A Journey of Resilience and Advocacy in a Complex Health Care Landscape
April 17th, 2024
In early 2015, during a routine doctor’s appointment, David Ford’s physician recommended a colonoscopy. However, it wasn’t until three months later, when Ford, a senior government relations manager with Southern California Edison, experienced rectal bleeding on his way to work, that the urgency of his situation became apparent. An emergency surgery revealed a tumor on his intestines, leading to a diagnosis of colorectal cancer — the second leading cause of death from cancer in the United States.
Navigating the Delivery System
Ford was thrust into a challenging health care journey, facing the intricacies of cancer treatment. Navigating the health care system added another layer of complexity. Ford had to coordinate appointments across different health care providers, understand the nuances of his insurance coverage and make informed decisions about his treatment options. The difficulty of this process was exacerbated by the need to decipher medical jargon and understand the implications of different medical procedures and tests.
Throughout his treatment, Ford, a Black man, became acutely aware of the disparities in health care access and the additional challenges faced by those in minority communities. Black Americans have a 20% higher incidence of colorectal cancer and a 40% higher death rate from the disease than white Americans, underlining the urgent need for action to reduce these inequities. During a recent PBGH California Quality Collaborative (CQC) webinar that explored disparities in colorectal cancer care, Ford shared his story, recounting his delay in undergoing a colonoscopy and how his experience may have been different had he been more proactive about undergoing the screening test.
During an annual physical exam in 2018, Ford’s physician conducted a test that revealed elevated prostate-specific antigen numbers, leading to a diagnosis of prostate cancer. After undergoing radiation treatment, he was able to make a full recovery. Ford’s experience underscores the critical need for proactive health management and screening for early detection through tools such as the EpiSwitch Prostate Screening (PSE), especially in communities of color, where distrust in the health care system and barriers to accessing care are common.
A Voice for Advocacy and Change
Today, Ford serves as a member of the Cancer Action Network board, actively engaged in lobbying and advocacy efforts. His experience has fueled his commitment to cancer research, funding and policy change, making him a vocal advocate for equitable access to care.
“There’s more advocacy and education to do through outreach and connection with community-based groups, churches and national organizations to get behind this campaign because I do think that this is a civil rights crisis, particularly in the African American community,” said Ford. Ford emphasizes the importance of early detection, especially given today’s innovative technology and testing options which are less invasive and allow for greater accuracy: “Cancer is much easier to treat and deal with if it’s early… get in to see someone as soon as possible when you think something is wrong.”
Strategies to Combat Colorectal Cancer Disparities
The following key strategies can help reduce disparities in colorectal cancer care within the delivery system:
- Multi-stakeholder collaboration. Alignment among health care providers, payers, policy makers and patient advocates is essential for comprehensive care and disparity reduction.
- Patient engagement and advocacy. Engaging patients in their health care journeys, especially through preventive measures like cancer screening, is critical for early detection and treatment.
- Research and data utilization. Utilizing comprehensive data and research findings to informs policy and practice, leading to more effective screening and improved health outcomes.
- Community outreach and education. Developing community-based programs and partnerships facilitates access to screening and treatment services, building trust and awareness within communities.
CQC is working to advance health equity through programs like Equity and Quality at Independent Practices in LA County, a quality improvement collaborative for primary care practices and independent physician associations focused on reducing health disparities for Medi-Cal enrollees of color.
To learn more about disparities in colorectal cancer care and what patients, providers, health plans and purchasers can do to advance equitable care, view a recording of CQC’s latest webinar, Addressing Disparities in Colorectal Cancer.
Exploring Capitated Payment for Primary Care in California
March 28th, 2024
A significant challenge in the pursuit of a high-performing health care system in the United States is the diminishing allocation of resources toward primary care. Experts argue that both the amount and structure of primary care spending has a significant negative impact on patient outcomes. Hybrid payments that include capitation offer a promising alternative to traditional fee-for-service models, focusing on quality over quantity to enhance patient outcomes and system efficiency.
