Figure 1
DHCS Oversees Two Medi-Cal Delivery Systems for Providing Care

Figure 1 is a chart showing the roles and responsibilities of various entities involved in the delivery of care to children enrolled in Medi-Cal. The delivery process begins with the Federal Centers for Medicare and Medicaid Services (CMS), providing federal oversight of Medicaid and approving state Medicaid plans through its oversight of the California Department of Health Care Services (DHCS). DHCS is responsible for overseeing Medi-Cal, California’s Medicaid program.

The chart further shows that DHCS oversees two Medi-Cal delivery systems for providing care. The first delivery system listed is the fee-for-service program. Under fee-for-service the State pays for individual services for children enrolled in this program. As of June 2018, fee-for-service covers 545,000 children, which is 10 percent of children enrolled in Medi-Cal.

The second delivery system listed is the managed care program. Under managed care the State pays a monthly premium for each beneficiary enrolled in this program. As of June 2018, managed care covers 4.9 million children, which is 90 percent of children enrolled in Medi-Cal.

Figure 2
Utilization Rates Were Low for Some of the Youngest Children in Medi-Cal
Fiscal Years 2013–14 Through 2017–18

Figure 2 is a vertical bar graph showing utilization rates for Medi-Cal beneficiaries from age 0 to 20 for the period from fiscal years 2013-14 through 2017-18. Some of the lowest utilization rates are for beneficiaries aged two, and 18 through 20, all with utilization rates below 25 percent. Some of the highest utilization rates are for beneficiaries aged 0, three through six, and 11 through 12, all with utilization rates above 50 percent, with the rate for age four at nearly 75 percent. Utilization rates for age 1, ages 7 through 10, and ages 13 through 16 are roughly between 40 and 45 percent, while the utilization rate for age 17 is between 35 and 40 percent. The bars in the figure are color-coded on a red-blue gradient, with darker reds indicating the lowest utilization rates and blues indicating the highest utilization rates. A legend in the upper right-hand corner shows this color gradient, indicating that utilization rates in this figure range from 15 percent to 65 percent and higher. We note that in addition to the methodology we used to calculate the utilization rates outlined in the Scope and Methodology section of our report, DHCS states that increased parental attention to newborn health and pre-scheduling check-ups could be possible reasons for the higher utilization rates, at nearly 70 percent, for children under age one, but it has not conducted an analysis to verify this. We also note that fiscal year 2017–18 data may be incomplete due to a delay in DHCS receiving data.

Figure 3
Utilization Rates Were Typically Lower in the Eastern Half of the State
Fiscal Years 2013–14 Through 2017–18

Figure 3 is a state map of California showing all counties and their utilization rates from fiscal years 2013-14 through 2017-18. The map is color coded based on a red and blue gradient color scale, with the darkest shade of red representing the lowest utilization rate at 15 percent, and the darkest shade of blue representing the highest utilization rate at 65 percent and above. The map shows that utilization rates were typically lower in the Eastern Half of the State, with a majority of the counties in the eastern region color coded in light to dark red. For example, Alpine, Plumas, Sierra, Mariposa, and Tuolumne are some of the counties with the lowest utilization rates, and are located in the eastern half of the State. The map shows that utilization rates are typically higher in the other regions of the State, with a majority of the counties in the western region color coded in light to dark blue. For example, Napa, Sonoma, Santa Barbara and Orange County are some of the counties with the highest utilization rates, and are located in the western half of the state. We note that fiscal year 2017–18 data may be incomplete due to a delay in DHCS receiving data.

Figure 4
California’s Utilization Rate for Children’s Preventive Services Ranked 40th in the Country
Federal Fiscal Year 2017

Figure 4 is a horizontal bar graph listing all fifty states in the country in the order of highest to lowest utilization rates for children’s preventive services during federal fiscal year 2017. The bars on the graph are color coded based on each states’ utilization rate. Bars for states with utilization rates above 50 percent are shown in various shades of green, while bars for states with utilization rates at or below 50 percent are shown in red. The graph shows that in federal fiscal year 2017, 34 states had utilization rates above 50 percent, while 16 states had utilization rates at or below 50 percent. This second group included California, which ranked 40th in the country with a utilization rate of 49 percent, which was below the national average of 58 percent during that time period. The graph shows that 17 states had utilization rates between 50 and 60 percent, nine states had rates between 60 and 70 percent, and eight states had rates of 70 percent or above. Iowa, Hawaii, Louisiana, Wisconsin and New York had the five highest utilization rates in the country for children’s preventive services during federal fiscal year 2017. We note that CMS calculated the utilization rate by dividing the total number of eligible children receiving at least one initial or periodic screening by the total number of eligible children who should receive at least one initial or periodic screening.

