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Private Equity in Health Care: Prevalence, Impact and Policy Options for California and the U.S.

May 7, 2024

At its most recent peak in 2021, private equity (PE) investment into the broad health care economy, which includes health care service providers, health care technology, and the pharmaceutical and biotech industries, totaled about $83 billion nationally and $20 billion in California. While the majority of overall PE dollars has gone to biotechnology and pharmaceuticals in recent years, PE acquisitions of health care service providers (such as outpatient clinics, hospitals and nursing homes) make up a significant portion of all PE health care deals.This brief synthesizes publicly available data and academic research to outline national and California-specific trends in PE investment in the broad health care economy, then dives deeper into PE investment in health care service providers. It then reviews the effect of PE acquisitions of health care service providers on economic and clinical outcomes and explores emerging national and state-based policyapproaches to oversight.

Building on CalAIM’s Housing Supports: Strengthening Medi-Cal for People Experiencing Homelessness

August 10, 2023

California's Medicaid program, Medi-Cal, is undergoing an ambitious transformation known as CalAIM (California Advancing and Innovating Medi-Cal).  A key focus of this transformation is removing barriers to care for populations who struggle to access services, including people experiencing homelessness. A critical goal of CalAIM is a more person-centered approach to publicly funded health care.This paper, from the Corporation for Supportive Housing, rests on a foundation of extensive research and examines the successes, challenges, and opportunities in providing person-centered care to people experiencing homelessness. In Part 1, the authors describe in detail how homelessness undermines a person's health. When people live outdoors or without reliable shelter, existing health issues are made worse, and people develop new ones. Californians experiencing homelessness die in large numbers from causes directly related to their lack of housing.The primary driver of homelessness is a lack of affordable housing. Part 2 describes opportunities in CalAIM, in the Providing Access and Transforming Health (PATH)  initiative, and in the Home and Community-Based Services Spending Plan to fund housing support services that connect people to housing and help keep people stably housed. This section also includes explanations of CalAIM's Enhanced Care Management benefit and Community Supports, seven of which specifically focus on people experiencing homelessness.Despite the promise of CalAIM and related programs, CalAIM's impact has been limited to date. Part 3 describes the challenges providers and managed care plans face in implementing CalAIM and the provision of housing support services. Health care and social service providers offering services under CalAIM must navigate differing reimbursement rates — which may not be enough — and differing requirements set by each managed care plan, even among plans operating in the same county. Managed care plans may not know how best to identify and reach people experiencing homelessness, and to connect people to housing and housing support services. Meanwhile, people who are unhoused must still find and access the care and services they need by navigating complex systems of care and fragmented provider networks.

Perspectives from the Field: Developing the Enhanced Care Management Workforce

March 21, 2023

The CalAIM initiative is an ambitious effort to transform California's Medi-Cal program. CalAIM includes a major new benefit — Enhanced Care Management — provided through Medi-Cal managed care plans working with a team of community-based providers to address the needs of 10 specific California populations with complex needs, including health-related social needs, as well as physical and behavioral health conditions.The whole-person model of care envisioned by Enhanced Care Management (ECM) requires providers to develop significant new capabilities to develop the trust and relationships needed to successfully navigate across Medi-Cal's different delivery systems on behalf of their clients. ECM teams must possess skills related to outreach and engagement, care planning, care coordination, health promotion, transitional care support, member and family education, and social services coordination.Staffing up for this work has proved to be a heavy lift for organizations providing ECM. To better understand what will be required for long-term success, the Camden Coalition conducted interviews and focus groups with numerous California-based frontline care managers, supervisors, program directors, organization leadership, and managed care plan representatives from organizations participating in ECM.While the interviewees recognized the need for high-quality, ongoing training for ECM staff, they also said they were prioritizing other challenges over the establishment of training protocols and programs, especially hiring and retaining staff. Yet they also described their approaches to training and provided thoughtful insights into the types of training that had been effective in their organizations.In Perspectives from the Field — Developing the Enhanced Care Management Workforce, hear directly from frontline workers and managers at organizations participating in ECM. Learn about the challenges they face in recruiting and retention, and the types of training they think are effective for new staff.

2023 Edition - California Health Care Spending

March 14, 2023

For the first time since 2017, the federal government has released health care spending data by state. The data, available for 1991 to 2020, cover spending on personal health care (PHC), which includes goods and services, such as hospital care, physician services, and prescription drugs, but excludes the net cost of health insurance, government administration, public health activities, and investment.In 2020, California PHC spending totaled $405 billion and accounted for 12% of total US PHC spending. On a per capita basis, California health care spending ($10,299) surpassed the US average ($10,191) for the first time since 1991.Between 2010 and 2020, health care spending in California grew faster on an annual average basis than health spending in the US and the economic growth in the state.

