, BUT ONE OF THE EFFECTS
OF THESE COULD BE TO ADD
SIMPLICITY, AND PARTICULARLY
TRANSPARENCY, TO THE RATE TO
PROVIDER RATES, BOTH IN FEE FOR
SERVICE AND MANAGED CARE, FOR
EXAMPLE, AS PART OF THOSE RULE
CHANGES, THE STATE MUST
PERIODICALLY COMPARE PROVIDER
PAYMENTS BOTH IN FEE FOR SERVICE
AND IN MANAGED CARE FOR CERTAIN
SERVICES. THAT CONCLUDES OUR
PRESENTATION. WE'RE AVAILABLE
FOR QUESTIONS. THANK YOU SO
MUCH. I WILL FIRST TURN TO MY
COLLEAGUE TO SEE IF HE HAS ANY
QUESTIONS. WELL, I WANT TO THANK
YOU FOR THIS REPORT AND FOR
DIGGING DEEP INTO THIS, THIS
QUESTION THAT MANY OF US HAVE,
AND I KNOW IT'S EXTREMELY
COMPLICATED. AND ONE OF THE
THINGS THAT FOR THOSE WHO WERE
ABLE TO READ IT, ONE OF THE
REOCCURRING THEMES IS THAT
BECAUSE OF LACK OF TRANSPARENCY,
IT'S OFTENTIMES VERY DIFFICULT
TO DETERMINE, PROVIDER PAYMENT
AND RATES. AND TO DO THAT
COMPARISON. AND SO YOU JUST
TALKED ABOUT, THE NEW RULES THAT
WOULD REQUIRE THE, TRANSPARENCY
BETWEEN THE STATE AND FEDERAL
GOVERNMENT, WOULD ANYONE ELSE
HAVE ACCESS TO THAT INFORMATION,
TO YOUR KNOWLEDGE? WITH WHAT YOU
WERE JUST REFERRING TO, THAT THE
STATES HAVE TO TALK MORE ABOUT
PROVIDER RATES AND MANAGED CARE
PLANS VERSUS FEE FOR SERVICE, OR
IS THAT JUST SOMETHING THAT THE
FEDERAL GOVERNMENT WOULD HAVE
ACCESS TO? I THINK WE'D NEED TO
Þ UNLESS IF IT SOUNDS LIKE THE
DEPARTMENT MIGHT HAVE SOME
TECHNICAL EXPERTISE THERE, THEY
COULD PROVIDE LINDY HARRINGTON,
ASSISTANT STATE MEDICAID
DIRECTOR, SO THE NEW RULES JUST
CAME OUT. THEY WILL BE FINALIZED
ON MAY 10TH, FORMALLY PUBLISHED,
BUT IN THE RULE THAT WAS
FINALIZED, IT WOULD BE REQUIRE
STATES TO DO A PUBLIC POSTING,
PERIODICALLY OF THE COMPARISON
OF RATES IN, A COUPLE OF
SPECIFIC CATEGORIES. I'M
REMEMBERING THEM, SIMILAR TO
PRIMARY CARE, MENTAL HEALTH, AS
WELL AS MATERNITY. SO THE CODES
THAT WE RECENTLY DID AN ANALYSIS
, IT WOULD BE SIMILAR TO THOSE
CODES. BUT WE ARE CONTINUING TO
REVIEW THE NEW RULE AND WE'LL
HAVE MORE INFORMATION ON IN THE
FUTURE. SO TO YOUR KNOWLEDGE IT
DOESN'T COVER ALL SPECIALTIES.
JUST THOSE. NO IT DOESN'T IT AT
THIS TIME IT DOES NOT COVER ALL
CODES. THERE'S SPECIFIC
CATEGORIES OF CODES THAT WE
WOULD BE REQUIRED TO PUBLISH.
BUT AGAIN WE ARE CONTINUING TO
REVIEW THE RULE THAT CAME OUT,
AND THE FINALIZATION. AND WE'LL
HAVE MORE INFORMATION. OKAY.
THANK YOU. AND, QUICK QUESTION.
YOU MIGHT KNOW THE ANSWER BEFORE
YOU LEAVE. WHEN YOU TALK ABOUT
MEDICARE RATES, DO THOSE RATES,
COMING DOWN FROM THE FEDERAL
GOVERNMENT, IS THAT A FLAT RATE
OR DOES IT VARY BY REGION? SO
FOR MEDICARE, DEPENDING ON THE
CATEGORY OF RATE. BUT FOR
PHYSICIANS IT VARIES. I BELIEVE
THERE'S 32, REGIONS WITHIN
CALIFORNIA THAT THEY SET THE
RATE FOR. OKAY. THANK YOU, WE
CAN HAVE THE DIRECTOR BACK. AND
I ALSO WANTED TO CLARIFY THAT
THAT THAT IS A CORE PART OF THE
ADMINISTRATION'S PROPOSAL IS TO
IN THE PAST, WHEN WE'VE COMPARED
TO MEDICARE, WE'VE EITHER
COMPARED TO WHAT THE AVERAGE IS
IN THE STATE OR TO THE LOWEST
RATE. AND WHAT THE
ADMINISTRATION IS PROPOSING IS
NOT JUST IS TO TIE EACH REGION'S
RATES TO THE TO THE MEDICARE
RATE. SO WHEN WE SAY WE'RE
VARYING REGIONALLY, IT'S TYING
TO THOSE TO THOSE VARIATION IN
THE MEDICARE RATES. THANK YOU.
AND ALONG THE LINES OF, OF
MEDICARE, ONE OF THE THINGS
THAT, LEO DISCUSSED AND IT'S
ALSO IN THEIR, IN THEIR PACKAGE
IS THAT, YOU KNOW, COMMERCIAL
PAYS MORE THAN MEDICARE. AND
MEDICAID IS GENERALLY AT THE
BOTTOM. UNDERSTANDING THAT WHAT
IS THE RATIONALE, RATIONALE
BEHIND TRYING TO GET THE
MEDICARE PAID RATES UP TO 82,
100% OF MEDICARE INSTEAD OF JUST
GETTING UP TO 100? OUR PROPOSAL
WAS BASED ON JUST THE AVAILABLE,
REVENUE FROM THE MCO TAX. AND SO
KIND OF WORKING WITH THE
AVAILABLE REVENUE AND ASSESSING
HOW WE CAN INCREASE THE RATES BY
CATEGORY, DEPENDING ON THE
AMOUNT 2% TO MEDICARE. OKAY AND
I'M NOT SURE IF YOU KNOW THIS,
BUT YOU KNOW, THIS CONVERSATION
ABOUT REIMBURSEMENT RATES HAS
BEEN A VERY LONG STANDING ONE
FOR A VERY LONG TIME. AND DO YOU
HAVE ANY KIND OF HISTORICAL
KNOWLEDGE AS TO WHY IT HAS TAKEN
THIS LONG FOR US TO HAVE ANY
MOVEMENT IN THE AREA AS FAR AS
REIMBURSEMENT? I MEAN, WE HAVE
SIGNIFICANT SHORTAGE OF
PROVIDERS IN EVERY AREA OF
MEDICINE UP AND DOWN THE STATE.
AND ONE OF THE MAIN THINGS THAT
IS CITED IS REIMBURSED ISN'T, DO
WE KNOW WHAT HAS TAKEN SO LONG,
I THINK IS THE ELIO NOTED JUST
THE BUDGET SITUATION OVER THE
LAST DECADES OR SO, REALLY KIND
OF REFLECTING, YOU KNOW, THE
ADDITIONAL SPEND TO, TO INCREASE
RATES TO THE LEVEL THAT WE'RE,
WE HAVE AS PART OF MAY REVISION
OR AS PART OF THE GOVERNOR'S
BUDGET. SO I THINK IT'S JUST
BEEN A MATTER OF, YOU KNOW, THE
BUDGET, THE BUDGET REQUESTS THAT
WOULD BE NECESSARY TO DO SO, NOW
FOR THE PROPOSAL FOR 2020, 2025
AND THE MCO TAX, IN THE LÀ Ó
REPORT, IT SAYS THAT IT WOULD
BROADLY APPLY TO MOST PROVIDERS.
IS THERE ANY PARTICULAR HEALTH
CARE PROVIDER THAT WOULD NOT SEE
AN INCREASE IN THEIR RATES, WITH
THE 2025 PROPOSAL? SO IN THE
CONTEXT OF PHYSICIAN RATES, JUST
SO WE WERE TALKING ABOUT, AS
ALLOCATION ACROSS CODES. SO I'M
SURE THE DEPARTMENT COULD
CLARIFY. THERE ARE I ALSO JUST
WANTED TO CLARIFY THAT THE MCO
TAX PACKAGE DOES HAVE OTHER,
PROVIDERS IN IT THAT BECAUSE WE
FOCUSED ON PHYSICIAN RATES, WE
DIDN'T DISCUSS. BUT THERE ARE,
YOU KNOW, HOSPITALS WOULD GET AN
INCREASE. AND THEN EVEN FOR THE,
FOR WHAT WE CALL THE PHYSICIAN
RATES, THERE ARE SOME
NON-PHYSICIAN PROVIDERS WHO ALSO
WOULD GET RATE INCREASES, LIKE
AUDIOLOGISTS, NURSE
PRACTITIONERS, SO THERE IS A
KIND OF A BROADER BUCKET BUCKET
OF MEDICAL PROVIDERS. BUT I
WOULD DEFER TO THE DEPARTMENT TO
CLARIFY ON THE ON THE PARTICULAR
PROCEDURES AND CODES, IF THERE
ARE ANY. THAT WOULD BE AND WHAT
I'M SPECIFICALLY REFERRING TO IS
IN 2024, WE REALLY FOCUSED ON
THREE MAIN AREAS PRIMARY CARE,
MATERNITY SERVICES AND
BEHAVIORAL HEALTH. RIGHT, SO ARE
WE EXPANDING THAT TO ESSENTIALLY
COVER EVERY SINGLE AREA WITHIN
HEALTH CARE? SO IT DOESN'T
MATTER IF I'M AN OB GYN OR AN
ENT OR A GENERAL SURGEON, THAT I
WOULD SEE A BUMP IN MY RATES IF
I MANAGED PATIENTS WHO HAVE
MEDI-CAL. THAT'S MY QUESTION.
