Enhanced Personal Health Care payment

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Transcript Enhanced Personal Health Care payment

A better state of health care Our Enhanced Personal Health Care payment innovation model

AUGUST 20, 2014

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We are Leading the Charge to Transform the System

Fee-for-Service 1960 Drivers of Cost

Fragmentation Lack of accountability & coordination Narrower focus of providers Waste; repetitive units 40 years of FFS

Introduction of Value-Based Payment Without value-based payment With value-based payment Today Bending the Cost Curve

• Aligned reimbursement • Empower with data • Invest in practice transformation 2

National Blue Footprint

Blue Distinction Total Care

PCMHs in 48 States

Patient-Centered Medical Home programs in 48 states, including D.C. and Puerto Rico

ACOs in 41 States

Accountable Care Organizations in 41 states

12 million

members participating in

PCMH/ACO

care delivery models

130,000

Participating

ACO/PCMH

providers

$65 billion

in Blue claims spend is tied to ALL value based 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

promoting accountability and care coordination across the healthcare continuum to improve the overall health of the population.

PERSONALIZED CARE PLANS

we are providing the tools and strategies to help strengthen the doctor patient relationship, even outside of office visits. 4

Empowering Providers

Information

• Standard reports and advanced analytics • Risk stratification • Identifying gaps in care • Avoidable ER use • Brand vs. prescription drugs • Interpretive guidance

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

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

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

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

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.

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 .

Preliminary results

Enhanced Personal Health Care

$8.75 PaMPM (2%)

savings over first 3 quarters 1

Trends from providers indicate they are changing their practice behaviors.

Increased rates of provider visits post discharge Significant increase in referral to preferred lab (NY, NH, VA and OH) Greater number of weekend visits for attributed members Significant decrease in the number of the low intensity (potentially avoidable) ER visits (VA & OH) Improvement in Inpatient and ER utilization 1 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

Contracting Network Evolution Demographic Reports Demographic Summary Non-Attributed Members Financial Reports Invoice Backup Value Reports Panel Performance Trend Management Program Overview – clinical/quality Program Overview – Utilization

Anticipated Delivery

Available Available Available Available Available Q42014

Comment

Report on number of in-networks providers under an Enhanced Personal Health Care contract Demographic profile of members attributed to Enhanced Personal Health Care Breakdown of members not attributed to a provider Provides back up of ASO invoice at subgroup and member level Report at intersection of provider panel and ASO customer Report on financial metrics Available Report on clinical and quality metrics Q42014 Report on utilization metrics • • • • 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 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