Anthem’s Investment in and Commitment to Primary Care: RIHN Cissy (Elizabeth) Kraft MD MHS FAAFP February 23, 2017 RVP Senior Clinical Officer, Colorado and Nevada Elizabeth.kraft@anthem.com ANTHEM PROPRIETARY AND CONFIDENTIAL – DO NOT COPY
Anthem’s Investment In and Commitment To Primary Care Investment in Primary Care over the years PCMH multi-payer pilot EPHC: Enhanced Personal Health Care Commitment to transformation Components: quality and utilization Anthem’s partnership and actions to preserve your shared savings Outcomes to date Appendix PC Joint Principles Sample screen shots of PCMS (patient gaps/hot spotters) Samples of ER reports 2017 webinars and seminars ANTHEM PROPRIETARY AND CONFIDENTIAL – DO NOT COPY 2
Anthem’s Investment in Primary Care Over the Years Date 2009 - 2012 2012 2014 2014 2016+ Program CO multi-payer PC2 (patient Anthem EPHC CPCi CPC+ PCMH pilot centered primary (Enhanced Personal care) Health Care) # practices/MDs 16 front range 45 practices 2550 physicians in all 42 practices 34 PCMH practices (CPCi and EPHC) value based programs Patients included Fully insured Fully insured and Fully insured and ASO Fully insured and Fully insured, ASO (no opt ASO (no opt out) (no opt out), PPO ASO (no opt out) out), PPO mandatory PCP mandatory PCP selection in small group selection in small and BlueCard group Type of program P4 (pay for PMPM with PMPM with ability to PMPM with ability PMPM with ability to earn performance) ability to earn earn shared savings to earn shared shared savings shared savings savings Measures • Preventive Acute and Acute and Chronic Acute and Chronic Acute and Chronic Care • Diabetes Chronic Care Care measures, Care measures, measures, Preventive, measures, Preventive, Utilization Preventive, Utilization and Preventive, and Improvement Utilization and Improvement Utilization and Improvement Improvement Utilization No Yes Yes Yes Yes ANTHEM PROPRIETARY AND CONFIDENTIAL – DO NOT COPY 3
Anthem’s Investment in Primary Care: CO PCMH Multi-Payer Pilot (2009 – 2012) PRACTICES Total P4P Payments: (does not include pmpm) • Belmar Fully insured membership only • Broomfield Fam Practice • Clinix • Michael Mignoli, MD 2011 total P4P payment: • Southwest PC $227,163 • Family Practice Associates • Ideal Family Healthcare 2012 total P4P payout: • Internal Med Clinic $175,691 • Lakewood Family Medicine • Lonetree Family Practice • Miramount Family Medicine • DeYoung • Mountaintop Family Health • Provident • Southpark Internal Medicine • Westminster Medical Clinic ANTHEM PROPRIETARY AND CONFIDENTIAL – DO NOT COPY 4
Anthem’s Commitment to Primary Care: EPHC (Enhanced Personal Health Care) Payment Model payment model zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA Medical Cost P r o Target Clinical Clinical v i d Coordination Coordination Establish a e r Payments Payments budget for S u p Change the Change the medical costs p Quality Score Card o payment model r t Population Establish quality Health Management expectations and tie Data and insights about results the provider’s patients to performance Attribution Enhanced Personal Care Delivery Transformation Identify the Partner throughout Health Care member’s PCP the care delivery process 5
Anthem’s Commitment to Primary Care Transformation Information Tools Resources • Risk stratification • Practice Advisor (ACP) • Dedicated local support • Analytics • Toolkits for Anthem’s EPHC • Guidance on getting the • Identification of gaps in Program most from data and tools care with drills to patient • Longitudinal Patient Record • Assistance with practice level transformation • Choosing Wisely • Avoidable ER use • Brand/generic drugs ANTHEM PROPRIETARY AND CONFIDENTIAL – DO NOT COPY 6
Anthem’s Commitment to Primary Care Transformation RIHN Dedicated Other Resources Care Consultant • Work flow and process • Helps practices develop care • Pharmacist : Supports pharmacy improvement expert management skills, interpret management and RX • Identifies interventions reports & ID high-risk patients reconciliation that improve health • Helps organizations manage • Network Director : Helps outcomes Attributed Members with provider groups understand • Works collaboratively with complex needs program contract and providers to establish • Fosters seamless coordination expectations transformation action between the PCP and plan- • Contract Advisor : Manages plans. sponsored programs onboarding process for participating providers 7