The Case for Capitation
The traditional fee-for-service payment model encourages quantity over quality of care, creating inefficiency within the health care system. By transitioning to a blended payment model that includes capitation, primary care practices can reduce their administrative burden and improve patient outcomes. Capitation provides the flexibility to invest in staff, improve clinical quality, adapt to shifts in patient preferences and most importantly incentivizes quality, not quantity, of patient visits. During the COVID-19 pandemic for example, capitated payment models enabled primary care practices to swiftly adapt to changing patient access preferences, a flexibility not afforded by fee-for-service models.
Understanding the Regulatory Environment
Regulatory oversight for health coverage in California is complex, determined by the characteristics of what entity is paying for care — the purchaser — and whether the coverage is fully insured or self-insured. Clear regulatory guidelines are crucial to ensuring the successful implementation and functioning of any new payment model. An exploration conducted by PBGH’s California Quality Collaborative and its partner Integrated Healthcare Association found that while self-funded plans in California can use capitation for primary care payments under specific conditions, the regulatory guidelines under the federal Employee Retirement Income Security Act (ERISA) of 1974 and the Knox Keene Act (KKA) of 1975 for implementing such payment models are not clearly defined.
An analysis of California’s regulatory framework to determine if self-funded plans can legally pay primary care providers through a capitated model did not yield a straightforward answer. It did, however, clarify the contexts in which capitation is feasible in California. These include scenarios within arrangements where employers partially cover costs through capitation, direct contracts between employers and providers, and through third-party administrators engaging with providers operating under specialized regulatory conditions or assuming financial responsibility for patient care.
Stakeholder Perspectives
The transition to a capitated payment model impacts different stakeholders in the health care industry in unique ways. Self-funded employers, third-party administrators, primary care providers and consumer advocates all have varied considerations when debating the merits of capitated payments. While some see the shift as a potential market differentiator, others may worry that it could not only limit patients’ access to diverse services but also potentially diminish consumer protection safeguards, such as ensuring comprehensive care coverage.
The Path Forward Through Collaboration
Strengthened collaboration among stakeholders, including health plans, primary care providers and purchasers will likely illuminate a clearer path toward a capitation model that advances health care quality, reduces disparities and ensures financial stability. By addressing regulatory uncertainties and fostering a broader dialogue among key decision-makers, we can work toward a hybrid payment model that values and incentivizes quality, supports widespread transformation of primary care delivery and ultimately delivers better health outcomes for all.
For a more detailed look into capitated payment for primary care in self-funded health insurance arrangements in California, read our latest issue brief.
Empowering Care: The Role of Alternative Payment Model Design in Advancing Equity
January 25th, 2024
Alternative Payment Models (APMs), incentivizing clinicians to provide high-quality, cost-efficient care beyond traditional fee-for-service payments, hold immense potential to revolutionize health care delivery, expanding access, improving outcomes and addressing health disparities. However, to unleash their transformative power, APMs must be thoughtfully designed to prioritize health equity and mitigate unintended negative consequences. Factors such as poverty, institutional racism, education, economic opportunities, insurance coverage and the living environment significantly influence health equity. When capitated payments and performance incentives fail to account for the necessary resources to provide adequate care, practices serving populations with higher medical and social risks may face financial challenges, ultimately impacting health outcomes negatively.
Multi-Stakeholder Alignment
Multi-stakeholder collaboration is pivotal in aligning the design and implementation of a payment model that champions health equity. Through the California Advanced Primary Care Initiative, PBGH’s California Quality Collaborative (CQC) and partner Integrated Healthcare Association (IHA) bring together health care payers to collectively strengthen primary care delivery. The initiative aims to facilitate the delivery of high-performing, value-based care, reducing costs while enhancing quality and equity. CQC and IHA collaborated with health plans to develop a common hybrid primary care payment model, incorporating key recommendations from subject matter experts in payment model design and health equity intended to strengthen health equity in APM design and implementation, regardless of geography. The payment model is comprised of three key elements: direct patient care payment, population health payment and performance-based payment.
