Coordinated by: Lead Support Major Support Additional Support

Strategic Partners:

Patient-Centered Primary Care Collaborative of Central Ohio

Q2 Learning Session - May 11, 2012

Health System Modernization: shifting from volume

to value-based purchasing and payments

Q2 Learning Session Sponsored by Nationwide

Please save the following dates for 2012 learning sessions (7:30-10:30AM):

• Friday, August 3

• Friday, December 7

www.accesshealthcolumbus.org

Patient-Centered Primary Care Collaborative of Central Ohio

WHY are we coordinating the Collaborative? To improve access to patient-centered primary care as the foundation of

accountable health care delivery to achieve better care, better health, and better value in our community

WHAT are the objectives? Improve the health of the people in our community Improve the patient experience of care Improve value of health care expenditures

Participating Primary Care Providers: Over 200 primary care providers practicing in private practice, hospital-affiliated,

and federally qualified health centers serving over 350,000 patients with Commercial insurance, Medicaid, Medicare, and the uninsured

Participating Health Plans & Purchasers: 7 health plans & 7 self-funded employers from the private and public sector

Health System Modernization: shifting from volume to value-based purchasing and payments

8:00 - 10:00AM: Sharing of national, state, and local modernization activity

Welcome & Framing, Jeff Biehl, President, Access HealthColumbus

Medicare Activity , Amy Rohling McGee, President, Health Policy Institute of Ohio

Medicaid Activity, John McCarthy, Ohio Medicaid Director, Ohio Department of Job and Family Services

Health Plan & Employer Activity

• Elizabeth Curran, Head, National Network Strategy & Program Development, Aetna

• Julie Schilz, Program Director, Patient Centered Primary Care Transformation, WellPoint

• Bruce Wall MD, Medical Director, OSU Health Plan

Learning from questions and discussions with presenters 10:00 - 10:30AM: Networking with colleagues

Collaborative Approach for Improving Patient-Centered Primary Care

Health Care Providers

Health Care Consumers

Health Care Payers

Health Care Purchasers

Improve Patient-Centered Primary Care

Catalyst for Modernizing Health Care Purchasing & Payments

Catalyst for Spread of Patient-Centered Medical

Homes

Advance Best

Practices for Modernizing

Primary Care

Delivery

Measure Value of Shift in Resources to Primary

Care

SPREAD: Patient-Centered Medical Homes (based on activities coordinated by Access HealthColumbus)

0

50,000

100,000

150,000

200,000

250,000

300,000

350,000

Patients Served by Patient-Centered Medical Homes

2011 + 20 practice sites NCQA recognized

2010 9 practice sites

NCQA recognized

2012-2013 + 42 practice sites working towards

NCQA recognition

NCQA = National Committee for Quality Assurance – Patient-Centered Medical Home National Standards

SPREAD: 2010-11 NCQA Recognized Patient-Centered Medical Homes

18

17 16

15

12

11 13

10

14

1 2

3

4

6

5

7 8

9

19

20

22

24

25

26

27

28

29

Note: based on activities coordinated by Access HealthColumbus

21 23

SPREAD: 2012-13 Primary Care Practices Working Towards NCQA Patient-Centered Medical Home Recognition

Note: based on activities coordinated by Access HealthColumbus

30

31

32

33

34 35 36

37

39

38

40

41

42

43

44

45 46 47

48 49

50 51 52

53

54

55

56

57

58

59 60

71

70

69 68

67

66 65 64

63

62

61

The following health plans and employers are participating in our local Collaborative and are implementing value-based purchasing starting with patient-centered medical homes: Aetna Anthem Blue Cross & Blue Shield Franklin County Cooperative Health Benefits Program Humana Medical Mutual of Ohio MediGold Nationwide Insurance Ohio Public Employees Retirement System School Employees Retirement System of Ohio State Teachers Retirement System of Ohio The Dispatch Printing Company The Ohio State University The Ohio State University Health Plan UnitedHealthcare

We anticipate additional purchasers will be joining our collaborative effort in 2012

Modernize Purchasing/Payments: Participating Health Plans & Employers

Participants: Self-insured employers and public employee retirement systems

Objectives: Working collaboratively with local colleagues: • Identify best practices that employers have used to improve results • Initiate improvements that have the potential to lead to fundamental

redesign of employee health strategies • Measure improvements over time (note: including but not limited to patient-centered medical homes)

