Aligning Incentives:
Anthem’s Accountable
Care Model
Anthem Quality In-sights®
Patient Centered Primary Care
John Syer
RVP
Provider Engagement and
Contracting
Anthem has experience in a broad range of
innovative solutions…
Value-Based
Reimbursement
Fee-forValue
Care Delivery Transformation Models
Global
Payments
(TBD)
Enhanced
FFS / P4P
Anthem
Quality
In-sights
(2012)
Patient
Centered
Primary
Care
(2012)
Path to value
Higher value =
Higher impact
QHIP
(2004)
Fee-forService
Partially
Integrated
Integration of Care Delivery
Fully
Integrated
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Anthem Quality In-sights® (AQI) Program
• Launched January 1, 2012
• Quality gate
• Applicable to all primary care physicians (PCP) in all Anthem
networks and products, including Medicaid
 Over 7,500 physicians in program
• PCPs can earn increases to E&M codes
• All clinical measures based on nationally recognized metrics
endorsed by:
 National Committee for Quality Assurance (NCQA)
 National Quality Forum (NQF)
 Ambulatory Quality Alliance (AQA)
 Centers for Medicare and Medicaid Services (CMS)
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Patient Centered Primary Care (PC2):
Taking AQI to a New Level
Drive the transformation to a patient
centered care model that promotes access,
coordination across the continuum,
prevention and wellness by collaborating
with primary care physicians in ways that
allow them to successfully manage the
health of their patients and thrive in a value
based reimbursement environment.
This strategy represents an aggressive and fundamental shift
in how we interact with and engage primary care physicians on all levels:
clinically, contractually, operationally and culturally.
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Patient Centered Primary Care: Foundational Pillars
This strategy will drive transformation to a patient-centered care model by aligning
economic incentives and giving primary care physicians the tools they need to thrive
in a value-based reimbursement environment.
Enhanced
reimbursement tied
to measurable
behavior changes
and outcomes
Expanded access
through innovation
Aligning care
management with
the delivery system
Exchange of
meaningful
information
Four Foundational Pillars
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Patient Centered Primary Care:
Transforming Physician Compensation
• Implement value based reimbursement that
promotes care coordination and shared
accountability for the member:
Meaningful
enhanced
reimbursement
tied to desired and
measurable
behavior changes
 New care coordination codes
 eVisits and telephonic communication Meaningful
 Shared savings opportunities
enhanced
Care
Exchange of
reimbursement
management
meaningful
tied to
• Leverage
and careprovider tools and resources to help
information
measurable
reduce
cost and thereby
increase primary
care
coordination
behavior
physician “shared savings”
changes
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Patient Centered Primary Care: Enhanced Access
• What it IS:
 Being Available – “First Contact of Care”
 Being “On Call” and calling back
 Having access to patient’s history 24/7
Meaningful
enhanced
Care
 Leveraging physician Exchange
extenders asofpart of the
care coordination
reimbursement
management
team with retail clinics or
nurse practitioners as appropriate.
meaningful
tied to
and care
information
measurable
coordination
behavior
• What's it IS NOT:
changes
 Utilizing web technology and eVisits
Expanded
Access
 “My office is currently closed, please go to the ER if this is an
emergency”
Five Foundational Pillars
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Patient Centered Primary Care:
Care Management and Care Coordination
• Create PCP Led Accountable Patient-Centric Team
• Attribute patients to each practice through a
predictive model
Care
management
and care
coordination
• Provide virtual care managers for their Anthem
patients or working with their embedded care
Meaningful
managers
enhanced
Care
• Provide access to Anthem’s
Memberreimbursement
Medical
Exchange of
management
meaningful
tied to
History
Plus (MMH+)
tool
and care
information
measurable

Web based tool that organizes claims data and lab results into
coordination
behavior
a “patient” record
changes

Same tool used by Anthem case management nurses

Also useful for meaningful
after hours coverage
Five Foundational
Pillars
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Patient Centered Primary Care: Bi-Directional Exchange
of Actionable Data
• In addition to providing 24/7 access to MMH+,
Anthem delivers actionable information in areas
such as cost, quality, efficiency, and utilization:

Bi-directional
exchange of
actionable data
Avoidable ER
Meaningful
enhanced
 Admissions/Readmissions
Care
Exchange of
reimbursement
management

Imaging/Lab site of service
meaningful
tied to
and care
information
measurable
 Anthem Care Comparison
(site specific cost and
quality
coordination
behavior
information)
changes
 Brand vs generic prescribing

Gaps in care

Specialty referral management
Five Foundational Pillars
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Anthem + Employer + Provider Partnership
To truly impact cost and quality of care, WE – Anthem, employers and
providers – need to migrate towards value based reimbursement
 Our local market penetration and breadth across
Virginia positions us well to provide solutions that
best respond to local market needs and foster
provider capabilities
 Value based contracting is a paradigm shift and will
be our standard method for compensating providers
going forward
 We can help drive positive change in quality and
cost when we bring all of our business to the table –
we can do this effectively in partnership with you
Working together (Anthem, Customer and Provider)
we can drive healthcare transformation
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