FOR PHYSICIANS, IT'S EVERY
SINGLE PHYSICIAN TYPE. BUT WE
HAVE OTHER MEDI-CAL PROVIDERS
WHO ARE NOT PART OF THE TARGETED
RATE INCREASES. THERE'S, SO IT
DOESN'T COVER EVERY SINGLE
MEDI-CAL PROVIDER, RIGHT? AS
PART OF THE MANAGED CARE. SO NOT
EVERY MEDI-CAL PROVIDER, BUT
EVERY PHYSICIAN THÀNH PROVIDER
WILL SEE A BUMP. RIGHT? BECAUSE
I WAS JUST TALKING WITH A
COLLEAGUE WHO SPOKE WITH, I
BELIEVE IT WAS THE ORTHOPEDIC
SURGEONS THAT WERE DOWN IN SAN
DIEGO, AND THEY WERE COMPLAINING
ABOUT THEIR MEDI-CAL
REIMBURSEMENT RATES. BUT SO THEY
WILL SEE A BUMP IN 2025. ALL
PHYSICIANS. YEAH. PROFESSIONAL
SERVICES. OKAY, GREAT. AND I
ALSO WANTED TO NOTE THAT, WHEN
WE TALK ABOUT WHICH WHICH CODES
ARE BEING INCREASED, YOU KNOW,
80 TO 100, SOME, YOU KNOW, SOME
SPECIALISTS ALSO SUBMIT CLAIMS
FOR THOSE CODES, TOO. SO IT'S
REALLY THE PROCEDURES THAT WOULD
GET THE RATE INCREASE. BUT IF A
PROVIDER PROVIDES AN OFFICE, YOU
KNOW, A RATE THAT'S AT 100, THEY
WOULD GET THAT 100% RATE. SO
IT'S NOT IT'S REALLY TIED TO THE
WHAT WHAT PROCEDURE IS PROVIDED.
NOT NECESSARILY THE EXACT,
PROVIDER. YEAH, I KNOW, BUT WITH
THE INITIAL, ROLLOUT OF THE MCO,
WE FOCUSED ON THREE VERY
IMPORTANT AREAS, BUT JUST MAKING
SURE THAT, ALL PHYSICIANS WOULD
BE MADE WHOLE IN 2025 OR
SOMEWHAT WHOLE. SO THERE WAS A
VALUE BASED PAYMENT PROGRAM,
THAT WE HAD. CAN SOMEONE PLEASE
EXPLAIN THAT AND JUST LET US
KNOW WHAT IT WAS, WHAT WHAT YOU
WERE FOCUSED ON, WHAT WAS THE
OUTCOME, SURE. SO FROM JANUARY,
I'M LOOKING UP THE DATES. NOW.
SO FROM JULY 1ST OF 2019 THROUGH
JUNE 30TH OF 2022, WE HAD A
DIRECTED PAYMENT IN THE MANAGED
CARE PROGRAM THAT ALLOWED US TO
DO A VALUE BASED PAYMENT,
ARRANGEMENT FOR PHYSICIANS IN
THE MANAGED CARE PROGRAM, AND IT
FOCUSED ON RISK BASED INCENTIVE
PAYMENTS THAT WERE TARGETED AT
ELIGIBLE NETWORK PROVIDERS THAT
MET SPECIFIC ACHIEVEMENT ON
METRICS TARGETING AREAS IN FOUR
SPECIFIC DOMAINS, THAT WAS
PRENATAL AND POSTPARTUM CARE,
EARLY CHILDHOOD PREVENTATIVE
CARE, CHRONIC DISEASE
MANAGEMENT, AND BEHAVIORAL
HEALTH CARE, WE WERE AUTHORIZED
THROUGH THE, THE FEDERAL
GOVERNMENT THROUGH CMS TO DO
THAT. THEY APPROVED OUR OUR
DIRECTED PAYMENT, WE ARE
CURRENTLY IN THE PROCESS OF
DOING THE EVALUATION, SO THAT IS
NOT FORMALLY OUT YET, BUT WE
WERE ABLE TO DEMONSTRATE THAT IN
FOR A MAJORITY OF THOSE METRICS
THAT WERE THERE. WE DID SEE
IMPROVEMENT FROM THE BASELINE TO
THE END OF THE PROGRAM PERIOD.
BUT NOT BUT NOT FOR ALL METRICS.
OKAY. SO YOU SAID PRENATAL AND
POSTPARTUM CARE EARLY CHILDHOOD
CARE, BEHAVIORAL HEALTH. AND
WHAT WAS THE OTHER ONE, CHRONIC
DISEASE MANAGEMENT. OKAY. AND,
AND SO FOR THE PROVIDERS THAT
PARTICIPATED IN THIS PROGRAM,
WERE THEY AWARE THAT THEY WERE
IN THIS NEW. SO IT WAS IT WAS
REALLY ALL PHYSICIANS THAT WERE
PART OF, THE MANAGED CARE
DELIVERY SYSTEM THAT PROVIDED
THIS. NO ONE HAD TO APPLY OR DO
ANYTHING, IT WAS BASED ON THE
SUBMISSION OF CLAIMS AND, AND
WHAT THE RESULTS OF THOSE WERE.
SO THERE WAS NO THE PHYSICIANS
DIDN'T NEED TO TAKE AN EXTRA
STEP TO RECEIVE A PAYMENT. IT
WAS PART OF THE DELIVERY OF
SERVICES AND REIMBURSEMENT
DURING THAT TIME PERIOD. SO THE
PROVIDERS WERE UNAWARE. AND SO
THE PROVIDERS WERE AWARE OF THE
PROGRAM. WE LET THEM KNOW THAT
THE PROGRAM WAS OUT THERE AND
WHAT THEY WOULD BE DOING. THERE
WERE PROGRAM GUIDES. WE HELD
MULTIPLE WEBINARS AND THINGS SO
THAT THEY WERE AWARE, BUT IT
DIDN'T REQUIRE THE PHYSICIANS TO
SUBMIT AN ADDITIONAL CLAIM.
OKAY, SO THEY KNEW THE TARGETS
THAT THEY SHOULD BE REACHING,
LIKE IF YOU'RE TRYING TO
DECREASE. CORRECT. WE HAD VERY
SPECIFIC, METRICS AND METRIC
GUIDES. OKAY AND YOU HAVE NO.
AND THIS FINISHED IN JUNE OF
2022. AND WE'RE CURRENTLY
FINALIZING THE EVALUATION. OKAY.
WHEN CAN WE EXPECT THAT? BECAUSE
NEXT MONTH IT'LL BE TWO YEARS
OUT FROM THE COMPLETION OF THE
PROGRAM. I KNOW THEY ARE WORKING
DILIGENTLY TO FINALIZE THAT SO
WE CAN SUBMIT IT TO THE FEDERAL
GOVERNMENT. OKAY DO YOU HAVE ANY
PRELIMINARY INFORMATION? WAS IT
A SUCCESS? DO YOU THINK SO?
THAT'S WHY I SAID, I THINK, YOU
KNOW, OUR INITIAL RESULT THAT
THEY'RE LOOKING AT, AND AGAIN,
THEY'RE CONTINUING TO REFINE WAS
THAT WE SAW IMPROVEMENT IN A
MAJORITY OF THE METRICS FROM
BASELINE TO THE END FOR THE
PERCENTAGE OF, PROVIDERS THAT
WERE MEETING THAT GOAL. OKAY AND
BACK TO THE OUR DIRECTOR, SORRY,
PLAYING MUSICAL CHAIRS. DO YOU
THINK THAT THIS IS SOMETHING
THAT EITHER YOUR DEPARTMENT OR
THE LEGISLATURE SHOULD LOOK
CLOSELY INTO SOME OF THESE
ALTERNATIVE PAYMENT MODELS OR
VALUE BASED PAYMENT MODELS? I
THINK IT'S, YOU KNOW, IT'S
DEFINITELY A METHOD TO KIND OF
INCENTIVIZE QUALITY AND
INCENTIVIZE OUTCOMES. WE KNOW
OUR MANAGED CARE PLANS OPERATE
SOME OF THEIR OWN INCENTIVE
PROGRAMS, AND, YOU KNOW, TO GET
TO THE RESULTS THAT THEY'RE
LOOKING AT. SO I THINK IT'S
ALWAYS A KIND OF AN IDEA WORTH
EXPLORING. OKAY ALL RIGHT, I'M
GOING TO HOLD RIGHT NOW AND TURN
IT OVER TO MY COLLEAGUE. ALL
RIGHT. SO I WANT TO GET TO THE
ELEPHANT IN THE LIVING ROOM. WE
HEAR THE TERM BUMP. WE'RE GOING
TO GET A BUMP. REIMBURSEMENTS
PRESENTLY DO NOT COVER THE COST.
WE ARE LOSING PHYSICIANS. WE ARE
LOSING ACCESS, I'VE GOT
PROVIDERS IN FRESNO THAT WHEN I
WAS ELECTED IN 2012, BY 2015
THEY WERE OUT OF BUSINESS. THE
QUESTION HERE IS WILL THESE
PRESUMED BUMPS COVER THE
PROVIDERS COSTS, OR ARE WE STILL
GOING TO HAVE PROVIDERS
RECEIVING LESS THAN THEIR COST,
MEANING THAT THEY'RE
SUBSIDIZING, AND MANY OF THEM
CAN'T DO IT AND ARE CLOSING THE
DOORS? WILL THE BUMP REACH THE
GOAL OF PAYING THE PROVIDER COST
? BUT IF IT DOESN'T, WHAT'S ALL
THE WORK BEEN GOING ON? WHAT ARE
WE WHAT ARE WE ACHIEVING IF IT
DOESN'T? SO CAN I GET A YES OR
NO ANSWER? THIS IS A SIGNIFICANT
NEW EXPENDITURE WITH REGARD TO
MEDI-CAL RATES MORE THAN WE'VE
EVER DONE. KIND OF IN THE
MEDI-CAL PROGRAM'S HISTORY. AND
SO OUR GOAL IS THAT IT WILL
ACHIEVE KIND OF IMPROVEMENTS IN
ACCESS TO MEDI-CAL SERVICES AND
RECOGNIZING THAT THERE ARE LOTS
OF FACTORS THAT GO INTO KIND OF
PLAY IN TERMS OF ACCESS AND
QUALITY FOR OUR MEDI-CAL
MEMBERS. AND WE THINK THIS WOULD
BE IS A SIGNIFICANT CONTRIBUTOR
TO ENSURING THAT THERE IS ACCESS
TO. WELL, I'M GETTING A LITTLE
BIT TIRED OF THE TERM, YOU KNOW,
COMPLICATED AND ALL OF THAT.
