ACA Opportunities: Transforming Health Care for Payers, Providers and Patients - PowerPoint PPT Presentation

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ACA Opportunities: Transforming Health Care for Payers, Providers and Patients

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  1. Quality health plans & benefits Healthier living Financial well-being Intelligent solutions ACA Opportunities: Transforming Health Care for Payers, Providers and Patients Donna Checkett

  2. Grace Hill House2600 Hadley StreetSt. Louis, MO 

  3. Who We Are: The Aetna Way We put the people we serve at the center of everything we do The Aetna Way outlines the values by which we live, as the foundation for our culture, strategy and how we run our business

  4. Aetna’s Medicaid Footprint

  5. Dynamic Environment Challenging environment provides opportunities to develop new solutions to the issues facing our country and our health care system Elections Supreme court Economic and fiscal pressure • Upheld the individual mandate • Eliminated compulsory Medicaid expansion • Significant milestone but does not change our strategy • Economic recovery still fragile • Job growth stagnant • Growth in spend on entitlement programs

  6. What if we imagined a move fromFee for Service to Fee for Value? Today’s Business Model Tomorrow’s Business Model Payment Reform Care Management Health Plan Services Patient Provider Integrated Care Plan Health Information Technology Focus on Volume Focus on Value • Personal Care Plan • Shared Comprehensive Health Record • Efficient Use of Member’s Time • Improving Outcomes • Impersonal Transactional Care Visits • Onus on Member to Share Health Information • Lost or Duplicative Tests • Treating Symptoms

  7. Our Vision for the Future of the Health Care Delivery System Future Today Online nurse Doctor Doctor Doctor Hospital Nurse Nurse Patient Patient Hospital Doctor Uncoordinated fee-for-service delivery Collaborative patient population management

  8. We see Accountable Care as a Broad, Transformational Commercial Model • Aetna Perspective • All patient model – Medicare, Medicaid, Commercial • All payor model – not limited to Aetna members • Committed to quality and total cost management • Symmetrical risk sharing • CMS Model • Medicare only • Defined network • Shared savings • Quality measures and reporting Aetna’s Accountable Care Solutions offering is a sustainable long-term model for change

  9. What Is An Accountable Care Organization? Internal ACO Goals Improve Efficiency • Share in the benefits they create • Increase patient share • Reduce payer concentration • Expand geographically • First mover advantages • Prepare for Medicare ACO requirements External ACO Goals Improve Quality Improve Satisfaction

  10. Driving Affordability Requires Steerage to Providers who can Effectively Manage Populations and Risk • Broad access to all providers – traditional network • Most costly option for members / employers • Transparency tools use critical Network Size Price National Network 100% 100% • Providers meet some minimum quality standard • Often higher quality at any cost vs. lower cost • Narrowing of network produces some savings Quality Designation Network 95% 60% • Savings achieved via steerage based on contract variation – drives affordability; not sustainable • Some consideration for quality Low Cost Networks 90% 40% • Most affordable option – steerage to providers who provide highly coordinated care aided by health IT, care management etc. that can deliver triple aim improvements and high patient engagement rates • Portability of data across ACOs via HIE capabilities High Value / ACO Network 25% 85%

  11. The Spectrum of Provider Collaboration

  12. Aetna’s Provider Collaboration Success

  13. Our Strategic Response for the 2014 Individual / Small Group & Exchange Market What it means Differentiating Strategies Our Strategic Focus • Accountable Care Solutions and Savings Plus Networks that position us for the best possible competitive position • Low-Cost Model • Competitive Medical, Dental, and Ancillary Benefits We will lead with lower-costnetworks that position us for the best possible competitive position and attract a balanced risk pool Affordable Options 1 • Easy, personalized shopping • Leverage our mobile capabilities We will differentiate through an engaging, simple, and satisfying purchasing and service experience Convenient & Engaging Experience 2 • Leverage HIT, HIE, and clinical decision support • Product Strategy and Data Analytics • Incentive programs for healthy behavior • Consumer engagement via online chats, social media, & apps We will employ product strategy, incentive program, and data analyticsto keep members healthy. Maintain Healthy Lives 3

  14. Our Challenges • Demand for Providers Will Continue to Grow • Primary Care; Dental; Behavioral Health all critical needs • Intense Rate Pressure Creating “Rate Shock” • ACA market reforms and fees will significantly increase premiums • MLR requirements tighten our administrative costs • Need to be able to offer lower-cost network that still meets access adequacy requirements of the Exchange • Need to have provider partners to help drive members to right care, in the right place, at the right time • Need providers with HIT capabilities and sophistication

  15. FQHCs Offer Unique Capabilities • Providers of primary care, behavioral health and dental services with experience and expertise in new ACA populations • Cultural competency • Effective, tested interventions on health issues critical to new populations • Located in key access areas • Are “Essential Community Providers” required for Exchange networks

  16. FQHCs: Nontraditional Provider for Most Companies Selling on Exchanges • What does the place look like? • Members, lay-out, location, equipment • Scope and Quality of Care? • Types of providers, training, skills • EHR and HIT capabilities ? • Willing to negotiate on rates? • Willing to share risk on members? ACOs and PCMH? • Willing to provide 24 hour coverage? • Willing to help us learn about you while you learn about us?

  17. Moving Forward: The Time is Now • Negotiating contracts and network now • Meeting with state officials now • Exchange strategies • Churn recommendations • Deciding which Exchanges now • Bidding on managed Medicaid contracts now • But recognizing this is an evolving process that will be years in the making. • Looking forward to learning together

  18. Thank you