Anthem, D-H focus on care in new pilot

A newly announced Anthem/Dartmouth-Hitchcock pilot program that could serve as the foundation for a so-called accountable care organization could have a direct impact on other providers, and similar projects, around New Hampshire.Anthem Blue Cross and Blue Shield in New Hampshire and Dartmouth-Hitchcock Medical Center announced their pilot in November.An accountable care organization, or ACO, is a group of hospitals, physicians, insurers and other providers that agree to share the risk for patient care as well as any cost savings from care that falls within a set of established quality guidelines. Such organizations are mandated in the landmark Patient Protection and Affordable Care Act of 2010, with the earliest forms of ACOs to be in place by 2012.This full-spectrum approach is what makes ACOs different from other mechanisms that tie quality care to reimbursement, said Dr. Barbara Walters, senior medical director of Dartmouth-Hitchcock’s southern New Hampshire community group practices.Other approaches, she said, “focused mainly on individual hospitals, while ACOs focus on a population across the continuum,” she said.The Anthem/Dartmouth-Hitchcock ACO pilot will include most if not all of the facilities in the Dartmouth-Hitchcock care network, said Anthem officials, and involve about 20,000 Dartmouth-Hitchcock patients who are Anthem members, said Douglas Wenners, president and general manager for Anthem New Hampshire.Since 2008, Anthem has studied a similar link between better care outcomes and reimbursement through its Quality Hospital Incentive Program, or Q-HIP.”Q-HIP conditioned some inpatient payment rates on the attainment of quality measures, but still maintained the fee-for-service payment structure. ACOs speak to a global medical cost target, sharing risk and ensuring quality,” said Wenners.‘First year critical’Officials from both organizations are currently hammering out what specific diagnoses and patient populations to study – and how the benefits of any realized cost savings will be shared.”What we’re asking is, ‘What did it cost over the last 12 months to care for these 20,000 members, and what will it cost 12 months from now?” Wenners said. “If the baseline trend is, for example, $100 per patient per year, and the trend is 10 percent a year, next year it will cost $110. How do we keep that at $105? And if we can, how do we share that $5 difference?”The pilot has five “work streams”: member attribution (how members will be assigned to the ACO); clinical and performance metrics; medical management; operations and data exchange; and contracting and communications.”This first year is critical,” said Wenners. “Of the five work streams, the results of the clinical work stream will have the most impact on the pilot for year two.”Without explaining the details of the agreement, Wenners did say that the risk – and any rewards – would be shared “equitably” between Anthem and Dartmouth-Hitchcock.The Anthem/Dartmouth-Hitchcock study is also not without significant cost. The sheer magnitude of just aligning computer systems to share data alone is expensive.Although Wenners said he did not have a dollar figure for how much the pilot would cost, he said, “To ‘not cost more’ is really the goal.””If we have to spend money, then we are not doing our part to lower the cost of care,” said Wenners, and likened the project to “redesigning the plane while in mid-air.”Anthem and Dartmouth-Hitchcock would both pay for the pilot through reallocating existing funds, he said.The new ACO pilot may have implications for agreements Anthem and Dartmouth-Hitchcock have made to another ACO pilot announced this past summer.Last July, more than a dozen hospitals, clinics and physicians groups across the state – including Cheshire Medical Center/Dartmouth-Hitchcock Keene – announced a similar ACO pilot study headed by the New Hampshire Citizens Health Initiative. All four of New Hampshire’s major health insurers, including Anthem, agreed in principle to be a part of Citizens Health Initiative pilot.Dr. John Schlegelmilch, Cheshire’s medical director and co-president, said his facility is “committed” to the Citizens Health Initiative pilot. “We are, however, a part of Dartmouth-Hitchcock system and will participate in that. We will have to see how this impacts the other commercial populations.”A strong stakeholder in the city of Keene’s Vision 2020 mission to create the nation’s healthiest community by 2020, the medical center has already reduced its inpatient admission by a third since 2008 – a long step toward an ACO’s goal to do just that. And that makes it a natural fit for the advanced stage of Anthem/Dartmouth-Hitchcock pilot.But because of its community focus, something the Citizens Health Initiative has spotlighted, it remains at this time an integral participant in that study.In fact, said Schlegelmilch, the medical center received permission from Dartmouth-Hitchcock to be a part of that pilot.Opportunity to shareAsked if Anthem would pull out of the Citizens Health Initiative pilot, Wenners acknowledged the insurer’s previous participation, but said “it’s too early to tell” the scope of future participation the insurer will have in the Citizens Health pilot.”Anthem and Dartmouth-Hitchcock were ready to do a pilot earlier than the Citizens Health Initiative,” said Wenners. “They are still trying to determine how it would work. We [Anthem and Dartmouth-Hitchcock] were much further in that discussion.”Indeed, the two providers have been sharing data for the past six months, he said.”The resources to do the pilot with Dartmouth-Hitchcock are substantial,” Wenners said. “The Citizens Health Initiative pilot is still in the ideation phase, so we wouldn’t have to commit resources right now anyway.”Heather Staples, consultant and project director for the Citizens Health Initiative pilot, sees only good things coming from the Anthem/Dartmouth-Hitchcock pilot. “We think there’s a positive benefit,” she said.According to Staples, members of the Citizens Health pilot are currently defining a global budget and care model, both at the individual and aggregate level, as well as defining outcome, efficiency and quality measurements.Dartmouth-Hitchcock’s Walters chairs the payment reform group of Citizens Health pilot and is well versed in Dartmouth-Hitchcock’s Medicare payment reform study.”The end point is the same with both [New Hampshire ACO] pilots – learning to collaborate across geographies and different entities,” said Walters.
Walters has been instrumental in helping the Citizens Health pilot “translate some of their findings” to a commercially insured population and will continue to participate, said Staples. “Anthem has helped in translating some of that, too.”She added: “We have opportunity to learn and to share back.”Cindy Kibbe can be reached at