YEAH, I SUPPOSE IT MIGHT BE. BUT
THE BOTTOM LINE HERE IS YOU'VE
GOT PROVIDERS WHO ARE DOING THE
WORK. IT'S COSTING THEM X AND
THEY'RE GETTING X MINUS
SOMETHING. AND I AM WITNESSING
IN MY AREA THE SLOW DESTRUCTION
OF OUR HEALTH CARE IN FRESNO AND
IN CENTRAL CALIFORNIA, WE LOST A
HOSPITAL BECAUSE OF THESE,
VALLEY CHILDREN'S HOSPITAL HAS
SIGNIFICANT ISSUES WITH RESPECT
TO THEIR THEIR, MIX. THAT WE'VE
TALKED ABOUT, THE PDCS AND, I'M
TELLING YOU, I'M NOT JUST ANGRY.
IT'S BREAKING MY HEART TO TAKE
THE KIND OF CALLS IN MY OFFICE
THAT WE TAKE AND IT'S ALMOST AS
IF IT'S SAYING ONE THING, BUT
IT'S DELIVERING SOMETHING ELSE.
SO AGAIN, THE QUESTION BECOMES,
AS YOU'VE BEEN YOU'VE BEEN
STUDYING RATES SINCE I GOT HERE.
WHEN DO WE STOP STUDYING AND
WHEN DO WE ESTABLISH RATES THAT
ACTUALLY PAY THE COST? BECAUSE
IF YOU DON'T PAY THE COST TO
PROVIDERS ARE GOING TO GO AWAY.
NOW, IF YOU CAN'T GET THERE, AT
LEAST SOMEBODY HAVE THE COURTESY
TO TELL US IT'S GOING TO FALL
SHORT IF IT WILL MEET THEIR
COSTS, LET US KNOW THAT. IS IT
SO COMPLICATED THAT WE CAN'T ADD
IT COSTS THIS AND THAT'S WHAT
WE'RE GOING TO GIVE THEM OR NOT.
SO HELP ME OUT WITH THIS. I
MEAN, IT SEEMS LIKE WE JUST KEEP
GOING AROUND AND AROUND AND
AROUND THIS CIRCLE, AND IT SEEMS
TO GET WORSE THE MORE WE GO
ROUND AND ROUND. SO THE QUESTION
IS, IS THE BUMP GOING TO COVER,
THE PROVIDER COST? I THINK I
WOULD JUST ADD THAT, WHILE WE
RECOGNIZE PROVIDERS HAVE COSTS,
ISN'T ALWAYS NECESSARILY THE
RIGHT APPROACH JUST TO, TO
REIMBURSE BASED ON COSTS, WE
WANT TO REIMBURSE BASED ON
EFFECTIVENESS AND EFFICIENCY AS
WELL. AND SO THERE ARE DIFFERENT
MODELS FOR HOW WE PAY FOR, OUR
FINANCING. WE JUST DID A REFORM
IN THE BEHAVIORAL HEALTH SPACE
FOR OUR COUNTY BEHAVIORAL HEALTH
THAT WENT FROM A COST BASED
REIMBURSEMENT TO MORE OF A FEE
FOR SERVICE, GETTING TOWARDS A
MORE CAPITATED WAY OF PAYING SO
THAT WE REALLY INCENTIVIZE OUR
PROVIDERS TO BE EFFICIENT WITH
THEIR, THIS IS THESE ARE STATE
DOLLARS AND FEDERAL DOLLARS. BE
EFFICIENT WITH THEIR DOLLARS AND
RECOGNIZE THAT COST BASED
REIMBURSEMENT ISN'T NECESSARILY
THE BEST APPROACH. SO. THAT
SOUNDS LIKE IT'S A PRESUMPTION
IN THAT YOU HAVE A THAT SOME OF
THESE DOCTORS AND PROVIDERS AND,
YOU KNOW, PEOPLE LIKE THE PDCS
ARE RUNNING SLIPSHOD OPERATIONS.
THAT WAS THE INTENT OF MY
COMMENT. IT WAS JUST A MATTER OF
THERE'S DIFFERENT METHODOLOGIES
FOR REIMBURSING PROVIDERS AND
REALLY RECOGNIZING THAT THE COST
BASED METHODOLOGY MAY NOT ALWAYS
BE THE BEST APPROACH. AND SO
THAT'S WHY WE HAVE THESE
DIFFERENT MECHANISMS OF
FINANCING. WHAT WHAT I BASICALLY
HEARD UNDER ALL OF THAT, WAS,
WAS BASICALLY IF OUR RATES DON'T
COVER YOUR COSTS, THEN YOU GOT
TO WORRY ABOUT YOUR COSTS. YOU
GOT TO PAY ATTENTION TO YOUR
COSTS. SO WHAT IT SOUNDS LIKE TO
ME.
YEAH, I THINK JUST TO JUST TO
FINE TUNE THE POINT THAT I, THAT
I HEAR, SO, AS YOU KNOW, AS WE
NOTED, THERE ARE, YOU KNOW, A
COUPLE OF DIFFERENT WAYS TO
THINK ABOUT RATES. AND WHAT I
HEAR IS THAT OF A PARTICULAR
CONCERN IS, IS IT IS IT ADEQUATE
TO SORT OF COVER COSTS AND TO
ENSURE THAT, YOU KNOW, MEDI-CAL
BENEFICIARIES HAVE ACCESS TO
CARE AND THAT THERE ISN'T A
FINANCIAL DISINCENTIVE FROM
SERVING PATIENTS? WE DID TRY TO
LOOK AT THAT IN THE CONTEXT OF
PHYSICIAN RATES, AND WE DIDN'T.
WE DID HEAR CONCERNS FROM
STAKEHOLDERS ALONG THE LINES
THAT THAT YOU JUST SAID THAT
THERE THERE ARE CONCERNS THAT
IT'S NOT ADEQUATE TO COVER
COSTS, WE WEREN'T ABLE TO FIND A
MORE COMPREHENSIVE LITERATURE
THAT REALLY LOOKED AT THAT. AND
WE DID FIND SOME, SOME RESEARCH
ON MEDICARE THAT THAT FOUND THAT
MEDICARE RATES MAY HAVE NOT HAVE
BEEN KEEPING PACE WITH THE
INCREASE IN COSTS FOR
PHYSICIANS, BUT THERE JUST
WASN'T ENOUGH SORT OF EVIDENCE
TO REALLY LOOK AT, SORT OF SAY
THAT COMPREHENSIVELY. SO IT IS
IT IS A LITTLE, IT IS A LITTLE
HARD TO MAKE SORT OF A GENERAL
STATEMENT, I KNOW I THINK
ANOTHER CHALLENGE IS THAT THE,
THE RATE SYSTEM IS STATEWIDE.
AND SO, YOU KNOW, COSTS DO VARY
REGIONALLY. AND, YOU KNOW, WHAT
I HEAR FROM THE ADMINISTRATION
IS THAT THERE IS A THERE'S AN
EFFORT TO, TO, TO BETTER SORT OF
MATCH THAT. BUT IT IS THERE JUST
WASN'T ENOUGH EVIDENCE. IT
WASN'T ENOUGH DATA FOR US TO
REALLY DIG INTO TO, TO REALLY
DEFINITIVELY SAY IN ALL CASES,
IS IT IS IT INADEQUATE TO COVER
COSTS, AT LEAST IN THE CASE OF
PHYSICIAN SERVICES? THERE ARE
OTHER PROVIDERS AND OTHER
FACILITY BASED PROVIDERS WHERE
THERE IS MORE. HOW MANY VOICES
RAISED IN CONCERN UP AND DOWN
THE STATE? DO YOU HAVE TO HAVE
TO HAVE ENOUGH EVIDENCE? YEAH.
YOU KNOW, WE DO. WE DO TRY TO
STICK TO THE TO THE EVIDENCE WE
LIKE. WE DID HEAR A LOT OF
CONCERNS FROM STAKEHOLDERS. AND
THIS IS A KEY AREA OF INTEREST
FOR THE LEGISLATURE. IT'S
SOMETHING THAT THE LEGISLATURE
COULD CONTINUE TO, TO WORK ON,
IT IS, IT IS A, IT IS A SORT OF
KEY AREA THAT THE LEGISLATURE
CAN CONSIDER WHEN IT'S
CONSIDERING RATE INCREASES.
RIGHT, I WANT TO TURN THE PAGE
JUST A MINUTE AND JUST, WE HAD,
SOME, FAIRLY DIRECT
CONVERSATIONS ABOUT THE PDC AND
ABOUT WHAT? WE BROUGHT THEM TO
THE TABLE AT THE MCO. THEY WERE
REJECTED. AND, THESE ARE
PEDIATRIC DAY CARE CENTERS UP
AND DOWN THE STATE TO TAKE CARE
OF VERY FRAGILE KIDS, I ASKED IF
YOU WOULD JOIN ME IN A TOUR AND
WE HAVE, THE CALENDAR MARKED FOR
JULY 12TH, I'M HOPING THAT
THAT'S A DATE THAT CAN HOLD,
BECAUSE INVITING THE PARENTS AND
THE. AND THE KIDS. I WANT YOU TO
SEE THE TOUR THAT I TOOK WHEN
THE PARENTS WERE THERE. THE KIDS
WERE THERE. THE CARETAKERS WERE
THERE. AND HEAR FROM THOSE
INDIVIDUALS. NOW, THERE'S A
LITTLE BIT OF GOOD NEWS. THE
LOCAL THERE ARE SOME SOME
NEGOTIATIONS, WITH VALLEY CARE
CENTERS, AND WE THINK THEY MIGHT
BE A LITTLE BIT HELPFUL, BUT
WE'RE, WE'RE TRYING TO GET TO
THE PLACE WHERE THESE, PDCS
DON'T CLOSE, I CAN ONLY TELL YOU
THAT BE PREPARED TO HAVE YOUR
EMOTIONS AND YOUR HEART REALLY
PULLED HARD, MY TOUR, I MEAN, I,
I WEPT ALL THE WAY THROUGH IT.
