News Release

Date Posted

Exchange releases report on Qualified Health Plan management and delivery system reform

The California Path to Achieving Effective Health Plan Design and Selection and Catalyzing Delivery System Reform

Stakeholder Input on Key Strategies


The mission of the California Health Benefit Exchange (“Exchange”) is to increase the number of insured Californians, improve health care quality, lower costs, and reduce disparities by providing an innovative and competitive marketplace in which consumers can choose health plans and providers that give them the best value. The Exchange also has the opportunity and the commitment to be a catalyst for change and delivery system improvement. The Exchange’s initial success in achieving its mission will be shaped, in large part, by decisions the Exchange will make about the selection of qualified health plans and the Exchange’s role as a catalyst for health system reform. To support the Exchange board making the best decisions possible, it conducted a wide range of stakeholder engagement efforts to get input on how it should structure its qualified health plan and delivery system reform strategies. This report summarizes the feedback provided by stakeholders.

Stakeholder Input Process Overview

One of the Exchange’s six key values is partnership. The Exchange seeks out partnerships and believes its efforts should be guided by work with stakeholder groups. The Exchange has used multiple avenues to solicit stakeholder input into its health plan strategy.
  • In addition to the formal Stakeholder Input process described in this Report, Exchange board members and staff leadership meet with a wide variety of interested groups, organizations and individuals and listens to their viewpoints about mutual concerns concerning many issues facing the Exchange and its role in improving the health of Californians. The Exchange has also invited public testimony at its board meetings, submission of comments in writing to the board and has organized panel presentations at board meetings. In particular, at its March 2012 board meeting, the board heard from three panels of stakeholders on issues related to health plan selection and promoting delivery reform. (Appendix D).
  • In February and March 2012 the Exchange convened in-person stakeholder group sessions. These sessions were held in: Los Angeles, Redding, Sacramento, San Diego and San Francisco to get input on plan selection and design issues. Over a hundred stakeholders were invited and participants included health care providers, consumer advocates, brokers and business representatives (see Appendix B). At these sessions, Peter V. Lee, Exchange executive director, asked stakeholders to focus on six key questions to get input on plan selection and design issues:o Regarding the optimal number of plans with which to contract, stakeholders were asked: As the Exchange exercises its authority to be a selective contractor, what considerations should be taken into account in deciding how many plans to contract with?
    • Regarding criteria for plan selection, stakeholders were asked: What would be important criteria to set for plans who participate in the Exchange?The California Path to Achieving Effective Health Plan Design and Selection and
    • Regarding network criteria, stakeholders were asked: What would be important criteria for the provider networks offered by plans who participate in the Exchange?
    • Regarding out-of-pocket cost design, stakeholders were asked: What are important considerations in designing a framework for out-of-pocket costs?
    • Regarding dental and vision coverage, stakeholders were asked: Would it be advisable for the Exchange to offer dental and vision plans for those who wish to purchase them?
    • Regarding health system reform, stakeholders were asked: What roles could the Exchange play in catalyzing health system reform?
  • The Exchange encouraged stakeholders to respond in writing by April 1, 2012 to 31 questions (see Appendix A) posted on the Exchange website and broadly distributed to stakeholders. Responses were received from 47stakeholder groups (see Appendix C).The Exchange board reviewed reports and background material more broadly to inform its work (see Appendix E).
  • The Exchange has engaged Pricewaterhouse Coopers, LLP (PwC) to assist it in reviewing this input and in developing options to inform the Exchange’s future decisions related to determining its qualified health plan certification standards and processes as well as delivery system reform strategies. This report on stakeholder input will inform both the Exchange’s board and staff and PwC in developing qualified health plan contracting criteria and delivery system reform strategies.
The Exchange plans to use this input as it develops its policies, which it plans to release for comment in July to be finalized in August. The Exchange plans to release its health plan solicitation in fall of 2012. It intends to make preliminary selections of health plans in early 2013 and final selections so that promotion can begin in July 2013 with enrollment starting October 2013 for coverage as of January 1, 2014. The Exchange reported on stakeholder input on topics related to enrollee engagement in a March, 2012 Exchange report, “Achieving Health Care Coverage Success in 2014 and Beyond: Stakeholder Input on Strategies for Marketing, Eligibility, Enrollment and Retention.

Major Highlights

Below are key highlights that Exchange staff heard at the in-person stakeholder sessions:
  • Most stakeholders believe that making care affordable is the key to theExchange’s success. Some stakeholders are concerned that - even taking subsidies into account - higher cost would equal fewer enrollees overall and, in particular, fewer enrollees among healthy people. Many made the point that a strong start in January 2014 will be critical to long-term success.
  • Most stakeholders felt that the Exchange should exercise the authority the legislature offered to be an active, selective contractor in making decisionsabout how many and which health plans to contract with.
  • Stakeholders want the Exchange to set criteria for participating health plans that support choice, quality and affordability.
Some encouraged requiring evidence based approaches to achieve this goal, but wanted to balance that with allowing plans discretion to test promising innovations. There was broad support for heading in the direction of some standardization of plan offerings to enable consumers to make informed choices.
  • Many stakeholders urged the Exchange to use existing measures of quality and access in the short term, so as not to overburden providers and plans with excessive reporting.
  • While they recommended relying on entities that already have responsibilities for monitoring plans, some articulated an expectation that the Exchange may need tostep in over time to monitor where existing monitoring proves inadequate.
  • Stakeholders grappled with the pros and cons of offering narrow and broad networksof providers and the direct implications for affordability, choice, and access. There were particular concerns about creating processes to assure access to subspecialists for those who need them without “breaking the bank.”
Affordability, affordability, affordability --that has to be the paramount goal. Do not try to get to the perfect system. First, nail down the foundation and then add changes later. Jean S. Fraser
San Mateo County Health System
  • Many stakeholders urged the Exchange to consider approaches, such as inclusion of safety net providers in plans’ provider networks, to support continuity of care for enrollees whose eligibility for enrollment in Medi-Cal and the Exchange will change based on fluctuations in their income.
  • There was widespread appreciation of the value of cultural and linguistic competency to genuine access and the challenges in assuring access to experienced and committed essential health providers.
  • Stakeholders raised concerns that, with so many new enrollees in the Exchange and Medi-Cal, access to providers, particularly primary care providers, may not be adequate. The Exchange was urged to closely monitor whether providers networks are actually meeting the rising demand.
  • While the federal Affordable Care Act and California legislative authority will constrain the Exchange’s discretion in relation to the benefit package, many stakeholders weighed in on the scope of benefits to be offered by the Exchange, with recommendations ranging from urging that certain benefits be included to encouraging that the benefit package be limited.
  • Many stakeholders hold out a lot of hope on the Exchange’s potential role in promoting health system reform and point to smart reforms as the only way to bend the cost curve over time. Access to primary care physicians and mid-level providers, chronic care management, and the importance of medical homes were key concepts raised many times. However, some stakeholders also point out that system reform takes time and the first priority for the Exchange is to maximize the number of uninsured who get affordable coverage.
Across geographies and across constituencies, stakeholders were very willing to think through implications of various positions and to think through what might be the best alternatives for the whole system the Exchange is working to create. There was a strong sense that California together is building something new and important and that the prospect of expanding coverage and access to millions of uninsured people is a shared aspiration and a real priority.[...]