Many of the national policy discussions today are focused on who will be covered and the scope of benefits consumers will receive. Unfortunately, as important as these issues are, neither of them in any way addresses the underlying issues of high health care costs and the highly variable quality of care in the United States. To foster sustainable reform, we need to focus on promoting high-value care, which means we need to address not only insurance coverage but also reform of the delivery system. Covered California, a state health insurance exchange, has taken advantage of its role as a purchaser to work with health plans and clinicians to implement policies to emphasize and enhance the role of primary care.

The evidence supporting the health- and value-promoting influence of primary care is well established. The Patient-Centered Primary Care Collaborative publishes an annual summary of the evidence, which has grown progressively more solid, demonstrating that investment in primary care is key to improving health care delivery that can achieve better care at a lower cost.

There is also evidence that primary care delivery can be greatly improved. Some health maintenance organizations (HMOs) assign primary care physicians the role of “gatekeeper,” controlling use through rules that transformed primary care physicians into utilization managers. Preferred provider organizations (PPOs) gained traction by promoting freedom from these rules, often with broad and unrestricted access to specialists. Within both business models, payment to providers was too often based on the volume of care they provided instead of any version of what we now describe as “value.” As a result, many primary care physicians report that their practices feel like a “hamster wheel.” They are demoralized and working in environments that fail to live up to their expectations. It does not need to be this way.

Covered California is the state’s health insurance Marketplace, where Californians can find affordable, high-quality health plans from leading insurance companies. In 2017, approximately 1.4 million Californians are enrolled through Covered California’s 11 health plans, with coverage about evenly divided between HMO and PPO models. About 600,000 more are enrolled in the same benefit designs under the exact same policies purchased directly from those health plans “off exchange.”

The Affordable Care Act (ACA) assigns exchanges a role in promoting delivery system reform in addition to expanding coverage. Federal regulations require health plans to adopt quality improvement strategies that align provider payment with a wide range of quality improvement goals, such as improving clinical outcomes, reducing hospital admissions, improving safety, promoting wellness and health, and reducing disparities. Instead of having each of the 11 health plans in California design and report their own approaches, Covered California has worked with all qualified health plans, provider representatives, and consumer advocates to adopt coordinated strategies to address all these requirements for the 2017–19 three-year contract. At the core of these common requirements is the promotion of a central role for primary care.

Covered California’s Strategy For Promoting Delivery System Reform

This strategy includes four interrelated elements: benefit design, primary care empanelment, payment reform, and patient-centered medical home (PCMH) recognition. This post describes each of these four elements and why they mutually reinforce one another as part of Covered California’s goal of moving to a delivery system that lowers cost and delivers better health with improved quality for all Californians.

1. Benefit Design

The ACA defines essential health benefits and establishes “tiers” of coverage with established actuarial values. To meet insurance design actuarial values of 60 percent (for bronze) or even 70 percent (for the silver that most select), deductibles can be high in many products. High deductibles have been documented to be a barrier to high-value care. Covered California has set a priority on ensuring access to care that can delay or prevent advancement of disease and thus reduce the use of expensive hospital care.

To this end, Covered California has worked through a process that has engaged insurers, clinicians, hospital representatives, and consumer advocates to establish patient-centered benefit designs. These designs ensure that for most tiers, neither primary care nor specialty ambulatory care visits are subject to the deductible, and copayments for primary care visits are lower than those for specialty or emergency department care. All 11 health plans offer identical patient-centered benefit designs, maximizing their impact on consumers and providers’ practices while minimizing the confusion for consumers and providers that all too often results in there being a range of different copayments or coverage terms. These priorities align benefit design with the goal of supporting patients in getting the right care at the right time.

2. A Primary Care Physician For Every Enrollee

As of 2017, Covered California required that all enrollees, whether covered by HMO or PPO products, be matched with a primary care physician or other primary care clinician (such as a nurse practitioner) as a first point of contact and advocate. In this new initiative, Covered California and health plan communications have emphasized that for PPOs, the primary care physician will not serve in a gatekeeper role, and that having a primary care physician imposes no rule-based requirements on enrollees for accessing other services. Rather, the intent is to reclaim the supportive role of primary care physicians as the preferred initial point of entry into a complex care system for all enrollees. Similarly, HMOs have worked to communicate and support the collegiality of primary care physicians and specialists working together to manage complex problems so that patients do not view the physician as a barrier to appropriate care.

