1. Actualizing the Triple Aim
PATIENT CENTERED SPECIALTY CARE (PCSC)
Impacting Cost of Care
Hello, My name is……. I am your …….. With ………… Today we are going to take some time to look at impacting cost of care to actualize the Triple aim of improved quality, increased patient satisfaction and lower health care costs.

2. Important note
The information, resources, and tools that Anthem provides to you through the Patient Centered Specialty Care Program are intended for general educational purposes only, and should not be interpreted as directing, requiring, or recommending any type of care or treatment decision for Anthem members or any other patient. Anthem cannot guarantee that the information provided is absolutely accurate, current or exhaustive since the field of health is constantly changing.
The information contained in presentations that Anthem makes available to you is compiled largely from publicly available sources and does not represent the opinions of Anthem or its personnel delivering the presentations.
If Anthem provides links to or examples of information, resources or tools not owned, controlled or developed by Anthem, this does not constitute or imply an endorsement by Anthem. Additionally, we do not guarantee the quality or accuracy of the information presented in, or derived from, any non-health plan resources and tools.
We do not advocate the use of any specific product or activity identified in this educational material, and you may choose to use items not represented in the materials provided to you. Trade names of commonly used medications and products are provided for ease of education but are not intended as particular endorsement. 
None of the information, resources or tools provided is intended to be required for use in your practice or infer any kind of obligation on you in exchange for any value you may receive from the program. Physicians and other health professionals must rely on their own expertise in evaluating information, tools, or resources to be used in their practice. The information, tools, and resources provided for your consideration are never a substitute for your professional judgment.   
With respect to the issue of coverage, each Anthem Member should review his/her Certificate of Coverage and Schedule of Benefits for details concerning benefits, procedures and exclusions prior to receiving treatment. If Members have any questions concerning their benefits, they may call the Member Services number listed on the back of their ID card.
I will summarize this slide. The information, resources, and tools that Anthem provides to you through the PCSC Program are intended for general educational purposes only, and should not be interpreted as directing, requiring, or recommending any type of care or treatment decision for Anthem members or any other patient. The information, tools, and resources provided for your consideration are never a substitute for your professional judgment
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3. PCSC Addresses the Triple Aim to Deliver Value – A Focus on Specialty Care
Outcomes that Demonstrate Value
Reduce the Cost of Care
Improve Quality Scorecard
The PCSC program is focused around supporting primary care with achieving the triple aim and demonstrating value outcomes such as:
Reduced the Cost of Care trend
Improved quality scorecard
Improved Patient Experience
Per the IHI-
“Benefits to an Approach in Line with the IHI Triple Aim
Organizations and communities that attain the Triple Aim will have healthier populations, in part because of new designs that better identify problems and solutions further upstream and outside of acute health care. Patients can expect less complex and much more coordinated care and the burden of illness will decrease. Importantly, stabilizing or reducing the per capita cost of care for populations will give businesses the opportunity to be more competitive, lessen the pressure on publicly funded health care budgets, and provide communities with more flexibility to invest in activities, such as schools and the lived environment, that increase the vitality and economic wellbeing of their inhabitants.
Successful health and health care systems of the future will be those that can simultaneously deliver excellent quality of care, at optimized costs, while improving the health of their population.”
Improve Patient Experience
Source:
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4. What does Cost of Care mean to stakeholders in the healthcare system?
Anthem
Employer
Provider
Patient
Bend the Trend on Premium/Patient Cost Share
Meet Program Cost Targets while maintaining quality care to Members
Increase Membership
Bend the Trend on Premium
Reduce employee out of pocket spend
Ability to earn fee for service enhancement
Reduce waste and enable an optimal and equitable distribution of scarce resources while reducing harm from unnecessary tests and procedures and sustaining/improving quality care to patients.
Respect and respond to Patient Cost burdens
Co-Pays; Co-Insurance, High Deductible Plans are an increasing burden on Patients’ budgets
When we think about cost of care, we should consider what that means to the stakeholders within our healthcare system. Addressing cost of care has impacts on multiple levels.
Reducing cost of care has different meaning to different stakeholders. We need to keep those perspectives in mind as we work with a variety of stakeholders and find common ground and common goals in reducing total patient cost of care.
Read through list
As health care has become more expensive and consumes more of both and employer and member’s budget, one of the most powerful messages is working through providers to help them identify the most cost effective, high quality solution in their health care choices. By promoting these “high-value” health care choices, we can help providers support patients their patients in making choices that work within limited budgets.
