Anthems Investment in and Commitment to Primary Care: RIHN Cissy - - PowerPoint PPT Presentation

Anthem’s Investment in and Commitment to Primary Care: RIHN

February 23, 2017

ANTHEM PROPRIETARY AND CONFIDENTIAL – DO NOT COPY

Cissy (Elizabeth) Kraft MD MHS FAAFP RVP Senior Clinical Officer, Colorado and Nevada Elizabeth.kraft@anthem.com

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 PCMH pilot PC2 (patient centered primary care) Anthem EPHC (Enhanced Personal Health Care) CPCi CPC+ # practices/MDs 16 front range PCMH practices 45 practices 2550 physicians in all (CPCi and EPHC) value based programs 42 practices 34 Patients included Fully insured Fully insured and ASO (no opt out) Fully insured and ASO (no opt out), PPO mandatory PCP selection in small group Fully insured and ASO (no opt out) Fully insured, ASO (no opt

• ut), PPO mandatory PCP

selection in small group and BlueCard Type of program P4 (pay for performance) PMPM with ability to earn shared savings PMPM with ability to earn shared savings PMPM with ability to earn shared savings PMPM with ability to earn shared savings Measures

• Preventive
• Diabetes

Acute and Chronic Care measures, Preventive, Utilization and Improvement Acute and Chronic Care measures, Preventive, Utilization and Improvement Acute and Chronic Care measures, Preventive, Utilization and Improvement Acute and Chronic Care measures, Preventive, Utilization and 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) Fully insured membership only

• 2011 total P4P payment:

$227,163

• 2012 total P4P payout:

$175,691

ANTHEM PROPRIETARY AND CONFIDENTIAL – DO NOT COPY 4

• Belmar
• Broomfield Fam Practice
• Clinix
• Michael Mignoli, MD
• Southwest PC
• Family Practice Associates
• Ideal Family Healthcare
• Internal Med Clinic
• Lakewood Family Medicine
• Lonetree Family Practice
• Miramount Family Medicine
• DeYoung
• Mountaintop Family Health
• Provident
• Southpark Internal Medicine
• Westminster Medical Clinic

Anthem’s Commitment to Primary Care: EPHC (Enhanced Personal Health Care)

Enhanced Personal Health Care

5

Attribution Identify the member’s PCP Medical Cost Target Establish a budget for medical costs Quality Score Card Establish quality expectations and tie results to performance Clinical Coordination Payments Change the payment model Population Health Management Data and insights about the provider’s patients Care Delivery Transformation Partner throughout the care delivery process Clinical Coordination Payments Change the payment modelzyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA

Payment Model P r

• v

i d e r S u p p

• r

t

Anthem’s Commitment to Primary Care Transformation

Information

• Risk stratification
• Analytics
• Identification of gaps in

care with drills to patient level

• Avoidable ER use
• Brand/generic drugs

Resources

• Dedicated local support
• Guidance on getting the

most from data and tools

• Assistance with practice

transformation

Tools

• Practice Advisor (ACP)
• Toolkits for Anthem’s EPHC

Program

• Longitudinal Patient Record
• Choosing Wisely

ANTHEM PROPRIETARY AND CONFIDENTIAL – DO NOT COPY 6

Anthem’s Commitment to Primary Care Transformation

• Work flow and process

improvement expert

• Identifies interventions

that improve health

• utcomes
• Works collaboratively with

providers to establish transformation action plans.

