A stronger model for turning managed care accountability into measurable provider performance
State Medicaid agencies set quality, access, and value-based care expectations. Contracted health plans are accountable for achieving them.
But when the same measures remain below target year after year, a different approach is needed—one that changes how improvement reaches providers.
Health plans already invest significant resources in quality improvement, provider education, care-gap reporting, incentives, technical assistance, and provider engagement. Those investments produce greater value when they are focused on the right priorities, reach the providers with the greatest opportunity, and translate into sustainable changes in how care is delivered.
Elevation Health Partners (EHP) helps states strengthen that infrastructure: prioritizing the measures that matter most, aligning health plans around a common transformation approach, directing technical assistance where it can have the greatest impact, and creating clear expectations for provider participation in improvement.
The Opportunity for States
A statewide approach can create greater focus, consistency, and accountability across health plans while directing provider transformation resources where they can have the greatest impact.
• Prioritize a manageable set of quality, access, and value-based care outcomes that matter across plans.
• Align provider-improvement resources around a common transformation framework and evidence-based change package.
• Target intensive support by provider performance, readiness, geography, and opportunity for lift.
• Establish clearer expectations for meaningful provider participation in improvement activities.
• Measure implementation and incremental performance lift, then spread the approaches that work.
What EHP has learned on the ground
In EHP's work with more than 100 directly coached Medicaid practice sites, 4,047 barriers to quality performance were documented. Fifty-seven percent were workflow-related. Across 1,194 Medi-Cal measure observations, 62% improved year over year. The recurring lesson: persistent quality gaps are often operating-system problems that require changes in workflows, roles, data use, outreach, and accountability.
The State Medicaid Provider Transformation Framework
1. Prioritize the outcomes that matter most
Select a focused set of quality, access, and value-based care priorities where coordinated provider transformation can create meaningful statewide impact.
Persistently underperforming measures
Measures affecting multiple contracted plans
Statewide access priorities
High-impact chronic disease and preventive measures
Value-based care readiness priorities
2. Identify where performance is breaking down
Use plan, provider, and readiness data to locate the providers, regions, and operating barriers that are limiting performance.
Provider and geographic variation
Implementation maturity
Data and reporting barriers
Workflow and access constraints
Organizational readiness
3. Establish a common transformation approach
Create a state-aligned change package that defines the provider capabilities, workflows, milestones, and evidence-based interventions associated with successful implementation while preserving plan flexibility in execution.
Common provider assessment and milestones
Evidence-based interventions
Standard work and workflow expectations
Leadership and care-team roles
Measures of adoption and sustainability
4. Match TA investment to provider need
Use a tiered support model so resources correspond to provider readiness and performance opportunity.
Broad support: tools, training, self-assessment, office hours, peer learning
Targeted support: action planning, collaboratives, facilitated improvement, performance review
Intensive transformation: direct coaching, workflow observation, root-cause analysis, PDSA testing, data support, leadership engagement
Design principle
Providers that contract with multiple Medicaid plans benefit from greater consistency across quality-improvement expectations. A common state-aligned framework can reduce duplication while allowing each plan to retain responsibility for its network and performance.
The Framework, Continued
5. Make provider participation meaningful
Assess the mechanisms available to establish clear, practical expectations for provider participation in targeted improvement activities. The solution can vary by state, provider type, and delivery system.
Health-plan provider contract requirements
State managed care contract provisions
Quality-improvement participation requirements
Value-based or alternative payment agreements
Incentive structures and provider performance expectations
Escalation pathways for persistent underperformance
Opportunities to align requirements across plans
Legal, regulatory, and procurement considerations
6. Move from education to implementation
Provider transformation converts performance priorities into reliable day-to-day execution.
Assess current state and identify root causes
Redesign workflows and clarify roles
Test evidence-based interventions
Use data to guide improvement
Monitor results and adapt when performance stalls
Move successful changes into standard work
7. Measure the incremental lift
Track whether transformation support is changing provider capability and producing additional performance improvement.
