Covered California Holding Health Plans Accountable for Quality

Cover Image

This report provides data and analysis on Covered California’s efforts to improve the performance of

California’s health care system and to ensure that its members receive affordable, high-quality care.

The people featured on the cover are individuals who have benefited from these efforts. Their stories —

and those of others told here: https://www.coveredca.com/real-stories/ — go beyond the data to provide

personal perspectives on what Covered California has achieved over the past five years.

This document is in the public domain and may be copied or reproduced without permission.

Suggested citation: Covered California. (2019). Covered California Holding Health Plans Accountable

for Quality and Delivery System Reform.

Foreword

The Affordable Care Act opened the door to quality care for millions of Americans who had previously

been shut out of our health care system. A companion to this report, “Covered California’s First Five

Years: Improving Access, Affordability and Accountability”, provides an overview of how California —

the state government, Covered California, and other stakeholders — are working together to use the

tools provided by the Affordable Care Act to lower costs for consumers and provide meaningful choice

and coverage that truly meets consumers’ needs. The state is now building on and going beyond the

Affordable Care Act on the path toward universal coverage.

This report details how for more than five years, Covered California has held itself accountable as a

public entity charged with assuring consumers get the right care at the right time, while we hold the 11

health insurance companies we have chosen to contract with accountable for making sure that

consumers receive high-quality care and that both insurers and providers are implementing the delivery

system reforms needed to improve care for all Californians.

For Covered California, accountability means making sure health plans are meeting consumers’ needs

today and seeing that they are taking concerted and deliberate action to improve how health care is

paid for, organized and delivered in California. The goal of this accountability is to have a health care

system that truly addresses the triple aim of improving health, delivering better-quality care and

lowering costs.

This report focuses on how contracted health insurers are held accountable for assuring quality care

and for promoting delivery system reform. Chapter 1 describes the framework that now guides this

work. Chapters 2 through 6 describe how Covered California holds insurers accountable for assuring

quality care, including not only the specific measures used to track performance, but also the progress

that has been made overall and by individual insurers on these measures. Chapters 8 through 11 then

summarize the approaches to holding each health insurer accountable for advancing health care

delivery reform.

We share this report not because we believe our work is done, but rather because it is just beginning.

Improving health care quality and lowering underlying health costs is long-term pursuit. That pursuit is

central to Covered California’s mission, and this report identifies progress made and areas of needed

attention as we move forward.

Peter V. Lee

Executive Director

 
 
Covered California Holding Health Plans Accountable for Quality  
and Delivery System Reform 
 
Table of Contents 
Chapter 1: Covered California’s Framework for Assuring Quality Care and Promoting  
Delivery System Reform ................................................................................................................. 1 
ASSURING QUALITY CARE ......................................................................................................... 6 
Chapter 2: Individualized, Equitable Care — Best Possible Care for All ....................................... 6 
Chapter 3: Health Promotion and Prevention .............................................................................. 25 
Chapter 4: Mental Health and Substance Use Disorder Treatment ............................................ 34 
Chapter 5: Acute, Chronic and Other Conditions ......................................................................... 43 
Chapter 6: Complex Care ............................................................................................................. 52 
EFFECTIVE CARE DELIVERY .................................................................................................... 59 
Chapter 7: Promotion of Effective Primary Care .......................................................................... 59 
Chapter 8: Promotion of Integrated Delivery Systems and Accountable Care Organizations .... 66 
Chapter 9: Networks Based on Value .......................................................................................... 73 
Chapter 10: Appropriate Interventions ......................................................................................... 79 
Chapter 11: Sites and Expanded Approaches to Care Delivery .................................................. 89 
Chapter 12: Summary and Implications for the Future .............................................................. 102 
APPENDICES ............................................................................................................................. 103 
Appendix 1: Limitations and Major Caveats about Health Disparities Data .............................. 104 
Appendix 2: Additional Health Plan Measures Reported to Quality Rating System ................. 105 
Appendix 3: 2019 Marketplace Quality Rating System Measure Set ........................................ 139 
Appendix 4: Additional Publicly Reported Hospital Quality and Safety Data ............................ 141 
 
   

Covered California Holding Health Plans Accountable for Quality and Delivery System Reform

CHAPTER 1

COVERED CALIFORNIA 1

Chapter 1: Covered California’s Framework for Assuring Quality Care and

Promoting Delivery System Reform

Covered California’s current contract requirements with qualified health plan (QHP) issuers (also

referred to as “health insurance companies”, “insurers” or “health plans” in this report)

are laid out in

Attachment 7: Quality, Network Management, Delivery System Standards and Improvement Strategy of

the QHP issuer contract. The contract is designed to hold insurers accountable for ensuring that people

get the right care at the right time and that care is individualized for their specific needs, while seeking

to improve how care is delivered and promoting care that is increasingly high-quality, equitable and

cost-effective.

The current Attachment 7 is composed of nine articles; each article has a distinct focus, including

ensuring networks are based on value and reducing health disparities. In addition, multiple articles have

elements related to quality improvement, network management and delivery system reform

requirements. Attachment 7 includes a number of initiatives that require concerted, multi-year efforts of

health insurance companies across the California delivery system. Insurers report annually and as part

of quarterly review meetings with Covered California on their Attachment 7 performance. Covered

California staff review and assess the information submitted for both contract compliance purposes and

to assess the success of the Attachment 7 initiatives in achieving the priority outcomes of quality care

and effectively delivering that care.

Covered California is working to update its health insurance company contract terms for the 2022-2024

plan years and is seeking to refresh its requirements for the future that continue to address the “Triple

Aim” of lowering costs, improving quality and improving health outcomes, with a focus on reducing

health disparities. This update will include a revised framework for Attachment 7 that is organized and

composed of two main strategies: Assuring Quality Care and Effective Care Delivery. This report

describes the progress Covered California contracted health insurance companies have made between

2014 and 2019

in implementing the requirements within the current Attachment 7 organized by the

revised framework described in Figure 1. Covered California’s Framework for Holding Plans

Accountable for Quality Care and Delivery Reform Framework.

Assuring Quality Care

Covered California is committed to ensuring that care is individualized and equitable for not only those

people currently needing or receiving treatment, but for those who are working to stay healthy. The

The term “health insurance companies” or “insurers” refers to the organizations providing health coverage and “health plan” refers to the

health coverage products they provide, such as an HMO plan vs. a PPO plan.

Beginning with the inaugural 2014 plan year and updated in 2017, Covered California set forth standards and strategies for quality

improvement and delivery system reform in its QHP issuer contract, specifically in the section of the contract titled “Attachment 7: Quality,

Network Management, Delivery System Standards and Improvement Strategy”. See more: https://hbex.coveredca.com/insurance-

companies/PDFs/Attachment-7_2020_Clean_Final-Model.pdf.

This report does not include data for plan year or measurement year 2014; rather it describes the progress Covered California contracted

health insurance companies have made since 2014 on Attachment 7 requirements with the first year of data representing plan year or

measurement year 2015 for most requirements.

Covered California Holding Health Plans Accountable for Quality and Delivery System Reform

CHAPTER 1

COVERED CALIFORNIA 2

Figure 1. Covered California’s Framework for Holding Plans Accountable for Quality Care and Delivery

Reform Framework

concept of individualized, equitable care

means regardless of one’s circumstances, race, gender,

where one lives or other socioeconomic factors — and for some decisions where more than one

evidence-based treatment is available, based on one’s values and preferences — every individual

deserves the best possible care that is personalized for them and delivered in the right setting at the

right time, does not cause harm and is the most cost-effective possible. These goals are consistent with

the six domains of health care quality identified by the Institute of Medicine:

safe, timely, effective,

efficient, equitable and patient-centered (STEEEP). In addition to assuring quality care for those

insured through the marketplace, Covered California will continue its efforts to identify and reduce racial

and ethnic health disparities for the entire population.

What follows are the organizing domains for assuring quality care beyond the cross-cutting concept that

all care should be individualized and equitable:

• Health promotion and prevention: Everyone is encouraged to receive preventive care

services and health screenings and use support tools that promote a healthy lifestyle. This

includes everything from regular checkups to smoking cessation and dietary programs.

• Mental health and substance use disorder treatment: Identifying, engaging and supporting

through treatment people with mental health conditions and substance use disorders and

ensuring that they are provided with timely and effective care that is integrated with their other

health care needs.

In the current contract, Covered California focused health equity efforts on reduction of health disparities. While inclusive of health

disparities reduction, the revised framework of Individualized, Equitable Care is intended to capture the broad goal of care that is

individualized to address an individual’s health needs.

Committee on Quality Health Care in America, Institute of Medicine. (2001). Crossing the quality chasm: a new health system for the 21st

century. Washington, D.C.: National Academy Press.

Covered California Holding Health Plans Accountable for Quality and Delivery System Reform

CHAPTER 1

COVERED CALIFORNIA 3

• Acute, chronic and other conditions: Actively managing care for people with acute

conditions, which are defined as illnesses or diseases that are short term and last typically a few

days to weeks, such as an infection or an injury; chronic conditions, which typically develop

slowly over time and last months to years, such as diabetes, most cancers, cardiovascular

disease, and infectious diseases like Human Immunodeficiency Virus (HIV); and other

conditions that are temporary, such as pregnancy or gestational diabetes.

• Complex care: Effectively managing very complex conditions for individuals that require a

multitude of specialty, high-cost treatments — such as cancer or transplants — or require end of

life care. These are individuals who need to be managed effectively or seen in very specialized

settings by providers who know how to manage their condition well and can provide coordinated

interventions.

The concept of individualized, equitable care as it applies to the specific care domains is illustrated in

Figure 2. Covered California’s Domains for Assuring Contracted Health Plans Deliver Quality Care,

recognizing that some members with mental health, substance use disorders or multiple chronic

conditions need care in multiple domains.

Figure 2. Covered California’s Domains for Assuring Contracted Health Plans Deliver Quality Care

Effective Care Delivery

In addition to addressing various populations and the care they receive, Covered California also

focuses on effective care delivery strategies and its contractual requirements promote improving the

way care is delivered for our enrollees and all Californians, whether it is provided by a primary care

physician, hospital, clinic or other provider. What follows are the organizing strategies for effective care

delivery:

Covered California Holding Health Plans Accountable for Quality and Delivery System Reform

CHAPTER 1

COVERED CALIFORNIA 4

• Effective primary care: The foundation of providing appropriate and equitable care is built on

team-based, data-driven primary care that is well integrated, coordinated and continuous. While

many consumers benefit from an ongoing continuous relationship with a single physician, there

is strong evidence that primary care through well-integrated sites of care or delivery systems are

more effective.

• Promotion of integrated delivery systems and accountable care organizations: Effectively

caring for and managing a person’s health requires an integrated care system that can

coordinate across providers, sites and time for a variety of conditions while delivering good

outcomes and quality at an affordable cost.

• Networks based on value: All clinicians, providers, hospitals and sites of care are selected and

regularly assessed based on how those individuals or institutions provide care that is safe,

timely, effective, efficient, equitable, and patient-centered. Ideally, every network is composed of

integrated systems, effective primary care and designed considering the value it provides.

Regardless of the organizing strategies — whether focused on primary care, an integrated delivery

system or the overall network — Covered California aims to ensure the interventions that patients

receive are both appropriate and delivered through sites and services that meet their needs:

• Appropriate interventions: The use of clinical interventions, such as prescriptions,

procedures, diagnostic tests and devices that are rooted in the STEEEP domains and based on

strong evidence and shared decision-making.

• Sites and expanded approaches to care delivery: Covered California supports patients in

getting health interventions and treatments in the most appropriate setting. That means assuring

quality care is delivered not only in hospitals, whether on an in-patient or outpatient basis, but in

ambulatory settings such as a doctor’s office, urgent care facilities, retail facilities such as drop-

in clinics, at home, or through telehealth. Expanded approaches to care delivery also include

who provides care in addition to physicians, such as registered nurses, pharmacists, midwives

or other non-licensed providers like community health workers.

Key Drivers of Quality Care and Effective Delivery

Covered California recognizes that moving health reform forward in an impactful way within a delivery

system shared among many purchasers and health insurance companies will require aligning with

other purchasers and working with all relevant payers in a way that reduces the burden on providers.

When considering the key drivers of quality care and effective delivery, Covered California has looked

to the National Quality Strategy

and mirrored many of the same levers initially noted in 2011.

Many of these levers or drivers are specifically articulated as expectations of health insurers in

Attachment 7 as ways to assure individuals get the right care. Insurers are working to improve the

delivery system over time. However, some of the “community drivers” that are identified may be outside

of the scope of an individual insurer’s responsibility or Covered California’s contract. Nevertheless, it is

important to recognize these drivers are a part of the context within which health care is delivered and

the quality of health that consumers experience. Examples of community drivers are detailed after the

roster of drivers specific to health insurer’s work. Key drivers include:

Agency for Healthcare Research and Quality. (2011) 2011 Report to Congress: National Strategy for Quality Improvement in Health Care.

Retrieved from https://www.ahrq.gov/workingforquality/reports/2011-annual-report.html

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.

Covered California Holding Health Plans Accountable for Quality and Delivery System Reform

ASSURING QUALITY CARE • CHAPTER 2

COVERED CALIFORNIA 6

ASSURING QUALITY CARE

Chapter 2: Individualized, Equitable

Care — Best Possible Care for All

Covered California’s overarching goal is to

ensure that everyone receives the best possible

health care. This goal entails striving to ensure

that care is personalized, does not cause harm,

is delivered in the right setting at the right time,

and is as cost effective as possible. For

decisions where more than one evidence-based

treatment is available, the goal is to support

individuals in choosing treatment based on their

values and preferences. In the framework

proposed by the Institute of Medicine 20 years

ago, everyone should receive care that is safe,

timely, effective, efficient, equitable, and patient-

centered (often captured by the acronym

“STEEEP”).

Unfortunately, the quality of care

delivered in the United States varies

dramatically.

Of the elements related to the Institute of

Medicine’s framework, the domain that has too

often not been given central focus is the charge

to ensure that care is equitable. Addressing

health equity and disparities in health care has

been integral to Covered California’s mission.

Given that focus, after reviewing some important

overall indicators of how health plans are

generally meeting consumers’ needs, much of

this chapter specifically addresses Covered

California’s focus on the issue of equity. The

other domains of the STEEEP framework are

addressed throughout the report and are integral

to Covered California’s approach. The Quality

Rating System (QRS), which includes

performance measures based both on clinical

measures and on patients’ reported experience

of getting care, provides a global picture of how

Covered California’s health plans are doing at

providing the best possible care. In this chapter,

the Global and Summary Components of the

Committee on Quality Health Care in America, Institute of Medicine. (2001). Crossing the quality chasm: a new health system for the 21st

century. Washington, D.C.: National Academy Press.

• Covered California enrollees are generally

very satisfied with their experience with

their health plans and their health care,

with the vast majority enrolled in plans that

score above the 50

percentile for enrollee

satisfaction with their health care and plan.

• Global Quality Ratings have improved

since their launch in 2016, but a dip in 2019

has generated further scrutiny.

• Covered California has launched a long-

term initiative to reduce health disparities.

In response to contractual requirements, 93

percent of enrollees are in plans that were

at or above the 80 percent requirement for

enrollee self-identification of race/ethnicity.

• All 11 insurers are analyzing disparities in

care for patients with diabetes,

hypertension, asthma and depression for

all of their lines of business, not just

Covered California, and planning targeted

interventions.

• Gaps in quality by race/ethnicity were

found for all insurers — but were not

consistent (e.g., for some insurers African

Americans warranted targeted

interventions for diabetes, and Latinos in

others).

• Racial and ethnic disparities are generally

smaller than the differences in quality

across plans: enrollment in Sharp Health

Plan or Kaiser Permanente is a better

predictor of receiving good care than race

or ethnicity is.

• Nevertheless, all insurers have identified a

disparity where a targeted intervention can

improve help reduce disparities and

improve health.

Highlights

Covered California Holding Health Plans Accountable for Quality and Delivery System Reform

ASSURING QUALITY CARE • CHAPTER 2

COVERED CALIFORNIA 7

health plan quality ratings are presented, along with two measures that relate to enrollee satisfaction

with their health plan and their care.

Social, economic and geographic disparities in health and health care pose a particularly serious

challenge to the goal of ensuring the best possible care for all. Because social and environmental

factors are powerful determinants not only of the care individuals receive but also of their underlying

health, reducing disparities requires efforts within the health care delivery system and in the broader

community. Covered California recognizes that meaningful progress will require multi-pronged and

multi-year efforts.

Covered California is working to reduce disparities and promote health equity. To this end, Covered

California has hired a new health equity officer who plans, implements and integrates Covered

California’s health equity agenda with Covered California’s quality improvement and delivery system

reform efforts. The health equity officer leads the work of the new Population Care Unit within the Plan

Management Division, which is composed of staff positions dedicated to quality improvement, health

equity and social determinants of health.

Covered California is working with health plans to reduce health disparities and promote health equity

by: (1) identifying the race/ethnicity of all enrollees; (2) collecting data on diabetes, hypertension,

asthma and depression to measure how quality varies by race/ethnicity; (3) conducting population

health-improvement activities and interventions to narrow observed disparities in care; and (4)

promoting community health initiatives that foster better health, healthier environments, and promote

healthy behaviors. This chapter describes how Covered California has moved forward in each of these

areas.

This chapter on individualized, equitable care is organized as follows:

Section 1. Qualified Health Plan Experience

Section 2. Health Plan-Reported Measures for Health Disparities

Section 3. Implications for the Future

Section 1. Qualified Health Plan Experience

Health Plan Measures Reported to the Quality Rating System

This section presents performance data reported by health insurance companies for contract

requirements and includes assessments and observations by Covered California. One key mechanism

used by Covered California for health plan oversight and accountability is public reporting of global and

individual health plan quality-performance measures to the Centers for Medicare and Medicaid

Services’ Marketplace Quality Rating System (QRS). In the current contract requirements, health plans

are required to:

1. Annually collect and report to Covered California for each product type the measure numerator,

denominator and rates for its QRS data, including Healthcare Effectiveness Data and

Information Set (HEDIS) measures, Consumer Assessment of Healthcare Providers and

Systems (CAHPS) survey data and other performance data.

2. Submit HEDIS and CAHPS scores to include the measure numerator, denominator and rate for

the required measures set reported to NCQA Quality Compass and the Department of Health

Care Services (DHCS), for each product type for which it has data in California.

Covered California Holding Health Plans Accountable for Quality and Delivery System Reform

ASSURING QUALITY CARE • CHAPTER 2

COVERED CALIFORNIA 8

Global and Summary Component Health Plan Quality Ratings

The Marketplace QRS global quality ratings show how health plans compare on helping members get

the right medical care and on member-reported experiences of care and service. Covered California

displays each health plan’s QRS rating to enrollees through the plan shopping experience and on

coveredca.com.

Plans are rated on a scale of one to five stars. To assign the star rating, each health plan’s results are

compared to about 200 marketplace health plans nationwide. A five-star plan means that health plan

scored among the top plans nationwide; a one-star rating means the plan’s score was among the

lowest.

QRS is composed of a global quality ratings and summary component ratings for three major aspects

of health plan performance.

Each health plan’s product (HMO, PPO, EPO) receives a separate QRS

rating.

Global quality rating: The global quality rating is a roll-up of three summary components per the

following weighting:

Summary Components

Weights

Getting Right Care (HEDIS)

66%

Members’ Care Experience (CAHPS)

17%

Plan Services (HEDIS and CAHPS)

17%

A global quality rating is constructed for each health plan that has at least two of the three component

scores, and one of the scores must be for the “Getting the right care” component:

• Getting the right care: Each year, a sample of members from each health plan is selected, and

their records are checked to compare their medical care with national standards for care and

evidence-based treatments. More than 30 HEDIS measures are tracked using medical charts

and billing records sent by providers and hospitals. These quality measures include how well

the health plan and its providers care for enrollees, such as controlling high blood pressure,

lowering cholesterol and getting the right medications.

• Members’ care experience: Members’ experiences with their doctor and care are based on the

CAHPS survey that asks about members’ recent experiences when visiting the doctor and

getting medical care. About one of every five people who receive a survey in the mail or by

phone provides a response, with about 250 members from each plan completing surveys.

CAHPS surveys are currently only available in English or Spanish, but insurers are encouraged

to translate the surveys into other languages that reflect their patient population. Translation

guidelines are readily available from CMS.

• Plan services for members: A sample of plan members’ records is checked to see if patients

got unnecessary care — services that could be harmful and wasteful. The CAHPS member

survey is also used to report on members’ experiences in getting help and information from the

insurer’s customer service staff.

See the Appendix 2 for the complete list of measures used to determine each summary component rating of QRS.

Covered California Holding Health Plans Accountable for Quality and Delivery System Reform

ASSURING QUALITY CARE • CHAPTER 2

COVERED CALIFORNIA 9

The QRS ratings of Covered California health plans have generally improved over time, but there was a

downward trend in 2019.

For the 2019 reporting year, which represents the 2018 measurement year,

the overall trend is lower star ratings compared to 2018: for the global rating, only one plan has a 5-star

rating and one plan has a 4-star rating while most have 2 and 3-star ratings (see Table 1. Global

Quality Ratings by Reportable Products for Individual and CCSB Markets, 2016-2019).

Table 1. Global Quality Ratings by Reportable Products for

Individual and Covered California for Small Business (CCSB) Markets, 2016-2019

Overall Quality Ratings by Reportable Products for Individual and CCSB Markets

# Products with

No Global Rating

1 Star

★

2 Star

★★

3 Star

★★★

4 Star

★★★★

5 Star

★★★★★

2019 QRS

2018 QRS

2017 QRS

2016 QRS

*No global rating if a newer product and not eligible for reporting or insufficient sample sizes to report results for at least 2 of the 3 summary

component categories.

Source: Covered California Health Plan QRS Reporting

Table 2 lists the global rating and the three summary component ratings for each Covered California

health plan for 2019. Covered California health plans generally performed well on the Plan Services for

Members component rating, with all plans receiving a 3-star rating or above on this component.

The 2018 reporting year, which represented the 2017 measurement year, was impacted by a federal statistical methodology that appears

to have inflated star ratings for that year. Covered California is working with CMS to achieve a more stable methodology that will allow

better year-to-year comparisons of star ratings based on changes in performance. This affected only the star rating, not the underlying

measure scores reported below.

Covered California Holding Health Plans Accountable for Quality and Delivery System Reform

ASSURING QUALITY CARE • CHAPTER 2

COVERED CALIFORNIA 10

Table 2. Covered California Health Plan QRS Global and Summary Component Ratings, 2019

Health Plan

Product

Type

Global Rating

Getting the

Right Care

Members’ Care

Experiences

Plan Services

for Members

Anthem

EPO

★★

★★★

Blue Shield

PPO

★★★

★★

★★★

Blue Shield

HMO

★★★

★★

★★★

CCHP

HMO

★★★

★★

★★★★★

Health Net

HMO

★★

★★★

★

★★★

Health Net

EPO

One Quality

Rating Available

★★

Not

Reportable**

Not

Reportable**

Health Net

PPO

Quality Rating

in Future*

Quality Rating

in Future*

Quality Rating in

Future*

Quality Rating

in Future*

Kaiser

HMO

★★★★★

★★★★

★★★★★

LA Care

HMO

★★★

★★

★★★

Molina

HMO

★★

★★★

Oscar

EPO

★★

★★★

★★★★★

Sharp

HMO

★★★★

★★★

★★★★

Valley

HMO

★★★

★★★★

★

★★★

WHA

HMO

★★

★★★

★★★★

Blue Shield

HMO/CCSB

★★★

★★

★★★

Health Net

PPO/CCSB

Quality Rating

in Future*

Quality Rating

in Future*

Quality Rating in

Future*

Quality Rating

in Future*

*Quality ratings are reported for a health plan product after its first two years with Covered California.

**Not enough data to calculate a score according to the quality rating methodology.

Source: Covered California Health Plan QRS Reporting

Enrollee Satisfaction With Their Health Care and Health Plan

Assuring that care is patient-centered requires assessment of a range of elements, including the extent

to which patients receive the right care, at the right time, and in the most appropriate setting. As

discussed in Chapter 10: Appropriate Interventions, it also means that care provided is informed and

based on the patient’s preferences and their understanding of the implications of their choices. At a

high level, however, a starting point of making sure care is patient-centered is considering patient

voices in assessing health plans’ performance.

Among the health plan measures reported to the Marketplace Quality Rating System are Consumer

Assessment of Healthcare Providers and Systems (CAHPS) measures that reflect consumers’

perspectives and their reported experience with care received. These Marketplace Quality Rating

System (QRS) standard performance measures are a key mechanism used by Covered California for

health plan oversight and accountability. To more sharply focus health plan accountability efforts,

Covered California examined over 40 measures used by QRS and is proposing to prioritize a subset of

13 measures that were selected based on the following criteria: (1) health impact; (2) extent of health

plan variation; (3) performance improvement opportunity; (4) alignment with other California

accountability programs; and (5) balance across domains of care, such as prevention, chronic illness

care and behavioral health. Three of the 13 measures overlap with the measures currently collected by

race/ethnicity for health disparities reduction interventions as discussed in Section 2 of this chapter.

Covered California Holding Health Plans Accountable for Quality and Delivery System Reform

ASSURING QUALITY CARE • CHAPTER 2

COVERED CALIFORNIA 11

The following tables display the priority measures for individualized, equitable care in the QRS measure

set and include the Covered California weighted average, the highest- and lowest-performing plans,

plan-specific performance and national percentiles for all marketplace plans:

1. Rating of Health Plan (Table 3).

2. Rating of All Health Care (Table 4).

These two CAHPS questions the reflect consumers’ overall satisfaction with their health plan and the

care they received. As evident from each of these measures, there is generally high satisfaction among

Covered California enrollees with their health plans (with 95 percent of enrollees reporting satisfaction

that is above the 50

percentile nationally) and with their care (75 percent of enrollees reporting

satisfaction that is above the 50

percentile nationally). (See Figure 3. Covered California Enrollment in

Health Plans by Consumer Rating of Health Plan — 95 Percent of Enrollees in Plans Scoring Above

the 50

Percentile Nationally, and All Enrollees in Plans Above the 25

Percentile, 2019.)

Figure 3: Covered California Enrollment in Health Plans by Consumer Rating of Health Plan — 95 Percent

of Enrollees in Plans Scoring Above the 50

Percentile Nationally, and All Enrollees in Plans Above the

Percentile, 2019

88%

Enrollees in Plans at 90th

Percentile and Above

Enrollees in Plans at 50th to

90th Percentile

Enrollees in Plans at 25th to

50th Percentile

Covered California Holding Health Plans Accountable for Quality and Delivery System Reform

ASSURING QUALITY CARE • CHAPTER 2

COVERED CALIFORNIA 12

Rating of Health Plan

The Rating of Health Plan measure indicates enrollee experience related to the rating of health plan

QHP Enrollee Survey question.

Table 3: Covered California Enrollees Rating of Health Plan (CAHPS)

2016

2017

2018

2019

Benchmark

Percent of

Enrollees

Number of

Enrollees

Number

of Plans

Plans at 90th Percentile and

Above

78 +

79 +

75 +

93,322

Plans at 50th to 90th

Percentile

72 to 78

73 to 79

69 to 75

88%

1,187,877

Plans at 25th to 50th

Percentile

67 to 72

68 to 72

69 to 73

64 to 69

64,031

Plans Below 25th Percentile

Below 67

Below 68

Below 69

Below 64

Covered California High/Average/Low Performers

Covered CA Highest

Performer

Covered CA Weighted

Average

Covered CA Lowest

Performer

Covered California Plan-Specific Performance

Anthem HMO

Anthem PPO

Anthem EPO

64,031

Blue Shield HMO

93,322

Blue Shield PPO

25%

335,176

CCHP HMO

10,013

Health Net HMO

11%

145,183

Health Net EPO

Health Net PPO

Kaiser Permanente HMO

36%

477,683

LA Care HMO

84,750

Molina Healthcare HMO

56,023

Oscar Health Plan EPO

35,962

Sharp Health Plan HMO

17,335

Valley Health Plan HMO

16,366

Western Health Advantage

HMO

9,386

Covered California Holding Health Plans Accountable for Quality and Delivery System Reform

ASSURING QUALITY CARE • CHAPTER 2

COVERED CALIFORNIA 13

Rating of All Health Care

The “Rating of all health care” measure is an overall indicator of enrollees’ satisfaction (0-10 scale) with

their health care based on the QHP Enrollee Survey.

Table 4: Covered California Enrollees’ Rating of All Health Care (CAHPS)

2016

2017

2018

2019

Benchmark

Percent of

Enrollees

Number of

Enrollees

Number

of Plans

Plans at 90th Percentile and

Above

85 +

86 +

82 +

Plans at 50th to 90th Percentile

82 to 85

83 to 86

78 to 82

75%

1,008,266

Plans at 25th to 50th Percentile

80 to 82

81 to 83

75 to 78

25%

336,964

Plans Below 25th Percentile

Below 80

Below 81

Below 75

Covered California High/Average/Low Performers

Covered CA Highest Performer

Covered CA Weighted

Average

Covered CA Lowest Performer

Covered California Plan-Specific Performance

Anthem HMO

Anthem PPO

Anthem EPO

64,031

Blue Shield HMO

93,322

Blue Shield PPO

25%

335,176

CCHP HMO

10,013

Health Net HMO

11%

145,183

Health Net EPO

Health Net PPO

Kaiser Permanente HMO

36%

477,683

LA Care HMO

84,750

Molina Healthcare HMO

56,023

Oscar Health Plan EPO

35,962

Sharp Health Plan HMO

17,335

Valley Health Plan HMO

16,366

Western Health Advantage

HMO

9,386

Covered California Holding Health Plans Accountable for Quality and Delivery System Reform

ASSURING QUALITY CARE • CHAPTER 2

COVERED CALIFORNIA 14

Covered California’s Attention to Equity and Health Disparities

Covered California has prioritized initiatives to narrow health care and coverage disparities and ensure

health equity for all. Reducing health disparities is part of Covered California’s vision and mission

statement and has the potential to benefit all Californians (with over 4 million consumers served to date

through Covered California

) and because the populations measured and targeted for improvement by

health insurance companies include all of their enrollees under age 65 across all lines of business.

While disparities are influenced by social

and economic factors beyond the control

of the health care delivery system, there

is agreement and evidence that health

care disparities can be narrowed through

quality improvement activities tailored to

the needs of specific populations and

targeting select measures at the health

plan level. To this end, Covered

California has laid out a health

disparities and health equity agenda

centered on four requirements:

1. Promoting community health initiatives that foster better health, healthier environments and

healthy behaviors.

2. Identifying the race or ethnicity of all enrollees through self-identification or imputed

methodology.

3. Collecting data by race/ethnicity for disease control and management measures for asthma,

depression, diabetes and hypertension — conditions with especially high levels of morbidity and

mortality experienced by disadvantaged populations.

4. Conducting population-health improvement activities and interventions to narrow observed

disparities in care.

See Section 2 for information on health plan progress in conducting interventions to narrow observed

disparities in care and collecting data by race/ethnicity for disease control and management measures

for asthma, depression, diabetes and hypertension.

Promoting Community Health Initiatives That Foster Better Health, Healthier

Environments, and Promotion of Healthy Behaviors

Under contract requirements, Covered California included requirements for engagement and promotion

of community-wide initiatives that foster better health, healthier environments, and the promotion of

healthy behaviors across the community. Covered California specifically encouraged community health

initiatives that have undergone or are being piloted through systematic review to determine

This figure only includes on-exchange enrollment since 2014. The figure is higher if off-exchange mirrored plan enrollment is included.

Covered California’s Mission and Vision

Covered California’s vision is to improve the health of

all Californians by assuring their access to affordable,

high quality care.

Covered California’s mission is to increase the number

of insured Californians, improve health care quality,

lower costs, and reduce health disparities through an

innovative, competitive marketplace that empowers

consumers to choose the health plan and providers that

give them the best value.

Covered California Holding Health Plans Accountable for Quality and Delivery System Reform

ASSURING QUALITY CARE • CHAPTER 2

COVERED CALIFORNIA 15

effectiveness in promoting health and preventing disease, injury or disability and have been

recommended by the Community Preventive Services Task Force. Such programs may include:

1. Partnerships with local, state, or federal public health departments such as Let’s Get Healthy

California.