Approach: Collaborative action-oriented work sessions focused on improving employee health, costs and care using the following framework: • Benefit Program Design • Payment and Contracting • Primary Care Services • Health and Wellness

Participating

Purchasers

(as of April

2012)

Dispatch Printing Company Franklin County Cooperative Health Benefits Program Nationwide Insurance Ohio Public Employees Retirement System School Employees Retirement System of Ohio State Teachers Retirement System of Ohio The Ohio State University

MODERNIZE PURCHASING: Value-Based Purchaser Collaborative

MEASURE VALUE: Patient-Centered Medical Home Improvement Dashboard

• Access Measures • Capacity to Schedule Same Day Appointments • Continuity of Care with Personal Physician

• Patient Experience • Provider and Staff Job Satisfaction

• Diabetes Patient Self-Health Management • Diabetes Management Screenings • Diabetes Management Testing Outcomes

• Utilization Outcome Measures

• Emergency Department Visits • Hospitalizations • Re-Hospitalizations • Prescriptions Filled by Generics • Admission Rate and Length of Stay for patients with Diabetes • Ambulatory Care Sensitive Admissions Rate • High Cost Imaging Visits

* Source: Agency for Healthcare Research and Quality

2012 Care Coordination Improvement Projects

• What is care coordination*? The deliberate organization of patient care activities between two or more participants (including the patient) involved in a patient’s care to facilitate the appropriate delivery of health care services.

• What does care coordination mean to patients? Help me navigate the health care system to get the care I need in a safe and timely manner

ADVANCE BEST PRACTICES: Improving Care Coordination

Access HealthColumbus is providing technical assistance to the following organizations utilizing a quality improvement methodology. Each project includes measures of success to be shared with others in Q4 2012. American Health Network Hilliard Columbus Neighborhood Health Centers Lower Lights Christian Health Center OSU Internal Medicine at Morehouse OSU Health Plan & Mt. Carmel Medical Group TriVillage Clinical Integration of Physical & Behavioral Health Services – TBD in Q3 2012

Patient-Centered Primary

Care

Better Care Coordination

Better Access

Better Alignment of

Incentives

Better Health Information Technology

What are the key components of Patient-Centered Primary Care? (starting with the patient-centered medical home model)

What is patient-centered primary care?

PATIENT CENTERED APPROACH

Patients’ chief complaints or reasons for visit determines care

Care is determined by today’s problem and time available today

Care varies by scheduled time and memory or skill of the doctor

Patients are responsible for coordinating their own care

I know I deliver high quality care because I’m well trained

Acute care is delivered in the next available appointment and walk-ins

It’s up to the patient to tell us what happened to them

Clinic operations center on meeting the doctor’s needs

TRADITIONAL APPROACH

We systematically assess all our patients’ health needs to plan care

Care is determined by a proactive plan to meet patient needs without visits

Care is standardized according to evidence-based guidelines

A prepared team of professionals coordinates all patients’ care

We measure our quality and make rapid changes to improve it

Acute care is delivered by open access and non-visit contacts

We track tests & consultations, and follow-up after ED & hospital

A multidisciplinary team works at the top of our licenses to serve patients

Health System Modernization: shifting from volume to value-based purchasing and payments

Modernization… which come first”

- improve delivery of care? - improve payment of care?

- improve both at the same time?

Voice of Health Care Professionals:

“please provide incentives to enable and sustain a

team approach to achieve the desired results”

Voice of Payers/Purchasers:

“please demonstrate your readiness and capabilities

to produce the desired results”

Amy Rohling McGee President

Health Policy Institute of Ohio

Medicare Activity

HPIO purpose

To provide state

policymakers with

the independent

information and

analysis they need

to create informed

health policy.

Strategic objectives

1. Achieving and maintaining health and wellness for all Ohioans

2. Ensuring access to care for all Ohioans

3. Developing tools for improved Ohio health system data transparency

4. Aligning public and private payments

with better health quality outcomes for

all Ohioans

Source: Lambrew JM. A Wellness Trust to Prioritize Disease Prevention. The Hamilton Project, Brookings

Institution, 2007. Discussion paper 2007-04: 1-36. University of California at San Francisco, Institute of the

Future, 2000. As cited in Reducing Health Care Costs Through Prevention, Prevention Institute and the

California Endowment with The Urban Institute, 2007.

