Aetna Better Health of Illinois

Transcription

1 Aetna Better Health of Illinois Navigating Relationships in an Evolving Healthcare Environment: Community Health Centers and Managed Care Organizations Forum October 1, 2013 Sanjoy Musunuri

2 Agenda Aetna Better Health overview Contracting philosophy and process Value based reimbursement programs Partnerships with CHCs Questions / Open discussion AETNA BETTER HEALTH 2

3 Aetna Today Founded in 1853, Aetna is one of the nation's leading providers of health care, dental, pharmacy, group life, and disability insurance Company One of the nation s largest health and benefits companies with over 49,000 employees worldwide Revenues of $35.5 billion for 2012 Customers Membership National Presence Products & Services Value-Added Technology Aetna Firsts Strong national brand and best reputation in our industry Serving individuals; small mid-sized, and large multi-site employers; federal, state and local governments; Medicare and Medicaid beneficiaries 22.0 million Medical members 14.3 million Dental members 13.8 million Pharmacy members Nationwide network of more than one million health care professionals Network includes over 5,300 hospitals and 597,000 primary care doctors and specialists First national, full-service health insurer to offer consumer-directed benefits Integrated medical, dental, pharmacy, life and disability insurance products Programs that control rising costs while improving the quality of health care Convenient tools and easy-to-understand information to make informed decisions ActiveHealth Management, Aetna Integrated Informatics SM, Aetna Navigator Aetna InteliHealth, itriage, Medicity, Healthagen First to offer high performance network (Aexcel) First to offer provider quality and cost information to consumers First health plan to join The Leapfrog Group quality care initiative as an employer First to launch integrated strategy to improve racial and ethnic disparities First to launch Personal Health Record with advanced clinical rules engine First to offer comprehensive end of life program (Compassionate Care) AETNA BETTER HEALTH 3

4 Aetna Experience Two decades of Medicaid experience 46 years experience serving Medicare populations 1.2 million Medicaid members nationally / 19K in Illinois 300K+ Medicare Advantage members nationally / 15K in Illinois and 11K in greater Chicago region SPD, Long Term Care and Dual experience, including an integrated program in Arizona (16K + Medicare and Medicaid members) AETNA BETTER HEALTH

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6 Aetna Better Health of Illinois One of 2 plans in ICP program serving 19,000 SPD members in Boone, DuPage, Kane, Kankakee, McHenry, Will, Winnebago and Suburban Cook County (excluding areas whose zip code begins with 606) One of 6 plans awarded the duals MMAI contract to serve 100K+ dual Medicare Medicaid Eligibles (MMEs) in greater Chicago service area (Lake, Kane, DuPage, Will, Kankakee and Cook County ) ICP Expansion Projected to launch Chicago on 2/1/2014 Local leadership and operations 100+ employees 2 offices: downtown Chicago and Downers Grove Acute and LTC services with field and office based care management On site provider and member services call center operations Follow any willing provider contracting process AETNA BETTER HEALTH 6

7 Current Network AETNA BETTER HEALTH 7

8 Our Contracting Approach We welcome ALL providers to be in our network Any Willing Provider Sources to identify providers State of Illinois provider lists Member requests Claims data Direct outreach from providers Contract requirements Access and availability, including ADA compliance Licensure / credentialing Administrative obligations Hospital / NH privileges Rates Partnership attributes Willingness to serve the population Cultural competence Medical home capability Quality focus / capability Delivery system innovation I.e. co-location of BH; Care management expertise AETNA BETTER HEALTH 8

9 Our Contracting Process Initial contract request Review contract template Finalize language / rate structure Credential providers Load contract and provide services AETNA BETTER HEALTH 9

10 What we know. State of Illinois would like to see more innovative approaches to engaging providers Want to move to a value based reimbursement system value = quality, outcomes, access and efficiency Wide variation in PCMH capability in the market Providers have requested more partnership based relationships Medicaid fee schedule in lowest decile so need alternative mechanisms to create value for providers to promote access Strong mission driven community health centers that are core to the delivery system for vulnerable populations Many IPA and PHO structures in market that prefer capitation and risk type agreements Competitors are utilizing shared savings and risk structures in the marketplace State has incentivized quality AETNA BETTER HEALTH

11 Engaging Providers - Supported Payment Structures PCMH Pay for Performance (P4P) Medicaid Health Homes and Patient-Centered Medical Homes Shared Savings Model Risk-Share Models Accountable Care Organizations (ACOs) Aetna Medicaid actively supports provider organizations in the development of ACOs. This typically includes data sharing/support, the development of tailored reimbursement structures (with either shared savings or risk), as well as quality benchmarks and outcome measurements. AETNA BETTER HEALTH

12 PCMH Program Program designed to embrace, incentivize and reward a patient centered medical home focus Understand providers are at various stages of the transformation so we utilize financial incentives that promote PCMH transformation efforts Utilize a PCMH assessment tool to understand each provider s PCMH capability looking at four key domains that are deemed essential for success Personal clinician relationship for each member Organizational Capacity/Access to meet the member s communication and informational needs for all aspects of care Coordination of Care/Services An orientation toward a collaborative team approach to coordinate each member s care across multiple care settings and environments Performance Measures/Quality Improvement Processes to measure and evaluate care and achieve outcomes that reflect a commitment to continuous quality improvement and evidence-based practice Financial incentives involve a PMPM PCMH fee based on capability Financial incentives adjusted every year to recognize improvements Program highlights Thirty PCMH practices will align with Aetna Better Health of Illinois during 2013 to serve our members Over 9,000 members (and growing) will be cared for by a PCMH practitioner in 2013 Our PCMH practices vary in size, organizational type and are in several locations enabling us to appeal to and service individuals with varying preferences and needs AETNA BETTER HEALTH

13 P4P.. Payment for quality performance and outcomes Promotes efficacy based care Demonstrates focus on population health and chronic disease management capabilities Alignment with State quality imperatives Quality Metrics in 2013 Comprehensive diabetes care HbA1c testing LDL-C screening Percent of members seen by PCP during year Percent of members seen by provider within 14 days of inpatient discharge Readmission rates Incentive opportunity: $ PMPM per measure if meets or exceeds established targets Practitioners supported by quarterly progress profile and gap analysis reports AETNA BETTER HEALTH

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15 VBP- Supporting PCMH and ACO Movement ACO Platform PCMH Care Transitions IT/Analytics VBP models Provider Alignment PCMH Delivery Reform + Payment Reform = Transformation IT/Analytics VBP models CM AETNA BETTER HEALTH

16 Questions? Aetna Better Health Prompt for providers-press 2 Select 5 to speak to a Provider Services Representative AETNA BETTER HEALTH