The goal of the population needs assessment (PNA) is to improve health outcomes for members and ensure Anthem is meeting members’ needs. It does this by identifying member health needs and health disparities; evaluating health education, cultural and linguistic (C&L) and quality improvement (QI) activities; and by utilizing available resources. The PNA aims to address identified concerns while setting targets and strategies for health education and C&L/QI programs and services.


Key findings

Anthem analyzed HEDIS® data for 12 reporting units across the Anthem contracted counties. 


Some of the key health disparities findings include:

  • All findings were related to health for children or women. The measures include:
    • Immunizations for Adolescents
    • Childhood Immunization Status
    • Well-Child Visits
    • Breast Cancer Screenings
    • Cervical Cancer Screenings
    • Prenatal and Postpartum Care
  • The Immunizations for Adolescents — combination 2 measure was the most identified health disparity, appearing in Alameda County (white and African American), Kings County (white), Madera County (white), Region 1 (white), Santa Clara County (African American) and Tulare County (Asian American and Pacific Islander).
  • The Breast Cancer Screening measure was the second most identified disparate measure, identified in Alameda County (white), Contra Costa County (white), Fresno County (Asian American, Pacific Islander and white), Kings County (white) and Tulare County (white).
  • Black and African American members were identified as the most disparate group
    seven times — Four of those seven measures were for the Prenatal and Postpartum Care measure.


In addition, Anthem assessed the existing Population Health Management program and determined the following opportunities are being pursued to address social determinants of health:

  • Food insecurity: The expansion of the Food is Medicine/Medical Meals program by increasing availability of referral pathways, increasing collaboration with enhanced care management programs and increasing membership
  • Primary care/case management: Increasing community health worker collaboration to provide in-person and/or telephonic support to members with social and health needs, including accompaniment/advocacy at provider appointments, assisting members with completing forms or gathering other necessary information to facilitate access to community resources

Defining PNA objectives

Based on these and other findings, Anthem is using the analysis to inform and align objectives for the PNA action plan for the 2020 reporting year. For this year and 2021, Anthem is working with the community to identify the following areas of focus and objectives:

  • Increasing the number of completed mammograms
  • Increasing the timeliness of prenatal and postpartum care for identified African American members
  • Increasing the utilization of interpreter services among providers and members
  • Increasing member engagement in care management programs to address social determinants of health

To receive a copy of the action plan, please contact

HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).

Featured In:
May 2021 Anthem Blue Cross Provider News - California