CA Medicaid Plan Seeks to Streamline Pay for Performance Model

CenCal Health, a Medicaid plan in California, is employing a pay for performance model to improve quality of care, called the Quality Care Incentive Program.

“The new Quality Care Incentive Program is an innovative step forward in CenCal Health’s strategy to ensure equitable health care for all,” said Marina Owen, chief executive officer of CenCal Health. 

“QCIP reinforces our enduring partnership with providers, and meaningfully recognizes them. I am proud of CenCal Health’s commitment to eliminating health disparities through compassionate service.”

The health plan’s network includes more than 1,500 providers, health systems, and healthcare facilities. The plan serves 210,000 members in two counties in California.

Prior to this shift, CenCal Health used five separate incentive programs to incentivize Medi-Cal providers to offer high-quality care.

The Quality Care Incentive Program is an effort to streamline incentive programs. The program reimburses participating providers based on monthly performance measures from the National Committee for Quality Assurance (NCQA).

The performance measures span chronic disease management and chronic disease prevention for expensive chronic conditions such as diabetes and cancer and wellness visits.

The Quality Care Incentive Program focuses on five measure domains: behavioral healthcare, diabetes care, pediatric care, respiratory care, and women’s healthcare. There are a total of 13 measures for which providers may receive incentive payments. These measures include medication management, testing, exams, screenings, immunizations, and wellness visits.

“We designed this incentive program to encourage increased utilization of evidence-based treatment, screening, and preventive health services,” said Carlos Hernandez, health quality officer at CenCal. “Performance is based on how often the standard of care is met. And no measures used in CenCal Health’s payment calculations encourage withholding of services.”

The State of California Department of Health Care Services, primary care providers, and internal health plan departments played a role in the program’s design and formation. 

The press release noted that the pay-for-performance model originally was intended to boost provider participation in Medicaid care delivery. However, in more recent years, the focus has shifted to quality of care, chronic disease prevention, and chronic disease management, such as in the Quality Care Incentive Program.

The Quality Care Incentive Program went into effect on March 1, 2022.

Pay-for-performance is considered one of the first steps that a provider organization might take toward entering into value-based care models.

In 2020, pay-for-performance remained one of the most popular value-based care models, according to research from an Insights report. 

However, interest in the model may have declined. Over half of all survey participants in the 2019 Insights report stated that they were participating in the pay-for-performance model (55 percent). By 2020, 37 percent of survey participants stated that they were in a pay-for-performance model.

That being said, all of the other alternative payment models that the survey analyzed also saw declines in participation in 2020. Researchers speculated that this decline may have been a side effect of the coronavirus pandemic.

But a drop in interest does not mean that the model is no longer useful. AHIP suggested that payers use pay-for-performance models to improve maternal healthcare costs. These expenses are incredibly burdensome for patients and may benefit from coverage through more consistent value-based contracting.