2. CMS Accountable Health Communities.

3. Organizations that operate preventive and other health programs, such as Cal Fresh.

4. Hospital activities undertaken under the Community Health Needs Assessment required every

three years under the Affordable Care Act.

Table 5. Covered California Insurer Activities to Improve Community Health, 2018 shows health insurer

reported initiatives, programs and projects that improve community health apart from the health delivery

system. Health insurance company involvement in external-facing activities is used by Covered

California to identify potential disparity-reduction opportunities.

Identifying the Race or Ethnicity of All Enrollees

Understanding disparities in care requires data collection on demographics and other social

determinants of health. Health insurance companies vary in the degree to which demographic data is

collected and integrated into member records. While state law requires health insurance companies to

collect race, ethnicity, and language data, insurers use different methods to obtain this information and

have different rates for the percentage of membership self-identifying race/ethnicity (i.e. race/ethnicity

self-identification rates).

Before the initiatives described below, no purchaser or state agency in

California monitored the success of collecting self-identification rates and there had been no broad

attempt to use the data to evaluate disparities in care.

To achieve high self-identification rates across all health insurance companies, Covered California set a

goal for all insurers to achieve identification of at least 80 percent of all Covered California membership

by year-end 2019 and encouraged use of various data collection methods beyond the membership

enrollment application to identify race/ethnicity. Starting with the 2018 plan year, insurers were

assessed on a contract performance standard for the self-identification rate and received financial

penalties or credits based on whether they achieved the target. Insurers proposed intermediate

milestones for the performance standard for the 2018 plan year and will be assessed on whether they

achieved a target of 80 percent in 2019.

Based on analysis of data gathered for this performance standard, eight insurers have achieved the 80

percent target as of 2018 and some have exceeded 95 percent. Insurers have attributed the increased

identification rates to improved data collection and incorporation of best practices for asking enrollees

for race/ethnicity information.

Senate Bill 853, Chapter 717, Statutes of 2009.

Covered California Holding Health Plans Accountable for Quality and Delivery System Reform

ASSURING QUALITY CARE • CHAPTER 2

COVERED CALIFORNIA 16

Table 5. Covered California Insurer Activities to Improve Community Health, 2018

Number of Health Plans

Internal facing, member related efforts

Health education portal

Quality collaboratives

Member outreach

Lifestyle or disease-specific workshops and classes

Educational materials

Incentive programs

Connections to outside orgs and programs

Internal facing, member related efforts non-health-related

Philanthropy

Non-health classes

Health insurance education

Financial counseling/decision-making support

Interpreting services availability education

External or community facing activities, health-related

Health fairs (starred if funded)

Screening events (starred if funded)

Enrollment fairs

Public health conferences

Statewide or community collaboratives and taskforces

Community workshops/classes or peer to peer support

Health promotors program

Financial support of community health programs

Educational materials

External facing, non-health-related

Employee volunteers

Ads and newsletters

Community events

Financial support of community non-health programs

Education support

Non-health coalitions (e.g. homelessness)

Health plan option education

Engaged with health systems for community risk assessments identifying high priority needs

Through providers

Health plan activities

Community health effort

School programs

In-home assessments

Educational campaign

Health plan-funded community health programs based on needs assessments or other activity

Grant programs

Health fairs

Health resource center(s)

Community clinics

Screening events

Participated in geographic disaster relief efforts

Safety policies

Member services in affected areas

Disaster relief as part of government

Disaster preparedness programs

Community partner support around disaster relief

Covered California Holding Health Plans Accountable for Quality and Delivery System Reform

ASSURING QUALITY CARE • CHAPTER 2

COVERED CALIFORNIA 17

Table 6. Number of Insurers Meeting the 80 Percent Target for Identification of Race/Ethnicity

2015

2016

2017

2018

Number of Insurers

Source: Covered California Staff Analysis of Qualified Health Plan Submitted Data

Challenges in Data Collection

Health insurance companies can collect self-identification data from several sources. The race/ethnicity

question in the Covered California enrollment application is voluntary and is included in the enrollment

file sent to insurers. Beyond enrollment data, insurers have reported receiving data from providers,

customer service, health risk assessments and website registration. Methods for data collection vary by

insurer, resulting in considerable variation during 2015-18 in how well each insurer met Covered

California’s goals for ensuring race/ethnicity identification for quality improvement purposes.

While all insurers have demonstrated improvement towards the 2019 target, it is important to note that

these rates represent Covered California membership only. As discussed in Section 2. Health Plan-

Reported Measures for Health Disparities, an objective of the health equity agenda is to track and trend

a select set disparities measures that include a health insurance company’s full book of business

excluding Medicare. Larger numbers are necessary to be able to accurately measure performance,

especially for relatively small minority populations. Identification of member race/ethnicity when

reporting health disparities measures is similarly challenging. For this reason, Covered California has

encouraged insurers to supplement self-reported identification with a proxy methodology based on

surname and census track. Covered California will continue to work with insurers to improve and

validate self-identification of race and ethnicity.

Section 2. Health Plan Reported Measures and Efforts to Narrow Health

Disparities

Many of Covered California’s contracted health insurance companies have been actively engaged in

efforts to understand and address health care disparities for many years. These efforts are reflected in

a range of activities. Four of Covered California’s health insurance companies, Health Net, Kaiser

Foundation Health Plan of Southern California, L.A. Care and Molina Healthcare, representing 36

percent (503,220 out of 1,384,030) of enrollment in 2018 earned the National Committee for Quality

Assurance’s (NCQA) Distinction in Multicultural Health Care (MHC), a program that recognizes

organizations that provide culturally and linguistically sensitive services and work to reduce disparities

in health and health care.

In 2017, Covered California began an initiative to measure and seek improvement in health equity

across all contracted insurers. In collaboration with health insurance companies and consumer

In 2018, Covered California examined current self-identification rates in the Covered California enrollment file to compare to insurer

reported rates. Covered California’s self-identification rate in 2017 was 75.5 percent across all insurers. In theory, insurer reported rates

should be equal to or higher than the rate provided in the enrollment file, assuming all data is transferred to the insurer and the insurer’s

other avenues of data collection supplement the race/ethnicity field in its membership file. In practice, some insurers have reported

considerably lower rates and are currently evaluating internal data collection to understand the discrepancies. Covered California is also

aware of some errors in the 834 data transmission related to race/ethnicity categorization and is actively working on a system change

request to appropriately identify membership answering this question in the enrollment application.

See more: https://www.ncqa.org/programs/health-plans/multicultural-health-care-mhc/.

Covered California Holding Health Plans Accountable for Quality and Delivery System Reform

ASSURING QUALITY CARE • CHAPTER 2

COVERED CALIFORNIA 18

stakeholders, Covered California targeted four conditions that affect large numbers of consumers, have

serious potentially avoidable complications, and for which there is strong evidence of racial or ethnic

disparities:

• Asthma: Although asthma affects all populations, the burden of this disease falls

disproportionately on minority populations: the prevalence of childhood asthma is 12.7 percent

among non-Hispanic blacks compared to 8 percent among non-Hispanic whites and 6.4 percent

among Hispanics. Even more striking, the asthma mortality rate among non-Hispanic black

children is nearly eight times that of non-Hispanic whites.

• Depression: National surveys indicate that nearly one in six Americans has experienced a

major depressive episode, with many experiencing multiple episodes. Depression is a leading

cause of disability and death, largely related to the nearly tenfold higher risk of suicide among

those with depression.

Depression is undertreated in all populations, but more so among

minorities. Although 40 percent of non-Latino whites with depression failed to receive treatment,

64 percent of Latinos, 69 percent of Asians, and 59 percent of African Americans failed to

receive any treatment.

• Diabetes: While diabetes affects almost 10 percent of the U.S. population overall, the

prevalence in Hispanics (11.9 percent) and African Americans (13.4 percent) is much higher

than it is in non-Hispanic Whites. Diabetes is the seventh leading cause of death and

contributes to an increased risk of heart attacks, stroke, amputation and kidney disease.

• Hypertension: Almost one third of adults have hypertension (high blood pressure), a major risk

factor for heart attacks (the leading cause of death in the U.S.) and strokes (the seventh leading

cause of death). The prevalence of hypertension among non-Hispanic blacks (41 percent) is

substantially higher than among whites (29 percent) or Hispanics (28 percent). Among those

with hypertension, the proportion who were well controlled differed dramatically: whites at 53

percent, non-Hispanic blacks at 43 percent and Hispanics at 30 percent.

Because of the public health importance of these conditions and the serious disparities in health and

health care that have been documented and the potential for targeted interventions to reduce morbidity

and mortality, Covered California selected 14 measures related to these conditions to track, of which

five are National Committee for Quality Assurance (NCQA) Healthcare Effectiveness Data and

Information Set (HEDIS) measures and nine are based on Agency for Healthcare Research and Quality

(AHRQ) Prevention Quality Indicators (PQI). Importantly, these measures are now being reported by

insurers annually not only for Covered California’s enrollees, but also for all non-Medicare commercial

Forno, E., and Celedón, J. C. (2012). Health disparities in asthma. American journal of respiratory and critical care medicine, 185(10),

1033–1035. doi:10.1164/rccm.201202-0350ED

McLaughlin K. A. (2011). The public health impact of major depression: a call for interdisciplinary prevention efforts. Prevention science:

the official journal of the Society for Prevention Research, 12(4), 361–371. doi:10.1007/s11121-011-0231-8

Alegría, M., Chatterji, P., Wells, K., Cao, Z., Chen, C. N., Takeuchi, D., … Meng, X. L. (2008). Disparity in depression treatment among

racial and ethnic minority populations in the United States. Psychiatric services (Washington, D.C.), 59(11), 1264–1272.

doi:10.1176/appi.ps.59.11.1264

Centers for Disease Control and Prevention. National Diabetes Statistics Report, 2017. Atlanta, GA: Centers for Disease Control and

Prevention, U.S. Dept of Health and Human Services; 2017. Retrieved from: https://www.cdc.gov/diabetes/pdfs/data/statistics/national-

diabetes-statistics-report.pdf.

Centers for Disease Control and Prevention. Prevalence of Hypertension and Controlled Hypertension — United States, 2007–2010.

Atlanta, GA: Centers for Disease Control and Prevention, U.S. Dept of Health and Human Services; 2013. Retrieved from:

https://www.cdc.gov/mmwr/preview/mmwrhtml/su6203a24.htm.

Covered California Holding Health Plans Accountable for Quality and Delivery System Reform

ASSURING QUALITY CARE • CHAPTER 2

COVERED CALIFORNIA 19

and Medi-Cal lives, with rates supplied by race/ethnicity (see Table 7. Covered California Insurer “All-

Plan” Reported Measures for Health Disparities).

Data for the full non-Medicare population was required for the following principal reasons: (1) narrowing

disparities requires quality improvement interventions regardless of coverage type; (2) the larger

population size makes measurement of disparities more accurate; and (3) high turnover in the

individual market results in consumers transitioning to other sources of coverage, such as employer-

based coverage or Medi-Cal. These markets are served by the same health insurance companies that

participate in Covered California.

During the first year of reporting for plan year 2015, insurers reported on 10 measures, and an

additional four measures were phased in for plan year 2016. Insurers will continue reporting the data for

all 14 measures through plan year 2020 as Covered California continues to evaluate insurer’s data and

the progress of planned interventions.

Table 7. Covered California Insurer “All-Plan” Reported Measures for Health Disparities

Measure

Steward

Years Reported

Condition

AMR - Asthma Medication Ratio Ages 5-85

NCQA

MY 2015, 2016,

2017

Asthma

Admissions for Asthma among Older Adults with

Asthma

AHRQ PQI

MY 2015, 2016,

2017

Asthma

Admissions for Bacterial Pneumonia among

Members with Asthma

AHRQ PQI

MY 2016, 2017

Asthma

Admissions for Asthma among Children and

Younger Adults with Asthma

AHRQ PQI

MY 2015, 2016,

2017

Asthma

Antidepressant Medication Management

(Effective Acute Phase Treatment)

NCQA

MY 2015, 2016,

2017

Depression

Antidepressant Medication Management

(Effective Continuation Phase Treatment)

NCQA

MY 2015, 2016,

2017

Depression

Diabetes Care: HbA1c Control < 8.0% (NQF

0575)

NCQA

MY 2015, 2016,

2017

Diabetes

Admissions for Diabetes Short-term

Complications among Members with Diabetes

AHRQ PQI

MY 2015, 2016,

2017

Diabetes

Admissions for Diabetes Long-Term

Complications among Members with Diabetes

AHRQ PQI

MY 2015, 2016,

2017

Diabetes

Admissions for Uncontrolled Diabetes among

Members with Diabetes

AHRQ PQI

MY 2016, 2017

Diabetes

Admissions for Lower-Extremity Amputation

among Members with Diabetes

AHRQ PQI

MY 2016, 2017

Diabetes

Controlling High Blood Pressure (NQF 0018)

NCQA

MY 2015, 2016,

2017

Hypertension

Admissions for Hypertension among Members

with Hypertension

AHRQ PQI

MY 2015, 2016,

2017

Hypertension

Admissions for Heart Failure among Members

with Hypertension

AHRQ PQI

MY 2016, 2017

Hypertension

Opportunities for Intervention

The dataset used to evaluate insurer populations for disparities is unique in that it aggregates data for

enrollees under 65 across all lines of business. In addition to serving different geographies with known

variations among them, each insurer has a very different mix of population served ranging from

Covered California Holding Health Plans Accountable for Quality and Delivery System Reform

ASSURING QUALITY CARE • CHAPTER 2

COVERED CALIFORNIA 20

predominantly employer-based commercial enrollees to predominantly Medi-Cal enrollees. Insurers

also have varying quality of data, most aggregating 400-person HEDIS samples for each line of

business but some having access to robust clinical data from electronic health records. For these

reasons and more as detailed in Appendix 1: Limitations and Major Caveats about Health Disparities

Data, Covered California has determined that the results cannot be used to compare performance

across plans.

However, Covered California and each insurer found actionable differences in measures across

race/ethnicity groups that justify interventions. In addition, one of the key observations was that the

apparent disparities based on race/ethnicity were in almost all cases far smaller than the differences in

care or treatment across health plans — with enrollment in Kaiser Permanente or Sharp Health Plan

being a far better predictor of receiving good care than race/ethnicity. This observation was consistent

with Covered California’s findings regarding the generally superior care provided by integrated delivery

systems (see Chapter 3 and Chapter 4).

The following sections present high-level summaries of key trends based on preliminary analysis of

insurer-reported data and examples of disparity reduction proposals.

Conducting Population Health Improvement Activities and Interventions to Narrow

Observed Disparities in Care

After collection and submission of three years of baseline data for the indicators of potential gaps in

care related to the four conditions, Covered California has worked with each insurer to select a quality

improvement project aimed at narrowing a health care disparity found in the baseline data related to the

four target conditions. Covered California has met with each insurer to discuss opportunities for

conducting quality improvement activities and interventions to narrow each health insurer’s specific

observed health care disparities. In 2020, each Covered California insurer will implement a quality

improvement project aimed at narrowing a health care disparity and will periodically report their

progress. Covered California will hold insurers accountable for narrowing the selected disparity while

maintaining or improving outcomes for targeted enrollees, which in most cases encompasses more

than just Covered California members — sometimes including all commercial enrollees and other

enrollees in the individual market or all Medi-Cal enrollees.

In addition to data reporting and analysis, insurers are reporting progress on infrastructure and staffing

enhancements needed to develop their health care disparity reduction project, as well as related and

aligned activities to support this Covered California initiative. These activities range in scope and scale:

some represent the next phase of multi-year efforts while others are starting by proposing time-limited

or smaller scale projects. The following are examples of activities reported by insurers:

• Enhanced member education, messaging, incentives and self-management tools.

• Enhanced provider education and clinical guidance reminders.

• Streamlined data collection processes to increase reporting and monitoring quality.

• Focused partnerships with community stakeholders.

• Disease registry development and sharing between providers and insurers.

• Outreach events and mobile care in at-risk communities.

• Enhanced care team support for affected populations.

Covered California Holding Health Plans Accountable for Quality and Delivery System Reform

ASSURING QUALITY CARE • CHAPTER 2

COVERED CALIFORNIA 21

These important efforts are building the foundation for increasingly effective interventions to improve

care for all while reducing disparities in both health and health care.

The tables below document four representative examples of the target populations, measurement gaps

and interventions proposed to be undertaken by health insurance companies.

Covered California Holding Health Plans Accountable for Quality and Delivery System Reform

ASSURING QUALITY CARE • CHAPTER 2

COVERED CALIFORNIA 22

Table 8. Health Net’s Proposed Interventions for Improved Diabetes and Hypertension Management

Rationale and Target Population(s) for Intervention

Summary of Select Interventions

Health Net proposes to target African American and Latino

members for improved diabetes and hypertension management

across Medi-Cal and individual market (Covered California and

off-exchange) lines of business.

Rationale and Target Population(s) for Intervention

• Rates for HbA1c control for African American members are 14

percent lower than white members with diabetes.

• Rates for blood pressure control for African American

members are 32 percent lower than white members with

hypertension.

• Rates for blood pressure control for Latino members are 28

percent lower than white members with hypertension.

Community, Member and Provider

Interventions

• Focus on the social determinants

of health (SDOH), social

marketing, and community

coalition and advisory group.

• Collection of member-level SDOH

data, one-stop clinics, medication

adherence bundle protocols;

nutrition and food insecurity pilot.

• Partnership with select clinic and

hospital; modified workflow;

motivational interviewing training.

Source: Covered California Staff Analysis of Qualified Health Plan Submitted Data

Table 9. LA Care’s Proposed Interventions for Improved Diabetes Management

Rationale and Target Population(s) for Intervention

Summary of Select Interventions

L.A. Care proposes to target African American and American

Indian/Alaskan Native members for improved diabetes

management for the Covered California line of business.

Rationale and Target Population(s) for Intervention

• The prevalence of diabetes among African Americans is 40

percent higher compared to the overall Los Angeles County

population.

• The prevalence of diabetes among American Indian/Alaskan

Natives is more than 50 percent higher compared to the

overall Los Angeles County population.

• Rates of HbA1c control for African American members are 8

percent lower than the total diabetes population.

• Rates of HbA1c control for American Indian/Alaskan Native

members are 12 percent lower than the total diabetes

population.

Member, Provider and Administrative

Interventions

• Online member portal diabetes

education course.

• Provider feedback, education and

reminders of guideline therapies

for members with diabetes control

below target.

• Systematic data collection process

improvements to improve the

accuracy and timeliness of HbA1c

laboratory data.

Source: Covered California Staff Analysis of Qualified Health Plan Submitted Data

Covered California Holding Health Plans Accountable for Quality and Delivery System Reform

ASSURING QUALITY CARE • CHAPTER 2

COVERED CALIFORNIA 23

Table 10. Kaiser Permanente’s Proposed Interventions for Improved Diabetes and Hypertension

Management

Rationale and Target Population(s) for Intervention

Summary of Select Interventions

Kaiser Permanente proposes to target African American and

Latino members for improved diabetes and hypertension

management across Commercial lines of business (employer-

based and individual market, for both Covered California and off-

exchange enrollment).

Rationale and Target Population(s) for Intervention

• Mortality due to diabetes is 50 percent higher in

Hispanic/Latino than in White members.

• Mortality due to hypertension is 4-5 times higher in African

Americans than in white members.

• Rates of HbA1c control among Hispanic/Latino members are

12 percent lower than the overall Commercial diabetes

population.

• Rates of blood pressure control for Black/African American

members are 7 percent lower than for the overall Commercial

hypertensive population.

Member, Provider, and Administrative

Interventions

• Forums across sites for sharing

best practices

• Ongoing review of patient-facing

materials for culturally responsive

messaging

• Language concordant care for

Latino diabetics

• Innovative approaches to

community outreach (e.g. Mobile

Health Vehicle to churches, blood

pressure checks in barber shops)

• Specialty blood pressure clinic for

Black/African American members

Source: Covered California Staff Analysis of Qualified Health Plan Submitted Data

Table 11. Anthem’s Proposed Interventions for Improved Depression Medication Management

Rationale and Target Population(s) for Intervention

Summary of Select Interventions

Anthem proposes to target Hispanic/Latino members for improved

depression medication management for the Covered California

line of business.

Rationale and Target Population(s) for Intervention

• Rates for the Antidepressant Medication Management

(Effective Acute Phase Treatment) for Hispanic/Latino

members are 40 percent lower than White Covered California

members.

• Rates for the Antidepressant Medication Management

(Effective Continuation Phase Treatment) for Hispanic/Latino

members are 32 percent lower than White Covered California

members.

Member, Provider, and Policy

Interventions

• Member outreach and coaching

through mail and telephone;

telehealth initiatives for psychology

and psychiatry services; pilot for

prescribing providers and

members

• Review of provider education

materials communications and

implement changes, as

appropriate, with aim to reduce

care gaps

• Updated evaluation of HEDIS

specifications for potential

advocacy

Source: Covered California Staff Analysis of Qualified Health Plan Submitted Data

Covered California Holding Health Plans Accountable for Quality and Delivery System Reform

ASSURING QUALITY CARE • CHAPTER 2

COVERED CALIFORNIA 24

Section 3: Implications for the Future

Satisfaction surveys (CAHPS) demonstrate that Covered California enrollees rate their health plans

highly on two comprehensive measures. The Covered California initiative to promote health equity

through individualized, equitable care for all is just beginning. As described in this chapter, finding

appropriate data to use as a baseline for building strategies has been and will continue to be a

challenge until all insurers have more complete clinical data. Despite these challenges, insurers have

found actionable disparities and early initiatives are underway. As with other efforts to improve the

performance of the health care system, addressing disparities in health and health care can best be

accomplished by using data and evidence to understand the underlying causes of poor performance

and by working with all involved to develop, test and spread successful interventions.

Even accounting for differences in measurement and populations, the findings regarding disparities in

care suggest that on some measures, the more integrated health insurance companies report better

quality scores for all groups – to levels that are among the best in the country. While some of these

insurers have long invested in and hired staff to support culturally competent care, these findings

suggest that integrated and coordinated approaches to care delivery may reduce racial or ethnic

disparities on some measures of quality.

Covered California is evaluating progress and identifying opportunities for expansion of its health equity

program in the future, including potentially analyzing health outcomes based on other demographic

categories such as: (1) income; (2) disability status; (3) sexual orientation; (4) gender identity; and (5)

limited English proficiency (LEP). Since the data is collected across all lines of business, Covered

California will seek collaboration with other purchasers, especially the Department of Health Care

Services (DHCS), which oversees California’s Medi-Cal program that serves over approximately one

third of the entire California population. Covered California is also considering encouraging all insurers

to acquire the National Committee for Quality Assurance’s (NCQA) Distinction in Multicultural Health

Care (MHC) as this program recognizes organizations that provide culturally and linguistically sensitive

services and that work to reduce disparities in health and health care.

In the current contract, Covered California requires its insurers to engage in and report on efforts to

impact the health of populations beyond their enrollees. Both the data provided by the insurers and

research conducted by Health Management Associates (HMA) did not find evidence of the efficacy of

such interventions.

There is, however, evidence of the impact of health insurance companies focusing

on specific social determinants of health for enrolled populations — such as providing transportation or

food assistance for insured individuals with particular needs. Given these findings, Covered California is

reassessing the contractual expectations of its insurers for addressing social determinants of health.

Covered California has a potentially critical role to play in promoting broad engagement among public

and private purchasers to address health equity. In work commissioned by Covered California,

PricewaterhouseCoopers found that while focusing on health equity and disparities was a priority for

public purchasers, very few private purchasers consider this issue a priority.

The most current best evidence is documented in Chapter 1, Health Equity: Reducing Disparities, of a companion Covered California

report, Current Best Evidence and Performance Measures for Improving Quality of Care and Delivery System Reform.

“Health Purchaser Strategies for Improving Quality of Care and Delivery System Reform.” Review conducted for Covered California by

PricewaterhouseCoopers. Available at: https://hbex.coveredca.com/stakeholders/plan-

management/library/coveredca_health_purchaser_strategies_07-19.pdf.

Covered California Holding Health Plans Accountable for Quality and Delivery System Reform

ASSURING QUALITY CARE • CHAPTER 3

COVERED CALIFORNIA 25

Chapter 3: Health Promotion and

Prevention

Health Promotion and Prevention relates to health

insurance company activities to encourage all

enrollees to receive preventive care services and

health screenings and use tools that promote a

healthy lifestyle. This includes everything from

regular checkups to smoking cessation and dietary

programs.

This chapter on Health Promotion and Prevention is

organized as follows:

Section 1. Qualified Health Plan Experience

Section 2. Health Plan Measures Reported to the

Marketplace Quality Rating System

Section 3. Implications for the Future

Section 1. Qualified Health Plan

Experience

Qualified Health Plan Experience presents

performance data reported by health insurance

companies for contract requirements and includes

assessments and observations by Covered

California. Prevention and wellness are key

components of high-value health care. Research

shows that treating those who are sick is often far

costlier and less effective than preventing disease

from occurring and keeping populations healthy.

Prevention occurs at three levels, each of which is

important in promoting enrollee health and wellness

and each of which is represented in Covered

California’s prevention reporting and requirements.

• Primary Prevention: Primary prevention

focuses on intervening before a health event

occurs. Promotion of healthy behaviors and

vaccinations are forms of primary prevention

that insurers play a role in promoting.

Intervening on risk factors for disease, like

obesity or smoking status, is also a form of

primary prevention.

• Secondary Prevention: Secondary

prevention includes screening for diseases to

identify diseases at an early stage. The

positive impact of timely screening for

• Kaiser Permanente frequently

performed at or above the 90

percentile nationally on preventive

screening measures while most other

plans performed in the 25

to 90

percentile.

• For the three HEDIS preventive care

measures Covered California identified

as priority measures — breast,

cervical, and colorectal cancer

screening — not only was there wide

variation observed among plans over

the past four years, but from two to six

health plans reported performance

below the 25

percentile nationally —

highlighting both the need and

opportunity for improvement.

• Across insurers, there exist robust

health communication processes to

inform enrollees about health and

wellness benefits. Insurers offered

information about free preventive

services, offered a 24/7 telephonic

nurse line, inbound and outbound

telephonic coaching, as well as

member reminders.

• Contract requirements call for reporting

on tobacco cessation and obesity

management programs, but this data

was incomplete due to the lack of

access to clinical data for most

insurers. Covered California is looking

at the feasibility of (1) better collection

of clinical data to improve enrollee

identification or requiring insurers to do

so and (2) better tracking of program

availability and participation rates.

• Covered California is assessing what

factors contribute to better

performance among some providers in

non-Kaiser Permanente insurers and

how Kaiser Permanente’s performance

can be replicated across California.

Highlights

Covered California Holding Health Plans Accountable for Quality and Delivery System Reform

ASSURING QUALITY CARE • CHAPTER 3

COVERED CALIFORNIA 26

cancer, for example, is well documented. This screening helps providers identify and treat

cancers early, before symptoms appear.

• Tertiary Prevention: Tertiary prevention focuses on managing diseases after a diagnosis to

help slow or stop disease progression and prevent debilitating or other negative impacts of

disease.

Covered California’s prevention and wellness requirements are centered on identifying enrollees who

are eligible for certain preventive and wellness benefits, notifying enrollees about the availability of these

services, and making sure those eligible receive appropriate services. Proactively identifying and

notifying enrollees eligible for prevention and wellness benefits, monitoring health status and making

appropriate referrals, and ensuring at-risk enrollees receive proactive coordinated care all center around

making sure people get the right preventive care when they need it at all three levels of prevention,

instead of waiting until more serious and costly manifestations of disease prompt care. Covered

California has identified several priority disease areas for reporting, including those with significant

evidence around the importance of prevention. Under contract requirements, insurers are required to

report the following:

1. Utilization of tobacco cessation intervention services;

2. Utilization of obesity management services;

3. Processes for communicating health and wellness benefits to enrollees and providers and the

way they incorporate and use of enrollee-specific health and wellness information; and

4. Utilization of necessary preventive services through the following select HEDIS measures:

breast cancer screening, cervical cancer screening, colorectal cancer screening, and chlamydia

screening for women.

Tobacco Cessation

Covered California health insurance companies reported significant data challenges in reporting both

the number of tobacco dependent enrollees and participation rates in smoking cessation programs.

Integrated delivery systems, such as Kaiser Permanente and Sharp Health Plan, reported the most

consistent data year-over-year, likely due to having access to clinical data that confirms a diagnosis of

tobacco dependency. Other insurers were hampered by data challenges that include a lack of access

to clinical data, inability to track physician referrals to tobacco cessation programs or educational

classes offered by medical groups that are not documented or billed on a claim, reliance on enrollee

provided data in health risk assessments that are not universally administered, and inability to track by

lines of business, such as Covered California membership. Given this set of challenges, the available

data reported for both Covered California enrollees and members in all lines of business (inclusive of

Covered California) ranged between less than 1 percent to as high as 70 percent.

Covered California

cautions these figures are likely incomplete. Future requirements in this area will need to consider the

feasibility of (1) collecting clinical data to improve identification of tobacco dependent members and (2)

better tracking of program availability and participation rates.

Health plans reporting participation rates on the high end of the range generally had a far smaller number of enrollees identified as

tobacco dependent. Covered California did not calculate a weighted average participation rate due to incomplete reporting and data

collection challenges.

Covered California Holding Health Plans Accountable for Quality and Delivery System Reform

ASSURING QUALITY CARE • CHAPTER 3

COVERED CALIFORNIA 27

Obesity Management

Covered California health insurance companies experienced a similar set of challenges for tracking

obese members; the most important of which is the lack of access to clinical data that documents a

diagnosis of obesity. Some insurers also reported they do not track specific lines of business, such as

Covered California membership, for participation in weight management programs. Some insurers

relied on data through health risk assessments, wellness portals, and self-referrals by enrollees. Given

this set of challenges, the available 2018 data reported for Covered California enrollees ranged

between less than 1 percent to roughly 40 percent. For members in all lines of business (inclusive of

Covered California),

the 2018 data ranged between roughly 1 percent to nearly 20 percent. Again,

Covered California cautions these figures are likely incomplete. Future requirements in this area will

need to consider the feasibility of (1) collecting clinical data to improve identification of obese members

and (2) better tracking of program availability and participation rates.

Processes for Communicating Health and Wellness Benefits

Through annual reporting, health insurance companies reported the methods used to communicate

health and wellness benefits to enrollees using pre-defined categories, such as customized printed

materials about free preventive services or 24/7 telephonic nurse lines. Table 12. Processes for

Communicating Health and Wellness Benefits for Commercial and Covered California Enrollees, 2016

summarizes this data which reflects insurers’ activities in 2016 as this information was not required in

later reporting.

Health communication processes offered to enrollees are relatively consistent across health insurance

companies. Most or all insurers offered information, both template and customized, about free

preventive services, offered a 24/7 telephonic nurse line, inbound and outbound telephonic coaching,

as well as member care service reminders. While not universally used, most health insurance

companies reported using nurse lines for specific populations (i.e., complex conditions or oncology

patients) as well as interactive voice response (IVR) member care/service reminders (offered by 7 out

of 12 insurers).

Health plans reporting participation rates on the high end of the range generally had a far smaller number of enrollees identified as

tobacco dependent. Covered California did not calculate a weighted average participation rate due to incomplete reporting and data

collection challenges.

