Data Analytic Services, including a PBGH shared data analyst resource

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Quality designation program for specialty areas (specialized networks, or programs)

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Specialty Program Strategy, Design, Selection, Measurement and Management

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Network Optimization with Hospital and TiC Data (CAA Data)

Using a unique combination of in-depth measurement and technical expertise in conjunction with newly available CAA data, gain the insights you need to make effective and efficient decisions on how to optimize your network in a specific geography and meet your fiduciary obligations.

Service Details:

• Establish comprehensive commercial cost and price benchmarks for specific geographic markets, providing a clear comparative framework.
• In-depth analyses of hospital and provider variations at the market basket level to inform and enhance contracting strategies.
• Compare hospital variations across different products, networks and carriers to identify optimization opportunities.
• Benchmark reimbursement variations for the top 100 procedures and services, offering detailed insights for strategic decision-making.
• Develop and implement tailored network configurations, including effective steerage and design, negotiation tactics and innovative alternative payment models.

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Fiduciary Training and Learning

Enhance your team’s understanding and compliance with CAA requirements through our tailored training curriculum. Designed for benefits, compliance, finance and leadership teams, our program covers critical aspects of CAA compliance including gag clauses, governance oversight, transparency requirements and more.

Service Details:

• Comprehensive Development and Delivery of Customized Curriculum:
  • In-depth exploration of fiduciary duties roles and responsibilities.
  • Detailed coverage of standards of conduct, communication policies, procedural rules and processes, documentation standards and risk mitigation strategies.
  • Extensive guidance on service provider and vendor oversight principles.
  • Emphasis on CAA responsibilities, health care affordability opportunities and using fiduciary governance as a defense against CAA litigation.
• Strategic Alignment:
  • Ensure organizational alignment on strategic health benefit compliance requirements, fostering a cohesive understanding across various departments.

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Fiduciary Governance

Enhance your organization’s fiduciary governance with our comprehensive services, focused on developing and implementing advanced structures, processes, policies and oversight strategies. Our approach ensures the highest level of fiduciary responsibility and efficiency in alignment with your unique needs.

Service Details:

• Health and Welfare Fiduciary Governance Strategy Development:
  • Design an optimal committee structure, including charter development, defining roles and responsibilities, establishing decision-making processes and documentation standards, setting meeting cadence and outlining procedural rules.
  • Implement prudent testing guidelines for purchasing, decision-making and documentation.
  • Establish robust procurement and purchasing principles, management and accountability policies.
• In-Depth Current State Assessment and Gap Analysis of Fiduciary Governance:
  • Comprehensive review and analysis of documents and contracts (e.g., service provider agreements, ASAs, contracts, point solution agreements).
  • Audit of existing policies and procedures to identify areas for improvement.
• Governance Structure Formation and Enhancement:
  • Create a decision-making infrastructure consistent with ERISA’s Prudent Expert standard, focusing on the development of procurement, purchasing and evaluation best practices.

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Supplier Accountability

Ensure your vendor, benefit consultants and brokers provide you with unconflicted, transparent and reliable information and are working in your best interest at a reasonable cost.

Service Details:

• Comprehensive independent selection of your vendor and consulting/broker service provider(s), including:
  • Full-scope request for proposal (RFP) services encompassing purchasing principles and guidelines, creation of a selection rubric, management of the RFP process, coordination of finalist meetings, assistance with best and final offer, and support in contract negotiations.
• Thorough review of vendor, benefit consultant and broker service agreements.
• Detailed analysis and benchmarking of 408(b)(2) compensation and fees, ensuring reasonableness, full disclosure and compliance.
• Development and implementation of vendor and consultant performance standards, including effective measurement and assessment procedures.

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California Data Exchange Framework

Rapid data exchange within the health care delivery system is integral to achieving equitable, patient-centered care for all Californians. The California Quality Collaborative (CQC) supports the California Health and Human Services Agency’s Data Exchange Framework (DxF), the first-ever statewide data sharing agreement, because it will accelerate and expand the exchange of health information among health care entities, government agencies and social service programs. Find the most up-to-date resources and events on the Connecting For Better Health Hub. 

