Covered California Imposes New Quality, Cost Conditions On Plans | California Healthline

It's about time!



In the early days of Medicaid when it was formed it was considered a safety-net for those who were uinsured,  unemployed, and below a certain poverty line to become eligible for 'state aid'. In reality the federal government subsidizes the state-run medicaid system.

Even then the system was riddled with deficits in reimbursement to providers hospitals, and quality of care was an issue.  The system was burdened with bureaucracy and late payments with little response from state agencies about errors in reimbursement and little  chance of adjudication of denied claims that were denied.



While federal and state programs set goals for private insurers in term of quality assurance Medicaid was not required to meet to meet those standards, until very recently.  The Affordable Care Act has begun a slow process of improvement.

Moving into a realm usually reserved for health care regulators, Covered California Thursday unveiled sweeping reforms to its contracts with insurers, seeking to improve the quality of care, curb its cost and increase transparency for consumers.

Among the biggest changes: Health plans will be required to dock hospitals at least 6 percent of their payments if they do not meet certain quality standards, or give them bonuses of an equal amount if they exceed the standards.

The plan, to be implemented over seven years, is based on a similar strategy pursued by the federal agency that oversees the government-run Medicaid and Medicare health insurance programs.

Seven years is a prolonged adjustment period for new regulations to be implemented.

Covered California will also require health plans to identify hospitals and doctors that are performing poorly on a variety of quality metrics or charging too much for care. The plans must dump the providers from their networks as early as 2019 if they don’t mend their ways. The plans could choose not to cut the hospitals or doctors, but they would have to explain in writing why, and detail what the providers are doing to address their deficiencies.

Some doctors have noted that provider networks in many of the health plans sold by Covered California are already thin and warned that cutting the networks even more would only exacerbate the problem. And, they say, some hospitals and physicians might balk at the stringent new requirements and decline to participate in Covered California networks.

Among other elements of Covered California’s contract overhaul:

• Health plans must assign a primary care doctor to enrollees within 30 days of coverage.
• Health plans and doctors must share data to better track and treat patients with chronic conditions such as diabetes.
• Plans are obliged to monitor and reduce health disparities among all their patients, starting with four major conditions: diabetes, hypertension, asthma and depression.
• They also are required to better manage the price of high-end pharmaceuticals and aid consumers in reducing the cost of expensive drug treatments.
• The health plans must help consumers better understand their diseases and treatment choices – and their share of the costs for those treatments.

While not dealing with problems, it is the first time Medicaid will be required to meet standards set for private insurers.

Perhaps some requirements of the Affordable Care Act will bear fruit.