• Helps practices develop care

management skills, interpret reports & ID high-risk patients

• Helps organizations manage

Attributed Members with complex needs

• Fosters seamless coordination

between the PCP and plan- sponsored programs

RIHN Dedicated Care Consultant

7

• Pharmacist: Supports pharmacy

management and RX reconciliation

• Network Director: Helps

provider groups understand program contract and expectations

• Contract Advisor: Manages
• nboarding process for

participating providers

Other Resources

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

Savings Achieved Quality & Utilization Performance RIHN Shared Savings Payout

8

x =

Manage IP care

• Utilization management/ discharge

planning

• Case Management / risk for

readmission

Care across the continuum:

• Diabetes Prevention Program

Manage specialty pharmacy drugs:

• Med Nec
• Site of service

Manage high tech radiology

• Site of service (voluntary to

prior authorized for exceptions)

Manage access

• Free standing ERs: contracts
• Live Health Online
• Contracted with Little Clinics,

retail, urgent care

Manage specialists

• Prior authorization by like specialists
• Cancer care: value based approach,

bundled XRT

• Some total joint bundles
• Out of network redirection

Anthem’s Partnership with Primary Care: What Are We Doing to Preserve Your Shared Savings?

Closing Gaps: Diabetic Retinopathy Screening

• $50 Gift Card Incentive
• Members in need of a dilated

retinal eye exam were mailed a $50 gift card offer to complete their screening by 12/31/16. The mailer included a tear-off which is intended to be filled out by the eye care professional and sent to the member’s PCP. Some members also received an IVR call and/or text to encourage them to open and redeem their offer. A reminder text was sent out in subsequent months to remind the member of the offer.

State/Product

# Outreached Marketplace HMO CO 172 Commercial HMO CO (letter only no incentive) 629

Get cheeked and activate a $50 gift card

Do you work hard to take good care of yourself? Maybe you watch what you eat, exercise and pay close attention to your blood sugar levels. But what about your eyes? These problems can cause vision loss or even blindness and can happen so slowly that you cant tell until it’s pretty serious. Problems may include: 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

• 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.* Whatyou should know about a dilated retinal eye exam:

• The test should be done by an eye doctor who is an ophthalmologist
• r an optometrist as its notjusta test for eyeglasses,
• The eye doctor will use eye drops to make the pupils bigger (dilate your

eyes) and look at the back ofyour eyes (the retina) to check for signs

• f da mage.

Detach and fill out both of the attached cards and bring them to your eye exam. Have your &/e doctor fill out the highlighted sections on both cards. Ask your eye doctor to send the card with the ecam results to your primaiy care physician (PCP), If you don't have a PCPyet, bring this card to your first vi sit. Return the other card to Anthem to start activation ofyour gift card, People with diabetes are at risk for diabetic eye disease* Diabetic retinopathy — damage to the blood vessels in the retina. Schedule a dilated retinal eye exam every year Here’s what you need to do 1.

2.

3. 4.

Y

• ur$50 gift card

GIFT CARD

People living with diabetes should take extra special care of their eyes

Thanks, in advance, for taking such good care of your eyes!

EPHC continues to deliver results in

Colorado

11

Fewer members admitted to the hospital

• Lower inpatient cost
• 0.9% fewer inpatient admits

Providers choosing preferred sites for radiology

• Lower costs on radiology services and

2.8% lower utilization

Declining cost and utilization of inpatient surgical services

• Lower inpatient surgical costs
• 8.9% fewer inpatient surgeries and

9.3% fewer surgical inpatient days

$17.11 PaMPM (4.3%)

Gross savings through September 2015

$14.44 net savings

Savings are the result of changes in provider practice patterns that significantly impact cost and utilization

* 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 results based on performance against targets 4/1/13-12/31/15

Appendix

• Primary Care Joint Principles white paper
• Screenshots of ACMP: performance reporting, specific gaps

with ability to drill down to individual patients’ gaps, hot spotters

• Webinar schedule for 2017

ANTHEM PROPRIETARY AND CONFIDENTIAL – DO NOT COPY 12

What is the Patient-Centered Medical Home?*

A primary care practice that provides patients with accessible, comprehensive continuous & coordinated care through a patient-centered, clinician-guided, team- based cost-efficient & longitudinal approach to care

• Each patient has an ongoing relationship

with a personal physician or clinician trained to provide first contact, continuous and comprehensive care

• Physician-directed medical practice in

which a team of individuals collectively take responsibility for ongoing care of patients: team based approach

• Whole-person orientation of care for all

stages of life: involved patient

• Care is coordinated and/or integrated

across all elements (practices, hospitals, nursing homes, consultants) of the health care system

