Covered Cal seeks care reforms

Covered California is moving aggressively to address quality of care issues via its new contracts with health insurers.

Covered California CEO Peter Lee - health insurance executiveMost contract provisions go into effect for the years 2017-19.

The changes include a system for identifying and penalizing health care providers who provide substandard care.

“We are creating a market that rewards quality over quantity and moves health reform forward in an impactful way,” Covered California chief Peter Lee, left, said in announcing the state Obamacare changes.

Covered California also moved to provide more care for 2017 that is not subject to deductibles.

The provider-reform moves include:

  • Requiring providers to meet quality standards, “to provide safe care for all, including various racial and ethnic groups.”
  • Putting at least 6 percent of reimbursement “at risk or subject to a bonus payment based on quality performance.”
  • Requiring health plans to identify hospitals and providers “that are outliers and deliver either poor-quality care or unwarranted high-cost care.”
  • Mandating that a primary care clinician be selected or assigned within 30 days of a plan taking effect.
  • Requiring plans “to help consumers be active participants in their health care by providing tools to help consumers better understand their diagnoses and treatment options.”
  • Reining in of use of high-cost pharmaceuticals and seeking alternatives.

The entire plan is to be phased in over a seven-year period.

The American Academy of Family Physicians applauded the requirement that patients acquire primary physicians in a timely fashion: “Research has consistently shown that people who have access to a usual source of health care are in better health and have lower medical costs,” said Douglas Henley, executive vice president and CEO of AAFP.

In addition, Covered California changes for 2017 include giving bronze plan consumers three outpatient visits not subject to the deductible, in addition to the free preventive visits. All outpatient care in Silver, Gold and Platinum plans will not subject to any deductible.

Covered California’s plans, as well as others nationwide under the Affordable Care Act, have been criticized for providing coverage but not making care affordable due to high deductibles and other out of pocket costs.

“Covered California is making it clear that we are about more than just getting consumers coverage, by ensuring they get the right care when they need it,” said California Health and Human Services Secretary and Covered California Board Chairwoman Diana Dooley.

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