Covered CA Board Update: A Quality Debate on Quality…

The California Health Benefit Exchange Board met Thursday with an open session that began at 12pm and ended around 5pm.

There were a total of three action items that were up for consideration by the Board. The discussion over when and how Covered California could implement a “Quality Rating System” was perhaps the single action item that drew the most heated discussion among the Board and stakeholders alike.

The meeting was the first since the launch of open enrollment on Oct 1, 2013. As such, the bulk of the agenda centered mostly on the launch of open enrollment and the progress Covered California has made since open enrollment launched about three weeks ago. The meeting also included a service center update, an update on legislation, marketing and outreach and CalHEERS.

Launch Update

Before delving into the launch update, Executive Director Peter Lee highlighted some key findings from the Kaiser Family Foundation Baseline Survey entitled “California’s Uninsured on the Eve of ACA Open Enrollment” which underscore the need and value of the Affordable Care Act. This study showed that 1,951,063 individuals have had problems paying medical bills in the past 12 months.  21% of those surveyed said they spent less on food because of medical bills and 20% said they had to borrow money from family and friends.

Lee went on to present an update on the total number of unique web visits, applications, total call volume, calls referred to counties, average daily call volume, average wait time and average handle time. Between Oct 1, 2013 and Oct 19, 2013, there were a total of 2,232,091 unique web visits, a total of 128,818 applications received and over 156,000 calls received. Average daily call volumes ranged between 13,177 and 7,518, average wait time ranged between 11.7 minutes to 45 seconds and average handle time ranged between 17.4 minutes and 15.2 minutes.

Key Challenges Identified:

Peter Lee assessed California’s launch as “not perfect, but pretty darn good, and improving every day.” Lee laid out the specific challenges Covered California has experienced in the last few months, and how they were already fixed, or in the process of being improved:

* CalHEERS/IT – The physician look-up tool was not functioning, but is live today and consumers can search for physicians. Peter added that Covered California plans to add clinics, hospitals and other facilities to the list of searchable items.

* Search function to find help near you – This search function is not working well at this time. It works if you are searching for someone in the same zip code, but does not allow for a search outside of your zip code. Staff is currently working to resolve this issue.

* Spanish Site – The Spanish site is generally working, but has had some quirks.  For example, some links on the Spanish site refer pages to English sites. Staff is currently working to resolve this issue.

* On the ground assistance – Covered California has experienced challenges in adequately preparing on the ground assistance, including insurance agents, community groups, etc.  Covered California has ramped up training to address issues.

* Training materials – Covered California continues to make improvements to training material and is also developing supplemental material, including “Welcome to Answers” fact sheets.

* Collateral/Printed Material – Some fact sheets and other printed material contained inaccurate information. There were language and image mismatches. Material has been improved.

* Printed applications – Covered California is waiting for federal approval to get printed application in other languages beyond English out as quickly as possible. In the meantime, non English speaking people who call for assistance are being referred to customer service representatives who speak their language.

Peter closed this segment of the board meeting by reminding everyone that while these challenges may be used by some as fodder on how California is failing, these challenges actually speak to Covered California’s core value to get health care right and make it responsive to the people.

Enrollment Support for Covered California

Peter Lee’s Executive Director’s report also provided for an update on Covered California progress of registering and certifying county eligibility workers, enrollment counselors and plan based enrollers.  Close to 11,000 County Eligibility Workers have been assisting consumers, over 18,000 Certified Agents have been registered and over 2,000 are certified. Over 4,000 Certified Enrollment Counselors are registered with close to 400 certified.  Lastly, over 1700 Plan Based Enrollers are registered with over 400 certified.

Service Center Update

Staff announced that while they have not achieved their performance goal of answering 80% of their calls within 30 seconds, they are close.  Staff was pleased to announce that no calls have received a busy signal.

Of the calls received, 87% were from English speaking consumers, 9% Spanish, 3% Asian and 1% were from consumers who speak a variety of other languages.  Staff’s goal is to have a staff person that speaks the language of the consumer available at all times.  When they don’t have someone available non English speaking consumers are referred to health care interpreters.

Consumer Website Report/CalHEERS

Staff announced they received authority from CMS to connect on September 30th and open enrollment was launched on October 1st at 8am.  Since Oct 1, CalHEERS has been running 90% of the time.  System enhancements and performance changes continue to be made to improve the system.

One of the early challenges revolved around the creation of logins for internal users (county workers, agents, enrollment counselors). This issue has been resolved.

Another early challenge revolved around performance of the CalHEERS system.  Staff expressed that there was a focused effort in the first two weeks to reduce the average page load time to below 2 seconds.  This adjustment required system downtime during off hours to implement enhancements and additional monitoring.  There were also several errors that were not detected prior to launch.  Priority fixes were completed to help consumers can enroll.

Staff expressed that they continue to work on improving consumer experience.  They are currently working on the release of CalHEERS 2.5 for SHOP and the release of the 3.0 system which is the CalHEERS integration with Medi-Cal enrollment (in the SAWS system) to begin January 1, 2014. Weekly readiness meetings to inform this work began this week.

There was some concerns raised by advocates upon staff’s announcement that they plan to take the CalHEERS system down some evenings for ongoing improvements and for 2-3 days to facilitate the release of the 2.5 and 3.0 systems.  The argument made by some advocates was that this is a key time when non English speaking individuals access the CalHEERS system. 

