Q2 Learning Session: Presentation Slides by Healthcare Collaborative of Greater Columbus

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

Please save the following dates for 2012 learning sessions (7:30-10:30AM): â&#x20AC;˘ Friday, August 3 â&#x20AC;˘ Friday, December 7

Q2 Learning Session Sponsored by Nationwide

www.accesshealthcolumbus.org Coordinated by:

Strategic Partners:

Lead Support

Major Support

Additional Support

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

Catalyst for Spread of Patient-Centered Medical Homes Advance Best Practices for Modernizing Primary Care Delivery

Health Care Providers

Health Care Consumers

Improve PatientCentered Primary Care

Health Care Payers

Health Care Purchasers

Catalyst for Modernizing Health Care Purchasing & Payments

Measure Value of Shift in Resources to Primary Care

SPREAD: Patient-Centered Medical Homes (based on activities coordinated by Access HealthColumbus) 350,000 300,000 250,000

2012-2013 + 42 practice sites working towards NCQA recognition

200,000 150,000 100,000 50,000 0

2011 + 20 practice sites NCQA recognized 2010 9 practice sites NCQA recognized Patients Served by Patient-Centered Medical Homes

NCQA = National Committee for Quality Assurance â&#x20AC;&#x201C; Patient-Centered Medical Home National Standards

SPREAD: 2010-11 NCQA Recognized Patient-Centered Medical Homes 15 19 22 18 28 26 1

21 2 17 12 10 16 9 24 7 8 25 5 13 3 11

14 20 27

Note: based on activities coordinated by Access HealthColumbus

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

52 46 37 43 36 54 48 32 68

47 45 40 31 35 49 55 69

57 62

71 53

66 64 30 42

65 58 44 50 51

34 41

33 61 56 59 60

Note: based on activities coordinated by Access HealthColumbus

Modernize Purchasing/Payments: Participating Health Plans & Employers

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: Value-Based Purchaser Collaborative

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  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

Participating Purchasers (as of April 2012)

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

ADVANCE BEST PRACTICES: Improving Care Coordination 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 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 * Source: Agency for Healthcare Research and Quality

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

Better Care Coordination

Better Health Information Technology

PatientCentered Primary Care

Better Alignment of Incentives

Better Access

What is patient-centered primary care? TRADITIONAL APPROACH

PATIENT CENTERED APPROACH

Patients’ chief complaints or reasons for visit determines care

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

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

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

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

Care is standardized according to evidence-based guidelines

Patients are responsible for coordinating their own care

A prepared team of professionals coordinates all patients’ care

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

We measure our quality and make rapid changes to improve it

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

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

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

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

Clinic operations center on meeting the doctor’s needs

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”

Medicare Activity

Amy Rohling McGee President Health Policy Institute of Ohio

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

$1.7 trillion

4% prevention

50%

Health behaviors

96%

Medical services

20% Environment

20%

Genetics

10%

Access to care

Factors influencing health

National health expenditures

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.

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

Medicaid Activity

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

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

Medical Hot Spot:

Emergency Department Utilization: Ohio vs. US Hospital Emergency Room Visits per 1,000 Population

600

United States 500

436 400

365

452 366

450 372

Ohio 449 382

468 382

472 383

488 387

509 396

516 401

523

404

29%

300 200 100 0 1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

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.

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) 8

Non-SMI

7.01

6.75

Severe Mental Illness (SMI)

5 4.86

4 3

3.53

3.69

4.18 3.24

2.33

1 0 Diabetes

COPD

Congestive Heart Failure

Asthma

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

Medical Hot Spot:

A few high-cost cases account for most health spending 100% 80%

72%

23% 34%

45% 27%

60% 40%

50% 20%

66% 3%

Population

5% of the US population consumes 50% of total health spending

47%

28%

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

Spending

Most people (50%) have few or no health care expenses and consume only 3% of total health spending

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

Health Care System Choices Fragmentation

vs.

