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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 Better Health of Illinois

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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 5

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 7

Current Network

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

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

Aetna Inc. AETNA BETTER HEALTH

Questions?

Aetna Better Health

1-866-212-2851

Prompt for providers-Press 2

Select 5 to speak to a Provider Services Representative