Figure 5
Many Areas Struggled to Meet Access Standards in 2018, Especially in the Eastern Parts of the State

Figure 5 is a state map of California showing all counties and the number of access exceptions DHCS approved for 2018. The map is color coded, with each color representing areas with different ranges of DHCS approved access exceptions. The map shows that many areas in the eastern parts of the state struggled to meet the access standards, as evidenced by the large number of access exceptions that DHCS approved for those areas. The map shows that DHCS approved 200 or more access exceptions for eight counties, five of which are in the eastern parts of the state. The map also shows that DHCS approved from 100 to 199 exceptions for four counties, three of which are also in the eastern parts of the state. For a majority of the remaining areas in the eastern parts of the state, DHCS approved from 10 to 99 exceptions. The map shows that the twelve counties which had from 1 to 9 exceptions, and the seven counties which had no exceptions are mainly in the western part of the state.

Figure 6
Utilization Rates Were Higher for Ages for Which DHCS Has Established Performance Measures
Fiscal Years 2013–14 Through 2017–18

Figure 6 is a vertical bar graph showing utilization rates for Medi-Cal beneficiaries from age 0 to 20 for the period from fiscal years 2013-14 through 2017-18. The utilization rate represents the percentage of eligible Medi-Cal beneficiaries from ages 0 through 20 who received the recommended preventive services during the time period. The X axis lists eligible beneficiaries’ age in years from zero to 20, and the Y axis show the corresponding utilization rate of preventive services for each age. The chart shows that utilization rates for preventive services are almost 70 percent for 0-year-olds (infants under one year of age), but drastically drop to between 40 and 45 percent for one-year-olds, and drop further to roughly 25 percent for two-year-olds. Rates then increase to nearly 70 percent for three-year-olds and nearly 75 percent for 4-year-olds, and then drop to slightly above 60 percent for five-year-olds, and about 55 percent for 6-year-olds. The bars for ages three to six, which show utilization rates from 55 percent to nearly 75 percent, are outlined in a red box, with a note indicating that DHCS has performance standards to monitor well-child visits for children aged three to six. Utilization rates then drop and stagnate in the mid-to-low-40’s for seven-to-ten year-olds, before increasing to about 55 percent for 11-year-olds and 50 percent for 12-year-olds. The rates again stagnate in the mid-to low 40’s for ages 13 to 16, then drop to about 35 percent for 17-year-olds, 25 percent for 18-year-olds, and between 15 and 20 percent for 19 and 20-year-olds. There is a horizontal black line drawn in the middle of the bar chart, indicating a statewide utilization rate of 47.1%. The bars in the figure are color-coded on a red-blue gradient, with darker reds indicating the lowest utilization rates and blues indicating the highest utilization rates. A legend in the upper right-hand corner shows this color gradient, indicating that utilization rates in this figure range from 15 percent to 65 percent and higher. Regarding the higher utilization rate for infants, we note that in addition to the methodology we used to calculate the utilization rates in the scope and methodology of the report, DHCS states that increased parental attention to newborn health and pre-scheduling check-ups could be possible reasons for the higher utilization rates for children under age one, but it has not conducted an analysis to verify this. We also note that fiscal year 2017–18 data may be incomplete due to a delay in DHCS receiving data.

Figure 7
Encounter Data Reported From Providers to CMS Are Transferred and Modified Multiple Times, Potentially Creating Inaccuracies With the Data

Figure 7 is a flow chart showing how encounter data is reported through multiple channels from providers to plans to DHCS to CMS. The flow chart process indicates that providers report encounter data either directly to managed care plans or else to subcontractors, such as physician associations, medical groups, and clinics. The subcontractors then report encounter data to managed care plans or subcontracted plans, which report the data to managed care plans. The chart further shows that managed care plans report the encounter data to DHCS, which then reports the data to CMS. A text box in the upper right corner of the figure explains that Medi-Cal managed care plans contract with other managed care plans, subcontractors, and directly with providers.

