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At the Forefront of Health Plan-Provider Collaboration: Aetna’s Commitment to Accountable Care

July 1, 2014
by Mark Hagland
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Things have been moving forward very rapidly these days, as Aetna pursues an accelerating number of private ACOs with provider organizations nationwide

Things have been moving forward very rapidly at the Hartford-based Aetna these days. The giant U.S. health insurer has made a firm commitment to developing accountable care relationships all across the country. At the time of this writing, Aetna had developed about 40 accountable care contracts for private accountable care organizations (ACOs) throughout the U.S., covering about 550,000 health plan members nationwide.

What’s more, confirms Gary Anthony, head of enablement services at Aetna, he and his colleagues expect the health insurer to have expanded its accountable care contracts with providers to at least 60 by the end of 2014, covering roughly 850,000 Aetna members. The first Aetna-provider ACO was announced with the Roanoke, Va.-based Carilion Clinic in March 2011. Since then, ACO development has accelerated dramatically, Anthony reports. In many cases, the provider organizations that Aetna is collaborating with are also participating in the Medicare Shared Savings Programs for accountable care—either the Pioneer or the “regular” MSSP. Anthony spoke recently with HCI Editor-in-Chief Mark Hagland regarding all this development work. Below are excerpts from that interview.

You have about 40 ACO contracts out in the field right now, and are continuously expanding your program. Tell me a bit about your collaborative relationships?

Yes, we have in the 39-40 range of accountable care organizations right now. We have a broad range of collaborative relationships with organizations, including some that are participating in PMCHs [patient-centered medical homes] and the MSSPs; but ours are anchored in a provider organization, typically, a hospital organization serving a regional market, and may include multiple contracts. So for example, Banner [in Phoenix] is both a Pioneer ACO but also has a commercial product, and patient-centered medical homes as well. Our definition of an ACO is around a large provider-based organization.

Gary Anthony

So we have roughly 40 of those in place today. We have about 550,000 members within them, and are projecting roughly 850,000 by the end of the year. So probably around 60 contracts around the end of the year, 60-plus. So we’ve been at this for a while and have certainly learned a lot.

So in three-plus years of doing this, we’ve built out what we believe is both a market-leading economic model of how you put these together and what an organization has to do be successful in the transition to population health-, value-based care.

What have been some of the broader key learnings so far?

There are five transitions, key transitions, involved in this kind of development work. First is around market growth; that could be getting a larger percentage of a patient’s spend in their market or acquiring new patients; certainly it means better referral patterns. Second is operational efficiency. The third is physician engagement and physician alignment—taking into account the culture of the physicians, and how you get the physicians engaged and aligned with you in this new care delivery model. Fourth is delivering on a next-generation care delivery model and care management. And then fifth is patient engagement, getting patients increasingly engaged in their care.

Though at a high level, the concepts of population health and value-based care delivery are broadly agreed on, but markets are different?

Yes, how they get from fee-for-service-based care to value-based care can differ greatly. That’s why we’ve created a fairly robust advisory service, to help organizations figure out where they are in our maturity model. And it’s not just that you’re a 1 or 2 or 3 on some scale, but also looking in more nuanced ways at these things, around culture, alignment, technologies, etc. But it does mean developing that roadmap.

So you’re creating somewhat different contracts and arrangements with different providers, then?

I would that say in all of these cases, there’s certainly a level of consistency and similarity in how we go to the market, but certainly there are uniquenesses around how you’ll work with a provider to drive market growth or engage major employers in an area or work on health information exchange; all that is unique to particular markets.

When you look at the issues around provider market consolidation—the fact that there has for years been a cycle of market consolidation moves among providers, then insurers, then providers, and so on. Each “side” has wanted greater market power and advantage. Overall, do you see provider consolidation as good or bad, in this context?

Without a doubt, there has to be some reduction in the fragmentation of our healthcare system. But that’s the very reason why we believe our highly collaborative approach with these organizations works and works well. We’ve gone in and built these highly collaborative relationships, and have learned where we’re coming from and the strengths we each bring to the table, and collaborate forward. And yes, the market is fragmented, and there will continue to be further consolidation, because we have to remove some fragmentation. But that’s the strength that we’ve brought to the table.

What have been the challenges and opportunities so far around sharing clinical and claims data for clinical performance improvement?

I would certainly agree that it’s not an easy thing to do. We have claims data that is highly codified and structured data, and clinical data, which is not, and is slowly moving in that direction; so bringing those two types of data together, along with patient data; but we believe that when you can bring clinical, claims, and patient-supplied data, it is only then that you can get where you need to.

Isn’t part of the core challenge that claims data can’t be made timely enough to help in care management?

Yes, claims data is inherently retrospective; and we have to be able to provide data at the point of care. For a care manager to work with data that is 60 to 90 days past, is not effective; so we have to be able to impact care at the time of care. That’s why we need patient-supplied data. And by its very nature, claims data is based on billing data, which is by its nature retrospective. So it still is going to be retrospective.

And what can you do to help providers do when they get this data together?

Back to your question on the definition of population health, it’s how you take this data and glean knowledge from it from across a whole population of patients—and then how you apply that knowledge to individual patients.  I call it population health, one patient at a time. You have to be able to do that. And we’ve shown we can do that, and when we allow care management to be seen as an extension of the physician-patient relationship—which I believe is the most sacred relationship in healthcare—we’ve been able to see dramatic improvements in outcomes.

Are you breaking down suspicion among physicians towards partnering with health plans?

Yes. I believe trust is earned; and we’ve gone to great lengths in this. We’ve created joint operating committees with physicians; we’ve created good governance structure in the ACOs, and we’ve made sure there’s good participation and governance from among physicians. And we’ve structured it that when they win, we win, and we win, they win. It’s an over-used phrase, but we really do make it a win-win strategy. We make sure we get their trust and work collaboratively together.

What would your advice be for CIOs and CMIOs in all this?

I would give them the advice that physicians are very data-driven individuals for the most part; they respond well to data. In many ways within our healthcare organizations, we have enormous amounts of information, but a lot of it is not actionable. Physicians want to do well.

A lot of it is raw data that has to be turned into information.

Yes, exactly. It’s a little bit like comparing giving them a jigsaw puzzle, to giving them a completed Mona Lisa to enjoy. I believe you need to create and build these systems so that physicians can see their populations of patients but also their individual patients, so that they can deliver quality care.

Would you like to add anything else?

Just that the way we combine our health plan aspects of the ACO along with our enablement services of advisory services, care management, and technology services, that’s very unique, and we’re seeing successes throughout the marketplace.






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