Anthem - Enhanced Personal Health Care

Accountable Care Organizations (ACOs) and Patient Centered Medical Homes (PCMHs) operate under Anthem’s Enhanced Personal Health Care framework.  Based on the lessons and results of the ACO and PCMH pilots, Anthem launched Enhanced Personal Health Care in 2013 which represents its comprehensive, long-term strategy to migrate from a volume-based to a value-based health care model by augmenting traditional fee-for-service payments with a shared savings program that enables participating providers to share in any achieved savings (when actual health care costs are below projected costs) provided that they meet threshold performance on quality and utilization measures.  Enhanced Personal Health Care covers commercial, Medicare and Medicaid lines of business, fully insured and self-insured clients and is applicable to any provider organization with a foundation in primary care (ACOs; PCMHs; IPAs; IDNs; small, independent PCPs and hospitals). 

Enhanced Personal Health Care provides a standard framework and set of principles that guide Anthem's engagement with all provider organizations, starting with provider organizations with a foundation of primary care.  What will vary based on provider type and capabilities are the tools, resources and services that each party contributes to the arrangement. Anthem meets providers where they are and provides them with the tools/support they need to adopt a patient centered model that improves patient engagement, optimizes the health of the population and reduces medical cost trend.   As a result, providers are empowered to address the fragmentation, lack of coordination and barriers to access that drive redundant care, avoidable admissions and avoidable ER visits.

To move away from highly fragmented, episodic health care toward a patient centered model that is proactive, holistic, efficient and focused on the health and well-being of each patient, Enhanced Personal Health Care focuses on the following core principles:

• Risk-stratified care management
• Coordination of care across the continuum
• Shared decision-making and accountability between physicians and their patients/caregiver
• Ensured access
• Promotion of wellness and prevention
• Measuring and monitoring compliance with evidence based guideline

Performance Evaluation:

The shared savings bonus payment component of this program rewards providers for successful management of the quality and overall health care costs of our participating members.  To qualify for shared savings, providers must first meet cost targets.  If these targets are met AND providers meet a quality threshold, they are eligible to receive a portion of the shared savings.  If the provider does not meet the quality threshold, the provider is not entitled to share savings bonuses, regardless of savings generated.

We leverage nationally recognized measures of quality to support our shared savings framework for our risk sharing arrangements.  These include measures endorsed by the NQF, CMS (e.g., the CMS Accountable Care Organization set, the Medicare Stars Scorecard) and metrics adopted by nationally recognized specialty societies.  The program currently includes 29 quality metrics (listed individually below) across the following categories:

• Preventative care, including cancer screening, childhood immunization and well child visits
• Acute and chronic care, including diabetes-related measures such as Hba1c and lipid profile testing, and monitoring persistent medication

The Enhanced Personal Health Care program also includes three utilization metrics that impact the level of payment: avoidable ER visits, ambulatory sensitive inpatient admissions, and generic drug dispensing rate.