The 2023 CHCF California Health Policy Survey

February 16, 2023

California is home to nearly 40 million people of different incomes, ages, and racial and ethnic backgrounds, and who live in different regions. Every year since 2019, the California Health Care Foundation has conducted a representative, statewide survey of residents' views and experiences on a variety of health care topics, some of which are tracked to detect meaningful shifts over time.The California Health Care Foundation and NORC at the University of Chicago, a nonpartisan research organization, conducted the survey again in late 2022. Results are reported and, where applicable, compared to the prior annual survey, which was conducted in late 2021.Key findings from this year's survey include:Health care costs. Like prior years, half of Californians (52%) report skipping or delaying health care due to cost in the past 12 months.  Of those who skipped or delayed care, half of them (50%) say their condition got worse as a result.Medical debt. More than 1 in 3 (36%) report having medical debt, and of those, 1 in 5 (19%) report owing $5,000 or more. Californians with lower incomes (52%) are more likely than those with higher incomes (30%) to report medical debt.

Listening to Black Californians: How the Health Care System Undermines Their Pursuit of Good Health

October 4, 2022

California, home to the most culturally diverse population in the country and the fifth largest Black population of any state, has a major opportunity to be a leader in health equity. But, again and again, research has shown that racism and structural barriers in the health care system prevent Black Californians from achieving the health they actively seek.Long-standing racial and ethnic health disparities laid bare by the COVID-19 pandemic, coupled with the powerful demonstrations against police violence catalyzed by the murder of George Floyd, prompted CHCF to investigate the relationship between racism and health care that leads to unacceptable health outcomes for Black Californians. To identify solutions for dismantling persistent health inequities, CHCF engaged EVITARUS, a Black-owned public opinion research firm in Los Angeles, to conduct qualitative and quantitative research that listens deeply to Black Californians talking about their experiences with racism and health care.Listening to Black Californians is one of the largest studies focused on the health care experiences of Black Californians to date. The qualitative phases, conducted from June to December 2021, included in-depth interviews with 100 Black Californians and 18 focus groups consisting of Black Californians and key health care stakeholders. The interviews and focus groups informed the content of a statewide survey, conducted from March to May 2022, and completed by 3,325 adult Black Californians recruited to reflect the population based on the 2020 US Census and 2019 American Community Survey.

CalAIM Community Supports: Promoting Independent Living Among Older Adults and People with Disabilities

April 26, 2022

Through CalAIM (California Advancing and Innovating Medi-Cal), a multiyear initiative to transform the Medi-Cal program, managed care plans now have the option to offer any of 14 Community Supports that provide person-centered services to address a variety of social drivers of health. Several of these Community Supports could help older adults and people with disabilities remain in their own homes, participate in their communities, and live independently in the setting of their choice.To support understanding and increased uptake of these services over time, this report provides an overview of and evidence summary for six Community Supports most relevant to supporting independent living for older adults and people with disabilities, including:Respite Services. Short-term services aimed at providing relief to caregivers of those who require occasional or temporary assistance or supervision.Nursing Facility Transition / Diversion to Assisted Living Facilities. Services that help people remain in the community by facilitating transitions from a nursing facility back into a home-like, community setting or prevent nursing facility admissions for those with imminent need.Community Transition Services / Nursing Facility Transition to a Home. Nonrecurring support, including setup expenses, to avoid further institutionalization and help people remain in the community as they return home from a licensed nursing facility.Personal Care and Homemaker Services. Supports for people needing assistance with daily activities, such as bathing, dressing, cooking, eating, and personal hygiene.Environmental Accessibility Adaptations (Home Modifications). Physical adaptations to a home when necessary to ensure health, welfare, and safety, or promote greater independence at home through improved functionality and mobility.Medically Supportive Food / Meals / Medically Tailored Meals. Meal services to help people achieve their nutritional goals at critical times (such as after a hospital or nursing facility stay) to regain and maintain their health.

Medi-Cal and Opportunities for Health Tech in Home-Based Medical Care

March 9, 2022

For people living with complex health needs, the usual model of going to the clinic or hospital for care does not always work well. Home-based medical care programs have been designed to fill this gap, providing better care to people living with multiple chronic conditions, functional limitations, and often social risk factors who have difficulty accessing care in traditional settings.This group, which includes seniors as well as younger people living with physical, mental, or developmental disabilities, is large. The state's Medicaid program, Medi-Cal, plays an outsized role in covering their care. Although Medi-Cal covers one in three Californians, it covers more than 50% of those living with a disability. In fact, there are 2.3 million seniors and people with disabilities covered by Medi-Cal, who represent roughly one in three Medi-Cal enrollees.Growing demand from consumers and their caregivers and a favorable policy environment create an opportunity for entrepreneurs and safety-net plans and providers to work together to improve access to these innovative models. This report explores opportunities for innovation, challenges, current policies, and implications for innovators. For this landscape report, the author interviewed a range of stakeholders to understand their perspectives and approaches to home-based medical care in an effort to showcase different models in California's health ecosystem.Readers should note this landscape overview is not intended to be exhaustive, nor is it an endorsement of the companies included. Finally, because solutions landscapes can evolve quickly, this brief may not fully reflect the current market.

