Behavioral Health –Value-Based Care Evolution

Charles Gross, PhDVice President Behavioral Health AnthemOpen Minds, Strategy and Innovations Institute, New Orleans, LAJune 6, 2018

“What is this?”

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About Anthem

Purpose Statement

Together, we are transforming health care with trusted and caring solutions

OUR MEMBERS

active grant dollars across our communities

$30 million

dispersed through 2017 associate Engagement programs

$4.5 million

about 50,000

21states and DC

14 statesBC or BCBS plan Medicaid presenceindividuals served

56,000

associates

Figures represent 1Q18 data

nearly 40 milliontotal medical members in affiliated health plans

1 in 8 Americans

over 74 milliontotal lives served

BC or BCBS licensed plans (6)

BC or BCBS licensed plans + Medicaid presence (9)

Medicaid presence (12)

`

over

74M

more than

associate volunteer hours logged in 2017

claims processed

749.3million

BENEFITS & CUSTOMER SERVICE

benefits paid

$264.6billion

servicecalls

51million

MEMBERSHIP & MARKET PRESENCE

Member access through the national BlueCard® PPO Program

SUBSIDIARIES

of physicians

Anthem: A Health Benefits Leader

5Except where otherwise noted, all figures represent end of year 2017 data.

93% 96%of hospitals

40%

20%16%

14%

4% 4%2%

LocalGroup

NationalAccounts

Medicaid BlueCard® Medicare FEP Individual

Local Group15,600

National Accounts7,800

Medicaid6,400

BlueCard®5,600

Medicare1,700

FEP1,500

Individual755

(in 000’s)

Anthem’s Enterprise Commitment to Value-based Care

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Menu of Payment Models Programs at Scale Unmatched Presence

Pro

vid

er r

isk

& s

op

his

tica

tio

n

Partial and GlobalCapitation

Joints, Maternity, Cardiology, Transplants

Bundled Payment

Upside only, Shared Risk, Multi-Payer

Shared Savings

Hospitals and Primary Care

Pay for Performance

159 Accountable Care Organizations (ACOs)

>76,000 providers in shared savings/shared risk contracts

7.3M members attributed to ACOs and PCMHs

805 Hospitals in Commercial P4P programs

192 groups in Medicaid Specialist P4P pilots

58%

57%

45%

45%

% Total medical spend in payment reform programs including

Pay for Performance

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Current BH Value-Based Payment Portfolio

It takes a village…

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Individuals with behavioral health conditions require unique attention and coordination across a broad care team to ensure successful treatment of not just

their behavioral health needs, but of their physical health

Value-based payment and Behavior Health: Challenges

Integrating

physical andbehavioral health

Enhancing

alternativepayment models

Maintaining

network adequacy

Attracting

and designing value-based payment

models for BH providers attractive to both sides

Our Current Outpatient Provider Footprint

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Care Efficiency / Utilization Metrics

• Acute Behavioral Health Inpatient 30-Day Readmissions

• Emergency Room (ER) Utilization

• PCP visits*

Quality of Care Metrics

• 7-Day Follow-Up visit after Mental Health Inpatient Discharge (FUH)

• 30-Day Follow-Up visit after Mental Health Inpatient Discharge (FUH)

• Follow –up care for children prescribed ADHD medication – Initiation Phase (ADD)*

• Antidepressant Medication — Initiation (AMM)

• Antidepressant Medication — Continuation (AMM)

• Diabetic Screening for Members with Schizophrenia and Bipolar Disorder on Antipsychotics (SSD)*

• Diabetic HbA1c Testing (CDC)

• Initiation of Alcohol and Other Drug Dependence Treatment (IET)

• Engagement of Alcohol and Other Drug Dependence Treatment (IET)

Both our Commercial and Medicaid lines of business offer outpatient BH provider incentive programs based on quality and care efficiency performance

– The Behavioral Health Quality Incentive Program (BHQIP) launched in 2016

– The Behavioral Health Provider Incentive Program (BHPIP) launched in 2017

The programs utilize a common set of quality and care efficiency metrics to provide outpatient providers with an incentive opportunity based on year over year improvement and performance vs. peers.

Our Current Outpatient Provider Footprint – Cont.

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In 2017 we also launched our multiple Behavioral Health Medical Integration Program (BHMIP) pilots in Commercial markets.