Recommendations to Advance Equity
Element 1: Direct Patient Care Payment
- Transition from fee-for-service (FFS) to capitated payments. Health Plans and other stakeholders working to develop APMs should consider gradually transitioning from FFS to capitated payments to provide upfront funding for clinical services and key staff roles, addressing social factors influencing health and advancing equity. Incremental approaches, such as phased strategies and tracking provider preferences, can facilitate a smooth transition.
- Incorporate risk adjustments for PMPM. Adopt risk adjustment into APM contracts, acknowledging the underlying clinical and social risk of the population. This ensures that reimbursements account for higher-risk populations, recognizing the need for additional resources to eliminate health inequities. Clear goals and method determination are essential in building an effective risk adjustment strategy.
Element 2: Population Health Management Payment
- Incorporate a distinct population health management payment. Separating the population health management payment from patient care payments supports practice improvement, especially for historically under-resourced providers serving populations experiencing health inequities. Payments can be tied to specific activities, with requirements related to the promotion of health equity, fostering targeted interventions and support.
- Provide technical assistance. Effective technical assistance should be offered to providers, encompassing guidance and support for culturally and linguistically appropriate quality improvement interventions. Tailored technical assistance can facilitate the integration of community-based providers, ensuring alignment with health equity goals.
Element 3: Performance-Based Payment
- Weight quality-based payments to equitable health outcomes. Develop financial incentives that meaningfully reward the reduction of health disparities and promote equitable health outcomes. Establish improvement and attainment goals with expectations for data stratification by race and ethnicity. Incentives should align with measures required to be stratified by national and state governing bodies, fostering a focus on equity performance.
APMs, with intentional design considerations for health equity, can uniquely contribute to addressing health disparities. Direct investments and dedicated support are crucial elements, ensuring that practices serving rural or underserved areas have a viable path to success within the payment model. Multi-stakeholder alignment and ongoing collaboration are key to driving cooperative changes and improving the delivery of care. The journey toward APMs requires collective efforts and guidance from diverse stakeholders, from payers and providers to community-based organizations and those receiving care.
For a more detailed look at the recommendations, read our latest issue brief.
From Data to Delivery: Measuring Advanced Primary Care in California
January 11th, 2024
The health care delivery system in the United States faces significant challenges, ranking poorly in quality, efficiency and outcomes among peer countries. Despite high spending on health care, primary care, a crucial element for better population health, is underfunded in the U.S. In California, over 65% of physicians work in solo or small practices and primary care providers often lack resources and technology, contributing to subpar patient outcomes.
Through the California Advanced Primary Care Initiative, PBGH’s California Quality Collaborative (CQC) and partner Integrated Healthcare Association (IHA) are working to understand and address these issues to help strengthen the state’s primary care delivery system. To that end, CQC and IHA executed a pilot project in California, bringing together four large health care purchasers — Covered California, California Public Employees’ Retirement System (CalPERS), eBay and San Francisco Health Services System — and 13,055 primary care practices.
Measurement Pilot Goals
The measurement pilot’s goal was to test the effectiveness of a measure set outlining key attributes of high-quality, comprehensive and patient-centered care and to test the use of existing IHA data to measure the performance of individual primary care practices. This data includes a significant portion of the commercial market and some Medicare Advantage and Medi-Cal data from health plans and providers in California. This would then help determine how well primary care practices performed when assessed against these rigorous patient care measures.
Key Findings
The analysis evaluated the performance of practices and observed which practices scored highest, average and lowest for each measure. This provided a picture of how practices are doing in California and helps identify measures where data collection can be improved.
The measure set was developed through a multi-stakeholder process that included input from purchasers, health plans, providers and patients. Measures focus on outcomes, represent both adult and pediatric patients and avoid redundancy. The measure set also aligns with other existing measurements where possible to reduce the reporting and administrative burden for providers.
Summary of the results for each measure:
- Controlling High Blood Pressure (CBP): Out of the 13,055 practices in the pilot, 2,352 had enough patients to assess CBP in a statistically significant way. 35 practices performed above the 66th percentile while others had zero success with this measure. This highlights the need for solid clinical data for practice-level measurement.
- Comprehensive Diabetes Care: Hemoglobin A1c (HbA1c) Control (<8%): 1,639 practices had a high enough number of patients to be statistically significant and 77 performed above the 66th percentile. This measure could be improved with more complete data.