Coordination

 Multiple separate providers

 Accountable medical home

 Provider-centered care

 Patient-centered care

 Reimbursement rewards volume

 Reimbursement rewards value

 Lack of comparison data

 Price and quality transparency

 Outdated information technology

 Electronic information exchange

 No accountability

 Performance measures

 Institutional bias

 Continuum of care

 Separate government systems

 Medicare/Medicaid/Exchanges

 Complicated categorical eligibility

 Streamlined income eligibility

 Rapid cost growth

 Sustainable growth over time SOURCE: Adapted from Melanie Bella, State Innovative Programs for Dual Eligibles, NASMD (November 2009)

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

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

www.healthtransformation.ohio.gov

Health Plan & Employer Activity

Elizabeth Curran Head, National Network Strategy & Program Development Aetna

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

Overview â&#x20AC;&#x201C; Aetnaâ&#x20AC;&#x2122;s PCMH Program Elizabeth Curran

Aetna Inc.

Aetnaâ&#x20AC;&#x2122;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 Four physician associations representing approximately 333,000 physicians developed the following joint principles to describe the characteristics of the PCMH: •

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

Core Components of our PCMH Key Payment Program Components • Attribution • Efficiency • Quality • Chronic Conditions

Aetna Inc.

PCMH Core Components - Attribution 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

Aetna Inc.

PCMH Core Components - Quality 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 Aetna Inc.

PCMH Core Components - Efficiency 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 Aetna Inc.

PCMH Core Components â&#x20AC;&#x201C; Chronic Conditions Chronic Conditions Focus on conditions that can reasonably be managed by an primary care provider to improve the healthcare for the community.

Aetna Inc.

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

Aetna Inc.

Aetna participating NCQA PCMH recognized physicians

WY NV

NE UT

PA IL

DE MD DC

SC AL

0-10

11-100 FL

TN MS TX

NJ CT

101-300 301-1000

1000+

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. Aetna Inc.

Health Plan & Employer Activity

Julie Schilz Program Director Patient Centered Primary Care Transformation WellPoint

WellPoint Value Based Payment Innovation Julie Schilz BSN MBA Program Director, Patient Centered Primary Care Transformation

May 11, 2012

Challenges in the US health care system… The US Ranks last or next to last in key areas1: • Quality • Access

Structural Challenges • Fragmented system lacking primary care foundation

• Efficiency

• Lack of evidence-based care… driving variation

• Equity

• Misalignment of incentives

• Health lives

• Transaction-based system • Lack of transparency

• Limited focus on quality 1

The Commonwealth Fund – June 2010 47

Waste in the system Of the $2.7T spend on health care in the US, it is estimated that one-third of these costs â&#x20AC;&#x201C; $700B â&#x20AC;&#x201C; are waste1 Administrative and system inefficiencies Provider inefficiencies and errors Lack of care coordination Unwarranted use Preventable conditions and avoidable care Fraud and abuse % of total medical costs that is wasted

4-6% 3-4% 1-2% 11-21% 1-2% 5-8% 30%

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 48

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

Anthem has the capabilities to drive the transformation… and the responsibility to act Anthem’s strengths are uniquely positioned… Commitment to Quality

National Scale

Broad Local Presence

Clinical and Analytic Support Tools

Payment Innovation

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

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

Fragmented Health System lacking Primary Care Foundation

Care continuum is collaborative amongst all stakeholders and primary care access is enhanced

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

Transactional Operations

Population health management

Lack of Transparency

Access to consistent longitudinal clinical information across care continuum

Limited Focus on Quality

Leverage performance risk to collaborate on care and service quality 51

Changing Market Dynamics: require multiple approaches to transition towards value How is value captured?

High

 Transition from fee for service to valuebased payment model

Value Based Payments

ACOs Bundled/ Episodic Payments

 Manage population health by preventing disease progression and driving appropriate and value driven utilization

Patient Centered Primary Care P4P – (AQI QHP)

 Focus on operational cost reduction and clinical integration

EFFS

Low

Care Integration

High 52

Anthem’s Payment Innovation Portfolio: covers the span of innovation options Strategy

Outcomes

Offerings

Design

Quality

Cost

Enhanced Fee Schedule

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.



