A Provider Leader Looks at California’s Multi-Plan Breakthrough Around Value-Based Care
A variety of different initiatives have been created and implemented across the U.S. around value-based contracting; they are extremely diverse, with every single one encompassing different elements. But an initiative that has just launched in California offers a real first: three major health plans operating in the Golden State have come together with a major national purchaser group and a statewide association representing provider interests, 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, 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 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 spoke with Dolores Yanagihara, general manager of performance measurement programs at the Oakland-based Independent Healthcare Association (IHA), about the initiative. Below are excerpts from that interview.
Per my interview with Crystal Eubanks of PBGH and CQC, this has all been a collaborative initiative, correct?
Yes, absolutely; Crystal and I, have been co-leading, with each organization bringing its strengths to the table.
What was your core motivation or strategy at IHA, for your involvement/leadership of this initiative?
We’ve done this kind of multi-payer convening and aligning before. Our Align Measure Perform P4P program has been in place for 20 years. The plans and providers all came together on measures. This has been our core work at IHA, to bring people together and to agree on a common way of doing things. But now this is a different unit of measurement, and we’re really focusing on primary care and the primary care practices, and focusing on the PPO market. That’s where the plans wanted to focus, because they didn’t really have a consistent way of doing things; the AMP program was focused on HMO work. So this is taking this towards more granular, to the practice level.
That was the core motivator. And the second thing that really has differentiated it, and it wasn’t necessarily the thing we anticipated going in, but we now have a standard way of measuring thing and implementing things; but the plans, to their credit, said, wouldn’t it be more impactful if we did this together, and worked together with the same practices? So from the practice perspective it makes sense. So it was really the plans’ idea to implement this together as a demonstration project. So this helped to create and implement the model together. So it grew into more than we had originally expected.
It was really was an iterative process, then?
Yes. We had wanted to create a common reporting platform from the beginning. We knew that if you have to go to all separate portals for different populations, that’s just not realistic, and it’s crazy-making, which is how the industry normally is. And so we started to talk about the common reporting platform; that will be critical. Practices can go to one place and see their performance by plan and across all three.
Might other health plans join?
Yes. There were other plans that expressed interest and even started working with us at the beginning. Some just realized their systems were set up for this or were going through system migrations, for example. But they continue to express interest. They understand the concept and believe in this multi-payer approach; they just weren’t able to move forward with it at the moment. The other thing: California is a different market. Who is contracting with the practices? Who is contracting? Plans contract with provider organizations, which are generally larger entities, and they’re delegated responsibility, and so provider organizations delegate with practices. Some of those are independent practice associations, though sometimes they belong to hospital systems.
You have that corporate practice of medicine law in California—that complicates all these initiatives, correct?
Yes, it definitely makes it all more challenging.
Meanwhile, the platform that you’ve all co-developed makes it easier for the practices to see their patient panels, correct?
Yes, and they’re thinking about their patient panels, not health plans. These are the patients they’re responsible for; so this is very helpful and empowering. And when you aggregate results across an entire population, you get more reliable results. It’s a small-sample issue.
Marrying clinical and claims data remains an ongoing challenge for everyone, doesn’t it?
That’s correct; and the clinical data is often located in separate little buckets. And we went through an RFP process when we were looking for a unified platform. We were looking for the ability to collect clinical data from different sources, whether that be a statewide registry or other organizations, and to link that to claims data. The solution is called Cosiva, from a vendor called Applied Research Works; we selected them because they had been doing this for many dozens of provider organizations and health plans across the state and in other states. And they’ve been able to collect data and link it and generate performance results that were more complete and accurate. That was a key piece we were looking for. It’s important to fill the data gaps, and you want to really understand what is a data gap and what is a performance gap, and be able to tell the difference.
As you’ve moved towards this announcement of this demonstration project, what have been the biggest learnings so far?
We knew it would be hard, and it’s been even harder than we expected. And part of that is that the commercial PPO population hasn’t had a lot of focus. And the contracting with practices doesn’t really get a ton of attention. There’s not a ton of engagement on a regular basis. This is engaging practices that don’t necessarily have a super-strong relationship with plans already established; it’s not something they’ve had experience with. It’s a different relationship in the PPO environment. That was really challenging. For one, we had to find practices that the three health plans wanted to focus on. Each plan agreed on the list of practices in common, and then, the practices needed to agree.
That was a really big step, and it took a lot of work to provide them with information and to build trust with them. And we’ve given the common reporting platform. But CQC is particularly focused on the practice support, the coaching. With this project, it’s one practice coach or improvement adviser, with funding from the plans; they’re co-funding that one individual to work with the practice across the plans. So you’ll see the data in a common platform, but you’ll also be working with an adviser. Some practices might not really have been doing this population health management before. It will help them to focus.
How many practices are involved altogether, and what are their sizes?
We’re saying eleven practices, and generally, we were looking at small to medium practices. We started with 10 physicians, and went up to 15 practices. And one practice has dozens of sites. It’s technically is one practice, but with all sorts of sites. So we have over 100 sites. And some of the practices are very small.
Northern California has a larger number of large practices, but there has been less consolidation of physician practices in Southern California, and that really speaks to the need for this kind of work, correct?
Yes, that’s correct; and there’s a role for these small, independent practices in the care delivery ecosystem, and it’s important to support that, to help the smaller practices to remain viable. So it means reaching in and trying to support these practices that haven’t really gotten much attention until now, and to support them.
What will happen in the next year?
We met with the practices this week for the first time, as a whole group. And one practice leader said that just from doing the assessment process, she said that they’re already starting to put practices in place even now. And that was even before it started to kick off. So I feel that there will be a lot of growth in the practices in terms of their ability to really do population health management. What does that look like at the individual practice level? I think we’ll see that. And the use of the common technology and common technical assistance, will really help.
And through measurement, we’ll quantitatively be able to see performance improvement around population health management. That’s our goal; we’ll be doing quarterly evaluation reports that we’ll share with the plans. And we’re going to give them information to be able to scale up beyond the demonstration project. And it is only a year long, so we’re trying to manage expectations in terms of what we’ll expect to see in a year.
And because it’s now real and up and running, I’m hoping that more interest will emerge. So bringing in other plans, bringing in provider organizations like IPA, we think that those conversations will flourish this year, as we’re able to show results.
