Appropriate Interventions include examining clinical interventions, such as prescription and
nonprescription pharmaceutical treatments, procedures (like surgery), diagnostic tests (lab tests, X-rays, MRIs, etc.) and devices (like implants and pacemakers), to ensure they are rooted in the National Academy of Medicine’s six aims for ensuring every individual’s care is safe, timely, effective, efficient, equitable, and patient-centered. Equally important is effective consumer and patient engagement that (1) supports consumers in making decisions about health care services, treatments, and providers that are consistent with their values and preferences and (2) fosters access to care.
Over the next few years, a wide range of innovations in care delivery will dramatically impact how care is provided, and the quality and cost of that care. Decision support to providers and patients at the point of care is particularly promising and bringing this information to where decisions are made appears to be critical to successful adoption. Covered California is continuously assessing the extent to which its contractual requirements can assist in prioritizing and standardizing implementation of best practices to benefit all Californians.
11.01 Demonstrating Action on High Cost Pharmaceuticals
11.01.1 Appropriate treatment with pharmaceuticals is often the best clinical strategy to treating conditions, as well as managing chronic and life-threatening conditions. Covered California expects the Contractor to ensure that its Enrollees receive timely access to appropriate
prescription medications. Covered California is also concerned with the trend in rising prescription drug costs, including those in specialty pharmacy, and compounding increases in costs of generic drugs, which reflect a growing driver of total cost of care. Access to affordable and effective prescription medications ensures equitable health outcomes for all Enrollees.
11.01.2 The Contractor must report in the annual application for certification a description of its approach to achieving value in delivery of pharmacy services, which must include a strategy in each of the following areas:
1) How it considers value in its selection of medications for use in its formulary, including the extent to which it applies value assessment methodology developed by independent groups or uses independent drug assessment reports on comparative effectiveness and value to design benefits, negotiate prices, develop pricing for consumers, and determine formulary placement and tiering within Covered California standard benefit designs. The Contractor shall report the specific ways it uses a value assessment methodology or independent reports to improve value in pharmacy services and indicate which of the following sources it relies on:
a) Drug Effectiveness Review Project (DERP)
b) NCCN Resource Stratification Framework (NCCN‐RF) c) ASCO Value of Cancer Treatment Options (ASCO‐VF)
d) ACC/AHA Cost/Value Methodology in Clinical Practice Guidelines e) Premera Value‐Based Drug Formulary (Premera VBF)
f) DrugAbacus (MSKCC) (DAbacus)
32 h) Or other value assessment methodology
2) How its construction of formularies is based on total cost of care rather than on drug cost alone;
3) Its process for managing specialty pharmacy and biologics management; and
4) How it provides decision support for prescribers and consumers related to the clinical efficacy and cost impact of treatments and their alternatives.
11.02 Enrollee Healthcare Services Price and Quality Transparency Plan
11.02.1 Enrollee access to cost and quality information is essential for an Enrollee to make informed decisions about their health care. This information also allows transparency and accountability in ensuring there is equitable health care being delivered to Enrollees.
11.02.2 The Contractor must report in the annual application for certification its approach to providing healthcare shopping cost and quality information available to all Enrollees. Covered California does not require using a specific form or format and recognizes that the timeline and expectations will differ, based on variables such as the Contractor’s membership size and current tool
offerings. Regardless of how the requirement is fulfilled, the Contractor’s planned approach must include:
1) Cost information:
a) That enables Enrollees to understand their exposure to out-of-pocket costs based on their benefit design, including real time information on member accumulation toward deductibles, when applicable, and out of pocket maximums. Health Savings Account (HSA) user information shall include account deposit and withdrawal or payment amounts.
b) That enables Enrollees to understand provider-specific consumer cost shares for prescription drugs and for care delivered in the inpatient, outpatient, and ambulatory surgery or facility settings. Such information must include the facility name, address, and other contact information and be based on the contracting rates to give the Enrollee estimates of out of pocket costs that are as accurate as possible.
c) Commonly used service information should be organized in ways that are useful and meaningful for consumers to understand.
2) Quality information:
a) That enables Enrollees to compare providers based on quality performance in selecting a primary care clinician or common elective specialty and hospital providers.
b) That is based on quality measurement consistent with nationally-endorsed quality information.
3) The Contractor shall monitor care provided out of network to ensure that Enrollees understand that their cost share will be higher and are choosing out of network care intentionally.
4) If the Contractor enrollment exceeds 100,000 for Covered California business, the cost and quality information shall be provided through an online tool easily accessible across a variety of platforms. If Contractor enrollment is under 100,000 for Covered California business, the information may be provided by alternative means such as a call center.
33 11.02.3 The Contractor must report in the annual application for certification:
1) The number and percent of Enrollees in Covered California and all lines of business that have accessed each of the consumer tools offered.
2) How Enrollees in Covered California and all lines of business are using the cost and quality information to aid in their health care decisions and how the Contractor assesses the effectiveness of its consumer tools.
11.03 Enrollee Shared Decision-Making
11.03.1 Covered California requires deployment of decision-making tools to support Enrollees in understanding their medical diagnosis and treatment options to aid in discussion with their provider. Educating Enrollees on their diagnosis and alternative treatment options is a powerful evidence-based approach to reducing overuse or misuse of clinical interventions. Covered California encourages the incorporation of Choosing Wisely decision aids to promote decisions about appropriate and necessary treatment (https://www.choosingwisely.org/).
11.03.2 The Contractor shall promote and encourage patient engagement in shared decision-making with contracted providers. The Contractor must report in the annual application for certification for Enrollees in Covered California and all lines of business:
1) Specific information regarding the number and percent of eligible Enrollees who have accessed consumer information or have participated in a shared decision-making process prior to reaching an agreement on a treatment plan. For example, the Contractor may adopt shared-decision-making practices for preference-sensitive conditions, including breast cancer, prostate cancer, and knee and hip replacements, that feature patient-decision- making aids in addition to physician opinions and present trade-offs regarding quality or length of life.
2) The percentage of Enrollees with identified health conditions above who received information that allowed the Enrollee to share in the decision-making process prior to agreeing to a treatment plan.
3) Participation in these programs and their results, including clinical, patient experience, and costs impacts.
4) How the Contractor is encouraging contracted providers to implement Choosing Wisely guidelines to aid in conversations with Enrollees on appropriate and necessary care. 11.04 Enrollee Personalized Health Record Information
11.04.1 Accessibility to Enrollee personal health management information equips the Enrollee to be active and engaged in decisions about their coverage, care, and health. This transparency and personal authority contribute to achieving equitable health care.
11.04.2 To ensure accessibility of Enrollee health record information:
1) The Contractor must report in the annual application for certification, the services the
Contractor provides for Enrollees in all lines of business, through its Enrollee portal, to easily access personalized information about their coverage and care. The Contractor shall explain services it makes available to Enrollees including:
a) Personal Health Record information and functions including provider appointment scheduling, test results look-up, prescription drug refill ordering, preventive screenings and vaccination history, visit summaries, wellness care and program enrollment; and
34 b) Coverage and cost information and functions including premium payment transactions,
coverage and cost-share schedule, benefits cost accumulation year-to-date, explanation of benefits look-up, price and service comparisons for shopping.
2) The Contractor will provide access and log-in credentials for Covered California staff per mutually agreed-upon terms to safeguard Contractor proprietary information and services.
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