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5. Overuse of Health Care Services is Harmful – Financially and Clinically
Virtually every family in the country, the research indicates, has been subject to over testing and overtreatment in one form or another. The costs appear to take thousands of dollars out of the paychecks of every household each year. Researchers have come to refer to financial as well as physical “toxicities” of inappropriate care—including reduced spending on food, clothing, education, and shelter. Millions of people are receiving drugs that aren’t helping them, operations that aren’t going to make them better, and scans and tests that do nothing beneficial for them, and often cause harm.
Atul Gawande, MD, MPH
This is a really great quote from Dr. Atual Gawande that brings home that overuse of healthcare services can be both clinically an financially harmful to patients.
The problem that Dr. Gawande highlights is that more is not necessarily better. Over-use of health care services is not an isolated event and it has a very real impact not only to healthcare budgets (employers, members and payers) but also an adverse impact on health status. These dollars could be re-directed to other critical areas that can make a difference in the lives of our patients.
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6. Providers can be Heroes by Saving Members Out-of-Pocket Costs
Reducing costs of care (using preferred labs, using high quality most cost effective radiology centers, using in network providers and specialists, selecting generic drugs, reducing unnecessary services) can save working families hundreds
This drives member satisfaction and retention for the practice
This significantly increases adherence with treatment plans and improves patient health- driving a virtuous cycle
Working together, we can help you be a hero.
One thing that we always must remember, is the impact cost of care has on patients
Reducing costs of care can save working families hundreds, if not thousands of dollars in cost sharing
This drives member satisfaction and retention for the practice
This significantly increases adherence with treatment plans and improves patient health- driving a virtuous cycle
Working together, we can help you be a hero to your patients
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7. Two Ways for Providers to Reduce Cost of Care
To reduce costs, providers must either reduce the number of services (duplication/overuse) or cost per service.
Number of Services
Cost for Each Service
Total Cost of Care X
Hospital admits / days, ER visits
Prescriptions
Lab tests
Referral decisions
Site of care
Examples
Reduction in duplicate / over use
Preventive care
Care coordination
Refer to lower cost vendors
Generic drug substitution
Urgent care vs. ER visits
How to reduce
When we think about reducing total cost of care, there are 2 ways that a provider can impact: reduce the number of services (thinking duplication/overuse) or cost of each service. In no way, is there the suggestion of patients not having necessary services, but rather looking at the services from the lens of providing care coordination, preventive care, utilizing site of care or referrals to support patients from having duplication/overuse of services or even utilizing high cost services when high quality/lower cost options may be available.
There are two key strategies:
Reduce unnecessary or wasteful services (e.g. number of services) OR
Identify the most cost effective provider for a given service.
Anthem’s PCSC program strives to empower providers with data that enables them to make those decisions
Talking points self explanatory in slide
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8. Cost of Care Opportunities
Lab Services
Infusion Services
Ambulatory Surgery
High Cost Imaging
Urgent Care vs. ER for non-urgent services
Finding the Most Cost Effective Site of Service
Care Compacts to coordinate care
Avoiding duplication / overuse of tests and procedures
Reducing overuse/duplication of services
Switching to Generic Equivalent when clinically appropriate and there is no contradiction to the patient
Generic Drugs vs. Brand Equivalent
We talked about looking at short term and long term cost of care opportunities. When we think about short term opportunities, there are some which may have some great value to your practice as a focus area.
Bullet #2 (under Reducing overuse/duplication of services): state how to avoid dup/overuse - share test results; coordinate which tests are needed /not for referrals, etc.
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9. By the Numbers – The Power of Redirection
Patients incur lower out of pocket costs when services are rendered at a free-standing ASC or imaging unit
Referral to an ASC with equivalent quality can contribute to increased shared savings for physicians
Over the next few slides, we are going to take a look at how addressing cost of care can impact a patient’s financial burden.
To start lets take a look at redirection to high quality, low cost providers. From this table, you can see that procedure costs for services can like mammographies, colonoscopies and MRI can be significantly lower when performed at a low cost facility with comparable quality. A colonoscopy screening at a high cost facility can cost $2,439 and a patient with a 20% co-insurance could have an OOP cost of $ That same procedure at a low cost facility would be $ and the patients oop cost would $ The patient could save $ which can be quite significant for the patient.
In addition to benefiting the patient, Referring to an ASC with equivalent quality can contribute to increased shared savings for physicians.
