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Upfront with Aetna

Upfront with Aetna

PCMH programs can help physicians provide improved care to patients

Today, payers and physicians are combining resources. Together, we’re coming up with innovative methods to help care for patients. We’re improving how:

  • Physicians deliver health care
  • We share clinical information across practices

Our Patient-Centered Medical Home (PCMH) programs lead the way in helping improve care.

PCMH programs can improve the quality and cost of care

We view these programs as a way to:

  • Improve care quality
  • Make a positive difference to our members’ health
  • Reduce medical costs through better efficiency and data sharing
  • Make it simple for patients to get appointments
  • Match patients with the right specialists
Patients receive more coordinated, streamlined care in a PCMH. They now have a team of doctors working for them. This is better than having many individual doctors who may not know what care the patient is getting from the others. Aetna’s PCMH programs start with care improvement options.

Here’s how PCMHs work

Aetna’s PCMH programs start with care improvement options.
Our programs include:
  • The use of health information technology such as electronic medical records
  • Disease management programs
  • Improved patient access to health services through nurses and physician assistants
  • Better care coordination through case management and patient health education classes

A look at our PCMH programs

We have two PCMH programs.

  1. PCMH Direct Contract Program: This program includes the Per-Member-Per Month (PMPM) care coordination payment model. But it also sets quality and cost improvement goals. Physician groups that meet these goals receive more payments. This is known as shared savings.

We find candidates in a number of ways. We pursue a mutually agreeable contract if they:

  • Received National Committee for Quality Assurance (NCQA) recognition
  • Got a positive assessment from Aetna about their population health management abilities
  • Aren’t part of another value based contracting model like Aetna Accountable Care Organization (ACO) or PCMH Direct
How member’s become aligned with doctors

We apply Aetna’s standard member attribution logic to help members select a primary care physician (Primary Care Physician). This logic uses information from claim experience or PCP selection when required by a plan. This ensures a viable population to provide credibility to clinical and financial assessments.

We also apply financial and clinical modeling to enhance opportunities for improvement and shared savings.

Efficiency and quality go hand-in-hand

PCPs are selected for members using these criteria:

1) The PCP the patient saw the most during a 12-month period.

2) If there were several single visits to multiple PCPs, the patient is attributed to the physician they most recently visited.

  • We charge the plan sponsor for the PMPM care coordination payment. This depends on the number of plan members attributed to the practice through Aetna’s attribution logic.
  • We calculate savings using seven efficiency and 21 quality measures.
  • Practices are eligible to share in 50 percent of the savings produced over a 12 month period.
Core areas of measurement

We measure:

  • Efficiency: improvements in the management of inpatient outpatient and prescription services
  • Quality: improvements in the testing and outcome rates of select clinical measures including:
    • Diabetic
    • Cardiovascular
    • Preventive screening
    • Pediatric
Keys to successful physician and health plan collaboration
  1. PCMH Recognition Program:  We reward NCQA PCMH recognized practices with a PMPM care coordination payment. This payment is in addition to fee-for-service payments that enable practices to improve care delivery and health outcomes. Eligible practices include, but are not limited to those that:
  • Have achieved NCQA PCMH recognition
  • Don’t participate in another Aetna value based contracting model, for example— Aetna ACO or PCMH Direct
  • Are in an area where the program is available

Certain Aetna markets may use their own criteria as long as it’s applied to that market. Every year, our medical economics unit reviews the program for improvement opportunities.

  • Sharing of clinical and financial data including:
    • Claim files
    • Summarized reporting package
    • Gaps in care
    • Daily inpatient census reports
  • Quarterly joint operating committee meetings
  • Quarterly scorecards

What’s next?

We’re excited to keep working with you as we share more updates on our PCMH programs. We have a sponsorship code with NCQA: CUSAEA. Use it to get a discount when you’re pursuing NCQA PCMH recognition.



Aetna is the brand name used for products and services provided by one or more the Aetna group of subsidiary companies, including Aetna Life Insurance Company and its affiliates (Aetna). This material is for information only. Health insurance plans contain exclusions and limitations. Information is believed to be accurate as of the production date; however, it is subject to change. For more information about Aetna plans, refer to

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