Accountable Care Organizations: A collaborative model for improving health care quality

Aetna views accountable care organizations (ACOs) as a model for working together with providers to transform patient care and bring greater quality and sustainability to the health care system. The evidence is in our more than three years of successful experience in designing collaborative care models in Aetna’s Medicare Advantage population. With our Aetna Accountable Care Solutions business segment focused on this important issue, we believe even greater success is possible. We have been accelerating our investments in health information technology (HIT) to enable providers and their patients to receive better and timelier access to key health care data.

Patient-centered, collaborative care models, such as ACOs, are an important component of Aetna’s vision for a more connected and effective health care system. We are building on our experience, our expanded capabilities and our strong provider relationships to help drive better quality, more efficient care, and an overall better patient health care experience.

• Patient-focused, collaborative care among health care providers is essential to improving quality and reducing unnecessary cost in our health care system.
• Payers and clinicians must be focused on the most important consideration – the patient and the value we deliver together through better care management and optimal and timely care.
• We support new market-based solutions of collaboration that can create a sustainable health care model for our nation.
• We view ACOs as an important model for transforming patient care.
• There is no single ACO model. ACOs vary based on the provider organization and local population needs, but strong physician commitment is essential in all models.
• We bring considerable experience and capabilities to lead provider organizations in establishing themselves as ACOs, including successful Medicare collaboration models with providers that have shown improved quality and reduced cost.
• Our capabilities are flexible and modular to accommodate an evolving marketplace.
• ACOs are not new to us; our first ACO started in 2007 with Medicare Advantage.
• ACOs are an important component of Aetna's vision for a more connected system.

The term "accountable care" is used to describe a new model for payment and delivery reform that ties provider reimbursements to health care quality metrics and reductions in the total cost of care for an assigned population of patients. A group of coordinated health care providers form an accountable care organization to provide care to a group of patients. The collaboration is supported by health information technology that provides for the exchange of patient information and intelligent clinical decision support among providers, and the management and assessment of health outcomes for a broad patient population.

Accountable care organizations are intended to improve patient health care and make it more affordable through:

• Personalized care and engagement that better meet the needs of patients
• Coordination and shared accountability among providers for the quality and cost of the care

Aetna has been an active leader in the development of ACOs. We are working with many hospital systems, independent delivery networks (IDNs), and groups of physician practices interested in becoming ACOs in their communities as a way to improve the quality and efficiency of patient care for broader populations. Physician commitment is an essential component to a successful ACO.

The structure of ACOs is varied and evolving. In general, an ACO would:

• Assume accountability for the health care and health outcomes for a defined patient population
• Employ advanced health information technology that continuously collects, connects and shares patient information with doctors, and provides clinical decision support backed by current medical evidence
• Operate an integrated, team-based model to coordinate care across the continuum of each patient’s health needs – from primary care and specialists to facilities
• Provide personalized care management and support for patients, particularly those with chronic conditions
• Track, assess and report on care quality and efficiency measures to CMS and payers
• Share responsibility for the quality and cost outcomes of the care it delivers to its patients

• The number one issue on the minds of health care consumers and employers is the cost of health care. Health care in the U.S. costs more than seven industrialized nations and without evidence this higher spending results in better overall quality and outcomes¹. The pressure to find market-based solutions is increasing.
• As 32 million more Americans gain access to health care coverage, physician shortages are projected to grow to about 63,000 in 2015.
• Annual health care spending is estimated to surpass $4.2 trillion in 2018, up from $2.5 trillion in 2009 and $75 billion in 1970.² 
• The projected cost of chronic diseases, such as diabetes, high blood pressure, asthma and cancer could be as high as $4 trillion by 2023.³ 

Aetna believes that all have a responsibility and a role in creating a sustainable health care system focused on quality, patient-centered care. ACOs are gaining support as a new market-based model to address escalating costs and patient demands for better, more coordinated care.

Both the public and private sectors have important roles to play in advancing ACOs. Government should – and is – setting quality standards and establishing an ACO framework around which innovation has room to grow. The public sector also is uniquely positioned to actively encourage medical providers to become engaged in the ACO approach by making it a condition for participation in public health care programs that serve millions of Americans.

The private sector, particularly health insurers, can help ACOs develop faster, more reliably and with greater innovation.

Private insurers have vast data resources, sophisticated analytics and successful experience with chronic care management that can help guide physicians and hospitals on their respective quality and cost performance. Insurers also have experience in establishing reimbursement models that encourage higher-quality performance. Insurers also have the actuarial expertise and predictive models necessary for assuming financial risk for patient populations. We can quickly help provider systems gain this knowledge and expertise.

We need to take advantage of these strengths to deliver on the full promise of accountable care.

¹ Karen Davis, Ph.D., Cathy Schoen, M.S., and Kristof Stremikis, M.P.P. Mirror, Mirror on the Wall: How the Performance of the U.S. Health Care System Compares Internationally, 2010 Update. Rep. Commonwealth Fund, 23 June 2010. Web. <http://www.commonwealthfund.org/Content/Publications/Fund-Reports/2010/Jun/Mirror-Mirror-Update.aspx>.

² Centers for Medicare & Medicaid Services, Office of the Actuary, National Health Statistics Group. http://www.cms.hhs.gov/NationalHealthExpendData/; Historical data from CY 1960-2008; Projected data from NHE projections 2009-2019.

³ Milken Institute (2007), Ross DeVol and Armen Bedroussian, "An Unhealthy America: The Economic Burden of Chronic Disease, Charting a New Course to Save Lives and Increase Productivity and Economic Growth." http://www.milkeninstitute.org/healthreform/PDF/AnUnhealthyAmericaExecSumm.pdf