Anthem - Enhanced Personal Health Care

Description: 

Accountable Care Organizations (ACOs) and Patient Centered Medical Homes (PCMHs) operate under Anthem’s Enhanced Personal Health Care framework.  Based on the lessons and results of the ACO and PCMH pilots, Anthem launched Enhanced Personal Health Care in 2013 which represents its comprehensive, long-term strategy to migrate from a volume-based to a value-based health care model by augmenting traditional fee-for-service payments with a shared savings program that enables participating providers to share in any achieved savings (when actual health care costs are below projected costs) provided that they meet threshold performance on quality and utilization measures.  Enhanced Personal Health Care covers commercial, Medicare and Medicaid lines of business, fully insured and self-insured clients and is applicable to any provider organization with a foundation in primary care (ACOs; PCMHs; IPAs; IDNs; small, independent PCPs and hospitals). 

Enhanced Personal Health Care provides a standard framework and set of principles that guide Anthem's engagement with all provider organizations, starting with provider organizations with a foundation of primary care.  What will vary based on provider type and capabilities are the tools, resources and services that each party contributes to the arrangement. Anthem meets providers where they are and provides them with the tools/support they need to adopt a patient centered model that improves patient engagement, optimizes the health of the population and reduces medical cost trend.   As a result, providers are empowered to address the fragmentation, lack of coordination and barriers to access that drive redundant care, avoidable admissions and avoidable ER visits.

To move away from highly fragmented, episodic health care toward a patient centered model that is proactive, holistic, efficient and focused on the health and well-being of each patient, Enhanced Personal Health Care focuses on the following core principles:

  • Risk-stratified care management
  • Coordination of care across the continuum
  • Shared decision-making and accountability between physicians and their patients/caregiver
  • Ensured access
  • Promotion of wellness and prevention
  • Measuring and monitoring compliance with evidence based guideline

Performance Evaluation:

The shared savings bonus payment component of this program rewards providers for successful management of the quality and overall health care costs of our participating members.  To qualify for shared savings, providers must first meet cost targets.  If these targets are met AND providers meet a quality threshold, they are eligible to receive a portion of the shared savings.  If the provider does not meet the quality threshold, the provider is not entitled to share savings bonuses, regardless of savings generated.

We leverage nationally recognized measures of quality to support our shared savings framework for our risk sharing arrangements.  These include measures endorsed by the NQF, CMS (e.g., the CMS Accountable Care Organization set, the Medicare Stars Scorecard) and metrics adopted by nationally recognized specialty societies.  The program currently includes 29 quality metrics (listed individually below) across the following categories:

  • Preventative care, including cancer screening, childhood immunization and well child visits
  • Acute and chronic care, including diabetes-related measures such as Hba1c and lipid profile testing, and monitoring persistent medication

The Enhanced Personal Health Care program also includes three utilization metrics that impact the level of payment: avoidable ER visits, ambulatory sensitive inpatient admissions, and generic drug dispensing rate. 

Payment Model: 

Enhanced Personal Health Care provides incentives for high-quality, coordinated and efficient care by through the following augmentations to a typical fee-for-service arrangement:

Shared Savings: 

The measures in Anthem's shared savings program are based on nationally accepted, credible standards (e.g. NCQA HEDIS, the American Diabetes Association and the American Academy of Pediatrics), and span preventive, acute and chronic care as well as health care utilization/efficiency measures (e.g., ambulatory sensitive hospital admissions, ambulatory sensitive emergency room visits, percentage of generic drug prescribing). Furthermore, the level of shared savings earned is tiered based on the provider’s performance on the program’s quality measures, allowing larger payouts for performance above the threshold.  Beyond measuring cost, quality and utilization, Anthem also tracks engagement rates of attributed members in care and disease management programs.  While this program is open to practices at all levels of care management sophistication, continued participation in this program is contingent on provider performance.

Care Coordination Payments: 

In certain cases, Anthem provides care coordination payments to compensate providers for a broad range of clinical interventions that do not have a CPT code and occur outside transitional office visits. These services could include care planning, maintaining health registries, enhancing access (e.g., responding to emails or offering web-based visits) or following up with patients via phone or e-mail to make sure that they fill new prescriptions. This type of proactive clinical coordination improves health and reduces costs.

Shared Risk: 

Several arrangements are in place today that moves to shared risk with many more discussions with providers underway to incorporate or move to shared risk

More advanced organizations, such as ACOs, who are willing and able to take on increased accountability for the quality and cost of care they deliver are also responsible for:

  • Moving from our aligned care management model to our collaborative care management model under which they assume  primary responsibility for care planning and care management with support from Anthem resources for more complex patients
  • Participating in bi-directional data exchange that includes sharing clinical data for outcome measurement as well as data integration and enrichment to create a single longitudinal patient record. 
Last updated February 2015
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