WHEN YOU HEAR THE PARENTS SAY,
IF YOU TAKE THIS AWAY FROM US,
WE'RE GOING TO HAVE TO QUIT OUR
JOBS. WE DON'T KNOW WHAT WE'RE
GOING TO DO. WE DON'T KNOW HOW
WE PAY OUR BILLS. I HEARD OTHER
PARENTS SAY, IF WE DON'T HAVE A
RESPITE AND WE'RE CARRYING THE
TENSION THAT THAT CREATES IN THE
FAMILY AND THE TENSION THAT IT
CREATES IN THE MARRIAGE, THESE
ARE REAL THINGS. BUT THEN YOU
SEE THE ALTERNATIVE AND YOU SEE
WHAT THESE KIDS GET. HOW THEY'RE
CARED FOR, THE FACT THAT THE
PARENTS HAVE A LIFE BEYOND EVERY
DAY AGONY OF TAKING CARE OF
CHILDREN THAT ARE IN SUCH
DIFFICULT SHAPE. SO I, I WANT
YOU TO BE PREPARED FOR SOME
EMOTION. AND THEN AT THE END OF
IT, I'D LIKE TO HAVE A PRIVATE
MEETING WITH YOU AND THE LITTLE,
MIRACLES, EXECUTIVE THERE. AND
I'M GOING TO ASK YOU IF THERE IS
SOME WAY THAT YOU CAN IDENTIFY
WAYS OF HELPING. I DON'T KNOW
WHAT WE CAN OR CAN'T DO WHERE WE
ARE. I UNDERSTAND THE BUDGET AND
ALL OF THAT, BUT IT WAS A
TERRIBLE DISAPPOINTMENT THAT,
AND I THINK WE WERE ASKING FOR
LIKE TWO. 2 MILLION, MAYBE 3
MILLION THAT THEY WERE BROUGHT
INTO THE STAKEHOLDERS DISCUSSION
AND APPARENTLY DIDN'T MAKE THE
CUT. AND I JUST LOOKED AT THAT
AND I SAY, HOW IN THE WORLD DO
THOSE CHILDREN NOT MAKE THE CUT?
SO WE'RE TRYING TO HELP IT, FIX
IT AND WORK ON IT. AND I THINK
IT'S IMPORTANT THAT YOU'RE
COMING. I APPRECIATE THAT. AND
LIKE I SAID, IT WILL BE IT WILL
BE A KIND OF A WRENCHING
EXPERIENCE, BECAUSE THERE'S THIS
THREAT, AND THAT THREAT IS
SCARING THE DAYLIGHTS OUT OF
THESE PARENTS AND, AND THE AND
THE OWNERS OF LORETTA'S LITTLE
MIRACLES. AND GOD BLESS THEM,
THE OWNERS, GIVEN THE SHORTFALL
IN THE HELP FROM THE STATE,
THEY'RE PUTTING THEIR OWN MONEY
INTO IT. AND IT SHOULDN'T BE
LIKE THAT, THAT JUST WON'T.
THAT'S NOT SUSTAINABLE. IT WON'T
LAST. SO I APPRECIATE YOU
HEARING ME OUT. I'M GRATEFUL
THAT WE HAVE A, JULY 12TH DATE,
AND I WANT TO ASK YOU TO BE
THINKING ABOUT. IS THERE
POSSIBLE WAYS THAT, AS THE
DIRECTOR OF THIS LARGE AND
SIGNIFICANT AGENCY IS THERE SOME
SUGGESTIONS ABOUT WHAT CAN BE
DONE TO MAYBE HELP CLOSE THOSE
GAPS? SO THANK YOU. THANK YOU.
ASSEMBLY MEMBER PATTERSON. I
THINK WHAT WHAT YOU'RE HEARING,
ESPECIALLY WHEN HE WAS REFERRING
TO PROVIDER RATES, FRUSTRATION
BECAUSE HE'S BEEN HERE FOR MANY,
MANY YEARS, IS THAT ALTHOUGH WE
MAY NOT HAVE THE DATA VÀ PER SE
BECAUSE OF A LACK OF TRANSPORT
AGENCY, SO YOU CAN'T REALLY SEE
PHYSICIAN RATES. WHAT WE DO SEE
ARE PHYSICIANS LEAVING. WHAT WE
DO SEE ARE HOSPITALS CLOSING.
WHAT WE DO SEE ARE LABOR AND
DELIVERY UNITS CLOSING, OTHER
UNITS CLOSING, AND THE NUMBER
ONE REASON THAT THEY'RE GIVING
IS BECAUSE OF LOW MEDI-CAL
REIMBURSEMENT RATES. AND SO, YOU
KNOW, AS WE GO BACK INTO OUR
DISTRICTS OR HAVE VARIOUS GROUPS
OR CONSTITUENTS COME UP TO
SACRAMENTO, THESE ARE THE THINGS
THAT WE'RE SEEING AND WE'RE
DEALING WITH ON A WEEKLY,
SOMETIMES A DAILY BASIS. AND
WHAT HAS BEEN DONE IN THE PAST
IS NOT WORKING. THE WAY IN WHICH
WE HAVE, PAID OUR PROVIDERS,
ESPECIALLY THOSE WITHIN THE
MEDI-CAL SYSTEM AND FOR ANYONE
WHO IS FAMILIAR WITH MEDI-CAL
PATIENTS, THEY OFTENTIMES HAVE
SOME OF THE MOST CHRONIC
ILLNESSES. THEY ARE SOMETIMES
THE SICKEST OF THE SICKEST
BECAUSE OF LACK OF ACCESS. SO
THEY COME AT THE VERY LAST
MINUTE. AND SO THESE PROVIDERS
ARE OFTENTIMES GOING ABOVE AND
BEYOND, WITH THE PATIENTS IN
THIS PARTICULAR SYSTEM. AND YET
THEY HAVE BEEN PAID LESS THAN
COMMERCIAL RATES, LESS THAN
MEDICARE RATES, AND THAT IS NOT
SUSTAINABLE. SO AS WE MOVE
FORWARD, I HOPE THAT WE LOOK AT
OTHER MODELS. I HOPE WE GET THAT
DATA FROM WHAT WAS STOPPED
ALMOST TWO YEARS AGO TO SEE IF
THOSE KIND OF THINGS CAN NOT
ONLY INCENTIVIZE OUR PROVIDERS,
BUT ALSO MAKE OUR RESIDENTS
HEALTHIER, BECAUSE WHAT WE DO
KNOW HERE IN THIS COUNTRY AND IN
THIS STATE IS WE PAY A LOT OF
MONEY TOWARDS HEALTH CARE, YET
WE STILL HAVE ISSUES WITH
ACCESS, AND YET WE STILL HAVE
SOME OF THE SICKEST, PEOPLE IN
THIS WORLD. AND SO WE DO NEED TO
DO SOMETHING DIFFERENT. I WAS
WONDERING, DIRECTOR, CAN YOU
GIVE US ANY MORE INFORMATION ON
THE EQUITY INDEX WITHIN THE MCO?
ANY ANY MORE INFORMATION ON WHAT
YOU ALL ARE THINKING? HOW THAT'S
GOING TO WORK? NO, AS AS WAS
ALLUDED TO AT GOVERNOR'S BUDGET,
WE HAVE ABOUT 80 MILLION FROM
THE MANAGED CARE ORGANIZATION
TAX RESERVE FUND. SO FOR ABOUT
200 MILLION TOTAL FUNDS, ABOUT
REALLY DOING AN EQUITY
ENHANCEMENT. WE DON'T HAVE ANY
FURTHER DETAILS TO SHARE. THOSE
WILL BE AVAILABLE AT MAY
REVISION. WE'VE LISTENED TO
STAKEHOLDERS OVER THE LAST FEW
MONTHS AS PART OF OUR INITIAL
PROPOSAL, GATHERED SOME
FEEDBACK, AND WE'LL HAVE MORE TO
SHARE LATER. OKAY, SO THAT WILL
BE COMING IN ABOUT TWO WEEKS.
OKAY, GREAT, AND THEN MY FINAL
QUESTION FOR YOU DURING THIS
PORTION IS WE TALK A LOT ABOUT
THE USE OF PROP 56 FUNDING IN
THIS REALM, CONSIDERING THAT
THAT IS A TOBACCO TAX AND WE
HAVE DONE SUCH AN AMAZING JOB
HERE IN CALIFORNIA AT INFORMING
PEOPLE OF THE HARMS OF SMOKING
AND THE FACT THAT THEY SHOULD
NOT BE SMOKING, AND THAT REVENUE
IS SIGNIFICANTLY GOING DOWN, AS
WE WOULD, WOULD HOPE, HOW IS
THAT GOING TO IMPACT THIS SYSTEM
? AS PART OF THE GOVERNOR'S
BUDGET, WE AND THE 2024 RATE
INCREASES, WE'VE BASICALLY
INCLUDED PROPOSITION 56 AS PART
OF THE BASE PAYMENT AND USING
THE MCO TAX REVENUES TO KIND OF,
BE USED TO, KIND OF KEEP THE
RATES AS EQUAL WITH THE PROP
$56. SO THAT'S HOW WE'RE
THINKING ABOUT IT, IN TERMS OF
REALLY THINKING ABOUT A BASE
RATE FOR OUR PROVIDERS. SO
THERE'S CONSISTENCY IN
UNDERSTANDING WHAT THEY WOULD BE
RECEIVING. BUT I GUESS MY
QUESTION IS, AS PROP SIX FUNDING
IS GOING DOWN, IS THAT GOING TO
HAVE AN IMPACT SINCE WE'RE USING
BOTH TO TRY TO KEEP IT STABLE,
ARE WE GOING TO BE DECREASING OR
ARE WE GOING TO SEE AN INCREASE
IN THE OTHER POT IN ORDER TO
KEEP THE NUMBERS THE SAME? SO,
SO THE WAY THE 2024 RATE
INCREASES IS THAT THE MCO TAX
REVENUE REALLY DOES OFFSET THE
KIND OF THE LOSS OR THE KIND OF
THE REDUCTION IN PROP 56. AND SO
THAT IS HOW WE'RE THINKING ABOUT
IT FOR THE FUTURE. THANK YOU.
DID YOU HAVE Þ? I THOUGHT THE
DEPARTMENT GOT THERE. IT WAS
THE, YOU KNOW, JUST TO EMPHASIZE
THAT PROP 56, YOU KNOW, THE AS
YOU KNOW, THE REVENUE IS SORT OF
HAS BEEN DECLINING, FOR, FOR
POLICY REASONS THAT YOU
INDICATED AND, AND, YOU KNOW,
COSTS HAVE NOT GENERALLY BEEN
DECLINING THAT THAT GENERALLY
HAS MEANT THAT IN THE IN THE
PAST, THE STATE HAS STARTED TO
USE SOME GENERAL FUND TO
BACKFILL THOSE DECLINES OR AND
SOME OF THOSE PROGRAMS HAVE ALSO
BEEN SHIFTED INTO THE BASE. TWO.