3. Payment Reform

As long as payment rewards only volume, it is not aligned with best practice of primary care. The Health Care Payment Learning and Action Network’s (HCP-LAN’s) 2017 white paper called for an evolution away from fee-for-service (FFS) toward models that include at least partial population-based payment and performance bonuses based on standard measures of quality, patient experience, and financial accountability. The report emphasizes that its call to action addresses both health plans and physician organizations such as independent practice associations (IPAs). IPAs may take capitation from health plans but too often compensate their physicians based on volume.

Health plans offered through Covered California have committed to implementing primary care payment models aligned with the HCP-LAN white paper over the 2017–19 contract. A strategy that has interested several health plans, and would meet Covered California requirements, is the Comprehensive Primary Care Plus (CPC+) demonstration from the Center for Medicare and Medicaid Innovation at the Centers for Medicare and Medicaid Services. This model is based on an FFS chassis but is supplemented by a risk-stratified care-management fee that adds a per-enrollee per-month payment to primary care physicians to provide revenue for alternatives to face-to-face care and for team-based care, neither of which is currently reimbursed under FFS. The CPC+ program also pays a bonus based on a mix of quality and patient-satisfaction measures as well as hospitalization and emergency department use that effective ambulatory care can minimize.

4. Patient-Centered Medical Home Recognition

Over the past 20 years, organizations representing both primary care specialties and other key stakeholders have come to together to define optimal primary care practice. The model includes empanelment, data-driven care, team-based care, population-based care, proactive care management, and continuous access through means including alternatives to face-to-face care. In combination, such a practice has been called advanced primary care or the PCMH. Covered California requires qualified health plans to ensure that a progressively larger share of enrollees receive their primary care from such practices and that these practices are paid to reflect their value.

It is not feasible for either Covered California or qualified health plans to implement their own PCMH certification process, so health plans will use the National Committee for Quality Assurance and the Joint Commission recognition programs, both of which have market presence in California, to measure progress toward attaining PCMH status among providers. While these third-party recognition programs have been criticized as overly process oriented and inadequate to measure “transformation,” Covered California is working with these organizations and others to encourage continued evolution to place greater emphasis on outcomes.

All Four Elements Work Together

Taking these elements in reverse, one can see their interdependence:

  • The ultimate goal is embodied in enrollees’ receiving high-value care, with primary care physicians practicing advanced primary care in the PCMH model to help assure they are getting the right care at the right time.
  • Advanced practice models with increased team-based staffing require revenue not available from FFS reimbursement. Payment reform aligned with the HCP-LAN model is necessary to promote the PCMH model.
  • Without matching enrollees with primary care physicians in panels, health plans have no record of their members’ attachment to a primary care physician practice for population-based payment or to measure performance.
  • If enrollees have to meet a high deductible before they can see a primary care physician, they may be deterred from seeking the care they need.

The four elements of the Covered California primary care strategy thus fit together. Working with the 11 health plans, these initiatives will reach not only the 1.4 million individuals enrolled through the exchange but also the 600,000 covered by mirrored products off the exchange. Health plans view the initiatives as a pilot that have the potential of being adopted for another 21 million people they cover beyond the individual market. These selected delivery-system reforms make business sense, unify requirements, and minimize the administrative burden on providers hoping to hit a tipping point for implementation of an effective primary care model that can serve as the fulcrum of a health care delivery system that delivers on the triple aim. Implementation of the full package of these four interdependent reforms is just the beginning of Covered California’s efforts; trends in quality, use, and costs will be tracked through Covered California’s Health Care Evidence Initiative, which pools data from all its contracted plans.

Finally, the primary care strategy has been informed by understanding that quality improvement requires reducing unwarranted variation in practice and accepting that there is wide and unwarranted variation in how purchasers and insurers are providing signals to the delivery system. It is a purchaser’s responsibility to align requirements across health plans to provide consistent direction for the delivery system. Covered California seeks to align its contract requirements with other purchasers, including CalPERS, which provides health care benefits to state employees, and the Department of Health Care Services, which manages Medicaid in California, as well as with major employers in the state. Together, we can support delivery-system reforms that include an emphasis on primary care, and thereby advance the transformation of practice that is needed to lower costs and improve quality.