A key goal of Anthem’s provider transparency efforts is to improve quality while controlling health care costs. One of the ways this is done is by giving primary care physicians (PCPs) in the Enhanced Personal Health Care (EPHC) Program quality and/or cost information about the health care providers to which the PCPs refer their Attributed Members (the “Referral Providers”). If a Referral Provider is higher quality and/or lower cost, this component of the Program should result in their getting more referrals from PCPs. The converse should be true if Referral Providers are lower quality and/or higher cost. Additionally, employers and group health plans (or their representatives or vendors) may also be given quality/cost information so that they can better understand how their health care dollars are being spent. This will give them the opportunity to educate their employees and plan members about the benefits of using higher quality and/or lower cost health care providers.

 

Cost Opportunity Report

  • The Cost Opportunity Report is available for EPHC providers to access via Provider Care Management Solutions (PCMS).
  • The report was created to help users quickly identify meaningful and actionable opportunities to optimize costs and help achieve shared savings targets within the EPHC Program.
  • By providing a standard set of potential cost opportunity metrics, the Cost Opportunity Report can be used to help evaluate the relative success of providers within the EPHC Program.
  • Metrics are selected based on size of financial opportunity, ability of PCPs to affect changes, mix of impacted service types, mix of utilization and unit price impact.
  • Metrics are reviewed on a periodic basis and may be added, changed or removed.

 

Cost Efficient Outpatient Surgery Report

  • The Cost Efficient Outpatient Surgery Report is a supplemental report available for EPHC providers in the Colorado market.
  • It provides a total cost comparison of providers who perform surgical/common procedures in outpatient or ambulatory surgery center (“ASC”) settings.
  • The Cost Efficient Outpatient Surgery Report helps EPHC providers determine who to refer Attributed Members to for more cost-effective care.
  • Total cost is case mix adjusted and includes professional, facility, anesthesia, and implants (if applicable).
  • Surgeons/providers are compared to their Colorado peers based on cases at outpatient and ASC locations.
  • Surgeon complication rates are reviewed as part of report generation

 

Anthem will share data on which it relied in making these quality/cost evaluations upon request, and will discuss it with Referral Providers including any opportunities for improvement. For questions or support, please refer to your local Market Representative or Care Consultant.



Featured In:
August 2018 Anthem Provider Newsletter - CO