By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

“Effectively, change is almost impossible without industry-wide collaboration, cooperation and consensus.”

– Simon Mainwaring, Author

On January 1, when some of us were thinking about New Year’s resolutions or football games, 10 California counties joined Partnership HealthPlan’s County Organized Health System. Partnership grew overnight from about 600,000 members to 920,000 members. On the same date, 81,000 Kaiser-assigned members transitioned to direct coverage by Kaiser Health Plan, and many thousands of individuals with unclear documentation status, aged 27-49, gained Medi-Cal coverage.

This was the largest increase in membership since the combination of an eight-county expansion in 2023 and the massive expansion of coverage associated with the implementation of the Affordable Care Act. For the first time ever in California’s history, every resident of California qualifies for some sort of affordable or costless health care coverage.

The degree of growth was larger than expected. While DHCS asked Partnership to Expand in early 2022, the final approval did not come until two months before, so staffing for the increased needs of this larger membership is ongoing. Retrospectively, it took most of 2014 to stabilize staffing after the 2013-2014 expansion. Similarly, we expect 2024 to be a year of steady staff growth, stabilizing by the end of the year. Given the trust our 24 counties have granted us, the Partnership team feels a profound sense of responsibility to build an excellent support framework for our members and for you, our clinical network.

However, we will not be able to catch our breath in 2025. DHCS has directed us to begin a Dual-Special Needs Plan (D-SNP) for our members who have both Medi-Cal and Medicare, going live in January 2026. This will require two large IT software changes, a number of smaller IT programs, as well as a team focused on the new operational compliance network, and quality requirements for a D-SNP. On average, a Medicare member has about five times the needs of a typical adult Medi-Cal-only member, so the new D-SNP plan is another phase in growth in the responsibilities of Partnership to provider greater depth of services to these members, compared to when their primary payer was Medicare

Medi-Cal and the D-SNP Medicare Advantage program have a very important similarity: the resources coming from California and the federal government, respectively, are both adjusted significantly based on an acuity adjustment, which depends largely on the coding done by providers in our network. As announced last year, our current Primary Care Provider network will have the PCP QIP adjusted by acuity starting in measurement year 2023. It is likely that an even larger alignment of incentives for robust coding of annual visits will be implemented out of the gate for the Medicare population in 2026.

The upshot? Ensuring your clinicians are well trained on the importance of addressing all major medical issues each year and capturing this in the coding for that visit is key to the resources CMS and DHCS will send to Partnership, which in turn impacts the resources Partnership can devote to rates, quality incentives, and financial supports for the community. This year, we ask you to please prioritize provider and staff training on optimal visit coding, as well as the auditing processes to support improvement.