96% Medical services

4% prevention

Access to care

10%

20% Genetics

20% Environment

50% Health

behaviors

Factors influencing

health

National health expenditures

$1.7 trillion

Medicare Inpatient Hospital Payment Changes

Hospital Inpatient Quality Reporting Program

Hospital Acquired Conditions (Current vs. ACA)

Hospital Readmissions

Hospital Value-Based Purchasing

Meaningful Use

* Other – Medicare shared savings programs and ACO

advance payment and pioneer models

$70 billion Medicare hospital payments tied to performance over 10 years

Medicare Physician Payment Changes

Value Based Payment Modifier

E-Prescribing

Physician Quality Reporting System

Meaningful Use

* Other – Medicare shared savings programs and ACO

advance payment and pioneer models

Center for Medicare & Medicaid Innovation

Bundled Payments

Comprehensive Primary Care Initiative

Health Homes

John McCarthy Ohio Medicaid Director

Ohio Department of Job and Family Services

Medicaid Activity

Health System Transformation: Shifting Payment from Volume to Value

John McCarthy, Director Ohio Medicaid

Patient-Centered Primary Care Collaborative of Central Ohio May 11, 2012

Ohioans spend more per person on health care than residents in all but 13 states1

Rising health care costs are eroding paychecks and profitability

Higher spending is not resulting in higher quality or better outcomes for Ohio citizens

41 states have a healthier workforce than Ohio2

24 Sources: (1) Kaiser Family Foundation State Health Facts (March 2011), (2) Commonwealth Fund 2009 State Scorecard on Health System Performance

Source: American Hospital Association Annual Survey (March 2010) and population data from Annual Population Estimates, US Census Bureau: http://www.census.gov/popest/states/NST-ann-est.html.

Medical Hot Spot:

Emergency Department Utilization: Ohio vs. US

365 366 372 382 382 383 387 396 401 404 436 452 450 449

468 472 488 509 516 523

0

100

200

300

400

500

600

1999 2000 2001 2002 2003 2004 2005 2006 2007 2008

United States Ohio

Hospital Emergency Room Visits per 1,000 Population

29%

Medicaid Hot Spot:

Hospital Admissions for People with Severe Mental Illness

Avoidable hospitalizations per 1000 persons for ambulatory care sensitive conditions (avoidable with proper treatment)

Source: Ohio Colleges of Medicine Government Resource Center and Health Management Associates, Ohio Medicaid Claims Analysis (February 2011)

3.53 3.69 3.24

2.33

7.01 6.75

4.18 4.86

0

1

2

3

4

5

6

7

8

Diabetes COPD Congestive Heart Failure

Asthma

Non-SMI

Severe Mental Illness (SMI)

72%

28% 66%

34%

0%

20%

40%

60%

80%

100%

Population Spending

Most people (50%) have few or no health care expenses

and consume only 3% of total health spending

5% of the US population consumes 50% of total

health spending

1% of the US population consumes 23% of total health

spending

23%

50%

45%

47%

27%

1%

Source: Kaiser Family Foundation calculations using data from AHRQ Medical Expenditure Panel Survey (MEPS), 2007

Medical Hot Spot:

A few high-cost cases account for most health spending

4%

3%

Fragmentation vs. Coordination

Multiple separate providers

Provider-centered care

Reimbursement rewards volume

Lack of comparison data

Outdated information technology

No accountability

Institutional bias

Separate government systems

Complicated categorical eligibility

Rapid cost growth

Accountable medical home

Patient-centered care

Reimbursement rewards value

Price and quality transparency

Electronic information exchange

Performance measures

Continuum of care

Medicare/Medicaid/Exchanges

Streamlined income eligibility

Sustainable growth over time

SOURCE: Adapted from Melanie Bella, State Innovative Programs for Dual Eligibles, NASMD (November 2009)

Health Care System Choices

Our Vision for Better Care Coordination

• The vision is to create a person-centered care management approach – not a provider, program, or payer approach

