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Covered California, the state鈥檚 health insurance marketplace under the Affordable Care Act, has devised what could be a powerful new way to hold hospitals accountable for the quality of their care. Starting in less than two years, if the hospitals haven鈥檛 met targets for safety and quality, they鈥檒l risk being excluded from the 鈥渋n-network鈥� designation of health plans sold on the state鈥檚 insurance exchange.

鈥淲e鈥檙e saying 鈥榯ime鈥檚 up,鈥欌�� said聽, the chief medical officer for Covered California. 鈥淲e鈥檝e told health plans that by the end of 2019 we want networks to only include hospitals that have achieved that target.鈥�

Here鈥檚 how hospitals will be measured: They must perform fewer unnecessary cesarean sections, prescribe fewer opioids and cut back on the use of imaging (X-rays, MRIs and CT scans) to diagnose and treat back pain. Research has shown these are problem areas in many hospitals 鈥� the procedures and pills have an important place, but have been overused to the point of causing patient harm, health care analysts said.

C-sections, in particular, have come under scrutiny聽.

Hospitals get paid more to perform a C-section than a vaginal delivery and C-sections usually take less time: 40 minutes for a scheduled procedure versus 24-hour on-call staffing for vaginal deliveries. Many women who don鈥檛 need a C-section聽聽according to the data 鈥� and rates vary by hospital. Even in low-risk cases, several California hospitals are delivering 40 percent of babies by C-section, Lang said. At one hospital, it鈥檚 78 percent.

鈥淭hat means that when a woman goes to a hospital, it鈥檚 the culture of the hospital that really determines whether or not she gets a cesarean section, not so much her own health,鈥� said Lang.

C-sections are major surgery. Doing them when they鈥檙e not needed exposes women to unnecessary risks: infection, hemorrhage, even death. Babies delivered by C-section are more likely to聽聽and spend more time in the neonatal intensive care unit.

That鈥檚 not quality health care, Lang said, and that鈥檚 why Covered California is telling hospitals they need to reduce their C-section rates to 23.9 percent or lower, for low-risk births.

In this case, 鈥渓ow-risk鈥� is defined as a healthy, first-time mom who has carried a single baby with its head down, all the way to full term 鈥斅�.

, the state health program for low-income residents,聽, the retirement program for state employees, and the聽, which represents self-insured employers, are also calling on hospitals to improve their quality measures. Together, these groups pay for the health care of 16 million Californians, or 40 percent of the state, which gives them substantial leverage with hospitals.

But only Covered California is telling hospitals that if they don鈥檛 play by the rules, they鈥檒l be benched.

鈥淚t鈥檚 probably the boldest move we鈥檝e seen in maternity care ever,鈥� said Leah Binder, CEO of the聽, a Washington, D.C.-based nonprofit that rates hospitals on quality.

Expecting hospitals to meet external metrics for quality control is a recent phenomenon, and compliance is still largely voluntary, she said.

鈥淏ack in the 鈥�80s and 鈥�90s, nobody ever thought that hospitals should have to report to anyone on how they were doing,鈥� she said. 鈥淭here鈥檚 never been a culture of accountability.鈥�

Covered California鈥檚 move is nationally significant, Binder said, given the consequences for hospitals, and the agency鈥檚 reach 鈥� 1.4 million people buy coverage through the marketplace 鈥� and they shop among plans offered by 11 state-approved insurance companies.

Insurers and business groups across the country are already keeping an eye on California鈥檚 effort, she said, to see how they might band together to demand similar change from the hospitals in their regions.

Overall, California鈥檚 hospitals are on board with the C-section goal. Of the 243 maternity hospitals in the state, 40 percent have met the target, Lang said, and another 40 percent have taken advantage of coaching and consulting to help educate doctors on how they can adjust their practices. They鈥檙e also finding they have to educate patients who request C-sections about the procedure鈥檚 risks.

鈥淲hile many may prefer [the surgery], when having the full information about the risk that they may be putting themselves and their babies in, they elect not to move in that direction,鈥� said Julie Morath, CEO of the聽, a subsidiary of the聽. Both groups support the C-section reduction goals as 鈥渢he right thing to do,鈥� she said.

The strategy has raised some concerns among mothers who hear about the 23.9 percent target and worry about rationing.

鈥淲e don鈥檛 just chase rates,鈥� Morath said in response to that concern, 鈥渂ut rather look at what the clinical needs are and how to best respond to those. So if there is an indication for a cesarean section, the mother will receive a cesarean section.鈥�

Still, not all hospitals will find it easy to comply. State data show there are about 40 hospitals that are still far off the target, including a cluster of hospitals in East Los Angeles that treat low-income, often uninsured, patients.

鈥淚f you have somebody who is on methamphetamines and is homeless and has not gotten any prenatal care, her chance of a C-section is way higher than someone who is not all those things,鈥� said Dr. Malini Nijagal, an OB-GYN at Zuckerberg San Francisco General Hospital. 鈥淎nd so the problem is, how do you adjust for the patient population of a hospital?鈥�

At Memorial Hospital of Gardena, the C-section rate is 45.2 percent. At East Los Angeles Doctors Hospital, the rate is 48.1 percent, according to publicly available state data listed on聽听补苍诲听. Both hospitals are working diligently to lower the rates, according to Amie Boersma, director for communications for聽, which owns both hospitals.

She said the hospitals will meet the 23.9 percent benchmark and are committed to doing so for the sake of their patients. Being excluded from Covered California health plan networks, she added, would make it even more difficult for those patients to get care. They would either have to pay out-of-network fees to be seen there, or they would have to travel farther to another facility that was still in the network.

鈥淲e are in underserved, economically challenged urban neighborhoods and it is vitally important that we continue to provide appropriate, high-quality care for our communities,鈥� Boersma said.

Health plans can request an exemption from Covered California鈥檚 contract rules (in order to keep noncomplying hospitals in their networks) 鈥� as long as they document their reasoning.

鈥淭hat is flexibility that we asked for to ensure that we maintain adequate access to providers,鈥� said Charles Bacchi, CEO of the聽, a trade group for insurers. 鈥淎ny major changes to health plan networks must be filed with regulators. And health plans have to ensure that patients continue to receive services in a timely manner.鈥�

So far, the prospect of exclusion, plus the coaching for hospitals on how to reduce the rates, have functioned as an effective motivator. By 2020, Covered California鈥檚 Lang predicted, all hospitals will either have met the target or be on their way.

鈥淚t鈥檚 a quality improvement project,鈥� Lang said, 鈥渂ut with a deadline.鈥�

This story is part of a partnership that includes , and Kaiser Health News.

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