{"id":2784,"date":"2024-05-16T11:25:09","date_gmt":"2024-05-16T11:25:09","guid":{"rendered":"https:\/\/healthynewsusa.com\/?p=2784"},"modified":"2024-05-16T11:25:12","modified_gmt":"2024-05-16T11:25:12","slug":"californias-12-billion-medicaid-makeover-banks-on-nonprofits-buy-in","status":"publish","type":"post","link":"https:\/\/healthynewsusa.com\/?p=2784","title":{"rendered":"California\u2019s $12 Billion Medicaid Makeover Banks on Nonprofits\u2019 Buy-In"},"content":{"rendered":"
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TURLOCK, Calif. \u2014 For much of his young life, Jorge Sanchez regularly gasped for air, at times coughing so violently that he\u2019d almost throw up. His mother whisked him to the emergency room late at night and slept with him to make sure he didn\u2019t stop breathing.<\/p>\n

\u201cHe\u2019s had these problems since he was born, and I couldn\u2019t figure out what was triggering his asthma,\u201d Fabiola Sandoval said of her son, Jorge, now 4. \u201cIt\u2019s so hard when your child is hurting. I was willing to try anything.\u201d<\/p>\n

In January, community health workers visited Sandoval\u2019s home in Turlock, a city in California\u2019s Central Valley where dust from fruit and nut orchards billows through the air. They scoured Sandoval\u2019s home for hazards and explained that harsh cleaning products, air fresheners, and airborne dust and pesticides can trigger an asthma attack.<\/p>\n

The team also provided Sandoval with air purifiers, a special vacuum cleaner that can suck dust out of the air, hypoallergenic mattress covers, and a humidity sensor \u2014 goods that retail for hundreds of dollars. Within a few months, Jorge was breathing easier and was able to run and play outside.<\/p>\n

Fabiola Sandoval\u2019s son, Jorge Sanchez.(Angela Hart\/KFF Health News)<\/span><\/figcaption><\/figure>\n

The in-home consultation and supplies were paid for by Medi-Cal, California\u2019s Medicaid health insurance program for low-income residents. Gov. Gavin Newsom is spearheading an ambitious $12 billion experiment<\/a> to transform Medi-Cal into both a health insurer and a social services provider, one that relies not only on doctors and nurses, but also community health workers and nonprofit groups that offer dozens of services, including delivering healthy meals and helping homeless people pay for housing.<\/p>\n

These groups are redefining health care in California as they compete with businesses for a share of the money, and become a new arm of the sprawling Medi-Cal bureaucracy that serves nearly 15 million<\/a> low-income residents on an annual budget of $158 billion<\/a>.<\/p>\n

But worker shortages, negotiations with health insurance companies, and learning to navigate complex billing and technology systems have hamstrung the community groups\u2019 ability to deliver the new services: Now into the third year of the ambitious five-year experiment, only a small fraction of eligible patients have received benefits.<\/p>\n

\u201cThis is still so new, and everyone is just overwhelmed at this point, so it\u2019s slow-going,\u201d said Kevin Hamilton, a senior director at the Central California Asthma Collaborative.<\/p>\n

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Community health workers also provided Sandoval with air purifiers, a special vacuum cleaner that can suck dust out of the air, hypoallergenic mattress covers, and a humidity sensor. Within a few months, her son, Jorge, was breathing easier and was able to run and play outside.(Angela Hart\/KFF Health News)<\/span><\/figcaption><\/figure>\n
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The collaborative has served about 3,650 patients, including Sandoval, in eight counties since early 2022, he said. It has years of experience with Medi-Cal patients in the Central Valley and has received about $1.5 million of the new initiative\u2019s money.<\/p>\n

By contrast, CalOptima Health, Orange County\u2019s primary Medi-Cal insurer, is new to offering asthma benefits and has signed up 58 patients so far.<\/p>\n

\u201cAsthma services are so difficult to get going\u201d because the nonprofit infrastructure for these services is virtually nonexistent, said Kelly Bruno-Nelson, CalOptima\u2019s executive director for Medi-Cal. \u201cWe need more community-based organizations on board because they\u2019re the ones who can serve a population that nobody wants to deal with.\u201d<\/p>\n

Newsom, a Democrat in his second term, says his signature health care initiative, known as CalAIM<\/a>, seeks to reduce the cost of caring for the state\u2019s sickest and most vulnerable patients, including homeless Californians, foster children, former inmates, and people battling addiction disorders.<\/p>\n

In addition to in-home asthma remediation, CalAIM offers 13 broad categories<\/a> of social services, plus a benefit connecting eligible patients with one-on-one care managers to help them obtain anything they need to get healthier, from grocery shopping to finding a job.<\/p>\n

The 25 managed-care insurance companies participating in Medi-Cal can choose which services they offer, and contract with community groups to provide them. Insurers have hammered out about 4,300 large and small contracts with nonprofits and businesses.<\/p>\n

So far, about 103,000 Medi-Cal patients have received CalAIM services and roughly 160,000 have been assigned personal care managers, according to state data<\/a>, a sliver of the hundreds of thousands of patients who likely qualify.<\/p>\n

\u201cWe\u2019re all new to health care, and a lot of this is such a foreign concept,\u201d said Helena Lopez, executive director of A Greater Hope<\/a>, a nonprofit organization providing social services in Riverside and San Bernardino counties, such as handing out baseball cleats to children to help them be active.<\/p>\n

