California Public Employees Retirement System Research Articles

Association of Participation in a Value-Based Insurance Design Program With Health Care Spending and Utilization

Value-based insurance design (VBID) has mostly been used in improving medication use and adherence for certain conditions or patients, but its outcomes remain uncertain when applied to other services and to all health plan enrollees. To determine the association of participation in a California Public Employees' Retirement System (CalPERS) VBID program with its enrollees' health care spending and utilization. A retrospective cohort study with difference-in-differences propensity-weighted 2-part regression models was performed in 2021 to 2022. A VBID cohort was compared with a non-VBID cohort both before and after VBID implementation in California in 2019 with 2 years' follow-up. The study sample included CalPERS preferred provider organization continuous enrollees from 2017 through 2020. Data were analyzed from September 2021 to August 2022. The key VBID interventions include (1) if selecting and using a primary care physician (PCP) for routine care, PCP office visit copayment is $10 (otherwise, PCP office visit copayment is $35 as for specialist visit); and (2) annual deductibles reduced by a half through completion of the following 5 activities: annual biometric screening, influenza vaccine, nonsmoking certification, second opinion for elective surgical procedures, and disease management participation. The primary outcome measures included annual per member total approved payments for multiple inpatient and outpatient services. The 2 compared cohorts of 94 127 participants (48 770 were female [52%]; 47 390 were younger than 45 years old [50%]) had insignificant baseline differences after propensity-weighting adjustment. The VBID cohort had significantly lower probabilities of inpatient admissions (adjusted relative odds ratio [OR], 0.82; 95% CI, 0.71-0.95), and higher probabilities of receiving immunizations (adjusted relative OR, 1.07; 95% CI, 1.01-1.21) in 2019. Among those with positive payments, VBID was associated with higher mean total allowed amounts for PCP visits in 2019 and 2020 (adjusted relative payments ratio, 1.05; 95% CI, 1.02-1.08). There were no significant differences for inpatient and outpatient combined totals in 2019 and 2020. The CalPERS VBID program achieved desired goals for some interventions with no added total costs in its first 2 years of operation. VBID may be used to promote valued services while containing costs for all enrollees.

Differences in Telehealth During COVID-19 Between Commercial and Medicaid Enrollees

To compare how in-person evaluation and management (E&M) visits and telehealth use differed during the COVID-19 pandemic between commercially insured and Medicaid enrollees, and to assess how insurance plan type-fee-for-service (FFS) vs managed care (MC)-and enrollee characteristics contributed to these differences. Retrospective cohort analysis of 2019 and 2020 data from the commercially insured California Public Employees' Retirement System (CalPERS) and the California Medicaid program (Medi-Cal). We conducted unadjusted comparisons of per capita E&M visits and the share of visits conducted via telehealth by payer (CalPERS vs Medi-Cal) and plan type (FFS vs MC). We estimated linear regressions of telehealth use that adjusted for patient demographics, rurality, and internet access. Among Medi-Cal enrollees, we examined telehealth use differences based on race, language, and citizenship status. Regression-adjusted share of telehealth visits as a proportion of all E&M visits was 22.6% for CalPERS FFS patients (the reference group), 38.2% for Medi-Cal FFS patients, 46.0% for Medi-Cal MC patients, and 53.5% for CalPERS MC patients. Among Medi-Cal enrollees, telehealth use as a share of all E&M visits was higher among Spanish speakers, female enrollees, and rural enrollees. Across most demographic characteristics, Medi-Cal patients enrolled in FFS were less likely to receive telehealth compared with those enrolled in MC. During the first year of the COVID-19 pandemic, California MC enrollees had higher rates of telehealth use compared with FFS enrollees, regardless of insurer. Among FFS enrollees, those enrolled in Medicaid had higher rates of telehealth use compared with those insured by CalPERS. Telehealth policies should be aware of this heterogeneity, as well as its implications for equity of telehealth access.

Understanding the distributional impacts of health insurance reform: Evidence from a consumer cost-sharing program.