These pilots utilize the standard outpatient quality and utilization metrics while including additional focus on care coordination with PCP partners through:

– Care Compact adoption

– Joint Accountability for key physical health quality measures with BH influences

Early learnings from our Commercial work will inform similar pilots in our Medicaid markets in 2018

50,000 attributed members

87 practices

16 markets

Our full outpatient footprint coverage

Measures follow-up appointment compliance after inpatient discharge for SUD

• 7 and 30 day versions of the measure

Focused on evaluating the successful transition and hand-off of patients from inpatient care into the outpatient arena

Measures readmission after hospitalization for SUD (“timer” starts 2 days post discharge)

• 30, 60 and 90 day versions of the measure

Focused on evaluating success of original inpatient

treatment in preventing relapse

Our Current Facility Partner Footprint

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Follow-up After Hospitalization

Readmission Outcomes

The Commercial line of business launched a targeted program for substance abuse facility partners in 2017, aimed at:– Promoting successful transitions out of

inpatient / residential care for SUD

– Avoidance of near-term readmission backinto a facility setting post-discharge

A portion of a facility’s overall reimbursement is at risk based on performance

The program currently began with 8 pilot partners across 7 markets and is expected in expand across all Commercial markets in 2018

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Where We’re Headed

Our Go-Forward Specialty Strategy

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ACO and PCMH models that focus on total cost of care put the weight of the cost “world” entirely on the shoulders of the primary care physician.

The problem with this approach in isolation is that specialists hold the reigns of considerable portions of the total cost picture and command a powerful seat at the table within the medical ecosystem.

Today specialists income opportunities favor procedures and high cost services over coordination with primary care and cost effective treatment regimens. There is a critical disconnect with the goals of the ACO / PCMH model.

The healthcare system needs a holistic payment framework for specialists that promotes alignment with high quality care and total cost management.

Specialty Care – Building Supportive Partnerships

Acute & Chronic Bundles

Payment for Chronic Mgmt.

& eConsults

Targeted Repricing

Value-Based FFS

Adjustments

Acute & ChronicBundled Payments

Specialist accountability for episodic cost of care

Chronic Care Management & eConsult Payments

New reimbursement for coordination with primary care

in an optimal fashion

Targeted Repricing

Analytically informed repricing of services that

are value unbalanced

Value-Based FFS

Adjustments up or down to the broader fee schedule based on specialty specific

care coordination, quality and cost efficiency measures.

We’re launching a new payment chassis that aligns specialist incentives with Accountable Care concepts and supports primary care in their pursuit of driving quality and impacting total cost of care.

Focus on Selected Specialties

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Primary Care

Cardiology

General Surgery

Endocrinology

Oncology

Orthopedics /

Neurosurgery

Behavioral Health

OBGYN

eConsultsCAD

Chronic Bundle

PCI Acute Bundle

Cardiology

Acute Knee/HIP

Bundle

Targeted Repricing

Orthopedic Surgery

Core Specialties Key cost of care impact areas

Existing acute / chronic bundle definition opportunities

Repricing opportunities for select services

Tailored ApproachesPillar combinations that make

sense for each specialty

Specialty Payment Chassis – Pillar 1

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Acute & Chronic Bundles

Acute BundlesProcedural Bundles

• Retrospective & Prospective

• Usually non-recurring

• Specific pre-to-post defined set of services to the procedure

• Clear site-of-care opportunities

Chronic/Condition Bundles

• Retrospective

• Often recurring in nature –annual or semi-annual snapshots of episodic care

• Cover all the care reasonably associated with a condition

• Savings focused on avoidable procedures / admissions

Payment for Chronic Mgmt. & eConsults

Specialty Payment Chassis – Pillar 2

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Reimbursement for non-visit based activities

Chronic Care Management Fees

Interprofessional Virtual Consultations (eConsults)

• Care planning

• Management of care transitions

• Supports team-based care concepts

• Provides reimbursement for specialist input without a face-to-face patient encounter

Change Healthcare Collaboration

• Coronary Artery Disease (CAD)

• Diabetes

• Low Back Pain

• Joint Degeneration

• Cancer*

• Depression & Anxiety

• Substance Use Disorder

In April of 2018, Anthem launched a new bundled payment analytics platform, HealthQX, in partnership with Change Healthcare

HealthQX utilizes third-party bundle episode definitions leveraged from the Prometheus model

Acute Condition Examples

• Maternity (C-Section & Vaginal Delivery)

• CABG / Valve Procedures

• Colonoscopy

• Coronary Angioplasty

• Hysterectomy

• Knee Replacement

• Lumbar Laminectomy

• Upper GI Endoscopy

Chronic / Long-term Condition Examples

• Cancer

• Coronary Artery Disease

• Depression & Anxiety

• Diabetes

• Gastro-Esophageal Reflux Disease

• Hypertension

• Low Back Pain

NOTE: This represents a sample of 90+ episode definitions available under the Change Healthcare platform.