• Services are integrated for all physical, behavioral, long-term care, and social needs

• Services are provided in the setting of choice

• Easy to navigate for consumers and providers

• Transition seamlessly among settings as needs change

• Link payment to person-centered performance outcomes

29 SOURCE: Ohio’s Demonstration Model to Integrate Care for Dual Eligibles, a proposal to the Center for Medicare and Medicaid Innovation (February 1, 2011)

www.healthtransformation.ohio.gov

Elizabeth Curran Head, National Network Strategy & Program Development

Aetna

Health Plan & Employer Activity

Aetna Inc.

Quality health plans & benefits Healthier living Financial well-being Intelligent solutions

Overview – Aetna’s PCMH Program

Elizabeth Curran

Aetna Inc.

Aetna’s PCMH Program Overview

Aetna Inc.

Headline News: PCMH

• The PCMH movement is gaining traction with plan sponsors, providers,

and competitors.

• While there is some evidence supporting the efficacy of medical homes,

the concept is still being actively tested in the community.

• PCMH is just one aspect of payment reform along with bundled payments,

P4P and risk-sharing arrangements.

• PCP practices that have already obtained PCMH recognition may be

eligible for recognition of their investment in improved population

management.

Aetna Inc.

Patient-Centered Medical Home Joint Principles

• Personal physician

• Each patient has an ongoing relationship with a personal physician

• Personal physician leads a team of individuals that takes responsibility for the ongoing care of patients

• Personal physician is responsible for providing for all the patient’s health care needs or arranging care with other qualified professionals

• Care is coordinated across health care system

• Enhanced access to care is available through open scheduling, expanded hours and new options for communication

• Improved quality and patient safety are hallmarks of the medical home

NCQA PCMH Recognition Program

Six “must pass” elements are essential for PCMHs at all three recognition levels. Practices must score of at least 50

percent on these elements. These scores result in a level – 1, 2 or3 of PCMH Recognition

http://www.pcpcc.net/content/joint-principles-patient-centered-medical-home

Four physician associations representing approximately 333,000 physicians developed

the following joint principles to describe the characteristics of the PCMH:

Access During Office Hours Support Self-care Process

Use of Data for Population Management Referral Tracking and Follow up

Care Management Implement Continuous Quality Improvement

Aetna Inc.

PCMH Expected Benefits to Health Care Consumers

• Reduced hospitalizations and ambulatory care • Includes primary and readmissions

• Includes sensitive specialty/facility and other costs

• Improved transition of care

• Shared decision making and behavioral engagement

• Increased patient engagement in preventive health and wellness

• Updated clinical decision-support tools to improve care management, tracking and adherence to evidence-based guidelines

Aetna Inc.

Key Payment Program Components

• Attribution

• Efficiency

• Quality

• Chronic Conditions

Core Components of our PCMH

Aetna Inc.

Criteria

• Traditional and HMO members (enrollment office not considered)

• PCP Types: FP, IM, Ped; PA and NP when no PCP visits also found

• 50 Total Codes, 46 CPT and 4 G codes for: Evaluation and Management

• Place of service: Outpatient and Physician Office

Logic

• Patient attributed to a Group (not individual physician)

• Most recent 12 months of claims

• Attributed to Group with 1 visit if no other visits to another Group

• With visits to more than 1 Group:

• Attributed to the Group with 2 or more visits in current year when one of their

visits is the most recent of all visits

• If no attribution reached, additional 12 months of claims are added

• Group with most visits, if tied, then, group the most recent of all visits

PCMH Core Components - Attribution

Aetna Inc.

Quality Reporting

Diabetes

• Diabetes: Lipid Measurement

• Diabetic: A Lipid management: LDL-C control <100

• Diabetes with LDL greater than 100 – Use of a lipid lowering agent

• Diabetes: HbA1C Measurement

• Diabetic: Hemoglobin A1c management

• Diabetes - Medical Attention for Nephropathy

• Diabetes: Retinal Eye Exam

Cardiovascular

• IVD: Complete Lipid Profile and LDL Control <100

• Annual Monitoring - Ace/Arbs

• Annual Monitoring - Diuretics

Preventative/Screening

• Breast Cancer Screening

• Cervical Cancer Screening

• Colorectal Cancer Screening

PCMH Core Components - Quality

Aetna Inc.

