He adds that Aetna wants to shift the traditional payer-provider relationship from rate-based to value-added-based. "The traditional payer-provider rate fights led to relationships without synergy because they were just based on contract discounts." Aetna's ACO program is based on aligning incentives such as shared savings so all parties are looking for opportunities to add value to the relationship and provide better patient care.
Aetna has profiled delivery systems across the country to identify which are likely to be successful in forming and operating an ACO. Aetna looks at a host of metrics, including typical considerations such as the size of the system or medical group and its patient volume, clinical utilization and outcomes, and patient mix. It also looks at the mix and size of the employer community and assesses the interest level of the insurance agent and broker community in an ACO product.
Culture and leadership also play a role in the assessment. "The ACO concept requires change. Some organizations are ready to embrace change and others are not," says Kennedy. He notes that filling hospital beds was once a sign of success and increased revenue. "In this new model, filling your beds may be a bad thing. It could mean you aren't doing a good job managing readmissions or coordinating care."
Existing Aetna contracts include Carilion Clinic (Roanoke, Va.), Banner Health Network (Phoenix), Sharp Community Medical Group (San Diego), Heartland Health (St. Joseph, Mo.), Emory Healthcare (Atlanta), and Cleveland Clinic (Cleveland). The relationships range from a collaboration that involves only Medicare patients, to cobranded health plans and new payment models with shared savings for meeting quality and clinical targets. Some of the arrangements have elements of ACO agreements but are not full ACO models at this time. In some cases, Kennedy and his team are helping put the processes in place to move toward ACOs.