Blog | Innovation and Disruption

Analysis: Details about CVS/Aetna's 2 new pilot programs

Blog | Innovation and Disruption

Analysis: Details about CVS/Aetna's 2 new pilot programs

  • CVS/Aetna announced two different pilots focused on improving outcomes for its members.
  • The first pilot’s focus is on social determinants of health.
  • The second is a care navigation pilot for Aetna members who are undergoing knee replacement surgeries.

CVS/Aetna announced two different pilots focused on improving care outcomes for its members.

Pilot 1 details: The first pilot’s focus is on social determinants of health (SDOH). Modern Healthcare is reporting the company is “…rolling out a network to provide its most vulnerable patients with access to local support for their social care needs. It will collaborate with social care coordinator platform provider Unite Us to launch a platform that will allow Medicaid and dual-eligible beneficiaries covered through its insurance arm Aetna to more easily find and access help from social care providers within their communities.”

The pilot will start with Aetna Medicaid and Medicare Advantage (MA) dual-eligible Special Needs Plan members in three markets. “Eligible members can be referred by a community healthcare provider or Aetna nurse case managers who will receive information through the platform,” according to Modern Healthcare.

Pilot 2 details: The second is a care navigation pilot for Aetna members, both commercial and Medicare Advantage, who are undergoing knee replacement surgeries, according to a Healthcare Dive article.

How will pilot 2 work: To manage pre- and post-operative care, CVS Aetna will use:

  • In-home clinical care teams
  • CVS brick-and-mortar pharmacy locations
  • Telehealth services

Takeaway

A couple of takeaways: 1. It’s not surprising that CVS/Aetna would focus on providing resources to help clinicians/care coordinators address SDOH for their Medicaid and MA dual members. Both are growing books of business for most health plans. Given the impact of SDOH on health spending, this presents an opportunity to reduce spending. Thanks to the Willie Sutton rule, savings for dual-eligible beneficiaries have been consistently higher in the Medicare Shared Savings Program (even going back to the Physician Group Practice demo) given there are significant opportunities to use care coordination and increased access to primary care to reduce avoidable emergency department and acute utilization.

Integration efforts: With the deployment of the Unite Us platform, not only is Aetna CVS aggregating all of the necessary community resources in one location (a task unto itself), but it appears to be integrating this into the members’ care plans and incorporating the data into its partnering physicians’ medical records so everyone’s on the same page.

2. No surprise on care coordination for knee replacement procedures either given its frequency in both the MA and commercial population. For example, I would anticipate that as part of the care pre-operative care coordination you may see more commercial and MA patients diverted for pre-habilitation when:

  • BMI is a little high
  • Lab values out of range
  • They need to develop lower body strength to begin rehab the day of surgery

This is a common strategy used by Bundled Payments for Care Improvement, Comprehensive Care for Joint Replacement and Bundled Payments for Care Improvement Advanced participants. It will likely reduce LOS for acute-care providers, reduce readmissions and the use of institutional PAC care.

Beyond the clinical care aspect of this, the focus on providing some of the coordination through the store will likely also help drive sales of everything from drugs (both OTC and prescription), low-dollar DME (such as canes) and groceries.

One important question: The one question I have on this is how will they integrate these efforts (both the SDOH and ortho navigation) with the patient’s providers? Many CINs or providers participating in ACOs are developing capabilities to address SDOH. And many orthopedists or hospitals have deployed advanced care coordination strategies. If they don’t coordinate these efforts with the member/patients’ providers, it will duplicate efforts and confuse and/or alienate the member/patient and have an adverse impact on both outcomes and future care coordination efforts for these patients. 

About the Authors

Chad Mulvany, FHFMA

is director, healthcare finance policy, strategy and development, HFMA’s Washington, D.C., office, and a member of HFMA’s Virginia-Washington, D.C., Chapter. 

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