Drivers of Payment Reform
• Increased attention to regional variation in costs and
quality
▪ Payment for care does not correlate with optimal outcomes
▪ Regional differences in health care supply, delivery and practice lead to variations in spending that do not correspond to health care quality
• Increased efforts to align payment incentives with
performance rather than volume
▪ Current FFS leads to inefficiencies in care
▪ Payment reform alternatives that reward lowest-cost/highest-outcome results are needed
Payment Innovation – Balanced Approach
Each strategy can include additional rewards and/or penalties related to quality of care goals, efficiency of care goals, other
aspects of care or care outcomes
Best Reforms to Pursue May Vary Based on Market Conditions
• Provider organizations
• Other delivery system infrastructure • Active payment initiatives
Fee-For-Service Enhancement
Procedure/Condition/
Episode-Based Payment Based Payment
Population-Performance Recognition Programs (P4P)
Accountable Care Organizations
The Accountable Care Organization (ACO) model is a
local health organization that is accountable for 100%
of the expenditures and care of a defined population
of members. The provision of value by ACOs will
require their coordination of care across all
continuums of care for the defined population.
Defining WellPoint Principles:
• 5 year relationship
• Transitioning to a global payment over the
term of the relationship
• Development of shared risks over the term of
ACO Criteria for Commercial PPO
WellPoint will contract with provider organizations which meet the criteria to operate as an Accountable Care Organization. These criteria include the following:
▪ A minimum population eligible for membership > 15,000 members
▪ Full complement of medical services with the exception of Transplants
▪ Must have a formal legal structure to receive and distribute reimbursement for member services
▪ An adequate network of ACO professionals to provide total care to the defined population
▪ Defined relationships with hospitals and physicians
▪ Demonstrated plan for reducing the cost of medical care
▪ Deploy an IT platform supporting the capture and electronic exchange of clinical information across the Ambulatory, Inpatient and Ancillary (lab, imaging, eRX, etc.) settings for the high volume ACO Professionals
▪ Electronic medical record system allowing for improved coordination of care
▪ A commitment from the senior leadership regarding the ACO initiative
Anthem ACO Model for 2011
All ACO partners will have the following features: Membership
• Defined by Attribution
Provider Network
• Full Network with the exception of Transplants Legal • Structure to receive / distribute savings • Management Structure IT • IT Infrastructure • Data Exchanges Medical Management
• Possible Delegated Medical Management
• Defined Processes to promote quality & coordinate care
Financial
Data Exchanges for ACOs
• Membership
▪ Electronic Membership File
▪ Membership additions/deletions
• Census
▪ Hospital Census ▪ Emergency Census
• Claims
▪ Two years of historical ▪ Monthly claims data file
• Medical Management
▪ Utilization Management ▪ Case Management▪ Disease Management
• Pharmacy
▪ Claims data files ▪ Analytic reports
• Reporting
ETG Attribution Overview
ETG Product: Symmetry/Ingenix Episode Treatment Group
Version 7.0.4.4
Purpose: to attribute members to an Accountable Care
Organization
Criteria:
▪ High probability of identifying members with a pre-existing clinical relationship with providers
ETG Attribution Overview (continued)
PPO Population for Anthem
Two years of PPO claims data
▪ Fully insured PPO lines of business
▪ Members with both medical and pharmacy claims ▪ Excluded members with no claims
ETG Exclusions
▪ Non-episodic Treatments ▪ Ungroupable Services
ETG Attribution Overview (continued)
Episode Matching Logic
Patient A Episode of Care
Provider Tax ID
Each Episode has a responsible Tax ID
Total Episodes
Calculate the total number of episodes for each patient
Match the total number of episodes for each
Tax ID
%
of patient’s episodes attached
Potential Payment Models
Examples Year 1 Year 2 Year 3 Year 4 Year 5
Option 1 FFS with yearly Reconciliation against a medical budget FFS with yearly Reconciliation against a medical budget Global PMPM with increasing risk sharing arrangement Global PMPM with full risk sharing arrangement
Global PMPM with full risk sharing arrangement Option 2 Global PMPM with partial risk sharing arrangement Global PMPM with increasing risk sharing arrangement Global PMPM with increasing risk sharing arrangement Global PMPM with full risk sharing
arrangement
Global PMPM with full risk sharing
Shared Savings – Quality Gate
Quality Gate
• Physician Quality Metrics • Hospital Quality Metrics Can participate in upside savingsQuality Metrics - Physician
• Breast Cancer Screening • Colorectal Cancer Screening
• Childhood Immunization Status (MMR + VZV) • Chlamydia Screening in Women
• HbA1C Screening • LDL Screening
• Nephropathy Monitoring
• Cholesterol Management LDL Screening
(Pts with/ Cardiovascular Conditions)
• Use of Imaging Studies for Low Back Pain
• Appropriate Testing for Children with Pharyngitis • Appropriate Treatment for Children with Upper
Respiratory Infection
• Avoidance of Antibiotic Treatment of Adults with Acute
Bronchitis
Quality Metrics - Hospital
▪ JC/CMS NHQM – AMI, PN, CHF & SCIP ▪ ACC Metrics for Cardiology
▪ STS metrics for Cardiac Surgery
• Deep Sternal Wound Infection • Prolonged Ventilation
• Operative Mortality for CABG • Surgical Re-exploration
• Pre-operative Beta Blockade
▪ National Healthcare Surveillance Network –
• Central line associated bloodstream infections • Ventilator associated pneumonia
• Catheter associated urinary tract infections
Draft Efficiency Score Card
Categories Metrics Points
Emergency Department Aggregated total - avoidable
visits per 1000 25
Prescription Medications
Rx pmpy or Rx/1000
Generic Prescribing rate 25
Imaging
Spine MRIs per 1000
Spine CTs per 1000 25
Abdominal CTs per 1000
Inpatient
Admits per 1000
Days per 1000 25
Current State
Initiatives for Jan 2011 implementation
▪ California
• Monarch Healthcare
• HealthCare Partners
• Sharp (Sharp Community & Sharp Rees-Stealy)
▪ New Hampshire
• Dartmouth Hitchcock
Pending Projects for later in 2011
▪ Expansion to other Anthem states ▪ Medicare Advantage
ACO Process for New Markets
Implementation Team
▪ Leverage SME’s ▪ Time table: 4 months
▪ Established multi-functional workgroups
• IM/IT • Actuary/Heathcare Analytics • Medical Management • Contracting/Network • Communications • Product Maintenance Team
▪ Local PE&C team ▪ PRG team
ACO Implementation Discussion Items
• Membership
▪ Lines of Business
▪ Member Attribution for PPO members
▪ Narrow focus (chronic disease) vs population focus ▪ Leakage
• Medical Management Opportunities
▪ Delegated Medical Management
▪ Understanding where medical costs can be better managed
• Site of Service • Pharmacy
• ED
• Operation Issues
▪ Communications • Member Notification • Employer Notification • Broker Notification ▪ Electronic eligibility • Additions/Deletions to membership▪ Reporting and Data Exchange
• Payment Methodologies
• Performance Metrics
▪ Quality Metrics ▪ Efficiency Metrics
2012 Draft ACO Products – California
ACO Core
• Only ACO Providers can be accessed
• Regional Offering where ACO presence is strong • Self Refer Option within ACO network
• Most Aggressively Priced Option
ACO Flex
• 3 Tier PPO offering
• Tier 1 – ACO Providers • Tier 2 – PPO Providers
• Tier 3 – Non Contracting Out of Network Providers • Flexibility to move between Tiers when accessing care