We examine the heterogeneous effects of reference pricing, a health insurance reform introduced by the California Public Employees' Retirement System (CalPERS), on the distribution of spending by patients and insurers. Using medical claims data for CalPERS and a comparison group not subject to reference pricing, we use the changes-in-changes approach to estimate the quantile treatment effects of the program across different medical procedures. We find that the quantile treatment effects vary across the patient spending distributions, with a range of positive and negative estimates of the QTE, depending on the medical procedure considered. However, across all procedures, the insurer's spending distributions tend to shift left, with the largest reductions occurring in the right-tail of the spending distributions. These effects are not captured by mean estimates but have important policy implications.

Impact of a commercial accountable care organization on prescription drugs.

To determine the long-run impact of a commercial accountable care organization (ACO) on prescription drug spending, utilization, and related quality of care. California Public Employees' Retirement System (CalPERS) health maintenance organization (HMO) member enrollment data and pharmacy benefit claims, including both retail and mail-order generic and brand-name prescription drugs. We applied a longitudinal retrospective cohort study design and propensity-weighted difference-in-differences regression models. We examined the relative changes in outcome measures between two ACO cohorts and one non-ACO cohort before and after the ACO implementation in 2010. The ACO directed provider prescribing patterns toward generic substitution for brand-name prescription drugs to maximize shared savings in pharmacy spending. The study sample included members continuously enrolled in a CalPERS commercial HMO from 2008 through 2014 in the Sacramento area. The cohort differences in baseline characteristics of 40483 study participants were insignificant after propensity-weighting adjustment. The ACO enrollees had no significant differential changes in either all or most of the five years of the ACO operation for the following measures: (1) average total spending and (2) average total scripts filled and days supplied on either generic or brand-name prescription drugs, or the two combined; (3) average generic shares of total prescription drug spending, scripts filled or days supplied; (4) annual rates of 10 outpatient process quality of care metrics for medication prescribing or adherence. Participation in the commercial ACO was associated with negligible differential changes in prescription drug spending, utilization, and related quality of care measures. Capped financial risk-sharing and increased generics substitution for brand names are not enough to produce tangible performance improvement in ACOs. Measures to increase provider financial risk-sharing shares and lower brand-name drug prices are needed.

Physician and Patient Adjustment to Reference Pricing for Drugs

Reference pricing has been shown to reduce drug spending in Europe and has been adopted by some employers and labor unions in the United States. Its association with patient cost sharing depends on whether and how quickly physicians adjust their prescribing patterns to favor the least costly alternatives within each therapeutic class. To examine whether the implementation of reference pricing is associated with physicians and patients shifting to lower-cost drugs, thereby reducing consumer cost sharing and the prices paid by employers. This economic evaluation included employees of Catholic organizations who purchased health insurance through the Reta Trust and a random sample of employees of public sector organizations who purchased insurance through the California Public Employees' Retirement System (CalPERS) as a comparison group between July 1, 2010, and December 31, 2017. Data analysis was performed from January 1, 2019, to September 1, 2019. The Reta Trust implemented reference pricing in July 2013; CalPERS did not adopt reference pricing during the study period. Probability that the drug prescribed was the least costly alternative within its therapeutic class, price paid per prescription, and patient cost sharing per prescription. Multivariable, difference-in-differences regression analysis of drug insurance claims was performed for patients before and after implementation of reference pricing, adjusted for patient characteristics, each drug's therapeutic class, and the month and year of the prescription. During the study period, a total of 1.2 million prescriptions were submitted by 34 319 individuals covered by Reta Trust and 2.1 million prescriptions were submitted by 738 159 individuals covered by CalPERS. In the first 2.5 years after implementation of reference pricing, the percentage of prescriptions made for the low-priced drug within each therapeutic class increased by 5.1 percentage points (95% CI, 1.8 to 8.4 percentage points), patient cost sharing increased by 10.3% (95% CI, -1.6% to -23.6%; this difference was not statistically significant), and prices paid decreased by 19.1% (95% CI, -30.2% to -6.2%) for Reta Trust patients compared with CalPERS patients. During the subsequent 2-year postimplementation period, the percentage of prescriptions made for the low-priced drug increased an additional 6.2 percentage points (95% CI, 2.3 to 10.1 percentage points), patient cost sharing decreased by 21.3% (95% CI, -31.2% to -9.9%), and prices paid increased by 7.2% (95% CI, -12.6% to 31.4%; this difference was not statistically significant). Relative to the change experienced by the CalPERS population, during the study period, the share of prescriptions for lower-priced drugs increased by 6.3 percentage points (8.9% relative increase), the mean prescription drug price decreased by $9.5 (12.1% relative decrease), and the mean patient cost sharing decreased by $1.8 (4.3% relative decrease). In this study, reference pricing was associated with a combination of lower prices paid by employers and lower cost sharing by employees but with a time lag in prescribing habits by physicians.