Covered California Holding Health Plans Accountable for Quality and Delivery System Reform

ASSURING QUALITY CARE • CHAPTER 3

COVERED CALIFORNIA 28

Table 12. Processes for Communicating Health and Wellness Benefits for Commercial and Covered

California Enrollees, 2016

Processes for Communicating Health and Wellness Benefits

Number of

Health Plans

Template newsletter articles/printed materials about free preventive services

Customized printed materials about free preventive services

24/7 Telephonic Nurse Line

24/7 Nurse Navigator for complex conditions

24/7 Nurse Navigator for oncology management

Inbound telephonic health coaching

Outbound telephone health coaching

Member care/service reminders (IVR)

Member care/service reminders (Paper)

Source: Covered California Staff Analysis of Qualified Health Plan Submitted Data

Section 2. Health Plan Measures Reported to the Marketplace Quality

Rating System

Health Plan Measures Reported to the Marketplace Quality Rating System details health plan

performance on Healthcare Effectiveness Data Information Set (HEDIS) and Consumer Assessment of

Healthcare Providers and Systems (CAHPS) measures reported to the Centers for Medicaid and

Medicare Services’ Quality Rating System (QRS). These standard performance measures are a key

mechanism used by Covered California for health plan oversight and accountability. To more sharply

focus health plan accountability efforts, Covered California examined over 40 measures used by QRS

and is proposing to prioritize a subset of 13 measures that were selected based on the following

criteria: (1) health impact; (2) extent of health plan variation; (3) performance improvement opportunity;

(4) alignment with other California accountability programs; and (5) balance across domains of care,

such as prevention, chronic illness care and behavioral health. Three of the 13 measures also overlap

with the measures currently collected by race/ethnicity for health disparities reduction interventions as

discussed in Chapter 2.

The following tables display the three measures for Health Promotion and Prevention in the QRS

measure set that Covered California has identified as priority measures (with eight additional measures

detailed in Appendix 2: Additional Health Plan Measures Reported to the Quality Rating System).

The 11 health insurance companies in Covered California are: Anthem Blue Cross, Blue Shield of California, Chinese Community Health

Plan, Health Net, Kaiser Permanente, L.A. Care, Molina Healthcare, Oscar Health, Sharp Health Plan, Valley Health Plan, and Western

Health Advantage. In this table, Health Net is counted twice because its reports data separately for Health Net Life (PPO/EPO products)

and Health Net of California (HMO/HSP products).

Covered California Holding Health Plans Accountable for Quality and Delivery System Reform

ASSURING QUALITY CARE • CHAPTER 3

COVERED CALIFORNIA 29

The tables include the Covered California weighted average, highest and lowest performing plans,

plan-specific performance, as well as national percentiles for all Marketplace plans. The priority

measures are:

1. Breast Cancer Screening (Table 13)

2. Cervical Cancer Screening (Table 14

3. Colorectal Cancer Screening (Table 15)

See Appendix 2: Additional Health Plan Measures Reported to the Quality Rating System, for eight

additional QRS measures that pertain to Health Promotion and Prevention:

4. Chlamydia Screening in Women (Table A1)

5. Adult BMI Assessment (Table A2)

6. Childhood Immunizations (Combination 3) (Table A3)

7. Immunizations for Adolescents (Combination 2) (Table A4)

8. Flu Vaccinations for Adults Ages 18-64 (Table A5)

9. Medical Assistance with Smoking and Tobacco Use Cessation (Table A6)

10. Weight Assessment and Counseling for Nutrition and Physical Activity for Children and

Adolescents (Table A7)

11. Annual Dental Visit (Table A8)

Appendix 2 also describes how to interpret the display of the measures.

Performance on other measures included in the QRS measure set are presented in relevant subject

chapters, but most are covered in Chapter 5: Acute, Chronic and Other Conditions.

For the Health Promotion and Prevention measures, some of the overall observations include:

• Kaiser Permanente frequently performed at or above the 90

percentile nationally on preventive

screening measures while most other plans performed in the 25

to 90

percentile.

• For the three HEDIS preventive care measures Covered California identified as priority

measures — breast, cervical, and colorectal cancer screening — not only was there wide

variation observed among plans over the past four years, but from two to six health plans

reported performance below the 25th percentile nationally — highlighting both the need and

opportunity for improvement.

• The variation in performance, with some health plans performing below the 25

percentile

nationally is reflected in the eight measures reported in Appendix 2.

Covered California Holding Health Plans Accountable for Quality and Delivery System Reform

ASSURING QUALITY CARE • CHAPTER 3

COVERED CALIFORNIA 30

Breast Cancer Screening

The Breast Cancer Screening measure is the percentage of women 50-74 years of age who have

received a mammogram to screen for breast cancer.

Table 13. Breast Cancer Screening for Covered California Enrollees

2016

2017

2018

2019

Benchmark

Percent of

Enrollees

Number of

Enrollees

Number

of Plans

Plans at 90th Percentile and

Above

MN-S

79 +

35%

477,683

Plans at 50th to 90th

Percentile

MN-S

70 to 79

118,451

Plans at 25th to 50th

Percentile

MN-S

65 to 70

43%

573,681

Plans Below 25th Percentile

MN-S

Below 65

13%

176,811

Covered California High/Average/Low Performers

Covered CA Highest

Performer

Covered CA Weighted

Average

Covered CA Lowest

Performer

Covered California Plan-Specific Performance

Anthem HMO

Anthem PPO

Anthem EPO

64,031

Blue Shield HMO

93,322

Blue Shield PPO

25%

335,176

CCHP HMO

10,013

Health Net HMO

11%

145,183

Health Net EPO

1,396

Health Net PPO

Kaiser Permanente HMO

35%

477,683

LA Care HMO

84,750

Molina Healthcare HMO

56,023

Oscar Health Plan EPO

35,962

Sharp Health Plan HMO

17,335

Valley Health Plan HMO

16,366

Western Health Advantage

HMO

9,386

*M-NS: This measure was not used in determining the overall QRS rating in 2016.

Covered California Holding Health Plans Accountable for Quality and Delivery System Reform

ASSURING QUALITY CARE • CHAPTER 3

COVERED CALIFORNIA 31

Cervical Cancer Screening

The Cervical Cancer Screening measure is the percentage of women 21-64 years of age who were

screened for cervical cancer.

Table 14. Cervical Cancer Screening for Covered California Enrollees

2016

2017

2018

2019

Benchmark

Percent of

Enrollees

Number of

Enrollees

Number

of Plans

Plans at 90th Percentile and

Above

72 +

71 +

74 +

73 +

35%

477,683

Plans at 50th to 90th

Percentile

55 to 72

56 to 71

56 to 74

56 to 73

38%

507,707

Plans at 25th to 50th

Percentile

46 to 55

47 to 56

48 to 56

20%

269,251

Plans Below 25th Percentile

Below 46

Below 47

Below 48

91,985

Covered California High/Average/Low Performers

Covered CA Highest

Performer

Covered CA Weighted

Average

Covered CA Lowest

Performer

Covered California Plan-Specific Performance

Anthem HMO

Anthem PPO

Anthem EPO

64,031

Blue Shield HMO

93,322

Blue Shield PPO

25%

335,176

CCHP HMO

10,013

Health Net HMO

11%

145,183

Health Net EPO

1,396

Health Net PPO

Kaiser Permanente HMO

35%

477,683

LA Care HMO

84,750

Molina Healthcare HMO

56,023

Oscar Health Plan EPO

35,962

Sharp Health Plan HMO

17,335

Valley Health Plan HMO

16,366

Western Health Advantage

HMO

9,386

Covered California Holding Health Plans Accountable for Quality and Delivery System Reform

ASSURING QUALITY CARE • CHAPTER 3

COVERED CALIFORNIA 32

Colorectal Cancer Screening

The Colorectal Cancer Screening measure is the percentage of adults 50-75 years of age who had

appropriate screening for colorectal cancer.

Table 15. Colorectal Cancer Screening for Covered California Enrollees

2016

2017

2018

2019

Benchmark

Percent of

Enrollees

Number of

Enrollees

Number

of Plans

Plans at 90th Percentile and

Above

MN-S

67 +

68 +

69 +

35%

477,683

Plans at 50th to 90th

Percentile

MN-S

52 to 67

54 to 68

55 to 69

17,335

Plans at 25th to 50th

Percentile

MN-S

44 to 52

45 to 54

47 to 55

52%

695,592

Plans Below 25th Percentile

MN-S

Below 44

Below 45

Below 47

12%

156,016

Covered California High/Average/Low Performers

Covered CA Highest

Performer

Covered CA Weighted

Average

Covered CA Lowest Performer

Covered California Plan-Specific Performance

Anthem HMO

Anthem PPO

Anthem EPO

64,031

Blue Shield HMO

93,322

Blue Shield PPO

25%

335,176

CCHP HMO

10,013

Health Net HMO

11%

145,183

Health Net EPO

1,396

Health Net PPO

Kaiser Permanente HMO

35%

477,683

LA Care HMO

84,750

Molina Healthcare HMO

56,023

Oscar Health Plan EPO

35,962

Sharp Health Plan HMO

17,335

Valley Health Plan HMO

16,366

Western Health Advantage

HMO

9,386

*M-NS: This measure was not used in determining the overall QRS rating in 2016.

Covered California Holding Health Plans Accountable for Quality and Delivery System Reform

ASSURING QUALITY CARE • CHAPTER 3

COVERED CALIFORNIA 33

Section 3. Implications for the Future

Covered California included reporting requirements related to smoking cessation and obesity

management programs because substantial evidence shows that effective interventions can improve

health outcomes and reduce health care costs.

Based on the inability of insurers to provide

information on program participation in a consistent manner, Covered California is considering other

ways to promote these services including exploring the feasibility of (1) collecting clinical data to

improve enrollee identification or (2) better tracking of program availability and participation rates and

perhaps using large databases that predict public health risks by census track. Covered California is

working with insurers to ensure these health promotion and prevention programs are offered in the

languages spoken by their enrollees and further promote the availability of translation services.

In the major areas related to health plan measures of screening, the main observation from the

reporting over the past four years is that there is wide variation among the plans. Kaiser Permanente

and Sharp Health Plan frequently report screening rate scores that are in the top 90

percentile in the

nation; while other most of the other plans have lower scores – ranging from the 25

to just above the

percentile. The fact that several health plans performed below the 25

percentile nationally on

cancer screenings and on other preventive care measures detailed in Appendix 2 — in particular, six

health plans had a breast cancer screening rate score below the 25

percentile — is concerning and

warrants concerted efforts from both Covered California and the health plans to address. Low

screening rates could be partially attributed to poor data collection techniques and lack of patient

education and engagement. Covered California is engaging with its contracted health plans to develop

strategies to improve their screening rates.

The ability of integrated systems, such as Kaiser Permanente and Sharp Health Plan, to achieve such

positive results is a clear indicator of what is possible with well-coordinated and integrated care. In

future years, Covered California should assess what factors can contribute to better performance

among non-integrated plans and how the performance of integrated systems can be replicated across

California. Covered California will seek to foster national benchmark performance across all plans.

The most current best evidence is documented in Chapter 2, Health Promotion and Prevention, of a companion Covered California report,

Current Best Evidence and Performance Measures for Improving Quality of Care and Delivery System Reform.

Covered California Holding Health Plans Accountable for Quality and Delivery System Reform

ASSURING QUALITY CARE • CHAPTER 4

COVERED CALIFORNIA 34

Chapter 4: Mental Health and

Substance Use Disorder Treatment

Mental Health and Substance Use Disorder

Treatment includes health insurance company

activities to identify, engage and provide treatment to

those with mental health conditions and substance

use disorders, and ensure that they are provided with

timely and effective care that is integrated with their

general health care needs.

This chapter on Mental Health and Substance Use

Disorder Treatment is organized as follows:

Section 1. Qualified Health Plan Experience

Section 2. Health Plan Measures Reported to the

Marketplace Quality Rating System

Section 3. Implications for the Future

Section 1. Qualified Health Plan

Experience

Qualified Health Plan Experience presents

performance data reported by insurers for contract

requirements and includes assessments and

observations by Covered California. Covered

California recognizes the critical importance of

mental health and substance use disorder treatment,

collectively “behavioral health services,” in improving

health outcomes and reducing costs. Consistent with

the ACA’s expansion of mental health and substance

use disorder services and promotion of integrating

these services into mainstream health care, Covered

California requires insurers to report progress on:

1. Making behavioral health services available

to enrollees;

2. Integrating behavioral health services with

medical services; and

3. Reporting the percent of enrollees cared for

in an integrated behavioral health model.

In the absence of an established best practice for

integrating medical and behavioral health services in

2016, the current contract requirements largely focus

on gathering qualitative information about health

insurance company strategies. Covered California

has summarized strategies reported by insurers but

• For the adult behavioral health

measures, there is wide variation in

performance among the plans over the

past four years with most health plans

performing poorly. For two of three

priority measures in 2019, six or more

plans performed below the 25

percentile. For each of the three

measures, only one plan performed at

or above the 90

percentile nationally.

Covered California is actively engaging

with insurers on how to improve in

these areas.

• To promote access to and availability

of behavioral health services, insurers

report a range of activities, including

increasing provider capacity,

implementing telehealth services, and

adopting new CPT codes that support

care collaboration.

• Insurers are pursuing a broad

spectrum of behavioral health

integration efforts, including co-location

of services, increased coordination

with carve-out vendors, and embedded

behavioral health staff in primary care

clinics.

• The percent of enrollees cared for

under an integrated behavioral health

model appears to have increased

between 2015 and 2018.

Requirements for future reporting are

being revised to better support tracking

and trending of behavioral health

integration.

• Covered California is exploring how

best to use patient-reported outcome

measures to track improvement in

behavioral health care. Monitoring

outcomes for behavioral health is a

major gap in assessing performance of

insurers and the delivery system.

Highlights

Covered California Holding Health Plans Accountable for Quality and Delivery System Reform

ASSURING QUALITY CARE • CHAPTER 4

COVERED CALIFORNIA 35

notes that these qualitative descriptions will benefit from standardized definitions to better quantify

adoption in future reporting.

Promoting Availability of Behavioral Health Services, 2015, 2017 and 2018

The following are strategies one or more health insurance companies adopted to promote the

availability of behavioral health services during 2015, 2017 and 2018:

• Added a full-time Behavioral Health Medical Director to the physician leadership team; added

mental health providers, psychiatrists (including with bilingual skills), and medical social workers

to the provider network;

• Increased access in the following ways:

o Offered more appointments through expanded hours and expanded and improved

facilities where mental health and wellness care is provided;

o Allow enrollees to self-refer to behavioral health providers instead of requiring prior

authorization;

o Provided open access to free-standing network for professional and facility behavioral

health providers;

o Offered a telehealth program, with some offering a 24/7 program for behavioral health

services, including programs to improve psychiatry access;

o Annually monitored access through provider-to-member ratios, provider surveys,

member experience surveys, grievances and appeals and HEDIS results;

o Required underperforming providers to implement a corrective action plan;

o Offered classes on behavioral health; and

o Provided online patient portals.

• Adopted Psychiatric Care Collaborative Current Procedural Terminology (CPT) codes to

Physician Fee schedules and removed prior authorization requirements for behavioral health

outpatient services;

• Expanded opioid treatment and implemented a disease management program for depression;

• Carve-out or subcontracted vendors educated primary care physicians about behavioral health

services via hotlines, online toolkits, and provided access to Behavioral Health Integration

specialists and Community Transition coordinators some of whom were also on the medical

staff of physician organizations; and

• Deployed an electronic care management program that provides virtual psychiatric support and

financial incentives to improve care for patients with behavioral health issues, including

screenings and online consultations.

Data only available for plan year 2015 and plan years 2017-18. Covered California waived data collection for plan year 2016.

Covered California Holding Health Plans Accountable for Quality and Delivery System Reform

ASSURING QUALITY CARE • CHAPTER 4

COVERED CALIFORNIA 36

Integrating Behavioral Health Services with Primary Care, 2015, 2017 and 2018

The following are strategies one or more health insurance companies engaged in to integrate

behavioral health services with primary care during 2015, 2017 and 2018:

• Developed a universal consent form to allow data sharing between primary care and behavioral

health providers;

• Primary care physicians and behavioral health providers coordinated care through the same

medical record or through an e-management model that facilitated communication and

electronic data sharing. Leveraged an integrated data warehouse (medical, behavioral health,

pharmacy, etc.) to identify gaps in care and at-risk members for interventions by case

managers;

• Primary care physicians referred directly to behavioral health case management programs for

assistance with complex care patients; case management departments at the plan level helped

facilitate referrals to medical groups or providers; outpatient behavioral health departments that

were in the same physical location as primary care, pharmacy, and specialty services helped

facilitated primary care physician referrals and team-based care;

• Implemented a “Feedback-Informed Care” model which involves soliciting an enrollee’s

feedback about the therapy process and allowing them to direct their care;

• Implemented a pay-for-performance program that connected primary care physicians with

behavioral health providers to coordinate on referrals and care coordination;

• Integrated behavioral health with providers participating in Accountable Care Organization

(ACO) models;

• Worked with a health system to integrate psychiatrists within primary care clinics;

• Provided care management following discharge from an inpatient setting;

• Implemented a co-management strategy that involves integrated clinical rounds between

medical and behavioral health teams; and

• Managed behavioral health needs through carve-out vendors or delegated providers as follows:

o Enhanced coordination of behavioral and physical health care through housing carve-out

vendors onsite, monthly joint clinical rounds or weekly integration meetings with co-

located providers.

o Carve-out vendors monitored outcomes, such as case management volume and

engagement, utilization management trends, and quality of care issues.

o Shared data with carve-out vendors to monitor drug interactions and compliance.

o Held periodic meetings with delegated behavioral health providers to focus on a variety

of topics, including data, best practices, communication and collaboration, referral

processes, HEDIS measures performance, and CAHPS Experience of Care and Health

Outcomes (ECHO) survey results.

Data only available for plan year 2015 and plan years 2017-18. Covered California waived data collection for plan year 2016.

Covered California Holding Health Plans Accountable for Quality and Delivery System Reform

ASSURING QUALITY CARE • CHAPTER 4

COVERED CALIFORNIA 37

Enrollees Cared for in an Integrated Behavioral Health Model, 2015 and 2018

Health insurance companies reported the percent of enrollees cared for in an integrated behavioral

health model (IBHM) based on their respective definitions as current contract requirements do not

include standard reporting on best practices implemented (e.g., use of unified care plans or patient

registries). It is important to note that this measure also does not capture the range of health insurance

company activities for behavioral health integration. As the percent of enrollees cared for in an IBHM is

a quantitative measure, the following numbers should be viewed with caution since (1) there has not

been a standard definition for an IBHM and (2) insurers reported incomplete data and Covered

California observed year-to-year inconsistencies.

In 2015, 2 percent of Covered California enrollees were cared for in an IBHM; with individual insurers

ranging from 0 to 6 percent.

Based on incomplete numbers for 2018, enrollees cared for in an IBHM

model appears to have increased to 11 percent, with reporting insurers ranging from 0 to 34 percent.

Given the challenges observed to date, requirements for future reporting will be based on standardized

best practices to support tracking and trending adoption of behavioral health integration.

Section 2. Health Plan Measures Reported to the Marketplace Quality

Rating System

Health Plan Measures Reported to the Marketplace Quality Rating System detail health plan

performance on Healthcare Effectiveness Data Information Set (HEDIS) and Consumer Assessment of

Healthcare Providers and Systems (CAHPS) measures reported to the Centers for Medicaid and

Medicare Services’ Quality Rating System (QRS). These standard performance measures are a key

mechanism used by Covered California for health plan oversight and accountability. To more sharply

focus health plan accountability efforts, Covered California examined over 40 measures used by QRS

and is proposing to prioritize a subset of 13 measures.

The following tables display the priority measures for Mental Health and Substance Use Disorder

Treatment in the QRS measure set (with one additional measure detailed in Appendix 2: Additional

Health Plan Measures Reported to the Quality Rating System) and include the Covered California

weighted average, highest and lowest performing plans, plan-specific performance, as well as national

percentiles for all Marketplace plans:

1. Antidepressant Medication Management (Table 16)

2. Follow Up After Hospitalization for Mental Illness (Table 17)

3. Initiation and Engagement of Alcohol and Other Drug Abuse or Dependence Treatment (Table

18)

See Appendix 2: Additional Health Plan Measures Reported to the Quality Rating System, for one

additional QRS measure that pertains to Mental Health and Substance Use Disorder Treatment: Follow

Up Care for Children Prescribed ADHD Medication (ADD) (Table A9). Covered California is evaluating

Data only available for plan year 2015 and plan years 2017-18. Covered California waived data collection for plan year 2016.

Data only available for plan years 2015 and 2018. Covered California waived data collection for plan year 2016 and 2017.

Covered California Holding Health Plans Accountable for Quality and Delivery System Reform

ASSURING QUALITY CARE • CHAPTER 4

COVERED CALIFORNIA 38

available behavioral health measures for children as part of its work in finding the right measures for

subpopulations.

Appendix 2 also describes how to interpret the display of the measures.

For the priority adult behavioral health measures, there is wide variation in performance among the

health plans over the past four years with most plans performing poorly. For two of three priority

measures in 2019 (Antidepressant Medication Management and Initiation and Engagement of Alcohol

and Other Drug Abuse or Dependence Treatment), six or more plans performed below the 25

percentile. For each of the three measures, only one plan performed at or above the 90

percentile

nationally.

Covered California recognizes that there are additional behavioral health measures, such as Utilization

of the Patient Health Questionnaire-9 to Monitor Depression Symptoms for Adolescents and Adults,

that use clinical data to monitor patients at the time of diagnosis and outcomes over time and therefore

better represent the quality of care for depression. However, slow progress has been made in California

in collecting clinical or patient reported outcome measures through 2018. Until most health insurance

companies are collecting clinical data-based measures, Covered California must rely on the existing

behavioral health measures.

Covered California Holding Health Plans Accountable for Quality and Delivery System Reform

ASSURING QUALITY CARE • CHAPTER 4

COVERED CALIFORNIA 39

Antidepressant Medication Management

The Antidepressant Medication Management measure is the percentage of members 18 years of age

and older who were treated with antidepressant medication, had a diagnosis of major depression and

who remained on an antidepressant medication treatment.

1. Effective Acute Phase Treatment: The percentage of members who remained on an

antidepressant medication for at least 84 days (12 weeks).

2. Effective Continuation Phase Treatment: The percentage of members who remained on an

antidepressant medication for at least 180 days (6 months).

Table 16. Antidepressant Medication Management for Covered California Enrollees

2016

2017

2018

2019

Benchmark

Percent of

Enrollees

Number of

Enrollees

Number

of Plans

Plans at 90th Percentile and

Above

MN-S

72 +

73 +

16,366

Plans at 50th to 90th

Percentile

MN-S

63 to 72

63 to 73

64 to 73

37%

495,018

Plans at 25th to 50th

Percentile

MN-S

58 to 63

57 to 63

59 to 64

10%

138,670

Plans Below 25th Percentile

MN-S

Below 58

Below 57

Below 59

52%

695,176

Covered California High/Average/Low Performers

Covered CA Highest

Performer

Covered CA Weighted

Average

Covered CA Lowest

Performer

Covered California Plan-Specific Performance

Anthem HMO

Anthem PPO

Anthem EPO

64,031

Blue Shield HMO

93,322

Blue Shield PPO

25%

335,176

CCHP HMO

10,013

Health Net HMO

11%

145,183

Health Net EPO

Health Net PPO

Kaiser Permanente HMO

36%

477,683

LA Care HMO

84,750

Molina Healthcare HMO

56,023

Oscar Health Plan EPO

35,962

Sharp Health Plan HMO

17,335

Valley Health Plan HMO

16,366

Western Health Advantage

HMO

9,386

*M-NS: This measure was not used in determining the overall QRS rating in 2016.

Covered California Holding Health Plans Accountable for Quality and Delivery System Reform

ASSURING QUALITY CARE • CHAPTER 4

COVERED CALIFORNIA 40

Follow Up After Hospitalization for Mental Illness

The Follow Up After Hospitalization for Mental Illness measure is the percentage of discharges for

members 6 years of age and older who were hospitalized for treatment of selected mental illness and

who had a follow-up visit with a mental health practitioner within 7 days after discharge.

Table 17. Follow Up After Hospitalization for Mental Illness for Covered California Enrollees

2016

2017

2018

2019

Benchmark

Percent of

Enrollees

Number of

Enrollees

Number

of Plans

Plans at 90th Percentile and

Above

67 +

64 +

59 +

39%

477,683

Plans at 50th to 90th

Percentile

48 to 67

41 to 64

38 to 59

39%

480,359

Plans at 25th to 50th

Percentile

38 to 48

31 to 41

29 to 38

110,657

Plans Below 25th Percentile

Below 38

Below 31

Below 29

12%

148,781

Covered California High/Average/Low Performers

Covered CA Highest

Performer

Covered CA Weighted

Average

Covered CA Lowest

Performer

Covered California Plan-Specific Performance

Anthem HMO

Anthem PPO

Anthem EPO

64,031

Blue Shield HMO

93,322

Blue Shield PPO

28%

335,176

CCHP HMO

Health Net HMO

12%

145,183

Health Net EPO

Health Net PPO

Kaiser Permanente HMO

39%

477,683

LA Care HMO

84,750

Molina Healthcare HMO

Oscar Health Plan EPO

Sharp Health Plan HMO

17,335

Valley Health Plan HMO

Western Health Advantage

HMO

Covered California Holding Health Plans Accountable for Quality and Delivery System Reform

ASSURING QUALITY CARE • CHAPTER 4

COVERED CALIFORNIA 41

Initiation and Engagement of Alcohol and Other Drug Abuse or Dependence Treatment

The Initiation and Engagement of Alcohol and Other Drug Abuse or Dependence Treatment (IET)

measure is the percentage of adolescent and adult members with a new episode of alcohol or other

drug (AOD) dependence who received the following:

1. Initiation of AOD Treatment: The percentage of members who initiate treatment through an

inpatient AOD admission, outpatient visit, intensive outpatient encounter or partial

hospitalization, telehealth or medication treatment within 14 days of the diagnosis.

2. Engagement of AOD Treatment: The percentage of members who initiated treatment and who

had two or more additional AOD services or medication treatment within 34 days of the initiation

visit.

Table 18. Initiation and Engagement of Alcohol and Other Drug Abuse or Dependence Treatment for

Covered California Enrollees

2016

2017

2018

2019

Benchmark

Percent of

Enrollees

Number of

Enrollees

Number of

Plans

Plans at 90th Percentile and

Above

28 +

30 +

31 +

32 +

36%

477,683

Plans at 50th to 90th Percentile

21 to 28

21 to 30

23 to 31

24 to 32

Plans at 25th to 50th Percentile

18 to 21

19 to 23

19 to 24

36%

490,372

Plans Below 25th Percentile

Below 18

Below 19

28%

377,175

Covered California High/Average/Low Performers

Covered CA Highest Performer

Covered CA Weighted Average

Covered CA Lowest Performer

Covered California Plan-Specific Performance

Anthem HMO

Anthem PPO

Anthem EPO

64,031

Blue Shield HMO

93,322

Blue Shield PPO

25%

335,176

CCHP HMO

10,013

Health Net HMO

11%

145,183

Health Net EPO

Health Net PPO

Kaiser Permanente HMO

36%

477,683

LA Care HMO

84,750

Molina Healthcare HMO

56,023

Oscar Health Plan EPO

35,962

Sharp Health Plan HMO

17,335

Valley Health Plan HMO

16,366

Western Health Advantage

HMO

9,386

Covered California Holding Health Plans Accountable for Quality and Delivery System Reform

ASSURING QUALITY CARE • CHAPTER 4

COVERED CALIFORNIA 42

Section 3. Implications for the Future

Covered California included reporting requirements related to mental health and substance use

disorder treatment services because of the significant unmet needs of enrollees and the increasing

evidence that integrating primary care and behavioral health services improves health outcomes and

delivers a return on investment by reducing downstream health care costs. Several models including

collaborative care, co-location and telehealth have demonstrated success.

While insurers report a wide array of approaches to promoting the availability of behavioral health

services and the integration of behavioral health services with primary care, it is difficult to measure if

these efforts are translating to better behavioral health care or outcomes for consumers. Covered

California is determining how to promote better measurement and accountability in this area which may

involve standardized definitions and use of best practices to support tracking and trending of available

services and adoption of behavioral health integration.

For measures of behavioral health quality, the main observation from the reporting over the past four

years is that there is wide variation among the plans and while some scores reflect high percentile

ranking, for many measures there are multiple health plans that are performing poorly compared to

national benchmark data. For the priority adult behavioral health measures, there is wide variation in

performance among the health plans over the past four years with most plans performing poorly. For

two of three priority measures in 2019 (Antidepressant Medication Management and Initiation and

Engagement of Alcohol and Other Drug Abuse or Dependence Treatment), six or more plans

performed below the 25

percentile. For each of the three measures, only one plan performed at or

above the 90

percentile nationally. This is concerning and warrants further concerted efforts from both

Covered California and its contracted health plans to address. Covered California is engaging with

health plans on adopting best practices for behavioral health care and developing strategies to improve

their performance on these behavioral health measures.

Covered California is also seeking to improve behavioral health measurement. The current HEDIS

behavioral health measures in the QRS measure set should be replaced or updated. None assess

behavioral health status or outcomes making performance assessment of health insurance companies

and the delivery system difficult. Covered California is exploring how best to use patient-reported

outcome measures for behavioral health. One promising measure is the use of the Patient Health

Questionnaire-9 (PHQ-9) because it can be used to both identify patients with depression symptoms

and monitor their outcomes over time. However, slow progress has been made in California because

this measure relies on collecting clinical data.

There is significant opportunity for collaboration on spreading integrated behavioral health models and

collecting clinical data through statewide collaboratives including the Integrated Healthcare Association

and California Quality Collaborative.

The most current best evidence is documented in Chapter 3, Mental Health and Substance Use Disorder Treatment, of a companion

Covered California report, Current Best Evidence and Performance Measures for Improving Quality of Care and Delivery System Reform.

Covered California Holding Health Plans Accountable for Quality and Delivery System Reform

ASSURING QUALITY CARE • CHAPTER 5

COVERED CALIFORNIA 43

Chapter 5: Acute, Chronic and Other

Conditions

Acute, Chronic and Other Conditions entails

health insurance companies actively managing

care for enrollees with acute conditions, which is

defined as an illness or disease that is short-term

and lasts typically a few days to weeks (such as

an infection, an injury or the misuse of

medications), chronic conditions, which typically

develop slowly over time and last months to years

(such as diabetes, most cancers, cardiovascular

disease, and infectious diseases like Human

Immunodeficiency Virus) and other conditions

that are temporary, such as pregnancy or

gestational diabetes.

In addition, this chapter, Acute, Chronic and

Other Conditions, encompasses subpopulations

covered in subject chapters of this report:

Chapter 4: Mental Health and Substance Use

Disorder Treatment; Chapter 6: Complex Care;

Chapter 7: Promotion of Effective Primary Care;

and Chapter 10: Appropriate Interventions.

This chapter on Acute, Chronic, and Other

Conditions is organized as follows:

Section 1. Health Plan Measures Reported to the

Marketplace Quality Rating System

Section 2. Implications for the Future

Section 1. Health Plan Measures

Reported to the Marketplace Quality

Rating System

As described in previous chapters, one key mechanism used by Covered California for health

insurance company oversight and accountability is public reporting of global and individual health plan

quality performance measures to the Centers for Medicaid and Medicare Services’ Marketplace Quality

Rating System (QRS). To more sharply focus health plan accountability efforts, Covered California

examined over 40 measures used by QRS and is proposing to prioritize a subset of 13 measures.

The following tables display the priority measures for Acute, Chronic and Other Condition measures in

the QRS measure set (with 11 additional measures detailed in Appendix 2: Additional Health Plan

Measures Reported to the Quality Rating System) and include the Covered California weighted

average, highest and lowest performing plans, plan-specific performance, as well as national

percentiles for all Marketplace plans:

1. Comprehensive Diabetes Care: Hemoglobin A1c (HbA1c) Control (<8.0%) (Table 19)

• For the measures related to care for

chronic conditions, there is wide variation

among plans, with Kaiser Permanente and

Sharp Health Plan being among the 90

percentile nationally, while other plans

have a range of scores. The ability of

these integrated delivery systems to

achieve such positive results is a clear

indicator of what is possible with well-

coordinated and integrated care. Covered

California is assessing what factors

contribute to better performance among

non-integrated systems and how this

performance can be replicated across

California.

• Enrollee satisfaction with their health plan

and care is comparable to nationwide

results for most Covered California plans.

