Trying to wean themselves off fee-for-service reimbursement, some health systems may be taking a non-committal strategy, dipping their toes in the water before deciding if they want to learn to swim. Insurers should be looking for more than that, if they can offer the right expertise.
Among numerous alternative reimbursement arrangements announced by insurers this summer and spring, more than a few came from Aetna, which inked accountable care contracts with physician groups and health systems around the country, including in Texas, where the insurer recently landed its biggest membership sale in company history, the state's public teachers benefit plan.
Along with attempting to link payments to health outcomes, Aetna's accountable care contracts are trying to gauge the financial ramifications that arise when providers find traditional fee-for-service incentives flipped upside down.
Paying for healthcare claims on the one side, the company is also offering health systems patient engagement and revenue management technology services and payment adjustments that help compensate for revenue lost to prevented hospitalizations and acute care episodes.
The task of evolving away from fee-for-service is such a large one that Aetna is selective in which providers it will work with on accountable care.
"Those just looking to stick their toe in the water are difficult," said Charles Kennedy, MD, one of the architects of Aetna's accountable care strategy.
While Aetna's contracts usually represent a small percentage of many health systems' overall reimbursement, the deemphasis of hospital care can be significant enough to disrupt revenue.
"When you make these changes, there are financial implications, and if you help the delivery system become more efficient, it may impact their bottom line in a negative way," said Kennedy, a native Californian, UCLA-trained internist and Stanford MBA who spent seven years at WellPoint become coming to Aetna in 2011.
It is a leap of faith of sorts for providers, data-driven though it may be in large part, which is why Aetna integrates a "LEAP" program for providers, a Lasting Economic Advance Plan, to help them sustainably provide new preventative services and cost-effectively manage chronic and acute care.
"If you can help them become efficient, they can become the dominant system is their particular geography, with lower prices to attract more patients," Kennedy said. "When I was practicing, I would focus on the patients with diabetes and hypertension when they came to see me. In an ACO, we want care management programs that focus on patients who are not getting care," with uncontrolled diabetes that puts them at risk of a need for acute care.
By working with health systems to prevent high-cost acute care and bring patients easy-to-access primary care and chronic condition management, Aetna can extend the ACO providers to its health plan network tiers, offering broad choices with higher-cost sharing and the ACO network at a budget price that's more attractive to members.
"What we're doing through our network strategy is creating a balance between lower cost and network options," Kennedy said. "We'll offer a concentric network: maximum financial benefit provided if you use the ACO, like a Banner ACO, but if you need care that for some reason is out of their expertise, you still have the Aetna overall network."