Efficiency Focus on areas of opportunity to control healthcare costs and establish an incentive “savings” pool for performance.

Inpatient Services

• 30-day readmissions rate

• Admissions per thousand (excluding trauma/maternity)

• Inpatient cost savings PMPM (excluding trauma/maternity)

Outpatient Services

• Avoidable ER Reduction

• ER visits per thousand

• Outpatient Procedure Steerage

• Radiology Steerage

• Lab Steerage

Prescription Services - Rx Steerage

PCMH Core Components - Efficiency

Aetna Inc.

Chronic Conditions Focus on conditions that can reasonably be managed by an primary care provider to improve the healthcare for the community.

PCMH Core Components – Chronic Conditions

Aetna Inc.

PCMH: Promising Results in First Year (Results from NJ PCMH)

Aetna participating NCQA PCMH recognized physicians

ME

VT

RI

NJ

MD

MA

DE

NY

WA

OR

AZ

NV

WI

NM

NE

MN

KS

FL

CO

IA

NC

MI

PA OH

VA MO

HI

OK

GA

SC

TN

MT

KY

WV

AR

LA

AL

IN IL

SD

ND

TX

ID

WY

UT

AK

CA

CT

NH

MS

101-300

0-10

11-100

1000+

301-1000

DC

Aetna Inc.

Conclusion

• Aetna was an early supporter of PCMH.

• Aetna continues to refine and expand PCMH models nationally.

• Aetna remains committed to this model as a way of improving the quality of care delivered to our members while reducing medical costs.

Julie Schilz Program Director

Patient Centered Primary Care Transformation WellPoint

Health Plan & Employer Activity

WellPoint Value Based Payment Innovation

Julie Schilz BSN MBA

Program Director, Patient

Centered Primary Care

Transformation

May 11, 2012

47

Challenges in the US health care system…

The US Ranks last or next to last in key areas1:

• Quality

• Access

• Efficiency

• Equity

• Health lives

Structural Challenges

• Fragmented system lacking primary care foundation

• Lack of evidence-based care… driving variation

• Misalignment of incentives

• Transaction-based system

• Lack of transparency

• Limited focus on quality

1 The Commonwealth Fund – June 2010

48

Waste in the system

Administrative and system inefficiencies 4-6%

Provider inefficiencies and errors 3-4%

Lack of care coordination 1-2%

Unwarranted use 11-21%

Preventable conditions and avoidable care 1-2%

Fraud and abuse 5-8%

% of total medical costs that is wasted 30%

Of the $2.7T spend on health care in the US, it is estimated

that one-third of these costs – $700B – are waste1

By eliminating 50-70% of waste,

we can reduce medical costs 15-20%

1 Thomson Reuters, 2009 White Paper: Where Can $700B in

Waste BE Cut From the US Healthcare System

49

Tipping Point: current costs, quality concerns…

We have reached the tipping point

• Further cost reduction under the current system would inherently

focus on rate scheduled reduction, which is unsustainable

• The focus on unit cost or transaction-based UM does not address

underlying structural drivers

A new collaborative patient-centered approach focused on

outcomes and value is required

• Necessitates changing many of the existing operating model

elements for provider collaboration and member incentives

The size and scale of the transformation is daunting

• Smart first steps to build effective programs that evolve over time

can drive change

50

Anthem has the capabilities to drive the

transformation… and the responsibility to act

Anthem’s strengths are uniquely positioned…

…to drive disruptive, but positive, change in the system

Commitment to

Quality

Clinical and

Analytic Support

Tools

Broad Local

Presence

Payment

Innovation

National

Scale

51

Patient Centered Care: transforming care delivery

Coupling rewards for quality and appropriate resource use with

clinical solutions can address the challenges in the current system

Current Challenges Future State Solution

Lack of Transparency

Access to consistent longitudinal clinical information across care

continuum

Transactional Operations Population health management

Lack of Evidence Based Care Focus on clinical integration and safe

and effective care

Misalignment of Incentives

Incentives aligned around outcomes and quality to address affordability

Fragmented Health System lacking Primary

Care Foundation

Care continuum is collaborative amongst all stakeholders and primary

care access is enhanced

Limited Focus on Quality Leverage performance risk to

collaborate on care and service quality

52

How is value captured?