However, compared to the nation,

enrollees report less favorably about their

access to care and how well their care is

coordinated. For these two priority CAHPS

Measures, Access to Care and Care

Coordination, most plans’ scores cluster

around the national 50

percentile or

below the 25

percentile. CAHPS results

for marketplace plans nationwide are

highly compressed with only a few points

difference among percentile and all results

are relatively high compared to other

measures.

Highlights

Covered California Holding Health Plans Accountable for Quality and Delivery System Reform

ASSURING QUALITY CARE • CHAPTER 5

COVERED CALIFORNIA 44

2. Controlling High Blood Pressure (Table 20)

3. Plan All-Cause Readmissions (Table 21)

4. Access to Care (Table 22)

5. Care Coordination (Table 23)

See Appendix 2: Additional Health Plan Measures Reported to the Quality Rating System, for the 11

additional QRS measures that pertain to Acute, Chronic and Other Conditions:

6. Proportion of Days Covered (RAS Antagonists) (Table A10)

7. Proportion of Days Covered (Statins) (Table A11)

8. Proportion of Day Covered (Diabetes All Class) (Table A12)

9. Comprehensive Diabetes Care: Eye Exam (Retinal) Performed (Table A13)

10. Comprehensive Diabetes Care: Hemoglobin A1c (HbA1c) Testing (Table A14)

11. Comprehensive Diabetes Care: Medical Attention for Nephropathy (Table A15)

12. Medication Management for People with Asthma (75% of Treatment Period) (Table A16)

13. Prenatal and Postpartum Care (Postpartum Care) (Table A17)

14. Prenatal and Postpartum Care (Timeliness of Prenatal Care) (Table A18)

15. Well-Child Visits in the First 15 Months of Life (6 or More Visits) (Table A19)

16. Well-Child Visits in the Third, Fourth, Fifth, and Sixth Years of Life (Table A20)

Appendix 2 also describes how to interpret the display of the measures.

For the measures related to care for chronic conditions, there is wide variation among plans, with

Kaiser Permanente and Sharp Health Plan being among the 90

percentile nationally, while other plans

have a range of scores. The ability of these integrated delivery systems to achieve such positive results

is a clear indicator of what is possible with well-coordinated and integrated care. Covered California is

assessing what factors contribute to better performance among non-integrated systems and how this

performance can be replicated across California.

The wide variation in performance is particularly meaningful for measures related to managing diabetes

and hypertension that target the opportunities to improve the morbidity and mortality attributable to

these conditions. Better performance on these indicators means there would be fewer adverse events

and more lives saved. A 1 percent reduction in HbA1c reduces diabetes-related deaths by 21 percent

and myocardial infarctions (heart attacks) by 14 percent.

For every 10 percent reduction in

HbA1c (e.g., 10 to 9 or 9 to 8) the risk of progression to blindness fell 44 percent, progression to kidney

failure fell 25 percent, and loss of sensation in the feet by 30 percent.

Another study estimated the

effect of having all health plans nationally achieve the 90

percentile on measures focused on diabetes

and cardiovascular disease found it would result in 2.3 million fewer heart attacks (a reduction of 22

percent), 800,000 fewer strokes (a reduction of 12 percent) as well as reduced incidence of several

Stratton, I. M., Adler, A. I., Neil, H. A., Matthews, D. R., Manley, S. E., Cull, C. A., … Holman, R. R. (2000). Association of glycaemia with

macrovascular and microvascular complications of type 2 diabetes (UKPDS 35): prospective observational study. BMJ (Clinical research

ed.), 321(7258), 405–412. doi:10.1136/bmj.321.7258.405

Nathan, D. M., Bayless, M., Cleary, P., Genuth, S., Gubitosi-Klug, R., Lachin, J. M., … DCCT/EDIC Research Group (2013). Diabetes

control and complications trial/epidemiology of diabetes interventions and complications study at 30 years: advances and

contributions. Diabetes, 62(12), 3976–3986. doi:10.2337/db13-1093

Covered California Holding Health Plans Accountable for Quality and Delivery System Reform

ASSURING QUALITY CARE • CHAPTER 5

COVERED CALIFORNIA 45

other less common complications over a ten year period.

The researchers estimated approximately

4.9 million years of life would have been saved during this same period.

Covered California health insurers generally have worse scores than the rest of the nation on the

Access to Care and Care Coordination measures, with the majority of insurers below the 25

percentile

and none above the 50

. It is important to note that the CAHPS results for marketplace plans

nationwide are highly compressed with only a few points difference among each percentile and all

results are relatively high compared to other measures. Also, California’s demographic diversity

includes greater numbers of people in race/ethnicity groups who tend to give plans lower scores. This

suggests insurers may not meet the needs of all groups equally. Covered California sees these

enrollee-experience scores as reason for both concern and future research. Covered California is

working with its health insurance companies to assure improvement in these areas and is seeking to

expand the number and sources of measures that can best assess consumers’ experience in access to

care, care coordination and other important quality domains.

Note these estimates are from a 2008 study based on the Archimedes simulation model. At the time, impacts were modeled for the U.S.

population of 210 million adults ages 18-85 over a ten-year period, 1995-2005: Eddy, D. M., Pawlson, L. G., Schaaf, D.

Covered California Holding Health Plans Accountable for Quality and Delivery System Reform

ASSURING QUALITY CARE • CHAPTER 5

COVERED CALIFORNIA 46

Comprehensive Diabetes Care: Hemoglobin A1c (HbA1c) Control (<8.0%)

The Comprehensive Diabetes Care: Hemoglobin A1c (HbA1c) Control measure is the percentage of

members 18–75 years of age with diabetes (type 1 and type 2) whose most recent HbA1c level was

less than 8 percent.

Table 19. Comprehensive Diabetes Care: Hemoglobin A1c (HbA1c) Control (<8.0%) for Covered California

Enrollees

2016

2017

2018

2019

Benchmark

Percent of

Enrollees

Number of

Enrollees

Number

of Plans

Plans at 90th Percentile and

Above

67 +

69 +

68 +

37%

495,018

Plans at 50th to 90th

Percentile

56 to 67

58 to 67

59 to 69

58 to 68

43%

582,871

Plans at 25th to 50th

Percentile

46 to 56

48 to 58

50 to 59

52 to 58

17%

223,389

Plans Below 25th Percentile

Below 46

Below 48

Below 50

Below 52

45,348

Covered California High/Average/Low Performers

Covered CA Highest

Performer

Covered CA Weighted

Average

Covered CA Lowest

Performer

Covered California Plan-Specific Performance

Anthem HMO

Anthem PPO

Anthem EPO

64,031

Blue Shield HMO

93,322

Blue Shield PPO

25%

335,176

CCHP HMO

10,013

Health Net HMO

11%

145,183

Health Net EPO

1,396

Health Net PPO

Kaiser Permanente HMO

35%

477,683

LA Care HMO

84,750

Molina Healthcare HMO

56,023

Oscar Health Plan EPO

35,962

Sharp Health Plan HMO

17,335

Valley Health Plan HMO

16,366

Western Health Advantage

HMO

9,386

Covered California Holding Health Plans Accountable for Quality and Delivery System Reform

ASSURING QUALITY CARE • CHAPTER 5

COVERED CALIFORNIA 47

Controlling High Blood Pressure

The Controlling High Blood Pressure measure is the percentage of members 18–85 years of age who

had a diagnosis of hypertension and whose blood pressure was adequately controlled.

Table 20. Controlling High Blood Pressure for Covered California Enrollees

2016

2017

2018

2019

Benchmark

Percent of

Enrollees

Number of

Enrollees

Number

of Plans

Plans at 90th Percentile and Above

76 +

77 +

75 +

35%

477,683

Plans at 50th to 90th Percentile

58 to 76

59 to 76

61 to 77

62 to 75

20%

273,647

Plans at 25th to 50th Percentile

49 to 58

47 to 59

49 to 61

54 to 62

37%

495,303

Plans Below 25th Percentile

Below 49

Below 47

Below 49

Below 54

99,993

Covered California High/Average/Low Performers

Covered CA Highest Performer

Covered CA Weighted Average

Covered CA Lowest Performer

Covered California Plan-Specific Performance

Anthem HMO

Anthem PPO

Anthem EPO

64,031

Blue Shield HMO

93,322

Blue Shield PPO

25%

335,176

CCHP HMO

10,013

Health Net HMO

11%

145,183

Health Net EPO

1,396

Health Net PPO

Kaiser Permanente HMO

35%

477,683

LA Care HMO

84,750

Molina Healthcare HMO

56,023

Oscar Health Plan EPO

35,962

Sharp Health Plan HMO

17,335

Valley Health Plan HMO

16,366

Western Health Advantage HMO

9,386

Covered California Holding Health Plans Accountable for Quality and Delivery System Reform

ASSURING QUALITY CARE • CHAPTER 5

COVERED CALIFORNIA 48

Plan All-Cause Readmissions

The Plan All-Cause Readmissions measure is a ratio that compares the number of acute inpatient

stays for members 18–64 years of age that were followed by an unplanned acute readmission for any

diagnosis within 30 days to the predicted number of acute readmissions.

This measure compares the

actual readmission rate of a health plan to the expected admission rate. If the actual readmission rate is

lower than the expected readmission rate, the plan is performing better at reducing readmissions than

expected and the plan would have a measure value less than 100. A plan can have a measure value

above 100 if their observed rate was greater than their expected rate meaning their performance was

worse than expected. A lower rate indicates better performance.

Table 21. Plan All-Cause Readmissions for Covered California Enrollees

2016

2017

2018

2019

Benchmark

Percent of

Enrollees

Number of

Enrollees

Number of

Plans

Plans at 90th Percentile and

Above

M-NS

<= 58

<= 53

<= 52

17,335

Plans at 50th to 90th Percentile

M-NS

78 to 58

76 to 53

71 to 52

54%

693,735

Plans at 25th to 50th Percentile

M-NS

88 to 78

86 to 76

77 to 71

37%

477,683

Plans Below 25th Percentile

M-NS

Above 88

Above 86

Above 77

94,136

Covered California High/Average/Low Performers

Covered CA Highest Performer

Covered CA Weighted Average

Covered CA Lowest Performer

163

119

Covered California Plan-Specific Performance

Anthem HMO

Anthem PPO

Anthem EPO

64,031

Blue Shield HMO

93,322

Blue Shield PPO

26%

335,176

CCHP HMO

163

Health Net HMO

11%

145,183

Health Net EPO

Health Net PPO

Kaiser Permanente HMO

37%

477,683

LA Care HMO

119

84,750

Molina Healthcare HMO

56,023

Oscar Health Plan EPO

Sharp Health Plan HMO

17,335

Valley Health Plan HMO

115

Western Health Advantage HMO

103

9,386

The observed to expected readmission rates are multiplied by 100 to convert to whole numbers.

Covered California Holding Health Plans Accountable for Quality and Delivery System Reform

ASSURING QUALITY CARE • CHAPTER 5

COVERED CALIFORNIA 49

*M-NS: This measure was not used in determining the overall QRS rating in 2016.

Access to Care

The Access to Care measure is based on four 2019 QHP Enrollee Survey questions about enrollee’s

experience of receiving care:

1. In the last 6 months, when you needed care right away, in an emergency room, doctor’s office, or

clinic, how often did you get care as soon as you needed?

2. In the last 6 months, how often did you get an appointment for a check-up or routine care at a

doctor’s office or clinic as soon as you needed?

3. In the last 6 months, how often was it easy to get the care, tests, or treatment you needed?

4. In the last 6 months, how often did you get an appointment to see a specialist as soon as you

needed?

Table 22. Access to Care for Covered California Enrollees

2016

2017

2018

2019

Benchmark

Percent of

Enrollees

Number of

Enrollees

Number of

Plans

Plans at 90th Percentile and

Above

81 +

82 +

84 +

80 +

Plans at 50th to 90th Percentile

76 to 81

77 to 82

80 to 84

75 to 80

Plans at 25th to 50th Percentile

72 to 76

74 to 77

77 to 80

72 to 75

62%

839,580

Plans Below 25th Percentile

Below 72

Below 74

Below 77

Below 72

38%

505,650

Covered California High/Average/Low Performers

Covered CA Highest Performer

Covered CA Weighted Average

Covered CA Lowest Performer

Covered California Plan-Specific Performance

Anthem HMO

Anthem PPO

Anthem EPO

64,031

Blue Shield HMO

93,322

Blue Shield PPO

25%

335,176

CCHP HMO

10,013

Health Net HMO

11%

145,183

Health Net EPO

Health Net PPO

Kaiser Permanente HMO

36%

477,683

LA Care HMO

84,750

Molina Healthcare HMO

56,023

Oscar Health Plan EPO

35,962

Sharp Health Plan HMO

17,335

Valley Health Plan HMO

16,366

Western Health Advantage

HMO

9,386

Covered California Holding Health Plans Accountable for Quality and Delivery System Reform

ASSURING QUALITY CARE • CHAPTER 5

COVERED CALIFORNIA 50

Care Coordination

The Care Coordination measure is based on six 2019 QHP Enrollee Survey questions about enrollee’s

experience of receiving care:

1. When you visited your personal doctor for a scheduled appointment in the last 6 months, how often

did he or she have your medical records or other information about your care?

2. In the last 6 months, when your personal doctor ordered a blood test, x-ray, or other test for you,

how often did someone from your personal doctor’s office follow up to give you those results?

3. In the last 6 months, when your personal doctor ordered a blood test, x-ray, or other test for you,

how often did you get those results as soon as you needed them?

4. In the last 6 months, how often did your personal doctor seem informed and up-to-date about the

care you got from specialists?

5. In the last 6 months, how often did you and your personal doctor talk about all the prescription

medicines you were taking?

6. In the last 6 months, did you get the help that you needed from your personal doctor’s office to

manage your care among these different providers and services?

Table 23. Care Coordination for Covered California Enrollees

2016

2017

2018

2019

Benchmark

Percent of

Enrollees

Number of

Enrollees

Number

of Plans

Plans at 90th Percentile and

Above

88 +

89 +

88 +

87 +

Plans at 50th to 90th Percentile

84 to 88

85 to 89

85 to 88

83 to 87

Plans at 25th to 50th Percentile

82 to 84

82 to 85

83 to 85

81 to 83

35,962

Plans Below 25th Percentile

Below 82

Below 83

Below 81

97%

1,309,268

Covered California High/Average/Low Performers

Covered CA Highest Performer

Covered CA Weighted Average

Covered CA Lowest Performer

Covered California Plan-Specific Performance

Anthem HMO

Anthem PPO

Anthem EPO

64,031

Blue Shield HMO

93,322

Blue Shield PPO

25%

335,176

CCHP HMO

10,013

Health Net HMO

11%

145,183

Health Net EPO

Health Net PPO

Kaiser Permanente HMO

36%

477,683

LA Care HMO

84,750

Molina Healthcare HMO

56,023

Oscar Health Plan EPO

35,962

Sharp Health Plan HMO

17,335

Valley Health Plan HMO

16,366

Western Health Advantage HMO

9,386

Covered California Holding Health Plans Accountable for Quality and Delivery System Reform

ASSURING QUALITY CARE • CHAPTER 5

COVERED CALIFORNIA 51

Section 2. Implications for the Future

For these health plan measures for addressing chronic illnesses, the main observation from the

reporting over the past four years is that there is wide variation among the plans. Kaiser Permanente

and Sharp Health Plan frequently report providing services or getting results that are in the top 90

percentile in the nation, while other plans have lower scores – ranging from the 25

to just above the

percentile. The wide variation in performance is particularly meaningful for measures related to

managing diabetes and hypertension that do a remarkable job of targeting the opportunities to improve

the morbidity and mortality attributable to those conditions. Improvement in performance across all

California plans would be potentially life-saving and clinically meaningful for hundreds of thousands of

Californians.

The ability of integrated delivery systems to achieve such positive results is a clear indicator of what is

possible with well-coordinated and integrated care. Covered California is assessing what factors

contribute to better performance among non-integrated systems and how this performance can be

replicated across California.

Covered California identified four priority CAHPS measures. For two of these measures — overall

satisfaction with care and with their health plan — most Covered California health plans perform above

the 50

percentile compared to national marketplace plans (see Chapter 2: Individualized, Equitable

Care). It is concerning that 8 health plans score below the 25

percentile on members' Access to Care

and that 11 health plans score below the 25

percentile for Care Coordination. It is important to note

that the CAHPS results for marketplace plans nationwide are highly compressed with only a few points

difference among each percentile and all results are relatively high compared to other measures.

Covered California sees these enrollee-experience scores as reason for both concern and future

research and is working with its health insurance companies to assure improvement in these areas.

Covered California is also seeking to expand the number and sources of measures that can best

assess consumers’ experience in access to care, care coordination and other important quality

domains.

Covered California Holding Health Plans Accountable for Quality and Delivery System Reform

ASSURING QUALITY CARE • CHAPTER 6

COVERED CALIFORNIA 52

Chapter 6: Complex Care

Complex Care involves effectively managing very

complex conditions for individuals that require a

multitude of specialty, high-cost treatments – such

as rare cancers or transplants – or require end of life

care. These individuals need to be managed

effectively, provided well-coordinated care, or be

seen in very specialized settings.

This chapter on Complex Care presents

performance data reported by health insurance

companies for contract requirements and includes

assessments and observations by Covered

California. This chapter is organized as follows:

Section 1. Qualified Health Plan Experience

Section 2. Implications for the Future

Section 1: Qualified Health Plan

Experience

Qualified Health Plan Experience presents

performance data reported by health insurance

companies for contract requirements and includes

assessments and observations by Covered

California. The current contract requirements for

Complex Care largely focus on health plan

processes for effectively managing at-risk enrollees

with complex conditions, defined as: “clinical

conditions that are of a complex nature that typically

involve ongoing case management support from

appropriately trained clinical staff. Frequently,

individuals have multiple chronic clinical conditions

that complicate management (“polychronic”) or may

have a complex, infrequent specialty condition that

requires specialized expertise for optimal

management.”

It has been shown that when high-risk enrollees are

identified early, they are most likely to benefit from

See Glossary of Key Terms for Attachment 7 to Covered California 2017 Qualified Health Plan Contract: Quality, Network Management,

and Delivery System Standards, and Improvement Strategy: https://hbex.coveredca.com/insurance-companies/PDFs/Attachment-7-

Amended-for-2019.pdf.

• All insurers leverage medical and

pharmacy claims as well as

demographic information to identify

high-cost or high-risk patients for

various care and case management

support, but there is no consistent

measurement of the efficacy of their

efforts, primarily due to the lack of

standard population identification or

quality measures for complex care.

• All insurers contracted with Centers of

Excellence (COE), with the most

common treatments being cancer care

and bariatric surgery. Identification and

performance measurement for COEs is

not standardized.

• Only one insurer had a formal steerage

program for transplants while most

insurers promote their COEs by relying

on member interactions with the

service center or care management

team.

• Most health plans offered Health Risk

Assessments (HRAs) to determine

enrollee health status on a voluntary

basis, but completion rates are very

low.

• A large-scale effort to support at-risk

enrollees in effective coverage

transitions coordinated by Covered

California and insurers occurred when

Anthem exited multiple rating regions

in 2018, affecting nearly 137,000

consumers.

Highlights

Covered California Holding Health Plans Accountable for Quality and Delivery System Reform

ASSURING QUALITY CARE • CHAPTER 6

COVERED CALIFORNIA 53

well-coordinated care. As such, Covered California has the following requirements for health plans to

address complex care:

1. Coordinating treatment for enrollees with conditions that required high specialized management,

such as transplant patients, and the use of Centers of Excellence (COEs) for these enrollees;

2. Collecting information to monitor enrollee health status;

3. Tracking changes in health status and the use of health risk assessments;

4. Supporting at-risk enrollees requiring transition; and

5. Identification and services for at-risk enrollees.

Centers of Excellence

Health insurance companies are required to report on how enrollees with conditions that require highly

specialized management, like transplant patients and burn patients, are managed by providers with

documented special experience and proficiency based on volume and outcome data, such as Centers

of Excellence (COEs). Centers of Excellence allow for complex care patients to be seen in very

specialized settings, such as National Cancer Institute designated cancer centers.

Although there are no standards for identifying COEs, described below are common themes discussed

by insurers about the process for use and promotion of COEs to enrollees with specialized conditions,

as well as the strategy for including COEs in each insurer’s network (see Table 24. Covered California

Insurer Processes and Strategies for Use of Centers of Excellence, 2015, 2017 and 2018). All insurers

contract with COEs but only one insurer has a formal steerage program to direct enrollees to COEs for

transplants. Most health insurance companies promote COEs through enrollee interactions with their

service centers or care management teams. Other insurers simply note that COEs are available in their

Evidence of Coverage documents.

Table 24. Covered California Insurer Processes and Strategies for Use of Centers of Excellence, 2015,

2017 and 2018

Process: Promotion of Centers of Excellence

• Steered all members to transplant COEs and encouraged use of COEs for other conditions

• Member services or concierge teams assisted members in locating designated facilities and managing

benefit requirements and limitations

• Care managers and medical directors drove appropriate use of these facilities

• Did not actively promote or steer members; identified COEs in coverage documents

Strategy: Basis for Inclusion in Network

• Must meet or exceed a specific level of volume and outcomes while demonstrating adherence to industry

standards; inclusion in network reviewed yearly

• Only contracted with COEs when a specific highly-specialized method of care was not available in-network;

established single case referrals with COEs for specific procedures

• Stringent selection criteria for choosing COEs; only included in provider directory if contracted for long-term

versus one-time arrangements

• Used COEs for transplants approved by the Department of Health Care Services (DHCS)

• No formal COEs, but network included specific hospitals for tertiary and transplant cases

Source: Covered California Staff Analysis of Qualified Health Plan Submitted Data

Data only available for plan year 2015 and plan years 2017-18. Covered California waived data collection for plan year 2016.

Covered California Holding Health Plans Accountable for Quality and Delivery System Reform

ASSURING QUALITY CARE • CHAPTER 6

COVERED CALIFORNIA 54

All 11 health insurance companies provided enrollees’ access to at least two types of Centers of

Excellence in 2018. Nine insurers provided access to at least one type of COE specializing in

transplants, eight health plans offered a COE for cancer care, seven health plans offered a COE for

bariatric surgery, and six plans offered a COE for burn care (see Table 25. Covered California

Enrollees’ Access to Centers of Excellence for Specialized Conditions, 2015, 2017 and 2018). A lower

number of health plans offered COEs for cardiac care and orthopedics (such as hip and knee surgery).

Table 25. Covered California Enrollees’ Access to Centers of Excellence for Specialized Conditions, 2015,

2017 and 2018

Number of Health Plans

2015

2017

2018

Cancer

Transplants

Cardiac Care

Bariatric Surgery

Orthopedics

Burn Care

Note: Covered California did not specifically ask if health plans contract with COEs for cardiac care or orthopedics. Additional health plans

may contract with COEs for these conditions.

Source: Covered California Staff Analysis of Qualified Health Plan Submitted Data

Collecting Information to Monitor Enrollee Health Status

Health insurance companies are required to describe how they collect and report, at both the individual

and aggregate levels, changes in enrollee health status. For example, reporting by insurers may

include a comparative analysis of health status improvements across geographic regions and

demographic groups. Health insurance companies are required to describe their process to monitor and

track health status, which may include identifying individuals who show a decline in health status, and

referral of such enrollees to care management programs.

In 2018, eight insurers described a system for collecting data on enrollee health status (either a clinical

system for determining health status or the use of a survey). All insurers leveraged medical and

pharmacy claims as well as demographic information to identify high-cost or high-risk patients for

various care and case management support. Integrated delivery systems, such as Kaiser Permanente

and Sharp Health Plan, leveraged access to more clinical data, such as lab results.

Health risk assessments (HRAs) can be used in concert with clinical data for predictive modeling for

early intervention. HRAs are an important tool that can accurately stratify individuals with the highest

risk because they capture both physical and behavioral health needs as well as social needs.

Data only available for plan year 2015 and plan years 2017-18. Covered California waived data collection for plan year 2016.

Covered California Holding Health Plans Accountable for Quality and Delivery System Reform

ASSURING QUALITY CARE • CHAPTER 6

COVERED CALIFORNIA 55

Determining Enrollee Health Status and Use of Health Risk Assessments

Health insurance companies are required to describe their capabilities in collecting information about

enrollees’ health status and behaviors for health promotion and improved care management. If the

insurer used health risk assessments to determine health status, the following requirements apply:

1. The assessment must be offered in all threshold languages to enrollees over the age of 18,

including those that have previously completed such an assessment;

2. The assessment tool must adequately evaluate an enrollee’s current health status and provide a

mechanism to conduct ongoing monitoring for future intervention(s); and

3. Enrollees should be made aware at the beginning of the assessment about how information

collected may be used, that they may opt in to receive information from the insurer, and that

participation in the assessment is optional.

Most insurers offered HRAs on a voluntary basis, but completion rates reported by insurers for 2018

were very low. HRA completion rates ranged from 0 to 38 percent with 8 of the 11 insurers reporting

under 6 percent completion.

While HRA completion rates were low for the overall population, insurers had several activities and

capabilities that supported HRAs and best evidence supports targeted HRA collection for at-risk

individuals (see Table 26. Covered California Insurer Activities and Capabilities Supporting Health Risk

Assessments, 2018).

Most health insurance companies took multiple steps to address at-risk

behaviors reported in an HRA. Eleven insurers generated a personalized report after completion which

provided members specific actions they can take to lower their risk and directed them to a targeted

intervention module. Three insurers auto-enrolled members into a disease management program and

two allowed members the option to send assessment results to their physician. Given the lack of data,

health insurance companies reported limited ability to proactively link enrollees with smoking cessation

or weight management programs that they all offer.

Table 26. Covered California Insurer Activities and Capabilities Supporting Health Risk Assessments,

2018

Number of

Health Plans

Addressing At-Risk Behaviors

Personalized HRA report is generated after HRA completion that provides member-

specific risk modification actions based on responses

Members are directed to targeted interactive intervention module for behavior change

upon HRA completion

At point of HRA response, risk-factor education is provided to member based on

member-specific risk

Case manager or health coach outreach call triggered via HRA results

Member can update responses and track against previous responses

Ongoing push messaging for self-care based on member's HRA results

Member is automatically enrolled into a disease management or at-risk program

based on responses

Member can elect to have HRA results sent electronically to physician

The capabilities reported by health insurance companies only apply to the small number of enrollees they reported as successfully

completing the Health Risk Assessment.

Covered California Holding Health Plans Accountable for Quality and Delivery System Reform

ASSURING QUALITY CARE • CHAPTER 6

COVERED CALIFORNIA 56

Tracking Health Status

HRA responses tracked over time to observe changes in health status

HRA responses incorporated into member health record

HRA responses used for analysis of health status across demographics

HRA responses used for analysis of health status across regions

Source: Covered California Staff Analysis of Qualified Health Plan Submitted Data

Supporting At-Risk Enrollees Requiring Transition

Health insurance companies must demonstrate that they are able to facilitate transitions of care with

minimal disruption for enrollees that (1) switched from one insurer into another or (2) into or out of

coverage through Covered California. This requirement for supporting at-risk enrollees is broader than

the continuity of care requirements in state law. Covered California’s contracts with the majority of

health insurance companies in California which places it in the unique position to better facilitate

transitions of care for this population that will result in enrollees receiving the right care at the right time.

Covered California is particularly concerned about transitions for the following “at-risk” enrollees:

1. Individuals in the middle of acute treatment, third trimester pregnancy, or those who would

otherwise qualify for continuity of care under California law;

2. Individuals in case management programs;

3. Individuals in disease management programs; and

4. Individuals on maintenance prescription drugs for a chronic condition.

If enrollees experience a service area disruption, Covered California may automatically transition the

enrollee into a different health insurance company to avoid gaps in coverage and facilitate care

transitions. If this occurs, the insurer terminating the enrollee has several requirements, including

conducting outreach to the affected enrollee, obtaining authorization to send personal health

information to the receiving health insurance company, and collaborating with impacted providers.

Identification and Services for At-Risk Enrollees

Health insurance companies are required to identify and proactively manage enrollees with existing and

newly diagnosed chronic conditions, including “at-risk enrollees” with diabetes, asthma, heart disease,

or hypertension, who are most likely to benefit from well-coordinated care. Insurers must agree to

support disease management activities at the insurer or provider level that meet standards of

accrediting programs such as NCQA. Health insurance companies provide Covered California with a

documented process, care management plan and strategy for targeting and managing at-risk enrollees.

Such documentation may include (but is not limited to) methods to identify and target at-risk enrollees,

description of predictive analytic capabilities, member communication plans, care and network

strategies, and data on the number of enrollees identified as well as the types of services provided.

Most health insurance companies reported identifying at-risk enrollees with algorithms and other

proprietary technology based on claims and utilization data.

Some insurers described using

demographic data, HRA data, hospital discharge data, clinical data, and nurse advice line and provider

referral data.

No data was summarized in a table for 2018 due to specific proprietary technologies mentioned and because four out of 11 insurers

explained what data they collected but did not explain how they analyzed the data for at-risk enrollee identification.

Covered California Holding Health Plans Accountable for Quality and Delivery System Reform

ASSURING QUALITY CARE • CHAPTER 6

COVERED CALIFORNIA 57

The type of services offered to at-risk enrollees varies substantially across insurers (see Table 27.

Types of Interventions for Covered California At-Risk Enrollees Eligible for Case Management, 2018).

All health insurance companies offered some level of live outbound telephonic coaching to members.

Most offered member-specific reminders for health maintenance services (10 of 11) or face-to-face

visits (six of 11). Online interactive self-management support was less common, with four of 11 plans

offering it to high-risk or all enrollees.

Supporting At-Risk Enrollees Transitioning between Covered California Insurers:

Experience Assuring Care Transitions for over 135,000 Californians in 2018

In much of the nation, there has been substantial instability in insurers serving different states’

individual market. One of the risks of insurers exiting markets is the potential for disruption of care

for those with complex health care needs. California has been marked by stability among its

insurers. The only significant disruption from an insurer changing its service areas occurred when

Anthem exited multiple rating regions in 2018, affecting nearly 137,000 consumers — about 10

percent of Covered California enrollees — while remaining in large portions of the state. Covered

California worked closely with Anthem and all other health insurers receiving transitioning enrollees

to assure effective transitions. Carrying out an effective transition of Anthem enrollees required

partnership and collaboration among Covered California staff, the health insurance companies

receiving transitioning enrollees, and Anthem. Covered California and receiving insurers began

working with Anthem staff months before the transitions in coverage to ensure appropriate and

seamless continuity and transitions of care to protect the most vulnerable populations. The goal was

to identify enrollees with specific care needs and to transfer information about enrollee’s care needs

to the receiving insurer.

This collaboration required Anthem and receiving insurers to agree to identifying an appropriate

level of data required for transitioning enrollees, parameters on data sharing and use and processes

to receive and act upon consumer information. At-risk enrollees included those undergoing case or

disease management services as well as those with pregnancy/maternity and specialty medication

needs. The data sharing resulted in receiving insurers having sufficient information to do timely

consumer outreach. This outreach was of utmost benefit to consumers who would have otherwise

navigated the health care system alone.

Covered California Holding Health Plans Accountable for Quality and Delivery System Reform

ASSURING QUALITY CARE • CHAPTER 6

COVERED CALIFORNIA 58

Table 27. Types of Interventions for Covered California At-Risk Enrollees Eligible for Case Management,

2018

Number of Health Plans

Type of Intervention

Not Offered

Offered in High-Risk

Program

Available for All

Enrollees

Member specific reminders for health

maintenance services

Member specific reminders for medication

events

5**

Interactive voice response with outbound

messaging only

Live outbound telephonic coaching program

Self-initiated text/email messaging

Online interactive self-management support

Face-to-face visits

*Includes contradictory responses from one health plan.

**Includes contradictory responses from two health plans.

Source: Covered California Staff Analysis of Qualified Health Plan Submitted Data

Section 2: Implications for the Future

Measurement of performance in caring for enrollees requiring complex care requires further

development. Covered California found no standard quality measures for Complex Care to include in

this chapter. The current Marketplace Quality Rating System measure set has one measure for

behavioral health subpopulations, Follow Up After Hospitalization for Mental Illness (FUH) (HEDIS),

which is presented in Chapter 4. The Plan All-Cause Readmissions measure, which is presented in

Chapter 5, may include complex care patients but does not specifically measure care management

processes or outcomes.

