Stung by Pointed Criticism, Department Aims for a Better Stakeholder Process

  ·  David Gorn, California Healthline   ·   Link to Article

Department of Health Care Services officials launched a public engagement initiative last week to revamp the way the department interacts with stakeholders and consumer representatives.

The announcement comes after mounting criticism from legislators and stakeholders dealing with the changing, growing department.

DHCS released a two-page overview of the initiative last week. The public is invited to participate by completing the stakeholder survey available online. The initiative also has a website.

Anastasia Dodson, associate director for policy at DHCS, said the department plans to gather stakeholder input on how to improve communication and interaction.

"We want to gather more information and to get specific ideas people have," Dodson said. "Now is a good time to take stock of what we've done this year, and get a little feedback."

Assembly Hearing Hits a Nerve

The department's efforts to reinvent itself were prodded forward in part by a public display of discord in the state Legislature last month.

Assembly member Richard Pan (D-Sacramento), a pediatrician and chair of the Assembly Committee on Health, prides himself on being respectful and reasonable with everyone. He generally speaks in a calm, deferential way.

But at an Assembly hearing in August, his exasperation with DHCS kept leaking out, like puffs of steam from a pressure cooker.

Pan said he'd been asking the same questions for two years and could never get the department to respond -- and during the hearing it was more of the same, with the "stonewalling" tactic of DHCS officials saying they needed to research the answers to his questions.

"The questions I asked at the hearing were not questions they hadn't heard," Pan said after the hearing. "They're not complex questions. How much do you pay for this type of blood test? In less than an hour, people [at DHCS] should be able to say, 'This is how much we pay' -- I mean, they set the rates. So why is it so difficult to come up with that information?"

If the head of the Assembly health committee encounters that kind of resistance over two years of polite and pointed queries, it must be infinitely more difficult for consumers and stakeholders with legitimate concerns to be heard, Pan said.

"I think that speaks to a cultural problem over there [at DHCS]," Pan said. "Now the question is, after all of this, I hope people think there needs to be a substantive change at the department."

DHCS officials heard him -- and that change may be coming.

High Volume of Work Partly to Blame, Critics Say

According to Ben Rubin, senior associate of health policy for Children Now, part of the problem with DHCS has been the volume of work it has had to do.

He ticked off DHCS' major programs one by one:

  • Duals demonstration project;
  • Medi-Cal expansion;
  • Changes in the adult day health program;
  • Healthy Families transition;
  • Low Income Health Program;
  • Denti-Cal changes;
  • Medi-Cal renewals; and
  • Computer problems and changes associated with each of those programs.

Rubin said it's a natural reaction for officials to balk at any new spoonfuls of work when their plate is so full already.

"There are some real issues they have to deal with, that they have to deal with posthaste," Rubin said. "Some are policy related, some are technological."

However, he said, circling the wagons and ignoring public input is not the way an agency should run.

"From a transparency point of view," Rubin said, "clearly there has been frustration over getting any information at all out of DHCS, ever. How many people are in Medi-Cal managed care now, what's going on with access to care, what's going on with enrollment? You just can't ever get any questions answered."

For an agency the size of DHCS -- which, according to Pan, oversees a $9 billion budget, the largest single agency in state government -- the amount of information released needs to be greater than other agencies, not less, Rubin said.

"I think it is unusual," Rubin said. "There is no reason they have to operate in that fashion. There are lots of positive things the department has done, like moving on the ABA issue [implementing access to applied behavior analysis autism treatment], for example."

Rubin pointed out that the California Department of Public Health released a huge amount of data for public consumption last month -- and that officials there were proud of their transparency effort.

"It would be a huge step forward if DHCS followed their lead," Rubin said.

A Fresh Start for DHCS, Stakeholders

"We have, over the last year really been paying attention to this," Dodson said. "Within the department, about a year ago, we started dialogues in many different areas."

The survey is the first step in gathering information from stakeholders about how to best use their input, how to make sure their voices are heard and understood, and that they're heard by the people in a position to incorporate their feedback into DHCS programs.

"Part of the survey is to tease out that certain improvements are needed," Dodson said. "We are doing that more and more, trying to increase transparency."

Stakeholders have privately raised concern that the stakeholder engagement initiative might really be a way for the department to consolidate all of the advisory committees that meet with DHCS officials -- a move they said that could actually reduce the amount of input DHCS receives.

That notion could not be farther from the truth, Dodson said. The only reason to spend so much time and energy on revamping the stakeholder process is to improve it for everyone, she said.

"We do have a number of stakeholder groups, we have been talking about making communication better with them over the last year or so," she said. "We have done some things like the calendar on our website. We do want to see how can we get more feedback, how we can improve the groups. That's part of the overall initiative that we've undertaken."

DHCS staff members deal with stakeholders from several camps. According to Anthony Cava, an information officer at DHCS, there are more than 60 different stakeholder meetings, committees and workgroups held at regular times throughout the year. That total includes "formal advisory groups such as the Stakeholder Advisory Committee, Medi-Cal Managed Care Advisory Group, Mental Health groups, Coordinated Care Initiative groups," Cava said in an email. That number does not include a number of informal or ad hoc stakeholder meetings, he said.

"There are pros and cons to having so many advisory groups," Dodson said. "Sometimes we get feedback from stakeholders not to add a new group. We do think it's possible that a separate group for this or that might be added into another group."

That's why the department is launching the initiative, Dodson said, to ask stakeholders what they think, to see what they think might work best.

"We want feedback on this, we don't have presupposed outcomes," Dodson said. "What's an efficient use of stakeholder time? We want to really make a process that's a good use of people's time, where the input is getting incorporated or at least responded to."

"We want that information to be absorbed, reviewed and considered," she said. "Often it's a feedback loop, an ongoing dialogue."

Now that so many programs have been implemented, including the dramatic shift of about 70% of Medi-Cal beneficiaries into managed care plans, it's a good time to take a step back and see how those implementations might be improved, Dodson said.

"We do hear what people are saying," she said. "Part of it, too, is there is just so much going on in policy. We try to triage the things that are the most important the most pressing, the most impact on people."

Department officials value the stakeholder community, she said, even if there have been times when time and resources have been too limited to pay close enough attention.

"This has been a wonderful year of opportunity, but it's very challenging," Dodson said. "There is a tremendous amount of alignment between the department and stakeholders, and there can be more."

"We don't want to do it in a bubble," Dodson said. "It doesn't make sense to do it in a bubble. Again, we're doing our best in a very challenging year. But it sounds like there is a need for more dialogue -- to get things all out in the open. To think about what the solutions are, and get down to specifics. And that's what we want to do."