L.A. Care Health Plan, an independent public agency created by the state of California, provides health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan, serving more than 2 million members.
Providing excellent member service should be the goal of every health plan. In fact, proving that you are doing so is the only way to maintain an acceptable accreditation ranking. But in California, where the delegated provider model reigns supreme, service quality can be a bit tricky to ensure.
In a delegated model, health plans do not directly employ or contract with providers to treat a plan’s members. Rather, the plan contracts with independent practice associations (IPAs), which are networks of independent physician practices that come together for contracting purposes.
There is no industry standard for grading IPAs. Thus, while health plans that have a direct provider network can easily monitor and manage performance, plans that contract with IPAs have used a smattering of different metrics that may or may not be validated. That is unacceptable, and it is exactly why we at L.A. Care Health Plan developed the Value Initiative for IPA Performance, or VIIP.
5 Domains of Evaluation
Once we decided we needed a better way to measure how our IPAs were doing, we had to develop a standard set of metrics that would provide a clear assessment and ultimately allow us to elevate our members’ health care. We settled on five domains.
Access and availability. The point of this domain is clear. If our members can’t get into a physician’s office, or if they can’t get through on the phone, they have no chance of getting the excellent care we want to ensure.
Healthcare Effectiveness Data and Information Set (HEDIS). This is the measuring tool used by the National Committee for Quality Assurance (NCQA). HEDIS metrics address important dimensions of care and service such as controlling high blood pressure, providing comprehensive diabetes care, screening for breast cancer, tracking childhood and adolescent immunization status, and assessing childhood and adult weight/BMI.
Member satisfaction. We send a version of an NCQA survey to a sampling of members in each IPA in our plan. Our aim is to make sure that every interaction between a member and the IPA is pleasant and positive. From these results, we can identify specific interactions that are high-value opportunities for IPAs to focus on for improvement.
Utilization. For this domain, we use five measurements of clinical utilization: admissions to the hospital, readmissions, one-day admissions, potentially avoidable emergency room visits, and inpatient bed days.
Encounter timeliness. At L.A. Care, we capitate payment. However, we still need the encounter data for clinical visits and services to determine utilization and quality rates, and providers have less incentive to send the data once they have received their capitation payment. We now include a requirement for timely return of encounter data in all contracts and have tied VIIP to new pay-for-performance incentives to ensure the data comes in.
We have not terminated any contracts since this assessment program started because our initial intent is to help the IPAs identify opportunities to make improvements. However, as time goes on, VIIP will help us identify and weed out persistently low-performing medical groups. This strategy will ensure we have the best-performing network and the highest possible payment rates as we transition to value-based contracting.
As low-performing IPAs are dropped, L.A. Care will continue to grow our Community Access Network, a direct provider network that eliminates the need for a third-party IPA or management services organization. L.A. Care will provide all the necessary resources that providers have received from IPAs.
Ramping up our direct network will not mean an end to L.A. Care’s association with IPAs. We work with some excellent medical groups, and we want to share their best practices with others. We are not competing with the delegated model, but we want to make sure that it’s adding value for our health plan and, most importantly, for our members.
John Baackes is CEO, L.A. Care Health Plan, Los Angeles.
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