provider collaboration: leading the way to a sustainable...

Provider Collaboration: Leading The Way To A Sustainable Future

COMPANY CONFIDENTIAL | DO NOT COPY

Presented By: Colin DrozdowskiVice President, National Provider Solutions

The Health Care System Today

Payer/Provider Dynamics (Historical)

- Lack of trust

- Payer wins and provider loses

- Provider wins and payer loses

- Payment for activity (not value)

- Lack of alignments (incentives) with patient, provider, and payer

- Episodic nature of the relationship: not an ongoing partnership

Lack of Trust (illustration #1)

Lack of Trust (illustration #2)

Current State of Our Healthcare System: Accountable Care Act

Landscape of Anthem Payment Innovation

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2,250 designations Blue Distinction Centers of Excellence

800 hospitals>75% of Commercial inpatient admissions

Hospital Payment for Quality and Safety

4.0 million membersAttributed to Anthem’s Enhanced Personal Health Care Program

54,000 providersIn Enhanced Personal Health Care Program and Comprehensive Primary Care Initiative Contracts

146 health systems Accountable Care Organizations

All value-based contracts $50B; 53% of total medical spend

April 2015

Quality Hospital In-Sights Program (QHIP)

COMPANY CONFIDENTIAL | DO NOT COPY 8

Q-HIP® (Quality Hospital In-Sights Program)

• Evidence-based standards from national organizations

• ≈ 800 hospitals participating

• Covers 76% of all admissions

• 47 performance measures

• Average 3% reimbursement

increase for achieving Q-HIP quality, safety, and satisfaction thresholds

Quality Based Reimbursement

55%Patient Health Outcomes

35%Patient Safety

10%Member

Satisfaction

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Hospital Quality: Q-HIP® Hospital Quality Program

Q-HIP® Hospital Pay-for-Performance rewards quality, safety, outcomes, and patient satisfaction

Patient Safety Section(35% of total Q-HIP® Score)

• Computerized Physician Order Entry (CPOE) Adoption (Stage 1 Meaningful Use Criteria)

• IHI Improvement Map – Medication Reconciliation

• WHO Surgical Safety Checklist

• NQF Recommended Safe Practices

• NQF Emergency Care Standards

• NQF Perinatal Measures

Member Satisfaction Section(10% of Total Q-HIP® Score)

• H-CAHPS Survey Results

Patient Health Outcomes Section(55% of total Q-HIP® Score)

PCI Indicators

• 4 ACC-NCDR/Indicators for Cardiac Catheterization/PCI

Joint Commission/CMS Nat’l Hospital Quality Measures

• Acute Myocardial Infarction (AMI) Indicator

• Heart Failure (HF) Indicator

• Pneumonia (PN) Indicators

• Surgical Care Improvement Project (SCIP) Measures

NSC Indicators

• 4 JC/NQF Nursing Sensitive Care Indicators

CABG Indicators

• 4 STS Coronary Artery Bypass Graft (CABG) Measures

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Enhanced Personal Health Care (EPHC)


Understanding the EPHC Model


Attribution:

Algorithm to assign members to PCPs

Medical Cost Target

Determines eligibility for shared savings

Quality Score Card

Calibrates shared savings eligibility

Clinical Coordination Payments

Support investment in population health

management Provider Care Management

SolutionsPopulation health analytic

support

Care Delivery Transformation

Team and resources for performance improvement

Enhanced Personal Health

Care

Developing Medical Cost Targets;Measuring Medical Cost Performance


MCT (Medical Cost Target)

Risk Score Normalization

Trend Adjustments

Adjustments for High Cost Claims

Baseline Claims Data

MCP (Medical Cost

Performance)

Risk Score Normalization

Adjustments for High Cost Claims

Performance Period Claims DataMCT

MCP

Accountable for QualityEPHC Commercial Scorecard Metrics and Weighting

.

60%

40%

Determines Eligibility for Shared Savings Proportion

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Helping Providers Thrive in the World of Value-based Care


InformationStandard reports and advanced analytics

Risk stratificationIdentification of gaps in care

Resources

Dedicated local support

Assistance on getting the most from data and tools

Guidance on Anthem Care Management resources

Tools

PCMS

MMH+

Practice Advisor

Toolkits for Enhanced Care Management

Provider Care Management Solutions (PCMS)

Performance Management

Population Management

• Alerts, icons, hover overs, drop downs, and drill-through to support population health management

• Supports workflows around care gap closure, utilization management, readmission prevention, and care coordination

• Ability to filter patient population by key conditions, risk factors, gaps in care, and visit history

• Integrated and dynamic financial scorecard to help identify most actionable performance measures

• Offers drill down capability into scorecard, to identify actionable opportunities (e.g. specific providers and/or members) that will improve organization’s financial performance

• In development: cost and utilization trends around impactful types of service

Simple, Actionable, and Relevant

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Anthem’s Approach to Care Delivery Transformation


Step 1 Step 2 Step 3 Step 4

Engage

practice

Provide Practice with

Tools of Transformation

Assess Practice

Transformation

Capabilities

Provide

targeted coaching

Welcome Packet

Intro Visits

Collaborative Learning

Reports and Data

Practice Advisor

Virtual Tool Kit

Cost of Care Resources

Transformation Action Plan

(TAP)

Intervention Bundles

Collaboratively establish

Smart Goals and targeted

Learning Plans

Teach QI skills, reliable work

flows and use of data

Teach skills for Care

Coordination and Care

Management

Function as external

consultant on roadblocks and

obstacles

Provide feedback on

progress

Anthem program experience from year one

*Cohort 1 (3/1/14) gross savings

*Gross savings before provider gain share. Net savings is gross savings less care coordination and shared savings payments, but includes RX; Combined results for Physician Cohorts A & B 2013-2014

Results from Anthem Enhanced Personal Health Care program Year 1

Cost of care

Quality

Member experience

Gross Medical allowed PaMPM decreased by $9.51 compared to matched sample

control group; net savings of $6.62*

Anthem EPHC providers performed better on quality measures than providers outside the program across

all 5 of our prevention and chronic condition management quality bundles

Anthem EPHC members report better access to

urgent care, better communication with

providers, and higher satisfaction with the amount of time they spent with their doctors


EPHC Delivers Cost of Care Savings

* Gross savings before provider gain share. Net savings is gross savings less care coordination and shared savings payments, but includes RX; Combined results for Physician Cohorts A & B 2013-2014

Results from Anthem Enhanced Personal Healthcare program year 1

Anthem Year 1 Results

7.8% feweracute inpatient admits per 1,000

5.1% PaMPM decreasein outpatient surgery costs

5.7% fewerinpatient days per 1,000

7.4% decreasein acute admissions for high risk patients, and an increase of 22.9 per 1,000 PCP visits for high risk patients

3.5% PaMPM decreasein ER visit costs and a 1.6% decrease in ER utilization

$9.51PaMPM GROSS SAVINGS

OVER THE FIRST YEAR(3.3%)

NET SAVINGS

$6.62


Anthem’s EPHC Program Physicians Offer Superior Quality

77.1%

84.2%

77.9%

86.7%

63.4%

72.7%

79.5%

73.6%

82.8%

53.8%

Adult Prevention Annual Monitoring forPersistent Meds

Diabetes Care Other Acute & Chronic CareMeasures

Pediatric Prevention

EPHC

Non-EPHC

Data from Q4 2014

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Additional Questions?


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