Covered California Holding Health Plans Accountable for Quality and Delivery System Reform
CHAPTER 1
COVERED CALIFORNIA 5
1. Benefit design: Helping consumers make informed decisions by standardizing benefit designs,
so they are easier to understand and compare, and incentivize access to the right care at the
right time. Benefit design may include incentives to encourage patients to use particular
providers or particular sites of care or formulary and other designs to encourage providers to
select particular interventions as appropriate.
2. Measurement for improvement, choice and accountability: Providing meaningful and
actionable performance feedback to providers, insurers and the public to improve care and
compare treatment results, cost and patient experiences for consumers.
3. Payment: Rewarding and incentivizing delivery of high-quality, patient-centered care that
promotes better health, quality improvement and value while also fostering innovation,
improving efficiency and adopting evidence-based practices.
4. Patient-centered social needs: Identifying, and, as needed, addressing patient-centered
support for non-medical services, recognizing that many people may face barriers that prevent
them from staying healthy and receiving the right care at the right time, such as food insecurity,
housing insecurity and lack of transportation to their doctor.
5. Patient and consumer engagement: Increasing support for and the level of participation by
patients and consumers in managing their health and making their personal health care
decisions.
6. Data sharing: Making patient data available and accessible to support clinical care and
coordination, decrease health care costs, reduce paperwork, improve outcomes and give
patients more control over their health care.
7. Data analytics: Inspecting, transforming and modeling data to discover timely and reliable
information that will aid in a patient or provider’s decision-making processes.
8. Administrative simplification and provider burden reduction: Implementing system
changes to maximize the time providers spend with patients and minimize unnecessary
administrative burden.
9. Certification, accreditation and regulation: Employing existing regulatory and accreditation
processes and work with other agencies and departments to ensure approaches meet safety
and quality standards. For example, California’s Departments of Insurance and Managed Health
Care enforce the regulatory standards that Covered California relies on for network adequacy.
The National Committee for Quality Assurance (NCQA), among others, conducts health plan
accreditation.
10. Quality improvement and technical assistance: Promoting initiatives that will lead to better
patient outcomes and better care delivery approaches, strengthening the evidence base to
inform better decision-making and fostering learning environments that offer training, resources,
tools and guidance to help organizations achieve quality improvement goals.
Beyond the drivers of more effective care and healthier populations that relate to what an individual
insurer can do or be held accountable for, Covered California recognizes and seeks to better
understand the impact of broader social and structural issues on health status, care and care delivery.
Community health drivers include:
• Workforce: Investing in people to prepare the next generation of health care professionals and
support lifelong learning for providers.
• Community-wide social determinants: Addressing structural social and economic influences
that impact individual and group differences in health.
• Population and public health: Increasing the health of a community through broad
interventions that address public health, homelessness or food insecurity.