In Their Own Words: Black Californians on Racism and Health Care

January 10, 2022

California, home to the most culturally diverse population in the country and the fifth largest Black population of any state, has a major opportunity to be a leader in health equity. But glaring racial and ethnic inequities pervade its health care system, from insufficient access to worse health outcomes to excess mortality. Black residents have the shortest life expectancy (75 years) at birth of any racial/ethnic group, six years shorter than the state average. Black Californians have the highest death rates from breast, cervical, colorectal, lung, and prostate cancers. Black birthing people experience the highest rates of prenatal and postpartum depression, preterm births, low birthweight births, and pregnancy-related mortality. And Black infants have the highest mortality rates.As part of its commitment to ending health inequities, CHCF is funding Listening to Black Californians, a three-phase qualitative and quantitative study to understand the health and health care experiences of Black Californians. This project will also explore the impact of racism on Black Californians' experiences in the health care system, as well as the detrimental effects of racism on their health.EVITARUS, a Black-owned public opinion research firm in Los Angeles, is conducting the research. An advisory group composed of academics, policymakers, providers, and community advocates is guiding the study. Listening to Black Californians will identify policy actions and practice changes at the clinical, administrative, and training levels that policymakers and health system leaders can take to eliminate discrimination in health care and to improve the health outcomes of Black Californians.This report describes the results of Phase I of the Listening to Black Californians study, which was conducted during the summer of 2021. The 100 people interviewed for this phase explained how they think about health and described their individual experiences with California's health care system. While each interview provided unique insights, taken together, the conversations revealed many similarities in how Black Californians view health and how they experience health care. Interviewees shared their perceptions about health, their experiences with racism and health care, and their perspectives on what constitutes quality health care. The study results are summarized on the following page.

Markets or Monopolies? Considerations for Addressing Health Care Consolidation in California

December 1, 2021

Over the past three decades, markets for health insurers and providers have gone through waves of consolidation. As of 2018, 95% of metropolitan areas in the United States had highly concentrated hospital markets. Markets for health insurers are also highly concentrated. Between 2006 and 2014, the combined market share of the top four insurers climbed from 74% to 83%. The coronavirus pandemic appears to be fueling another round of consolidation — especially acquisition of providers by private equity firms.Markets or Monopolies? Considerations for Addressing Health Care Consolidation in California compiles the latest research and data on California's health care systems and shows that consolidation is not limited to any one system, market segment, or geographic region in the state: Most markets across California are highly concentrated. Hospital markets, in particular, are now approaching "monopoly levels" in many California counties. In addition, there is mounting evidence that mergers of health care companies are resulting in increased prices for health care services, with little or no improvement in quality for consumers.The report highlights several actions policymakers could consider, given significant consolidation. For example, California's attorney general has the authority to block transactions that transfer a "material amount of the assets" only for nonprofit health facilities. To increase scrutiny of provider mergers in California, policymakers could require all health care providers — not just nonprofit ones — to provide written notice to, and obtain the written consent of, the attorney general.  Policymakers could also expand the authority of state regulatory agencies to include "affordability standards" when they review health insurance plans for sale in California.

The Medi-Cal Maze: Why Many Eligible Californians Don’t Enroll

September 13, 2021

Millions of Californians have gained health coverage through Medi-Cal, yet many eligible for the program remain uninsured. CHCF commissioned qualitative research to better understand what prevents eligible Californians from enrolling and to identify ways California can make Medi-Cal even more accessible to the population it is designed to serve. Through virtual focus groups and in-depth interviews with 91 Californians, the research team explored the knowledge, attitudes, and enrollment experiences of people who are likely eligible for Medi-Cal yet remain uninsured.

Breaking Down Silos: How to Share Data to Improve the Health of People Experiencing Homelessness

July 13, 2021

Housing is a key social determinant of health. Stable housing can help maintain health and reduce unnecessary emergency room use and hospital admissions, while research indicates that addressing the health-related needs of people experiencing or at risk of homelessness is crucial to accessing and sustaining housing.Because homelessness in California exists on an unprecedented scale — with more than 150,000 people experiencing homelessness on any given day — purposeful collaborations between the health care and homeless systems of care are critical. Such efforts have taken a variety of forms, including Whole Person Care pilot programs and collaborations aimed at improving care for those who frequently touch both the health care and homeless systems of care — while reducing the costs of the two systems so they can serve more people.This report focuses on ways in which California's housing and health care sectors are sharing data to better coordinate and support mutual clients within their communities. Data sharing has been pivotal in breaking down silos and improving coordination between the two systems to better address clients' needs.Yet despite dedicated and committed partnerships in place for cross-sector collaboration, data sharing efforts have not occurred without challenges. Communities have raised a common set of barriers they have faced, including privacy issues, relationships and collaboration, interoperability, and data quality.While there are no uniform ways to address the common challenges, communities have creatively employed strategies and taken advantage of opportunities to continue pushing forward data sharing efforts. These opportunities have proven most effective when tailored to each community's own needs, structures, relationships, and motivations.