San Francisco Health Network projects QIP gains; CMS funding expansion could raise pool to about $110 million

San Francisco Health Network officials reported to the Health Commission on progress in California's Quality Incentive Pool (QIP) program, describing longstanding success capturing available funding and outlining data and operations work to sustain performance and prepare for program changes.

Program summary and significance

Kathleen Chung, medical director for value-based care, said QIP is a statewide managed-care pay-for-performance program designed to align priorities and reduce disparities by paying public systems for meeting quality targets among Medi-Cal managed-care enrollees assigned to the network. In 2023 the network's QIP program value was about $68.9 million based on enrollment (roughly 51,000 enrollees assigned to San Francisco Health Network primary care). Chung said an approval by CMS to expand funding for program-year 2025 could raise the program's annual value to approximately $110 million if enrollment holds steady; that expansion would raise per-metric dollar values for the network's measures.

Why this matters: QIP has provided sustained, unrestricted dollars to support DPH operations and programs. Over prior program years, the network reported achieving near- or full-program targets and returning funds to the DPH general fund.

How the program works and the network's approach

Chung explained that QIP comprises 40 metrics: 20 required statewide measures and 20 elective measures the network selects from a larger menu. Data sources include claims from health plans, the enterprise electronic medical record (EPIC) and data exchanges with insurers. The value-based care team partners closely with the network's primary-care, hospital quality, analytics and IT teams and with the two local health plans. The department emphasized investments in data integrity and the enterprise medical record; since 2019 the health system has been consolidating disparate records into a single EMR and completing Epic rollouts across divisions.

Performance and operational highlights

- Historical results: The network reported achieving 100% of available QIP targets from program years 1 through 6 and expects to meet most 2024 targets; the team estimated performance above 95% and noted it waits for formal reporting and audit to confirm final attainment. - Data and partnerships: Strong analytics and plan partnerships helped the network capture care delivered outside SFHN and reduce duplication. The department is preparing for potential state changes that could shift primary reporting responsibility from the network to health plans in future cycles and is deepening those plan partnerships accordingly. - Equity and clinical priorities: The QIP measure set now includes more maternal/child measures and behavioral-health metrics; SFHN highlighted improvements in several cancer-screening and childhood measures and cited local leadership in metrics such as exclusive breastfeeding and HIV screening.

Future risks and work

The department said it is preparing for state strategy changes expected in 2026, stabilizing staffing for quality-reporting functions, expanding partnerships with CalAIM and Whole Person Integrated Care and improving claims capture for work currently recorded in the medical record rather than on billing. Commissioners asked about timing of changes to plan-based reporting and urged continued attention to data exchange and quality-measure integrity.

Ending

No vote was required. The commission received the update and commissioners requested continued reporting on data metrics, plan-exchange improvements and operational steps to protect long-term QIP funding.