In a Covered California sponsored report released in July 2019, Current Best Evidence and

Performance Measures for Improving Quality Care and Delivery System Reform, Health Management

Associates (HMA) recommended a hybrid method of population stratification starting with automated

data to identify high cost enrollees combined with survey data such as HRAs, behavioral health

screening, screening for social needs or measuring patient activation to determine enrollees who are

likely to continue to be high-risk and high-cost. In the same report, PricewaterhouseCoopers (PwC)

recommended that Covered California use its claims data warehouse to track rates of inpatient and

Emergency Department use and Emergency Department follow-up among complex care patients. PwC

also recommended that Covered California consider the Transition of Care HEDIS measure which

would require collection of discharge information that includes test results.

Covered California is working with health insurance companies and other stakeholders to establish best

practices for population identification and management including a standardized approach to defining

and measuring performance of Centers of Excellence.

Covered California Holding Health Plans Accountable for Quality and Delivery System Reform

EFFECTIVE CARE DELIVERY • CHAPTER 7

COVERED CALIFORNIA 59

EFFECTIVE CARE DELIVERY

Chapter 7: Promotion of Effective

Primary Care

Effective Primary Care that is accessible, well-

integrated, coordinated, continuous, team-based,

and data driven is a core foundation of providing

appropriate and equitable care. While many

consumers benefit from an ongoing continuous

relationship with a single physician, others may be

able to receive effective primary care through

sites of care or delivery systems that are well-

integrated.

This chapter on Promotion of Effective Primary

Care presents performance data for current

contract requirements reported by health

insurance companies for the 2015-18 plan years

and includes assessments and observations by

Covered California. This chapter is organized as

follows:

Section 1. Qualified Health Plan Experience

Section 2: Health Plan Measures Reported to the

Marketplace Quality Rating System

Section 3. Implications for the Future

Section 1: Qualified Health Plan

Experience

Covered California believes promoting the Triple

Aim and promoting health equity requires a

foundation of effectively delivered primary care,

which the Institute of Medicine defines as follows:

“the provision of integrated, accessible health

care services by clinicians who are accountable

for addressing a large majority of personal health

needs, developing a sustained partnership with

patients, and practicing in the context of family

and community.”

To this end, Covered California

promotes effective primary care with the following

requirements:

Institute of Medicine. 1994. Defining Primary Care: An Interim Report. Washington, DC: The National Academies Press.

https://doi.org/10.17226/9153.

• Starting in 2017, virtually all Covered

California’s enrollees either selected or

were matched with a primary care

provider — including all enrollees in PPO

model plans. Covered California is

assessing the impact of this novel effort.

• While virtually all primary care provided in

Kaiser Permanente is delivered by

patient-centered medical home-

recognized practices, outside of this

system, enrollment served by PCMHs

increased from 3 percent to 11 percent

between 2016 and 2018.

• Several insurers are supporting primary

care providers in clinical transformation to

advanced primary care, though not

meeting PCMH standards. Measurement

of primary care performance will likely

need to go beyond PCMH recognition

process measures to include outcomes.

• Based on the Health Care Payment

Learning and Action Network Alternative

Payment Model Framework, 10 insurers

now have Positive Incentives or Strong

Incentives for transitioning from volume-

based to value-based primary care

payment.

• Significant increases were observed for

shared savings and capitation-based

payments between 2015-18. However,

further assessment is needed to

determine the extent to which capitation to

medical groups or physician organizations

cascades to individual providers.

• For insurers to continue to adopt value-

based primary care payment or to

increase investment, measurement of

primary care performance will likely need

to include outcomes.

Highlights

Covered California Holding Health Plans Accountable for Quality and Delivery System Reform

EFFECTIVE CARE DELIVERY • CHAPTER 7

COVERED CALIFORNIA 60

1. Ensure that all enrollees either select or be matched with a primary care physician (PCP) within 60

days of enrollment;

2. Insurers are required to have an increasing percentage of their enrollees cared for in patient-

centered medical home models and annually report the number and percent of enrollees who

obtain their care in a patient-centered medical home (PCMH); and

3. Describe how the insurer’s payment strategy supports primary care physicians in adopting

accessible, data-driven, team-based care with accountability for meeting the Triple Aim goals of

enhanced quality, improved outcomes and lower costs.

Primary Care Physician Matching

In January 2017, Covered California required that all enrollees in preferred provider organizations

(PPO), health maintenance organizations (HMO), and exclusive provider organizations (EPO), be

matched to a primary care physician (PCP) or other primary care clinician, such as a nurse practitioner,

upon enrollment. The purpose of the requirement was to bring the PCP match concept to the PPO and

EPO environment and give enrollees a single point of contact who can help them navigate the health

care system. A primary care physician can provide continuity and

address most health care needs, helps consumers select the proper

specialist, coordinates their care with other providers and ensures

they understand their treatment options. While having a PCP can

help select and coordinate care across specialty providers, enrollees

in PPO and EPO plans can still choose to navigate the health care

system on their own without permission from their PCP to seek

treatment or a referral to see a specialist.

Since 2017, virtually all Covered California’s enrollees, over 99

percent, either selected or were matched with a PCP upon enrollment

which was nearly a 30-percentage point increase from the 2016

baseline rate of 70 percent.

Covered California believes this PCP match will ultimately help people get better access to care in a

timelier manner. However, many enrollees may need more explanation of why working with their PCP

is beneficial. Covered California is currently working with its plans to examine the data to understand

the patient experience and clinical and financial effects of this program. Covered California will look to

examine outcomes of clinical measures that may improve with a strong foundation in primary care.

Promoting Enrollment in Patient-Centered Medical Homes

A growing body of evidence shows that advanced models of primary care, which include patient-

centered medical homes (PCMHs), greatly improve the care delivered to patients and support Triple

Aim goals. Advanced primary care models utilize a patient-centered, accessible, team-based approach

to care delivery, enrollee engagement and data-driven improvement, as well as integration of care

management, behavioral health and community resources for patients with complex conditions. Under

the existing contract requirement, insurers are required to have an increasing portion of enrollees who

Covered California Holding Health Plans Accountable for Quality and Delivery System Reform

EFFECTIVE CARE DELIVERY • CHAPTER 7

COVERED CALIFORNIA 61

obtain their care in a PCMH model and plans must use formal recognition programs to assess which

providers are PCMHs.

While there have been significant increases in the percentage of enrollees seen in PCMH settings,

health insurance companies report that many in their primary care networks believe the current

requirement tied to PCMH recognition is too limited and burdensome. As of 2018, about 40 percent of

Covered California enrollees received primary care through providers that met PCMH standards. The

great majority of that enrollment, however, was through Kaiser Permanente, which represented 82

percent of total PCMH enrollment in 2018. The percentage of enrollees cared for by PCMH-recognized

practices, outside of the Kaiser Permanente system, increased threefold from 3 percent to 11 percent

between 2016 and 2018, an 8-point increase (see Table 28. Percentage of Covered California

Enrollees Cared for in Patient Centered Medical Homes, 2016-18). When looking at all insurers during

the three years, the percent of Covered California enrollees who were cared for in PCMHs increased

from 25 percent in 2015 to 40 percent in 2018. One of Sharp Health Plan’s integrated medical groups

achieved PCMH recognition in 2018 to comply with the Covered California requirement and this change

accounts for most of the overall increase outside Kaiser Permanente. The percent of Sharp Health Plan

enrollees cared for in a PCMH increased from 15 percent in 2017 to 66 percent in 2018.

Table 28. Percentage of Covered California Enrollees Cared for in

Patient-Centered Medical Homes, 2016-18

2016

2017

2018

All Enrollment

25%

32%

40%

Kaiser Permanente

100%

Non-Kaiser Permanente

11%

Source: Covered California Staff Analysis of Qualified Health Plan Submitted Data

Covered California has found that formal PCMH recognition programs have limitations and have been

challenged as other measures of advanced primary care have evolved. The formal PCMH recognition

programs largely document process improvement without measuring outcomes. Many advanced

primary care practices have not sought formal recognition and many that have been recognized have

implemented process improvements, but these may not have led to improvement in clinical quality or

reduced cost. Additionally, several health insurance companies are focusing on primary care practice

transformation programs that include practice coaching to support primary care providers in improving

quality and efficiency rather than requiring or promoting PCMH recognition. Based on this feedback

from health insurance companies and providers, Covered California is examining alternative

approaches to promote improvements in primary care and assuring more enrollees benefit from these

programs.

Payment Strategies that Promote Effective Primary Care

The Affordable Care Act included several demonstration projects and grants to test payment reforms

that would shift volume-driven Fee-for-Service (FFS) payments to methods that link provider payment

The current contract requirements list the following recognition programs: a) National Committee for Quality Assurance PCMH recognition;

b) The Joint Commission Primary Care Medical Home certification; c) Accreditation Association for Ambulatory Health Care, Inc. Medical

Home accreditation; and d) URAC PCMH Certification.

Covered California Holding Health Plans Accountable for Quality and Delivery System Reform

EFFECTIVE CARE DELIVERY • CHAPTER 7

COVERED CALIFORNIA 62

with performance on cost and quality. To measure health insurance company progress in payment

strategies that promote accountability for Triple Aim goals, Covered California leveraged the four

categories in the Health Care Payment Learning and Action Network (HCP LAN) Alternative Payment

Model (APM) Framework

(see Table 29. Covered California Assessment of Primary Care Payment

Strategies Based on the HCP LAN Alternative Payment Model Framework, 2015, 2017 and 2018).

While PCMHs are delivery models, not payment models, the Alternative Payment Model Framework

notes that PCMHs and advanced primary care need the support of value-based payment models.

Shifting payments from FFS to payments that increasingly hold primary care providers financially at-risk

for high-quality care creates incentives for managing cost and quality. In assessing payment strategies,

Covered California requires its contracted health plans to pay increasingly based on “Category 3:

Shared Savings” and “Category 4: Population-based Payment,” which Covered California reports below

as having Positive Incentives and Strong Incentives, respectively.

As of 2018, Covered California assessment found that 10 health insurance companies were paying

providers with either Positive Incentives or Strong Incentives for value – an increase of two insurers

from 2015. More insurers are now assessed to have Positive Incentives or Strong Incentives.

Table 29. Covered California Assessment of Primary Care Payment Strategies

Based on the HCP LAN Alternative Payment Model Framework, 2015, 2017 and 2018

Number of Health Plans

Covered

California

Assessment

APM Framework

2015

2017

2018

Strong

Incentives

Category 4 – Population-based Payment

• Condition-specific population-based payment

including per member per month payments

• Comprehensive population-based payment such

as global budgets or percent of premium

payments

• Integrated finance and delivery system such as

global budgets in integrated systems

Positive

Incentives

Category 3 – APMs built on an FFS architecture:

• APMs with shared savings (upside risk only)

• APMs with share savings and downside risk

Weak

Incentives

Category 2 – FFS– Link to quality and value

• Foundational payments for infrastructure and

operations

• Pay for reporting

• Pay for performance

• Rewards and penalties for performance

Category 1 – Fee-for-Service (FFS)– No link to

quality and value

Health Care Payment Learning and Action Network. (2017). Alternative Model Payment Framework. Retrieved from http://hcp-

lan.org/workproducts/apm-refresh-whitepaper-final.pdf.

Data only available for plan year 2015 and plan years 2017-18. Covered California waived data collection for plan year 2016.

Covered California Holding Health Plans Accountable for Quality and Delivery System Reform

EFFECTIVE CARE DELIVERY • CHAPTER 7

COVERED CALIFORNIA 63

Source: Covered California Staff Analysis of Qualified Health Plan Submitted Data

As expected, payment strategies to PCPs vary widely (see Figure 4. Covered California Insurer

Payment Strategies for Primary Care Providers, 2015 – 2018), but from 2015 to 2018 there has been a

significant increase in payment to providers being based on capitation (increasing from 41 percent to 53

percent) and shared savings (increasing from 8 percent to 18 percent). The decline in payments to

primary care providers based on fee-for-service and the fact that Covered California plans now pay 71

percent of primary care providers using capitation or shared savings is important progress. At the same

time, based on discussions with insurers and provider groups, there is reason to be concerned that

capitation payments made to medical groups or physician organizations may not cascade to individual

providers, many of whom continue to be largely paid on a fee-for-service basis.

Figure 4. Covered California Insurer Payment Strategies for Primary Care Providers, 2015 – 2018

Note: “Other” refers to payments types that insurers could not breakdown into the four HCP LAN categories. These percentages are

enrollment weighted and may not equal 100 due to rounding.

Source: California Staff Analysis of Qualified Health Plan Submitted Data

According to the HCP LAN, in calendar year 2018, about 56 percent of national commercial market

total health care payments were FFS (Category 1), 14 percent of payments were FFS with a link to

quality (Category 2), 28 percent of payments were shared savings (Category 3) and only 2 percent of

payments were population-based payments or capitation.

This data is collected through surveys of

Health Care Payment Learning and Action Network. Measuring Progress: Adoption of Alternative Payment Models in Commercial,

Medicaid, Medicare Advantage, and Traditional Medicare Programs. October 24, 2019. Retrieved from: http://hcp-

lan.org/workproducts/apm-methodology-2019.pdf.

Covered California Holding Health Plans Accountable for Quality and Delivery System Reform

EFFECTIVE CARE DELIVERY • CHAPTER 7

COVERED CALIFORNIA 64

health insurance companies and represents about 133.5 million covered lives which is 61 percent of the

national commercial market. Although this data represents all commercial health care payments, it

suggests that Covered California insurers have made significant progress in moving towards capitation

or population-based payment and away from FFS payments for primary care providers compared to the

rest of the nation. In 2018, only 22 percent of Covered California insurer’s primary care payments were

FFS compared to the national rate of 56 percent FFS for all health care payments for the commercial

market.

Interaction of Payment Strategies, Patient-Centered Medical Homes, and Promotion of

Advanced Primary Care

At this time, there is not enough information to establish a link between payment strategies and the

percent of members cared for in a PCMH. There appears to be a clearer relationship between

increased enrollment in a PCMH model and whether the plan is part of an integrated delivery system.

Some health insurance companies assessed by Covered California to have Strong Incentives for their

payment strategies also had a higher percent of enrollees cared for in PCMHs (e.g., Kaiser

Permanente pays 100 percent of its primary care physicians a population-based payment, which is

considered a Category 4 APM, and 100 percent of its providers are PCMH recognized). Kaiser

Permanente and Sharp Health Plan, both fully integrated delivery systems, are high outliers for

enrollment in a PCMH model. However, the other nine health insurance companies of which some are

considered to have Weak Incentives because they paid their providers FFS, had similar percentages of

enrollees cared for in a PCMH as those with Strong Incentives or Positive Incentives. In some

instances, it was also difficult to attribute a relationship between specific payment strategies and

enrollees cared for in a PCMH because some providers simultaneously received enhanced

reimbursements for PCMH recognition from other payers, such as Medi-Cal.

Strategies to Enroll or Attribute Enrollees to Patient-Centered Medical Homes

Although not definitive, there may be a relationship between promoting PCMH-recognized providers to

enrollees and the percent of enrollees cared for in a PCMH. Between 2015 and 2018, most health

insurance companies did not actively promote PCMH providers to enrollees or actively assign or match

enrollees to PMCHs. The few insurers that listed PCMH recognition in provider directories were

observed to have higher rates of enrollees cared for in a PCMH.

Section 2: Health Plan Measures Reported to the Marketplace Quality

Rating System

Health Plan Measures Reported to the Marketplace Quality Rating System details health plan

performance on Healthcare Effectiveness Data Information Set (HEDIS) and Consumer Assessment of

Healthcare Providers and Systems (CAHPS) measures reported to the Centers for Medicaid and

Medicare Services’ Quality Rating System (QRS). These standard performance measures are a key

mechanism used by Covered California for health plan oversight and accountability.

See Appendix 2: Additional Health Plan Measures Reported to the Quality Rating System, for Quality

Rating System measures that pertain to Promotion of Effective Primary Care:

1. Rating of Personal Doctor (CAHPS) (Table A21)

2. Rating of Specialist (CAHPS) (Table A22)

The patient experience reporting of enrollees Rating of Personal Doctor showed wide variation but was

marked by the fact that 9 of 11 health plans — representing 89 percent of enrollees — had ratings

Covered California Holding Health Plans Accountable for Quality and Delivery System Reform

EFFECTIVE CARE DELIVERY • CHAPTER 7

COVERED CALIFORNIA 65

below the 25

percentile nationally. However, the range of scores is exceedingly narrow; for Rating of

Personal Doctor, a raw score below 86 is below the 25

percentile, while a raw score of 90 is the 90

percentile.

Section 3: Implications for the Future

Ensuring all enrollees have a PCP, regardless of their health plan product, provides a single point of

contact to help them navigate the health care system. Covered California is evaluating the impact of

PCP matching in EPO and PPO plans based on outcomes including utilization, continuity of care, cost

and quality that may improve with a strong foundation in primary care. Covered California continues to

work with insurers to help all enrollees understand the value of primary care.

Further assessment is needed to determine the extent to which capitation to medical groups or

physician organizations cascades to individual providers. Covered California will continue to require

health insurance companies to increasingly implement value-based payments for primary care

providers like shared savings and population-based payment or capitation. One of the biggest barriers

to full adoption of advanced primary care, despite the changes to payment structure described above,

appears to be inadequate revenue or resources to support well-rounded care teams, underscoring the

importance of continued efforts at primary care payment reform.

For health insurance companies to make these investments, measurement of performance will likely

need to go beyond the PCMH recognition process measures to include outcome measures that reflect

the impact advanced primary care can have improving quality, enhancing the patient experience, and

reducing total cost of care and documenting a return on investment for insurers that increase primary

care payment such that it accounts for a larger share of the overall health care budget.

Covered California Holding Health Plans Accountable for Quality and Delivery System Reform

EFFECTIVE CARE DELIVERY • CHAPTER 8

COVERED CALIFORNIA 66

Chapter 8: Promotion of Integrated

Delivery Systems and Accountable

Care Organizations

Promotion of integrated delivery systems and

accountable care organizations is premised on

the increasing evidence that effectively caring for

and managing a person’s health requires an

integrated care system that can coordinate

across providers, sites and times for a variety of

conditions while delivering good outcomes and

quality at an affordable cost.

This chapter on Promotion of Integrated Delivery

Systems and Accountable Care Organizations

presents performance data reported by health

insurance companies for contract requirements

and includes assessments and observations by

Covered California. This chapter is organized as

follows:

Section 1. Qualified Health Plan Experience

Section 2. Implications for the Future

Section 1: Qualified Health Plan

Experience

Covered California has the following

requirements for integrated delivery systems

(IDSs) or accountable care organizations (ACOs):

1. Increase enrollment over time and report

the number and percent of enrollees who

are managed under an IDS or ACO as

well as provide comparison reporting for

other lines of business;

Covered California’s recently completed evidence review affirmed the value and positive impact on quality and cost of effective care

integration and some models of Accountable Care Organization (see Current Best Evidence and Performance Measures for Improving

Quality Care and Delivery System Reform). In addition, recent data from the Integrated Health Care Association (IHA) Cost and Quality

Atlas, shows clinical quality was higher for ACO and HMO members compared to PPO members for commercial plans (see

https://atlas.iha.org/story/aco).

An integrated delivery system (IDS) is a network of physicians and healthcare facilities that provide a continuum of healthcare services

managed under one organization or one parent company. Accountable care organizations (ACOs) are groups of physicians and

healthcare facilities that share financial and medical responsibility for providing coordinated care, with financial incentives to provide high-

quality care and to limit avoidable, unnecessary spending.

• In 2018, 60 percent of Covered California

enrollees were cared for in an Integrated

Delivery System (IDS) or an Accountable

Care Organization (ACO), which

represents a 12-point increase from 2015.

After excluding the fully-integrated delivery

systems, Kaiser Permanente and Sharp

Health Plan, 25 percent of Covered

California enrollees were cared for in an

ACO, which represents a 4-point increase

from 2015 and far exceeds state and

national benchmarks.

• Nine insurers reported offering technical

support, data sharing support, or

promoting participation in health

information exchanges for providers in

2018, an increase from four insurers in

2015. Covered California has also seen a

steady increase in the number of insurers

using other common components of

integrated coordinated care such as

population health management support

and holding providers accountable using

standard quality measure sets.

• Insurers are required to report 2018

performance based on the IHA

Commercial ACO measures by year-end

2019, which will allow better

understanding of performance variation of

different ACO models and inform future

contract requirements.

Highlights

Covered California Holding Health Plans Accountable for Quality and Delivery System Reform

EFFECTIVE CARE DELIVERY • CHAPTER 8

COVERED CALIFORNIA 67

2. Provide details on the key design characteristics of existing or planned integrated systems of

care and how these systems of care compare to the definition in the Covered California

contract; and

3. Report performance of different ACO models for all lines of business using the IHA Commercial

ACO Measure Set once data becomes available for plan year 2018.

Percent of Enrollees in an Integrated Delivery System or Accountable Care Organization

Covered California requires health insurance companies to report the number and percent of enrollees

who are managed under an IDS or ACO as well as provide comparison reporting for their other lines of

business. Insurers are also are required to demonstrate an increase in the percent of enrollees who

obtain their care in an IDS or ACO model between 2017 and 2019.

Nationally, the Centers for Medicare and Medicaid Services (CMS) is leading a drive to implement

value-based payment models including integrated and coordinated delivery models such as ACOs.

Leavitt Partners tracks the growth and spread of ACOs including the new models supported by CMS

and their commercial and Medicaid analogs.

As of 2018, 10 percent of the U.S. population or 32.7

million Americans were cared for in ACOs in the commercial, Medicaid and Medicare markets. This

includes every state, with penetration ranging from 2 percent to over 20 percent. Leavitt Partners

reports that between 10 to 15 percent of Californians are cared for in such models.

In 2018, 60 percent of Covered California enrollees were cared for in an IDS or ACO, which represents

a 12-point increase from 2015 (see Figure 5. Covered California Enrollment in Integrated Delivery

Systems or Accountable Care Organizations, 2015 and 2018).

Figure 5. Covered California Enrollment in Integrated Delivery Systems or Accountable Care

Organizations, 2015 and 2018

Muhlestein et al. (2018). Recent Progress in The Value Journey: Growth of ACOs and Value-Based Payment Models in 2018. Health

Affairs blog. Retrieved from https://www.healthaffairs.org/do/10.1377/hblog20180810.481968/full/

Data only available for plan year 2015 and plan year 2017-18. Covered California did not ask this question in the Certification Application

for plan year 2016.

Covered California Holding Health Plans Accountable for Quality and Delivery System Reform

EFFECTIVE CARE DELIVERY • CHAPTER 8

COVERED CALIFORNIA 68

Source: Covered California Staff Analysis of Qualified Health Plan Data Submitted for 2015 and 2018

Note: Enrollment figures reflect only on-Exchange enrollment.

Two insurers, Kaiser Permanente and Sharp Health Plan, are fully integrated delivery systems and

account for about 60 percent of the overall number.

As of 2018, after excluding enrollment in Kaiser

Permanente and Sharp Health Plan, 25 percent of Covered California enrollees among the other

insurers were cared for in an ACO, which represents a 2-percentage point increase from 2015. It is this

latter statistic that is most comparable to the national data from Leavitt Partners; based on this report,

California has greater penetration of these new models than the U.S. and Covered California

penetration exceeds the rest of California even excluding those enrolled with Kaiser Permanente or

Sharp Health Plan.

Health Plan Components of Integrated Delivery Systems or Accountable Care

Organizations

Covered California places great importance on the adoption and expansion of integrated, coordinated

and accountable systems of care. As such, health insurance companies are required to provide details

on existing or planned integrated systems of care and how these systems of care compare to the

following definition:

1. A system of population-based care coordinated across the continuum including multi-discipline

physician practices, hospitals and ancillary providers; and

2. Having combined risk sharing arrangements and incentives between the health insurance

company and providers, and among providers across specialties and institutional boundaries,

holding the ACO accountable for nationally recognized evidence-based clinical, financial, and

operational performance, as well as incentives for improvements in population outcomes.

Based on the descriptions of their IDS or ACO models provided by insurers, Covered California has

identified several components many insurers are using in their respective models. In 2018, most

insurers (nine out of 12) reported offering technical support, data sharing support, or promoting

participation in health information exchanges for providers, an increase from four insurers in 2015 (see

Table 30. Components of Covered California Insurer’s Support for Integrated Delivery Systems or

Accountable Care Organizations, 2015, 2017 and 2018). Covered California has also seen a steady

increase in the number of health insurance companies using other common components like population

health management support and holding providers accountable using standard quality measure sets.

In Covered California, Kaiser Permanente and Sharp Health are fully integrated delivery systems while other health plans base their ACO

model on existing provider organizations, such as integrated medical group and hospitals.

Covered California Holding Health Plans Accountable for Quality and Delivery System Reform

EFFECTIVE CARE DELIVERY • CHAPTER 8

COVERED CALIFORNIA 69

Table 30. Components of Covered California Insurer’s Support for Integrated Delivery Systems or

Accountable Care Organizations, 2015, 2017 and 2018

Component

Number of Health Plans

2015

2017

2018

Data Sharing, Data Exchange and Health Information

Technology

Offers providers technical support, data sharing support, or

promotes participation in health information exchanges

Provider Support and Feedback

Offers providers opportunities to share best practices,

participate in learning collaboratives, or offers practice coaching

Quality Measurement and Improvement

Providers are held accountable for improvement using a

standardized measure set

Population Health and Case Management

Supports providers in case management or population health

management such as providing registries or care gap reports

Financial Incentives

Uses population-based capitation, shared savings or shared

risk, may also use incentives for quality

Note: Not all insurers are listed for each component. Some insurers may only be using one of these components, while others are using

several.

Source: Covered California Staff Analysis of Qualified Health Plan Data Submitted for 2015 and 2017-18.

Comparing Performance of Different ACO Models using the Integrated Healthcare

Association Commercial ACO Measure Set

The Integrated Healthcare Association (IHA) has developed a Commercial ACO Measure Set

derived

from their long-standing physician organization performance measures which has been widely adopted

in California. While it is early to assess ACO performance in California as there is enormous variation in

the structure of ACO contracts and many have only a few years of performance, IHA has begun to

report on results from using the Commercial ACO Measure Set for 85 ACO contracts in California

based on 2017 performance.

In the charts below, IHA reports performance for three mutually exclusive groups: members cared for

by ACOs representing a mix of models built on both HMO and PPO platforms, members cared for by

provider organizations under capitated, delegated HMO contracts (excluding Kaiser Permanente

medical groups), and members cared for by physicians under PPO contracts aggregated across the 19

Covered California pricing regions (see Figure 6. California Commercial ACO Performance Compared

to HMOs and PPOs, 2017). Based on IHA analysis, ACOs provide care that is the same quality at a

somewhat lower cost than either HMOs or PPOs.

Data only available for plan year 2015 and plan years 2017-18. Covered California waived data collection for plan year 2016.

The 11 health insurance companies in Covered California are: Anthem Blue Cross, Blue Shield of California, Chinese Community Health

Plan, Health Net, Kaiser Permanente, L.A. Care, Molina Healthcare, Oscar Health, Sharp Health Plan, Valley Health Plan, and Western

Health Advantage. In the tables below, Health Net is counted twice because its reports data separately for Health Net Life (PPO/EPO

products) and Health Net of California (HMO/HSP products).

See more: https://www.iha.org/our-work/accountability/commercial-aco.

Covered California Holding Health Plans Accountable for Quality and Delivery System Reform

EFFECTIVE CARE DELIVERY • CHAPTER 8

COVERED CALIFORNIA 70

Figure 6: California Commercial ACO Performance Compared to HMOs and PPOs, 2017

Source: Integrated Healthcare Association, 2019

The aggregate ACO performance is encouraging but represents an average with wide variation among

the ACOs measured (see Figure 7. Variation in Quality and Cost in California Commercial ACO

Performance, 2017).

Figure 7: Variation in Quality and Cost in California Commercial ACO Performance, 2017

Source: Integrated Healthcare Association, 2019

The 14 “high value” ACOs in the upper right-hand quadrant — representing both lower cost and better

quality — rival and sometimes exceed the performance of the best medical groups contracting with

insurance companies within HMO models and one third of these high value ACOs are operating under

PPO contracts (see Figure 8: Characteristics of 14 “High Value” ACOs in California, 2017).

Covered California Holding Health Plans Accountable for Quality and Delivery System Reform

EFFECTIVE CARE DELIVERY • CHAPTER 8

COVERED CALIFORNIA 71

Figure 8: Characteristics of 14 “High Value” ACO in California, 2017

Source: Integrated Healthcare Association, 2019

This first report from IHA comparing ACOs to other models demonstrates the potential value of

integration and coordination through ACOs and that they can be implemented through all health plan

products including PPOs.

The IHA Commercial ACO Measure Set reports for performance based on 2018 were recently released

and health insurance companies are required to report these results to Covered California. The

variation in performance among ACO contracts will be examined in cooperation with IHA, insurance

companies and provider organizations and compared to the design elements MedPAC and others

have cited as predictors of success including two-sided risk, physician leadership (as compared to

hospital leadership) and greater emphasis on advanced primary care.

Section 2: Implications for the Future

Outside of the integrated delivery systems, Covered California’s contracted health insurance

companies that share overlapping networks are implementing a variety of ACO models or components

of ACO models within their networks. Covered California enrollment in ACOs, excluding integrated

delivery systems, exceeds comparisons in California and the nation. Performance variation among

ACO models may be attributed to design elements such as the structure of financial incentives

including downside risk, the role of physicians in sponsorship and leadership structure, the percent of

budget spent in primary care and the sophistication of population health and case management

The most current best evidence is documented in Chapter 8, Promotion of Integrated Delivery Systems and Accountable Care

Organizations, of a companion Covered California report, Current Best Evidence and Performance Measures for Improving Quality of Care

and Delivery System Reform.

Primary Care Collaborative. (August 2018). Advanced Primary Care: A Key Contributor to Successful ACOs. Retrieved from:

https://www.pcpcc.org/sites/default/files/resources/PCPCC%202018%20Evidence%20Report.pdf.

Covered California Holding Health Plans Accountable for Quality and Delivery System Reform

EFFECTIVE CARE DELIVERY • CHAPTER 8

COVERED CALIFORNIA 72

strategies. IHA is building a registry based on such elements for all ACOs they measure. As discussed

above, Covered California is working with insurers to use the performance data from the IHA

Commercial ACO measure set to establish correlations with the design elements in the registry of ACO

characteristics to determine best practices and inform future contract requirements. This report cites

several ways in which integrated delivery systems are outperforming network model health plans. The

success of ACOs in replicating the performance of integrated delivery systems may depend on

alignment in adopting common best practice design elements.

Covered California Holding Health Plans Accountable for Quality and Delivery System Reform

EFFECTIVE CARE DELIVERY • CHAPTER 9

COVERED CALIFORNIA 73

Chapter 9: Networks Based on Value

As a major strategy for effective care delivery,

Covered California requires health insurance

companies to select and regularly assess all

clinicians, providers, hospitals and sites of care to

ensure that care is safe, timely, effective, efficient,

equitable, and patient-centered. Ideally, every

network is designed to integrate and coordinate care,

provides effective primary care and maximizes its

value to enrollees.

For many consumers, whether the provider they

want to see is in their network or not is the first sign

of value. Assuring consumers have access to the full

range of providers and treatments and that networks

are composed of a range of quality providers is a

central part of Covered California’s review and

selection process of its contracted insurers (see

“Covered California Network Composition Review”).

Covered California works to ensure health plan

networks are designed and maintained with a

deliberate strategy to promote better quality, lower

cost, improved health and health equity.

This chapter on Networks Based on Value presents

performance data and processes reported by health

plans for contract requirements and includes

assessments and observations by Covered

California. This chapter is organized as follows:

Section 1. Qualified Health Plan Experience

Section 2. Implications for the Future

Section 1: Qualified Health Plan

Experience

Covered California’s requirements for “Networks

Based on Value” include multiple elements related to

ensuring that network design and selection of

providers considers quality and patient experience in

addition to cost and efficiency.

