- Covered California is putting hospitals on notice to hit specified safety and quality goals or risk losing out in the state’s Affordable Care Act insurance exchange market, WBUR reports.
- Specifically, California's ACA marketplace is telling participating health plans to exclude hospitals that don’t hit certain goals from in-network status. Those goals include performing fewer unnecessary cesarean sections, prescribing fewer opioids and reducing the use of X-rays and other imaging to diagnose and treat back pain.
- “We’re saying ‘times’s up,’” Lance Ling, chief medical officer for Covered California, said. “We’ve told health plans that by the end of 2019, we want networks to only include hospitals that have achieved those targets."
The threat should get hospitals’ attention. Tying quality measures to payment size is one thing, but this links performance on specific metrics with even being in a network.
Unnecessary or inappropriate care is a huge problem. The U.S. wastes about $200 billion a year on excess medical tests and treatment, contributing to some 30,000 deaths due to errors and injuries.
C-sections have been on the radar for years. In the past decade, the U.S. rate of C-section births has climbed by 50%, and today a third of all babies have a surgical birth, according to the California Health Care Foundation. Unnecessary C-sections are a concern not just for their cost, which tends to run about 50% higher than a vaginal delivery, but because there is a greater chance of major complications for the mother and baby.
Covered California’s plan may have been influenced by Smart Care California, which launched the Choosing Wisely program last year to reduce medical waste by promoting safer, more cost-effective care. The coalition is initially focused on reducing elective C-sections, opioid use and treatment for patients with lower back pain.
But despite widespread agreement that unnecessary care is bad for patients and hospitals, change has been slow. An analysis in Health Affairs earlier this year found physicians often resist Choosing Wisely recommendations out of concern about malpractice, patient demand and satisfaction and a desire for more information to reduce uncertainty. In one study, 85% of physicians said they fear of malpractice led to overtreatment.