Report 2019-105 Recommendation 1 Responses

Report 2019-105: Childhood Lead Levels: Millions of Children in Medi-Cal Have Not Received Required Testing for Lead Poisoning (Release Date: January 2020)

Recommendation #1 To: Health Care Services, Department of

Because of the severe and potentially permanent damage that lead poisoning can cause in children, DHCS should ensure that all children in Medi-Cal receive lead tests by finalizing, by December 2020, its performance standard for lead testing of one- and two-year-olds. DHCS should use its existing data to assess the progress of managed care plans in meeting that performance standard and impose sanctions or provide incentive payments as appropriate to improve performance.

Annual Follow-Up Agency Response From December 2023

- Effective measurement year 2022, DHCS is holding Medi-Cal MCPs to the national 50th percentile for the Lead Screening HEDIS measures, which the list of measures including lead screening can be found here.

o MCPs performing below the national median will subject to Enforcement action such as monetary sanctions, and additional QI and HE projects to better support higher screening rates. DHCS is currently reviewing measurement year 2022 quality score results for blood lead screening and anticipates issuing Enforcement actions in the coming months.

- DHCS will continue to work with the EQRO to produce the annual Preventive Services Report, which reports on Title 17 and HEDIS Blood Lead Screening indicators. The report is located here.

- DHCS will also continue to monitor the Preventive Services Report and work on implementing report recommendations. The recommendations are updated annually, and the report is published and presented to external partners. We track all of EQRO's recommendations in our annual report found here. Throughout the report recommendations are made, and the report addresses how the previous year's recommendations were addressed.

California State Auditor's Assessment of Annual Follow-Up Status: Partially Implemented

DHCS has not yet demonstrated that it has implemented this recommendation. It asserts that it will use the Lead Screening HEDIS measure to assess managed care plans' performance in providing lead tests to children in Medi-Cal and that it will conduct enforcement actions for plans that do not meet the 50th percentile for lead screening. However, it did not provide evidence that it has begun doing so, nor did it provide documentation of its communication of these expectations upon our request that it do so. We will reassess DHCS's response to this recommendation after it provides All Plan Letters or worksheets showing that its expectations have been communicated to the MCPs, its assessment of MCPs progress toward meeting the performance standard, and evidence that it has imposed sanctions or provided incentive payments as appropriate to improve MCP performance in meeting the standard. In addition, although the implementation of this performance standard is an improvement in measuring whether children have received lead tests, it is important to recognize that it will not measure compliance with state law. The measure that DHCS describes assesses only whether a child has had one or more lead tests by their second birthday. With limited exceptions, state law requires that a child enrolled in Medi-Cal receive a lead screening test at 12 months of age and at 24 months of age.

Annual Follow-Up Agency Response From October 2021

DHCS released the Preventive Services Report Addendum in February 2021 which provided statewide and MCP-level rates for Title 17 and HEDIS Blood Lead Screening indicators using 2019 data. The Addendum presented findings and analysis related to the Blood Lead indicators which DHCS used to develop the Blood Lead Screening Approach Proposal. In July 2021, DHCS released the Proposal for stakeholder feedback and recommended to utilize the HEDIS Lead Screening in Children (LSC) measure as a proxy for Title 17 age stratifications. DHCS is reviewing the feedback and continuing internal discussions with a goal to release the finalized performance standard by the end of the year. Please see the attached Blood Lead Screening Approach Proposal document for further details on DHCS' recommendation.

California State Auditor's Assessment of Annual Follow-Up Status: Pending

DHCS's continued failure to implement this recommendation is troubling. A year has passed since the date we suggested for implementing this recommendation, and DHCS's own estimate of when it will implement this recommendation has been extended by a year since its 6-month response. However, it has not provided an explanation for this delay. The delay is especially troubling because its failure to implement this performance measure prevents the public from holding DHCS accountable for meeting the legal mandate to ensure children in Medi-Cal receive lead tests. If children are not receiving these tests they may suffer additional damage from continued lead poisoning.

1-Year Agency Response

DHCS is finalizing efforts to calculate the rate of Blood Lead Screening for each MCP per National Committee for Quality Assurance, Healthcare Effectiveness Data and Information Set technical specifications. The use of nationally-recognized technical specifications allows DHCS to compare California's performance to the performance of other Medicaid plans nationally and will assist DHCS in establishing adequate performance standards.