Under current contract requirements, insurers report

progress to Covered California for the following:

1. The factors used to select providers and hospitals in the health plan network, including cost,

clinical quality, patient reported experience, or other factors.

• Between 2015 and 2018, more health

insurance companies were assessed

as having Considered Comprehensive

Factors (cost, quality, and patient

experience) or Considered Cost Only

as criteria for selecting or contracting

with providers and hospitals.

• For selecting providers, most insurers

noted using provider credentialing,

member satisfaction results,

grievances and appeals information,

and quality based on HEDIS

measures. Fewer insurers reported

using referral patterns to hospitals,

value or cost reduction, or IHA Align

Measure Perform (AMP) program

results for selecting providers.

• All insurers indicated that a hospital’s

designation as a Center of Excellence

was a selection factor and most

reviewed and tracked publicly reported

quality data from the Leapfrog Group,

CMS Hospital Compare, and other

quality-based organizations to

determine whether to contract with a

hospital. Fewer insurers reported

evaluations of cost or participation in

quality collaboratives as a factor in

hospital selection.

• Hospital acquired infection rates are

now reviewed routinely by health plans

with their contracted hospitals. Cal

Hospital Compare has provided health

plans four partially overlapping lists of

hospitals with consistently low

performance. Covered California is

tracking and learning how insurers use

these lists to determine next steps.

Highlights

Covered California Holding Health Plans Accountable for Quality and Delivery System Reform

EFFECTIVE CARE DELIVERY • CHAPTER 9

COVERED CALIFORNIA 74

2. Adopt policies and procedures to only contract with providers and hospitals that demonstrate

quality and promote safety at a reasonable price. Based on a definition provided by Covered

California, develop plans to exclude “outlier poor performers” on either cost or quality or

document the rationale for continued contracting with poor performers, including any

improvement efforts the provider or hospital has undertaken by year-end 2020.

3. Demonstrate action on high cost providers

by annually reporting the following:

a. The factors a health plan considers in assessing the relative unit prices and total costs of

care;

b. The extent to which the reasons for cost factors are adjusted or analyzed by elements

such as area of service, population served, market dominance, services provided by the

facility (e.g., trauma or tertiary), or other factors;

c. How such factors are used in the selection of providers and hospitals; and

d. Identification of specific hospitals and their distribution by cost deciles or other ways

providers and hospitals are grouped by costs, e.g., as a percentage of Medicare costs.

There are few best practices broadly adopted for managing networks based on value. Integrated

delivery systems such as Kaiser Permanente and Sharp Health Plan have largely exclusive networks of

hospitals and medical groups. This chapter includes an assessment of these integrated delivery

systems but largely focuses on the various strategies adopted by health insurance companies that do

not have fully integrated delivery systems and often have overlapping hospital and provider networks.

Covered California adopted a common strategy in assessing hospital quality based on publicly reported

data described in the “Sites and Expanded Approaches to Care Delivery” chapter. The hospital quality

and safety requirements serve as a foundation on which insurers can build networks based on value.

In addition to requiring insurers to design their networks based on value, Covered California conducts

annual reviews of each health plan’s network (see Covered California Network Composition Review).

Covered California also requires health plans to report on the use of cost transparency tools as one of the strategies to ensure providers

are not charging unduly high prices. See Chapter 10, Appropriate Interventions for health plan reporting on this topic.

Covered California Network Composition Review

As part of its annual contracting cycles, Covered California assesses network composition including

the number and types of physicians, medical groups and hospitals that are unique to particular health

plans or available through multiple plans. Covered California also assesses the geographical

distribution of health plan networks through drive times to hospitals and other indicators of how a

health plan’s distribution of providers assures consumers have timely access to care. Covered

California coordinates with the California Department of Managed Health Care and the California

Department of Insurance to ensure each health plan’s network meets network adequacy standards

and time and distance standards.

Covered California also requires its contracted insurers to include Essential Community Providers

(ECPs) who serve low-income and medically underserved communities in their provider networks.

Covered California provides insurers a list of ECPs each year that includes federally designated 340B

providers, California disproportionate share hospitals, federally qualified health centers and Indian

health and Tribal health organizations, among others. Each year, Covered California assesses the

degree to which health plans have included a variety of ECPs in their networks.

Covered California Holding Health Plans Accountable for Quality and Delivery System Reform

EFFECTIVE CARE DELIVERY • CHAPTER 9

COVERED CALIFORNIA 75

Factors Used by Insurers to Select Medical Groups and Individual Providers

As described below (Table 31. Assessment of Factors Used by Covered California Insurers to Select

Physician Organizations and Individual Providers, 2015, 2017 and 2018), Covered California assessed

the number of health insurance companies using cost, quality and patient experience as criteria for

selecting or contracting with a provider.

Between 2015 and 2018, Covered California assessment of

provider selection factors found that the number of insurers that Considered Comprehensive Factors or

Considered Cost Only increased from seven to 10.

Table 31. Assessment of Factors Used by Covered California Insurers to Select Physician Organizations

and Individual Providers, 2015, 2017 and 2018

Source: Covered California Staff Analysis of Qualified Health Plan Submitted Data

For plan years 2017 and 2018, health insurance companies were asked generally about factors used to

select providers.

For both years, most insurers reported using provider credentialing, member

satisfaction results and grievances and appeals information, and quality or HEDIS measures for

selecting providers. While six Covered California insurers formally participate in IHA’s Align Measure

Perform (AMP) program, few insurers described using AMP program results for selecting providers

during 2017-18.

Three insurers reported reviewing referral patterns of providers or provider groups to

determine whether they refer to in-network hospitals or have established referral patterns to in-network

hospitals. Only two insurers cited cost savings or cost reduction as a factor for selecting providers.

Factors Used by Insurers to Select Hospitals

Covered California assessed and categorized the number of health insurance companies using cost,

quality and patient experience as criteria for selecting or contracting with hospitals (see Table 32.

Assessment of Factors Used by Covered California Insurers to Select Hospitals, 2015, 2017 and

The 11 health insurance companies in Covered California are: Anthem Blue Cross, Blue Shield of California, Chinese Community Health

Plan, Health Net, Kaiser Permanente, L.A. Care, Molina Healthcare, Oscar Health, Sharp Health Plan, Valley Health Plan, and Western

Health Advantage. In the tables below, Health Net is counted twice because its reports data separately for Health Net Life (PPO/EPO

products) and Health Net of California (HMO/HSP products).

Data only available for plan year 2015 and plan year 2017-18. Covered California did not ask this question in the Certification Application

for plan year 2016.

Information described here is based on insurers’ narrative responses to questions in the Certification Application. Covered California asked

generally about factors considered and did not specifically prompt insurers about each of them. As such, insurers could be using a factor

to select providers but may not have described it.

For the IHA AMP program, one insurer does not formally participate but reviews the program results as a provider selection factor and

another insurer is planning to participate but does not formally participate currently.

Number of Health Plans

Assessment

2015

2017

2018

Considered Comprehensive Factors

Includes cost, quality, and patient experience in selecting providers

Considered Cost

Includes cost in provider selection

Considered Minimal Factors

Does not include cost, quality, or patient experience in selecting providers

Covered California Holding Health Plans Accountable for Quality and Delivery System Reform

EFFECTIVE CARE DELIVERY • CHAPTER 9

COVERED CALIFORNIA 76

2018).

Covered California’s assessment of hospital selection factors found that as of 2018 four

insurers Considered Comprehensive Factors, while others considered cost. While many insurers do not

currently use comprehensive factors in hospital selection, most insurers have been actively engaged in

work to promote improvement in hospital quality performance as described in Chapter 11: Sites and

Expanded Approaches to Care.

Table 32. Assessment of Factors Used by Covered California Insurers to Select Hospitals,

2015, 2017 and 2018

Number of Health Plans

Assessment

2015

2017

2018

Considered Comprehensive Factors

Include cost, quality, and patient experience in selecting hospitals

Considered Cost

Includes cost in hospital selection

Considered Minimal Factors

Does not include cost, quality, or patient experience in selecting hospitals

Source: Covered California Staff Analysis of Qualified Health Plan Submitted Data

For 2017 and 2018, health insurance companies were asked generally about factors used to select

hospitals.

For both years, all Covered California insurers indicated that they had processes to

designate a hospital as a Center of Excellence which was a factor for determining inclusion of a

hospital in-network. Several health plans also reviewed and tracked publicly reported quality data from

the Leapfrog Group, CMS Hospital Compare, and other quality-based organizations to determine

whether to contract with a hospital.

Health insurance companies considered the cost or prices charged by a hospital when determining

whether to contract with them. For example, some insurers evaluated costs as a percentage of

Medicare rates and used Diagnosis-Related Group (DRG) case-mix adjusted cost per discharge to

identify and group hospitals by cost deciles. Similarly, other insurers developed cost indices for

hospitals and used a combination of cost and quality measures to determine whether to remove the

hospital from their network.

One insurer reported hospital participation in collaboratives, such as the California Maternal Quality

Care Collaborative, as a factor for contracting with hospitals during 2017-18.

The 11 health insurance companies in Covered California are: Anthem Blue Cross, Blue Shield of California, Chinese Community Health

Plan, Health Net, Kaiser Permanente, L.A. Care, Molina Healthcare, Oscar Health, Sharp Health Plan, Valley Health Plan, and Western

Health Advantage. In the tables below, Health Net is counted twice because its reports data separately for Health Net Life (PPO/EPO

products) and Health Net of California (HMO/HSP products).

Data only available for plan year 2015 and plan year 2017-18. Covered California did not ask this question in the Certification Application

for plan year 2016.

Information described here is based on insurers’ narrative responses to questions in the Certification Application. Covered California asked

generally about factors considered and did not specifically prompt insurer about each of them. As such, insurer could be using a factor to

select hospitals but may not have described it.

Covered California Holding Health Plans Accountable for Quality and Delivery System Reform

EFFECTIVE CARE DELIVERY • CHAPTER 9

COVERED CALIFORNIA 77

Covered California Targeting Outlier Poor Performance for Potential Exclusion from

Networks

Covered California requires health insurance companies to exclude a hospital from their network if the

hospital is an outlier poor performer and not working to improve safety and maternity care. To support

insurers in meeting the requirement to exclude hospital outlier poor performers, Covered California has

worked with Cal Hospital Compare to determine if there is a valid way to define outlier poor

performance for hospitals in a way that can be implemented consistently across all insurers. This

definition is based on specific measures of cost and quality, national benchmarks, analysis of variation

in California performance, best evidence for quality improvement, and effective stakeholder

engagement. Based on their review, Cal Hospital Compare found no single composite measure

meeting these criteria was available so they provided insurers with four distinct lists of hospitals with

consistently low performance based on:

1. The Hospital Acquired Condition Reduction Program (HACRP) through CMS that uses six

publicly available measures in to publicly report and financially penalize hospitals that perform in

the bottom 25 percent of all hospitals nationally;

2. An honor roll of top hospital performers developed by Cal Hospital Compare using the CMS

HACRP metrics;

3. The Leapfrog Group’s Hospital Safety Score; and

4. A report from the California Department of Public Health focused only on Hospital Associated

Infections.

These tools do not meet the requirement for a single composite system, and none include key safety

concerns where there is no standard publicly reported measure, like Adverse Drug Events. However,

these four lists provide “signals of concern” and the measures on these lists include the five Hospital

Associated Infections (HAIs) that Covered California has focused on. The greater the number of “low

performance” lists a hospital appears on, the greater the concern. These lists are not yet publicly

reported but have been provided to insurers for use in hospital negotiations. Insurers are responsible to

notify Covered California which if any of these hospitals will be excluded from their networks or reasons

for continued inclusion by year-end 2020.

Covered California’s requirements for hospital quality and safety serve as a foundation for which health

insurance companies can build networks based on value. As such, the requirement for excluding

“outlier poor performers” and describing the factors they use to select hospitals is related to the

requirement for insurers to work with hospitals to improve quality and safety, described in Chapter 11:

Sites and Expanded Approaches to Care.

Assessing Relative Unit Prices and Total Costs of Care

Covered California supports strategies that promote a competitive market with restraint on prices and

provides access to high quality care. Health insurance companies consider a range of processes and

factors when assessing the relative unit prices and total costs of care at the hospital, medical group, or

provider level. Insurer reported data shows that most insurers compared the cost of providers and

hospitals to other similar providers in the market or region when assessing the costs of providers (see

Table 33. Covered California Insurer’s Process and Factors for Assessing Costs of Providers and

Hospitals, 2015, 2017 and 2018). Most insurers also used specific fee schedules or fee schedules

based on a percent of Medicare reimbursement in their contracts with providers. Three health

insurance companies annually adjusted capitation payments to providers and hospitals or paid as a

Covered California Holding Health Plans Accountable for Quality and Delivery System Reform

EFFECTIVE CARE DELIVERY • CHAPTER 9

COVERED CALIFORNIA 78

percent of premium. One insurer used Office of Statewide Health Planning and Development (OSHPD)

data to understand the cost-to-charge ratios of specific hospitals.

Table 33. Covered California Insurer’s Process and Factors for Assessing Costs of Providers and

Hospitals, 2015, 2017 and 2018

Number of Health Plans

Process and Factors Used

2015

2017

2018

Compare the cost of providers and hospitals to other similar providers in

the market or region

Use specific case rates, fee schedules or fee schedules based on a

percent of Medicare reimbursement when contracting with providers

Annually adjust payments to providers and hospitals or pay as a percent of

premium

Use Office of Statewide Health Planning and Development data to

understand the cost-to-charge ratios of specific hospitals

Source: Covered California Staff Analysis of Qualified Health Plan Submitted Data

Section 2: Implications for the Future

Covered California holds health insurance companies accountable to manage variation across their

networks in addition to reporting overall quality measures which reflect averages. In managing

variation, enrollees should be assured that any provider they go to for care will meet high standards for

quality and cost management. Variation in hospital performance was a first target since performance is

publicly reported for several key safety measures. Insurers joined Covered California in focusing on a

common set of measures in hospital performance evaluation and contracting. As reported in Chapter

11, this effort has led to improvements in hospital quality and safety. Covered California plans to

continue to work with insurers, other purchasers, hospitals and other stakeholders to assess what can

be done to establish common summary quality and cost hospital performance indicators that would

appropriately be used for purposes of either targeting hospitals for improvement or exclusion from

Covered California networks.

Covered California is also partnering with the Integrated Healthcare Association’s (IHA) California

Regional Health Care Cost and Quality Atlas to profile insurer’s physicians and physician organization

networks based on the wide variation in clinical quality, satisfaction, and total cost of care across the 19

Covered California regions by insurance type. Covered California encourages insurers to use the IHA

Atlas data to profile their networks by displaying the cost and quality of physician organizations and

physicians that serve HMO, EPO and PPO enrollees. Covered California is working with other

purchasers, insurers, physician organizations and other stakeholders to define or create a standard for

low-quality and high-cost physician organizations that could be the basis for targeted improvement or

removing such physician organizations from their networks. As with variation in hospital networks, the

first priority will be to seek ways to align efforts to improve care.

Data only available for plan year 2015 and plan year 2017-18. Covered California did not ask this question in the Certification Application

for plan year 2016.

Covered California Holding Health Plans Accountable for Quality and Delivery System Reform

EFFECTIVE CARE DELIVERY • CHAPTER 10

COVERED CALIFORNIA 79

Chapter 10: Appropriate

Interventions

Appropriate Interventions include examining

clinical interventions, such as prescription and

nonprescription pharmaceutical treatments,

procedures (like surgery), diagnostic tests (lab

tests, X-rays, MRIs, etc.) and devices (like

implants and pacemakers), to ensure they are

rooted in the Institute of Medicine’s six aims for

ensuring every individual’s care is safe, timely,

effective, efficient, equitable, and patient-

centered.

Equally important is effective

consumer and patient engagement that (1)

supports consumers in making decisions about

health care services, treatments, and providers

that are consistent with their values and

preferences and (2) fosters access to care.

Appropriate Interventions is an expansive topic,

but this chapter, focuses on the following: (1)

pharmacy utilization management; (2) consumer

and patient engagement, which includes the use

of cost transparency tools and shared decision-

making; (3) addressing overuse of care through

Smart Care California; and (4) appropriate use of

services, as measured through standard

measures in the Marketplace Quality Rating

System.

This chapter on Appropriate Interventions is

organized as follows:

Section 1. Qualified Health Plan Experience

Section 2. Health Plan Measures Reported to

the Marketplace Quality Rating System

Section 3. Implications for the Future

Section 1. Qualified Health Plan Experience

Qualified Health Plan Experience presents performance data reported by health insurance companies

for contract requirements and includes assessments and observations by Covered California.

Committee on Quality Health Care in America, Institute of Medicine. (2001). Crossing the quality chasm: a new health system for the 21st

century. Washington, D.C.: National Academy Press.

• In 2018, ten insurers considered value in

pharmacy formulary management and ten

insurers used at least one third-party value

assessment methodology (e.g. ICER Value

Assessment Framework).

• All health insurance companies use a

systematic, evidence-based process for

monitoring off-label use of

pharmaceuticals.

• Virtually all of Covered California enrollees

have access to cost transparency tools to

assist consumer decision making about

treatments or procedures (ten of 11

insurers covering 99 percent of enrollees).

• Insurers are approaching completion of

implementation of many of the

recommended Smart Care California

improvements to reduce opioid overuse

including limiting the quantity of tablets in

first prescriptions, removing barriers to

medication-assisted treatment and drugs

used to reverse overdoses. This

collaborative work with other California

state purchasers has contributed to

reduced opioid prescribing and increased

prescribing for buprenorphine, the leading

medication to treat opioid disorders.

• Covered California is continuing to expand

the scope and nature of its efforts to reduce

waste and assure patients are only getting

medically necessary care.

Highlights

Covered California Holding Health Plans Accountable for Quality and Delivery System Reform

EFFECTIVE CARE DELIVERY • CHAPTER 10

COVERED CALIFORNIA 80

Pharmacy Utilization Management

One component of appropriate interventions is the appropriate use of prescriptions and how health

insurance companies consider cost and quality in determining their drug lists or formularies. Drug costs

continue to increase at a higher rate than other health care costs for generics, name brands and

specialty drugs across all insurance markets. Health insurance companies can put downward pressure

on drug spending through a variety of mechanisms. Covered California requires insurers to describe

ways they are working to achieve value in drug spending, ranging from formulary decision making to

decision support tools. Covered California collects information on health insurance company activities

to inform its analysis of the relative efficacy of different strategies. As part of contract requirements on

achieving value in prescription drug spend, insurers annually report the following:

1. How they currently consider value in formulary selection;

2. If independent value assessment methodologies are used, which ones are used;

3. If and how construction of formularies is based on total cost of care;

4. If and how off-label use is monitored; and

5. The extent of decision support provided to prescribers and members.

Because insurers reported information in a narrative format, further data would be needed to assess

the effectiveness and impact of their activities, which may be facilitated by the addition of cost data to

the information currently submitted by insurers to Covered California.

Ten of 11 health insurance companies considered value in pharmacy formulary management in 2018

(see Table 34. Covered California Insurer’s Consideration of Value in Formulary and Value Assessment

Methods, 2017 and 2018). Nine insurers described the use of a value assessment methodology as part

of their Pharmacy and Therapeutics (PandT) Committee, which all insurers are required to use.

Health insurance companies also report on the use of the following third-party value assessment

methodologies:

• Drug Effectiveness Review Project (DERP)

• NCCN Resource Stratification Framework (NCCN‐RF)

• NCCN Evidence Blocks (NCCN‐EB)

• ASCO Value of Cancer Treatment Options (ASCO‐ VF)

• ACC/AHA Cost/Value Methodology in Clinical Practice Guidelines

• Oregon State Health Evidence Review Commission Prioritization Methodology

• Premera Value‐Based Drug Formulary (Premera VBF)

• DrugAbacus (MSKCC) (DAbacus)

• The Institute for Clinical and Economic Review (ICER) Value Assessment Framework (ICER‐

VF)

• Real Endpoints

• Blue Cross/Blue Shield Technology Evaluation Center

• International Assessment Processes (e.g., United Kingdom’s National Institute for Health and

Care Excellence (NICE))

Eight of 11 insurers used at least one third-party value assessment methodology as part of its PandT

Committee process in 2018. Seven insurers consider value assessment in formulary tier placement.

Health insurance companies use one of several different independent value assessment methodologies

listed, but the Institute for Clinical and Economic Review (ICER) assessment is the most commonly

used. ICER is considered to have a strong methodology compared to others and emphasizes

Covered California Holding Health Plans Accountable for Quality and Delivery System Reform

EFFECTIVE CARE DELIVERY • CHAPTER 10

COVERED CALIFORNIA 81

transparency, conflict-free funding, and actionable activities for plans that consider the total cost of

care. ICER also includes a framework for evaluating short and long-term budget impacts, and includes

a “value-based price benchmark,” reflecting how each drug should be priced to appropriately reflect

long-term improved patient outcomes.

Table 34. Covered California Insurer’s Consideration of Value in Formulary and Value Assessment

Methods, 2017 and 2018

Number of

Health Plans

Consideration of Value

2017

2018

Consider value in pharmacy management

Use value assessment methodology as part of Pharmacy and Therapeutics

(PandT) process

Use at least one third-party value assessment methodology

(e.g. ICER Value Assessment Framework)

Consider value assessment in formulary tier placement

Source: Covered California Staff Analysis of Qualified Health Plan Submitted Data

For constructing formularies based on the total cost of care, seven of 11 insurers used a process for

analyzing drug efficacy in context of total cost of care and outcomes (see Table 35. Covered California

Insurer’s Consideration of Total Cost of Care in Formulary, Off-Label Use Monitoring and Decision

Support for Providers and Consumers, 2017 and 2018).

All 11 health insurance companies engaged in systematic, evidence-based process for monitoring off-

label use of pharmaceuticals, which reflects state law requirements for using nationally recognized

sources for evidence-based off label monitoring.

In 2018, nine of 11 insurers provided member-specific decision support for both prescribers and

consumers, of which seven provided this support at the point-of-care. Several new software products

have recently become available and are now being used by Covered California’s insurers to allow

physicians to see pricing information on drugs they are prescribing and the availability of cheaper,

equally effective alternatives. Examples of these software tools include Gemini Health’s Drug-Cost

Transparency Service, Sure Scripts Real-Time Prescription Benefit, and OptumRx’s PreCheck

MyScript.

Table 35. Covered California Insurer’s Consideration of Total Cost of Care in Formulary, Off-Label Use

Monitoring and Decision Support for Providers and Consumers, 2017 and 2018

Number of

Health Plans

Consideration of Total Cost of Care

2017

2018

Analyze drug efficacy in context of total cost of care and outcomes

Use a systematic, evidence-based process for monitoring off-label use of

pharmaceuticals

Offer member-specific decision support initiatives for both the prescriber and

consumer, including point-of-care support software

Offer member-specific decision support initiatives for both prescriber and

consumer, but not at the point of care

Source: Covered California Staff Analysis of Qualified Health Plan Submitted Data

Covered California Holding Health Plans Accountable for Quality and Delivery System Reform

EFFECTIVE CARE DELIVERY • CHAPTER 10

COVERED CALIFORNIA 82

Consumer and Patient Engagement

Cost Transparency Tools

Covered California supports strategies that promote a competitive market with restraint on prices and

provide access to high quality care. As part of its requirements for demonstrating action on high cost

providers, Covered California required insurers to report on their efforts to make variation in provider or

hospital cost transparent to consumers and the use of cost transparency tools by consumers.

Cost

transparency tools have the potential to reduce costs by enabling patients to switch to lower priced

providers and publicly acknowledging high-priced providers which could lead to these providers

reducing their prices.

Covered California required health insurance companies with more than 100,000 enrollees to deploy

online tools and 10 of the 11 insurers now do so, representing 99 percent of Covered California

enrollees. Table 36. Covered California Insurer’s Use of Cost Transparency Tools, 2015, 2017 and

2018 describes the number of insurers that use cost transparency tools, what services are provided,

and the percentage of enrollees with access to each type of tool.

As of 2018, the tools offered to the

most enrollees were Online Procedure and Treatment Cost Estimators, which were available through

three different health plans to about 70 percent of enrollees. Other tools include Provider-Specific Cost

Information which three health plans provide to about 21 percent of enrollees.

Table 36. Covered California Insurer’s Use of Cost Transparency Tools, 2015, 2017 and 2018

Number of Insurers

Number of

Enrollees with

Access to Tool

Percent of

Total

Enrollment

(1,384,030)

2015

2017

2018

Insurers Offering Cost Transparency Tools

1,371,720

99%

Services Offered

Online Cost and Quality Tool

67,070

Provider-Specific Cost Information

289,460

21%

Online Procedure and Treatment Cost Estimator

974,780

70%

Online Drug Cost Lookup Tool

706,140

51%

Online Real-time Tracking of Out-of-Pocket

Costs

1,218,270

88%

Planning to add Cost Information Online

N/A

Source: Covered California Staff Analysis of Qualified Health Plan Submitted Data

The consumer utilization of available tools varied widely among Covered California’s contracted health

insurance companies. The tools available to the largest number of enrollees were used by 3 percent to

Network design and reference pricing are also strategies in this requirement. Network design is discussed in Chapter 9: Networks Based

on Value in the sections on provider and facility selection criteria. No insurers reported using reference pricing, which would require

Covered California making changes to its standard benefit design.

Mehrotra, Ateev. "Defining the Goals of Health Care Price Transparency: Not Just Shopping Around." NEJM Catalyst, June 26 (2018).

Data only available for plan year 2015 and plan year 2017-18. Covered California did not ask this question in the Certification Application

for plan year 2016.

Covered California Holding Health Plans Accountable for Quality and Delivery System Reform

EFFECTIVE CARE DELIVERY • CHAPTER 10

COVERED CALIFORNIA 83

7.5 percent of consumers. There are not standard national benchmarks to assess the volume and type

of consumer utilization of cost transparency tools, so Covered California is in the process of

determining how best to assess what volume and type of utilization best meets consumers’ needs.

While there is growing research on how best to effectively engage consumers in their care, discussions

about value should both educate consumers and help them work with their providers to make better

choices to align their preferences and likely outcomes.

However, there are currently no standard

benchmarks related to use of consumers tools and definitions of the types of users. Similarly, there are

multiple definitions for consumer engagement, with all assuming that consumers have the knowledge

and skills to understand and participate in the engagement process.

Covered California is reviewing

these issues and the available evidence to inform future contract expectations.

Shared Decision-Making

There is clear evidence that for many “preference-sensitive” conditions, clinicians do not regularly elicit

patients’ preferences or provide information to support informed patient decision-making. Too often

variation in care tracks with provider preferences rather than those of patients. Shared decision-making

engages patients in bringing their values and preferences to bear often with the help of decision aids

that present the basic science of the condition being treated, the various options for treatment and the

tradeoffs such as quality or length of life. Shared decision-making is designed for preference-sensitive

conditions, such as breast cancer, prostate cancer, and knee and hip replacements where more than

one evidence-based treatment is available or where the evidence is incomplete or uncertain. Variation

in treatment of these conditions based on patient preferences is important and the Covered California

contract requirements included reporting how insurers support shared decision-making including the

proportion of patients with preference sensitive conditions who have used a decision aid.

The requirement for health insurance companies to report on shared decision-making was put on hold

to enable health insurance companies to focus on cost and quality tools and implement the Smart Care

initiatives described below. Based on Covered California’s ongoing discussions with insurers, several

have contracts with vendors that publish decision aids and are using them in case management.

Evidence documents that when patients use decision aids to support shared decision-making with their

clinician at the time and place decisions are made, their knowledge of their options improves, and they

feel better about what matters to them.

There are a variety of vendors for decision aids which vary in

quality and evidence supporting their effectiveness. Each insurance company and many medical

groups have made their own vendor selections and therefore offer different tools. None has achieved

implementation at scale and it’s unlikely they will with this diversity. Covered California has an

opportunity over the next several years to work with stakeholders across the delivery system to

consider selecting a single vendor and to support broad adoption of shared decision-making at the

point of care.

S, Delbanco, T. Delbanco, Technology and Transparency: Empowering Patients and Clinicians to Improve Health Care Value, Ann Intern

Med. 2018;168(8):585-586.

Hibbard JH. (September 2017). Refining Consumer Engagement Definitions and Strategies. Journal of Ambulatory Care Management.

The most current best evidence is documented in Chapter 9: Appropriate Interventions of a companion Covered California report, Current

Best Evidence and Performance Measures for Improving Quality of Care and Delivery System Reform.

Covered California Holding Health Plans Accountable for Quality and Delivery System Reform

EFFECTIVE CARE DELIVERY • CHAPTER 10

COVERED CALIFORNIA 84

Addressing Overuse of Care through Smart Care California

In 2015, Covered California joined the other state purchasers, the Department of Health Care Services

(DHCS) and the California Public Employees’ Retirement System (CalPERS), to form a multi-

stakeholder workgroup called Smart Care California to address overuse of services that result when

evidence-based practices are not being followed. This multi-stakeholder work group is facilitated by the

Integrated Healthcare Association (IHA), with funding and thought leadership from the California Health

Care Foundation (CHCF). Smart Care California selected three areas of focus from the list of Choosing

Wisely guidelines published by the American Board of Internal Medicine Foundation in cooperation with

other specialty societies: (1) low-risk (nulliparous term, singleton, vertex (NTSV)) deliveries performed

without medical indication; (2) opioid overuse and misuse; and (3) imaging for low back pain.

Health insurance companies are invited to participate in the development of improvement strategies

and are required to adopt the guidelines developed by Smart Care California. All insurers are

participating either as regular attendees or by implementing guidelines published by Smart Care

California. Work is underway for adopting best practices for payment for maternity services as well as

for combatting the opioid crisis. At this time, Smart Care has focused on these two areas, while overuse

of imaging for low back pain, which would entail a large-scale effort to change the care patterns of

thousands of physicians across California, has been on hold while resource and other implementation

challenges are considered. The measure for imaging for low back pain will still be collected in

Marketplace QRS and other quality measurement programs.

Health insurance companies’ efforts to reduce low-risk C-section deliveries are impacting the entire

maternity population served at each plan’s network hospitals, not just Covered California’s enrolled

population. In addition, Covered California, DHCS, and CalPERS are collaboratively engaged in efforts

to reduce low-risk C-sections, so the same initiatives are positively impacting their hospitals and care

regardless of the source of the consumer’s coverage. Further discussion of efforts to reduce low-risk C-

sections is included in Chapter 11: Sites and Expanded Approaches to Care Delivery.

Smart Care California Efforts to Reduce Opioid Overuse

The Smart Care California work group has surveyed health insurance companies on their efforts to

reduce opioid overuse in four categories: (1) preventing new starts; (2) managing pain safely; (3)

treating addiction; and (4) stopping death. Comparison of performance in these areas are based on

aggregated survey data from Covered California, CalPERS and DHCS is provided in Figure 9. Smart

Care California Purchaser Level Performance on Opioid Overuse Reduction, 2018. Covered California

insurers are approaching completion of implementation for many of the recommended improvements

including limiting the quantity of tablets in first prescriptions, removing barriers to medication-assisted

treatment and for drugs used to reverse overdoses. The table below reflects remarkable improvement

as none of these recommendations were practices before Smart Care California published their

guidelines. This survey will continue to be conducted annually.

According to the Smart Care survey, all 11 Covered California insurers now implement quantity limits

for new starts of opioids and nine Covered California insurers have removed prior authorization for

physical therapy for back pain, improving timely patient access to care and preventing new starts of

opioid medications. The survey also indicates that more than half of insurers have increased access to

See more: https://www.iha.org/our-work/insights/smart-care-california.

Covered California Holding Health Plans Accountable for Quality and Delivery System Reform

EFFECTIVE CARE DELIVERY • CHAPTER 10

COVERED CALIFORNIA 85

behavioral health services for patients with chronic pain, while two insurers are in the planning stages

to increase access. These improvements have the potential to greatly aide in curbing the opioid

epidemic in the state.

