Join us June 20 at our Health Policy Update webinar. Register now
Join us June 20 at our Health Policy Update webinar. Register now
At IHA, we’ve been finding solutions for healthcare’s biggest challenges for over 25 years. Over the past few decades, our team has collaborated with providers, payers, partners, regulators, researchers, and grantors on initiatives that push the industry forward and make high-value care a reality.
Below you’ll find a selection of our key projects. Expand each section to read the details and download the relevant resources.
One common risk-based payment method—long used in California but less common elsewhere—is capitation. Under capitation, providers receive prospective per member, per month payments to provide all contracted patient care instead of filing piecemeal fee-for-service claims for individual services after the fact. In lieu of claims data, health plans using capitation rely on providers to submit patient encounter data to track health care quality and costs and to adjust provider payment levels.
Complete, timely, and accurate encounter data are critical to risk-adjusting provider payments to account for health differences in patient populations enrolled in California HMOs. Yet, provider payment incentives, multiple data handoffs and variation in data collection hamper exchange of encounter data among contracting parties, ultimately impacting HMO enrollment.
To increase understanding and identify potential solutions, IHA launched a multi-stakeholder initiative to assess market challenges and develop ways to standardize encounter data exchange processes.
As evidence that standardizing encounter data is a statewide imperative, the California Department of Managed Health Care included community investments to improve completeness and accuracy of encounter data as a requirement for the approval of the Centene acquisition of Health Net.
IHA’s initial assessment of encounter data in the current California environment and production of the issue brief was funded by the California Health Care Foundation.
Encounter Data White Paper: Challenges in Encounter Data Submissions
Encounter Data Issue Brief: Issues and Implications for California’s Capitated, Delegated Market
Many experts believe piecemeal, volume-based fee-for-service payment encourages fragmented and inefficient care that not only costs more but is lower quality. One alternative is bundled payment—paying for services on the basis of an episode of care rather than individual tests, procedures, or visits. IHA spearheaded California pilots to test bundled payment approaches for orthopedic and maternity care and developed a wide array of resources, such as episode definitions and model contracts, to lay the groundwork for others’ work on bundled payments.
IHA’s engagement with bundled payment emerged from a value-based purchasing project as a promising opportunity to align incentives and improve coordination across care settings. In 2009, the California Health Care Foundation funded an IHA pilot project to test implementation of bundled payments in California. A year later, the Agency for Healthcare Research and Quality awarded IHA a three-year grant to expand the bundled payment demonstration. In 2012-2013, IHA also served as a Facilitator Convener for the Center for Medicare and Medicaid Innovation’s Bundled Payments for Care Improvement (BPCI) initiative, supporting several California hospitals as they explored the BPCI opportunity.
IHA is committed to sharing knowledge, resources, and lessons learned from payment reform efforts through issue briefs and other publications for both policymakers and practitioners. Available resources, most of which were released in 2013 when the initiative concluded, are included below.
Maternity care is suitable for a bundled payment strategy based on high volume, high costs, and a defined episode of care. Unlike fee-for-service reimbursement, which pays providers for each service, bundled payment combines services provided during a defined episode of care into a single, fixed payment rate. Bundled payment creates financial incentives for providers and hospitals to be more accountable for efficiency and coordination across care settings. For more information on maternity care bundled payment, download the following publications:
Issue Brief: Transforming Maternity Care: A Bundled Payment Approach
Maternity Episode Definition: Case Rate Delivery Only
Maternity Episode Definition: Pregnancy and Delivery (Mother Only)
Project Information
AHRQ Demonstration Overview
Bundled Episode Payment & Gainsharing Demonstration Results Presentation
Publications
Issue Brief: Bundled Payment for Orthopedic Surgery
Issue Brief: Bundled Payment Care Redesign
Issue Brief: Bundled Payment Approach to Maternity Care
Issue Brief: Redesigning Insurance Benefits and Consumer Copayments for High Cost Surgical Service
Issue Brief: Aligning Consumer Cost-Sharing with Episode of Care Provider Payment
Article: Implementing Bundled Payment: Learning From Our Failures
Article: Implementing Bundled Payment: No Pain No Gain
Contract Templates
Health Plan and Hospital Agreement
Hospital and Physician Agreement
Bundled Payment Contract Model Scenario
Episode Definitions
Orthopedics: Total Knee Replacement, Total Hip Replacement, Unicompartmental Knee Arthroplasty, Knee Arthroscopy with Meniscectomy, and Cervical Spinal Fusion
Cardiovascular: Diagnostic Cardiac Catheterization and Angioplasty with Stents
Smart Care California is a public-private partnership working to promote safe, affordable health care in California. The group currently focuses on three issues: C-sections, opioid overuse and low back pain. Collectively, Smart Care California participants purchase or manage care for more than 16 million Californians—or 40 percent of the state. Smart Care California is co-chaired by the state’s leading health care purchasers: DHCS, which administers Medi-Cal; Covered California, the state’s health insurance marketplace; and CalPERS. From 2015 to 2019, IHA convened and coordinated the partnership with funding from CHCF.
By some estimates, up to 30 percent of all patient care in the United States is at best ineffective or at worst harmful while increasing costs for everyone. In order to address concerns regarding the increased use of wasteful medical services, Smart Care California, previously known as the Statewide Workgroup on Reducing Overuse, was formed in 2015. Smart Care California engages participants representing physicians, hospitals and health systems, health plans and other payers, purchasers, and consumer organizations to tackle the issue of overuse.
The Maternity Care initiative, one of four key initiatives included in California’s State Innovation Model (CalSIM) grant, promotes healthy, evidence-based obstetrical care to reduce the quality shortfalls and high costs associated with unnecessary cesarean deliveries. IHA provided technical assistance to the California Health and Human Services Agency to further develop the four components of the Maternity Care Initiative. As a part of our work, IHA identified patient engagement strategies that enable pregnant women to make informed decisions to improve their care, their health, and the health of their babies.
Issue Brief: Maternity Care Patient Engagement Strategies
IHA also did work on reducing unnecessary cesarean deliveries as part of Smart Care California. You can learn more about this work under the Smart Care California section on this page.
Additionally, IHA developed maternity episode definitions that can be used for bundled payments. You can learn more about this work under the bundled payment section on this page.
This proof-of-concept demonstration project, funded by the California Health Care Foundation, explored how state cancer registry data can be combined with commercial claims and encounter data to measure cancer care quality for physician organizations—as either data source alone is insufficient. The project linked these two data sources and developed specifications to make the combined data available as standardized measures. Results—which were calculated statewide, regionally, and for physician organizations serving commercial HMO enrollees in California—revealed geographic variation in the quality of cancer treatment. Project challenges included lengthy data access processes, a low data linkage rate, and insufficient sample size for reliable measurement and analysis at the PO level.
An IHA white paper—Linking Cancer Registry and Claims Data for Quality Measurement—summarizes findings from the project and offers tangible suggestions for improving data linkages and timeliness, expanding allowable uses of data, and streamlining the data access process.
We’re always happy to help people who are interested in our work. If you have a question about encounter data, bundled payment, maternity care, or Smart Care—and you can’t find the answer above—contact us.