Health insurers are gearing up to comply with a new Covered California rule that will require them next year to ensure that all enrollees have a primary care provider.
The policy change for 2017 is part of a broader push by the exchange to improve the quality of care, even as it faces double-digit premium increases.
Health insurers selling through Covered California will designate a family doctor — or in some cases a nurse practitioner or physician’s assistant — for every plan holder who doesn’t already have one within 60 days of the coverage start date. The role of the assigned provider will be to help enrollees “navigate the system,” the exchange said last week.
The new policy applies to all enrollees, including those in Preferred Provider Organizations (PPOs), in which patients choose the physicians they want, and in HMOs, where the doctor networks are narrower and patients need a referral from their primary care doctor to see other providers.
“You need a captain of the ship,” Lance Lang, chief medical officer of Covered California, said of the role primary care providers play in coordinating patient health. These clinicians “[know] the patient, not just their statistics and lab values.”
Lang said the new policy is meant to improve both the quality and cost efficiency of care.
As the agency unveiled its 2017 health plans and premium rates last week, Executive Director Peter Lee said officials wanted to make sure that “having coverage means [policyholders] also have access to care.”
PPO enrollees will still have the freedom to choose their own providers and will not require referrals from their primary care doctors to see other providers.
For them, “this isn’t a ‘mother may I’ doctor,” said Lee.
Consumers Union, a nonprofit advocacy group with a seat on a Covered California advisory committee, supported the change but wants the exchange to make sure it’s easy for consumers to change doctors if they need to and to find providers in their network who are accepting new patients.
The move to more coordinated care did not surprise health policy experts.
“California has definitely, relative to the nation as a whole, been far more aggressive in moving into managed care,” said Dr. Geoffrey Joyce, director of health policy at the University of Southern California’s Schaeffer Center.
However, Joyce said the Covered California policy change is not a full shift to managed care because the primary care assignments would not be as binding or restrictive as in traditional HMOs, in which patients have to pay more if they see doctors to whom they are not referred.
But the new policy could have clinical and financial benefits, he said.
“Everyone’s moving towards better integrated care, better coordinated care. And so having one primary care provider be your sort of gatekeeper and your focal point makes sense,” Joyce said.
Lang said that Covered California is moving away from a “fragmented, disorganized, wild west” kind of care but is not trying to steer consumers away from PPOs and into HMOs.
Primary care relationships can simply help avoid unnecessary medical costs, Lang said, because a family doctor can prevent duplication of tests and other services and make it less likely a patient will be readmitted to a hospital.
The new primary care requirement is part of a series of new measures meant to improve the quality of care in Covered California health plans. The exchange’s board of directors recently approved rules that include penalizing hospitals financially for underperforming and even removing them — or doctors — from health insurance networks if they perform too poorly or charge too much.
Health plans will also be required to share data about chronic diseases among their patients and work to reduce health disparities.
Covered California’s health plan premiums will increase by an average of 13.2 percent statewide next year, but Lang said rising costs are not the impetus for the policy change on primary care. A body of research shows the benefits of coordinated care, he said.
How many of the 1.4 million Covered California enrollees who currently have primary care doctors is unknown, but about half of the patients in the marketplace are in HMOs, where primary care physicians are the first point of contact.
The California Academy of Family Physicians applauded the Covered California decision, saying primary care can help reduce costs in the current health care system, where “patients sometimes think the emergency room is their only option for urgent care.”
The success of Covered California’s effort depends on how it’s carried out, and the implementation should be monitored to make sure there is adequate number of providers for patients, the family doctors group said.
California laws and insurance exchange rules require health plans to ensure that patients can see providers within a certain timeframe. But in some areas where there is a shortage of primary care providers, patients already have to wait to see a clinician, Joyce said.
It’s possible patients will still have to wait to see a provider under the new Covered California policy, but being assigned to a primary care provider might help expedite a patient’s search for an in-network doctor, Joyce said.