Figure 9. Smart Care California Purchaser Level Performance on Opioid Overuse Reduction, 2018

Source: Smart Care California, 2019

As seen below in Figure 10. California 2010-2018 Progress on Opioid Overuse Reduction, prescribing

for opioids is falling and prescribing for buprenorphine, the leading medication to treat opioid disorders,

is rising. But overdose deaths remain high. The reason overdoses are still such a threat appears to be

Covered California Holding Health Plans Accountable for Quality and Delivery System Reform

EFFECTIVE CARE DELIVERY • CHAPTER 10

COVERED CALIFORNIA 86

that street drugs are replacing prescription drugs as the cause of death.

This data implies that neither

California or the nation has found the right balance for treating opioid addiction. Opioid prescriptions

appear to have fallen faster than capacity for treatment has expanded.

Figure 10: California 2010-2018 Progress on Opioid Overuse Reduction

Source: California Health Care Foundation analysis of data from the California Department of Public Health

www.cdph.ca.gov/opioiddashboard

Much more needs to be done to support providers in reducing opioid prescriptions safely including

expanding access to medication assisted treatment. While efforts to address the opioid epidemic have

benefited from many sectors focusing needed attention on this problem, Covered California believes

the Smart Care initiative is an example of how improvement can be encouraged when major

purchasers — in this case Medi-Cal, CalPERS and Covered California — align to work with insurers

and providers to meet a common clinical need. Additionally, Covered California is more closely tracking

opioid use and medication assisted treatment use through its Healthcare Evidence Initiative database.

Section 2: Health Plan Measures Reported to the Marketplace Quality

Rating System

Health Plan Measures Reported to the Marketplace Quality Rating System details health plan

performance on Healthcare Effectiveness Data Information Set (HEDIS) and Consumer Assessment of

Healthcare Providers and Systems (CAHPS) measures reported to the Centers for Medicaid and

Medicare Services’ Quality Rating System (QRS). These standard performance measures are a key

mechanism used by Covered California for health plan oversight and accountability.

The New York Times, “Short Answers to Hard Questions About the Opioid Crisis”, Josh Katz, August 10, 2017

https://www.nytimes.com/interactive/2017/08/03/upshot/opioid-drug-overdose-epidemic.html.

Covered California Holding Health Plans Accountable for Quality and Delivery System Reform

EFFECTIVE CARE DELIVERY • CHAPTER 10

COVERED CALIFORNIA 87

See Appendix 2: Additional Health Plan Measures Reported to the Quality Rating System, for six

Quality Rating System measures that pertain to Appropriate Interventions:

1. Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis (Table A23)

2. Appropriate Testing for Children with Pharyngitis (Table A24)

3. Appropriate Treatment for Children with Upper Respiratory Infection (Table A25)

4. Use of Imaging Studies for Low Back Pain (Table A26)

5. Annual Monitoring for Patients on Persistent Medications (Table A27)

6. Access to Information (Table A28)

These measures address the both the overuse of low value services and the appropriate use of

services. The first three measures above reflect efforts to reduce overuse of antibiotics which is

resulting in wide spread resistance to potentially lifesaving treatment.

Imaging for low back pain, especially CT and MRI scans, should only be used when considering

surgery for intractable pain or neurologic complications related to low back pain.

Many patients with conditions like rheumatoid arthritis are on complex medications with potential side-

effects. Standard routine monitoring, as measured by Annual Monitoring for Patients on Persistent

Medications, may be overlooked if not tracked and implemented systematically.

As detailed under the section on shared decision-making, supporting patients with the right information

to partner with their providers to decide on appropriate interventions for their care is critical not only for

preference sensitive care but to increase adherence to evidence-based care.

Section 3: Implications for the Future

There is good evidence that a very high proportion of care delivered is unwarranted or delivered poorly;

some diagnostic tests are overused, and there is limited information available to assess relative efficacy

and value of many drugs, devices and even some surgical interventions. Genetic testing is starting to

show value in guiding clinical decisions and “personalized” approaches to cancer care are being

developed and tested. All these innovations come with extraordinary costs and only preliminary

understanding of which patients will benefit the most.

Shared decision making requires that there is active and transparent information sharing between

consumers and their providers. Cost and quality tools provide consumers with the knowledge to better

engage with their own health decision making, but even among the tools that are available today there

is little success engaging patients or providers in their adoption. Future improvements in technology

and data sharing will lead to better consumer engagement. Covered California is continuing to monitor

insurers to ensure that consumers are being provided the most reliable tools and information so that

they can receive the best care at the right time. Covered California has an opportunity over the next

several years to work with stakeholders across the delivery system to consider selecting a single

vendor and to support broad adoption of shared decision-making at the point of care.

Over the next few years, a wide range of innovations in care delivery will have dramatic impacts on how

care is provided, and the quality and cost of that care. Covered California has shown how purchasers,

payers and providers can work together in adopting best practices to reduce variation in hospital

performance and address overuse of opioids. Decision support to providers and patients at the point of

care is particularly promising, whether through consumer cost tools integrated with the medical record,

shared decision-making decision aids or point of care software integrated with electronic health record

order entry to support adherence to formularies, bringing this information to where decisions are made

Covered California Holding Health Plans Accountable for Quality and Delivery System Reform

EFFECTIVE CARE DELIVERY • CHAPTER 10

COVERED CALIFORNIA 88

appears to be critical to successful adoption. Covered California is assessing the extent to which its

contractual requirements can assist in prioritizing and standardizing implementation of best practices to

benefit all Californians.

Covered California Holding Health Plans Accountable for Quality and Delivery System Reform

EFFECTIVE CARE DELIVERY • CHAPTER 11

COVERED CALIFORNIA 89

Chapter 11: Sites and Expanded

Approaches to Care Delivery

Covered California is better understanding and

promoting evidence-based health interventions and

treatments beyond the traditional physician office

and hospital-based care, whether on an inpatient or

outpatient basis: urgent care facility, retail facilities

such as drop-in clinics, at home, or through a variety

of emerging telehealth strategies. Expanded

approaches to care delivery also includes who

provides care in addition to physicians including

clinically appropriate providers such as registered

nurses, pharmacists, midwives, nurse practitioners,

physician assistants or non-licensed providers like

community health workers.

This chapter on Sites and Expanded Approaches to

Care Delivery has a different organization. “Sites”

refer to the traditional medical care settings of

hospitals and physician offices. Care in physician

offices is covered in Chapter 7: Promotion of

Effective Primary Care, while Chapter 10:

Appropriate Interventions, examines various clinical

interventions largely delivered in or ordered by

physician offices, to ensure they are rooted in the

Institute of Medicine’s six aims for safe, timely,

effective, efficient, equitable and patient-centered

care.

Hospital care is a broad topic and can include a

range of system level reforms. This chapter focuses

on publicly reported performance data that health

insurance companies are using to establish contract

requirements for hospital quality and safety, which

are (1) within an insurer’s oversight authority; (2)

help foster alignment across contracted insurers and

their contracted hospitals; and (3) benefit from the

availability of publicly reported hospital performance

data reflecting the experience of the hospital’s entire

patient population. Covered California has worked

with hospitals and the California Hospital Association

to select measures for which coaching programs,

Committee on Quality Health Care in America, Institute of Medicine. (2001). Crossing the quality chasm: a new health system for the 21st

century. Washington, D.C.: National Academy Press.

• The California Department of Public

Health reports that as of 2018 there

has been a statistically significant

reduction in major types of hospital

associated infection rates in California

hospitals (CLABSI, SSI, MRSA, and C.

difficile bacterial). Covered California’s

contract requirements — aligned with

those of CMS and other purchasers —

insurer engagement, and work with

improvement collaboratives have

contributed to 3,392 infections avoided,

251 lives saved and over $62M in one-

year cost savings.

• Covered California’s support for

appropriate C-Sections helped 56% of

California hospitals achieve the

national goal of NTSV C-section rates

of 23.9% or lower in 2018,

representing a 12-point improvement

from 2015, avoiding 7,200 C-sections

over 3 years.

• The number of insurers that

participated in the Smart Care

California collaborative, increased from

six to all 11 by 2017 with full

participation continuing since then.

Similarly, the number of insurers that

participated in Partnership for Patients

collaborative increased from two to ten

insurers between 2016 and 2018.

• For insurer engagement of network

hospitals, 10 insurers were assessed

as having Full Engagement or

Engaged for hospital safety in 2018.

For maternity care, all 11 insurers were

assessed as Full Engagement or

Engaged for maternity care in 2018.

Highlights

Covered California Holding Health Plans Accountable for Quality and Delivery System Reform

EFFECTIVE CARE DELIVERY • CHAPTER 11

COVERED CALIFORNIA 90

quality collaboratives and change packages are available and aligned with priorities established by

national consensus including CMS and Healthy People 2020.

For expanded approaches to care delivery, current requirements pertaining to (1) telehealth and (2)

Centers of Excellence are discussed, while Covered California has not developed reporting or contract

requirements related to many of the existing and evolving sites of care or approaches.

Qualified Health Plan Experience

For hospital quality and safety, Covered California has the following requirements of contracted

health plans:

1. Encouraging hospital participation in quality improvement collaboratives and coaching programs

2. Reducing the avoidable hospital associated infections (HAIs) starting with the metrics included

in the CMS Hospital Acquired Condition Reduction Program (HACRP)

a. Catheter associated urinary tract infection (CAUTI)

b. Central line associated blood stream infections (CLABSI)

c. Methicillin-resistant Staphylococcus aureus (MRSA)

d. Clostridioides difficile (formerly Clostridium difficile bacterial infection) (CDI)

e. Surgical site infection of the colon (SSI Colon)

3. Reducing low-risk, nulliparous term singleton vertex (NTSV) C-section rates to 23.9 percent or

lower (a national Healthy People 2020 goal);

4. Expanding value-based payments for hospital quality and maternity care including:

a. Tying two percent of hospital payments to value by the end of 2019

b. Eliminating financial incentives for hospitals or physicians to perform C-Sections; and

5. Excluding a hospital from their network initially by year-end 2020 if the hospital is an outlier poor

performer and not working to improve safety and maternity care.

For expanded approaches to care delivery, Covered California requires health plans to use

technology, including telehealth and remote home monitoring,

to assist in higher quality, accessible,

patient-centered care.

Hospital Quality and Safety

Encouraging Hospital Participation in Coaching Programs and Collaboratives

Health insurance companies are required to encourage hospitals to participate in the Partnership for

Patients coaching program, which is funded by the federal Department of Health and Human Services

(HHS) to support designated Hospital Improvement Innovation Networks (HIINs).

In California, there

are 5 HIINs which engage individual hospitals and systems to participate in trainings to reduce hospital

associated infections, adverse drug events, falls, pressure ulcers, and other negative health events that

occur in hospital settings.

This encouragement can be accomplished through hospital administrator

Currently, hospital quality and safety performance are tracked at general acute care (GAC) hospitals, because specialized hospitals (such

as long-term care) have different performance benchmarks and variables to consider.

First pregnancy (nulliparous), full term, no twins or beyond (singleton), and head down (vertex) or NTSV pregnancies are generally thought

of as low risk. See more: https://www.healthypeople.gov/2020/topics-objectives/topic/maternal-infant-and-child-health

Telehealth services can include remote monitoring when used for disease management in between visits.

See more: https://partnershipforpatients.cms.gov/about-the-partnership/aboutthepartnershipforpatients.html.

In California, the five HIINs are: (1) Health Services Advisory Group, which is managed by the Hospital Quality Institute, (2) Dignity, (3)

Vizient (created by the VHA/UHC merger), (4) Children’s Hospitals’ Solutions for Patient Safety, and (5) Premiere Inc.

Covered California Holding Health Plans Accountable for Quality and Delivery System Reform

EFFECTIVE CARE DELIVERY • CHAPTER 11

COVERED CALIFORNIA 91

engagement, letter campaigns to providers, contracting discussions, and other creative means that

communicate the importance and urgency of reducing the incidence of avoidable negative health

events in hospitals.

Covered California also requires insurers to engage with their network hospitals to promote awareness

of (1) NTSV C-section rates, (2) availability of provider and consumer education, and (3) promote

participation in data sharing and coaching offered by the California Maternal Quality Care Collaborative

(CMQCC), with the goal of reducing NTSV C-sections to the national Healthy People 2020 target of

23.9 percent of deliveries or lower. The CMQCC is a multi-stakeholder organization that provides real

time data sharing, quality improvement toolkits, and coaching collaboratives to improve maternal and

neonatal health in several measure areas, including NTSV C-sections. Additionally, Smart Care

California built consensus around a menu of payment structures to promote the goal of ending financial

incentives for providing NTSV C-Sections: (1) blended case rates; (2) low risk C-section reduction as a

metric for payment incentive programs; or (3) population-based payment models.

As shown in Table 37. Covered California Insurer Participation in Improvement Collaboratives, the

number of insurers that participated in Smart Care California increased from six to 11 between 2016

and 2017 and this trend of full participation continued through 2018. Similarly, the number of insurers

that participated in Partnership for Patients increased from two to ten health plans between 2016 and

2018.

Table 37. Covered California Insurer Participation in Improvement Collaboratives

Collaborative

2016

2017

2018

Smart Care California

Focuses on outreach to reduce NTSV C-Sections through

collaboration with California Maternal Quality Care Collaborative

Partnership for Patients

U.S. Department of Health and Human Services program that

focuses on reducing infections in hospitals

Source: Covered California Staff Analysis of Qualified Health Plan Submitted Data

Health insurance companies have engaged network hospitals on the importance of reducing hospital

associated infections and NTSV C-sections and are spreading awareness of ways that performance

can be improved, such as coaching programs through Partnership for Patients funded HIINs and

CMQCC. Insurer activities range from sending tailored mail to hospitals, physicians and administrative

staff, tracking measures and discussing performance in regular hospital quality meetings or contract

renewal meetings, including participation in coaching programs as a metric in hospital incentive

programs, hosting webinars, adjusting website content for members and providers, and visiting

hospitals to distribute materials.

As summarized below (Table 38. Covered California Insurer Engagement with Network Hospitals),

Covered California assessment of insurer engagement activities with hospitals on improving quality

Smart Care California. October 2017. Aligning Birth Payment to Reduce Unnecessary C-Section.

http://www.iha.org/sites/default/files/files/page/c-section_menu_of_payment_and_contracting_options.pdf

Covered California did not ask the specific collaborative participation question in 2019 QHP Certification Application (reported in 2018).

The year in these tables refers to the year the information was submitted by the insurer to Covered California, so it may refer to activities in

the previous year or in the first quarter of that year. For example, a summary for 2017 likely includes activities from 2016 and the first

quarter of 2017.

Covered California Holding Health Plans Accountable for Quality and Delivery System Reform

EFFECTIVE CARE DELIVERY • CHAPTER 11

COVERED CALIFORNIA 92

found the number of insurers with Full Engagement for hospital safety tripled from three to nine

between 2016 and 2017. As of 2018, 10 insurers had Full Engagement or were Engaged for Hospital

Safety. For maternity care, most insurers have consistently had Full Engagement from 2016 to 2018,

with all plans having Full Engagement or Engaged as of 2018.

Table 38. Covered California Insurer Engagement with Network Hospitals

Hospital Safety

Maternity Care

Assessment

2016

2017

2018

2016

2017

2018

Full Engagement

Active engagement with hospitals in quality

improvement includes best practices to be potentially

shared among health plans.

Engaged

Has initiated engagement with hospitals either through

internal planning or external action.

Minimal Engagement

Has not acted either internally or externally to engage

with hospitals.

Source: Covered California Staff Analysis of Qualified Health Plan Submitted Data

Partly as a result of insurers’ encouragement and other factors, including growing hospital awareness

of Covered California’s focus on outlier poor performance, there is now nearly universal participation in

improvement collaboratives among California’s hospitals. Publicly reported data on hospital

participation in quality improvement programs shows a positive trend over the past four years, with 148

hospitals participating in 2014 to 251 hospitals in 2018 (see Figure A2. California Hospitals Involved in

Hospital Quality Institute Hospital Improvement Innovation Networks, 2014-18 in Appendix 4: Additional

Publicly Reported Hospital Quality and Safety Data). Participation in the five HIIN improvement

programs is near universal, with fewer than ten acute care hospitals in California not participating,

according to the Hospital Quality Institute.

Collectively Reducing Avoidable Hospital Associated Infections

Covered California has focused on aligned and collaborative efforts to promote hospital safety based

on the recognition that improving hospital performance in this area requires a comprehensive and

cross-payer approach.

Every day, about one in 25 hospital patients nationally contracts at least one hospital associated

infection (HAI).

These infections can significantly delay recovery, increase the expense of a hospital

stay, and even result in death. Of the approximately two million American patients who acquire a HAI

annually, an estimated 90,000 will die.

Before implementation of the Partnership for Patients program,

Centers for Disease Control and Prevention. Healthcare-associated Infections. Retrieved from: https://www.cdc.gov/hai/index.html.

Stone, P. W. (2009). Economic burden of healthcare-associated infections: an American perspective. Expert review of

pharmacoeconomics and outcomes research, 9(5), 417-422.

Covered California Holding Health Plans Accountable for Quality and Delivery System Reform

EFFECTIVE CARE DELIVERY • CHAPTER 11

COVERED CALIFORNIA 93

it was estimated that HAIs and other avoidable hospital complications were associated with more than

400,000 deaths per year.

Not only are HAIs harmful, they are also a burden on the healthcare system. The cost of a single case

can range from just under $1,000 to nearly $50,000, with costs borne by insurers, employers, and

patients through out-of-pocket expenses.

Depending upon the type of infection, the direct cost of HAIs

to hospitals ranges from $28 billion to $45 billion.

Measures to track HAIs are readily available through CMS Hospital Compare, California Department of

Public Health (CDPH), and Cal Hospital Compare. Covered California determined the five HAIs to focus

on through consultation with stakeholders and subject matter experts including CDPH, Cal Hospital

Compare, Hospital Quality Institute (a quality improvement center within the California Hospital

Association), Centers for Medicare and Medicaid Services (CMS), insurers, and consumer advocates.

The criteria for selecting these measures were:

• Clinical importance;

• Robust, publicly available performance data;

• Alignment with other purchasers including CMS;

• Wide variation in performance among California hospitals; and

• Availability of coaching collaboratives with change packages to support improvement for free or

minimal cost to hospitals.

Understanding Hospital Performance Variation to Target Quality Improvement Efforts

Covered California assists insurers in understanding hospital performance variation to enable better

targeting of hospitals for engagement and quality improvement. Covered California displays hospital

performance through graphic distributions where every California hospital’s measure score is

represented by a dot, and dots are color coded to denote in- or out-of-network status. The goal of these

graphs is to bring attention to the variation in hospital performance on each HAI and to help insurers

know which hospitals to focus on in their engagement and quality improvement efforts. For example,

below Figure 11. Sample of One Covered California Insurer’s Hospital Associated Infection Incidence

for Catheter-associated Urinary Tract Infection (CAUTI) — In-Network and Out-of-Network Hospitals,

2018 shows the performance of an insurer’s 2018 network for CAUTI standardized infection ratios. The

hospitals identified by blue dots on the right-hand side of the chart represent in-network hospitals for

this insurer that have infection rates above the risk adjusted expected rate. Covered California’s

identification and display of hospital infection rates provides additional information for insurers to use in

their design of networks and in their engagement with hospitals to encourage participation in quality

improvement initiatives.

James, J. T. (2013). A new, evidence-based estimate of patient harms associated with hospital care. Journal of patient safety, 9(3), 122-

128.

Potentially avoidable errors were grouped into the following categories: 1) errors of commission; 2) errors of omission; 3) errors of

communication; 4) errors of context; and 5) diagnostic errors.

Castlight and The Leapfrog Group. (2018). Healthcare-Associated Infections. Retrieved from: https://www.leapfroggroup.org.

Ibid.

Covered California Holding Health Plans Accountable for Quality and Delivery System Reform

EFFECTIVE CARE DELIVERY • CHAPTER 11

COVERED CALIFORNIA 94

Figure 11. Sample of One Covered California Insurer’s Hospital Associated Infection Incidence for

Catheter-associated Urinary Tract Infection (CAUTI) — In-Network and Out-of-Network Hospitals, 2018

Source: 2018 Data from Cal Hospital Compare and California Department of Public Health (CDPH).

To develop tailored approaches for targeting network hospitals for improvement, insurers can also

leverage the 2018 HAI reports from CDPH,

which list hospitals with better or worse HAI incidence

than the national baseline by county (see Appendix 4: Additional Publicly Reported Hospital Quality and

Safety Data).

Publicly reported data on HAIs are reported at the hospital level, not the insurer level, through CDPH

data on infection rate trends. According to the CDPH, there has been a statistically significant reduction

in CLABSI, SSI, MRSA, and C. difficile bacterial infection rates between 2015 and 2018 (see Figure 12.

Hospital Associated Infection Incidence in California Hospitals, 2015-18).

For these four HAI measures, the above chart shows a steady drop over three years, of which C.

Difficile infections were the last to show progress, but as of 2018 has dropped 41 percent since 2015.

The rates are expressed as a ratio of observed over a risk adjusted expected rate based on national

standards. For all infection rates to be falling and for all rates to be below the national expected ratio of

1.0 reflects concerted effort among many stakeholders in California and represents remarkable

progress. CDPH does not include hospital CAUTI information in its analysis.

See more: https://www.cdph.ca.gov/Programs/CHCQ/HAI/Pages/AnnualHAIReports.aspx.

For additional data, see C. Diff Incidence Rates in California Counties in Appendix 4.

Covered California Holding Health Plans Accountable for Quality and Delivery System Reform

EFFECTIVE CARE DELIVERY • CHAPTER 11

COVERED CALIFORNIA 95

Figure 12. Hospital Acquired Infection Incidence in California Hospitals, 2015-18

Note: Hospital associated infections are reported as a standardized infection ratio (SIR), a risk-adjusted measure managed nationally that

compares observed versus expected number of complications per year. The dashed line represents an SIR of 1.0. A score of 1.0 means a

hospital has an expected rate while below 1.0 is better and above is worse.

Source: California Department of Public Health. November 2019.

It is challenging to calculate the impact of hospital infections that have been prevented. However, Cal

Hospital Compare, with support from IBM Watson, calculated the mortality rates of hospital associated

infections and the usual costs of caring for those infections based on evidence from the literature. They

have evidence to support this calculation for four of the targeted infections: CLABSI, CAUTI, SSI Colon,

and C. Diff. The result, for the twelve months between October 1, 2017 and September 30, 2018,

compared to April 1, 2016 to March 31, 2017, shows that 3,392 infections were avoided resulting in 251

Californian lives saved and $62 million dollars saved.

It is important to note that Covered California insurer engagement and payment strategy efforts did not

create this improvement alone, but the contract requirements were likely helpful contributors to the

success.

Covered California has partnered with existing stakeholder groups and organizations, to

implement hospital quality and safety requirements that include a standard set of metrics and several

common approaches to quality improvement with aligned expectations across 11 health insurance

companies. Prior to 2016, health insurance companies did not find most hospitals receptive to

discussion of quality performance in contract discussions and insurer medical management and

network management teams were traditionally siloed internally. Importantly, under the leadership of the

Hospital Quality Institute, the California Hospital Association has taken a lead in increasing the focus on

quality. Health insurance companies also reported that the alignment of 11 insurers with consistent

message of insurer accountability for variation and a prioritized set of measures has changed the

environment and supported measurable improvement.

Of note, these requirements became effective in 2017 but stakeholder discussions on the importance of quality improvement began in

summer of 2015. Some plans began engaging hospitals earlier than 2017 and some as early as summer 2015.

Covered California Holding Health Plans Accountable for Quality and Delivery System Reform

EFFECTIVE CARE DELIVERY • CHAPTER 11

COVERED CALIFORNIA 96

Collectively Reducing Unnecessary C-Sections: Reduce Low-Risk NTSV C-Section

Rates to 23.9 Percent or Lower

C-sections can be life-saving, but significant numbers of healthy first-time mothers are undergoing this

major surgery when it is not medically necessary. Unnecessary C-sections are dangerous for the

mother and baby, increasing the risk of complications such as hemorrhage, infection, transfusions,

blood clots, respiratory complications, and neonatal intensive care unit (NICU) admission.

Roughly 90

percent of women with a prior C-Section currently deliver by C-section for future births, leading to

higher risks of additional complications, including placenta previa or accreta and uterine rupture (which

can cause hemorrhage, hysterectomy, or death).

Compared to vaginal delivery, babies born by repeat

C-section have higher rates of respiratory morbidity and NICU admission rates resulting in longer

hospital stays and higher medical costs.

Covered California holds health insurance companies responsible to manage variation in provider

performance across their contracted networks rather than manage to average performance. To that

end, insurers are required to engage with their network hospitals to promote awareness of (1) low risk

C-section rates, (2) availability of provider and consumer education, and (3) promote participation in

data sharing and coaching offered by the California Maternal Quality Care Collaborative (CMQCC), with

the goal of reducing NTSV C-sections to 23.9 percent of deliveries or lower (as set in the national

Healthy People 2020 goals).

CMQCC gained national attention for contributing to California’s decreasing maternal mortality rates

and now works to reduce NTSV C-sections. Hospital participation in the CMQCC data collection and

improvement collaborative is now nearly universal partly due to insurer encouragement and inclusion in

contracting discussions with hospitals. As of July 2018, nearly 95 percent of California hospital births

occur at hospitals participating in data reporting or collaboratives managed by the Maternal Data Center

(MDC) within the CMQCC (see Figure A3: Percentage of California Hospital Births at CMQCC

Participating Hospitals in Appendix 4: Additional Publicly Reported Hospital Quality and Safety Data).

Progress to reduce NTSV C-sections has been substantial between 2015 and 2018. In 2015, the

variation in C-section rates for NTSV deliveries among maternity hospitals in California was enormous,

ranging from 10 to 75.8 percent. Figure 13. Distribution of NTSV C-section Rates for Hospitals that

Reported to the California Maternal Quality Care Collaborative, 2018 shows the range of NTSV C-

section rates for hospitals reporting to CMQCC in 2018. The range was 6.2 to 41.1 percent with an

aggregated rate of 23.3 percent and a median of 23.2 percent, which are both below the Healthy

People 2020 target of 23.9 percent. The absence of the highest outliers signifies substantial change in

maternity practice in the state of California.

J. P. Souza et al., “Caesarean Section Without Medical Indications Is Associated with an Increased Risk of Adverse Short-Term Maternal

Outcomes: The 2004-2008 WHO Global Survey on Maternal and Perinatal Health,” BMC Medicine 8 (November 10, 2010): 71,

doi:10.1186/1741-7015-8-71.

Smart Care California. (2017). Aligning Birth Payment to Reduce Unnecessary C-Section: A Menu of Options. Retrieved from

http://www.iha.org/sites/default/files/files/page/c-section_menu_of_payment_and_contracting_options.pdf

Kamath, B. et al. “Neonatal Outcomes After Elective Cesarean Delivery”. Obstetrics and Gynecology. 113(6):1231-1238, JUN 2009.

As of July 2018, 221 of 240 maternity hospitals representing nearly 95 percent of California hospital births occur at hospitals participating

in data reporting or collaboratives managed by the Maternal Data Center (MDC) within the CMQCC.

Covered California Holding Health Plans Accountable for Quality and Delivery System Reform

EFFECTIVE CARE DELIVERY • CHAPTER 11

COVERED CALIFORNIA 97

Figure 13. Distribution of NTSV C-section Rates for Hospitals that Reported to the

California Maternal Quality Care Collaborative, 2018

Note: Each of the blue bars represents each of the hospitals for which there is data available. HP 2020 refers to the Healthy People 2020

target of reducing NTSV C-Sections to 23.9 percent or less of deliveries.

Source: CMQCC Maternal Data Center

After concerted effort by almost every maternity hospital in the state with contractual and other support

from the three large state purchasers — Medi-Cal, CalPERS and Covered California — and the Pacific

Business Group on Health, representing both public and private purchasers, 56 percent of California

maternity hospitals that report to CMQCC (122 of 221) have achieved the national goal of NTSV C-

section rates of 23.9 percent or lower.

On an aggregate level, CMQCC reported that 7,200 C-sections

were avoided statewide from 2015 to 2018.

As of the first half of 2019, the number hospitals that participate in CMQCC and meet the NTSV C-

section target was 63 percent (compared to 44 percent in 2015) and there has been a 22 percent

decrease in the percent of hospitals with a rate above 26 percent (42 percent in 2015) (see Figure 14.

Hospitals with C-Sections Rates Below 23.9 Percent or Above 26 Percent Reported to the California

Maternal Quality Care Collaborative, 2018).

Smart Care California. (2018). 2018 Hospital C-Section Honor Roll. Retrieved from

https://www.iha.org/sites/default/files/2018_hospital_award_winners_final.pdf.

Covered California Holding Health Plans Accountable for Quality and Delivery System Reform

EFFECTIVE CARE DELIVERY • CHAPTER 11

COVERED CALIFORNIA 98

Figure 14. Hospitals with C-Sections Rates Below 23.9 Percent or Above 26 Percent

Reported to the California Maternal Quality Care Collaborative, 2018

Source: CMQCC Maternal Data Center, 2019

Expand Value-based Payments for Hospitals and Maternity Care

Just as Covered California promotes changes in how physicians are paid to foster payments that

encourage coordination and advanced primary care (see Chapter 7: Promotion of Effective Primary

Care), it requires insurers to change payments to improve hospital quality and maternity care. Health

plans are required to adopt payment methods that (1) tie at least two percent of hospital payments to

value, and (2) eliminate financial incentives for hospital facilities or physicians to perform C-Sections.

Hospital Payments: Health insurance companies are required to adjust payments to hospitals so that

at least two percent of overall hospital payments are tied to value for each product by the end of 2019

and increasing over the following years to at least 6 percent by year-end 2023. This can be

accomplished by either withholding payment pending documentation of quality performance, bonuses,

or a combination of both depending on the circumstances at each hospital. Health insurance

companies are required to include the five specific HAI measures and the NTSV C-section measure,

but insurers are given flexibility to include appropriate additional metrics based on their judgment and

priorities such as patient satisfaction, additional clinical quality measures, safety, or readmissions.

However, the entire two percent cannot be attributed to readmissions due to concern that hospitals

serving a disproportionate share of disadvantaged populations may be inadvertently harmed.

Maternity Care Payments: Health insurance companies are encouraged to adjust labor and delivery

payments to physicians and hospitals so that by year-end 2019 payment does not incentivize

performing C-sections. To provide guidance to hospitals and insurers, Smart Care California, a public-

private multi-stakeholder workgroup led by California state purchasers, built consensus around the

following payment structures: (1) blended case rates; (2) low risk C-section reduction as a metric for

Covered California Holding Health Plans Accountable for Quality and Delivery System Reform

EFFECTIVE CARE DELIVERY • CHAPTER 11

COVERED CALIFORNIA 99

payment incentive programs; or (3) population-based payment models.

While Smart Care California

emphasizes blended case rates, any of the payment structures would fulfill the requirement for payment

to not incentivize performing C-sections.

As described in Table 40. Covered California Insurer Engagement in Changing Payments to Hospitals,

2016-18, most insurers have been Re-contracting with value-based payments for hospitals. As of 2018,

10 insurers were Actively Re-contracting or Re-contracting. The percent of network hospitals with

value-based payments from the insurer is an indicator for the extent to which the insurer is scaling the

program. Data reported for 2018 indicates wide variation in the extent to which an insurer’s network

hospitals have value-based payments, after excluding insurers with integrated delivery systems (Kaiser

Permanente and Sharp Health Plan). Four insurers reported between 20 to 100 percent of hospitals

have value-based payment contracts, two insurers reported less than 10 percent of hospitals have

value-based payment contracts, and four insurers reported that 0 percent of network hospitals have

value-based payment contracts.

For value-based payments for NTSV C-Sections, health plans made significant progress, from six

health plans assessed as Actively Re-contracting or Re-contracting in 2016 to 10 health plans in 2018.

Table 40. Covered California Insurer Engagement in Changing Payments to Hospitals, 2016-18

Hospital Payments

NTSV

C-Sections

Assessment

2016

2017

2018

2016

2017

2018

Actively Re-contracting

Active re-contracting of network to adjust payment.

Re-contracting

Describes efforts to start re-contracting payments (e.g.

internal planning) and has initiated the process.

Minimal Re-contracting

Has not yet started re-contracting toward value-based

payment to hospitals.

