A new collaboration between three health plans is aiming to improve primary care in California and reduce physician burnout.
Blue Shield of California, Aetna and Health Net are all participating in the California Advanced Primary Care Initiative, which includes a unique value-based payment structure.
The demonstration project is facilitated by the Purchaser Business Group on Health’s California Quality Collaborative (CQC) and the Integrated Healthcare Association (IHA). If successful, the program could be scaled beyond the state.
Walmart, state marketplace Covered California, the California Public Employees’ Retirement System and the California Department of Health Care Services are among the companies, organizations and agencies monitoring the demonstration’s progress and outcomes, said Todd May, M.D., vice president medical director of commercial at Health Net.
“We even had a visit from the Centers for Medicare & Medicaid Services (CMS),” he told Fierce Healthcare in an interview. “Lots of eyes of really important organizations are on this.”
In 2016, the CQC began a CMS project called the Transforming Clinical Practice Initiative, where the organization gave technical assistance to 4,500 primary care providers in the state. The efforts resulted in $180 million of cost savings over five years.
The organization then began defining advanced primary care standards before the COVID-19 pandemic, with the IHA subsequently designing a payment model. Once developed, six health plans signed a memorandum of understanding, a precursor to the collaboration today.
“In 2021, health plans were telling me they wanted to work with other folks; they just didn’t know how,” said Crystal Eubanks, executive director at the CQC.
How it works
Aetna, Blue Shield of California and Health Net helped develop a value-based payment model designed to help physicians and further a population health approach to primary care.
Primary care providers can be paid through several avenues.
They can receive direct payments through various “tracks” based on the level of capitation. Plans may pay fee-for-service for all direct patient care services, or they might take a hybrid approach and pay a prospective, per-member per-month payment for some services, such as evaluation and management services.
“I think what the evidence shows is full capitation isn’t always the best thing for quality and outcomes,” said Eubanks. Some services, like cancer screenings or vaccines, should be incentivized through high volume, she added.
Physicians are also paid to support population health metrics, like referrals, patient outreach, care transitions, data reporting and more. Based on performance outcome, these providers receive scaled incentive payments.
Payouts can be as much as 30% higher. Admittedly, the top level benchmarks are “pretty rigorous,” said Dolores Yanagihara, general manager at the IHA, but primary care will still receive a significant financial boost at any achieved threshold.
“This is, frankly, pretty revolutionary when you get down to it,” said May.
The additional money to practices can be used to invest in the capital they need to advance their businesses. The initiative will track how providers spend the money to see which investments best correlate to good health outcomes.
Practices will use one data platform that shows consolidated information on patients across the three insurers. Information will include who is due for a preventive care screening, who needs to schedule a follow-up and more.
Instead of using different reporting systems, practices can log in to one system and view aggregated dashboards immediately useful to physicians. The goal is to reduce administrative burden and help point to care gaps that need addressing.
Primary care is facing many challenges. Today, primary care is under-resourced, there are fewer PCPs in the field and they often get paid less than specialists in medicine. These problems are exacerbated by everyday administrative burden and by attempting to balance fee-for-service models with newer value-based care contracts, a report from Chartis explained.
“If we're going to ask these practices to now take more of a population health management approach … that’s a lot of work and there should be a payment for that,” said Yanagihara.
Physicians will also receive coaching to help bring them up to speed on the new platform.
Health plans will test the demonstration and assist practices this year before an evaluation process occurs in 2026. Plans will also be given quarterly reports this year.
Health Net is a Centene company with a significant part of its business from Medi-Cal.