Anthem Care Compare is a tool that we can share with your office to support redirection to those High quality, low cost facilities
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10. Choosing Wisely
Choosing Wisely is an initiative of the American Board of Internal Medicine (ABIM) Foundation
ABIM mission is “to advance core values of medical professionals to promote excellence in health care”
Choosing Wisely encourages providers and patients to work together to improve the quality and safety of healthcare in America by reducing duplication-waste.
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11. How can Choosing Wisely be a resource?
Designed to help providers and patients engage in conversations aimed at reducing unnecessary or potentially harmful tests and procedures
Supporting patients in their efforts to make smart and effective care choices.
Focus on the ‘Five Things’ list developed by over 30 United States specialty societies representing more than 500,000 physicians.
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12. Choosing Wisely “Things to Question”
Consumer Reports partnered with Choosing Wisely and many provider organizations to create specialty specific lists of “Things to Question”.
There are provider and patient focused specialty specific lists.
Each list is developed to guide care decisions and provide specific, evidence-based recommendations.
The lists generate more conversation between the patient and provider about the need for testing and treatment.
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13. By the Numbers – Lab
Patients incur lower out of pocket costs when services are rendered at a an In-Network Independent lab
Referral to an In-Network Independent lab when possible and clinically appropriate can contribute to increased shared savings for physicians
One of the most common services a patient will receive is lab testing. Labs performed by in-network independent labs typically cost much less than those performed at a hospital lab or an out of network independent lab. Referrals to In-Network Independent labs when possible and clinically appropriate can contribute to increased shared savings for physicians, and again, lower OOP cost for the patients
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14. By the Numbers – Switching to Generics
How does it work?
Generics are often just one-fifth the cost of a brand name drug and cost your patients less than brand options. Overall, generic prescribing and utilization is high. However Anthem has identified select therapeutic classes where there may be additional opportunity to maximize generic utilization.
Who Saves?
Generic medications are on Tier 1 of the formulary and have lower member out of pocket cost compared to brand products. Individual member savings varies based on benefit design.
Another there area of focus that can have a significant impact on provider shared savings and member financial burden is brand versus generic medications. Generics are often just one-fifth the cost of a brand name drug and cost your patients’ less than brand options. Overall, generic prescribing and utilization is high. However Anthem has identified select therapeutic classes where there may be additional opportunity to maximize generic utilization
Drug Class
Average P
harmacy
Savings per Rx
Average Member Savings per Rx
Statins $
108
$66
ARB/ARB Combos 55
$65
Beta Blockers
$54
$71
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15. Cost of Care Tools Offer Concrete Advice on How to Reduce Costs While Maintaining Quality
Total Cost of Care
Inpatient
BD Centers of Excellence+
Anthem Care Comparison
Outpatient
AIM
Preferred Lab
Pharmacy
Pill splitting
Preferred Glucometer
Generic Prescribing
Anthem buckets costs into four key categories – Pharmacy, Outpatient and Inpatient costs. In addition to the population health management strategies that we’ve covered in other areas of this program, we’ve also developed materials to support cost of care strategies in each of these cost categories.
I want to share a list of tools currently available that can impact the various cost categories (Inpatient, Outpatient, and Pharmacy). These are not the only tools, our Intervention Bundles work in conjunction with these tools for full impact.
Many of these tools can be used for your full population and not limited to Anthem members.
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16. Final One Pager
American Imaging Management (AIM)
AIM helps you and your patients focus on receiving necessary radiology services at a high quality/cost efficient location
By using the AIM Portal:
APPROPRIATE
Real-time review and case approval with peer-to-peer consultation using appropriate use criteria and medical policy prior to testing or therapy
AFFORDABLE
Engaging physicians and patients in selecting the site of service that meets high quality and lower cost criteria
SAFE
Help for providers to eliminate unnecessary testing and procedures that can lead to patient harm by showing previous testing as part of patient record
© 2015 AIM Specialty Health®. All Rights Reserved.

17. Help your patients find high-quality, cost-effective care.
Anthem Care Compare
Final One Pager
Anthem Care Comparison (ACC) is an innovative shopping tool that discloses real price ranges for common services at specified area hospitals.
Why Use ACC? Drive Cost Reduction, Improve Patient Satisfaction, Embrace Transparency Around Costs, Refer to Facilities that Deliver High-Quality Care.
Help your patients find high-quality, cost-effective care.
How-to use ACC. Your Community Collaboration Manager can provide information with easy step-by-step guides to share how-to use and can also help educate your patient population through campaigns and more.
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18. Anthem’s Preferred Glucometer Program
Final One Pager
Anthem’s preferred glucometers include OneTouch® and ACCU-CHEK® products.
Test strips for these meters are on the preferred brand tier and cost less than the non-preferred alternatives.