Figure 8
Utilization Rates Were Not Necessarily Higher for More Common Languages
Fiscal Year 2016–17

Figure 8 is a horizontal bar chart showing average utilization rates of children’s preventive services by primary language group during fiscal year 2016-17. The utilization rate represents the percentage of eligible Medi-Cal beneficiaries from ages 0 through 20 who received the recommended preventive services during the time period. The Y-axis of the figure lists the names of 29 different language groups, and the bars on the X-axis show the corresponding utilization rate for each of those language groups. The language groups with the highest utilization rates are at the top of the figure, while those with the lowest utilization rates are at the bottom. For example, the top of the chart indicates that Cantonese and Vietnamese speakers had the highest utilization rates, with between 60 and 70 percent of eligible child beneficiaries in those language groups receiving preventive services. The bottom of the figure indicates that Hmong and Russian speakers had the lowest utilization rates of all language groups, at approximately 35 percent each. In addition, as shown in a legend on the right side of the figure, the bars in the chart are color-coded different shades of blue based on the number of child beneficiaries in each language group, with a lighter shade indicating fewer child beneficiaries in a language group and a darker shade indicating more child beneficiaries in a language group. There are five shades representing from 1 to 100, 101 to 1000, 1,001 to 10,000, 10,001 to 50,000, and more than 50,000 children. For example, the bars for the Cantonese and Vietnamese language groups at the top of the chart are color-coded the second-darkest shade of blue, indicating that there were between 10,001-50,000 Cantonese and Vietnamese child beneficiaries receiving preventive services, while the bars for the Hmong and Russian groups at the bottom of the chart are the middle shade, indicating that there were between 1,001-10,000 Hmong and Russian child beneficiaries receiving preventive services during the time period. Overall, the figure indicates that utilization rates are not necessarily higher for more common languages. For instance, Spanish speakers had utilization rates around 55 percent, which was lower than five other less common languages, even though the color-coding indicates that Spanish is among the most common languages spoken in Medi-Cal. Similarly, the figure indicates that English speakers had even lower utilization rates of below 45 percent, which was below 20 other language groups, even though the chart indicates that English is also among the most common languages spoken in Medi-Cal.

Figure 9
Utilization Rates Were Not Necessarily Higher for More Common Ethnicities
Fiscal Year 2016–17

Figure 9 is a horizontal bar chart showing average utilization rates of children’s preventive services by ethnicity during fiscal year 2016-17. The utilization rate represents the percentage of eligible Medi-Cal beneficiaries from ages 0 through 20 who received the recommended preventive services during the time period. The Y-axis of the figure lists the names of 18 different ethnicities, and the bars on the X-axis show the corresponding utilization rate for each of those ethnicities. The ethnicities with the highest utilization rates are at the top of the figure, while those with the lowest utilization rates are at the bottom. For example, the top of the chart indicates that the Vietnamese ethnic group had the highest utilization rate, with about 60 percent of eligible children in that group receiving preventive services, followed by the Chinese ethnic group which had about a 55 percent utilization rate. The bottom of the figure indicates that the Guamanian and Samoan ethnic groups had lowest utilization rates of all ethnic groups, at just over 35 percent each. In addition, as shown in a legend on the right side of the figure, the bars in the chart are color-coded different shades of blue based on the number of child beneficiaries in each ethic group, with a lighter shade indicating fewer child beneficiaries in a language group and a darker shade indicating more child beneficiaries in a language group. There are four shades representing from 101 to 1000, 1,001 to 10,000, 10,001 to 50,000, and more than 50,000 children. For example, the bars for the Vietnamese and Chinese ethnic groups at the top of the chart are color-coded the second-darkest shade of blue, indicating that there were between 10,001-50,000 Vietnamese and Chinese child beneficiaries receiving preventive services, while the bar for the Samoan group at the bottom of the chart is the second-lightest shade, indicating that there were between 1,001-10,000 Samoan child beneficiaries receiving preventive services during the time period. Overall, the figure indicates that utilization rates are not necessarily higher for more common ethnicities. For instance, white and black child beneficiaries had utilization rates of approximately 40 percent, which was lower than twelve other ethnic groups, even though the color-coding indicates that those two are among the most common ethnic groups in Medi-Cal.