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NDHI NAT IONAL DIALOGUE FOR Healthcare Innovation Enhanced Personal Health Care Program Organization Overview • Anthem, Inc. is one of the nation’s leading health benefits companies, offering a broad range of medical and specialty products and covering one in nine Americans’ health benefits • Anthem aims to transform healthcare with trusted and caring solutions Background The U.S. provides low-quality healthcare relative to other industrialized nations, despite spending nearly eight times the international average on delivering that care. Much of this wasteful spending is thought to originate from the misaligned financial and clinical incentives between providers and payers, which has ultimately led to low-value care for patients. As a result, policymakers are seeking to shift healthcare into value-based payment (VBP) models, in which reimbursement is tied to care quality and outcomes. The U.S. Department of Health and Human Services (HHS) has published ambitious goals for implementing VBPs. By 2018, HHS expects to migrate 90% of all Medicare payments to quality- or value-based programs and at least 50% of all Medicare payments to alternative payment models. Private payers have also been rapidly transitioning to these models over the last five years. Anthem was an early adopter – today, more than 50% of commercial plan payments are linked to quality, with over 37% of payments made through alternative payment models. Anthem aims to continue expanding its VBP programs with provider systems. In order to create a collaborative approach to VBPs in primary care, Anthem established the Enhanced Personal Healthcare (EPHC) program. Program Details EPHC has three main goals: 1. Support providers’ transition to VBP by providing financial, clinical, and analytic support as well as contract flexibility based on system sophistication 2. Improve patients’ quality and experience of care, as well as their health status and outcomes 3. Slow the growth of total cost of care, in order to ensure the affordability of high-value coverage To participate, EPHC providers agree to: • Provide 24/7 access to members through extended hour and/or after hours call coverage • Have a dedicated position within their practices that supports participation in EPHC and practice transformation • Participate regularly in collaborative learning sessions and use support tools, such as hot-spotting reports, to identify gaps in care • Use a disease registry to manage care for patients with certain chronic conditions and engage in care planning for the high-risk population • Use generic prescription drugs when clinically appropriate • Engage in quality and performance measurement, and meet appropriate performance standards on nationally endorsed quality measures While the program design is flexible, most providers receive: • Upfront clinical coordination payments, to offset the costs of care coordination and program imple- An Initiative of the 5 | Enhanced Personal Health Care Program
NDHI NAT IONAL DIALOGUE FOR Healthcare Innovation mentation and enable investments into necessary technological resources for care coordination Value of EPHC in Year One (2013-2014) • Access to online tools and resources • Support from Transformation Teams that work onsite with providers to establish action plans, identify high risk patients, and interpret data • Actionable clinical data for care coordination, through a web-based application Providers are eligible to receive 30-35% of the shared savings generated when their attributed members’ care is less costly than projected and when quality of care is maintained or improved over a 12-month performance period. Some EPHC providers are moving into true risk-sharing agreements, sharing up to 50% of either care savings or excess costs. Value Delivered The Enhanced Personal Healthcare Program has: • Garnered participation from more than 54,000 providers, including more than 44% of primary care physicians who contract with Anthem plans • Delivered value-based care to approximately 4.6 million patients • Improved patient-centric care: Patients seen by providers in EPHC reported higher care quality, preventive service use, access to care, and overall experience • Decreased patient costs: EPHC patients had lower per-member, per-month costs than those seen by non-participating providers • Shared best practices and results publicly to improve care delivery Path Forward As VBP programs become more widespread,their evaluation will also become more complex. Anthem believes that the healthcare system must solve several challenges to ensure appropriate VBP program evaluation: • Identification of appropriate comparison groups • Isolation of savings drivers • Determination of program value to purchasers, such as health plans and employers Based on the early results of EPHC, Anthem proposes that policymakers: • Extend VBP models to a broader range of provider types, with increasing risk-bearing opportunity over time • Expand on private-sector VBP programs and other care delivery innovations to promote rapid national adoption of Alternative Payment Models (APMs) • Encourage collaborations between providers, health plans, and other stakeholders to use existing platforms in order to transition to VBPs Enhanced Personal Health Care Program | 6
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