Marketing and Outreach

Peter Lee began this segment of the agenda by sharing news of Sacramento Mayor Kevin Johnson recent annoucement that November 16 would be Covered Sacramento Day. Other mayors throughout the state have followed suit.

As of today, over 1,500 activities have been completed by outreach and enrollment grantees with over 650,000 consumers and small businesses reached. 50% of the education contacts resulted in leads (over 33,000).

Additionally, 120 organizations have signed an MOU to partner with Covered California in the Community Outreach Network.  An additional 137 organizations are in the process of becoming partner organizations.

Another key update was that of the progress towards streamlining the enrollment entity application process which was based on feedback from consumers.  Additionally, staff clarified that agents will receive payments for successful Medi-Cal enrollment. The payment structure will follow Enrollment Assistance Program rules.  If the application is a “mixed program family” no $58 payment will be issued.  Lastly, agents do not need to be Enrollment Counselors to receive payment.

Additionally, staff is developing “Welcome to Answers” fact sheets which are a series of education tools.  The key topics that will be covered to date are immigration, youth and students and enrollment for individuals with existing conditions.  Staff clarified that this list of topics is a working draft and encouraged stakeholder feedback.  Recommendations for topics can be emailed to

Also during the Marketing and Outreach segment of the meeting was a presentation of the NORC baseline survey of approximately 2700 uninsured and privately insured Californians.  The purpose of this report is to inform the development of the Covered California marketing/outreach campaign. This report revealed that the top three key shopping decision making factors considered by consumers (beyond price) are whether pre-existing conditions are covered, the quality of plans and the ease of plan comparison.

Action Items 

Federal Rules Update: The first action item entitled “Federal Rules Update” required a vote of the Board to authorize staff to provide CMS comments on the Individual Shared Responsibility Payment Exemption Application by November 15, 2013 (before the next Board meeting). The Board approved this action item and urged staff to work on comments that communicate the need for the most consumer friendly process for exemptions. There was also a discussion of the key federal issues being considered/explored by staff during this segment of the agenda.  Some key issues being explored include, restructuring pediatric dental benefits to allow embedded plans without offering “9.5” plans, eliminating the “family glitch”, allowing provisional enrollment in catastrophic plan pending receipt of penalty exemption and allowing states to determine whether insurers can offer supplemental coverage (supplemental vision coverage, for example).

Federal Establishment Support and Blueprint Application: This action item essentially consisted of a recommendation by staff to request additional financial support from the federal government.  The board approved this action item.

Quality Rating System:

“Quality Rating System” was perhaps the single action item that resulted in the most heated discussion among board members and stakeholder participants alike. 

Despite the Board’s assurance during last month’s board meeting that QRS information would be made available as soon as possible with a target date of January 1, 2014, staff’s recommendation today was to delay providing QRS information until open enrollment in 2015, for plans in 2016.

Staff went on to explain how the federal exchange does not provide quality ratings just as many states. But several states do provide for quality reporting include, Oregon, Maryland, Colorado, Connecticut, and Massachusettes. New York and New Mexico are still in process of deciding.

At the onset of this discussion, Peter Lee expressed that he believed it was better to wait until there was solid information on all plans that could be presented to consumers.  He expressed concern about those plans who have limited historical data and the potential for these plans to be viewed negatively by consumers for this reason.

Secretary Diana Dooley, seemingly inclined to supporting the staff’s recommendation, expressed the need to “do this right” so that good and fair information can be presented to everyone. Dooley also raised the issue of setting up different experiences for consumers if the Board decided to provide QRS information in January 2014 – some consumers (who enrolled prior to January 2014) will have made decision without QRS information and some will have access to it.

Susan Kennedy was very vocal in her position that in terms of fairness, the board should err on the side of consumers. Susan expressed, to withhold QRS information from consumers takes away a very important data point that consumers have a right to have access to. She urged the board to not withhold QRS information from consumers.

Dr. Bob Ross expressed that he was most compelled by comments from Susan Kennedy and referred to a letter received from consumer advocates including Health Access, Consumers Union, CPEHN among other organizations before asking if the suggestion by advocates to utilize Consumer Assessment of Healthcare Providers and Systems (CAHPS) data had been considered. There was considerable debate that continued for another 30-45 minutes on this topic from this point on. Board members Paul and Kim also weighed in expressing their concerns about delaying consumer access to QRS data.

Belshe reminded the board that making QRS data available to consumers was consistent with Covered California’s values around transparency, consumer empowerment and driving towards a competitive marketplace.

The overwhelming feedback from stakeholders and advocates was that QRS data should not be delayed and should be accessible to consumers as soon as possible.  Consumers Union argued that providing QRS data will create a competitive incentive for plans to improve on quality of care.  Young Invincibles argued that waiting two years to provide consumers with QRS is “like, forever” for young adults.  Before siting consumer experience on sites like Amazon, the Young Invicibles reminded the board that it is not at all a foreign idea that people will have to consider plans that don’t all have ratings.  This group also reminded the board that young adults and others are depending on Covered California as the trusted source for quality information. CalPIRG , another group who spoke to the importance of quality ratings to young adults shared “our generation – we don’t buy a sandwich without looking at ratings”.

The general sentiment and urge made by stakeholders was that more data was better than none and while not perfect, the data that is available should be accessible to consumers for the next year until a more robust system can be developed.

In conclusion, the board did not approve staff’s recommendation to delay QRS data reporting and instead asked staff to come back with a plan to CAHPS data available to consumers on the 10 plans where this data is available and make available whatever data exists on the remaining plans.