Covered California, the health insurance marketplace for the Golden State, has revised its contract for 2022 by requiring qualified health plans to participate in an advanced primary care (APC) pilot using measures developed by the Purchaser Business Group on Health's California Quality Collaborative (CQC). The results of the pilot will inform future contracting requirements to increase APC practices within health plan networks.
The pilot program will leverage existing statewide data infrastructure (Integrated Healthcare Association's Align/Measure/Perform programming) to assess practice-level performance across the suite of APC measures. By applying a quality threshold approach, IHA will be able to identify individual practices delivering advanced primary care and the concentration of those practices within each health plan's network. IHA will disseminate pilot results directly to health plans and share aggregated findings with participating purchasers.
The measures, focused on health outcomes, patient safety and patient experience, are designed to encourage high-quality, high-value primary care statewide.
The Purchaser Business Group on Health (PBGH) is a nonprofit coalition representing nearly 40 private employers and public entities across the U.S. that collectively spend $100 billion annually. It said the APC measures were developed through a multi-stakeholder process that included input from purchasers, health plans, providers and patients. CQC's shared standard, defined from the patient’s perspective, includes two components:
• Attributes: Articulate the highest-order care processes that reflect high-value and high-quality primary care. The attributes allow flexibility for practices to design care tailored to their patients’ needs. These attributes were selected with the understanding that many other foundational elements and processes are in place to achieve such a standard.
• Measures: A narrow set of measures reflecting the patient's outcomes and experience of care with a provider that has implemented advanced primary care attributes. Performance across the suite of measures will allow purchasers and patients to identify practices delivering APC and provide a path for development of alternate payment models. Selected measures can be used by any payer type and are aligned across performance and measurement reporting and payment programs within California and nationally.
Covered California provides coverage for 1.6 million Californians and will contract with 12 health plans in 2022. Covered California is piloting the measure set to build on current health plan contract requirements to support advanced primary care, including ensuring all patients have access to a primary care provider and implementing alternative payment models for primary care.
Informed by the results of the pilot, Covered California intends to incorporate the measure set into all health plan contracts to increase advanced primary care practices within all health plan networks.
“Raising the bar on the quality of care delivered not only leads to better outcomes for Californians, it also continues our mission to address the underlying costs of care, and making coverage more affordable to everyone,” said Alice Chen, M.D., Covered California’s chief medical officer, in a statement. “Covered California is committed to going beyond just getting people healthcare coverage — we want to make sure consumers are getting the quality care they need – and that starts with high-performing primary care.”
The California Public Employees’ Retirement System (CalPERS), which provides health benefits for 1.5 million California public employees, retirees and their families, also is participating in the pilot. CalPERS will pilot the measure set in its 2022 health plan contracts to assess the use of advanced primary care practices by plan networks and providers. This pilot period will inform future requirements for health plans to address the variation in performance of their contracted primary care practices.
“As the largest purchaser of public employee benefits in California, CalPERS has long advocated that patient-centered primary care is vital in the delivery of exceptional health care for our members,” said Julia Logan, M.D., M.P.H., CalPERS chief medical officer, in a statement. “We look forward to piloting this measure set in our contracts to drive higher quality health care that improves our members’ experience.”
PBGH said performance across the suite of measures will allow purchasers and patients to identify practices delivering advanced primary care and strengthen the development and implementation of alternate payment models. Successful incorporation of the measures into Covered California and CalPERS contracts is expected to elevate the standard of primary care in California and provide a model for other large healthcare purchasers.
