Aetna’s Model of Value-Based, Financially Viable Accountable Care Improves Health Outcomes

June 2014, Vol 5, No 5

Charles Kennedy, MD, Chief Executive Officer of Aetna’s Accountable Care Solutions, is responsible for leading Aetna’s accountable care partnerships with healthcare providers. Dr Kennedy also serves as the health insurance industry representative on the Health IT Policy Committee, a federal advisory committee that makes recommendations to the National Coordinator for Health IT on a policy framework for the development and adoption of a nationwide health information infrastructure. Value-Based Cancer Care (VBCC) interviewed Dr Kennedy in connection with his discussion of accountable care organizations (ACOs) at the 2014 Medical Informatics World meeting.

VBCC: How many ACOs does Aetna have, and what is the driving force behind them?

Dr Kennedy: We have signed 35 accountable care agreements with various health systems and provider organizations across the country. As of the end of 2013, Aetna had 550,000 members in these accountable care arrangements, and we project that we will have 850,000 by the end of 2014. Value-based, patient-centered care models, including ACOs, are an important component of Aetna’s vision for a more connected and effective healthcare system.

VBCC: Can you describe the “smart approach to patient steerage” to a narrow network of providers?

Dr Kennedy: Narrow networks that are centered on the ACO can play an important role in creating accountability for creating financial and quality outcomes for members in our ACOs. By improving the quality of patient care and the cost of that care, the ACO becomes more efficient with its care delivery. When linked to our gain-share contracts, ACO-based services can create savings that benefit everyone—the ACO, the insurance company, and, ultimately, the purchaser of healthcare services, the patient.

In our ACO-based arrangements, members are still able to choose providers from Aetna’s broad network, but they receive a higher level of benefits when they seek care from providers who are part of the ACO.

VBCC: How does the strong emphasis on patient loyalty fit into Aetna’s model of ACO?

Dr Kennedy: The ACO and the physicians participating in it must focus more than ever on patient loyalty and patient satisfaction. Keeping the patient within the ACO network affects the physician’s ability to proactively and effectively manage that patient’s care, health outcomes, and costs.

There are many ways to enhance patient loyalty. Care management, wellness programs, patient outreach, expanded hours, and web-based and mobile technology all play roles. These programs improve loyalty by improving the experience and increasing convenience.

Furthermore, we need to ensure that members understand the benefits of participating in an accountable care model. For example, because doctors want to ensure care, you have access to them when you need them, rather than going to the emergency department, and they may offer extended hours. When you see a specialist in the accountable care network, this physician may have more information about your health history because of the data-sharing tools that we work with the ACO to implement. As a result, providers can make better decisions about care, can order fewer redundant tests, and can require fewer forms for patients to complete.

If patients suffer from a chronic condition such as diabetes or asthma, they may receive additional education and support from their care team to help manage their health condition. Physicians are encouraged and are financially compensated by Aetna to work together and to focus on preventive care, because it can reduce the development or progression of chronic disease.

VBCC: How does Accountable Care Solutions plan to migrate to a model of upside and downside risk?

Dr Kennedy: Aetna’s goal is to provide a financially viable, multiyear strategy to help the health delivery systems move from a volume-based approach (where they are paid based on number of services, admissions) to a value-based approach (where their revenues are derived from their ability to deliver better healthcare value).

We work with these systems or ACOs to assess the level of risk they are able to assume, and we meet them where they are.

VBCC: How does Accountable Care Solutions use federal programs as a part of these strategies?

Dr Kennedy: We frequently use federal programs as part of the strategy when working with a care delivery system, because commercial spending in healthcare is a mere fraction of the spending within Medicare. For example, if Aetna’s commercial business represents 10% to 15% of the patients they see, it would be difficult for a delivery system to see the return on investment it needs to fully transform its model. Aligning our programs with federal programs, such as the Multipurpose Senior Services Program, or Medicare Advantage, offers the patient share and volume to be able to justify the reengineering, the new programs, and the new technologies that need to be put in place to be successful. Therefore, federal programs are critical to our overall strategy for success.

VBCC: What are some of the services Accountable Care Solutions uses to achieve these goals?

Dr Kennedy: Aetna offers a wide range of consulting services, products, and technologies to support accountable care models. For example, we help ACOs grow their patient base through jointly marketed insurance services in the marketplace—directly and through public and private exchanges.

We offer enablement solutions and advisory services to support the transformation to value-based care. This could include next-generation, data-driven electronic medical records; health information exchange solutions from our Medicity subsidiary to enable the exchange of patient clinical information across different sites of service; personal health records customized for patient use; and care management platforms integrated with physician and patient tools.

Our health plan experience and analytics can help providers keep patients in their ACO network, streamline operations, and improve care delivery for populations. For example, we can provide analytics to show the ACO which of their patients are receiving care outside the ACO network. We then work with them on a wide range of strategies to keep more of those patients in their network where it is appropriate. Aetna’s iTriage is a useful solution in these cases. It is easy to use and can help patients identify in-network healthcare options for particular symptoms, and make appointments from the convenience of their smartphone or the Internet.

Health plans have extensive experience managing populations of patients. We work collaboratively with them on care management programs and technology to better manage high-risk populations and to improve outcomes at the individual and population level.

Finally, we offer solutions, such as iTriage, to engage patients and help guide them to the right level of care at the right time.

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