Covered CA Unveils Next Stage of Delivery System Reform: Highlights from January 21, 2016 Board Meeting

Thursday’s Covered CA Board meeting featured an overview of certification parameters for Qualified Health Plans (QHPs) to be offered in 2017, proposed changes in benefit design, and new data-driven initiatives to improve quality and equity over time.

As Governor Brown said proudly in his State of the State address earlier that day, California has “wholeheartedly embraced the Affordable Care Act… enrolling 13.5 million Californians in Medi-Cal and another 1.5 million in Covered California.” As an active purchaser exchange focused on standardized benefits, Covered CA has driven much of the state’s progress to date on health reform. “In many respects Covered CA has “dared to do what others dream of,” said Covered CA Board Chair Diana Dooley, quoting Gov. Brown.

Consumer advocates have worked with Covered California to build on that success to tackle the “quadruple aim” (better health outcomes for individuals, healthier populations, lower costs, and improved health equity). Much of that input is reflected in the proposals presented in Thursday’s meeting.

Recommended Certification Standards for 2017 QHPs

To go further on its mission to improve health care quality, lower costs, and reduce health disparities, says Director Peter Lee, Covered CA must leverage its active purchasing authority to shape the delivery system itself. As proposed, the 2017 certification standards encourage the plans to use payment and other incentives to move providers toward more integrated approaches to care, whether through accountable care arrangements, use of telehealth, or whatever makes sense in the given community—whatever it takes to ensure access to a patient-centered medical home. Payment methodologies should include incentives to provide care at the right time and place and to minimize harmful or wasteful care, utilizing proven tools like Choosing Wisely to educate patients on how to make more informed decisions about their care.

To offer products in 2017, QHPs will need a coherent strategy for continuous quality improvement, in alignment with new federal requirements, (QIS) that focus as well on the unique economic, demographic, and regional variations that exist within the enrollee population. Data collection is key to this new direction—“you cannot can’t change what you can’t measure”—so 2017 will have plans establishing benchmarks around all of the data points so they can track progress on the plan’s QIS. Earlier discussions entertained Value-based Insurance Benefit Designs (VBID), but this focus has been smartly delayed until sufficient data is available on utilization.

Benefit designs (more details below) can be adjusted from year to the next, as needed, to achieve QIS aims, but they should focus on prevention and access to primary care and cost sharing to complement access to care. On this point caution is in order, say several consumer advocates, lest people living with chronic conditions face discrimination by virtue of their need to use more specialty care. For these patients the plans must provide incentives to efficiently coordinate care.

Benefit Design 2.0

The proposed 2017 benefit designs build on Covered California’s strong foundation of standardizing benefit designs to prioritize primary care while staying sensitive to those with chronic conditions; placing limits on cost sharing; and providing transparency for consumers so they can make informed choices. Any adjustments to these levers are necessarily constrained by the overarching requirement to stay within or close to the actuarial value (AV, which represents the percentage of health care costs covered by the insurer) limits by metal tier.  We are left, therefore, with fairly modest adjustments, including:

  • Promote access to care by reducing copays for primary and mental health care and rehab.
  • Promote access to urgent care when needed—for example, workers who cannot visit the doctor during the daytime need affordable copays for urgent care.
  • Improve consumers’ understanding of benefits and cost sharing obligations.
  • Meet new regulatory requirements, as per Health Access-sponsored AB 339, by applying the drug cap after the deductible, and so on.

To meet the AV test, benefit designs will have increased cost sharing in silver/bronze deductibles; a higher MOOP (maximum out-of-pocket) limit in gold and silver plans; higher copays for x-rays and diagnostics; and increased ER facility copays. The only VBID-like change, which we welcome, is the new $0 copay for diabetes self management.


Consumers come out just ahead in these proposed changes and in another requirement on the QHPs to apply best efforts to enroll all subsidy-eligible populations in subsidized products.

See Health Access and key partners’ letter weighing in on these changes—and clarifying rationale for going further. As an active participant in Plan Management Advisory Committee where these proposals were developed, Health Access remains grateful for the opportunity to weigh in (almost) every step of the way.

