A Health Plan Leader’s Perspective on California’s Multi-Plan Value Breakthrough
Leaders of stakeholder groups from across California continue to demonstrate why the Golden State keeps setting the pace in so many areas of U.S. healthcare. Just last month, leaders from the purchaser, health plan, and provider worlds announced a groundbreaking value-based payment structure that involves three major health plans that are competitors in the state’s healthcare market working together with an organizing purchaser organization, to pursue integrated care delivery and care management work with physicians in group practices across the state.
The Jan. 30 press release, published by the San Francisco-based Purchaser Business Group on Health (PBGH), which represents more than 40 employers nationwide, and explaining it all, began thus: “In an unprecedented collaboration, three leading California health plans — Aetna, Blue Shield of California and Health Net — have united to co-implement a shared value-based payment model under the California Advanced Primary Care Initiative’s Payment Model Demonstration Project. Led by the California Quality Collaborative (CQC) and the Integrated Healthcare Association (IHA), the new payment model will span 11 provider organizations statewide, representing over 100 care sites and a collective patient population of approximately 17,000. The demonstration project prioritized recruitment of small independent practices and will address long-standing disparities in primary care payment, promote health equity, and improve population health in California. It is designed to scale across the state and beyond.”
“Participating in this project is crucial for us as a health plan because it aligns with our commitment to promoting healthcare excellence in California,” said Todd May, M.D., Vice President Medical Director for Commercial at the Woodland Hills-based Health Net, in a statement contained in the press release. “By co-investing in a unified value-based payment model, and providing technical assistance for practice transformation, we’re better supporting primary care practices in ways that can improve patient outcomes. And high-functioning primary care is the foundation of a high-quality and cost-effective health care system.”
The press release went on to note that, “Through the demonstration project, participating health plans will offer a common value-based payment model, which is designed to invest more revenue into the practices, rewarding improvement and strong performance on the Advanced Primary Care Measure Set. This approach provides flexibility while ensuring a focus on meeting patients’ needs with tailored, high-impact care.”
In addition, it noted that “CQC is providing comprehensive technical assistance to help participating practices implement the new payment model, integrate behavioral and physical health services, improve care coordination and achieve better patient outcomes. IHA selected Cozeva to serve as the common reporting platform for the initiative. Practices will be able to view data on their patients across plans for actionable insights related to performance to help close care gaps and better manage their patient panels.
“This project marks a significant step forward in our mission to elevate primary care across the delivery system,” said Crystal Eubanks, Executive Director at CQC and Vice President, Care Transformation at the Purchaser Business Group on Health. “Health plans are doing something that’s never been done before — they’re not just aligning payment models but co-implementing a unified one. They’re paying differently and paying more to help primary care practices deliver high-quality care while addressing cost and advancing equity across the state.”
Following the announcement, Healthcare Innovation Editor-in-Chief Mark Hagland interviewed several of the leaders involved in the initiative, including Health Net’s Dr. May, who, in addition to being the health plan’s vice president medical director, is also practicing family physician. Below are excerpts from that interview.
What about this moment in payer-provider relations and the evolution of value-based contracting made this initiative particularly possible right now?
Health Net’s been engaged in value-based care programs with our providers for many years, as have other health plans. But we’ve come to the realization that for health plans to have a real impact on care delivery, that we need to align with a cohesive multi-provider strategy. The more we can align together, the more we can amplify our impact. This really came together in July 2022 with a partnership agreement with Health Net and other payer organizations. And we’ve really been working closely together from the very beginning. And there’s a value to a more cohesive, aligned, strategy, to help providers reach a more advanced, high-functioning practice.
What do those terms mean in the context of this kind of work?
In terms of advanced primary care, there have been various models; this is an integrated, comprehensive, patient-centered, team-based care model. It’s not just individual docs in the office, but a whole team working together. It’s outcomes-driven. It’s a full wraparound approach. And we use a population health management approach; so rather than being reactive, in this case, you step back, use data, and look at your entire panel of patients, and assess their needs, and actively contact patients and bring them into your practice and meet their needs; that’s a working definition of advanced primary care that I use.
What are Health Net’s main strategic goals in this initiative? A balance of outcomes and cost?
Yes, absolutely. It’s well-demonstrated that a strong primary care workforce results in better outcomes, and it saves money; it’s cost-effective. Our goal at HealthNet is to transform the health of a community. One of the key elements here is improving blood pressure control and diabetes control, and improving levels of vaccinations and screenings. Look at diabetes and blood pressure; those are major drivers of morbidity and mortality; and the action takes place in the primary care office.
