State finds Contra Costa Co. ECM Medi-Cal program failed to ensure medical care

In a newly released audit report, the California Department of Health Care Services (DHCS) found Contra Costa Health Plan (CCHP) failed to ensure proper medical care for its sickest, most medically complicated, and expensive patients.

It also found the Plan failed to handle medical grievances properly, did not ensure an independent compliance officer, and failed to properly report all suspected fraud cases to the state.

The State says it expanded the scope of its audit because of publicly reported concerns about CCHP’s Enhanced Care Management (ECM) program first exposed by NBC Bay Area’s Investigative Unit last May.

Public health nurse manager Irene Graham said the county’s ECM program ignored the medical needs of its members. Often, medical appointments were handled by someone with no medical training, she said, putting patients at risk. For instance, they were handled by a social worker or a housing specialist instead of a nurse or a doctor.

“I still feel like I have to come forward, although it's pretty hard, because I met some of the patients that this was affecting and some of them are no longer with us,” she told NBC Bay Area in an earlier interview.

In an email to the Investigative Unit, DHCS said it found “no evidence that [[Contra Costa Health Plan’s deficiencies]] directly caused patient harm or death.” However, according to its audit report, that’s based on the state’s assessment of a sample size of 22 patients, out of thousands.

NBC Bay Area confirmed with the state, Contra Costa Health took in $2.5 billion in Medi-Cal revenue in 2022 and 2023 combined. Of that, it spent $56 million on Enhanced Care Management services.

CCHP deficiencies involve clinical care, grievances, compliance and fraud reporting

In its report, DHCS confirmed several serious deficiencies that it describes as “significant areas of improvement.” Those findings include:

• Contra Costa Health Plan did not ensure clinical care for ECM members
• The Plan did not properly handle medical grievances
• CCHP failed to hire an independent compliance officer
• And the Plan failed to properly report all suspected fraud to the state

As described in the audit report, the Contra Costa County ECM patients whose medical needs were not properly address included a member with “a history of ischemic cardiomyopathy, high blood pressure, heart failure, peptic ulcer disease, and Stage 3 chronic kidney disease. However, documentation did not show that the ECM provider made an assessment to identify and address gaps in care or health care concerns related to the member’s health history.”

Another patient whose medical needs were not properly addressed by CCHP, according to the state, included a person with “abnormal renal function, anxiety, drug use, history of panic attacks, auditory hallucinations, schizophrenia spectrum disorder with psychotic disorder, depression, chronic low back pain, tension headaches, arm paresthesia (tingling, numbness, prickling, or pins and needles), and leukemia.”

“I’m glad the state conducted a thorough investigation. I hope the findings from this audit lead to adequate training, staffing levels and support for Frontline health workers so that they are able to provide appropriate care to vulnerable populations and complex patients in Contra Costa County,” Graham told NBC Bay Area in response to these audit findings.

Contra Costa Health leadership overhaul

Currently, Contra Costa Health Services (CCHS) is undergoing major leadership changes.

Anna Roth, CEO of CCHS, which oversees the health plan, recently left the agency. According to this post by CCHS, Roth started a new role at a similar system in Tahoe.

Last October, the agency’s CFO Patrick Godley stepped down, according to a staff email from Roth.

And Contra Costa Health Plans’ CEO Sharron Mackey is retiring at the end of the month.

The Investigative Unit reached out to the executives and Contra Costa Health about the state’s findings and CCH’s leadership changes. Roth, Godley and Mackey have not responded. An agency spokesperson sent a written statement saying, “We recognize the concerns identified in the audit and take them very seriously. We are proud of the high caliber executive leadership of Contra Costa Health. It is not at all unusual for other counties or systems to hire from our ranks or to see our senior leaders retire from public service. To imply otherwise would be inaccurate reporting.”

During at staff town hall this past Monday, interim CCH CEO Ori Tzvieli, MD, told employees, “I know the health plan has a lot going on. There's always audits or corrective action plans. It's just part of the way of doing business here. There's also more scrutiny of that…I think the constant that we will have throughout that process is to keep the focus on the patients, to try to serve them as best we can, to break down the silos for them, make things easier for them to access care and to get their needs met.”

Next steps and State DOJ criminal investigation

Contra Costa Health Plan has 30 days to respond to DHCS with how it plans to address the deficiencies.

The concerns raised by Graham and the Investigative Unit’s reporting on CCHP have prompted a criminal investigation by the State Justice Department’s Division of Medi-Cal Fraud and Elder Abuse, according to sources with knowledge of the investigation.

Part 1:  Whistleblower: Contra Costa Health is cutting dangerous corners, harming Medi-Cal patients

Part 2: Nurse whistleblower helps lead to Contra Costa Health criminal investigation by DOJ

Part 3: Contra Costa Health CEO is leaving months into DOJ criminal investigation

Part 4: State finds Contra Costa Co. ECM Medi-Cal program failed to ensure medical care

Candice Nguyen is the investigative reporter on this story. If you have a comment on this report or if you have another investigative tip, email her at candice.nguyen@nbcuni.com.