Transition from fee

for service to value-

based payment

model

Manage population

health by preventing

disease progression

and driving

appropriate and

value driven

utilization

Focus on operational

cost reduction and

clinical integration

High

Low High Care Integration

Va

lue

Ba

se

d P

aym

en

ts

Bundled/

Episodic

Payments

EFFS

P4P –

(AQI

QHP)

Patient Centered

Primary Care

ACOs

Changing Market Dynamics: require multiple

approaches to transition towards value

53

Offerings Design Quality Cost

Enhanced

Fee

Schedule

CM

Fee

Gain

Share

Risk

Share

QHIP

(Hospital

P4P)

Annual scorecard that drives following

year reimbursement; nationally approved

measures; collaboration on scorecard

Physician

P4P

Annual performance on quality measures

drives 1-6% increase to standard fee

schedule.

PC2 / PCMH

Payment incentives, care management

extenders and data exchange to increase

population management quality and

lower medical cost.

Bundled Share risk of cost variation with hospitals

on select conditions

ACO

Gain share and risk share based on

quality measure achievement and

reduced PMPM medical costs

Strategy Outcomes

Anthem’s Payment Innovation Portfolio: covers

the span of innovation options

54

Local PI Programs: leverage local presence to

spread innovations across the country

55

Anthem’s Pilots: demonstrating improvements in

quality and decreasing costs

Lessons learned from Anthem’s pilot programs indicates that

strengthening the primary care relationship makes a

meaningful differences in patient quality, quality and cost

Pilot Programs Colorado New Hampshire New York Dartmouth -

Hitchcock

Program Type PC Pilot PC Pilot Yr 2 PC Pilot PCMH Pilot ACO Pilot

Quality

Improvement

Improved all

diabetes measures

Improved all

diabetes measures

12 – 23% lower

Inpatient

Admissions/1K per

year

Decrease 3.6% Decrease 18% vs

18% increase in

control

Decrease 3.6% 12 – 23% lower for

PCMH Providers

Decrease 5.81%

ER Visits/1K per

year

Decrease 6.1% Decrease 15% vs

4% increase in

control

Decrease 6.1% 11 – 17% lower for

PCMH Providers

Decrease 10.66%

-18% “avoidable”

Specialist Visits Decrease 2.0% Flat vs to 10%

increase control

Decrease 2.0%

Rx Usage Increase 1.3% in

persistent Rx

usage

Increase 1.3% in

persistent Rx

usage

Decrease 2.85%

brand Rx usage

Overall Medical

and Rx Cost/ROI

Overall ROI

2.5:1 - 4.5:1

14.5% lower than

non-PCMH

Providers

3.4% PMPM

reduction to

projected cost

56

The goals of the Patient-

Centered Primary Care (PC2)

model

Drive the transformation to a

patient centered care model that

promotes access, coordination

across the continuum, wellness and

prevention by collaborating with

primary care physicians in ways

that allows them to successfully

manage the health of their patients

and thrive in a value based

reimbursement environment

Patient Centered Primary Care – The Anthem Solution

■Financial Alignment■Meaningful & Actionable Information■ Resources■Tools■

Informa-

tion

Exchange

Care

Coordination

Better

Access

Incentive

Alignment

57

The PC2 Solution

New transformation models should be PATIENT CENTERED

to make an impact on care delivery

Better Access

to Care

Pillar 1

Alignment of

Stakeholder

Incentives

Pillar 2

Information

and

Transparency

Pillar 3

Care

Management &

Coordination

Pillar 4

PC2 Solution

58

Provider maturity levels will vary by market

Stage 1: Smart

first steps

Stage 3:

