SACRAMENTO, Calif. — Coverage California has released the first-year results of its first-in-the-nation Health Plan Accountability Program. Initiatives for quality reform(QTI), at today’s board meeting.
The QTI is designed to improve health care outcomes and reduce disparities among its members and was created with input from consumer advocacy groups, health care providers, and health insurance companies. It was developed in collaboration with the Department of Health Services and CalPERS.
QTI provides direct and substantial financial incentives (first year (up to 1% of premiums, rising to 4% of future premiums). A set of meaningful health outcome measures. These equity-centered outcome measures include blood pressure and diabetes management, colorectal cancer screening, and childhood immunizations.
Nearly all eligible health plan issuers saw year-over-year improvements in these categories in the first year of their quality transformation initiatives. These improvements translate into important health outcomes for eligible California enrollees. That means more enrollees will receive recommended cancer screenings, more children will be vaccinated, and more Californians will be able to manage their chronic conditions. Despite these improvements, Covered California plans to collect more than $15 million from health insurance companies that did not deliver the level of results for which the Quality Transformation Initiative was responsible. These dollars will be invested in eligible California enrollees through targeted national health investments in 2025.
“We are extremely proud of this first-of-its-kind program in the nation that aims to hold health plans accountable to ensure Californians receive the equitable health care they all deserve.” said Dr. Monica Soni, California’s chief medical officer and health plan leader. Program implementation team. “We wanted to select a set of interventions with high clinical efficacy to improve the health outcomes of as many Californians as possible.”
Figure 1: First year of quality transformation initiative leads to improvements in health exams[1]
Images are available in PDF format.
Covered California health plans made the greatest improvements in chronic disease management measures, with 12 of 13 issuers managing high blood pressure and increasing the percentage of members managing diabetes. Overall, diabetes control improved by an average of 6% and blood pressure control by an average of 12%. Blood pressure was chosen because it is an important risk factor for cardiovascular disease (heart attack and stroke), the leading cause of death in the United States. Additionally, 50% of Californians have diabetes or pre-diabetes, making it a major health concern for all demographics in the state.
10 out of 13 health insurance companies also increased their colorectal cancer screening rates by an average of 12% among their members. Cancer is the second leading cause of death in the United States after heart disease, and colorectal cancer is the second leading cause of cancer death after lung cancer.
While some health insurers have improved childhood vaccination rates, the market as a whole has declined on average, indicating broader national trends in vaccinations. “Childhood immunizations have declined over the past five years, but this trend needs to be reversed, and Covered California will continue to focus on results,” Dr. Soni said. Childhood immunizations prevent up to 10.5 million illnesses annually, and every $1 spent on immunizations can save up to $29 in health care costs.
“The Quality Transformation Initiative is another example of how California is ensuring health care is fair across the state under the Affordable Care Act,” said Covered California Executive Director Jessica Altman. Masu. “We want to thank our partners at DHCS and CalPERS for working together to hold health insurance issuers accountable and make health care more equitable in California.”
Figure 2: Diabetes and blood pressure control performance improved in all subpopulations.
Images are available in PDF format.
Up to 2% of 2024 premiums are at risk under the Quality Transformation Initiative, and 2025 premiums could increase to up to 3%. With increased levels of financial responsibility, covered California health insurance companies will continue to increase premiums. We make critical investments to improve health care outcomes for our members.
“These performance improvements are exactly what we expected when we created the Quality Transformation Initiative,” said Dr. Soni. “We are optimistic that eligible health insurance issuers will continue to improve each year and ultimately ensure that all Californians receive the care they deserve.”
Figure 3: Qualified health plan issuers participating in quality transformation initiatives[2]
2023 | FY2024 | FY2025 | FY2026 |
national anthem | national anthem | Etna | Etna |
blue shield of california | blue shield of california | national anthem | national anthem |
Balance by CCHP | Balance by CCHP | blue shield of california | blue shield of california |
health net | health net | Balance by CCHP | Balance by CCHP |
kaiser permanente | kaiser permanente | health net | health net |
LA care | LA care | kaiser permanente | Inland Empire Health Plan |
Molina Healthcare | Molina Healthcare | LA care | kaiser permanente |
sharp health plan | sharp health plan | Molina Healthcare | LA care |
valley health plan | valley health plan | sharp health plan | Molina Healthcare |
Western Health Advantage | Western Health Advantage | valley health plan | sharp health plan |
Western Health Advantage | valley health plan | ||
Western Health Advantage |
About Covered California
Covered California is the state’s health insurance marketplace where Californians can find affordable, high-quality coverage from top insurance companies. Covered California is the only place where eligible individuals can receive sliding scale financial assistance to reduce their premiums. Consumers can compare health insurance plans and choose the plan that best fits their health needs and budget. Depending on their income, some consumers may be eligible for low-cost or no-cost Medi-Cal programs.
Covered California is an organization independent of the state government whose mission is to make the health insurance market work for California consumers. It is overseen by a five-member board of directors appointed by the governor and the Legislature. For more information about Covered California, please visit www.CoveredCA.com.
[1] Comparison of quality rating system performance in 2022 and 2023.
[2] Participating means being included in the program and evaluation and does not necessarily mean borrowing funds.