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October 1, 2013
Aetna Better Health of Illinois Navigating Relationships in an Evolving Healthcare Environment: Community Health Centers and Managed Care Organizations Forum
Sanjoy Musunuri
Aetna Inc. AETNA BETTER HEALTH
Agenda
• Aetna Better Health overview
• Contracting philosophy and process
• Value based reimbursement programs
• Partnerships with CHCs
• Questions / Open discussion
2
Aetna Inc. AETNA BETTER HEALTH 3
Aetna Today Founded in 1853, Aetna is one of the nation's leading providers of health care, dental, pharmacy, group life, and disability insurance
Company
Membership
National Presence
One of the nation’s largest health and benefits companies with over 49,000 employees worldwide
Revenues of $35.5 billion for 2012
Nationwide network of more than one million health care professionals
Network includes over 5,300 hospitals and 597,000 primary care doctors and specialists
Products & Services
First national, full-service health insurer to offer consumer-directed benefits
Integrated medical, dental, pharmacy, life and disability insurance products
Programs that control rising costs while improving the quality of health care
Value-Added Technology
Convenient tools and easy-to-understand information to make informed decisions
ActiveHealth Management®, Aetna Integrated InformaticsSM
, Aetna Navigator Aetna InteliHealth®, iTriage, Medicity, Healthagen
Customers Strong national brand and best reputation in our industry
Serving individuals; small mid-sized, and large multi-site employers; federal, state and local governments; Medicare and Medicaid beneficiaries
First to offer high performance network (Aexcel)
First to offer provider quality and cost information to consumers
First health plan to join The Leapfrog Group quality care initiative as an employer
First to launch integrated strategy to improve racial and ethnic disparities
First to launch Personal Health Record with advanced clinical rules engine
First to offer comprehensive end of life program (Compassionate Care)
Aetna Firsts
22.0 million Medical members
14.3 million Dental members
13.8 million Pharmacy members
Aetna Inc. AETNA BETTER HEALTH
Aetna Experience
• Two decades of Medicaid experience
• 46 years experience serving Medicare populations
• 1.2 million Medicaid members nationally / 19K in Illinois
• 300K+ Medicare Advantage members nationally / 15K in Illinois and 11K in greater Chicago region
• SPD, Long Term Care and Dual experience, including an integrated program in Arizona (16K + Medicare and Medicaid members)
Aetna Inc. AETNA BETTER HEALTH 6
Aetna Better Health of Illinois
• One of 2 plans in ICP program serving 19,000 SPD members in Boone, DuPage, Kane, Kankakee,
McHenry, Will, Winnebago and Suburban Cook County (excluding areas whose zip code begins
with 606)
• One of 6 plans awarded the duals MMAI contract to serve 100K+ dual Medicare Medicaid
Eligibles (MMEs) in greater Chicago service area (Lake, Kane, DuPage, Will, Kankakee and Cook
County )
• ICP Expansion – Projected to launch Chicago on 2/1/2014
• Local leadership and operations
• 100+ employees
• 2 offices: downtown Chicago and Downers Grove
• Acute and LTC services with field and office based care management
• On site provider and member services call center operations
• Follow any willing provider contracting process
Aetna Inc. AETNA BETTER HEALTH 8
Our Contracting Approach • We welcome ALL providers to be in our network – Any Willing Provider
• Sources to identify providers
State of Illinois provider lists
Member requests
Claims data
Direct outreach from providers
• Contract requirements
Access and availability, including ADA compliance
Licensure / credentialing
Administrative obligations
Hospital / NH privileges
Rates
• Partnership attributes
Willingness to serve the population
Cultural competence
Medical home capability
Quality focus / capability
Delivery system innovation – I.e. co-location of BH; Care management expertise
Aetna Inc. AETNA BETTER HEALTH 9
Our Contracting Process
Initial contract request
Review contract template
Finalize language /
rate structure
Credential providers
Load contract
and provide services
Aetna Inc. AETNA BETTER HEALTH
What we know….
• State of Illinois would like to see more innovative approaches to engaging
providers
• Want to move to a value based reimbursement system → value = quality,
outcomes, access and efficiency
• Wide variation in PCMH capability in the market
• Providers have requested more partnership based relationships
• Medicaid fee schedule in lowest decile so need alternative mechanisms to
create value for providers to promote access
• Strong mission driven community health centers that are core to the
delivery system for vulnerable populations
• Many IPA and PHO structures in market that prefer capitation and risk type
agreements
• Competitors are utilizing shared savings and risk structures in the
marketplace
• State has incentivized quality
Aetna Inc. AETNA BETTER HEALTH
Engaging Providers - Supported Payment Structures
• PCMH
• Pay for Performance (P4P)
• Medicaid Health Homes and Patient-Centered Medical Homes
• Shared Savings Model
• Risk-Share Models
• Accountable Care Organizations (ACOs) – Aetna Medicaid actively supports
provider organizations in the development of ACOs. This typically includes
data sharing/support, the development of tailored reimbursement structures
(with either shared savings or risk), as well as quality benchmarks and
outcome measurements.
Aetna Inc. AETNA BETTER HEALTH
PCMH Program • Program designed to embrace, incentivize and reward a patient centered medical home focus
• Understand providers are at various stages of the transformation so we utilize financial incentives that promote PCMH transformation efforts
• Utilize a PCMH assessment tool to understand each provider’s PCMH capability looking at four key domains that are deemed essential for success
Personal clinician relationship for each member
Organizational Capacity/Access to meet the member’s communication and informational needs for all aspects of care
Coordination of Care/Services – An orientation toward a collaborative team approach to coordinate each member’s care across multiple care settings and environments
Performance Measures/Quality Improvement – Processes to measure and evaluate care and achieve outcomes that reflect a commitment to continuous quality improvement and evidence-based practice
• Financial incentives involve a PMPM PCMH fee based on capability
• Financial incentives adjusted every year to recognize improvements
• Program highlights
Thirty PCMH practices will align with Aetna Better Health of Illinois during 2013 to serve our members
Over 9,000 members (and growing) will be cared for by a PCMH practitioner in 2013
Our PCMH practices vary in size, organizational type and are in several locations enabling us to appeal to and service individuals with varying preferences and needs
Aetna Inc. AETNA BETTER HEALTH
P4P…..
• Payment for quality performance and outcomes
• Promotes efficacy based care
• Demonstrates focus on population health and chronic disease management
capabilities
• Alignment with State quality imperatives
• Quality Metrics in 2013
• Comprehensive diabetes care
• HbA1c testing
• LDL-C screening
• Percent of members seen by PCP during year
• Percent of members seen by provider within 14 days of inpatient discharge
• Readmission rates
• Incentive opportunity: $ PMPM per measure if meets or exceeds established targets
• Practitioners supported by quarterly progress profile and gap analysis reports
Aetna Inc. AETNA BETTER HEALTH
ACO Platform
PCMH
Care Transitions IT/Analytics
VBP models
Provider Alignment
VBP models
CM
IT/Analytics
PCMH
VBP- Supporting PCMH and ACO Movement
Delivery Reform + Payment Reform = Transformation