Anthem Blue Cross Blue Shield has five large medical groups participating in its ACO efforts. As a first step in launching the projects, the payer took three years of claims data and downloaded it to the respective databases of the groups, says Antonio Linnares, M.D., medical director at Anthem. The data gave the practices a head start in analyzing patient utilization, Linnares told the audience at the ACO symposium at the HIMSS12 Conference in Las Vegas.

Next, the payer assigned patients to the practices, analyzing its own claims to see who was in need of primary care services. That level of data sharing between payers and providers is critical will be critical for accountable care to succeed, Linnares says.

Another critical need is speed, he adds. He cited the example of a patient moving out of network. It’s important for the payer to let the ACO provider know, particularly when a patient seeks care in the emergency department. “We need to explore real-time data exchange, with bi-directional data from payer to ACO,” Linnares said. “Capturing quality metrics consistently is a challenge,” he said, noting that one of the largest likely failure factors for an ACO is not identifying cost-effective physicians.

In addition to building out its data exchange capabilities, the health plan is looking to enable Web visits for patients and launch a “virtual case management” program in which case managers could track high-risk patients via access to provider EHRs.

Anthem’s programs are similar to federal ACO models, Linnares says, with reimbursement based on meeting certain quality metrics. Anthem has several ACO projects underway in the patient-centered medical home model, in which a primary care practice acts a central coordinator of care. Under the program, various medical home efforts in Colorado, New Hampshire and New York have seen significant improvement in diabetic care, Linnares says, citing fewer instances of emergency department visits, decreased pharmacy costs, and increase preventive services.


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