Provider Insider

Value-Based Contracts

Winter 2020 | Issue No. 8

New Programs from Anthem


As most of you are probably aware, January 1, 2020 brought the end to our participation in Anthem’s commercial value-based program Enhanced Personal Health Care (EPHC). The network was successful over three program years in improving quality outcomes and generating savings that were shared among network providers.


We are replacing EPHC with a new commercial value-based program from Anthem titled Cooperative Care. Structured similarly to EPHC, prospective payment is made available as well as potential for shared savings. What is different is the inherent construct of “capabilities.” These are necessary abilities that participating practices must work to employ to be able to participate in the program over time. We will be working with each of our member practices individually to help develop these capabilities.


Cooperative Care’s capabilities are divided into four domains:


Quality metrics will also be employed in Cooperative Care, but unlike the 31 quality metrics of EPHC, Cooperative Care will have eight quality metrics.


Cooperative Care will have eight quality metrics:


• Emergency department visits
• Controlling high blood pressure
• Diabetic hemoglobin A1c control
• Acute admissions for select conditions
• All cause 30-day readmission rate
• Opioid management
• Depression screening and follow-up plan
• CG-CAHPS survey administered to random patients by Anthem


We will work with individual member practices on process improvement plans for each of the quality metrics.


Our Medicare Advantage program with Anthem has also changed. One year ago, Anthem won the contract to provide benefits to the Public Employees Retirement Association of Colorado (PERA). As of January 1, 2020, all PERA patients in your practices will be enrolled in our Anthem Medicare Advantage value-based program. This is a sizable population of patients and will augment the total attribution of each of our member practices. Now that each practice will be receiving prospective payment for all of these Medicare Advantage lives with Anthem, there should be significant increase in net revenue to each practice.


Because this additional patient population changes the risk profile of the entire Medicare Advantage population and hence the prospective payment the Network receives from Anthem, we will treat this as a new program option for the practices. As such, we will offer the option to each practice to “opt-in” to participation in Anthem Medicare Advantage, even if you have participated in the past.