Payment Reimbursement and Managed Care

How to Be a Good Payer Partner

November 7, 2017 2:21 pm

Aetna provider partnerships have achieved $9.9 million in shared savings over a three-year period, and an 11.5 percent reduction in medical costs.

In this interview, Carlotta Rinke, MD, senior medical director for the provider transformation team, Aetna Accountable Care Solutions, Chicago, offers advice to CFOs on achieving success in accountable care organizations (ACOs) and joint ventures with health plans.

On ACO partnerships with providers. Since 2014, Aetna has partnered with providers to create more than 60 ACOs in the Midwest and West. Many have been upside-only arrangements, while others have involved some downside risk. 

Through these partnerships, Aetna and the providers have achieved $9.9 million in shared savings over three years. “The majority of the ACOs came under the annual per member, per month [PMPM] target, so they were able to participate in shared savings if they achieved their quality targets,” Rinke says.

The ACOs also have achieved an 11.5 percent reduction in medical costs versus expected costs. In addition, they have decreased avoidable surgical readmissions by 24 percent and increased generic prescribing by 4 percent.

On getting organized for population health. When considering potential provider partners, Aetna looks for three main qualities:

  • A well-organized physician governance structure, such as a clinically integrated network (CIN), to drive greater accountability among employed and affiliated physicians
  • Strong care management capabilities, which Aetna supports through a PMPM accountable care payment
  • A data registry to help identify and track members with the greatest utilization and the highest cost of care

One of Aetna’s flagship ACOs, which has evolved into a joint venture with the provider organization, drove down inpatient utilization by 25-30 percent from baseline. “Part of that success was driven because the health system was poised and organized for population health,” Rinke says.

The organization has developed a high-performing network of specialists who work with hospitalists and emergency department (ED) physicians to determine which patients can be discharged appropriately. For example, a network cardiologist might help ED physicians identify if a patient with chest pain has a low probability for cardiac issues and can be discharged and scheduled to have an outpatient stress test the following day.

“Being able to coordinate specialists and deliver on-the-spot care is important to support population health,” Rinke says.

On the benefits of stable leadership. Rinke says that CFOs can reinforce strong physician governance to support coordination among the many groups involved in these arrangements. Rinke points to one joint venture in which the CIN structures its physician governance into “neighborhoods,” each with medical directors who report to a chief medical officer. These medical directors meet monthly and coordinate with a practice outreach team to educate physicians and nurses on what it takes to achieve success under their payer contracts.

On identifying targets and building trust with providers. Rinke and her team—which includes a senior clinical strategist, a data analyst, a pharmacist, and a senior engagement manager—hold monthly meetings with their provider partners to prioritize and review initiatives. Specifically, they work with the CIN’s medical directors and other leaders to develop a clinical savings roadmap, which outlines specific opportunities based on Aetna’s historical claims data for the market. “Generally, these are big ticket items, such as inpatient and emergency department utilization, pharmacy, and out-of-network specialty spend,” Rinke says. “By developing roadmaps to clinical savings together, we develop trust and transparency,” she says.

On engaging providers. Aetna shares claims data with its provider partners in easy-to-read monthly reports. The reports divide PMPM costs into categories, such as inpatient utilization, ED utilization, medical pharmacy, pharmacy, primary care, specialty, home health, and behavioral health. Financial and clinical leaders also can review data by plan sponsor, if needed. Data show cost per unit, cost per visit, aggregate cost, and variation compared with the previous 12 months.

In these reports, members who have entered the ED at least three times during the past 12 months as well as those with high predicted utilization are highlighted for provider outreach. “The goal is to identify these high-risk, high-cost members and help them get the care they need,” Rinke says.

On pharmacy savings. The pharmacist on Aetna’s team helps organizations improve their generic prescribing rates by reaching out directly to providers. Together, they focus on major drug classes in the ambulatory setting: antidepressants, antihypertensives, statins, and ulcer medications.

For costly specialty drugs, the pharmacist also informs providers when there is a cheaper alternative that is equally effective—and could lead to member cost savings as well. “We discuss the opportunities with our partners so they can develop their own strategies,” she says.

On the importance of investing in IT. CFOs can help ensure the success of payer-provider partnerships by investing in initiatives to standardize or connect the electronic health record across the CIN, Rinke says. “This is essential for effective care coordination,” Rinke says. “The most advanced ACOs that are moving into joint ventures or capitated, full-risk contracts have that ability.”

On building aligned incentives. “CFOs should ensure that the alignment of incentives is consistent across their organization,” Rinke says. “The hospital CEO might want to keep beds full, but the CIN wants to empty the beds. The same is true for the emergency department. I’ve seen conflicted alignments in a few ACOs where the message wasn’t clear.” 

Laura Ramos Hegwer is a freelance writer and editor based in Lake Bluff, Ill.

Interviewed for this article:

Carlotta Rinke, MD, MBA, FACP, is senior medical director for the provider transformation team, Aetna Accountable Care Solutions, Chicago. For more information, contact Ethan Slavin, public relations, Aetna.

Discussion Starters:

Forum members: What do you think? Please share your thoughts in the comments section below. 

  • What are some pitfalls to effective payer-provider partnerships?
  • What can be done to stabilize physician leadership in an ACO?
  • Which datasets should be shared to ensure the success of payer-provider partnerships?


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