AND WHAT YOU SEE IN THE MCO TAX
PROPOSAL IS TO SOME EXTENT A BIT
OF A FURTHERANCE OF THAT. THE
ADMINISTRATION'S PROPOSING TO
MOVE SOME OF THESE SUPPLEMENTAL
PAYMENTS INTO THE BASE. AND
THEN, YOU KNOW, AS PROPOSITION
56 FUNDING CHANGES, THEIR
GENERAL FUND OR THE MCO TAX
FUNDING WOULD, SORT OF BACKFILL
THAT. YOU KNOW, THERE IS A
THERE'S SORT OF A, YOU KNOW,
LONG, YOU KNOW, BROADER QUESTION
HERE, GIVEN THE SORT OF FISCAL
CONSTRAINTS OF THE STATE, YOU
KNOW, THAT THAT THAT WOULD BE
SOMETHING TO KEEP AN EYE ON AS
WE GET MORE INFORMATION ON THOSE
GENERAL FUND BUDGET PROBLEM AND
JUST JUST TRACKING TO SEE HOW
THAT, HOW THAT SORT OF WORKING
IN THE PROP 56 SYSTEM. THANK
YOU. WE WILL NOW MOVE ON TO OUR
SECOND PORTION OF A PANEL. WE'LL
START WHENEVER YOU'RE READY.
THANK YOU VERY MUCH. CAN YOU ALL
HEAR ME OKAY. EXCELLENT. GOOD
AFTERNOON. I'M MICHAEL HEIFETZ,
REPRESENTING THE CAMPAIGN FOR
TRANSFORMATIVE THERAPIES. AND
I'LL BE TALKING ABOUT A LOOSELY
RELATED ITEM HERE TODAY THAT
FITS ALONG WITH THE REST OF THE
PANEL. YOU'LL SEE SOME DIFFERENT
TACKS TO IT, BUT YOU'LL HEAR
SOME SIMILAR TERMINOLOGY AS
WELL, JUST FOR A REAL QUICK
BACKGROUND, I'M A FORMER
MEDICAID DIRECTOR AND STATE
BUDGET DIRECTOR FROM THE GREAT
STATE OF WISCONSIN, SO I'VE HAD
THE PRIVILEGE OF HOLDING THE TWO
BEST AND WORST JOBS IN STATE
GOVERNMENT. IN MY HUMBLE OPINION
. SO I HAVE ALSO BEEN A CEO OF A
MEDICAID HEALTH PLAN IN THE
MIDWEST. AND FORMERLY DROVE A
ZAMBONI FOR BADGER HOCKEY. SO I
ALWAYS LIKE TO THROW THAT IN,
EVEN IN A STATE LIKE CALIFORNIA.
SO I'VE BEEN ON A LOT OF SIDES
OF ALL OF THESE ISSUES. SO IT'S
FASCINATING TO HEAR ALL OF, ALL
OF THIS DISCUSSION. SO I'LL BE
TALKING ABOUT VALUE BASED
ARRANGEMENTS FOR GENE THERAPIES.
YOU HAVE A SHORT HANDOUT. AND I
DESCRIBED A LITTLE BIT THE
CAMPAIGN FOR TRANSFORMATIVE
THERAPIES. THE UNIQUENESS OF IT
IS IT IS A COALITION OF PAYERS,
PATIENTS AND THE MANUFACTURING
INDUSTRY ITSELF. SO DON'T ALWAYS
SEE THOSE THREE GROUPS GETTING
ALONG TOGETHER. AND IT'S REALLY
FOCUSING ON THE ACCESS ISSUES
AND EQUITY ISSUES THAT WE'LL GET
TO IN JUST A SECOND. AND REALLY
FOCUSING AS WELL ON STATE BASED
SOLUTIONS. AND I WAS INSTRUCTED
TO SAY, NEXT SLIDE PLEASE. SO
LET'S GO ONE MORE PLEASE. THANK
YOU. A QUICK QUESTION WHY WHY
VALUE BASED ARRANGEMENTS. AS I
MENTIONED PROMOTING ACCESS AND
EQUITY, THESE THESE NEW
TREATMENTS WHILE TRANSFORMATIVE,
ARE ALSO EXPENSIVE. AND ACCESS
AND EQUITY CAN BECOME AN ISSUE.
EQUITY CLEARLY WAS A SIGNIFICANT
COMPONENT OF THE PREVIOUS
DISCUSSION THAT YOU JUST HAD.
AND IT RINGS TRUE HERE AS WELL.
WE'RE ALSO LOOKING TO BUILD
ACCOUNTABILITY AND SHARE SOME
RISK WITH THE MANUFACTURERS THAT
WHEN I WAS A MEDICAID DIRECTOR,
REALLY WASN'T A COMPONENT OF THE
CONVERSATION. GENERALLY, FOLKS,
WHEN THEY WOULD PITCH THINGS TO
OUR MEDICAID TEAM AND WE WOULD
SAY BACK, WELL, WHAT IF IT
DOESN'T DO WHAT YOU SAY IT'S
GOING TO DO? THEY WOULD JUST
SORT OF LOOK AT US AND NOTHING
MUCH MORE HAPPENED. THAT IS
CLEARLY CHANGING, ACROSS THE
SPECTRUM. A KEY ELEMENT OF THIS
IS THAT IT WOULD BE VOLUNTARY.
SO THE PAYERS DON'T HAVE TO
ENTER INTO IT, AND THE INDUSTRY
DOES NOT HAVE TO ENTER INTO IT.
BUT, THERE WOULD BE INCENTIVES
FOR BOTH. AND THAT'S REALLY THE
GIST OF THE DISCUSSION, THERE
WOULD BE MEASUREMENT OF
OUTCOMES. I KNOW YOU JUST HAD A
LENGTHY DISCUSSION ABOUT ABOUT
OUTCOMES OF A CERTAIN STUDY, AND
THIS WOULD PROVIDE FOR THAT
COMPONENT AS WELL IN THIS
CONVERSATION. SO IT'S REALLY
DESIGNED TO ADDRESS THOSE ISSUES
AND TO DETERMINE IF Ã EXPENSIVE
POTENTIALLY TREATMENT IS WORKING
FOR A PATIENT OR A SET OF
PATIENTS. AND THEN IF IT ISN'T
WORKING AS INTENDED AND AGREED
TO CONTRACTUALLY, THEN THERE
WOULD BE SOME DIFFERENT
MECHANISM TO ADDRESS THAT. AND
THE BOTTOM LINE IS OBVIOUSLY
IMPROVING PATIENT LIVES. AND
THAT ALL GETS AT THIS AS WELL.
NEXT SLIDE PLEASE. YOU SEE
BEFORE YOU I WILL NOT READ THE
LIST TO YOU. THESE ARE JUST A
FEW OF THE TRANSFORMATIVE
THERAPIES FROM THE LAST FEW
YEARS. YOU CAN SEE TWO FOR
SICKLE CELL DISEASE. MOST
RECENTLY, APPROVED BY THE
FEDERAL GOVERNMENT. AND THEN
THERE ARE A FEW MORE FOR SOME
OTHER CHALLENGING DISEASES
HEMOPHILIA ARE BOTH ON THE A AND
B SIDE HAS HAD A LOT OF ACTIVITY
IN THIS REALM, AND ALSO YOU SEE
ZOLGENSMA FOR SPINAL MUSCULAR
ATROPHY FOR CHILDREN AGED TWO
AND UNDER. AND THAT THAT IS
OBVIOUSLY A VERY DIFFICULT
DISEASE AND CONDITION, WHEN I
WAS MEDICAID DIRECTOR, THIS DRUG
WAS NOT THIS TREATMENT WAS NOT
AVAILABLE. THERE WAS A DIFFERENT
TREATMENT THAT HAD HAD SOME
MIXED RESULTS IN THE CLINICAL
TRIALS. AND IT'S WISCONSIN. IT'S
NOT A BIG STATE. WE ONLY HAD A
COUPLE OF FAMILIES THAT WOULD
HAVE NEEDED THAT TREATMENT
PURSUANT TO THEIR PROVIDER
TEAMS. SO IT WAS EASY FOR US TO
SAY YES. IF THE PHYSICIANS AND
THE TEAM SAYS THEY NEED THIS,
WE'RE NOT CERTAIN IF IT'S GOING
TO WORK, BUT IT'S A CHANCE WE
WERE ABLE TO COVER IT, BUT HAD
IT BEEN SOMETHING WHERE THE
VOLUME WAS MUCH HIGHER, WE WOULD
HAVE HAD TO MAKE SOME DIFFERENT
POLICY DECISIONS OR HAVE A
DIFFERENT CONVERSATION WITH YOU
AS AN APPROPRIATOR ABOUT THESE
DYNAMICS, YOU KNOW, A 1 IN 2
OFF, SO TO SPEAK, WOULD NOT BLOW
UP OUR $8 BILLION BUDGET, WHICH
DOESN'T COMPARE TO YOUR $150
BILLION MEDICAID BUDGET. BUT THE
SCALE APPLIES, BUT IF IT HAD
BEEN A VOLUME ISSUE, THEN WE
WOULD HAVE HAD TO HAVE A
DIFFERENT CONVERSATION ABOUT IT,
NEXT SLIDE PLEASE. SO THE OTHER
GIST OF ALL OF THIS IS THE
CHANGING ENVIRONMENT THAT WE'RE
LIVING UNDER. YOU CAN SEE SOME
OF THE DATES OF WHEN THINGS HAVE
BEEN APPROVED IN THE
TRANSFORMATIVE GENE AND CELL
THERAPY UNIVERSE, AND YOU CAN
REALLY FOCUS ON THE BOTTOM HALF
OF THAT, WHERE YOU SEE HOW MANY
ARE EXPECTED TO BE APPROVED, 60
PLUS IN THE US MARKET BY 2030.
AND, YOU KNOW, THAT'S THE
NATIONAL INSTITUTES OF HEALTH.