We all know about the old adversarial relationship that existed in the past between providers and health plans. How is that changing, with the implementation of programs like this one?
Yes. Let’s be frank: providers aren’t necessarily the biggest fans of health plans in general, and for good reason; there’s some skepticism about health plans. And as we moved along to design this, we made the important realization that once we had a general outline, a model, a roadmap, we’d better check in with primary care practices. So we’ve had multiple sessions where we’ve brought in primary care groups to sit down with us and ask them what they thought, what worked, what could be made better.
And it was fascinating; they came in really skeptical, and left saying, ‘I never thought I’d be sitting down with a bunch of health plans asking me what’s important to me and how they can help my practice be more effective; and they’re going to pay me more money to do this right.’ But that was a key point for us. And we invited them back after we fleshed it out. And that’s key. And there are primary care docs from the health plans, and we know this stuff; but we’re still the health plans, but we need to make sure we’re on the right track; and that’s been really gratifying.
Another element is the participation of PBGH and of IHA together with the health plans. How did all the stakeholders come together to create goals that everyone could support?
I want to credit PBGH and the California Quality Collaborative and IHA: they came to us, invited us to partner with them. And we jumped right in. And a number of health plans and provider groups came together for initial explorations. And this is really new and innovative. And not everybody was ready to move forward; so we ended up with Health Net, Aetna, and Blue Shield, and developed this partnership and have worked together throughout. And it’s not just PBGH, CQC, and IHA; we also have keen interests and support from Cover California, CalPERS, Health Net, and the San Francisco Health Service System, which represents the employees of the City and County of San Francisco. The CA Department of Health Care Services has come to our meetings; and CMS has come to our meetings. They’re very interested in promoting primary care, and wanted to learn from us. And that’s upper-exciting.
What will be the challenges that might arise, and how are all participants ready to overcome them?
Change is always hard. And we’re talking about changing provider organizations. But Health Net and the other plans were committed to supporting these practices and wanted to make sure they succeeded. We’re providing support in a number of ways; we’re paying for their participation and their commitment to transform their practice and engage in population health management. We’re providing tools, support, practice management, and data; and value-based incentives for performance as a result of implementation. So all of this together will help them to adopt this model of care.
Talk about the challenges of marrying clinical and claims data? Everyone tells us that that remains an ongoing issue.
I’ve been in quality improvement for decades now; and timely, accurate, and actionable data is the key for all performance improvement, period. We’re making it a lot easier for these provider groups to access their data and readily see where there are actionable gaps in care. So we’re providing access to a uniform data platform. We’re working with data-aggregator companies to present data in a cohesive, usable format, so they can go to the same source of data and look at their patients who are our members in the three health plans and see exactly where those patients stand, where they are on their targets. A major problem in healthcare is the myriad records and data systems; but for the primary care doctors, it was a deal-breaker if we didn’t provide a uniform, unified data set among the three plans; and we’re paying for that.
Remind us of the timeframe around all of this?
It’s up and running now. The contracts were signed in the late summer and fall of last year. And then the engagement started with an assessment. We have a team that provides the coaching and at-the-elbow training and support; and they started doing technical and process assessments, and we’re starting the program this month.
What will happen in the first year or so?
I’m very optimistic about this; we spent a lot of time on this. It’s very different, very new, for health plans to come together. You can only imagine what it takes to get everybody on the same page and aligned. But we’ve gotten there with our primary care stakeholders. We’re using processes and methodologies and a care model, that all work. It’s relatively small-scale right now, a demonstration project. It’s not a pilot, though; it went live in January.
How many practices and physicians are involved?
There are 11 provider organizations, and 100 actual offices, more than 150 physicians to start with, and altogether, about 17,000 patients. And what I expect to see is high levels of adoption among these practices; we’ll see improvement in outcomes. We’re establish performance metrics—high-value targets that have an impact on outcomes. And we’re incentivizing performance on these metrics, and will reward improvements based on the implementation of this model. And we’ll be able to demonstrate that this can actually produce results; and in the long run, we’ll aim for broader adoption statewide. We’ll have to demonstrate that it works, but I have a high degree of confidence. And the key players are involved and backing this. And that’s important to realize that this is high-profile and a lot of folks are very interested in seeing how this develops.
