Interview: Dr. Michael Belman, M.D., Medical Director of Payment Innovation, Anthem

Recently, Anthem Blue Cross of California reported that four medical groups within its Accountable Care Organizations (ACO) saved $14.8m in one year. Savings were attributable to a 7.7% reduction in inpatient days/1000 and almost 3% decline in outpatient length of stay.

State of Reform sat down with Dr. Michael Belman,M.D., Medical Director of Payment Innovation at Anthem, to discuss the EPHC program, and plans to expand this further.

Q: The $14.8m in savings is from four medical groups within Anthem’s ACO.  Are you seeing comparable trends of cost savings in other medical groups’ inpatient, outpatient, and pharmacy? Would you say that this example is an average or exceptional case with the EPHC program?

A: We have a limited number of medical groups that are ACOs, currently a little over 20 at this time, and this particular group was the second cycle to start. These savings are similar to what we saw in the first group and what we are seeing in other groups. Overall, we are looking at a subset of our total PPO population, only 25% of our total PPO are within ACOs.

Q: What other indicators does Anthem use to measure +/- in quality of patient care? How is this data reported to Anthem by ACO members?

A: These particular measures noted in our release are regarding utilization and cost data. But a critical and essential component are a set of quality metrics that track the usual HEDIS measures for quality for preventative health in mammograms, cervical cancer screening, and childhood immunizations, and a set of chronic diseases measures for diabetes, asthma, etc. Those measures are a critical component, and we only pay savings in the groups that achieve a significant threshold in the quality measures , and all of these groups did. It is both a quality and a cost savings measure that we look at. These are reported by PPO members, not capitated members in the HMO, where there are sometimes issues with claims. In this population we have the claims for these members, so we know from the claims whether the mammograms were done or not, and then we have the claims for the services delivered in terms of what was done in the hospital or outpatient physician reimbursement and prescriptions, and that is what we use for the measurement.

Q: Are there plans to grow the EPHC program to include more medical groups in the state?

A:. Yes, we have gradually increased, and we are above 20, and have added a couple more this year and there are others in the pipeline. The plan is to expand. Up until now, we started off trying to cover as much of the state as possible, so on the total list of the groups that we have, we have groups from San Diego up to Humboldt, which includes both the coast and then Inland through Fresno and the Sacramento area. We added a group in the Inland area this year, Primecare, which started a couple of months ago.

What is encouraging is that in most cases, in the majority of groups that we are dealing with, we have achieved significant savings, which is very encouraging. We also find that on the part of the groups that we work with, that there has been a very positive response from their end in terms of being able to better manage the PPO population now.  Hopefully the members, as a result of  improved utilization can reduce hospitalization, ER visits and the like, and have a positive impact on them. Overall, we are certainly encouraged, and it is reason for us to continue to push forward and expand this further.