Divestment as an ESG Tool: Calpers and Tobacco Stocks (a)

This case uses the California Public Employees' Retirement System (CalPERS) to set the stage for unfolding an analysis of economics and values in the decision to divest tobacco stocks and bonds from the internally managed portion of the CalPERS portfolio. Written from public sources, it offers a discussion about fiduciary responsibility for long-term retirement security and investment policies around environmental, social, and governance (ESG) strategies for the public pension fund. The material includes financial data that further allows calculations and discussion on tobacco investments outperforming the broader market. This A case opens with the CalPERS investment committee having made a decision to recommend removing tobacco investment restrictions. The CIO reflects on whether supporting investment in tobacco firms conflicts with CalPERS's member health and health care mission. Did supporting continued divestment mean CalPERS was putting its own social priority and ideals ahead of its clients' investment goals? The case data should lead most to conclude the fund was breaching its fiduciary duty. Excerpt UVA-F-1948 Rev. Jan. 22, 2021 Divestment as an ESG Tool: CalPERS and Tobacco Stocks (A) As he prepared for the December 2016 Investment Committee meeting, Ted Eliopoulos was conflicted. As the chief investment officer (CIO) of the California Public Employees' Retirement System (CalPERS), he oversaw an investment office of over 300 employees and was responsible for investment policies, risk management, corporate governance standards, and environmental, social, and governance (ESG) strategies for the public pension fund. At a time when some worried that the rising numbers of California retirees put significant burdens on pension funds, Eliopoulos was under pressure to shore up long-term retirement security while also staying true to the state's ESG principles. He knew this would require some difficult decisions. California's promise to pay pension benefits in future decades entailed a fiduciary obligation to ensure that as market conditions changed, the balance between risk and return on CalPERS's investments was appropriate. In 2014, CalPERS had initiated an investment strategy review under the Policy Revision Project, and by the spring of 2016, this had led the investment committee to revisit the organization's restrictions around tobacco investments. Over 15 years earlier, tobacco stocks and bonds had been divested from the internally managed portion of the CalPERS portfolio, though they were still permitted in externally managed portfolios. The belief at the time was that the tobacco industry would not survive the heavy regulation headed its way, nor would it recover from the immense litigation against tobacco companies. Despite these threats, by 2016 the tobacco industry had outperformed the broader market substantially, with significant cumulative returns. . . .

Impact of Reference Pricing on Cost and Quality in Total Joint Arthroplasty.

Prices for total joint arthroplasty vary widely. Insurers have experimented with reference-based benefit designs (reference pricing) to control costs by setting a contribution limit that covers lower-priced facilities but necessitates higher out-of-pocket payments at higher-priced facilities. The purpose of this study was to evaluate the impact of reference pricing on the cost and quality of care for total joint arthroplasty. The California Public Employees' Retirement System (CalPERS) implemented reference pricing for total joint arthroplasty in January 2011. We obtained data on 2,023 CalPERS patients who underwent total joint arthroplasty from January 2009 to December 2013 and comparison group data on 8,024 non-CalPERS patients from the same time period. Trends in 9 cost and quality-related metrics were compared between the CalPERS group and the comparison group: patient choice of a lower-priced hospital, insurer payment, consumer payment, 90-day complication rate, 90-day readmission rate, annual surgical volume of the chosen hospital, length of stay, travel distance, and rate of discharge to home. The impact of reference pricing was estimated with difference-in-differences multivariable regressions, adjusting for covariates. An increase of 19 percentage points (95% confidence interval [CI], 13.0 to 25.6 percentage points; p < 0.01) in the selection of lower-priced hospitals was attributable to reference pricing, with a concurrent mean savings for the insurer of $5,067 (95% CI, $2,315 to $7,819; p < 0.01) and an increase in the mean patient out-of-pocket payment of $1,991 (95% CI, $1,053 to $2,929; p < 0.01). No significant change in any quality indicator was attributable to reference pricing, with the exception of an 8% reduction (95% CI, 3.3% to 12.7% reduction; p < 0.01) in the length of stay for hip replacement. Reference pricing motivates patients to choose lower-priced hospitals for total joint arthroplasty, with no measurable adverse impact on quality. Reference pricing represents a viable strategy in the shift toward value-based care.