- Colorectal Cancer Screening (COL): 4,089 practices had enough patients to demonstrate valid results. This measure had more practices receive an average score (199) compared to other measures.
- Childhood Immunization Status (CIS): Only 221 practices had enough patients for this measure to be assessed, and those who were scored poorly. More data, especially from the California Immunization Registry, would help improve this measure.
- Risk Adjusted Acute Hospital Utilization (AHU): 1,720 practices were identified as average performers. On average, there were 18 hospital discharges per thousand member years, which is equivalent to the highest national benchmark.
- Risk Adjusted Emergency Department Utilization (EDU): 2,419 practices had high enough patient populations to be statistically significant for this measure. On average, there were 129 emergency department visits per thousand member years. 1,154 practices performed at the average score, showing that this measure performed better overall than other clinical quality measures that were assessed.
Recommendations for the California Health Care Delivery System
Examining how individual practices performed on the Advanced Primary Care Measure Set revealed the following needs within the California health care system. Each of the identified opportunities for improvement listed below can be addressed by leveraging partnerships between payers, purchasers, providers and data exchange organizations.
- Expansion of Clinical Data Exchange: Enhance reporting capabilities and foster payer/purchaser collaboration to reduce administrative hassles for providers, such as logging into multiple interfaces to view and assess data. Refer to the California Advanced Primary Care Initiative for an example of multi-payer alignment work.
- Comprehensive Views of Practice-Level Data for Providers: Interoperability of systems, standard data specifications and alignment of formats can facilitate bringing data together for improved insight. Full views of performance with more of a provider’s population included will result in clear goals for enhancing patient care and reducing disparities.
- Improved Performance: Focus on practice-level improvement for key primary care quality indicators with low scores, especially the quality indicators with the overall lowest scores in this pilot (blood pressure control, depression screening and childhood immunizations).
- Additional Resources: Boost care delivery quality by providing shared tools, technical assistance programs such as CQC’s Practice Transformation Initiative and team support for practices.
For a more detailed look at the results and recommendations, read our latest issue brief.
Better Data Collection Essential to Understanding and Addressing Health Inequities
December 14th, 2022
The COVID-19 pandemic exposed and exacerbated the weaknesses of the U.S. health care system and highlighted long-standing inequities for minority communities. Highlighted during this period was the profound impact of economic stability, education, social and community life, one’s neighborhood and access to high-quality health care—social determinants of health—on the overall health and well-being of communities.
As a result, addressing health inequities has become a top priority for many employers, purchasers and health care providers. The ability to effectively collect a range of data points about patients and the care they receive is an essential component to creating meaningful change and ensuring populations achieve their full health potential.
Looking at health quality data by race, ethnicity, language and other patient characteristics, is crucial for understanding how long-standing systems of privilege and oppression impact the health of minority populations and communities. However, patient self-reported race, ethnicity and language (REaL) data across health insurance markets is widely variable and overall limited. While race and ethnicity data in California’s Medicaid program (called Medi-Cal) is broadly available likely because of legislation requiring health plans to collect this information starting in 2009, corresponding data for the majority of patients who receive health benefits through the commercial market – via employers or on the private market –is low or absent.
These limitations of known race and ethnicity data hinder the ability to see where disparities exist and for the health system to react with meaningful interventions. For health plans and large employers and purchasers, who provide health benefits for more than half the U.S., it is crucial to uncover variation in the access to care and the quality and experience of care being provided.
With better self-reported patient demographic information, employers, purchasers, payers and providers can tie this data to health care access, quality, patient experience and outcomes to illuminate exactly where disparities exist. These insights can enable tailored interventions and support for improvement.
How to Improve Data Collection
Legislation, Policy and Regulation
Legislation and regulations can incentivize or require health plans, providers and other health system organizations to increase the collection and quality of self-reported demographic data. Legislation and statute also have the potential to enforce standardization for data fields and definitions, which enables largescale purchasers of health care to align with their health plan and provider industry partners and enhance their ability to share, aggregate or disaggregate data to identify trends and implement plans for improvement.
