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Anthem rolls out new bonus system for docs

September 21, 2013

Anthem Blue Cross and Blue Shield is rolling out a new program that will pay Indiana primary care physicians extra money to manage the overall health of their patients.

The Indianapolis-based health insurer expects to pay, on average, $3.50 per month for every patient enrolled in one of Anthem’s commercial health plans. Those payments could be half as low for healthy kids or twice as high for an adult with multiple chronic diseases.

In addition, if a doctor’s Anthem patients spend less on health care in a year than their historical patterns, Anthem will share a chunk of those savings with the doctor.

Carlson-Cristo Carlson-Cristo

“Our goal is to help redesign the current payment model to move from volume-based to value-based payment,” said Meredith Carlson-Cristo, Anthem’s network director for payment innovation.

She said Anthem has yet to settle on a name for the program, which has so far been referred to as the Patient-Centered Primary Care, or PC2, initiative.

The concept is known throughout the health care industry as a patient-centered medical home. That means a doctor takes responsibility to coordinate all health care services that his or her patients need—whether provided by the doctor personally, or by a specialist or imaging center or hospital.

To do this extra work, physician practices use nurses, health coaches and even social workers to try to keep patients healthier and guide them through the complexities of the health care system.

The calculus for Anthem is that, if primary care providers spend more time with patients, they’ll do a better job at prevention and catch developing problems sooner. If it works as planned, such efforts would reduce patients’ trips to hospital emergency rooms or, perhaps, their need for expensive surgeries.

Anthem could save much more by avoiding hospitalizations than it pays in extra fees to doctors.

The program has been received favorably by physicians around the state, even as some say Anthem’s payments won’t completely cover the costs physicians will incur to meet the demands of the program.

The Indiana State Medical Association featured the Anthem program on the cover of its Sept. 3 newsletter to its physician members.

Dr. Ben Park, CEO of American Health Network, praised Anthem’s program. Anthem will require American Health’s physicians to document that they are providing high-quality care in 32 areas, which is similar to a Medicare “accountable care” program that American Health is already a part of.

“It’s good,” Park said. “It’s changing our behavior.”

American Health also participated in quality-based bonus payments that Anthem has been giving in recent years through a program called Quality Health First. That program is ending at the end of 2013, because Anthem’s parent company, Indianapolis-based WellPoint Inc., wanted to have a program that was consistent across the country.

The PC2 program will also offer doctors “shared savings” payments. Anthem said its payments could range as high as 35 percent of the money saved, compared with patients’ prior history of medical claims.

Anthem expects more than 1,000 doctors around Indiana to participate when the program kicks off in January. It thinks that number could rise to nearly 3,400 by 2016—which would represent 75 percent of the primary care physicians Anthem already has contracts with.

“We know not every primary care provider is going to participate,” Carlson-Cristo said during a Sept. 10 presentation on the PC2 initiative.

She added that physician practices that have fewer than 250 Anthem patients would probably not be able to cover the upfront expenses needed to participate in PC2. She said the “sweet spot” for the program is physician practices with 500 or more Anthem patients.

Not every patient in an Anthem plan will be eligible for the program. Seniors that are part of an Anthem Medicare Advantage plan are not eligible. Neither are patients in the Hoosier Healthwise Medicaid plan managed by Anthem.

But that still leaves a lot of patients who are. Anthem and its parent company WellPoint claim about 55 percent of all the commercially insured patients in Indiana.

To entice physicians to participate, Anthem is also offering to make analysts, pharmacists, social workers and other experts available to help doctors get better at managing patients’ health.

Between the Anthem and Medicare programs, Park said, 60 percent of American Health’s patients will now be covered by programs that pay financial rewards for managing patients’ health and reducing hospitalizations.

“That’s huge,” he said. “We still have some conflicting incentives, but it’s getting better.”•

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