Reference-Based Benefits for Colonoscopy and Arthroscopy: Large Differences in Patient Payments Across Procedures but Similar Behavioral Responses.

This study examines how reference-based benefits (RBB) affect patient out-of-pocket payments across outpatient procedures. The California Public Employees' Retirement System (CalPERS) implemented RBB asymmetrically for outpatient procedures in 2012, only applying RBB to outpatient procedures performed in a hospital outpatient department (HOPD), and not applying RBB to outpatient procedures performed in a lower cost ambulatory surgery center. Using claims data (2009-2013) on arthroscopy and colonoscopy services, we found that for colonoscopy, CalPERS patients paid an average of 63.9% (p < .01) more for HOPDs than ambulatory surgery centers in 2012. For arthroscopy, no statistically different cost sharing was found on average. However, high-priced HOPDs were 17.3% and 17.9% less likely to be chosen by CalPERS patients in 2012 for colonoscopy and arthroscopy, respectively. These magnitudes increased in 2013 to 25.2% and 24.2% less, respectively. Overall, responsiveness to RBB with regard to the most expensive HOPDs was similar despite varying cost sharing by procedure.

The moral hazard effects of consumer responses to targeted cost-sharing

This paper examines the effects of the reference pricing program implemented by the California Public Employees Retirement System (CalPERS) in 2012. The program uses targeted cost-sharing to incentivize patient price shopping. We find that the program leads to a 10.3% increase in the use of low-price providers and reduces the average cost per procedure by 12.5%. We further estimate that the program reduces medical spending by $218.8 per procedure, which we estimate is approximately 53.7% of the excessive spending that is due to patient choice of higher price providers caused by insurance coverage, at the expense of a $94.3 (or 12.5%) reduction in consumer surplus. The cost savings from the reference pricing program is about two to three times as large as the reduction from implementing a high-deductible health plan, while the accompanying consumer surplus reduction is much smaller under reference pricing.

Does shareholder activism improve operating performance of targeted companies: a re-examination of CalPERS' focus list program

This paper examines the effectiveness of California public employees' retirement system (CalPERS)' activism on improving operating performance of companies targeted by its Focus List program over the 1992-2009 period. We find that operating performance of the Focus List firms, through various measures, improved significantly over the 2 years subsequent to being targeted by CalPERS. The empirical evidence suggests that CalPERS' activism is more effective in improving the targeted firms' operating performance than previously recognised in the literature.

Benchmarking the Worlds Leading Pension Funds: How Fares the Government Service Insurance System of the Philippines

This practical research looks into the application by the government service insurance System (GSIS) of the Philippines of responsible investment strategies espoused in the delivery of social security benefits by the leading public pension funds in the world. Two of these, namely the ABP (Stichting Pensioenfonds) of The Netherlands and the California public employees’ retirement system (CalPERS) of the USA, are in focus here. This study was undertaken to highlight the performance of the GSIS Pension Fund as a business case and to evaluate the sustainability of the GSIS fund management practices vis-a-vis responsible investment strategies that have been espoused by the leading pension funds of the world.

Impact of Economic Incentives on Patient Selection of Surgical Facility: Commentary on an article by James C. Robinson, PhD, et al.: "Consumer Choice Between Hospital-Based and Freestanding Facilities for Arthroscopy. Impact on Prices, Spending, and Surgical Complications".