THAT'S IT'S NOT NECESSARILY A
BIASED GROUP. SO THIS IS GOING
TO CHANGE THE DYNAMIC
SIGNIFICANTLY. AND WHEN YOU'RE
TALKING ABOUT, TREATMENTS THAT
COST SEVEN FIGURES, OCCASIONALLY
THE NUMBERS BECOME LARGE, EVEN
IN A STATE LIKE CALIFORNIA, WITH
THE LARGE NUMBERS THAT YOU WERE
JUST REFERENCING IN THE PREVIOUS
CONVERSATION. SO THIS DATA
REALLY IS WHAT DRIVES A LOT OF
THIS AND PARTIALLY WHAT DRIVES
THE INDUSTRY TO SAY, OKAY, WE
NEED TO COME TO THE TABLE IN A
DIFFERENT WAY HERE. AND TAKE
SOME ACCOUNTABILITY IN THIS
REGARD. NOW, THAT DOESN'T MEAN
IT'S THE SIMPLEST THING IN THE
WORLD TO DO, BUT IT'S A
DIFFERENT CONVERSATION THAN IT
USED TO BE. AND THAT'S PART OF
WHY YOU SEE SOMETHING LIKE A
CAMPAIGN FOR TRANSFORMATIVE
THERAPIES. NEXT SLIDE PLEASE.
YOU CAN SEE THE LIST OF STATES
THAT HAVE STATE PLAN AMENDMENTS
THAT GIVE THE STATES THE
PERMISSION TO PURSUE THESE TYPES
OF ARRANGEMENTS DOES NOT REQUIRE
THEM TO DO SO. AND YOU CAN. YOU
ALSO KNOW THAT CALIFORNIA HAS
SUBMITTED ITS STATE PLAN
AMENDMENT FOR FEDERAL APPROVAL.
SO THAT'S OBVIOUSLY A GREAT STEP
FORWARD. IT'S THE FIRST STEP.
BUT IT'S A REQUIRED STEP. AND
THESE HAVE TYPICALLY BEEN
APPROVED IN A REASONABLE FASHION
BY CMS. NOT A LOT OF BACK AND
FORTH WHERE THEY HAVE A TON OF
QUESTIONS, WHICH I'M SURE THE
DIRECTOR AND OTHERS ON THE TEAM
HAVE LIVED THROUGH WITH OTHER
MECHANISMS WITH CMS. SO
HOPEFULLY THIS WILL BE AS SMOOTH
AS IT AS IT HAS BEEN IN OTHER
STATES AND FROM MY HOME STATE OF
WISCONSIN, WE HAVE A UNIQUE
ELEMENT WHERE THE LEGISLATURE
HAS TO APPROVE CERTAIN STATE
PLAN AMENDMENTS BEFORE THEY ARE
SENT TO, THE FEDERAL GOVERNMENT.
AND SO THE LEGISLATURE JUST SAID
JUST APPROVED LEGISLATION TO
SAY, HEY, YOU MUST SUBMIT THIS
STATE PLAN AMENDMENT. SO
WISCONSIN IS MOVING FORWARD IN
THAT REGARD, AGAIN, I WOULD
EMPHASIZE IT'S NOT A MANDATE ON
ANYONE INVOLVED. SO THAT IS A
KEY COMPONENT OF IT. YOU CAN
EXPLORE IT AT YOUR OWN PACE,
WHOEVER YOU MAY BE. IT COULD BE
THE STATE, IT COULD BE THE
MANUFACTURERS. BUT IT GIVES SOME
FLEXIBILITY AS WELL. AND THAT
COULD BE A PART OF THAT
DISCRETION THAT A STATE AND OR
MANUFACTURER MIGHT PURSUE. SO
THAT IS A PRETTY HIGH LEVEL
OVERVIEW. I'M SURE IN THE Q&A
WE'LL GET INTO SOME MORE
SPECIFICS ABOUT IT. AND, YOU
KNOW, THERE'S VERY FASCINATING
DATA ABOUT WHAT SICKLE CELL AND
OTHER DISEASES COST TODAY, IN
THE TRADITIONAL THERAPY
ENVIRONMENT VERSUS WHAT IT LOOKS
LIKE IN THIS ENVIRONMENT. BUT
THE KEY ELEMENTS OF THIS ARE THE
VOLUNTARY NATURE AND JUST THE
CHANGING CONVERSATION OF HAVING
THE MANUFACTURING INDUSTRY COME
TO THE TABLE AND SAY, OKAY,
LET'S LET'S PAY FOR THIS A
LITTLE DIFFERENTLY. LET'S THINK
A LITTLE DIFFERENTLY ABOUT HOW
TO DO THIS AND HAVE IT BE MORE
OF A TWO WAY CONVERSATION. SO
THOSE CONCLUDE MY FORMAL
REMARKS, MADAM CHAIR, THANK YOU.
I WILL SEE IF MY COLLEAGUE HAS
ANY QUESTIONS. OKAY. SO, JUST TO
KIND OF YOU JUST SAID THAT IN
YOUR STATE, THE LEGISLATURE
DIRECTED THE IMPLEMENTATION OR
THE REQUEST FOR A, A STATE PLAN
AND SBA THAT'S CORRECT, MADAM
CHAIR. YES, IT'S A LEGISLATIVE
REQUIREMENT. AND THERE ARE A FEW
OTHER STATES THAT HAVE SOMETHING
SIMILAR TO IT. INTERESTING. SO I
HAVE MIXED OPINIONS, HAVING BEEN
A LEGISLATIVE STAFFER AND A
MEDICAID DIRECTOR. YEAH, YEAH.
BUT ONE THING IT DOES IS IT
KEEPS THE LEGISLATURE INFORMED,
IT DOES. THE STATE PLAN
AMENDMENT PROCESS IS A PUBLIC
ONE, ALTHOUGH IT'S NOT THE MOST
HIGH PROFILE ONE. BUT THERE IS A
PUBLIC REQUIREMENT TO IT. EVEN
TODAY. OKAY. SO TO OUR DIRECTOR,
DCS SUBMITTED, A STATE PLAN
AMENDMENT. CORRECT CORRECT. IN,
IN MARCH, IN MARCH. AND ARE YOU
ABLE TO DISCUSS ANY
COMMUNICATION YOU'VE HAD WITH
CMS? DO YOU HAVE A TIME FRAME
WHEN YOU THINK THAT IT MAY BE
APPROVED, NO, WE DON'T HAVE,
DETAILS ON THAT. BUT I WOULD
ALSO NOTE THAT ON MARCH 24TH, WE
ALSO SUBMITTED A LETTER OF
INTENT TO PARTICIPATE IN THE
CELL AND GENE THERAPY ACCESS
MODEL WITH CMS, IN THE FIRST
TARGET FOR THESE MODELS ARE NEW
THERAPIES FOR SICKLE CELL. AND
THAT IS EXPECTED TO START IN
JANUARY 2025, SO KIND OF THAT'S
I THINK THE KIND OF THE NEXT
STEP IN TERMS OF, OF, OF THE
WORK THERE. AND THE GOAL OF THIS
MODEL IS REALLY TO IMPROVE THE
LIVES OF INDIVIDUALS WITH
MEDI-CAL, WITH RARE AND SEVERE
DISEASES BY INCREASING ACCESS TO
THESE POTENTIALLY LIFE SAVING
TREATMENTS, AND SO THE GOAL IS
TO GET MANUFACTURERS AND STATES
IN THIS MODEL TO WORK TOGETHER
TO COME TO SOME OF THESE VALUE
BASED AGREEMENTS. SO THAT'S KIND
OF SEPARATE AND APART FROM THE
STATE PLAN AMENDMENT. WE ARE
ALSO PARTICIPATING IN THIS MODEL
AS WELL. OKAY AND SO WE HAVE
APPROVAL FOR THAT ONE OR WE'RE
STILL WAITING. WELL, WE SENT A
LETTER OF INTENT TO THE FEDERAL
GOVERNMENT. SO WE'RE WAITING TO
HEAR OFFICIALLY. BUT I, YOU KNOW
, WE ARE WE ARE RAISED OUR HAND
TO WANT TO PARTICIPATE. OKAY
GREAT. AND ONCE SO PROCESS WISE,
ONCE THEY GIVE US THE APPROVAL,
KNOCK ON WOOD THAT THEY WILL,
THEN THAT'S WHEN YOU ALL START
THE CONVERSATIONS TO FIGURE OUT
HOW THE PLAN. CALIFORNIA.
ACCORDING TO CMS, THAT'S
ANTICIPATED TO BE, AT THE
BEGINNING OF JANUARY OR 2025,
THAT YOU COULD START OR THAT THE
CONVERSATION STARTS. OKAY. SO
THEN ALL OF THIS CONVERSATION
WOULD HAPPEN BEFORE 2025. THE MY
UNDERSTANDING IS THAT THIS, THIS
THIS MODEL STATES BEGIN
PARTICIPATION BETWEEN JANUARY
2025 AND JANUARY 2026. OKAY. IN
IN THIS MODEL. OKAY. SO HOW HAVE
THESE ALTERNATIVE PAYMENT MODELS
BEEN APPROACHED IN OTHER STATES?
BECAUSE I SAW A SLIDE WHERE
YOU'VE GOT A COUPLE OF OTHER
STATES THAT, IT'S BEEN IT'S BEEN
APPROACHED, ARIZONA IS A GOOD
EXAMPLE WITH ZOLGENSMA. A LOT OF
THE CONTRACTUAL TERMS ARE
PROPRIETARY FOR VARIOUS REASONS,
BUT THERE'S TRANSPARENCY IN
REGARDS TO THE EFFECTIVENESS AND
THE PROCESS IN THAT REGARD.
MICHIGAN IS UTILIZING THIS GETS
MORE ADMINISTRATIVE IN ITS
NATURE. SO IT MIGHT BE A LITTLE
LITTLE DULL. BUT MICHIGAN IS
ADMINISTERING A SIMILAR PROGRAM
BUT THROUGH ITS CLAIMS DATA. AND
THEY'RE TRYING TO REALLY MAKE
IT. THESE ARE MY WORDS. MAKE IT
AS SIMPLE TO IMPLEMENT AS
POSSIBLE BY USING SOME DATA THAT
THEY CLEARLY AND OFTEN WORK WITH
AND UNDERSTAND AND KNOW HOW TO
UTILIZE. SO, OTHER STATES HAVE
DONE THIS IN SIMILAR FASHION,
BUT THAT'S GOING TO DIFFER STATE
TO STATE. SO I WOULD NOT YOU
KNOW, CALIFORNIA IS MAKING A
DECISION TO GO THROUGH THE
FEDERAL MECHANISM, WHICH
ABSOLUTELY HAS MERITS. OTHER
STATES WILL CHOOSE NOT TO FOR
VARIOUS REASONS. AND I WOULDN'T
GUESS WHO WOULD OR WHO WOULDN'T.
