Health + Behavior

Medicaid waiver program helped public hospitals improve care to California’s most needy

Results of UCLA report are the first from a national effort to reform public hospitals

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Hospital
iStock.com/Sandra Nicol

What worked in California hospitals to improve health care for the poor, can work in other hospitals, too, UCLA research indicates.

A five-year Medicaid waiver program that infused billions of dollars into public hospitals prompted significant improvements in health care to California’s neediest population — the poor and uninsured, according to an extensive evaluation by the UCLA Center for Health Policy Research.

Seventeen designated public hospitals participated in the $3.3 billion “pay-for-performance” experiment, including five University of California hospital systems and 12 county‐owned-and‐operated hospital systems. Collectively, these facilities serve more than 2 million patients every year, including most of the state’s Medi-Cal patients. Medi-Cal is California’s version of Medicaid.

Participating hospitals saw increased rates of mammogram screenings, flu vaccinations, child weight screenings, and tobacco cessation, according to the evaluation. A higher proportion of patients received timely appointments and controlled their cholesterol and blood glucose levels in participating hospitals compared to patients at hospitals that did not participate in the program.

Among people with HIV, the rate of mental health screenings increased dramatically, from 3 percent to 67 percent, according to the evaluation. There was also a dramatic increase in the rate of Hepatitis B vaccinations, which rose from 11 percent to 58 percent.

California is the first of nine states in the program to report on participating hospitals’ efforts to transform their systems and improve quality of care for low-income patients.

“California’s health system reforms are a beacon for the rest of the nation,” said Nadereh Pourat, the director of research of the UCLA Center for Health Policy Research and leader of the evaluation project. “These strong results are significant, because they show how national reform can be successfully implemented. The waiver program illustrates that with an adequate supply of funds, California has improved the health of its population by strengthening its health care delivery system under Medicaid.”

Waiver established as part of the Affordable Care Act’s “Bridge to reform”

California established the Medicaid waiver, called the Delivery System Reform Incentive Payment program, in 2010.

The program incentivized participating hospitals to test innovative strategies to improve care by rewarding them if they met specific milestones.

The UCLA Center for Health Policy Research’s evaluation found that hospitals met 97 percent of the 3,764 milestones related to 44 projects organized under five broad categories:

Category 1: Develop ambulatory care infrastructure. Example: Increase primary care providers and clinics.

Category 2: Redesign of care delivery. Example: Measure and improve patient experience of care.

Category 3: Track population health measures. Example: Track proportion of diabetic patients with controlled blood glucose levels.

Category 4: Improve urgent care. Example: Reduce stroke mortality and infections from surgery during hospitalization.

Category 5: Improve quality of care for patients with HIV. Example: Increase number of patients on antiretroviral therapy.

Hospitals exceeded the challenge of implementing these projects. For example, UC San Francisco Medical Center exceeded its milestone for the number of elderly and disabled patients assigned to a medical home by 2,666 percentage points. UCLA hospitals reduced the proportion of patients with pressure sores from 3.92 percent to 1.75 percent. Ventura County Medical Center increased the percentage of HIV patients receiving antiretroviral therapy from 82 percent to 93 percent.

The evaluation reported that additional federal funding through the subsequent Public Hospital Redesign and Incentives in Medi-Cal Program allowed many of the hospitals to continue projects that began under the Delivery System Reform Incentive Payment program.

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