Aetna’s Unusual Medicare Plan Uses ACO-Style Approach

The outcomes have been promising for some 20,000 elderly people and the insurer wants to replicate the effort in other lines of business

Frank Diamond

Managing Editor

Outcomes for about 20,000 beneficiaries in Aetna’s Medicare Advantage offering underscore that health reform’s emphasis on accountable care organizations (ACOs) could pay off in the long run — and even the short run. About three years ago Aetna pushed for a closer working relationship with doctor groups, specialists, and hospitals to create a “more accountable” way to deliver care.

“We have not created our own ACO,” says Randall S. Krakauer, MD, Aetna’s national Medicare medical director. “Rather, working with providers, we’ve created models that meet the needs and conditions of that market, similar to ACOs. We created an ACO model for the participating primary care practices.”

What it takes

Key components of this effort, which does not have an official name, include:

  • Personalized care management and support
  • Advanced technology that connects doctors with up-to-date patient information and current medical evidence
  • Financial arrangements that encourage doctors to share in the improvement of patients’ health and take into account additional time and resources needed to care for patients with chronic conditions

A case study described by the Commonwealth Fund in September 2010 showed that the program’s use of embedded case managers (nurses) reduced duplicate and unnecessary services. Compared to nonparticipating Medicare recipients, the Medicare Advantage members received 43 percent less acute hospital care in 2010.

The nurse case managers work with doctors in 36 primary care practices. Aetna pairs the doctor groups with specialists, hospitals, and community social services that can provide in-home services, home-delivered meals, caregiver support, and respite care.

“Our care management program has improved health outcomes to the advantage of everyone,” says Krakauer. “In the special case of advanced illness [end-of-life care], the impact of our specialized case management program has been dramatic.” That program was highlighted in an article in the September/October issue of Health Affairs. Krakauer was the primary author.

The study found that “the increase in hospice election and decrease in acute care services was estimated to reduce medical costs 22 percent, compared to a historical control group during the period of time members were engaged in the care management program.”

Krakauer says that Aetna was willing to make the effort worthwhile for participating providers. “Physicians and facilities earned additional payments for meeting certain quality measures that helped patients stay healthier so they can avoid more extensive care,” Krakauer says .

Expansion planned

Aetna is further putting its money behind the effort by planning to expand the program. “The work we began with the Medicare Advantage members is just a start,” says Krakauer. “The models will continue to evolve and change. We are creating a range of models similar to ACOs, including those for commercial medical plans. Our collaboration programs were, in fact, very similar to ACOs before the name went into common usage.”

“We can help a medical group with data management and case management, areas in which we have expertise,” says Randall S. Krakauer, MD, Aetna’s national Medicare medical director.

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