BUT THERE ARE DEFINITELY
ADVANTAGES TO THAT. AND THE
FEDERAL GOVERNMENT HAS A LOT OF
CAPABILITIES IN DATA AND
UNDERSTANDING HOW THESE
PROCESSES WILL WORK, BUT STATE
TO STATE, THERE ARE DIFFERENCES
IN HOW DATA IS COLLECTED AND
UTILIZED AND, YOU KNOW, FROM MY
STATE, WE HAD PLENTY OF DATA. IT
WASN'T ALWAYS THE EASIEST TO
EXTRACT IN A USABLE FORMAT, SO
THAT I COULD SHARE IT WITH ALL
OF YOU IN A TIMELY FASHION. THAT
HAS PROBABLY CHANGED SINCE MY
TIME THERE, BUT OTHER MEDICAID
PROGRAMS WILL HAVE SIMILAR OR
DIFFERENT STORIES IN THAT REGARD
ABOUT HOW TO PULL THE MECHANICAL
COMPONENTS OF THIS. SO THAT'S
WHY YOU'LL SEE DIFFERENT
APPROACHES STATE TO STATE. YOU
WILL ALSO SEE DIFFERENT
APPROACHES BASED ON VARIOUS
DISEASE CONDITIONS AND THINGS OF
THAT NATURE. STATES MORE, YOU
KNOW, IF YOU HAVE A HIGHER
POPULATION WITH SICKLE CELL,
THAT MIGHT BE A FOCUS.
CALIFORNIA HAS BALLPARK 4000
PLUS PEOPLE WITH SICKLE CELL. SO
THAT COULD BE A POINT OF
EMPHASIS FOR YOU. AND IN OTHER
STATES IT COULD BE SOMETHING
DIFFERENT. THAT IS THEIR BIGGER
HEALTH CARE CHALLENGE. AND THEY
WILL FOCUS IN THAT REGARD. SO
THAT'S PART OF THE SIMPLICITY OF
IT. AS A STATE CAN CHOOSE WHAT
ROAD IT GOES DOWN AND THE
FEDERAL GOVERNMENT FOR NOW IS
GIVING SOME PRETTY GOOD LATITUDE
IN THAT REGARD. SO HOPEFULLY
THAT HELPS ANSWER IT. AND, HAPPY
TO TALK MORE. YEAH. SO I'M VERY
HAPPY THAT WE, WILL BE FOCUSING
ON SICKLE CELL. ARE THERE ANY
OTHER CONDITIONS THAT WE ARE
LOOKING AT FROM A STATE WIDE
PERSPECTIVE, THAT WE MAY WANT TO
ENTER INTO ONE OF THESE MODELS?
I KNOW THAT SICKLE CELL IS THE
TOP OF OUR LIST. I DON'T KNOW
THAT WE HAVE KIND OF ADVANCED
ANY OTHER THOUGHTS ON OTHER
OTHER CONDITIONS? OKAY SO ARE
THERE ANY BARRIERS TO
IMPLEMENTATION OF VPI VÆ BEEPS,
THAT REQUIRE ACTION BY THE
LEGISLATURE? NOT THAT I'M AWARE
OF. WE'RE PENDING CMS APPROVAL.
THAT'S THAT'S THE FIRST STEP.
AND THEN AND THEN, YOU KNOW,
THIS MODEL FOR THIS PARTICULAR
FOR SICKLE CELL. AND SO I'M NOT
TRACKING ANY, ANY BARRIERS OR
CHALLENGES OKAY. SO AS FAR AS
WHICH CONDITION OR WE HAVE A
CONDITION NOW AND ANY IN THE
FUTURE IS THIS SOMETHING THAT
WOULD BE DECIDED BY DCS ALONE OR
HOW WOULD THAT BE DETERMINED
BASED ON CONVERSATIONS WITH
STAKEHOLDERS AND KIND OF JUST,
YOU KNOW, LOOKING AT OUR DATA IN
TERMS OF THE MEDICAID SPACE,
WHAT WHAT MIGHT BE THE MOST
EFFECTIVE, YOU KNOW, UTILIZATION
THÀNH, COST OF DRUGS, ETC. I
THINK THAT'S KIND OF HOW WE
WOULD LOOK AT IT. AND THEN HAVE
CONVERSATIONS WITH STAKEHOLDERS.
SO A LOT OF THIS IS ACTUALLY
DISCUSSED AND DECIDED OUTSIDE OF
THE LEGISLATIVE PROCESS. IT'S
ALL KIND OF A PUBLIC FORUM AS AS
WAS NOTED BEFORE, THESE
CONVERSATIONS ARE NOT REALLY
IT'S KIND OF AS AS DATA COMES UP
AND AS YOU KNOW, INITIATIVES
COME FORWARD. ALL OF OUR, OUR,
SPAS OR PENDING SPAS ARE ALL
PUBLIC NOTICE, AND SO THERE'S
OPPORTUNITY FOR PUBLIC COMMENT
IN THAT RESPECT. BUT IF THERE'S
IF THERE'S INTEREST HERE, I
MEAN, WE CAN DEFINITELY ENGAGE
ON THIS ON THIS TOPIC AND KIND
OF HAVE FURTHER CONVERSATIONS.
OKAY WHAT OBSTACLES HAVE YOU
SEEN OR HAVE YOU ENCOUNTERED IN
IMPLEMENTING THESE VALUE BASED
ARRANGEMENTS, THERE ARE A COUPLE
THAT COME TO MIND SOMETIMES IT
COULD BE CONTRACTUAL, JUST
REACHING AN AGREEMENT WITH WITH
A MANUFACTURER BETWEEN THE STATE
AND A MANUFACTURER, SO THAT
THAT'S A PROCESS THAT HAS TO BE
A PART OF THIS. AND AND
OBVIOUSLY THERE WILL BE SOME
POINTS OF DISCUSSION IN HOW
CLINICAL EFFICACY IS MEASURED
AND HOW IT'S WRITTEN DOWN IN A
CONTRACT, AND THEN HOW IT
ACTUALLY PRACTICALLY PLAYS OUT
FOR PATIENTS AND FAMILIES AND
MEMBERS. SO THAT'S A COMPONENT
OF IT. THE ADMINISTRATIVE SIDE,
AS I MENTIONED, WILL VARY STATE
TO STATE, BUT IT DEPENDS ON THE
CLINICAL KNOWLEDGE WITHIN THE
DEPARTMENT OR ACCESS TO THAT
CLINICAL KNOWLEDGE. AGAIN,
DEPENDING ON THE CONDITION THAT
WE MAY BE TALKING ABOUT AT AND
THE AVAILABILITY. AND
WORKABILITY OF THE DATA THAT
YOU'RE USING TO DETERMINE THE
EFFECTIVENESS AND MEETING THE,
YOU KNOW, SORRY TO BE CRASS
ABOUT IT, MEETING CONTRACTUAL
TERMS REGARDING EFFECTIVENESS
AND CLINICAL RESULTS. SO THOSE
THOSE ARE A COUPLE OF THEM. BUT
STATE TO STATE THEY WILL BE
OVERCOME IN DIFFERENT WAYS. OKAY
QUESTION FOR YOU ON I'M NOT EVEN
SURE IF YOU'VE STARTED THINKING
THIS, BUT SINCE WE ARE LOOKING
INTO JUMPING INTO THE SICKLE
CELL GENE THERAPY SPACE, HOW HOW
HAVE THE DISCUSSIONS GONE AS FAR
AS WHERE THIS WOULD BE PROVIDED,
HOW PATIENTS WOULD HAVE ACCESS
TO IT? WILL THERE BE CERTAIN
CENTERS THAT INDIVIDUALS WOULD
HAVE TO GO TO, OR WOULD IT BE
PRETTY MUCH PROVIDED UP AND DOWN
THE STATE? WE WOULD HAVE TO GET
BACK TO YOU. I KNOW THAT IN OUR
APPLICATION, WE DID LIST OUR
CENTERS OF EXCELLENCE. OR WERE
THESE WHERE IT'S ADMINISTERED
TODAY? BUT WE WOULD WE'D HAVE TO
GET BACK TO YOU ON KIND OF HOW
THIS WOULD ACTUALLY BE.
EFFECTUATED, I DON'T KNOW THAT
WE HAVE THOSE DETAILS YET. OKAY.
ALL RIGHT. YEAH. AS SOON AS YOU
FIGURE THAT OUT, PLEASE LET ME
KNOW, BECAUSE I KNOW ACCESS IS
ALWAYS AN ISSUE AS WELL, FOR
MANY OF THESE PATIENTS. ANY
QUESTIONS? OKAY. ALL RIGHT.
WELL, WITH THAT, WE WILL
CONCLUDE OUR HEARING AND WE WILL
OPEN IT UP TO PUBLIC COMMENT.
IF ANYONE HAS PUBLIC COMMENT,
YOU WILL HAVE ONE MINUTE TO
SPEAK. THANK YOU. HI THERE, ABBY
ALVAREZ WITH THE CALIFORNIA
CALIFORNIA ASSOCIATION FOR ADULT
DAY SERVICES, WHICH REPRESENTS
294 LICENSED, COMMUNITY BASED
ADULT SERVICE, OR CBAS CENTERS,
HERE TO ASK FOR CONSIDERATION OF
ESTABLISHING A MINIMUM RATE
FLOOR TIED TO THE CURRENT
MEDI-CAL PUBLISHED BASE RATE,
WHICH IS BEING DONE FOR PROVIDER
SERVICES. CALIFORNIANS,
ESPECIALLY THOSE LIVING IN RURAL
AND UNDERSERVED COMMUNITIES, ARE
LOSING ACCESS TO CBS CENTERS.
