A better state of health careOur Enhanced Personal
Health Care payment
innovation model
AUGUST 20, 2014
0
Welcome
Today’s presentation will begin shortly.
In order to hear the audio for this presentation, please turn up your speakers.
If you would rather use a toll free dial in number and access code, click on the
“Info” tab above this presentation in the upper-left hand corner of your screen.
All lines have been placed on mute. If you’d like to ask a question, please use
the Q&A window on the right
A copy of this presentation is available on Time Well Spent. Access the URL for
your state:
 CA: http://timewellspent-ca.anthem.com
 NY: http://timewellspent.empireblue.com
 GA: http://timewellspent.bcbsga.com/
 All other states: http://timewellspent.anthem.com/
1
We are Leading the Charge to
Transform the System
Introduction of
Value-Based Payment
Fee-for-Service
Without value-based
payment
Healthcare Costs
Drivers of Cost
Fragmentation
With value-based
payment
Lack of accountability &
coordination
Bending the Cost Curve
Narrower focus of
providers
• Aligned reimbursement
• Empower with data
• Invest in practice transformation
Waste; repetitive units
1960
40 years of FFS
Today
2
2
National Blue Footprint
Blue Distinction Total Care
PCMHs
in 48 States
ACOs
in 41 States
Patient-Centered Medical
Home programs in
48 states, including D.C.
and Puerto Rico
Accountable Care
Organizations in
41 states
12 million
members
participating in
PCMH/ACO care
delivery models
130,000
$65 billion
Participating
ACO/PCMH
providers
in Blue claims spend
is tied to ALL valuebased payment
programs
Beginning in 2015 all Blue Plans will use
a common data exchange platform
(Blue Distinction Total Care) to recognize
resident BlueCard members in the host
plan payment innovation programs.
3
3
Common building blocks to drive
transformation
Driving change by rewarding and empowering PCPs
PAYMENT
INNOVATION
moving from volume to
value-based payment
models.
DATA AND INSIGHTS
we empower providers by
providing information,
tools, practice support and
resources to thrive under an
outcome-based
compensation model.
POPULATION
HEALTH
PERSONALIZED
CARE PLANS
promoting accountability
and care coordination
across the healthcare
continuum to improve the
overall health of the
population.
we are providing the tools
and strategies to help
strengthen the doctorpatient relationship, even
outside of office visits.
4
4
Information
• Standard reports and advanced analytics
• Risk stratification
• Identifying gaps in care
• Avoidable ER use
• Brand vs. prescription drugs
• Interpretive guidance
Empowering
Providers
Tools
• Information Sharing
• Toolkits for Enhanced Care Management
• Practice Advisor tool by the American College
of Physicians for PCMH evaluation
• MMH+
• Advanced Longitudinal Patient Record
Resources
• Dedicated local Anthem resources with
hands-on assistance for practices.
• Help with use of the new data, reports, and
tools and support practice transformation
• Guidance on appropriate toolkits and Anthem
Care Management resources
• We will meet providers where they are and
help them move forward
5
5
Foundation: Defining the
Population
•
Attribution is the method we use to identify the provider’s patient population
•
It is the foundation for clinical coordination payments as well as shared
savings calculations and payments.
There are two
processes used for
attribution depending
on the product type:
Open Access Products (PPO)
Attribution is based on:
historical claims data incurred in a 24-month period
Products Requiring PCP Selection
Attribution is based on:
covered individuals selection during a 12-month
period
6
6
Clinical Coordination Payments
• Clinical coordination payments compensate primary care providers for
work such as preparing care plans for patients with multiple and complex
chronic conditions, maintaining health registries, and following up with
patients to ensure they understand and are following their treatment plan
• These activities improve health and reduce costs
• Upfront PMPM payments enable PCPs to invest in supporting
infrastructure (outreach staff, IT) and transform their practices to
manage the health of their patients
• While a new form of payment for the physicians receiving them, these
payments are included in our unit cost forecasts and are managed just like
we manage fee schedule adjustments today
7
7
Provider Performance Payments
(shared savings)
Shared savings applies in all of our Enhanced Personal Health Care
arrangements.
