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November 2022 - Pillar Round Table: Addressing Health and Social Disparities (members only)


The Department of Health Care Services (DHCS) is innovating and transforming the Medi-Cal (California Medicaid) delivery system. ​California Advancing and​ Innovating Medi-Cal (CalAIM) is moving Medi-Cal toward a population health approach that prioritizes prevention and whole-person care with the goal of extending support and services beyond hospitals and health care settings offering a more equitable, coordinated​, and person-centered approach to maximizing their health and life trajectory.​

In this round table discussion on November 1, HC3 member Terry Group shared a case study about how the CalAIM program is addressing health equity and social determinants of health (SDoH) for high-risk populations in California. Lessons learned from CalAIM can inform programs here in Illinois seeking to better integrate medical care and social services to advance health equity.

Featured Presenter:

John Zweifler, MD, MPH, Physician Consultant, Terry Group

The recording is available to HC3 members by emailing Meghan@HC3.Health / Details were distributed in the November 11 HC3 Weekly Email.

Event Recap


Dr. Zweifler’s presentation covers three main topics: population health and its relationship to social determinants of health (SDOH), a new Medicaid program in California that focuses on health equity and SDOH, and things communities can do to address health equity and SDOH. Health disparities are defined as preventable differences in the burden of disease that are experienced by socially disadvantaged populations. Current trends that are shaping health equity include value-based care, digital solutions, and population health.

Value-Based Care

Organizations that implement value-based care have an emphasis on cost and quality. Value-based care is more focused on reducing costs by keeping people healthy and out of the hospital. This is in contrast to the fee-for-service model, which is the model under which most clinicians still operate. Fee-for-service incentivizes doctors to perform a higher volume of medical procedures rather than focus on preventive care. Value-based care changes the incentive and opens the door for health organizations and health plans to get the necessary support to address social determinants so we can prevent people from ending up in the hospital. It also opens the door to thinking of alternative ways to address the needs of people and how services are provided.

Digital Solutions

Digital solutions have focused on increasing access to care. The COVID-19 pandemic opened the door for improved digital healthcare. While we have made progress, we have only scratched the surface and there are still many opportunities to leverage digital solutions in consultations, emergency rooms, and other settings. Expanding digital health beyond the doctor’s office is important for populations that struggle with access to care.

Population health

Population Health is a holistic approach to health that encompasses social determinants and is built on principles of public health and chronic care management to address low-risk and high-risk populations. The three categories of populations commonly used in population health are low-risk populations, rising-risk populations, and high-risk populations. For low-risk populations, the focus is often keeping them healthy and the major factors that contribute to this are a healthy diet and good exercise. This means in access to these things in addition to health education is critical. These become the determinants of their health. A lot of the health education required by this population can be provided more efficiently through public health interventions such as public service announcements and social media. Furthermore, things like exercise and diet cannot be effectively changed by a doctor but are more likely to be impacted by community investments such as walking trails and healthy food suppliers. The rising risk population refers to those who are already sick or have chronic conditions like diabetes. It also includes individuals who are predisposed to these conditions because of social determinants. To cater to this population, the opportunity exists to coordinate with community agencies and use team-based approaches to address their needs before they become critical. The high-risk populations (those in the hospitals) require an incredible amount of coordination of care. This coordination of care is necessary for both medical and social determinants-focused interventions. Team approaches are important in delivering the care that this population requires.

California Advancing Innovation for mediCAL (CalAIM)

CalAIM is the new California Medicaid program that was created through an 1115 demonstration project to enable the state of California to offer a range of services that address health equity and social determinants. The goals of CalAIM are to increase or improve upon the following areas:

o Coordinated access to care

o Culturally competent care

o Behavioral health and physical health integration

o Primary care investment

o Reinvestment in community

o Engagement with community advisory groups

o Increased transparency

One of the most concrete enhancements associated with CalAIM is enhanced care management. The goal of CalAim’s enhanced care management program is to provide a whole-person approach to care that addresses the clinical and non-clinical needs of high-need Medi-Cal beneficiaries. Extensive case management services are provided through navigators, promotoras, community health workers, etc. to help address social determinants. CalAIM defines its population as “high-risk”, which includes people experiencing high-utilization of services, homelessness, mental illness, substance use, incarceration transition, or at-risk circumstances.

Although voluntary, CalAIM encourages the Managed Care Plans to provide community support, the include services like housing issues, food, support for seniors, and sobering centers all of which will be revenue neutral. The state turned over the responsibility for CalAIM to the Managed Care Plans which largely use care managers. The challenge with this approach is that to respond to issues within substance use, mental illness, or housing, care managers need to work with other government agencies/community-based agencies who don’t necessarily have additional resources to connect. These organizations also do not have the same of incentives that care managers have. An approach in which care managers were assigned to community-based organizations, government agencies, and health care providers allowing them to work together to provide the services may be more effective. Although not a perfect model, it is helping to address some of the issues that exist in the community. It also helps provides community resources. One of the challenges when dealing with social determinants is that there are so many entities that play a role, identifying who takes the lead and who plays specific roles is often tricky. There are several benefits that can accrue from addressing social determinants that don’t show up on the bottom line of the health care plan.

Community Strategies to address Health Equity and SDOH

At the community level there are three basic ways we can think of intervening to improve social determinants:

1. Investing more in public health – What can we do to improve the infrastructure of our communities to ensure people are healthy?

2. Health care systematically screening for social determinants and having navigators who can connect people to resources. It would be helpful for communities to take the lead in putting navigators in place.

3. Digital solution – Communities may need to step up and use digital solutions, especially to address access-related issues.

Highlights from the Q&A Session:

Q: Considering the private-public relationship in value-based care, how do we look to communities? Private entities are instilling value-based care in hospital systems, but how do we make value-based care a prime target for how two do business?

A: There is an incentive to develop models that achieve those objectives, when it comes to social determinants there is a gray area of where responsibility lies. There are coordination issues regarding who will take the lead, but it would be best for the lead-out to come from the community level because it would be more effective than the health systems taking it on.

Q: How to bridge the gap for the “working poor” who don’t qualify for Medicaid services?

A: Providing a continuum of care, and trying to build out more digital solutions to increase access will be important. Consider how we can more easily access the services we need.

Q: Does CA have digital divide issues in the major cities?

A: Ensuring adequate internet access is critical, especially in rural areas of CA. There are initiatives in CA that are intended to bridge gaps.

Q: Are CA community-based organizations receiving public funding to support their public health efforts?

A: No, but FQHCs can become enhanced care management providers. Not many have, which is surprising because it’s a great chance to get a free care manager.


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