Enhanced Personal Health Care Basic practice support for transformation: • Risk adjusted pmpm to RIHN based upon attribution • Now includes BlueCard members • ASO (self-insured) clients are required to participate • PPO members need a PCP selection • 10 auto-credit points if NCQA PCMH level II or III Under the Shared Savings program: • Increase the amount of savings by reducing costs • Increase the percent of savings they can take home by meeting quality and utilization targets established in the program’s scorecard • Must meet minimum threshold Quality & RIHN Savings Utilization = x Shared Savings Achieved Performance Payout 8
Anthem’s Partnership with Primary Care: What Are We Doing to Preserve Your Shared Savings? Manage specialists • Prior authorization by like specialists • Cancer care: value based approach, Manage access bundled XRT • Free standing ERs: contracts • Some total joint bundles • Live Health Online • Out of network redirection • Contracted with Little Clinics, retail, urgent care Manage specialty pharmacy drugs: • Med Nec • Site of service Manage IP care • Utilization management/ discharge planning • Case Management / risk for Manage high tech radiology readmission • Site of service (voluntary to Care across the continuum: prior authorized for exceptions) • Diabetes Prevention Program
Closing Gaps: Diabetic Retinopathy Screening • $50 Gift Card Incentive People living with diabetes should • Members in need of a dilated take extra special care of their eyes retinal eye exam were mailed Get cheeked and activate a $50 gift card Do you work hard to take good care of yourself? Maybe you watch what you a $50 gift card offer to eat, exercise and pay close attention to your blood sugar levels. But what a bout your eyes? complete their screening by People with diabetes are at risk for diabetic eye disease* even blindness and can happen These problems can cause vision loss or 12/31/16. The mailer so slowly that you cant tell until it’s pretty serious. Problems may include: Diabetic retinopathy — damage to the blood vessels in the retina. o included a tear-off which is o Cataracts- clouding of the eye's lens; cataracts develop at an earlier age in people with diabetes. Glaucoma — an increase in fluid pressure inside the eye that leads to intended to be filled out by o o pti c n erve d a mage a nd loss of vi si on. A p erson with d la betes is nearly twice as likely to get glaucoma as other adults.* the eye care professional and Schedule a dilated retinal eye exam every year Whatyou should know about a dilated retinal eye exam: sent to the member’s PCP. o The test should be done by an eye doctor who is an ophthalmologist or an optometrist as its notjusta test for eyeglasses, Some members also received o The eye doctor will use eye drops to make the pupils bigger (dilate your o u r $ 5 0 gift card Y eyes) and look at the back ofyour eyes (the retina) to check for signs an IVR call and/or text to of da mage. Here’s what you need to do encourage them to open and 1. Detach and fill out both of the attached cards and bring them to your eye exam. 2. redeem their offer. A Have your &/e doctor fill out the highlighted sections on both cards. 3. Ask your eye doctor to send the card with the ecam results to your GIFT CARD primaiy care physician (PCP), If you don't have a PCPyet, bring this reminder text was sent out in card to your first vi sit. 4. Return the other card to Anthem to start activation ofyour gift card, subsequent months to remind Thanks, in advance, for taking such good care of your eyes! the member of the offer. State/Product # Outreached Marketplace HMO CO 172 Commercial HMO CO (letter only no incentive) 629
EPHC continues to deliver results in Colorado Fewer members admitted to Providers choosing preferred sites Declining cost and utilization of the hospital for radiology inpatient surgical services • Lower inpatient cost • Lower costs on radiology services and • Lower inpatient surgical costs 2.8% lower utilization • 0.9% fewer inpatient admits • 8.9% fewer inpatient surgeries and 9.3% fewer surgical inpatient days Savings are the result of changes in provider practice $17.11 PaMPM (4.3%) patterns that significantly Gross savings through September 2015 impact cost and utilization $14.44 net savings * Based on financial performance of BDTC programs against Medical Cost Targets 4/1/13 – 9/30/15 for all Anthem markets; net savings are net of provider shared saving bonus payout. Utilization and site of service 11 results based on performance against targets 4/1/13-12/31/15
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