Leading the Way in Transforming Health Care

His team not only ensures that these members have access to high quality care, but also must operate effectively under the strict financial constraints of publicly funded programs.

“In the government space, you are really forced to contain costs while innovating and thinking through the complexity of managing the health of a population with a lot of challenges,” says Haytaian. “I call it ‘doing well by doing good’—operating successfully as a business while also meeting the needs of a vulnerable segment of society.”

“In this business in particular, you can see a dramatic impact on the quality of care by the little things—like helping a pregnant mom get her baby off to a healthy start in life,” he adds. “All of us on the team feel good knowing that we can help improve people’s lives in important ways.”

Anthem’s government business team is doing well by doing good on a large scale, growing by 600,000 new members in 2016. This represents an additional $5 billion in revenue for the year, which exceeded expectations. Anthem’s Medicaid teams won all six of the state Medicaid contracts they bid on in 2016.

Anthem Medicaid Contracts

2016 Medicaid Contracts  Medicaid Programs

 

600K

New Members

Anthem’s government business division grew by 600,000 new members in 2016

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51%

of Medicare Advantage members in 2017 are enrolled in plans that achieved four stars or higher

compared to

22%

of Medicare Advantage members in 2016 were enrolled in plans that achieved four stars or higher

Anthem’s Medicare business is also well-positioned to meaningfully grow membership in 2017 and beyond, as the result of significant company investments over the past three years. In the most recent star quality ratings released by the federal government’s Centers for Medicare & Medicaid Services, Anthem’s Medicare Advantage 2017 plans scored significant increases—with nearly 51 percent of Anthem’s Medicare Advantage members enrolled in plans that achieved four stars or higher (on a scale of five stars). By comparison, 22 percent of members in 2016 were enrolled in plans that achieved four stars or higher.

The government business division’s growth comes as the Affordable Care Act (ACA) broadened Medicaid beyond the traditional focus on mothers and children to provide services to all non-elderly adults at or below 138 percent of federal poverty. The ACA also encouraged states to provide more social support services like housing and employment assistance.

“We’ve really moved beyond serving just medical needs to taking a holistic approach to member health,” Haytaian says. “We’re working to ensure community resources come together cohesively for members, because the lack of one of those services—like housing—can translate into further medical problems. Health care is a critical part of an interconnected web of social services that together can make a huge difference in the well-being of people and their communities.”

Dr. Sepideh Chegini, regional medical director for CareMore’s Los Angeles and Orange County operations, and her team work to better coordinate the care of what can be a population with complex health issues—some patients are still very active, while others are dealing with chronic conditions, and still others may not be appropriately managing multiple health issues and conditions. Dr. Chegini and her team work daily—in a highly coordinated and interactive manner—to improve the lives of the patients they see—and it is working. This is a model that Anthem is now incorporating into its Medicaid programs and individual health benefits.

“What is quality health care, and what is a quality outcome? The answer is actually a very personal issue—it’s different for elite athletes compared to someone with complex medical conditions,” Mathai says. “Twenty years after my graduate studies, I’m still very passionate about helping people find their personal health care solutions.”

In her role as vice president of account management for Anthem’s national accounts, Mathai now helps some of the biggest companies in the U.S. create their own personalized approach to offering health care to their employees. Innovating to meet the needs of Fortune 500 companies is a big responsibility, but it’s one that Mathai and her team are well positioned to consistently deliver.

“Our account executives must know our companies inside and out to serve them well—we have to be closely tied into their business challenges and understand the environment in which they operate,” she says. “We’re helping customers solve for bigger problems beyond answering their customer calls and paying medical claims; we’re helping them gain a competitive advantage by offering benefits that attract and retain top talent while also controlling costs.”

For Kroger Co., parent of Harris Teeter, Ralphs, Kroger supermarkets, and several other banners, a key challenge is managing the health of some 150,000 associates in their company-sponsored health care plan spread across the country. The grocery business runs on tight margins, so cost management is a major priority. But Kroger’s workforce can’t shoulder high deductibles or other cost-shifting approaches typically used by many employers.

