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State-Wide Program for Care Improvement in New York’s Underserved Communities

Rationale / Objectives

Despite being the most costly in the world, US’s healthcare system is lagging behind other countries and failing to deliver consistent value to the people who use it every day.2 In many underserved communities of New York, inequality and high cost of healthcare limit accessibility to its residents.

Project/Program Description & Major Achievements

Empire Blue Cross, as part of Anthem Blue Croos Blue Shield launched the Enhanced Personal Health Care Program. This allows primary care physicians (PCPs) to improve quality, patient experience and affordability. Since its beginnings in 2012, participation has grown to 47,000 Anthem network providers who care for more than 3.8 million Anthem members – a number projected to reach 4.4 million by the end of 2015.

Lessons Learned

The program has lots of potential to growth. Opportunities are growing for telemedicine, after-hours access in retail settings, and the involvement of other health professionals in care teams. 4

Further Description

Enhanced Personal Health Care is Anthem Blue Cross Blue Shield's “marquee value-based payment initiative and part of a national collection of programs called Blue Distinction Total Care”. “Participating Anthem providers are compensated with both up-front care coordination payments and the opportunity to earn shared savings in recognition of high-quality, efficient care”.1 4 Anthem aimed to:

  • Make a significant investment in primary care that allows primary care physicians and their practice team to: manage all aspects of their patients’ care.
  • Provide primary care physicians with tools, resources and meaningful information that, lead to improved quality and affordability for our customers and their patients.
  • Help redesign the current payment model to move from volume based to value based payment.
  • Improve the patient experience by:
    • creating better access to a primary care physician who will not only care for their “whole person” but will become their health care champion and help them navigate through the complex health care system
    • making them active participants in their health care through shared decision making, and
    • optimizing their health 2

To be eligible, physicians had to have a 10 percent Medicaid patient volume. To participate, practices had to commit to following patient-centered principles of care. Under the project, the department agreed to pay the software licensing fees for eligible practices, provide on-site training and tools, and help practices obtain National Committee for Quality Assurance recognition.4 This strategy will shift primary care reimbursement from a volume-based model, in which physicians are paid only for patient encounters, to a value-based model that rewards quality and efficiency and compensates doctors for clinical interventions that occur outside a traditional office visit. 5

Major Achievements

Since its beginnings in 2012, participation has grown to 47,000 Anthem network providers who care for more than 3.8 million Anthem members – a number projected to reach 4.4 million by the end of 2015. Across the five states in which data was available, Anthem found a gross medical savings of $9.51 per attributed member, per month (PaMPM), or about $130 million in savings for the entire set of members attributed to Anthem providers over the period studied. 4

Metric Result Detail
Hospital Visits:   11% fewer ED visits for adults; 17% fewer visits for children   Health Affairs (September 2012)
Improved health Lower rates of inappropriate antibiotic use (27.5% v. 35.4% p<.001)  
Cost savings 14.5% lower PMPM* for adults 8.6% lower for children
Preventive Services 5% increase in HbA1c* testing

*risk-adjusted total per patient per month *key indicator of diabetes control 5