Because of pressures to contain health-care-related costs, the proportions of procedures performed in the outpatient setting continue to increase across the surgical subspecialties. Correspondingly, advancements in anesthesia and surgical technique have further enabled this shift in the operative setting. Similarly, the frequency of outpatient orthopaedic procedures continues to increase1 because of greater operating room efficiency, decreased overhead costs, and lower risk of nosocomial complications. In their article, Robinson et al. utilize insurance claims data from the California Public Employees’ Retirement System (CalPERS) to assess the impact of reference-based benefits on consumer selection of the surgical facility (hospital outpatient departments compared with freestanding ambulatory surgery centers) for knee or shoulder arthroscopy. By implementing reference-based benefits, patients are required to pay the difference in costs if they elect to undergo surgery at a higher-priced facility. The …

Shifting From Volume to Value: Opportunities and Challenges for the Field of Orthopaedic Surgery.

Shifting From Volume to Value: Opportunities and Challenges for the Field of Orthopaedic Surgery.

Reference-based benefit design changes consumers' choices and employers' payments for ambulatory surgery.

Some employers are using reference-based benefit (RBB) designs, also known as "reference-based pricing," to encourage patients to select lower-price ambulatory surgery centers instead of expensive hospital outpatient departments. This article analyzes the impact of such benefit designs for cataract removal surgery from the period 2009-13, using data on 2,347 surgical patients covered by the California Public Employees Retirement System (CalPERS), in comparison to 14,867 patients enrolled in non-CalPERS Anthem Blue Cross plans, which are not covered by RBB. After adjusting for changes in patient case-mix and other factors, the shift to RBB was associated with an increase in ambulatory surgery center use by 8.6 percentage points compared to trends among Anthem enrollees. Total employer and employee payments per procedure, after adjusting for changes in case-mix severity and market factors, declined by 19.7percent compared with Anthem enrollees not subject to RBB. Consumer cost-sharing requirements increased for CalPERS patients who continued to use hospital outpatient departments but who were not exempted from RBB because of geographic or clinical factors. Reference-based benefits for cataract surgery saved CalPERS $1.3million in the two years after implementation.

Backtested Pension Math: An Empirical Look at the Causes of CalPERS Underfunding

This article takes an empirical look backward to identify causes of the current underfunding of public-sector pension plans administered by the California Public Employees Retirement System (CalPERS). It studies six CalPERS plans using actuarial valuation reports from the past eighteen years. It finds, contrary to conventional wisdom, that investment return played only a minor role in the current underfunding. The primary cause was that annual required contributions were too small to provide full funding. In particular, the normal rate of contribution could not have kept up with the actual growth in liabilities, even had investments performed exactly as assumed. The article proposes that actuarial valuations include a comparison of ex ante versus ex post normal rates, meaning the normal rate that was used to determine the annual required contribution (ex ante) versus the normal rate that in hindsight would have been correct (ex post). Such a comparison would allow stakeholders to directly understand the past accuracy of a plan’s actuarial forecast. <b>TOPICS:</b>Pension funds, legal/regulatory/public policy

Calpers Absolute Return Strategies: Hedge Fund Risk and Return

This case is suitable for students in both undergraduate and MBA-level investments courses. With an estimated $3 trillion in assets under management, hedge funds have become an important component of many institutional investors' portfolios. For many of these investors, investments in these funds are motivated by the potential for diversification combined with equity-like and bond-like risk. At the same time, the difficulty of appropriately benchmarking hedge fund returns and risk, in addition to the high fees associated with these funds, has some investors questioning their decision to invest in these strategies. Using CalPERS's April 2014 reexamination of its Absolute Return Strategies/hedge fund investments as a backdrop, this case examines the decision to invest in hedge funds as a part of a well-diversified institutional portfolio. Excerpt UVA-F-1735 Jun. 29, 2015 CalPERS Absolute Return Strategies: Hedge Fund Risk and Return The California Public Employees' Retirement System (CalPERS) headquarters near the Sacramento River was as beautiful as it was functional. With courtyards and terraces, beautiful landscaping, an architecturally stunning glass-and-steel entry pavilion, and a soaring glass atrium that flooded the building with natural light, it appeared to be as tranquil a work setting as the Zenlike spaces that dotted its interior and exterior. In the spring of 2014, however, internal sources suggested that a storm was brewing within the building over CalPERS's hedge fund investments. Two of CalPERS's most senior investment professionals, Curtis Ishii and Egidio “Ed” Robertiello, disagreed strongly about the future of these investments. Hedge funds had been a part of CalPERS's portfolio for 22 years, but there was a strong push by Ishii, the senior investment officer responsible for fixed income, to eliminate CalPERS's allocation to Absolute Return Strategies (ARS). In addition to the high fees CalPERS was paying to hedge fund managers, Ishii was convinced that hedge fund investments were an unacceptable risk for the pension fund. On the other hand, Robertiello, the senior portfolio manager for ARS, believed that the ARS allocation should be almost tripled. Robertiello argued that not only would an increased allocation to hedge funds help to diversify CalPERS's portfolio generally, but that hedge funds offered better downside protection than equities. . . .

