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Research Questions

  1. Was the GPP successful in driving a shift in the provision of services from inpatient to outpatient settings (including non-traditional services) over the course of the GPP?
  2. Did the GPP allow PHCSs to leverage investments in primary care, behavioral health, data collection and integration, and care coordination to deliver care to the remaining uninsured?
  3. Did the percentage of dollars earned based on non-inpatient non-emergent services increase across PHCSs?

There are approximately 2.8 million remaining uninsured individuals in California and they often have limited access to cost-effective preventive care and mental health services. To address this issue, California initiated the Global Payment Program (GPP), a pilot program included in the state's current Section 1115 demonstration waiver to support public health care system (PHCS) efforts to deliver more cost-effective and higher-value care to the state's uninsured.

The GPP seeks to improve care to the uninsured by providing GPP funds that can be used to pay for a broad set of services, including non-traditional services and services provided in non-traditional settings. California developed a system of points to provide a value for each service and to track service use relative to each PHCS's budget. The goal is to provide a flexible payment system that encourages the delivery of high-value services, particularly those in lower-intensity care settings to address the needs of PHCS patients.

This report documents findings of the final evaluation of the GPP. Through the GPP, PHCSs have put in place a variety of strategies and offered a wider range of services to improve care for the uninsured in California. Utilization of outpatient, non-emergency services increased over the three-year period, while emergency room services and inpatient days decreased. Non-traditional service utilization increased in different ways across PHCSs, indicating that the PHCSs were able to tailor their services to the needs of their patient populations.

Key Findings

PHCSs have strengthened infrastructure to support the goals of the GPP

  • PHCSs implemented broad health system improvement strategies to further GPP goals and changed their provision of services, suggesting that the GPP is a foundation for improving care for the uninsured.
  • As PHCSs gained familiarity with the GPP, they appear to be individualizing the services they provide to their own settings.
  • PHCSs indicated that the strategies they are adopting to build their infrastructures and the services they are delivering are having a positive impact on GPP outcomes.

PHCSs are prioritizing expanded use of outpatient and non-traditional services

  • The number of points earned for outpatient non-emergent services increased by 12 percent, points for inpatient medical and surgical services decreased by 15 percent, and points earned for ER visits decreased by 14 percent.
  • The use of non-traditional services as a share of all outpatient and residential services increased from 12.9 percent to 17.3 percent — a 4.4-percentage point increase. Use of non-traditional services was concentrated in a small number of services (particularly Registered Nurse–only visits, eConsults, and case management) but increased slightly overall.
  • Use of all outpatient mental health and substance use services decreased and inpatient behavioral health utilization increased. Despite these unexpected trends, there were favorable reductions in the use of mental health emergency room and crisis stabilization services.
  • Uninsured costs increased from the baseline year to year 1, but then decreased slightly between year 1 and year 2. Per capita uninsured costs increased slightly between year 1 and year 2.

Table of Contents

  • Chapter One


  • Chapter Two

    Changes in PHCS Infrastructure

  • Chapter Three

    Changes in Utilization of Health Care Services to the Uninsured

  • Chapter Four

    Changes in Payments and Costs During the GPP

  • Chapter Five

    How Health Systems Use Strategies and Services to Respond to GPP Incentives

  • Chapter Six

    Conclusions and Implications

  • Appendix A

    Evaluation Methods

  • Appendix B

    Supplemental Data Exhibits

  • Appendix C

    California's Global Payment Program (GPP): Final Evaluation Survey

  • Appendix D

    Interview Guides

  • Appendix E

    Additional Exhibits Regarding the Association Between Survey-Reported Strategy Use and GPP Outcomes

Research conducted by

The research described in this report was sponsored by the California Department of Health Care Services and conducted with the Payment, Cost, and Coverage Program within RAND Health Care.

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