In response, Anthem’s recently launched integrated medical, dental and vision insurance program provided a unique opportunity to help Kroger identify and manage health issues at an early stage for its insured population before those issues spiraled into costly medical events. For example, if an ophthalmologist seeing a patient for an annual eye exam notices a high blood pressure reading, that information is flagged to the member’s primary care doctor—who can then get the member in for early treatment of high blood pressure before it leads to serious health issues.

“What we’re starting to see with programs like this one is early identification of gaps in care or health issues so doctors can intervene, and intervene earlier,” Mathai says. “Improved healh and quality care will lead to lower cost of care, and better compliance around evidence-based guidelines.”

According to Mathai, programs that integrate benefits are just the beginning of a new era in managing health benefits in which payers can share information with providers to make critical early interventions and employers have new ways to measure outcomes and manage population health.

“The health care industry has been fragmented, but Anthem—as a leading provider of innovative health care solutions—can play a huge role in helping to make health care more personalized and effective for employers and consumers,” she says.

Customer Care Representative Aaron Person is the voice of Anthem. He embodies Anthem values in every call he takes—easing concerns, resolving questions and guiding members through their health benefits, often at one of the most stressful times in the lives of members.

Anthem has made collaboration with providers one of its highest strategic priorities. That strategy has grown beyond offering payment incentives that reward prevention and quality care, to a deeper collaboration in which we foster success by giving doctors and hospitals the support they need to thrive under those arrangements.

Shifting from a system that pays doctors for the volume of care they deliver to one that compensates them for the quality and efficiency of care they provide is not a small task. Anthem is providing doctors and hospitals with the tools and data they need to make this shift, but also prompting the cultural shifts that will make the transformation successful.

“We’re moving from being the payer of claims to the partner that provides solutions across the doctor’s patient base,” says Lakhani. “Provider groups vary dramatically in their level of experience and sophistication with value-based payment programs, so we have to come to the table and meet them where they are to help them on this transformational journey,” she adds.

For example, Anthem provides doctors participating in its value-based health care contracts with free software that flags patients’ missed follow up visits, prescription drug refills and other actionable information. A team of care consultants in every market works full time to help providers apply Anthem’s tools and technology, such as helping to create action plans to successfully identify and reach out to high-risk patients struggling to manage diabetes so that those patients stay healthy, manage blood sugar levels and avoid ER and hospital visits.

Lakhani and her team are constantly working to analyze member data so participating doctors can identify their high risk patients. In real time, the team can identify practices in which there are opportunities to close a care gap with a patient before it spirals into a major—and costly—medical crisis.

“Instead of leaving patients on their own to deal with the specialist and the labs and the pharmacy, value-based care is about making it easier for the patients to navigate the system—by connecting and coordinating that care,” Lakhani says. Enhanced Personal Health Care is Anthem's umbrella strategy covering all of our patient-centered care and value-based contracting initiatives.

Doctors participating in EPHC (and receiving value-based payments) had $14.08 per member per month, or 3.5 percent, in gross savings in medical costs compared to expected trend as of September 2015. That resulted in $11.34 per member per month in net savings.

Anthem’s family of health plans counts more than 64,000 doctors receiving value-based payments, and the company is committed to having 50 percent of its spending in shared savings and shared risk contracts by the end of 2018, up from more than 43 percent now.

The effort appears to be paying off for members and providers alike. Members who see a primary care doctor participating in Anthem’s value-based payment program rate their overall provider experience higher than members who see a doctor outside the program—noting that they have better communication and access to their doctor outside typical office hours. Their doctors are also more likely to deliver high quality care, making sure that patients get recommended preventive care, such as breast cancer screenings, diabetes eye exams, and measles, mumps and rubella vaccinations.

Sherry Dubester, vice president of Behavioral Health and Clinical Programs, and her team are taking these successful strategies and applying them to address other significant public health concerns, such as diabetes, cancer care, behavioral health and wellness.