Participation and engagement
Implementation maturity and milestone completion
Adoption of standard work
Movement in priority measures
Participating vs. comparable non-participating performance
Variation across plans, regions, and provider types
Sustainability after intensive support ends
8. Build the infrastructure to sustain and spread
Create reusable assets and internal capability so successful approaches can scale across plans and provider networks.
Repeatable change packages and assessments
Coaching tools and implementation playbooks
Performance dashboards
Train-the-trainer models
Processes for spread and sustainability
Participation and accountability are part of the design
The framework includes an explicit investigation of the levers a state can use to strengthen provider participation. That may include contractual obligations, value-based agreements, incentive design, or other mechanisms. The work begins by assessing the state's available options and designing an approach that is enforceable, coordinated across plans, and operationally workable for providers.
Evidence That Provider Transformation Can Create Greater Lift
EHP's approach was shaped through the CMS/CMMI Transforming Clinical Practice Initiative (TCPI), a national effort designed to build and test scalable approaches to practice transformation and value-based care readiness. EHP has continued to apply and refine that model across California Medicaid and safety-net initiatives and in other markets.
800+ providers
CMS/CMMI TCPI | L.A. Care Los Angeles Practice Transformation Network
EHP served as the lead practice transformation coaching firm, using the CMS transformation framework, maturity assessment, direct Masters Coaching, change packages, and continuous performance improvement.
- 21 of 23 health centers completed all transformation phases
- Clinical quality improvement ranged from 5%–33%
- 21 of 23 centers improved at least 10% on three of four primary quality measures
- 200+ trainings delivered
- More than $150M in initiative-reported savings associated with reduced ED and hospital utilization
Medicaid sites
Health Net / Centene | QIPM and PQCI
EHP used payer and practice data, barrier analysis, root-cause review, measure-specific action plans, and direct coaching across a large California Medicaid provider network.
- 4,047 documented performance barriers; 57% workflow-related
- 62% of 1,194 Medi-Cal measure observations improved year over year
- San Joaquin CIS-10: +21.62 points among participating providers vs. +0.78 among non-participants
- San Joaquin adolescent immunization: +13.16 points vs. a 1.32-point decline
- Stanislaus blood pressure control: +28.69 points vs. +7.00
- Los Angeles well-child visits: +7.48 points vs. +3.77
footprint
California Medicaid & Safety-Net Transformation
EHP has replicated the transformation model across statewide, multi-county, health-plan-funded, and safety-net initiatives.
- 50+ customized engagements through California's PATH Technical Assistance Marketplace
- Health-plan-funded transformation initiatives reaching up to 180 Medicaid practices
- 10 years of HCCN transformation supporting 27–47 community health centers across grant cycles
- California Quality Collaborative work supporting 80 health centers and 465 providers
- Multi-county quality improvement work translating payer data and Medicaid priorities into provider-level change
A Practical Statewide Model
The framework can be implemented as a statewide strategy or tested first with a focused priority. States can begin with one measure, a small set of shared priorities, a region, a provider cohort, a subset of plans, or a value-based care readiness initiative.
What a State Can Explore With EHP
Which measures and provider segments warrant a coordinated statewide transformation strategy.
How current plan-funded TA and quality-improvement resources are being deployed and where they can be focused for greater impact.
Which provider participation and accountability mechanisms are available through managed care contracts, provider contracts, value-based agreements, incentives, or other state levers.
How to create a common change package, maturity assessment, and tiered support model across plans.
How to measure incremental lift and establish the evidence for statewide expansion.
The question for state Medicaid leaders
How can a statewide provider transformation model help contracted health plans convert quality and access accountability into stronger, more consistent provider-level results?
Request a State Medicaid Performance Briefing
EHP can share the framework, compare it with your state's current provider-improvement approach, and identify practical opportunities to strengthen provider transformation across contracted health plans.
Elevation Health Partners | elevationhealthpartners.com