It is crucial to ensure that national and state standards do not contradict each other.
Contracting and Business Relationships
Contracting requirements and incentives as part of large-scale public and private purchaser and payer programs can increase the collection, reporting and use of REaL data and thereby bolster efforts to mitigate disparities. Large purchasers could add incentive payouts if plans are able to stratify measures across self-reported REaL data. Health plans, provider organizations and other payers that contract within the health system can use incentive payouts for better data collection and stratification and other efforts to reduce disparities. Another approach is to build tiered networks that point patients to providers who have proven to be stronger at collecting, reporting and using REaL data.
It is important for purchasers and payers to avoid siloed initiatives that conflict with each other.
Organizational Leadership, Systems Structure and Culture
Organizations that pay for services at the point of care (e.g., health plans and independent physician associations, or IPAs) have the potential to increase REaL data collection, reporting and use by assessing and enhancing data collection opportunities, sharing data internally and creating a culture that values the collection of this information. This starts with organizational leadership. It is important to normalize data collection into regular workflows to improve the quality and ensure the most accurate information possible.
Purchasers, health plans and provider organizations can increase patient self-reporting by increasing awareness of how the data will be used and educating enrollment counselors and other staff with direct patient interaction on why it is important to collect this data.
Certification Requirements
The National Committee for Quality Assurance (NCQA) has required plans to report their percentage of self-reported REaL data for certain key measures, with a goal of 80% self-reported data. Additional accrediting organizations, purchasers and others could adopt similar certification requirements to support reporting and stratification for the same measures and self-reported data goals as NCQA. This would increase the consequences for not aligning and support the overall goal of greater availability of self-reported REaL data.
Read more in our latest issue brief.
California Providers and Health Plans Sign Agreement to Expand Investment and Increase Access to Advanced Primary Care
July 26th, 2022
Coalition of Large California Payers Commit to Accelerating Widespread Adoption of Advanced Primary Care with The Goal of Reducing Costs and Improving Quality and Equity
As part of a new multi-stakeholder initiative, six health care organizations serving California have signed a memorandum of understanding (MOU) to increase investment in and access to ‘advanced primary care,’ a model that emphasizes comprehensive, person-focused care, integration of behavioral and physical health services and high-quality outcomes. The agreement outlines a new initiative that strengthens the primary care delivery system throughout the state by enabling primary care practices to transform to a high-performing, value-based care model that reduces costs and improves quality and equity.
Known as the California Advanced Primary Care Initiative, the effort is jointly led by California Quality Collaborative (CQC), a program of the nonprofit coalition Purchaser Business Group on Health (PBGH), and the Integrated Healthcare Association (IHA). CQC and IHA convened the state’s largest payers to collectively adopt a model to transform primary care statewide.
The six organizations committed to the California Advanced Primary Care Initiative include Aetna, Aledade, Blue Shield of California, Health Net, Oscar and UnitedHealthcare. The initiative is a first-of-its kind agreement that represents a voluntary joint effort among payers to standardize the way they finance, support and measure the delivery of Advanced Primary Care.
“This initiative builds upon a long history of stakeholder collaboration to improve the care and health of Californians and moves us from vision to action with aligned priorities to scale high-quality primary care throughout the state,” says Crystal Eubanks, senior director of CQC.
“This initiative reflects our understanding that the impact of any one payer alone is limited,” says Peter Long, executive vice president of Strategy and Health Solutions at Blue Shield of California. “That’s why Blue Shield is committed to partnering with our peer payers and providers to scale delivery of high-quality primary care across the state. Ultimately, we know this is what is best for our members, and we all must work together to make this vision a reality.”
California Advanced Primary Care Initiative stakeholders committed to pursuing the following goals in the MOU:
- Transparency: Report primary care investment and adoption of value-based payment models that support the delivery of advanced primary care and performance on the advanced primary care measure set jointly developed by CQC and IHA, a list of metrics that enable purchasers, health plans and providers to identify primary care practices in a given market that are delivering the best results for patients.
- Payment: Adopt an agreed upon value-based payment model for primary care providers that offers flexibility, supports team-based care delivery and incentivizes the right care at the right time.