Patients can get select OneTouch® and ACCU-CHEK® meters for free.
Preferred strips can help patients save $50 per 30-day prescription on average compared to non-preferred strips for a potential $600 annual savings.
ACCU-CHEK®
ACCU-CHEK Nano
ACCU-CHEK Aviva Plus
OneTouch®
OneTouch Verio
OneTouch Verio IQ
OneTouch Verio Synch System
OneTouch Ultra 2
OneTouch UltraMini
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19. Anthem’s Half Tablet Program
Final One Pager
Write prescriptions for qualified once daily medications with directions to take ½ tablet per day.
Members with this benefit pay just half their usual copay on select medications prescribed with instructions to take half of a tablet.
Patients with a coinsurance save by paying their coinsurance percentage on a fewer number of tablets.
Patients paying towards a deductible will pay out of pocket on a fewer number of tablets.
Prescribing half tablets for qualified medications lowers overall pharmacy costs.
Average pharmacy savings per 30-day prescription of qualified statin medications is $5 for generic and $35 for name brand. This adds up to $60-$420 annually.
1 tablet 1x/day
Quantity = 30
Crestor® 40 mg
Take ½ tablet 1x/day
Quantity = 15
Crestor® 20 mg
Example:
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20. Getting Started – Reducing Total Patient Costs
Identify the opportunities in your practice
Assess short term and long term opportunities
Identify area of focus based upon opportunities
Create a SMART goal
Leverage Cost of Care Tools
Reducing cost of care is a win/win/win for you, your providers and Anthem and the PCSC program supports you getting started in a variety of ways.
Select an area of focus based on your high impact opportunities
Assess ST and LT opportunities
Develop a goal to guide your work. We like to use the SMART Goal format – Establishing a concrete plan of action that is Specific, Measureable, Achievable, Realistic and Time bound
Identify which tools and resources that are available to you to implement your plan of action.
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21. Questions for Specialty Care
What is the current process for evaluating cost of care?
Are there opportunities to support patients with reduced financial burden?
What are the short term and long term cost of care opportunities for my practice?
What resources do I need to support cost of care opportunities?
How do I best engage patients in cost of care discussions?
What potential financial impacts are there?
What data do I need to support cost of care initiatives?
When we start thinking about impacting cost of care, it may be beneficial to ask some starting questions such as
Read the questions
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22. Build Your Quality Improvement Foundation
Representation from each area of the office
Set-up a Multidisciplinary Team
What do you want to work on?
Determine Area of Focus
State what you intend to improve
Global AIM Statement
Map out current state or ideal state
Process Mapping
Specific AIM, SMART goals, measure, ideas
Model for Improvement
Performs small test of change
PDSA (Plan-Do-Study-Act)
We have reviewed steps that can be put in place to support management of cost of care, but how do we know that what they have done is working or not. This is where the QI piece comes into play. Establishing a method for monitoring the quality indicators allows a practice to refine the workflows or protocols we have discussed.
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23. What are we trying to accomplish?
Practice Name: _______________________ Practice Champion: _________________________ What is Your Plan?
What are we trying to accomplish?
How will we know that a change is an improvement?
What change can we make that will result in improvement?
What will you do prior to our next session?
Here we have included a slide that you may use to help get started with creating your plan for impacting cost of care
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24. Legal PROPRIETARY AND CONFIDENTIAL
Anthem Blue Cross and Blue Shield is the trade name of: In Colorado: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. In Connecticut: Anthem Health Plans, Inc. In Indiana: Anthem Insurance Companies, Inc. In Kentucky: Anthem Health Plans of Kentucky, Inc. In Maine: Anthem Health Plans of Maine, Inc. In Missouri (excluding 30 counties in the Kansas City area): RightCHOICE® Managed Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. In Nevada: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc., dba HMO Nevada. In New Hampshire: Anthem Health Plans of New Hampshire, Inc. In Ohio: Community Insurance Company. In Virginia: Anthem Health Plans of Virginia, Inc. trades as Anthem Blue Cross and Blue Shield in Virginia, and its service area is all of Virginia except for the City of Fairfax, the Town of Vienna, and the area east of State Route 123. In Wisconsin: Blue Cross Blue Shield of Wisconsin (BCBSWi), which underwrites or administers the PPO and indemnity policies; Compcare Health Services Insurance Corporation (Compcare), which underwrites or administers the HMO policies; and Compcare and BCBSWi collectively, which underwrite or administer the POS policies. Independent licensees of the Blue Cross and Blue Shield Association. ® ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.
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