Tiffany Sickler runs Koinonia Family Services<\/a>, which offers California foster children mental health and other types of care, and even helped a patient pay off parking tickets. But the program is struggling on a shoestring budget.<\/p>\n

\u201cIf you want to do this, you have to learn all these new systems. It\u2019s been a huge learning curve, and very time-consuming and frustrating, especially without adequate funding,\u201d she said.<\/p>\n

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\n\t\t\t\t\t\t\tAlondra Mercado, a community health worker with the Central California Asthma Collaborative, helps provide services through an ambitious California Medicaid initiative.\t\t\t\t\t\t(Angela Hart\/KFF Health News)<\/span><\/figcaption><\/figure>\n<\/p><\/div>\n
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\n\t\t\t\t\t\t\tIn January, community health workers visited Sandoval\u2019s home. They scoured it for hazards and explained that harsh cleaning products, air fresheners, and airborne dust and pesticides can trigger an asthma attack.\t\t\t\t\t\t(Angela Hart\/KFF Health News)<\/span><\/figcaption><\/figure>\n<\/p><\/div>\n<\/p><\/div>\n<\/div>\n

Brandon Richards, a Newsom spokesperson, defended CalAIM, saying that it was \u201con the cutting edge of health care\u201d and that the state was working to increase \u201cawareness of these new services and support.\u201d<\/p>\n

For nonprofits and businesses, CalAIM is a money-making opportunity \u2014 one that top state health officials hope to make permanent. Health insurers, which receive hefty payments from the state to serve more people and offer new services, share a portion with service providers.<\/p>\n

In some places, community groups are competing with national corporations for the new funding, such as Mom\u2019s Meals, an Iowa-based company that delivers prepared meals across the United States.<\/p>\n

Mom\u2019s Meals has an advantage over neighborhood nonprofit groups because it has long served seniors on Medicare and was able to immediately start offering the CalAIM benefit of home-delivered meals for patients with chronic diseases. But even Mom\u2019s Meals isn\u2019t reaching everyone who qualifies, because doctors and patients don\u2019t always know it\u2019s an option, said Catherine Macpherson, the company\u2019s chief nutrition officer.<\/p>\n

\u201cUtilization is not as high as it should be yet,\u201d she said. \u201cBut we were well positioned, because we already had departments to do billing and contracting with health care.\u201d<\/p>\n

Middleman companies also have their eye on the billions of CalAIM dollars and are popping up to assist small organizations to go up against established ones like Mom\u2019s Meals. For instance, the New York-based Nonprofit Finance Fund<\/a> is advising homeless service providers how to get more contracts and expand benefits.<\/p>\n

Full Circle Health Network<\/a>, with 70 member organizations, is helping smaller nonprofit groups develop and deliver services primarily for families and foster children. Full Circle has signed a deal with Kaiser Permanente, allowing the health care giant to access its network of community groups.<\/p>\n

\u201cWe\u2019re allowing organizations to launch these benefits much faster than they\u2019ve been able to do and to reach more vulnerable people,\u201d said Camille Schraeder, chief executive of Full Circle. \u201cMany of these are grassroots organizations that have the trust and expertise on the ground, but they\u2019re new to health care.\u201d<\/p>\n

One of the biggest challenges community groups face is hiring workers, who are key to finding eligible patients and persuading them to participate.<\/p>\n

Kathryn Phillips, a workforce expert at the California Health Care Foundation, said there isn\u2019t enough seed money for community groups to hire workers and pay for new technology platforms. \u201cThey bring the trust that is needed, the cultural competency, the diversity of languages,\u201d she said. \u201cBut there needs to be more funding and reimbursement to build this workforce.\u201d<\/p>\n

Health insurers say they are trying to increase the workforce. For instance, L.A. Care Health Plan, the largest Medi-Cal insurer in California, has given $66 million to community organizations for hiring and other CalAIM needs, said Sameer Amin, the group\u2019s chief medical officer.<\/p>\n

\u201cThey don\u2019t have the staffing to do all this stuff, so we\u2019re helping with that all while teaching them how to build up their health care infrastructure,\u201d he said. \u201cEveryone wants a win, but this isn\u2019t going to be successful overnight.\u201d<\/p>\n

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Fabiola Sandoval has struggled to help her son, Jorge Sanchez, control his asthma since he was an infant. She has received several items from California\u2019s Medicaid program, including air filters, cleaning products, pillow and mattress covers, and a specialized vacuum, which she\u2019s holding, that can suck dust out of the air.(Angela Hart\/KFF Health News)<\/span><\/figcaption><\/figure>\n

In the Central Valley, Jorge Sanchez is one of the lucky early beneficiaries of CalAIM.<\/p>\n

His mother credits the trust she established with community health workers, who spent many hours over multiple visits to teach her how to control her son\u2019s asthma.<\/p>\n

\u201cI used to love cleaning with bleach\u201d but learned it can trigger breathing problems, Sandoval said.<\/p>\n

Since she implemented the health workers\u2019 recommendations, Sandoval has been able to let Jorge sleep alone at night for the first time in four years.<\/p>\n

\u201cHaving this program and all the things available is amazing,\u201d said Sandoval, as she pointed to the dirty dust cup in her new vacuum cleaner. \u201cNow my son doesn\u2019t have as many asthma attacks and he can run around and be a normal kid.\u201d<\/p>\n

This article was produced by <\/em>KFF Health News<\/em><\/a>, which publishes <\/em>California Healthline<\/em><\/a>, an editorially independent service of the <\/em>California Health Care Foundation<\/em><\/a>.<\/em>\u00a0<\/p>\n