Blue Shield of California’s Role in a Groundbreaking Payer-Provider Initiative
Even as the leaders of health plans, medical groups, and hospital-based organizations have struggled in some markets to make real headway with value-based contracting that produces long-term results, a statewide initiative in California is already reaping results. And one of the keys to the success so far of that initiative lies in long-term relationships that have been developed over years—even decades.
In this case, the collaboration involves three very large and influential health plans, a major national purchaser group based in the San Francisco Bay Area, and a provider organization representing providers statewide, particularly physician groups. The purchaser organization, the San Francisco-based Purchaser Business Group on Health (PBGH), which represents more than 40 employers nationwide, announced the initiative’s rollout in a Jan. 30 a press release. The press release, posted to that organization’s website, 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.”
The press release noted 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.”
Shortly after the announcement of the rollout was made, Healthcare Innovation Editor-in-Chief Mark Hagland spoke with Nina Birnbaum, M.D., medical director of health transformation at the Oakland-based Blue Shield of California, about the initiative and Blue Shield’s involvement in it. Below are excerpts from that interview.
In addition to your role at Blue Shield of California, you continue to practically clinically, correct?
Yes, I’m still practicing as a family physician. I was medical director of a multispecialty medical group in the East Bay, and have retained a sliver of that practice, and continue in that role. It very much informs the work I do here at Blue Shield. I’m a Sutter East Bay Physicians Medical Group doctor.
Physicians in smaller practices have been frustrated at times by certain health plan-driven quality programs, given all the different programs and their different requirements, correct?
I think that where we started with this at Blue Shield of California is that we were grounded by pursuing comprehensive value-based payment. Our PPO space remains pretty unexplored in terms of value-based payment. And we have the largest PPO portion of Covered California, the exchange. So we really wanted to look at our overall strategy for comprehensive value-based payment. And second, our investment in primary care. We know that as a payer, we can move primary care forward or hold it back; and it was really important for us… we wanted to move towards value-based payment and help our members receive whole-person, longitudinal care. And how can we as a payer make life better and make practice better for primary care physicians? And when we ran into barriers, we wanted to overcome them.
And one of the barriers we bumped up against was, OK, we’re going into a small practice. And nearly 50 percent of our members seeing a primary care physician were seeing a physician in a small practice. And we wanted to pay them better. And so they might have just 100 patients attributed to them out of 2,000-3,000 patients. And no doctor is going to focus on 100 out of 3,000 patients, to log into a separate portal. So we realized that it wouldn’t work if we pursued it totally alone. And because we’re very much a multi-payer state here in California, there’s not a single dominant commercial payer; and while we were thinking through this, our wonderful partners at IHA and PBGH, were turning their eyes to, OK, we manage well in the HMO space; but what can we do in the PPO space? And so they became this neutral convener of multiple payers. And we were already there; so we really jumped into the work with IHA and CQC; we were the early health plan sponsor of this work.
The time of the physician is really a core issue in all of this, correct?
Yes, that’s correct. Doctors will immediately say, I won’t treat my patients differently. And we want to make it possible for them to treat all their patients in the same way; we want them to have standard processes for care delivery. But the barrier for them around that is literally the data they have in front of them. Doctors use “chase lists”—the patients due for a test, an assessment, procedure. And doctors need those chase lists. They’re spending their time talking with Mrs. Jones about her high blood pressure, but I’m forgetting she hasn’t gotten her needed mammogram. The doctors need these chase lists, to remind Mrs. Jones to get a mammogram or a colonoscopy done. And the tools need to be up-to-date, timely, and actionable.
And one of the most fascinating things about this process has been the collaboration among the plans, which have historically been fierce competitors. But the plans involved have really been able to listen to each other and work together. And the initial impulse was, well, we’re going to use our data. And it’s hard to move to a shared platform; but through the really great collaboration hosted by IHA and CQC, we decided to move to a single platform, realizing that that would dramatically reduce the burdens on these small practices. And we can have hard conversations with our competitors, as long as we don’t talk finances.
Was it technically hard to develop the shared platform?
No, it wasn’t hard technically, because we chose Coseva; and IHA did the vendor assessment, and selected them as the shared platform. What was hard was that each of the plans had to create separate contracts with that platform; and contracts are hard to do—there are legal and privacy concerns. And we had to make sure each health plan had to not be able to see other health plans’ information; so that was a little tricky to set up.
How will this initiative evolve forward over the next year? What will happen?
Well, it’s already happening: the technical assistance teams of practice improvement coaches are already working with the practices. They’re making sure they understand the payment model and their baseline performance, so they can figure out the changes they’re going to make to improve outcomes, based on the shared metrics and performance levels, so that they can really start making workflow plans in their day to day, week to week, and month to month practice. And of course, the goals are aligned financially. So the data is going to be at hand; we’ve got these one-on-one practice coaches helping them; and they’re going to combine that knowledge of their capabilities with the data they’re getting, to make changes on behalf of their patients. So those chase lists are so important, in terms of screenings and childhood immunizations. So they’re going to move forward on that.
And my years of experience trying to drive quality improvement on the physician practice side shows me that this is not rocket science; it’s what everybody wants to do. And with a little bit of data, and elbow grease, and changes in your workflow, this is achievable. And it makes people proud. That’s what I think we’re going to see; and we’re going to see better outcomes for patients; and of the doctors and their teams, too. This is going to remove some of the frustrations and limitations placed on these practices, that get in the way of practicing the way that they want.