Payment incentives, care management extenders and data exchange to increase PC2 / PCMH population management quality and lower medical cost.



Share risk of cost variation with hospitals on select conditions



Gain share and risk share based on quality measure achievement and reduced PMPM medical costs



Bundled

ACO

CM Fee

Gain Share



Risk Share

 

Local PI Programs: leverage local presence to spread innovations across the country

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

Program Type

PC Pilot

Quality Improvement

Improved all diabetes measures

Inpatient Admissions/1K per year

Decrease 3.6%

ER Visits/1K per year

PC Pilot Yr 2

New Hampshire

New York

Dartmouth Hitchcock

PC Pilot

PCMH Pilot

ACO Pilot

Improved all diabetes measures

12 – 23% lower

Decrease 18% vs 18% increase in control

Decrease 3.6%

12 – 23% lower for PCMH Providers

Decrease 5.81%

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

Overall Medical and Rx Cost/ROI

Increase 1.3% in persistent Rx usage Overall ROI 2.5:1 - 4.5:1

Decrease 2.85% brand Rx usage 14.5% lower than non-PCMH Providers

3.4% PMPM reduction to projected cost 55

Patient Centered Primary Care – The Anthem Solution The goals of the PatientCentered 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

Better Access

Incentive Alignment

Care Coordination

Information Exchange

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

The PC2 Solution New transformation models should be PATIENT CENTERED to make an impact on care delivery Pillar 1

Pillar 2

Pillar 3

Pillar 4

Better Access to Care

Alignment of Stakeholder Incentives

Information and Transparency

Care Management & Coordination

PC2 Solution

Provider maturity levels will vary by market Stage 2: Align capabilities & stakeholders Stage 1: Smart first steps Provider Capabilities

Stage 1

Stage 2

Stage 3: Achieve sustainable model

Stage 3

 Limited knowledge and experience with population health management

 Access to systems / data to support population heath management

 Automated processes and systems to support population health management

 Limited availability of resources and staffing to support CM and coordination activities

 Shared resource for CM and coordination activities

 Fully dedicated resource for CM and coordination activities

 Basic knowledge of analytics and measures to monitor outcomes

 Actively utilize analytics to monitor outcomes

 Limited analytics  Minimal monitoring of outcomes

 Willingness to participate in alternative risk arrangements

 Knowledge of and/or participating in risk based fee arrangements

Our staged evolution meets physicians where they are and drives transformation to the next level STAGE 1: Smart first steps Primary care engagement

STAGE 2: Align stakeholders and capabilities Comprehensive enablement

Payment Models

• EFFS + Care Management payment + Phased Gainsharing

• FFS + Care Management PMPM + Gainsharing

Provider Maturity

• Transformation support to beginners PCPs for smart first steps

• Transformation of PCP maturity stage • Increased performance expectations

Care Management

IT Capabilities

• Aligned care management

• Core reporting set • Aligned care management workflows

Day 1

STAGE 3: Achieve sustainable model Refined steady state

• FFS + Care Management PMPM + Shared Risk • Performance risk bearing collaborative • Cross continuum clinical alignment

• Collaborative care management • Increased care and quality expectations

• Comprehensive care management across continuum

• 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 2

Day 3

PC2 Timeline PC2 Capabilities in Market 2012 Market

2013 Q3

Wave 1

CO OH NH NY VA CT

Wave 2

GA ME MO NV

Wave 3

WI IN KY

Phase 1 Capabilities

Phase 2 Capabilities 60

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

Health Plan & Employer Activity

Bruce Wall MD Medical Director OSU Health Plan

The Potential Value of a Payer Beyond Payment Bruce Wall MD, Medical Director, OSU Health Plan Friday, May 11, 2012

The Payment Continuum: U N I T

Care co-ordination fees

F E E

Pay for performance

S C H E D U L E

Bundled payment

Shared savings

VA LU E Volume risk of overutilization

Volume risk of underutilization

C A P I T A T I O N

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 â&#x20AC;&#x201C; 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. â&#x20AC;&#x153;W.I.I.F.Mâ&#x20AC;? 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.