These payments reward PCPs when they successfully manage the
quality and overall health care costs for their patient population
Quality
metrics
met
Savings
achieved
Provider group
qualifies for
shared savings
payment
Amount of shared savings payment based on:
• Scores on quality of care and either utilization and/or patient engagement metrics –
both designed to measure the impact of PCP activity.
• Total amount of savings calculated during the measurement period
8
8
How will ASO Customers Fund
Provider Performance Payments?
▪ We will charge ASO customers a uniform, per-attributed member per-month (PaMPM)
amount that we actuarially determine will cover shared savings payments.
▪ Because the cost of care varies by market and each program rolls out at a different time
within each market the PaMPM will vary by program and by market to align with their
unique expectations for that year. The PaMPM will be updated from year to year based
on our experience and projections.
▪ The shared savings payment will appear on invoices alongside clinical coordination
payments, listed under “other provider payments”.
▪ All funds collected will be used to pay shared savings payments to providers.
▪ Customers do not need to accrue anything.
9
9
What kind of savings might customers
experience?
•
We estimate that in their first year of participation, providers will generate savings that
produce 1%-2% lower than projected medical spend, increasing to a cumulative 8%
by their third year of participation.
•
The evidence tells us that patient-centered care saves money in several ways:
 Better management of chronic conditions like diabetes and asthma and better
access to care resulting in reduced admissions and ER visits
 Care based on the best available clinical evidence – reducing waste in the system.
 Value-based decisions by physicians, such as higher rates of generic drug
substitutions, lowering the overall cost of prescription drugs.
 Many factors, including the number of patients attributed to participating providers, and
the length of time each provider has been participating in the program impacts the
savings projections for any one customer.
10
10
Preliminary results
Enhanced Personal Health Care
$8.75 PaMPM (2%)
savings over first 3 quarters1
Trends from providers indicate they are changing their practice behaviors.
Increased rates of provider
visits post discharge
Significant increase in
referral to preferred lab
arrangements
(NY, NH, VA and OH)
Significant decrease in the
number of the low intensity
(potentially avoidable) ER
visits (VA & OH)
1
Greater number of
weekend visits for
attributed members
Improvement in Inpatient
and ER utilization
11
Gross savings before provider gain share. Performance period (4/1/13 – 12/31/13). Per attributed member per month.
Measure the merits with
value-based reporting.
Providing timely and evolving data on:
•
•
•
Projected participation and savings
Quality, cost and patient experience
Targeted populations for improvement
12
Proposed Value Based Reporting
Roadmap
Anticipated
Delivery
Comment
Contracting
Network Evolution
Available
Report on number of in-networks providers under an
Enhanced Personal Health Care contract
Demographic
Reports
Demographic Summary
Available
Demographic profile of members attributed to Enhanced
Personal Health Care
Non-Attributed Members
Available
Breakdown of members not attributed to a provider
Invoice Backup
Available
Provides back up of ASO invoice at subgroup and
member level
Panel Performance
Available
Report at intersection of provider panel and ASO customer
Trend Management
Q42014
Report on financial metrics
Program Overview –
Value Reports clinical/quality
Available
Report on clinical and quality metrics
Program Overview –
Utilization
Q42014
Report on utilization metrics
Financial
Reports
•
•
•
•
Value reports supplement current client reporting
Identifies members that could be targeted
Quarterly reports at the customer level
State and industry level reports available
• Reports are actionable, timely, and evolving
– Metrics span quality, utilization and cost
– Future reports will include provider transformation
13
and patient experience
13
Coming soon
Program enhancements
New financial value reporting
Benefit steerage
Beginning in Q4 2014, in addition to the clinical
value reports we offer, a new suite of financial value
reports will show you what these programs mean to
you and your bottom line.
2014
• Q4 - Group level
financial value
reports
Subject to change
2015
• Enhanced Personal HealthCare
fully integrated into Blue
Distinction Total Care
2016
• Introduction of benefits steerage
around Blue Distinction Total Care
14
14
Questions?
15
15