Behavioral Health Bundled Payment Opportunities

While Physical Health conditions make up the majority of bundle opportunities, the Prometheus suite includes multiple BH related conditions:

These conditions are currently under evaluation for potential use in either case-rate / global bundle models and/or to establish monthly management payment models for these conditions

The alternative payment model for opioid use disorder (P-COAT) recently proposed by AMA/ASAM is also under review

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• Attention Deficit Disorder• Bipolar Disorder• Depression & Anxiety

• Schizophrenia• Substance Use Disorder

Continued Evolution of Existing Program Structures

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We expect to pilot two additional Medicaid payment model types in 2018 (in addition to the Integration program):

We’re working to leverage of substance use disorder incentive program learnings to launch a SUD center of medical excellence network in 2019

A Behavioral Health Facility Incentive Program (BHFIP) focused on general behavioral inpatient conditions, but

utilizing similar metrics to the Commercial SUDFIP program for substance abuse

A Pediatric Residential Treatment Quality Incentive Program (PRTQIP) for licensed

residential treatment centers for populations <21 years of age

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Value-based payment and Behavioral Health: Dreams for the future

Expand access through digital telehealth platforms and payment for eConsult collaboration

Adopt measurement modalities that focus on true treatment outcomes rather than processes

Expand the traditional BH umbrella and embrace value-based care for autism and related disorders

Deliver robust centers of excellence networks with benefit structures the promote their use

Acknowledge the impact of SDOH and introduce new payment approaches and care delivery techniques that address them

LAN Alternative Payment Model (APM) Framework

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We’d love your feedback…

“The Eagle has landed”

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LAN Alternative Payment Model (APM) Framework

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“Who knew value-based care was so complicated.”

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“I hope you like sports metaphors.”

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New Yorker 2009

The auto industry is dead– what killed it and what does that have to teach us about behavioral health?

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On Demand

Fuel Source

Autonomous

Fuel Source – Automotive IndustryGas to Electric

“The future has a plug. Everybody sees it.” Dan Neil

Wall Street Journal October 10, 2015

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Fuel Source – Health CareVolume to Value

Evolving reimbursement methodologies are shifting dollarstowards value vs. service-based.

The result is a system-wide effort to transform delivery models.

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Autonomous – Automotive IndustryControl shifting from Driver to Driver +

The ‘mechanics’ of driving are moving towards seamless integrationof the consumer and ‘smart’ technology offerings.

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Autonomous – Health Carefrom “Doctor” to “Doctor + Patient”

“The largest and least used resource in medicine is the patient.”Warner Slack MD, Harvard Medical School

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On Demand – Automotive IndustryThe car is available when and where you need it

On-demand car services are providing cost-efficient alternativesand alleviating the need to own a car.

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On Demand – Health CareThe care is available when and where you need it

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On Demand Behavioral Health

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On Demand Psychiatry

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On Demand Psychology

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The evolution of the Auto Industry & Behavioral Health

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• Pay for Value

• Technology that simplifies achieving value

• Platforms for comprehensive BH case management

• Delegated risk / Incentive structures

• Real time tracking / gap remediation

Fuel=Value

• The Autonomous patient

• Technology that aids in creating patient autonomy

• Online peer support groups

• Connected patient

• Text capabilities

Autonomy=Doc + Patient

• Data driven bi-directional texting capabilities

• App can interact with patient, lead to text and respond

• Technology that delivers on-demand services

• Apps with mood trackers, remote monitoring

• Tele psych

Demand=Care where & when needed

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LAN Alternative Payment Model (APM) Framework

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Value based care will not evolve, the health care system will evolve.

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“Who knew value-based care was so complicated.”

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There is no value based care outside of health ecosystem evolution

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What is this?....“The future is already here –it’s just not very evenly distributed.” William Gibson

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We’d love your feedback…