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HLCCompendium
HLCCompendium
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NDHI<br />
NAT IONAL DIALOGUE FOR<br />
Healthcare Innovation<br />
Enhanced Personal Health<br />
Care Program<br />
Organization Overview<br />
• Anthem, Inc. is one of the nation’s leading health<br />
benefits companies, offering a broad range of<br />
medical and specialty products and covering one<br />
in nine Americans’ health benefits<br />
• Anthem aims to transform healthcare with trusted<br />
and caring solutions<br />
Background<br />
The U.S. provides low-quality healthcare relative to<br />
other industrialized nations, despite spending nearly<br />
eight times the international average on delivering<br />
that care. Much of this wasteful spending is thought<br />
to originate from the misaligned financial and clinical<br />
incentives between providers and payers, which has<br />
ultimately led to low-value care for patients.<br />
As a result, policymakers are seeking to shift healthcare<br />
into value-based payment (VBP) models, in which<br />
reimbursement is tied to care quality and outcomes.<br />
The U.S. Department of Health and Human Services<br />
(HHS) has published ambitious goals for implementing<br />
VBPs. By 2018, HHS expects to migrate 90% of all<br />
Medicare payments to quality- or value-based programs<br />
and at least 50% of all Medicare payments to<br />
alternative payment models.<br />
Private payers have also been rapidly transitioning to<br />
these models over the last five years. Anthem was an<br />
early adopter – today, more than 50% of commercial<br />
plan payments are linked to quality, with over 37% of<br />
payments made through alternative payment models.<br />
Anthem aims to continue expanding its VBP programs<br />
with provider systems. In order to create a collaborative<br />
approach to VBPs in primary care, Anthem established<br />
the Enhanced Personal Healthcare (EPHC) program.<br />
Program Details<br />
EPHC has three main goals:<br />
1. Support providers’ transition to VBP by providing<br />
financial, clinical, and analytic support as well as<br />
contract flexibility based on system sophistication<br />
2. Improve patients’ quality and experience of care,<br />
as well as their health status and outcomes<br />
3. Slow the growth of total cost of care, in order to<br />
ensure the affordability of high-value coverage<br />
To participate, EPHC providers agree to:<br />
• Provide 24/7 access to members through extended<br />
hour and/or after hours call coverage<br />
• Have a dedicated position within their practices<br />
that supports participation in EPHC and practice<br />
transformation<br />
• Participate regularly in collaborative learning<br />
sessions and use support tools, such as<br />
hot-spotting reports, to identify gaps in care<br />
• Use a disease registry to manage care for patients<br />
with certain chronic conditions and engage in care<br />
planning for the high-risk population<br />
• Use generic prescription drugs when clinically<br />
appropriate<br />
• Engage in quality and performance measurement,<br />
and meet appropriate performance standards on<br />
nationally endorsed quality measures<br />
While the program design is flexible, most<br />
providers receive:<br />
• Upfront clinical coordination payments, to offset<br />
the costs of care coordination and program imple-<br />
An Initiative of the<br />
5 |<br />
Enhanced Personal Health Care Program