Cigna Plans Aggressive Expansion for ACO-like Program

Cigna is doubling down on its commercial ACO strategy.

The insurer has accelerated the development of its collaborative accountable care (CAC) program. The CAC is Cigna's variation on the accountable care organizations (ACO) created as part of federal healthcare reform.

While ACOs focus on physicians and hospitals providing coordinated care to improve quality and lower the cost of care for Medicare beneficiaries, Cigna's version of the comercial ACO is an insurer-physician partnership that provides coordinated care to improve quality and contain healthcare costs across Cigna's commercial and Medicare Advantage books of business.

Leavitt Partners, a Salt Lake City–based health intelligence business estimates that there are currently nearly 200 commercial ACOs or ACO-like organizations at some stage of development. Aetna is one of them. Blue Shield of California is another.

Like Cigna’s efforts, Aetna’s ACO program is in its infancy but has plans for significant growth. It has 10 ACO agreements in place and expects to have 20 under contract by the end of 2012. It plans to develop a national ACO network over the next five years.

Cigna has fashioned the original ACO concept into a model that enables the insurer to use its extensive member database in a more formal care management relationship with selected physician partners.

The Connecticut-based insurer added 20 CACs this year, including 10 in July alone. Cigna now has 32 CACs covering 300,000 members in place in 16 states. Its goal is to have 100 CACs serving one million members in place across the United States by 2014, says Dick Salmon, MD, Cigna's national medical director for performance measures and improvement.

CAC contracts include Palo Alto Medical Foundation (California), New West Physicians Group (Denver), Mount Carmel Health Partners (Columbus, Ohio), and Dartmouth-Hitchcock Clinic (New Hampshire), and Medical Clinic of North Texas (Dallas-Fort Worth).

The aggressive expansion schedule reflects competition?Aetna is also committed to a nationwide ACO network as well as the promising results delivered by Cigna's CACs so far.

The physician-focused CAC model involves large primary care or multispecialty physician groups, and independent physician associations, as well as some integrated delivery systems (IDS) and physician-hospital organizations (PHO). Even when an IDS or PHO is involved in a CAC, the physician is still the focus because "physicians hold the power of the order pen," Salmon says.

Participating physician groups each have at least 10,000 Cigna members in their practice. Salmon explains that measuring total medical costs and quality parameters is difficult and can be unreliable for smaller populations.

Cigna looks for physician groups that have already worked for several years on improving traditional quality metrics such as Healthcare Effectiveness Data and Information Set (HEDIS) and are prepared to take on the bigger issue of improving broad, population-based metrics through care coordination. "Cigna becomes the payer partner that helps make that effort financially sensible and rewarding," says Salmon.

He adds that "a large multispecialty group that only cares about fee-for-service generation isn't going to be a good partner for us in this."

CAC contracts are typically for three years and are customized to reflect the improvement goals of individual physician groups. Goals are usually based on the extensive practice profiles and data maintained by Cigna.

For example, data might indicate that a group has a high rate of emergency department visits. The action plan developed to reduce the rate of visits would reflect the preferences of the physician group, which could include making more urgent care appointments available throughout the day, as well as adding evening and weekend office hours.

In the first year, Cigna pays a care management fee based on the planned improvements. After that, rewards are based on meeting the improvement goals.

The CAC program includes a clinical collaboration component between Cigna and the physicians, so participating physicians are required to hire one embedded care coordinator for every 10,000 Cigna members in the practice.

Salmon explains that it is the job of the care coordinator to use Cigna's health informatics on hospitalizations and gaps in care to improve patient care coordination. Predictive modeling is used by the care coordinator to identify patients in the practice who might be at risk for health problems.

Care coordinators also can assess a patient's foundational knowledge of their condition. An outreach call to resolve gaps in care for a diabetic, for example, could result in the patient being referred to Cigna's diabetic coaching program to become a more active participant in their care.

In early results, Cigna says that individual CACs have outperformed their market in several areas, including avoidable emergency room visits, improved control of A1c blood sugar levels in diabetes, and reductions in the cost of ambulatory surgery. For the eight CACs that have been in place for more than one year, 50% are meeting both quality and cost goals.