Q&A: Aetna's Accountable Care Chief on Providers Assuming Risk

The CEO of Aetna's ACO business unit discusses how the insurer is working with healthcare providers to retool their organizations in order to deliver services based on value rather than volume.

Aetna is taking a leadership role in accountable care contracting.

The Hartford, CT-based commercial insurance carrier has established dozens of accountable care collaborations with healthcare providers across the country, and an internal business unit, Accountable Care Solutions from Aetna, is working with providers who want to assume greater risk in delivery of services.

Daniel Finke, MBA, became CEO of ACS last September. Finke and I recently talked about how ACS is helping healthcare providers retool their organizations to deliver services based on value rather than volume.

HLM: What are the main ways ACS is helping healthcare providers assume risk in care delivery?

Finke: The bottom line of this is that we have 160 years of experience in managing risk, and we're using those assets to give providers help in assuming risk themselves. We offer optimal risk contracting to meet the providers where they are in readiness to assume risk, with a range of risk options as well as medium- and long-range solutions.

There are simple models where there is only upside risk and concentration on cost of care. There are models with upside and downside risk, bundled payments, and ACO contracts that have both upside and downside risk.

We're working with providers to put them in the insurance business. We provide a wide variety of risk-based solutions. It's not one-size-fits-all. That's for sure.

HLM: How do you build an optimal infrastructure for value-based care and patient engagement?

Finke: There are three focuses: Contracting at the right level of risk for the provider, establishing the right infrastructure for data and technology, and [determining] the right mix of clinical services for care management at the local level and point of care. We also use things like benefit design and tiering to pull the patient into the care as well.

HLM: How do you align providers' financial incentives with value-based care?

Finke: About 30% of Aetna's overall payments are in some form of value-based model. It's about $20 billion [annually]. The key factor is making sure the risk contract is right and to help make sure providers have a good contract experience.

HLM: How do you get payers, providers and patients on the same team?

Finke: We can align payer and provider risk, but we have to have the patient involved as well. You have to have a network of providers focused on quality and clinical outcomes. You need to provide most of the services [health plan] members want and make arrangements for services that are not in the provider network. You need consumer engagement tools to help ensure success… Web-based tools give members the ability to check their deductible status and support care management.

HLM: How do you assess the readiness of a healthcare provider to adopt value-based care?

Finke: Most of our providers are asking for help in assessing their readiness. Our ACS consulting group looks at providers' capabilities for managing risk. They ask a lot of questions. When it comes to IT, are all the physicians in an organization on the same electronic health record system? What services can they provide members and where would they secure out-of-network services?

There are at least a half-dozen assessments, and a consultant works on-site. There is a wide variety of readiness. It's a cultural question within most provider organizations. It's also market-driven, with Medicare pushing value-based payment models.

HLM: How can technology unlock the power of evidence-based care and preventive care?

Finke: Integrating clinical and claims data is a key capability, and integrating data collection into workflows at health systems is really important.

HLM: Do healthcare providers have to establish a minimal level of digital capabilities to succeed in accountable care contracting? If they do, what is in the minimal set of digital capabilities such as electronic patient health records, digital billing processes, and analytics?

Finke: Paper records would be challenging. You have to have some sort of electronic health record. Having the ability to share data is critically important. Ideally, providers should have an online capability to interact with their patients. It allows things to happen more timely.

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What we're trying to do is provide care at the right time and the right place. When it comes to patient engagement, providers are more effective than payers. Provider care managers connect with [health plan] members better than payer care managers. Patients are more inclined to listen to them…

We can provide a variety of solutions to a provider's IT needs. There are some minimal analytics and clinical reports that can help providers grab the low-hanging fruit of value-based care."

HLM: How do you simultaneously decrease service volumes while maintaining high quality and cost-effectiveness in care delivery?

Finke: The key to this question is coordination of care. If you have coordinated providers and apply precision medicine whenever possible, then over time, the unnecessary utilization is kicked out of the system.

HLM: Which incentives and value-based payment models are best-suited for the healthcare industry?

Finke: There's no one perfect payment model. Joint ventures have a lot of promise, but the market will determine which are the best models.