• Use evidence-based guidelines in the

treatment of chronic conditions, acute illness and injury, and the provision for preventive care: Technology platform for accountable use of clinical performance data

• Patients have enhanced access to care

through systems such as open scheduling, expanded hours and new options for communication

• Payment appropriately recognizes the

added value to patients who have a medical home

* *Based upon the Joint Principles 3/07: AAFP, AAP, ACP, AOA

Provider Care Management Solutions (PCMS)

Population Management Performance 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

• rganization’s financial performance
• In development: cost and utilization trends around

impactful types of service

Simple, Actionable, and Relevant

ANTHEM PROPRIETARY AND CONFIDENTIAL – DO NOT COPY 14

Anthem Hot Spotter Patients

A practice can determine the number of hot spotter patients from their home page, and can view details on those patients by clicking the ticker

ANTHEM PROPRIETARY AND CONFIDENTIAL – DO NOT COPY 15

Anthem Hot Spotter Patients

Details include patient demographics, risk score, care opportunities, a listing of conditions, as well as utilization and cost data

ANTHEM PROPRIETARY AND CONFIDENTIAL – DO NOT COPY 16

All data can be exported to excel for easier viewing, and analysis

PCMS Report – Potentially Avoidable ER

17

Data Source: Claims Reporting Period: Claims incurred through 06/30/2016 Paid through 09/30/2016

ER Utilization – 2 Year Trend

18

Data Source: Claims Visit Count Date Range: 10/01/2015 – 09/01/2016

†

◄

†

◄

† †

◄ ◄

Risk Adjustment, Documentation and Coding Events

October IB, 2017 Documentation and Coding: Guidance: Neoplasm July 19, 2017 Documentation and Coding: Dependency/Substance Abuse April 19, 2017 Documentation and Coding: Mental/Behavioral Health January 13,2017 Documentation and Coding: Diabetes January 4, 2017 - February 1, 2017 - March 1, 2017 — April 5, 2017 — May 3, 2017 — June 7, 2017

July 5, 2017 — August 2, 2017 — September 5, 2017 — October 4, 2017 — November 1. 2017 — December 7, 2017

Rec u rring p re sentation Medicare RishAdjustmentand DocumentationGuidance December 14, 2017 Anxiety and Substance Use In Adolescents October 19, 2017 Unintended Consequences Related to Antimicrobial Exposures Septe mber21,2017 Care Planning an d Coordin atlon: M an agiin g Com pi ex Patie nts f o r Well Visits and I m m u n izati ons January 26, 2017 GettingAdol escents in November 15, 2017 Informing Treatment Dec is ions with Medication Reconciliation August 17, 2017 Emerging Best Practices: Non-Pharmacologic Treatment of Pain Ju ly 20, 2017 MedicatlonA ssisted Treatm e nt (MAT} for th e Treatment of Opioid Use Disorder June 15, 2017 Guidelines for Prescribing Opioids for Chronic Pain May 18, 2017 The Vital Role of Palliative Care in Patient Outcomes March 14, 2017 How-to Succeed in Value-Based Payment Arrangements February 16. 2017 Reducing Hospital Read missions - Letts show you how and why Fulll event descriptions are available by clicking or the evert title below. To register for the event, click the event date.

2017 National Collaborative Learning Webinar Schedule

ANTHEM PROPRIETARY AND CONFIDENTIAL – DO NOT COPY 19

General Practice Transformation Events Pediatric Events

CEU/CME credits: 1.5 CEU/CME credits: 1.5 CEU/CME credits: 1.5 CEU/CME credits: 1.5 CEU/ CME credits: 1.5 CEU/CME credits: 1.5 CEU/ CME credits: 1.5 CEU/CME credits: 1.5 CEU/CME credits: 1.5 CME credits: 1.0 CME credits: 1.0 CME credits: 1.0

CME credits:

1.0 CME credits: 1.0

April 20, 2017 National Crisis: Update onZika Clinical Virus Syndrome