DxF implementation is a multi-year process that has involved extensive stakeholder engagement. With stakeholders, the California Health and Human Services Agency’s Center for Data Insights and Innovation (CDII) has published a data sharing agreement and associated policies and procedures that explain the “rules of the road” for data sharing in California, and these materials will be continuously updated as needs change and standards evolve. There is also a mandate that certain specified entities sign the DSA by January 31, 2023 and begin sharing data by January 31, 2024.

CQC is part of a multi-association collaborative promoting participation in the DxF. Get more information, including timelines and updates, here.

Additional information is also available from the California Medical Association.

All-Payer Claims Databases

PBGH has been a pioneer in the development of multi-payer claims databases, which can provide essential insights for quality improvement and cost management. Only when claims data is aggregated across large populations can systemwide trends, patterns and comparisons emerge.

Gathering All-Payer Information

California recently created an all-payer claims database (APCD) to collect both public and private health claims data across the state. The Healthcare Payments Data Program (HPD) is designed to increase transparency for stakeholders and inform policymakers by building out an accurate and holistic view of health care services provided in California.

Voluntary Participation

An estimated 4-to-5 million Californians are covered by ERISA self-funded employers and purchasers. These purchasers are not required to submit data to the HPD. However, their voluntary contributions will go a long way toward creating the most comprehensive picture possible of California’s population and health care system.

Key Comparisons

Participating in the all-payer claims database can help self-funded employers and purchasers illuminate new cost-saving and quality improvement opportunities, furthering the goal of more transparency in health care pricing. Key insights and capabilities will include:

• Medicare Reference Pricing: Compare the rates you’re paying in the commercial market to Medicare rates for the same services.
• Price Variation: Compare price differentials for outpatient surgical procedures in hospital-based settings versus free-standing facilities.
• Low-Value Care: Isolate instances of care that is medically unnecessary, duplicative or provides no health benefits to patients.
• Prescription Drug Pricing: Assess pricing for prescription drugs across the most common therapeutic classes.
• Outcomes Benchmarking: Benchmark performance to reveal provider variation and resulting implications for quality, cost and patient experience.
• Health Equity: Understand differences across populations in access, quality of care and health outcomes.

Seizing the Moment

PBGH has long been an advocate for the development of all-payer claims databases – information viewed in isolation is of limited value for understanding care variation and cost shift to private payers. With new transparency rules mandating price disclosures by providers and other health care vendors, it is essential that purchasers develop tools to maximize the value of this information. California’s HPD is creating an ever-expanding and increasingly accurate picture of health care services in the state. We urge all PBGH members to contribute to this database to support improvements in health care value, quality, access and equity.

To learn more about how you can participate in this effort, visit the California HPD website.

Behavioral Health Integration Initiative

Meeting patients’ mental health needs and considering social impacts on their health are fundamental to providing comprehensive, patient-centered and high-quality care. However, the lack of improvement in screening and care access demonstrates the need for greater investment to support primary care practices in efforts to integrate behavioral health services. 

CQC will work on a Behavioral Health Integration Initiative from 2022 through 2027 that will accelerate integration efforts by small and independent primary care practices throughout the state. The initiative aims to improve screening, diagnosis and treatment of patients’ mild-to-moderate behavioral health needs, like depression, anxiety and substance use disorder.  

This includes: 

• Direct technical assistance and funding to primary care practices engaged in improvement efforts through the CalHIVE Behavioral Health Integration Improvement Collaborative 
• Better understanding patient perspectives of their behavioral health needs, access to care and treatment through expanded surveying 
• Development of common standards for patient privacy, consent and data sharing among payers and providers to reduce administrative burden to integrating care 

Support

CQC’s Behavioral Health Integration Initiative is possible thanks to the generous support of Centene Corporation, California Health Care Foundation and Blue Shield California Industry Initiatives.