Achieve

sustainable

model

Stage 2: Align

capabilities &

stakeholders

Provider

Capabilities

Limited knowledge and

experience with population

health management

Limited availability of resources

and staffing to support CM and

coordination activities

Limited analytics

Minimal monitoring of outcomes

Access to systems / data to

support population heath

management

Shared resource for CM and

coordination activities

Basic knowledge of analytics

and measures to monitor

outcomes

Willingness to participate in

alternative risk arrangements

Automated processes and

systems to support population

health management

Fully dedicated resource for CM

and coordination activities

Actively utilize analytics to

monitor outcomes

Knowledge of and/or

participating in risk based fee

arrangements

Stage 1 Stage 2 Stage 3

59

Our staged evolution meets physicians where

they are and drives transformation to the next

level

Care Management

Payment Models

Provider Maturity

IT Capabilities

STAGE 2: Align stakeholders and

capabilities Comprehensive enablement

STAGE 1: Smart first steps

Primary care engagement

STAGE 3: Achieve sustainable

model Refined steady state

• EFFS + Care

Management payment

+ Phased Gainsharing

• Aligned care

management

• FFS + Care

Management PMPM +

Gainsharing

• Transformation of PCP

maturity stage

• Increased performance

expectations

• Collaborative care

management

• Increased care and

quality expectations

• FFS + Care

Management PMPM +

Shared Risk

• Performance risk bearing

collaborative

• Cross continuum clinical

alignment

• Comprehensive care

management across

continuum

• Transformation support

to beginners PCPs for

smart first steps

• Core reporting set

• Aligned care

management workflows

• Targeted use of data and

analytics

• Automated bi-directional data

exchange for care management

• Automated workflows

• Robust use of data and

analytics

• Automated bi-directional

data exchange

• Automated workflows

Day 1 Day 2 Day 3

60

PC2 Timeline

Market

2012 2013

Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1

Wav

e 1

CA

CO

OH

NH

NY

VA

Wav

e 2

CT

GA

ME

MO

NV

WI

Wav

e 3

IN

KY

PC2 Capabilities in Market

Phase 2 Capabilities Phase 1 Capabilities

61

It Takes a Village…

To truly impact cost and quality, WE – Anthem, our clients, our

providers – need to migrate towards value-based reimbursement

The Blues local market presence positions us well to

provide solutions that best respond to local market

needs and leverage and foster provider capabilities

Value based contracting is a paradigm shift and will

be Anthem’s standard method for compensating

providers going forward

We can 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, we can drive health care

transformation

Bruce Wall MD Medical Director OSU Health Plan

Health Plan & Employer Activity

The Potential Value of a Payer

Beyond Payment

Bruce Wall MD, Medical Director,

OSU Health Plan

Friday, May 11, 2012

UNIT FEE SCHEDULE

The Payment Continuum:

CAPITATION

Bundled payment

Pay for performance

Care co-ordination fees

Shared savings

V A L U E

Volume risk of underutilization Volume risk of overutilization

The Potential Value of a Payer Beyond

Payment

Information Sharing:

1. Should complement characteristics of useful

information that which already exists

(moving target within a network).

2. Needs to be timely relative to the desired

outcomes.

3. Needs to be potentially actionable (difference

between a history lesson vs. creating the future).

Example:

Preventive Services Pay for Quality Program:

• Identified clinical areas for improvement based

on data analysis.

• Acknowledged existing benefit plan design

considerations.

• Distributed physician-specific member level

detailed report on work to be done for the

coming year.

• Provided interim updates.

Result:

A significant increase of (approximately 10 – 15%

of the entire population) in the proportion of

members receiving each of the services.

The Potential Value of a Payer Beyond

Payment

Personnel Sharing:

1. Needs to make business sense for both entities.

2. “W.I.I.F.M” needs to continue to be satisfactorily

answered.

3. A potential means to an end (teach a person to

fish or fish for them).

4. Acknowledge relative strengths and weakness

in co-creating an approach.

Examples:

1. Existing physician based disease management

program with patient-specific careplans already

developed. These are shared with health plan

clinical staff who do interim telephonic outreach

reaffirming plans between visits to the office.

2. Establishing group visit sessions at an office

utilizing health plan staff for face to face service

initiation to be followed up telephonically.

Provider:

Clinician patient relationship. Wealth of patient specific clinical information.

Va l u e P r o p o s i t i o n

Health Plan:

Information systems experience (predictive analytics) assessing longitudinal care.

Information about care delivered to patients by other parts of the delivery system that a given

provider may not be aware of.