WITH 18 CENTERS CLOSING IN THE
LAST FIVE YEARS. WE NEED YOUR
HELP TO ESTABLISH A SUSTAINABLE
RATE AND A MINIMUM FLOOR TO
AVOID FURTHER COSTS OR FURTHER
CLOSURES. THANK YOU. THANK YOU,
MADAM CHAIR AND MEMBERS, RAND
MARTIN HERE ON BEHALF OF AVIANA
HEALTH CARE AND PINCH HITTING
FOR THE CALIFORNIA ASSOCIATION
OF HEALTH SERVICES AT HOME. WHAT
WE ALSO SEE, MADAM CHAIR, ARE A
THOUSAND KIDS SITTING ON A
WAITING LIST WAITING FOR PRIVATE
DUTY NURSING CARE HAVE BEEN
AUTHORIZED BY MEDI-CAL FOR A
CERTAIN NUMBER OF HOURS. ARE NOT
RECEIVING THOSE. THOSE KIDS ARE
SITTING ON THAT WAITING LIST AND
HAVE NOT MOVED IN TWO YEARS,
THERE MUST BE ROOM SOMEWHERE IN
MCO OR ELSEWHERE TO MAKE SURE
THAT THE 40% RATE INCREASE THAT
WE'VE BEEN ASKING FOR, FOR THREE
YEARS, CAN BE ACCOMMODATED IN
THIS BUDGET CYCLE BEFORE WE
START SEEING COMPANIES LEAVING
CALIFORNIA AND FOCUSING THEIR
EFFORTS ELSEWHERE. I REALLY
ENCOURAGE YOU TO DO SOMETHING
MEANINGFUL THIS YEAR. THANK YOU.
THANK YOU. GOOD AFTERNOON, CHAIR
MEMBERS KELLY LARUE WITH
RESILIENT ADVOCACY HERE ON
BEHALF OF PHI HEALTH AND AIR
AMBULANCE PROVIDER HERE IN
CALIFORNIA, THE MEDI-CAL AIR
AMBULANCE INDUSTRY OBTAINED A
MEDI-CAL SUPPLEMENTAL RATE
EXPENDITURE AUTHORITY LAST YEAR,
BUT IT DIDN'T COME WITH
ACCOMPANYING FUNDING. WE
APPRECIATE THE DISCUSSION TODAY
ON MAINTAINING CRITICAL SERVICES
FOR CALIFORNIANS, AND WE LOOK
FORWARD TO CONTINUING THOSE
DISCUSSIONS AND THE DISCUSSION
TODAY ABOUT MEDI-CAL RATE BASE
RATES BEING INADEQUATE, AS
TYPICALLY WITHOUT THE
AUGMENTATION, IT'S A IT ONLY
COVERS 20% OF THE COST OF AN AIR
AMBULANCE TRANSPORT. BUT WE PICK
UP ANYONE WHO NEEDS IT, AND WE
LOOK FORWARD TO THOSE
DISCUSSIONS AS PART OF THE
BUDGET. THANK YOU. THANK YOU.
GOOD AFTERNOON, NORA LYNN WITH
CHILDREN. NOW WE SUPPORT THE
MEDI-CAL MULTIYEAR CONTINUOUS
ENROLLMENT POLICY AND THINK THAT
IT SHOULD BE IMPLEMENTED. IT'S
IMPORTANT TO BOTH ADDRESS
PROVIDER RATES AND FOR THE STATE
TO FOLLOW THROUGH IN MAKING SURE
THAT YOUNG KIDS STAY COVERED SO
THEY CAN SEE THOSE PROVIDERS.
THANK YOU. THANK YOU. CHAIR AND
COMMITTEE. NORLAND ASHBROOK WITH
AXIOM ADVISORS REPRESENTING
PRIME HOME HEALTH AND TEAM
SELECT PROVIDERS OF PRIVATE DUTY
NURSING. AND I JUST ALIGNED MY
COMMENTS WITH BRIAN MARTIN.
THANK YOU. THANK YOU, THANK YOU,
MADAM CHAIR AND MEMBERS.
AIRBRIDGE, ON BEHALF OF MAXIM
HEALTHCARE SERVICES, ALSO A
LARGE PROVIDER OF PRIVATE DUTY
NURSING CARE IN THE STATE OF
CALIFORNIA, ALIGNED MY COMMENTS
WITH THOSE OF MY COLLEAGUES. BUT
JUST WANT TO REITERATE THAT
WHILE WE ARE IN A SIGNIFICANT
BUDGET DEFICIT, OURS IS ONE OF
THE ONLY ONES THAT HAS A
SIGNIFICANT COST SAVINGS THAT IS
ACTUALIZED WITHIN THE FIRST NINE
MONTHS OF THE FIRST YEAR THAT
YOU IMPLEMENT A RATE INCREASE.
THANK YOU. THANK YOU, MADAM
CHAIR. MEMBERS OF THE COMMITTEE,
BRANDON MARTIN WITH THE
CALIFORNIA MEDICAL ASSOCIATION.
WE WANT TO THANK THE GOVERNOR,
THE ADMINISTRATION DIRECTOR
BOSS, THIS COMMITTEE AND THE
LEGISLATURE FOR REALLY
IMPLEMENTING THE MCO DEAL AND
WORKING DILIGENTLY TO DO SO FOR,
FOR THE LAST SEVERAL YEARS, THE
LEGISLATURE AND THE NEWSOM
ADMINISTRATION HAVE WORKED TO
ADDRESS TWO LEGS OF THE THREE
LEGGED STOOL THAT HOLD UP OUR
MEDI-CAL PROGRAM. WE HAVE
INCREASED BENEFITS. WE HAVE,
ESSENTIALLY VIRTUALLY COVERAGE
FOR ALL IN CALIFORNIA. THIS MCO
DEAL AND THE PROVIDER RATE
INCREASES THAT COME WITH IT,
WOULD ADDRESS THAT THIRD LEG,
WHICH IS ACCESS TO CARE FOR
PATIENTS IN CALIFORNIANS, AS THE
LAW REPORT NOTES, PHYSICIANS
HAVE NOT SEEN BASE RATE
INCREASES SINCE THE LATE 1990S.
THE PROPOSAL IS CRITICAL TO
IMPROVING ACCESS TO THE MEDICARE
PROGRAM. AND, QUOTE, RESEARCH
SUGGESTS THAT RATE INCREASES ARE
ASSOCIATED WITH IMPROVEMENTS IN
PATIENTS ABILITY TO GET AN
APPOINTMENT, HAVE A REGULAR
SOURCE OF CARE, AND RECEIVE
TIMELY CARE. WE LOOK FORWARD TO
WORKING FURTHER IN THE FUTURE AS
THE MCO TEXT GETS IMPLEMENTED
FURTHER. THANK YOU. THANK YOU.
MADAM CHAIR MEMBERS TIM MADDEN,
REPRESENTING THE CALIFORNIA
CHAPTER OF THE AMERICAN COLLEGE
OF EMERGENCY PHYSICIANS. WE'D
ALSO TO, LIKE TO VOICE OUR
SUPPORT FOR THE ADMINISTRATION'S
PROPOSAL, FOR THE MCO TAX AND
THE INCREASES TO THE PROVIDER
RATES. WE'D ALSO LIKE TO ALSO
THANK THE DEPARTMENT AND THE
DIRECTOR SPECIFICALLY FOR THEIR
TIME IN LISTENING TO OUR
CONCERNS AROUND TRYING TO BRING
RATES UP TO THAT MEDICARE LEVEL.
IT WILL GO A LONG WAYS IN OUR
EMERGENCY DEPARTMENTS TO BE ABLE
TO INCREASE THOSE RATES,
MAINTAIN THE NUMBER OF EMERGENCY
PHYSICIANS THAT ACTUALLY STAFF
THOSE HOSPITALS, WHICH WILL
CONTINUE TO BRING A HIGH QUALITY
CARE FOR THOSE INDIVIDUALS.
THANK YOU. THANK YOU. GOOD
AFTERNOON, MADAM CHAIR, AND
MEMBERS, NICK BROKAW FROM
SACRAMENTO ADVOCATES HERE ON
BEHALF OF THE CALIFORNIA ACADEMY
OF AUDIOLOGY, TO EXPRESS OUR
APPRECIATION AND GRATITUDE TO
THE ADMINISTRATION FOR INCLUDING
AUDIOLOGISTS IN THE PROVIDER.
RATE INCREASES, ECHOING THE
THEME OF ACCESS IN THIS CASE FOR
INDIVIDUALS WHO ARE DEAF AND
HARD OF HEARING. AND I ALSO JUST
WANT TO MAKE NOTE THAT AS THIS
ADMINISTRATION HAS DEDICATED
RESOURCES AND FUNDING TO THE
ROLLOUT OF THE HEARING AID
COVERAGE FOR CHILDREN'S PROGRAM,
HAVING ADEQUATE REIMBURSEMENT
RATES FOR AUDIOLOGISTS, AND THAT
IS TOTALLY, LINKED TO MEDI-CAL
REIMBURSEMENT RATES WILL GO A
LONG WAY IN ENSURING WE HAVE
ACCESS TO THE PROVIDERS WHO
PROVIDE THESE SERVICES TO KIDS.
THANK YOU. THANK YOU. THANK YOU,
MADAM CHAIR. VANESSA KHN, ON
BEHALF OF THE CALIFORNIA ACADEMY
OF FAMILY PHYSICIANS, VERY MUCH
APPRECIATE THE WORK AND
ATTENTION THAT THIS SUBCOMMITTEE
HAS PAID TO THE ROLE THAT
PRIMARY CARE PLAYS, TO THE CARE
OF MEDI-CAL BENEFICIARIES
THROUGHOUT THE STATE OF
CALIFORNIA. WE ALSO ARE VERY MCO
TACKS AND WANT TO ENSURE THAT
PRIMARY CARE IS ADEQUATELY
REIMBURSED IN THAT. SO THANK YOU
FOR THESE ONGOING DISCUSSIONS.
THANK YOU. CHAIR GONZALEZ, ON
BEHALF OF THE ASSOCIATION OF
NORTHERN CALIFORNIA ONCOLOGISTS,
AS WELL AS THE MEDICAL ONCOLOGY
ASSOCIATION OF SOUTHERN
CALIFORNIA, WE'RE IN STRONG
SUPPORT OF INCREASING THE
PROVIDER REIMBURSEMENT RATES.
AND WE WANT TO, OF COURSE,
REMIND THE ADMINISTRATION AND
THE LEGISLATURE THAT CANCER CARE
IS DIRECTLY LINKED TO
SURVIVABILITY. SO IT'S
INCREDIBLY IMPORTANT THAT THE
REIMBURSEMENT RATES FOR THE
CODES BE ADEQUATE. THANK YOU SO
MUCH. THANK YOU. AND I WANT TO
GIVE A SINCERE THANK YOU TO OUR
PANEL AND MY FELLOW ASSEMBLY
MEMBER. AND WITH THAT, THIS
HEARING IS ADJOURNED. OKAY.