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Quality health plans & benefitsHealthier livingFinancial well‐beingIntelligent solutions
Pamela MilburnNetwork Operations HeadSE Region
August 12, 2015
Network Management Update
Agenda
I. Value Based Contracting
II. Provider Service Center Model
III. Oncology Program ‐ New Century Health
IV. Medical Policy Updates
V. Open Discussion and Questions
V. Open Discussion and Questions
Value Based ContractingOur goal: transform to a value‐driven health system
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Aetna has 28% of spend in value‐based models. We plan to surpass 50% by the end of 2018 and 75% in 2020.
We deploy a range of models to meet providers where they are on the transformation continuum.
Pay for performance
Patient CenteredMedical Home
ACO attribution
ACOproduct
Jointventures
Provider Service Center Model
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Copies of this distribution will be available following the presentation.
New Century Health – Oncology Program
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• July 1, 2015: Oncology‐related chemotherapeutic drugs and supportive agents will now require a pre‐authorization from NCH.
• Uses clinical guidelines based on nationally recognized, evidence‐based criteria. This helps decide medical necessity in cancer care.
• Works closely with physician offices to develop a team approach. Offers peer‐to‐peer discussions with medical oncologists.
• Makes the administrative process faster and easier.
Medical Policy Updates
• Readmission Policy Expansion – Effective 7/1/2015 DRG Contracts 30 Days Includes Commercial Members
• Observation > 24 Hours – Effective 7/1/2015 Requires Precertification Considered Inpatient Stay Subject to Timely Notification Requirement
• Timely Notification Policy– Effective 1/1/2015 $10,000 2 Business Days
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Thank you
Copyright 2015 Aetna Inc.