Covered CA Quality and Delivery System Reform

Efforts to raise the bar on the Triple Aim (or really quadruple aim—including equity) through delivery system reforms are off to a promising start, thanks to the efforts of Covered CA Chief Medical Officer Dr. Lance Lang and the Plan Management and Quality Committee.  Starting with the 2017 and the QHP certification process, QHPs, providers, and patients will have incentives and tools like shared decision making to deliver and seek health care in the right time and place. Plans and providers will track, trend, and reduce health disparities based on race/ethnicity, geography, gender, gender identity and sexual orientation, and other demographic factors.  Plans will increase self-reported identity data to 85% by 2019—and proxy measures based on a combination of zip codes and surnames will be used to make up that difference. Disparities reduction strategies will focus at first on diabetes, hypertension, asthma, and depression—conditions which have significant disparities but that are also amenable to change.

By aligning these quality initiatives and QIS strategies to improve outcomes, prevent hospital readmissions, improve patient safety, and promote population health and wellness with large purchasers in the state like Medi-Cal and CalPERS, and applying certain requirements to the QHP’s entire book of business, Covered CA’s next stage of delivery system reform can have statewide and market-wide impact.

It will be up to the QHPs to build provider networks that are aligned with these admittedly ambitious goals.  Any variations in quality of care will need to be addressed either by dropping certain providers or explaining why they are being retained. The point is for each QHP to have their own coherent plan for meeting triple or quadruple aim objectives, working from benchmarks initially and from there collecting all of the data needed to track improvements over time. NCQA (or URAC or AAAHC) accreditation will be required of all QHPs—that will open up access to robust tools and learning communities to support triple aim goals.

Population health incentives for the QHPs start out fairly modest and conventional by comparison to the above. Plans will identify high-risk enrollees and promote utilization of preventive care, tobacco cessation, and obesity management. Patients, for their part, will have transparency tools to choose quality providers and share in decision making about their care. This last feature builds on research showing that the more consumers know about their options, especially at the end of life, the less likely they are to choose medically unnecessary and expensive procedures.

If we like where all of this is headed, or if we see any tweaking, we need to act fast. Comments are due February 11.

Other Updates

  • Lee reported that open enrollment 2016 has gotten 290,137 Californians newly enrolled by January 18. The deadline to enroll in January 31—and this year there will be no extension. New dental coverage has 142,552 already enrolled.
  • Tribal glitch: Covered CA is planning to fix a glitch in eligibility facing Indian families with mixed tribal status. As noted by the California Rural Indian Health Board, eligibility is messy for Indians living in mixed tribal status households, where some members have tribal affiliation and others do not. Eligibility policy and processes need to be updated to handle these situations.
  • Section 1332 State Innovation Waivers. Next week will be the official start of the state’s Section 1332 State Innovation waiver process, starting with a public forum on January 26 3:00-4:00 PM (register here) dedicated to guiding proposal development. Section 1332 of the ACA allows a state to pursue a different path to achieving the ACA’s goals with respect to access, affordability and patient protections. Based on Federal guidance for Section 1332 waivers, released last month, California’s options to use Section 1332 to cover the remaining uninsured are limited by the constraints of budget neutrality and other factors. Still, several consumer advocates like Betzabel Estudillo of California Immigrant Policy Center, made the case to leverage the Sec. 1332 opportunity and be the first state to “open the exchange to all.” Whether undocumented Californians can get subsidies or not, having a single point of entry for the entire family, said a representative of the Greenlining Institute, will help boost enrollment in hard to reach immigrant families and improve the risk mix, indirectly lowering costs. To meet the January 2017 deadline when Section 1332 waivers can first go into effect, enabling legislation would need to be passed in this session, noted Beth Capell for Health Access CA.

As for next steps, take a look at Covered CA’s revised 2016 calendar and prepare for next week’s forum on the Section 1332 waiver opportunity (register here).