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Future of Children’s Program Up in Air

A group of four children’s advocacy organizations has come out publicly against the state’s current plan to retool the California Children’s Services (CCS) program.

The state wants to redesign CCS into a Medi-Cal managed care program called the Whole Child Model. The plan, released in June by the Department of Health Care Services, would begin by moving roughly one-third of CCS children in 19 counties by July 2017 into managed care.

The concept of the whole-child model of care is appealing to children’s health advocates, according to a letter they sent this month to officials at the Department of Health Care Services, which oversees Medi-Cal. But the plan advanced by the state creates more problems than it fixes, advocates said.

“We see this proposal as being fatally flawed,” said Kelly Hardy, executive director of Children Now, one of the four children’s groups. “We like the idea of it, but we believe there are fundamental problems with the overall framing of the proposal.”

California Children’s Services serves about 195,000 California children with severe and rare diseases. The program’s managed-care carve out is due to sunset in January 2016. A bill in the state legislature — AB 187 by Assembly member Rob Bonta (D-Oakland) — proposes to put off the state’s shift of kids in the CCS program for a year, till January 2017.

One of the advocates’ concerns, given the frail nature of these children’s health, is that any disruption in current care could harm them. Hardy said the state wants the Legislature to pass something this session to replace CCS with Medi-Cal managed care.

“They’re hoping to get language passed this session [to change the current CCS program],” Hardy said. “We feel that is far too rushed a timeframe to get rid of a program that’s been around [so long].”

Anthony Cava, an information officer at DHCS, said in an email that there currently is no legislative author for a bill. “The intent is to continue to work with stakeholders and the Legislature on the Whole Child Model concept,” Cava wrote. 

The four children’s advocacy groups — Children Now, The Children’s Partnership, California Coverage & Health Initiatives and the Children’s Defense Fund-California — raised a number of specific concerns:

  • Utilization review and eligibility determination would be done by managed care insurers rather than the county experts familiar with these children’s sometimes arcane health needs;
  • Protections are not in place to make sure children see specialists who are out of the county or occasionally even out of the state;
  • The idea of analyzing a pilot transition program has been seemingly abandoned in favor of simply going ahead in a staggered transition of the whole program;
  • Metrics and standards to assess the ongoing effectiveness and access to care of the program is lacking; and
  • Network adequacy and provider directories already are issues DHCS is trying to address, and the state may want to wait till the concerns raised by the California State Auditor about those issues are fixed before the state launches another program transition.

According to DHCS information officer Cava, the proposal does allow some out-of-county movement.

“The Whole Child Model includes health plan requirements permitting access to CCS-approved specialists and sub-specialty providers, which may in some cases be out of county,” Cava wrote. “Additionally, the Whole Child Model will include continuity of care provisions that maintain existing patient/provider relationships, with a few exceptions.”

The counties, he said, will continue to determine CCS eligibility.

As for the concern about using pilot programs to test the system before implementation, Cava said in his email: “The Whole Child Model will be implemented in select counties where health care is provided through a County Organized Health System (COHS). COHS health plans are locally developed with strong community ties, a number of which already provide health care to CCS-eligible children.”

There is one other major concern, Hardy said, a recent development that is not outlined in the stakeholder letter.

“It looks like they struck the existing language about having a separate rate for CCS kids,” Hardy said. “If that’s the case, that seems like a deal-breaker for us, and would really be a deal-breaker for the entire system of children’s health care.”

Hardy’s concern is that, if children with rare and serious illnesses are moved into the general pool of Medi-Cal children, the cost for their care would shift into the general cost of Medi-Cal — and that could lower the amount of money available to everyone else, which could affect the vast majority of Medi-Cal kids.

“Why dismantle a system without having something known and certain in place to replace it?” Hardy said. “I question whether this kind of move could save any money at all. The cost of care would just be delayed for a few months, because if you don’t treat these kids right away it’s going to be more expensive going forward.

“We’re not opposed to making changes in the program, making it into a whole-child model,” Hardy said, “but this isn’t the way to do it.”

Related Topics

Capitol Desk Medi-Cal