A Qualitative Study to Improve Performance of Medi-Cal's Grievance & Appeals System Through a New Conceptual Framework

Abstract

In 2022, Medicaid expenses represented 18% of national health care spending costs totaling $805.7 billion, while health inequities cost approximately $146.8 billion. The Centers for Medicare & Medicaid Services (CMS) requires all Managed Care Organizations (MCOs) to administer a Grievance & Appeal (G&A) system if they provide medical coverage to any of the 88 million Medicaid beneficiaries living in the United States, giving Medicaid beneficiaries the legal right to report any problem using their Medicaid plan to their MCO who has a responsibility to investigate. This includes health inequities and disparities such as wrongfully denied hospitalizations, botched surgeries, discriminatory treatment, doctor refusing to treat Medi-Cal patients, and/or complaints against the MCO itself. Formally called Medi-Cal, California administers the largest state Medicaid program in the nation. In 2022, it incurred $109 billion in health care costs for its 15 million Medi-Cal enrollees, yet 70% of all MCOs were operating non-compliant with Federal and/or State G&A regulations according to evidence-based research. Member-reported problems go unsolved due to multiple deficiencies resulting untimely, ineffective, and incorrect investigations, if conducted at all. The number of G&A cases have increased by an astounding 480% since California enforced CMS’ Final Rule on July 1, 2017. This study explores the new Medi-Cal G&A Best Practice (M-GABp) Framework, a systems-thinking approach to improve the performance of Medi-Cal’s G&A system to foster a more equitable and accountable healthcare system. It establishes guiding principles for conducting high-quality investigations and resolving systemic issues equitably, while offering transparency to community stakeholders regarding G&A performance metrics and equitable solutions to inequitable problems. Drawing insights from 21 G&A Experts - including directors, physicians, investigators - who participated in three focus groups from 10 local MCOs, this deductive qualitative study examines their professional insights about the utility of the M-GABp Framework. Research findings showed G&A Experts agreed with M-GABp’s best practices and 85% agreed with transparency via MCPs’ website. It also revealed deficiencies responsible for today’s poor G&A performance. This paper provides a roadmap for implementation, leveraging Kotter’s 8-Step change management system to guide MCOs in adopting this transformative framework with continuous improvement post-implementation.