VIable

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