CalPERS details population health work, Included Health PPO services and behavioral‑health access study

CalPERS staff presented an enterprise clinical update that included: (1) prevalence and cost trends for common chronic conditions across basic and Medicare populations; (2) early utilization and engagement metrics for Included Health (the new population health vendor for PPO members); and (3) planned and ongoing behavioral‑health initiatives, including a secret‑shopper timely‑access study led by UC researchers and contract amendments to better measure behavioral‑health access and spending.

Data highlights included: hypertension and diabetes as the most prevalent chronic conditions with higher prevalence in Medicare and PPO populations; cancer as the largest single condition driver of total medical spend ($1.64 billion in 2024) and diabetes accounting for about $617 million of combined medical and pharmacy costs. Staff flagged GLP‑1 medications (e.g., semaglutide/Ozempic class) as a significant driver of pharmacy spend for diabetes and obesity management and said the plans now report GLP‑1 spend to CalPERS on a routine basis.

Included Health (PPO population health vendor) activity through April showed most use in provider‑matching and concierge referrals, nurse triage and live clinical support, and a growing number of virtual urgent‑care and non‑physician behavioral‑health visits. Included identified about 15,300 “high‑opportunity” PPO members for care/case management outreach (categories include high annual spend, recent hospitalization, pregnancy, spine surgery risk, complex new diagnosis, or multiple ER visits). Staff reported 86% of those identified had an outreach attempt and about 19% had been reached; 22% of reached members had enrolled in care plans, and Included plans targeted focus groups and surveys to raise engagement.

On behavioral health, staff reported increasing prevalence of anxiety and depression in basic members (adolescent prevalence notably high), stable substance‑use rates and incremental increases in virtual behavioral‑health utilization. CalPERS will publish UC timely‑access results in early 2026 after UC completes calls for HMO and PPO provider samples; results will help identify provider directory accuracy issues and access barriers. Staff described Blue Shield’s decision to bring behavioral health in‑house from a third‑party vendor to reduce fragmentation and improve oversight, and said CalPERS is working with Covered California and the Department of Health Care Services on behavioral‑health spending benchmarks and primary‑care/behavioral‑health integration measures.