Developing APMs to Better Serve Populations Most in Need

“About 40 percent of our membership is touched in some way by a value-based program – and we plan to reach 50 percent by the end of 2016.” — Dr. Andrea Gelzer

AmeriHealth Caritas is part of the Independence Health Group in partnership with Blue Cross Blue Shield of Michigan. AmeriHealth Caritas is one of the nation’s leaders in health care solutions for those most in need. Operating in 18 states and the District of Columbia, AmeriHealth Caritas serves more than 5.9 million Medicaid, Medicare, and CHIP members through its integrated managed care products, pharmaceutical benefit management, specialty pharmacy services, behavioral health services, and other administrative services. Headquartered in Philadelphia, AmeriHealth Caritas is a mission-driven organization with more than 30 years of experience serving low-income and chronically ill populations.

CAMH talked with Andrea D. Gelzer, MD, senior vice president and corporate chief medical officer of AmeriHealth Caritas, to gain her perspective on alternative payment models and the LAN initiative. Dr. Gelzer is responsible for overseeing medical management strategy, medical policy development, quality management, corporate provider network strategy, and medical informatics for all AmeriHealth Caritas health plans. The company is a LAN Committed Partner, and Dr. Gelzer is a member of the LAN’s Alternative Payment Model Framework & Progress Tracking Work Group. She also chairs the Chief Medical Officer Leadership Council of America’s Health Insurance Plans (AHIP), actively participates in the Core Quality Measure Collaborative, and is a member of the Technical Expert Panel (TEP) for the Assessment of Impact of CMS Quality Measures.

We found out about the LAN through our work with AHIP. The LAN’s goals were well-aligned with ours at AmeriHealth Caritas, so we pledged to be a Committed Partner and attended the kick-off events at the White House and the U.S. Department of Health and Human Services (HHS) in March 2015.

My interest in APMs dates back to 2002. I was involved in the early days of the Ambulatory Care Quality (AQA) Alliance – a multi-stakeholder effort focused on gaining agreement on a strategy for measuring and reporting performance at the physician level.

AmeriHealth Caritas initially developed pay-for-performance programs, primarily for our Pennsylvania-based health plans, and quickly learned that alignment among providers, state governments, and Medicaid managed care organizations (MCOs) is critical.

In 2010, AmeriHealth Caritas launched its PerformPlus® suite of value-based incentive programs for participating primary care and specialist physicians, hospitals and integrated delivery systems, and Federally-Qualified Health Centers. Our incentive programs, based on LAN’s APM Framework Category 2, are designed to reward providers for timely, appropriate care and positive patient outcomes. PerformPlus® programs are also aligned with efforts in the Medicare and commercial markets. In some markets, our PerformPlus® program has advanced to the LAN’s APM Framework Category 3A, APMs built on fee-for-service architecture. Assessing provider readiness and working together in partnership is how we’ve been able to successfully transition providers from a Category 2 to 3A APM. Today, about 40 percent of our membership is touched in some way by a value-based PerformPlus® program – and we plan to reach 50 percent by the end of 2016.

Eventually, we want to move the vast majority of our participating providers into alternative payment structures. However, because we work primarily with Medicaid in multiple states, our ability to accelerate participation depends on how progressive the Medicaid market is in each state. Some states, offer quality-based incentives and/or withholds to encourage the adoption of APMs. Other states include specific goals for APM adoption and market penetration in contracts with Medicaid MCOs. It’s still too soon to evaluate which approach is most successful.

It’s a gradual process. As we look at the APM Framework, we start with a Category 2 quality incentive program. Program participants have no downside risk but are rewarded for improving quality and certain utilization metrics, such as preventable emergency room visits. Once this works successfully for participants, we try to move them into a shared savings program, Category 3. Our greatest success with APMs has been with integrated delivery systems that have critical patient volume, and the infrastructure and resources to support practice transformation. We do not yet have anyone in Category 4, but our goal is to do so by the end of the year.

It’s important that APMs also align with provider’s internal quality goals for their practice or health system – and health plans must remain flexible. We collaborate with our provider partners to reach consensus on a set of quality measures and develop a customized program that’s a win-win for everyone. Our collaborative approach has resulted in multi-year shared savings arrangements with multiple providers and demonstrated improved quality outcomes.

We have seen improvements in both quality and efficiency measures from our provider partners. Measures such as preventable admissions, preventable readmissions, and low acuity emergency room utilization have shown improvement, in addition to quality measures for post-partum and prenatal care. Payment models that only offer financial incentives to deliver care within a cost target could have unintended consequences for patients. Unfortunately, quality metrics have not yet caught up with financial alignment, particularly in gauging the effectiveness of treating individuals with chronic conditions and ensuring we’re optimizing outcomes for these patients. I think we’ll have a lag period of at least three to five years before we get it right.

I believe that we will see improved outcomes for individuals with chronic diseases. I believe we will see more proactive patient engagement in health care across the board. And I think these achievements will not only be driven by APMs but also by big data and predictive modeling opportunities that we’re just beginning to realize. The LAN is a powerful catalyst in accelerating our path forward.