Health insurer Aetna is leading in its development of accountable care partnerships. In the last month alone, its Accountable Care Solutions division has announced three such collaborations, and more are likely on the way.
Ralph Holmes, President of Aetna's operations in Texas, where two ACOs were announced in late January, one with Dallas-based Texas Health Resources and the other with Houston-based MHMD Memorial Herman Physician Network (MHMD), says its ACO partnership with MHMD took a year of planning.
"It took a while," says Holmes. "We think we've partnered with the right system because they're the largest system in town. But, I think because the size of the system, it actually made the agreement more complex in trying to bring all the pieces together. They have more at stake than a smaller player might."
MHMD is one of the largest independent physician networks in Texas with 3,900 clinically integrated, primary care and specialty physicians. Its clinically integrated physicians already collaborate with Memorial Hermann Health System's inpatient and outpatient sites to practice evidenced-based medicine, which Chris Lloyd, CEO of MHMD, says will help the ACO hit the ground running on April 1.
"I think there was increasing complexity on one hand," says Lloyd. "On the other hand, we weren't starting from the same point that a lot of organizations would be starting from. Evidenced-based medicine and protocol becomes the basis for how we start to move the underlying metrics and risk models."
Moving past hurdles, building trust
Lloyd and Holmes both say that initially the two organizations struggled to trust that they were on the same page. One hurdle was laying aside the memories of attempts to change healthcare in the 1990s, which left organizations wary of sharing risk.
"Those early meetings were sort of the traditional looking-across-the-table-at-your-foe and you're trying to see what you can get for both your interests," says Holmes. "And it took a little while before we both began to say, 'Okay, we have to trust one another; we have to share information at a level we've not done before.' That transparency, I think created some trust."
Holmes also calls the level of transparency between Aetna and MHMD "unprecedented." Sharing data is part of a long list of other shared responsibilities, but it is crucial to maintaining the trust the two have established. It also plays an important role in figuring out best practices with a relatively new model of care.
Learning from claims data
And data sharing is key to the biggest variable in any healthcare arrangement, especially ACOs—the patient. Lloyd is confident it will lead to better engagement with patients because physicians will know them better.
"We [will] know a lot more about these patients because we'll get claims data from Aetna passed to us, and we'll look at that together," says Lloyd. "Physicians and physician organizations and hospital organizations simply do not have access to that information. Now we do. I know how many diabetics have co-morbid conditions. I know who their primary care physician is."
Along with predictive modeling tools, those extra pieces of patient information, says Lloyd, will help physicians and care managers understand when to call patients, or at least be alerted to the probability of an emergency department visit.
While the patient engagement piece starts with the physician, Holmes says the agreement Aetna has with MHMD is collaborative.
"It is our intent, depending on the size, with some customers, that AETNA, MHMD, and Memorial will engage plan sponsors where they are," says Holmes. "We'll work in tandem to attack issues with specific plan sponsors that are willing to have us come out and engage directly with their employees."
Lloyd believes the "rubber meets the road" at care delivery, or rather changing the model of care delivery.
Aligning incentives
"Historically the firewalls between what a payer would do as a plan and what a hospital or physician network would do were typically pretty well defined," says Lloyd. "We have sort of stepped back and taken a look at that and said 'Aetna's willing to do this piece, MHMD is willing to do this piece,' and then test whether we're doing well—that's a very big shared responsibility. And then, ultimately how do we align our incentives so that we're all encouraged to advance the model. That's a tricky dynamic."
The specific details of the financial incentives have not been disclosed, but under the agreement, Aetna will reward MHMD physicians for quality, efficiency, and patient satisfaction, as well as:
- Raising the percentage of Aetna members who get recommended preventive care and screenings
- Better management of patients with chronic conditions such as diabetes and heart failure
- Reductions in avoidable hospital readmission rates
- Reductions in emergency room visits
Measuring success
Aetna and MHMD are expecting to see promising results six months after the ACO launches. They say patient volumes as well as positive quality outcomes are positioned to increase. Ahead of the launch, the two organizations are meeting monthly to prepare, and it's clear both Lloyd and Holmes are excited.
"We see a lot of cities and towns who are strapped by the budget constraints looking for a solution," says Holmes.
"They don't want to ration care for their employees. What they want to do is improve the care in a way that allows them to stay healthy and on the job... and we think if we deliver that in partnership with Memorial Hermann and the physicians that will create something that has value to the market and will attract more members to Aetna."
Jacqueline Fellows is a contributing writer at HealthLeaders Media.