In addition, DHCS is finalizing the development of a California specific indicator and benchmarks with stratifications consistent with California's Title 17 CCR section 37100. The stratifications will be used in the metric including screening rates for one-, two-, and six-year-old members with no record of a screening, in alignment with Title 17 requirements. Options for benchmarking a Minimum Performance Level will be included in the Preventative Services Report Addendum scheduled for release in February 2021. Stakeholder engagement will occur in early 2021 so DHCS can finalize benchmarks/performance standards. MCPs not meeting the established benchmarks will be placed under a CAP. DHCS will impose sanctions and/or penalties on MCPs not complying with the CAP.

DHCS implemented a Value Based Payment Program which incentivizes providers to conduct various activities relating to care for Medi-Cal beneficiaries. Providers receive a payment for completion of a measure relating to said activities. Blood Lead Screening is one of the measures. Incentive payments are to be issued to plans upon DHCS' receipt of encounter data demonstrating lead screening, subject to federal approval. CMS approved DHCS' proposal for the Value Based Payment Program on May 5, 2020.

California State Auditor's Assessment of 1-Year Status: Pending

We will review DHCS' performance standard and its implementation of that standard once DHCS implements and provides documentation of the activities described.

6-Month Agency Response

DHCS released proposed measures, including Blood Lead Screening, for the 2020 Report for public comment on January 17, 2020. The public comment period ended February 3, 2020. DHCS is continuing to evaluate feedback to determine which measures need modifying to provide accurate and relevant information for the Report with the External Quality Review Organization, and continuing to move forward with production of the Report.

DHCS will utilize MCP administrative data to calculate the rate of Blood Lead Screening for each MCP per National Committee for Quality Assurance, Healthcare Effectiveness Data and Information Set, technical specifications. The use of nationally-recognized technical specifications will allow DHCS to compare California's Medi-Cal MCP rates to the performance of other Medicaid plans nationally, assisting DHCS with establishing a performance standard for DHCS to utilize in driving quality improvement. MCPs not meeting the established benchmark will be placed under a CAP. DHCS will impose sanctions and/or penalties on MCPs not complying with the CAP.

In addition, DHCS is in the process of developing a metric for Blood Lead Screening for infants up to age one. A Minimum Performance Level will also be developed. The metric will be included in the first version of the Report to be completed by December 2020.

DHCS implemented a VBPP which incentivizes providers to conduct various activities relating to care for Medi-Cal beneficiaries. Providers receive a payment for completion of a measure relating to said activities. Blood Lead Screening is one of the measures. Incentive payments are to be issued to plans upon DHCS' receipt of encounter data demonstrating lead screening, subject to federal approval. CMS has not yet approved the DHCS proposal for the VBPP.

California State Auditor's Assessment of 6-Month Status: Pending

We will review DHCS' performance standard and its implementation of that standard as soon as DHCS provides documentation of, and implements, the activities described.

60-Day Agency Response

DHCS released proposed measures, including Blood Lead Screening, for the 2020 Report for public comment on January 17, 2020. The public comment period ended on February 3, 2020. DHCS is reviewing the comments received, and determining any feasible adjustments to the performance measures for the Report with the External Quality Review Organization (EQRO), and continuing to move forward with production of the Report.

DHCS will utilize Medi-Cal MCP administrative data to calculate the rate of Blood Lead Screening for each MCP per National Committee for Quality Assurance, Healthcare Effectiveness Data and Information Set, technical specifications. The use of these nationally-recognized technical specifications will allow DHCS to compare California's Medi-Cal MCP rates to the performance of other Medicaid plans nationally. This will assist DHCS with establishing a performance standard that DHCS will utilize to drive quality improvement. MCPs that do not meet the established benchmark will be placed under a CAP. Should they not come into compliance with the CAP, DHCS will impose sanctions and/or penalties.

In addition, DHCS is in the process of developing a metric for Blood Lead Screening for infants up to age one. A Minimum Performance Level will also be developed. The metric will be included in the first version of the Report to be completed by December 2020.

Of note, DHCS has already implemented a VBP Program which incentivizes providers to conduct various activities relating to care for Medi-Cal beneficiaries. Providers receive a payment for completion of a measure relating to said activities. Blood Lead Screening is one of the measures. Incentive payments are to be issued to plans upon receipt by DHCS of encounter data demonstrating lead screening, subject to federal approval. The Centers for Medicare & Medicaid Services (CMS) has not yet approved the DHCS proposal for the Value Based Payment Program.

California State Auditor's Assessment of 60-Day Status: Pending

We will review the performance standard and DHCS' implementation of the standard after it has been implemented.

All Recommendations in 2019-105

Agency responses received are posted verbatim.