Hedge Funds: Where Investors Get It Wrong (and Right)

The decision by the California Public Employees’ Retirement System (CalPERS) and other institutional money managers to eliminate or drastically reduce their investments in hedge funds has again raised the suggestion that hedge fund investment is a poor choice for both institutional investors and individuals alike. The reasons given are generally twofold: Hedge funds have not performed up to expectations and the related costs (fees and due diligence) and external perception (public acceptance) are not worth the effort of investing in them.

When does CalPERS’ activism add value?

The California Public Employees’ Retirement System (CalPERS) is a pioneer of shareholder activism and a leading proponent of governance reform among public pension funds. We examine factors (such as board structure, ownership structure, past performance, and size of target firms, as well as proposed governance reform) that may be associated with the value of CalPERS’ activism. The results can be useful in guiding institutional governance efforts in the future. The results show that poor prior performance, smaller firm size, and a larger board are associated with greater announcement period returns. In addition, there is weak evidence of greater announcement returns when the board includes a greater number of insiders, CEO ownership is high, and director and officer (excluding CEO) ownership is low.

Increases In Consumer Cost Sharing Redirect Patient Volumes And Reduce Hospital Prices For Orthopedic Surgery

Some employers are implementing reference-pricing benefit designs, which establish limits on the amount they will pay for some procedures covered by employer-sponsored insurance. Employees are required to pay the difference between the employer's contribution limit and the actual price received by the hospital. These initiatives encourage patients to select low-price facilities and indirectly encourage facilities to reduce prices to increase patient volume. We evaluated the impact of reference pricing on the use of and prices paid for knee and hip replacement surgery by members of the California Public Employees' Retirement System (CalPERS) from 2008 to 2012, using enrollees in Anthem Blue Cross as a comparison group. In the first year after implementation, surgical volumes for CalPERS members increased by 21.2percent at low-price facilities and decreased by 34.3percent at high-price facilities. Prices charged to CalPERS members declined by 5.6percent at low-price facilities and by 34.3percent at high-price facilities. Our analysis indicates that in 2011 reference pricing accounted for $2.8million in savings for CalPERS and $0.3million in lower cost sharing for CalPERS members.

Institutional Investor Corporate Engagement Theory: An Empirical Review of the Calpers Focus List Program

The institutional investor corporate engagement theory holds that investors may use their position of ownership to monitor and engage corporations within which they are invested in order to better align managers’ interests with their interests. The financialization of pension funds has generated a group of institutional investors interested in long-term fundamental corporate value. The maintenance of long-term value often requires good corporate governance as the two are positively correlated. Institutional investors, notably pension funds, are increasingly resorting to corporate engagement initiatives to ensure that good corporate governance practices and structures are implemented within corporations in which they are invested. The California Public Employees Retirement System (CalPERS) has been a market leader in corporate engagement. The success of the CalPERS program has not yet been investigated with respect to its stated objectives. By conducting an industry-matched control group based investigation over a 15 year study period (1992-2006) it has been determined that the CalPERS corporate governance engagement program is a success. Corporations which were once financially under-performing report industry-specific average 1, 3, and 5-year shareowner returns post-engagement (p