- Investment: Collaboratively set increased primary care investment quantitative goals without increasing the total cost of care.
- Practice Transformation: Provide technical assistance to primary care practices to implement clinical and business models for success in value-based payment models, integration of behavioral health and reduction of disparities.
“Primary care is the heart of all health care,” says Jeff Hermosillo, California Market President, Aetna. “This innovative initiative will help ensure accessible, affordable and high-quality primary care to improve the well-being of all Californians. Working together with our peers, providers, plan sponsors and members, we are committed to primary care that makes a difference in people’s lives.”
“Health Net is proud to be part of this groundbreaking collaboration that will support physicians in providing high-quality, coordinated care for millions of Californians. As a practicing primary care doctor, I am especially heartened by the opportunity to better integrate behavioral and physical health, a key strategy for effectively addressing our behavioral health crisis.” says Todd May, M.D., vice president, medical director of Health Net’s commercial business.
CQC and IHA have been collaborating since 2019 to develop shared standards of advanced primary care, including common definitions of practice attributes, a performance measure set, methods to identify quality at the practice level and a value-based primary care payment model.
“I am so inspired to see payers collaborating together in a new way toward this timely, crucial cause that will elevate primary care and improve patient lives in California,” says Dolores Yanagihara, vice president of Strategic Initiatives at IHA.
Strengthening Primary Care: A Pilot with Four Large Purchasers
June 10th, 2022
Extensive research and pilot programs have shown that easily accessible, person-centered and team-based primary care that integrates behavioral health and other supports can significantly improve patient outcomes and experience. It can also increase population health, reduce overall costs and serve to improve equity in our health care system.
It is for these reasons that PBGH’s California Quality Collaborative (CQC) has been working for over a decade to improve primary care. That work has culminated in the development of shared attributes and measures that enable purchasers, health plans and providers to identify primary care practices in a given market that are delivering the kind of care research tells us will bring about the best results for patients.
Together with the Integrated Healthcare Association (IHA), PBGH brought together four large health care purchasers in California to pilot this set of performance measures that emphasize patient experience and outcomes. The PBGH/IHA partnership, known as the Advanced Primary Care Measurement Pilot, began in January 2022, and participating purchasers include Covered California, California Public Employees’ Retirement System (CalPERS), eBay and San Francisco Health Services System.
Partnering to Better Primary Care in California
Our already weak primary care system has been further hampered by the pandemic, and these purchasers recognize that the time to strengthen it is now. The four participating purchasers have aligned by incorporating the same Advanced Primary Care attributes and measures into their health plan contracts. The goal is to identify the primary care practices throughout the state performing at the highest levels and delivering high-quality patient care.
The set of performance measures being tested through the pilot reflect the shared standard of Advanced Primary Care as defined through a multi-stakeholder process led by PBGH’s California Quality Collaborative that included input from purchasers, health plans, providers and patients.
The outcome will be an increase in understanding of where patients are getting the highest quality primary care. The pilot will give purchasers and health plans information to help them make decisions about their provider networks, resource distribution and consumer incentives. This information can be used to better connect patients to practices delivering Advanced Primary Care and incentivize improvement for other providers, increasing the availability of Advanced Primary Care.
How the Pilot Works: Existing Data for a New Purpose
Data already available through IHA is being used, so health plans and providers do not have to report anything new. The existing data will be used for a new purpose – to assess individual practices.
Performance information can be diluted when data from multiple practices is combined. By looking at each individual practice separately, we can gain the best understanding of which practices are delivering the best primary care and which ones need improvement.
The data will also be aggregated across purchasers and health plans for the first time to provide a more complete view of each individual practice’s performance, rather than looking at small segments of patients in a vacuum. This will allow for a better assessment of whether a practice has the systems in place to consistently provide high-quality care for everyone
Currently, ways to account for socio-economic and demographic differences in the performance analysis is being explored. This lens is crucial to ensure decisions made around the pilot promote equity and do not inadvertently increase the challenges vulnerable communities already experience in accessing high-quality care.
The analysis will include data from January through December 2022, and results and findings are expected mid-2023.