Source: Covered California Staff Analysis of Qualified Health Plan Data Submitted for 2016-2018.

Covered California has worked with some insurers to amend their contract on this requirement, either

because they function as a capitated integrated delivery system that has a payment structure aligned

with quality performance or their population is too small to be the basis for leverage in contract

negotiations to change the business model. The common elements in amendments involve continuing

to track measures, engaging hospitals to improve and continually making efforts to change payment if

not already aligned.

In summary, Covered California has worked with the California Hospital Association, Cal Hospital

Compare, CMQCC and Smart Care California, all multi-stakeholder forums that include insurers, to

adopt a focused list of maternity and safety metrics for hospitals. By working together and aligning 11

insurers on a common set of metrics and payment structure, quality performance is now part of hospital

contract discussions in ways it was not in prior years. The state is seeing reductions in NTSV C-

sections and avoidable hospital associated infections.

Smart Care California. October 2017. Aligning Birth Payment to Reduce Unnecessary C-Section. Retrieved from:

http://www.iha.org/sites/default/files/files/page/c-section_menu_of_payment_and_contracting_options.pdf.

Covered California Holding Health Plans Accountable for Quality and Delivery System Reform

EFFECTIVE CARE DELIVERY • CHAPTER 11

COVERED CALIFORNIA 100

Covered California’s requirements link hospital payment reform with hospital improvement efforts.

Hospital performance is improving faster than implementation of hospital payment reforms. Sustaining

these improvements in hospital quality and safety will be reinforced as payment is gradually more

aligned with quality and safety goals.

Expanded Approaches to Care Delivery

Telehealth

Health insurance companies are required to report the extent to which they support and use technology

to assist in higher quality, accessible, patient-centered care and the utilization for enrollees on the

number of unique patients and number of separate services provided for telehealth. Health insurance

companies must describe whether these models are implemented in association with patient-centered

medical homes, integrated delivery systems or accountable care organization models of care or are

independently implemented.

All Covered California insurers offered a telehealth or web-based service in 2018, but they vary in their

capabilities. Most insurers that offered a telehealth service in 2018 used a vendor with two insurers

offering telehealth visits only through contracted medical groups and not as a free-standing program

(see Table 41. Covered California Insurer Telehealth Capabilities, 2015, 2017 and 2018).

The percent of enrollees with a telehealth visit for Covered California insurers ranged from 0 percent to

59 percent in 2018. The high outlier, Kaiser Permanente, an integrated delivery system that uses

telehealth as part of their model, reported that 59 percent of enrollees used telehealth or had a web visit

in 2018. Oscar Health Plan reported that 17 percent of enrollees used telehealth or a web visit in 2018.

Oscar Health Plan consistently and actively promotes the use of telehealth to its enrollees. Most other

insurers reported that fewer than 10 percent of enrollees had engaged with care through telehealth.

Table 41. Covered California Insurer Telehealth Capabilities, 2015, 2017 and 2018

Number of Health Plans

2015

2017

2018

Telehealth

Telehealth with video through vendor

Telehealth through medical groups only

Telehealth with phone

Telehealth for mental health visits only

Web Visit using instant messaging

Note: 10 health plans offered a telehealth service in 2017 while all 11 health plans offered a telehealth service in 2018.

Covered California Holding Health Plans Accountable for Quality and Delivery System Reform

EFFECTIVE CARE DELIVERY • CHAPTER 11

COVERED CALIFORNIA 101

Table 42. Covered California Insurer Telehealth Cost Shares and Promotion to Enrollees, 2017-18

Number of Health Plans

2017

2018

Cost-Share

No cost-share*

Same cost as primary care or specialist visit

A $5 copay with vendor, but other services are the same an in-person visit

Promotion to Enrollees

Promoted via email, print, online resources

Added telehealth visit cost-share next to ED cost-share on member ID card

Used as Follow up to Lab Visits

Promoted through Open Enrollment marketing

Promote on website, member portal, or mobile app

Promotes through medical groups

Did not promote telehealth services

*Note Bronze High Deductible enrollees or those with a Health Savings Account are subject to the deductible.

Source: Covered California Staff Analysis of Qualified Health Plan Submitted Data

Implications for the Future

Improving hospital quality and safety through reducing HAIs and NTSV C-section rates will continue to

be areas of focus for Covered California. Additional measures will be incorporated as they are publicly

reported. As acute care appropriately moves from the hospital to hospital outpatient centers and to

ambulatory surgery centers, Covered California will support efforts to obtain and publicly report on the

quality of care delivered in these sites. Covered California is exploring opportunities to measure

volume, both in the number of patients served and the number of services delivered, as a proxy for

safety at all sites of care. In addition, Covered California recognizes the need to look at additional

measures or indications of health care quality or safety, including what other measures or indicators of

appropriate care should be used.

The adoption of telehealth services, retail or convenience clinics and Centers of Excellence are

examples of using alternative sites of care or expanded approaches to care delivery beyond the

traditional hospital and physician office. Others include care at home and expanded use of technology

such as eConsult and Project ECHO to facilitate integration and coordination across specialties and

adoption of team-based care. Covered California is working with insurers to ensure telehealth or other

technology programs are offered in the languages spoken by their enrollees and further promote the

availability of translation services. Covered California is assessing how best to evaluate the extent to

which these programs foster care that improves quality and patient experience while lowering costs.

Although this report heavily focuses on the hospital and physician office experience, Covered California

recognizes that health care is being delivered to consumers outside of these traditional venues. Moving

forward, Covered California will be evaluating quality outcomes from sites such as outpatient surgery

centers, birthing centers, retail clinics and home care services. More and more consumers are turning

to these non-traditional care sites and Covered California has an obligation to ensure that these sites

meet its high-quality standards while keeping health care costs affordable.

Covered California Holding Health Plans Accountable for Quality and Delivery System Reform

EFFECTIVE CARE DELIVERY • CHAPTER 11

COVERED CALIFORNIA 102

Chapter 12: Summary and Implications for the Future

This report presents the initial findings of insurer progress towards meeting Covered California’s

contractual requirements to assure quality care and promote delivery system reform.

The most consistent finding across all domains was the remarkable variation in performance with the

consistent high performance for Kaiser Permanente and Sharp Health Plan. This was true not only for

measures included in the Quality Rating System, but also for disadvantaged populations when profiled

for disparities. Hospitals in these integrated systems show much less variation in safety scores and

both insurers have adopted best practices in primary care. Their focus on integrated, coordinated care

likely explains their performance and reinforces Covered California’s intent to promote ACOs to better

organize care in the delivery systems of other insurers. While the integrated plans excelled, it was

reassuring that, with few exceptions, most performance was between the 25

and 90

percentile

nationwide for other plans across a wide range of measures. There are some measures, especially for

behavioral health and preventive care, where several plans perform below the 25

percentile. However,

Covered California has no outlier poor performing health plans.

Covered California worked with insurers to collect baseline data on race and ethnicity for all enrollees

under 65 across all lines of business. Despite significant challenges with data quality, each insurer is

moving ahead to address health disparities based on actionable differences found across a wide variety

of population characteristics. This program is a priority to enhance and expand.

All Covered California enrollees now have a primary care physician and a growing number are cared

for within Integrated Delivery Systems or ACOs. Significant work remains to support the implementation

of advanced primary care models and to establish best practices for ACOs as they attempt to replicate

the success of integrated systems.

Covered California holds health insurance companies accountable to manage variation in performance

in addition to reporting overall average measurement through the Quality Rating System. Hospital

performance was an initial focus using publicly reported data and supported by collaborative programs

improving safety and maternity care. There has been important progress made demonstrating the value

of alignment across multiple purchasers and payers as well as significant leadership from providers.

Hospital care in California is safer as a result.

Covered California has established a framework and approach to systematic improvement that has

started to show important results: slower cost growth, modest improvement in quality measures,

adoption of more effective primary care models, progress toward implementation of integrated delivery

systems and ACOs and, through collaboration with others, substantial gains in patient safety.

Moreover, by requiring all insurers to stratify performance measures by race and ethnicity, Covered

California has set the stage for achieving progress in reducing disparities.

Much remains to be done, especially in the arena of consistent and effective measurement that

supports quality improvement strategies for better health outcomes. Covered California acknowledges

that efforts to meet the long-term goals of consistent measurement would potentially increase

administrative burden initially for providers and hospitals but if done effectively and carefully, would

establish consistent data measurement across insurers and purchasers that targets improvement

opportunities for the delivery system in quality, cost, effectiveness and equity. In the end, this would be

expected to reduce administrative burden and complexity. Covered California is committed to working

collaboratively and transparently to ensure that we contribute to a state where “Health Care for All”

means that all Californians receive the best possible care.

Covered California Holding Health Plans Accountable for Quality and Delivery System Reform

APPENDICIES

COVERED CALIFORNIA 103

APPENDICES

Covered California Holding Health Plans Accountable for Quality and Delivery System Reform

APPENDICIES

COVERED CALIFORNIA 104

Appendix 1: Limitations and Major Caveats about Health Disparities Data

The data collected for the health disparities measures described in Chapter 2 is unique because it

includes data for enrollees under age 65 across all lines of business for 11 insurers. Covered California

cautions that it has several limitations and major caveats:

• These are baseline results not reported for accountability: Insurers have been required to

collect ethnic and racial identity by law in California since 2003. The results were used only to

determine which language translation services were needed. This is the first time ethnic and

racial identity information has been used to stratify clinical outcomes data for the purpose of

defining and addressing disparities. It has taken three years to establish a baseline for which

strategies are being developed to reduce disparities.

• Varying populations by insurer: Health insurance companies collected data for their entire

populations under 65 regardless of line of business. Because each insurer has different

proportions of commercial and Medi-Cal populations, the results cannot be compared between

insurers.

• No formal audit process: While insurers were encouraged to follow the measures

specifications for HEDIS and PQI, the data reported by insurers has not been verified through a

third-party audit as it would be for reporting to the National Committee for Quality Assurance’s

Quality Compass. Third-party auditors examine information practices and control procedure,

sampling methods and procedures, data integrity, compliance with HEDIS specifications,

analytic file production, and reporting and documentation.

• Variation in data quality and collection: Data quality varies by insurer, with some missing key

data elements such as identification of certain groups (e.g., Native Hawaiian) and ability to

identify claims using the measure specifications for admissions. Most insurers aggregated their

400-person HEDIS samples across all lines of business and a few had access to robust clinical

data from electronic health records. HEDIS samples are drawn to represent the entire

population but may not represent the ethnic and racial diversity of the plan’s population.

• Small denominators: Because the health disparities measures are based on a subset of

individuals with a diagnosed chronic condition and reported by six race/ethnicity categories, this

results in small denominators among some groups for certain measures and make it difficult to

identify actual differences in care and outcomes. Some admissions measures and American

Indian/Alaskan Native populations are especially impacted by small denominators. As a result,

no insurer proposed an admission measure as a focus of disparity reduction efforts. However,

admissions are important enough that further work is needed to determine if interventions might

be appropriate despite the small numbers.

• Interpretation of data and identifying health Care disparities: Health insurance companies

report the numerators, denominators, and rates by race/ethnicity for each measure, and early

discussions between Covered California and insurers have centered on observed rate

differences in admissions, disease control, and medication management between race/ethnicity

groups. An observed rate difference may require further analysis to consider confounding

factors and statistical significance.

Covered California Holding Health Plans Accountable for Quality and Delivery System Reform

APPENDICIES

COVERED CALIFORNIA 105

Appendix 2: Additional Health Plan Measures Reported to Quality Rating

System

The following tables display the Covered California weighted average, highest and lowest performing

plans, plan-specific performance, as well as national percentiles for all Marketplace plans for the

remaining measures in the Marketplace Quality Rating System (QRS) measure set. A priority set of 13

measures were presented in the subject chapters of this report.

How to Interpret Quality Performance Data

Within the QRS measure set, HEDIS measures rely on claims or encounter data while CAHPS

measures are collected as part of the Qualified Health Plan Enrollee Survey. Since insurers can offer

multiple products that vary by network type (HMO, PPO, or EPO), the data below shows 16 total plans.

The data is listed by year the health plans reported the QRS measure set data such that the 2019

reporting year data represents health plan performance during the 2018 calendar year or measurement

year and so on.

Only data for products meeting CMS participation criteria for QRS score eligibility are displayed in the

tables. Blank cells indicate the following: (1) CMS participation criteria were not met for scoring

because the health plan did not offer a product for two consecutive years through Covered California;

(2) CMS participation criteria were met but denominator size for a given measure was below the

minimum threshold for scoring; or (3) the health plan chose not to report the measure (Not

Reported/NR).

The percentile values provide benchmark information for measure rates, allowing a health plan to

compare its results to all other health plans and products nationally. CMS reports benchmark values

that include the standardized 25

, 50

, 75

, and 90

percentile values for the numerical rates across all

health plans and products. To create these benchmark values, CMS uses only measure rates that have

met the minimum denominator size criteria for scoring.

Centers for Medicaid and Medicare Services. (2018). Quality Rating System and Qualified Health Plan Enrollee Experience Survey:

Technical Guidance for 2019. Retrieved from https://www.cms.gov.

Covered California Holding Health Plans Accountable for Quality and Delivery System Reform

APPENDICIES

COVERED CALIFORNIA 106

Additional Measures Related to Health Promotion and Prevention

In Chapter 3: Health Promotion and Prevention, three QRS measures are presented as potential

“Priority Measures.” These measures and the eight additional QRS measures pertaining to Health

Promotion and Prevention are:

Potential Priority Measures

1. Breast Cancer Screening (Table 13)

2. Cervical Cancer Screening (Table 14)

3. Colorectal Cancer Screening (Table 15)

Additional Measures

4. Chlamydia Screening in Women (Table A1)

5. Adult BMI Assessment (Table A2)

6. Childhood Immunizations (Combination 3) (Table A3)

7. Immunizations for Adolescents (Combination 2) (Table A4)

8. Flu Vaccinations for Adults (Table A5)

9. Medical Assistance with Smoking and Tobacco Use Cessation (Table A6)

10. Weight Assessment and Counseling for Nutrition and Physical Activity for Children and

Adolescents (Table A7)

11. Annual Dental Visit (Table A8)

Covered California Holding Health Plans Accountable for Quality and Delivery System Reform

APPENDICIES

COVERED CALIFORNIA 107

Chlamydia Screening in Women

The Chlamydia Screening measure is the percentage of women 16–24 years of age who were

identified as sexually active and who had at least one test for chlamydia during the measurement year.

Table A1. Chlamydia Screening in Women for Covered California Enrollees (HEDIS)

2016

2017

2018

2019

Benchmark

Percent of

Enrollees

Number of

Enrollees

Number

of Plans

Plans at 90th Percentile and

Above

61 +

64 +

65 +

67 +

36%

477,683

Plans at 50th to 90th

Percentile

44 to 61

45 to 64

48 to 65

47 to 67

46%

622,371

Plans at 25th to 50th

Percentile

37 to 44

38 to 45

39 to 48

40 to 47

18%

245,176

Plans Below 25th Percentile

Below 37

Below 38

Below 39

Below 40

Covered California High/Average/Low Performers

Covered CA Highest

Performer

Covered CA Weighted

Average

Covered CA Lowest

Performer

Covered California Plan-Specific Performance

Anthem HMO

Anthem PPO

Anthem EPO

64,031

Blue Shield HMO

93,322

Blue Shield PPO

25%

335,176

CCHP HMO

10,013

Health Net HMO

11%

145,183

Health Net EPO

Health Net PPO

Kaiser Permanente HMO

36%

477,683

LA Care HMO

84,750

Molina Healthcare HMO

56,023

Oscar Health Plan EPO

35,962

Sharp Health Plan HMO

17,335

Valley Health Plan HMO

16,366

Western Health Advantage

HMO

9,386

Covered California Holding Health Plans Accountable for Quality and Delivery System Reform

APPENDICIES

COVERED CALIFORNIA 108

Adult Body Mass Index Assessment

The Adult BMI measure is the percentage of members 18–74 years of age who had an outpatient visit

and whose body mass index (BMI) was documented during the measurement year or the year prior to

the measurement year.

Table A2. Adult Body Mass Index Assessment for Covered California Enrollees (HEDIS)

2016

2017

2018

2019

Benchmark

Percent of

Enrollees

Number of

Enrollees

Number

of Plans

Plans at 90th Percentile

and Above

MN-S

95 +

94 +

96 +

35%

477,683

Plans at 50th to 90th

Percentile

MN-S

84 to 95

85 to 94

86 to 96

24%

329,670

Plans at 25th to 50th

Percentile

MN-S

73 to 84

75 to 85

79 to 86

12%

157,353

Plans Below 25th

Percentile

MN-S

Below 73

Below 75

Below 79

28%

381,920

Covered California High/Average/Low Performers

Covered CA Highest

Performer

Covered CA Weighted

Average

Covered CA Lowest

Performer

Covered California Plan-Specific Performance

Anthem HMO

Anthem PPO

Anthem EPO

64,031

Blue Shield HMO

93,322

Blue Shield PPO

25%

335,176

CCHP HMO

10,013

Health Net HMO

11%

145,183

Health Net EPO

1,396

Health Net PPO

Kaiser Permanente HMO

35%

477,683

LA Care HMO

84,750

Molina Healthcare HMO

56,023

Oscar Health Plan EPO

35,962

Sharp Health Plan HMO

17,335

Valley Health Plan HMO

16,366

Western Health Advantage

HMO

9,386

*M-NS: This measure was not used in determining the overall QRS rating in 2016.

Covered California Holding Health Plans Accountable for Quality and Delivery System Reform

APPENDICIES

COVERED CALIFORNIA 109

Childhood Immunizations Status (Combination 3)

The Childhood Immunization Status measure is the percentage of children 2 years of age who had four

diphtheria, tetanus and acellular pertussis (DTaP); three polio (IPV); one measles, mumps and rubella

(MMR); three haemophilus influenza type B (HiB); three hepatitis B (HepB), one chicken pox (VZV);

and four pneumococcal conjugate (PCV) vaccines by their second birthday. The measure calculates a

rate for each vaccine and one combination rate.

Table A3. Childhood Immunization Status (Combination 3) for Covered California Enrollees (HEDIS)

2016

2017

2018

2019

Benchmark

Percent of

Enrollees

Number of

Enrollees

Number

of Plans

Plans at 90th Percentile and

Above

MN-S

85 +

86 +

Plans at 50th to 90th Percentile

MN-S

76 to 85

75 to 86

77 to 86

46%

562,433

Plans at 25th to 50th Percentile

MN-S

69 to 76

65 to 75

65 to 77

17,335

Plans Below 25th Percentile

MN-S

Below 69

Below 65

52%

637,712

Covered California High/Average/Low Performers

Covered CA Highest Performer

Covered CA Weighted Average

Covered CA Lowest Performer

Covered California Plan-Specific Performance

Anthem HMO

Anthem PPO

Anthem EPO

64,031

Blue Shield HMO

93,322

Blue Shield PPO

28%

335,176

CCHP HMO

Health Net HMO

12%

145,183

Health Net EPO

Health Net PPO

Kaiser Permanente HMO

39%

477,683

LA Care HMO

84,750

Molina Healthcare HMO

Oscar Health Plan EPO

Sharp Health Plan HMO

17,335

Valley Health Plan HMO

Western Health Advantage HMO

*M-NS: This measure was not used in determining the overall QRS rating in 2016.

Covered California Holding Health Plans Accountable for Quality and Delivery System Reform

APPENDICIES

COVERED CALIFORNIA 110

Immunizations for Adolescents (Combination 2)

The Immunizations for Adolescents (Combination 2) measure is the percentage of adolescents 13

years old who had one dose of meningococcal vaccine, one tetanus, diphtheria toxoids and acellular

pertussis (Tdap) vaccine, and have completed the human papillomavirus (HPV) vaccine series by their

birthday. The measure calculates a rate for each vaccine and two combination rates.

Table A4. Immunizations for Adolescents (Combination 2) for Covered California Enrollees (HEDIS)

2016

2017

2018

2019

Benchmark

Percent of

Enrollees

Number of

Enrollees

Number

of Plans

Plans at 90th Percentile and

Above

MN-S

31 +

36 +

44%

562,433

Plans at 50th to 90th Percentile

MN-S

19 to 31

23 to 36

24%

311,863

Plans at 25th to 50th Percentile

MN-S

15 to 19

17 to 23

27%

344,562

Plans Below 25th Percentile

MN-S

Below 15

Below 17

64,031

Covered California High/Average/Low Performers

Covered CA Highest Performer

Covered CA Weighted Average

Covered CA Lowest Performer

Covered California Plan-Specific Performance

Anthem HMO

Anthem PPO

Anthem EPO

64,031

Blue Shield HMO

93,322

Blue Shield PPO

26%

335,176

CCHP HMO

Health Net HMO

11%

145,183

Health Net EPO

Health Net PPO

Kaiser Permanente HMO

37%

477,683

LA Care HMO

84,750

Molina Healthcare HMO

56,023

Oscar Health Plan EPO

Sharp Health Plan HMO

17,335

Valley Health Plan HMO

Western Health Advantage

HMO

9,386

Note: National percentiles not scored for Reporting Years 2016 and 2017. Between Reporting Years 2016 and 2019, this measure was

renamed to “Immunizations for Adolescents (Combination 2)” and expanded to include the HPV vaccine alongside the Tdap and

meningococcal vaccines.

*M-NS: This measure was not used in determining the overall QRS rating in 2016 or 2017.

Covered California Holding Health Plans Accountable for Quality and Delivery System Reform

APPENDICIES

COVERED CALIFORNIA 111

Flu Vaccinations for Adults

The Flu Vaccination for Adults measure is the percentage of members 18-64 years of age who received

a flu vaccination between July 1 of the measurement year and the date when the QHP Enrollee Survey

was completed. This is the only immunization measure that includes adults, who make up the majority

of Covered California plan enrollment.

Table A5. Flu Vaccinations for Covered California Enrollees Ages 18-64 (CAHPS)

2016

2017

2018

2019

Benchmark

Percent of

Enrollees

Number of

Enrollees

Number

of Plans

Plans at 90th Percentile and

Above

50 +

54 +

58 +

Plans at 50th to 90th Percentile

40 to 50

43 to 54

47 to 58

62%

829,225

Plans at 25th to 50th Percentile

35 to 40

37 to 40

38 to 43

43 to 47

18%

238,505

Plans Below 25th Percentile

Below 35

Below 37

Below 38

Below 43

21%

277,500

Covered California High/Average/Low Performers

Covered CA Highest Performer

Covered CA Weighted Average

Covered CA Lowest Performer

Covered California Plan-Specific Performance

Anthem HMO

Anthem PPO

Anthem EPO

64,031

Blue Shield HMO

93,322

Blue Shield PPO

25%

335,176

CCHP HMO

10,013

Health Net HMO

11%

145,183

Health Net EPO

Health Net PPO

Kaiser Permanente HMO

36%

477,683

LA Care HMO

84,750

Molina Healthcare HMO

56,023

Oscar Health Plan EPO

35,962

Sharp Health Plan HMO

17,335

Valley Health Plan HMO

16,366

Western Health Advantage HMO

9,386

Covered California Holding Health Plans Accountable for Quality and Delivery System Reform

APPENDICIES

COVERED CALIFORNIA 112

Medical Assistance with Smoking and Tobacco Use Cessation

The Medical Assistance with Smoking and Tobacco Use Cessation measure is comprised of the

following components:

1. Advising Smokers and Tobacco Users to Quit: A rolling average represents the percentage of

members 18 years of age and older who were current smokers or tobacco users and who

received advice to quit during the measurement year.

2. Discussing Cessation Medications: A rolling average represents the percentage of members 18

years of age and older who were current smokers or tobacco users and who discussed or were

recommended cessation medications during the measurement year.

3. Discussing Cessation Strategies: A rolling average represents the percentage of members 18

years of age and older who were current smokers or tobacco users and who discussed or were

provided cessation methods or strategies during the measurement year.

Table A6. Medical Assistance with Smoking and Tobacco Use Cessation for Covered California Enrollees

(CAHPS)

2016

2017

2018

2019

Benchmark

Percent of

Enrollees

Number of

Enrollees

Number

of Plans

Plans at 90th Percentile and

Above

MN-S

59 +

60 +

63 +

Plans at 50th to 90th Percentile

MN-S

50 to 59

50 to 60

54 to 63

Plans at 25th to 50th Percentile

MN-S

45 to 50

48 to 54

Plans Below 25th Percentile

MN-S

Below 45

Below 48

Covered California High/Average/Low Performers

Covered CA Highest Performer

Covered CA Weighted Average

Covered CA Lowest Performer

Covered California Plan-Specific Performance

Anthem HMO

Anthem PPO

Anthem EPO

Blue Shield HMO

Blue Shield PPO

CCHP HMO

Health Net HMO

Health Net EPO

Health Net PPO

Kaiser Permanente HMO

LA Care HMO

Molina Healthcare HMO

Oscar Health Plan EPO

Sharp Health Plan HMO

Valley Health Plan HMO

Western Health Advantage HMO

*QRS did not collect this measure in 2016.

**M-NS: This measure was not used in determining the overall QRS rating in 2016.

Covered California Holding Health Plans Accountable for Quality and Delivery System Reform

APPENDICIES

COVERED CALIFORNIA 113

Weight Assessment and Counseling for Nutrition and Physical Activity for Children and

Adolescents

The Weight Assessment and Counseling for Nutrition and Physical Activity for Children and

Adolescents measure is the percentage of members 3-17 years of age who had an outpatient visit with

a PCP or OB/GYN and who had evidence of the following during the measurement year:

• BMI percentile documentation. Because BMI norms for youth vary with age and gender, this

measure evaluates whether BMI percentile is assessed rather than an absolute BMI value;

• Counseling for nutrition; and

• Counseling for physical activity.

Table A7. Weight Assessment and Counseling for Nutrition and

Physical Activity for Covered California Children and Adolescents Enrollees (HEDIS)

2016

2017

2018

2019

Benchmark

Percent of

Enrollees

Number of

Enrollees

Number

of Plans

Plans at 90th Percentile and

Above

82 +

83 +

84 +

87 +

35%

477,683

Plans at 50th to 90th

Percentile

56 to 82

63 to 83

66 to 84

69 to 87

10%

128,464

Plans at 25th to 50th

Percentile

46 to 56

51 to 63

53 to 66

59 to 69

25%

331,886

Plans Below 25th Percentile

Below 46

Below 51

Below 53

Below 59

30%

408,593

Covered California High/Average/Low Performers

Covered CA Highest Performer

Covered CA Weighted

Average

Covered CA Lowest Performer

Covered California Plan-Specific Performance

Anthem HMO

Anthem PPO

Anthem EPO

64,031

Blue Shield HMO

93,322

Blue Shield PPO

25%

335,176

CCHP HMO

10,013

Health Net HMO

11%

145,183

Health Net EPO

1,396

Health Net PPO

Kaiser Permanente HMO

35%

477,683

LA Care HMO

84,750

Molina Healthcare HMO

56,023

Oscar Health Plan EPO

35,962

Sharp Health Plan HMO

17,335

Valley Health Plan HMO

16,366

Western Health Advantage

HMO

9,386

Covered California Holding Health Plans Accountable for Quality and Delivery System Reform

APPENDICIES

COVERED CALIFORNIA 114

Annual Dental Visit

The Annual Dental Visit measure is the percentage of members 2–20 years of age who had at least

one dental visit during the measurement year.

Table A8. Annual Dental Visit for Covered California Enrollees (HEDIS)

2016

2017

2018

2019

Benchmark

Percent of

Enrollees

Number of

Enrollees

Number

of Plans

Plans at 90th Percentile and

Above

55 +

57 +

55 +

Plans at 50th to 90th

Percentile

27 to 55

27 to 57

32 to 55

31 to 55

1,396

Plans at 25th to 50th

Percentile

9 to 27

8 to 27

13 to 32

16 to 31

94%

758,424

Plans Below 25th Percentile

Below 9

Below 8

Below 13

Below 16

43,087

Covered California High/Average/Low Performers

Covered CA Highest

Performer

Covered CA Weighted

Average

Covered CA Lowest Performer

Covered California Plan-Specific Performance

Anthem HMO

Anthem PPO

Anthem EPO

64,031

Blue Shield HMO

12%

93,322

Blue Shield PPO

42%

335,176

CCHP HMO

Health Net HMO

18%

145,183

Health Net EPO

1,396

Health Net PPO

Kaiser Permanente HMO

LA Care HMO

11%

84,750

Molina Healthcare HMO

Oscar Health Plan EPO

35,962

Sharp Health Plan HMO

17,335

Valley Health Plan HMO

16,366

Western Health Advantage

HMO

9,386

Covered California Holding Health Plans Accountable for Quality and Delivery System Reform

APPENDICIES

COVERED CALIFORNIA 115

Additional Measures Related to Mental Health and Substance Use Disorder

Treatment

In Chapter 4: Mental Health and Substance Use Disorder, three QRS measures are presented as

potential “Priority Measures.” These measures and one additional QRS measure pertaining to Mental

Health and Substance Use Disorder are:

Potential Priority Measures

1. Antidepressant Medication Management (Table 16)

2. Follow Up After Hospitalization for Mental Illness (Table 17)

3. Initiation and Engagement of Alcohol and Other Drug Abuse or Dependence Treatment (Table

18)

Additional Measures

4. Follow Up Care for Children Prescribed ADHD Medication (ADD) measure (Table A9)

Covered California is evaluating available behavioral health measures for children as part of its work in

finding the right measures for subpopulations.

Follow Up Care for Children Prescribed ADHD Medication (HEDIS)

The Follow Up Care for Children Prescribed ADHD Medication (ADD) measure is the percentage of

children newly prescribed attention-deficit/hyperactivity disorder (ADHD) medication who had at least

three follow-up care visits within a 10-month period, one of which was within 30 days of when the first

ADHD medication was dispensed. Two rates are reported:

1. Initiation Phase: The percentage of members 6–12 years of age as of the Index Prescription

Start Data (IPSD) with an ambulatory prescription dispensed for ADHD medication, who had

one follow-up visit with practitioner with prescribing authority during the 30-day Initiation Phase.

2. Continuation and Maintenance (CandM) Phase: The percentage of members 6–12 years of

age as of the IPSD with an ambulatory prescription dispensed for ADHD medication, who

remained on the medication for at least 210 days and who, in addition to the visit in the Initiation

Phase, had at least two follow-up visits with a practitioner within 270 days (9 months) after the

Initiation Phase ended.

Covered California Holding Health Plans Accountable for Quality and Delivery System Reform

APPENDICIES

COVERED CALIFORNIA 116

Table A9. Follow Up Care for Covered California Children Enrollees Prescribed ADHD Medication (HEDIS)

2016

2017

2018

2019

Benchmark

Percent of

Enrollees

Number of

Enrollees

Number

of Plans

Plans at 90th Percentile and

Above

MN-S

53 +

63 +

51 +

59%

477,683

Plans at 50th to 90th Percentile

MN-S

36 to 53

41 to 63

45 to 51

41%

335,176

Plans at 25th to 50th Percentile

MN-S

29 to 36

35 to 41

39 to 45

Plans Below 25th Percentile

MN-S

Below 29

Below 35

Below 39

Covered California High/Average/Low Performers

Covered CA Highest Performer

Covered CA Weighted Average

Covered CA Lowest Performer

Covered California Plan-Specific Performance

Anthem HMO

Anthem PPO

Anthem EPO

Blue Shield HMO

Blue Shield PPO

41%

335,176

CCHP HMO

Health Net HMO

Health Net EPO

Health Net PPO

Kaiser Permanente HMO

59%

477,683

LA Care HMO

Molina Healthcare HMO

Oscar Health Plan EPO

Sharp Health Plan HMO

Valley Health Plan HMO

Western Health Advantage

HMO

*M-NS: This measure was not used in determining the overall QRS rating in 2016.

Covered California Holding Health Plans Accountable for Quality and Delivery System Reform

APPENDICIES

COVERED CALIFORNIA 117

Additional Measures Related to Acute, Chronic and Other Conditions

In Chapter 5: Acute, Chronic and Other Conditions, five QRS measures are presented as potential

“Priority Measures.” These measures and the 11 additional QRS measures pertaining to Acute, Chronic

and Other Conditions are: