California is often seen as a bellwether state — a leader in everything from clean energy to defending immigrant rights — so it’s no surprise that health care in California is the theme of a special issue of Health Affairs. The September 2018 issue examines delivery system innovation, markets and regulation, the quest for universal coverage, and more in the nation’s most populous state.

In California Healthline, Anna Gorman describes California as “a health care laboratory with mixed results.” Though the state has been a pioneer in embracing the Affordable Care Act (ACA), its vast size, diverse population, and the realities of implementing health policy and innovations in a contentious political environment “have made for some messy experiments.” Let’s take a look at what’s brewing in the California laboratory.

A “Four-Pronged Plan of Attack” Against Maternal Deaths

In 2006, California looked at its rising maternal mortality and morbidity rates — challenges echoed across the country — and decided to act. The California Department of Public Health supported the founding of the California Maternal Quality Care Collaborative (CMQCC) at Stanford University. The California Health Care Foundation (CHCF) and the Centers for Disease Control and Prevention provided funding for CMQCC’s data center, a crucial element of its quality improvement work. An article in Health Affairs authored by CMQCC researchers, including medical director Elliott Main, MD, describes how the organization harnessed a public-private partnership to cut the state’s maternal death rate by more than half in only seven years. This progress bucked the national trend.

In the San Francisco Chronicle, Kimberly Veklerov writes that CMQCC’s “four-pronged plan of attack [against maternal mortality] combined analyzing public health data, convening an array of public and private health groups, creating a data system for hospitals to measure their progress, and developing health interventions for use across the state.” Each of these parts is an impressive project in and of itself. For example, a lifesaving health intervention adopted at the hospital level was CMQCC’s integration of quality improvement toolkits for pregnancy-related emergencies like obstetric hemorrhage. “When you’re in the midst of a crisis, you’re very focused on the patient and the emergency, and having a checklist that someone can read to you is a very important tool,” said Malini Nijagal, MD, MPH, an obstetrician-gynecologist at the University of California, San Francisco (UCSF).

Tony Abraham reports in Healthcare Dive that among 99 hospitals that collaborate with CMQCC on quality improvement, 20% reduced severe maternal morbidity among women by using an obstetric hemorrhage toolkit.

Consolidation of California’s Health Systems

Another study published in the new Health Affairs finds that California’s health systems are gobbling up physician practices. Researchers at UC Berkeley and the RAND Corporation in Santa Monica assessed consolidation trends and found that between 2010 and 2016, the percentage of California physicians in practices owned by a hospital increased from 25% to more than 40%.

This growing consolidation is linked to higher health insurance premiums and higher prices for specialty and primary care visits, as Catherine Ho reports in the San Francisco Chronicle. During the study period, market concentration raised ACA premiums 12%, boosted prices of outpatient doctors’ visits in four specialty areas by 9%, and increased prices for primary care office visits by 5%. One reason for these increased costs could be “a potential branding effect,” Richard Scheffler, PhD, the study’s lead author, explains. People may be willing to pay more for care from well-known health systems, and because “insurance companies like to have that in their plan, they charge more for it.”

California Healthline’s Chad Terhune writes that hospital and physician groups defend consolidation as being good for patients. They argue that hospital-physician mergers can help coordinate care and negotiate with insurance companies to lower health care costs. On the other hand, critics of consolidation say that mergers are producing “mega-enterprises” that exhibit anticompetitive behavior and provide no measurable improvement in quality, care coordination, or patient satisfaction. Right now, all eyes are on a lawsuit that California Attorney General Xavier Becerra filed this year accusing the sprawling Sutter Health system of “overcharging patients for years and illegally driving out competition in Northern California.” Sutter denies allegations of anticompetitive behavior.

Nurse Practitioners Struggle to Practice

Even as California’s physician shortage worsens, its workforce of nurse practitioners (NPs) grows. It would be logical to think that NPs should provide a straightforward solution to the problem, but a UCSF study published in Health Affairs shows that several barriers limit the state’s ability to leverage NPs.

First, while California isn’t the most restrictive state when it comes to scope of practice laws, it is the only western state that requires NPs to follow written standardized procedures to practice and to prescribe. UCSF’s Joanne Spetz, PhD, the study’s lead author, explained to Reuters reporter Linda Carroll that these restrictions mean NPs “are able to do less in practice even if they are side by side with a physician.” California’s restrictions stand in contrast to the 22 states that allow NPs to practice and prescribe without physician oversight. A new CHCF report on California’s nurse practitioners suggests that the elimination of unnecessary barriers to NP care could help the state meet its workforce needs, especially in rural and underserved areas.

Additionally, there aren’t enough training programs in California’s rural areas, where physician shortages are particularly severe. Amy Baxter reports in HealthExec that NPs tend to live in areas with a high density of both NPs and physicians. Only eight of California’s 23 NP education programs are in counties with lower-than-average NP and physician density, suggesting that the creation or expansion of nursing schools to rural areas could improve the workforce supply there.

Read the Health Affairs September Issue

CHCF has arranged free access to the three Health Affairs articles mentioned above. Subscribers can access the full California theme issue here, and everyone can sign up to watch the live webcast of a briefing on the publication here. The briefing, set for 9:00 AM (PT) on September 17 at the RAND Corporation in Santa Monica, will feature 19 authors of California theme issue articles discussing their findings. The breakout panels are divided into delivery system innovation, markets and regulation, access to services, the search for universal coverage, and California’s evolving demographic profile. The California theme issue and the briefing are funded by CHCF, the Blue Shield of California Foundation, The California Endowment, and the Leonard D. Schaeffer Center for Health Policy and Economics at the University of Southern California.

Did you read the September issue of Health Affairs? Let me know what your favorite article was — tweet at me with #EssentialCoverage or email me.

Xenia Shih Bion

Xenia Shih Bion is a communications officer at CHCF, where she helps to lead communications around the foundation’s work to create health equity. She is the founding author of the “Essential Coverage” column in The CHCF Blog. Read More

More by this Author:

‘You Want Your Immune System Protecting You and Your Baby’, Envisioning a More Just and Inclusive Health Care System, Spreading the Stories of Joyful Black Births