Anthem’s Enhanced Personal Health Care program represents a significant shift in healthcare, moving away from a system focused on volume to one that prioritizes value. This innovative program builds upon the foundations laid by Accountable Care Organizations (ACOs) and Patient Centered Medical Homes (PCMHs), taking the lessons learned from these pilot initiatives to create a comprehensive, long-term strategy. Launched in 2013, Anthem Enhanced Personal Health Care fundamentally restructures payment models by supplementing traditional fee-for-service arrangements with a shared savings program. This program incentivizes healthcare providers to deliver high-quality, efficient care.
Core Principles of Enhanced Personal Health Care
The Anthem Enhanced Personal Health Care Program is built upon a set of core principles designed to foster a patient-centered healthcare experience. These principles are intended to guide Anthem’s collaborations with all types of provider organizations, particularly those rooted in primary care. The program recognizes that different providers possess varying capabilities and therefore tailors the tools, resources, and services offered to meet them where they are. The ultimate goal is to empower providers to adopt a proactive and holistic patient care model. The key principles include:
- Risk-Stratified Care Management: This principle emphasizes tailoring care management strategies to the individual risk levels of patients. By identifying and addressing the specific needs of different patient segments, resources can be allocated more effectively, leading to better outcomes.
- Coordination of Care Across the Continuum: Fragmentation in healthcare can lead to inefficiencies and poorer patient experiences. Enhanced Personal Health Care prioritizes seamless coordination of care across all settings – from primary care to specialist visits, hospital stays, and home healthcare.
- Shared Decision-Making and Accountability: A patient-centered approach necessitates that decisions are made collaboratively between physicians and their patients (and caregivers, when appropriate). This shared responsibility fosters patient engagement and adherence to treatment plans.
- Ensured Access: Timely and convenient access to care is crucial. The program aims to break down barriers to access, ensuring patients can receive the right care when and where they need it.
- Promotion of Wellness and Prevention: Proactive healthcare is better and often more cost-effective than reactive treatment. Enhanced Personal Health Care emphasizes wellness programs and preventive services to keep patients healthy and reduce the likelihood of future health issues.
- Measuring and Monitoring Evidence-Based Guideline Compliance: To ensure quality and effectiveness, the program incorporates mechanisms for measuring and monitoring provider adherence to established, evidence-based clinical guidelines.
Performance Evaluation and Shared Savings
A cornerstone of the Anthem Enhanced Personal Health Care program is its performance evaluation framework, which includes a shared savings component. This element is designed to reward providers who effectively manage both the quality and the overall cost of healthcare for Anthem members. To be eligible for shared savings, providers must first achieve predetermined cost targets. Meeting these targets is only the first step; providers must also meet or exceed a defined quality threshold.
If both cost and quality benchmarks are met, providers become eligible to receive a portion of the savings generated – that is, the difference between actual healthcare costs and projected costs. Crucially, if a provider achieves cost savings but fails to meet the quality threshold, they will not receive any shared savings bonuses. This mechanism ensures that cost savings are not achieved at the expense of quality of care.
Quality and Utilization Metrics
Anthem’s program utilizes nationally recognized quality measures to assess performance within its shared savings arrangements. These measures are drawn from reputable sources such as the National Quality Forum (NQF), the Centers for Medicare & Medicaid Services (CMS) (including the CMS Accountable Care Organization measure set and the Medicare Stars Scorecard), and specialty societies recognized at the national level. Currently, the program incorporates 29 quality metrics spanning key areas of care, including:
- Preventative Care: This category encompasses vital preventative services such as cancer screenings, childhood immunizations, and well-child visits, all aimed at promoting long-term health and well-being.
- Acute and Chronic Care: This area focuses on the management of both acute and chronic conditions. Examples of metrics include diabetes-related measures like HbA1c and lipid profile testing, as well as the monitoring of persistent medications to ensure appropriate and ongoing care for chronic illnesses.
In addition to quality metrics, the Enhanced Personal Health Care program incorporates three utilization metrics that directly influence payment levels. These metrics are:
- Avoidable ER Visits: Reducing unnecessary emergency room visits is a key focus, as ER care is often more expensive and less efficient for non-emergency conditions.
- Ambulatory Sensitive Inpatient Admissions: These are hospital admissions for conditions that, ideally, could be managed effectively in outpatient settings. Lowering these admission rates reflects better preventative and primary care.
- Generic Drug Dispensing Rate: Promoting the use of cost-effective generic medications, when clinically appropriate, helps to manage overall healthcare costs.
By focusing on these core principles, performance evaluations, and key metrics, the Anthem enhanced personal health care program strives to create a more efficient, patient-centered, and value-driven healthcare system.
