Mark Bertolini, CEO, Aetna | Photo Credit: HIMSS 2014 Event Staff
By Jonah Comstock
There may not have been a lot of news from payers (or health insurance companies) at HIMSS 2014 in Orlando, Florida, but their presence was definitely felt. Aetna CEO Mark Bertolini's keynote address laid out the stakes well: healthcare costs are rising markedly, and it's everyone's job to try to keep them down. That's why the theme of HIMSS this year seemed to be, in EY's Dr. Bill Fera's words, the "migration path to accountable care." Both Aetna and Cigna discussed some of their plans surrounding ACOs and provider partnerships, and UnitedHealth and others made moves too.
Aetna sharpens strategy, changes at its Healthagen unit
In Bertolini's keynote, he alluded to focusing on two core businesses: consumer health and accountable care. Other indications suggest that this strategy is in the midst of being implemented and it might include some changes at Healthagen.
Bertolini's talk was notably sponsored not by Aetna, but by Healthagen, an Aetna business unit that until recently was something of an incubator for Aetna acquisitions and spin-off businesses. Healthagen's name was also emblazoned on Aetna's booth on the HIMSS show floor, with only two Aetna properties represented there: clinical data exchange company Medicity and Aetna Accountable Care Solutions.
Although Healthagen the brand was front and center, Healthagen's most well-known company, iTriage, was relegated to a distant corner of the show floor. Aetna CarePass, which has been Aetna's headline at most major events for the last year, wasn't mentioned in Bertolini's talk or present in the company's booth.
Even more intriguingly, InvolveCare, the Healthagen caregiver app that just launched last fall at Health 2.0, was nowhere in sight. Two days ago, InvolveCare posted a blog post on its site saying that the consumer app would be discontinued effective April 28th.
"InvolveCare is in the process of being integrated into another company’s service offering," the blog post reads. "As a result, the consumer-facing app will become unavailable to accommodate the new company's servicing needs."
Aetna acquired the Healthagen brand along with iTriage in 2011. Just last year it re-purposed the brand to cover its health and technology offerings. Now it looks like it's repurposing the brand once more with a more streamlined mission -- one that may or may not include iTriage.
The payer-provider relationship in the age of accountable care
Fera, leader of EY's (formerly Ernst & Young) Health Care Provider Group, spoke with MobiHealthNews at HIMSS about how as providers take on more risk in accountable care, payers and providers find themselves both needing to reduce costs and improve care for the populations they manage. This requires two things: large datasets to understand population health, which payers have, and the trust of the patient, which providers have.
"I think historically, payers have had the advantage because they've had the information and they've always had the claim services," said Fera. "They understand risk stratification, they understand population health. The providers are trying to catch up to meet them to understand these shared risk arrangements. What payers have found is they cannot do care management alone. They've been trying to do case management and disease management in a vacuum and they've had real difficulty getting patients to engage. So if we took the strengths of the payers and the strengths of the providers to work in collaboration we should be able to advance everybody's goals, most importantly patients' goals."
So increasingly, as with Aetna's Accountable Care Solutions group, payers are working with providers to implement accountable care, integrating their own data with hospital data. Cigna Director of Clinical Integration Solutions Cameron Ough presented at an education session Monday about some of the challenges Cigna has had integrating with ACOs since it launched its Collaborative Accountable Care initiative in 2011. The payer currently has 86 collaborative accountable care initiatives under way.
Ough said that "if you’ve done one physician integration, you’ve done one physician integration," which is to say, the different data systems in place at hospitals and different physician preferences make it hard to scale procedures for integrating. Current hospital systems are designed to make it easy for physicians to extract data about a single patient and are not well suited to pulling data on multiple patients to do population management. Accountable Care depends on proactively reaching out to patients that need to be seen, not just following up with ones that are already coming in, and current systems aren't well built for that either.
"Historically, there's a lot of tension. I think there's genuine interest at this time for payers and providers to work together," Fera said. "I think they're all figuring out how to do that. If you look at Cigna, they have a multitude of pilots throughout the country trying to figure out what is the best model to collaborate, what really makes sense, which one are we going to codify and go to market with as a general model of working with providers. I think Aetna's in a similar boat. They have basically a consulting service around building these arrangements, they have some technology with Medicity that's their interoperability play."
Other payers, Fera suggested, are opting to buy provider organizations and "learn from the inside out what needs to be done". He pointed to UnitedHealth Group's purchase of Monarch HealthCare back in 2011 and their ACO pilot at the Tuscon Medical Center. He also mentioned Humana's 2012 acquisition of Metropolitan Health.
Humana also owns Certify Data Systems, which launched the latest version of population health management tool HealthLogix at HIMSS. HealthLogix is an interoperability play similar to Aetna's Medicity. And UnitedHealth Group also partnered last fall with Dignity Health, a hospital system, to launch Optum 360, a revenue cycle management company meant to help both accountable care and traditional fee-for-service health systems manage their spending.
Population health management but individual engagement
One of the biggest recent changes for payers, of course, has been the Affordable Care Act, which -- among other things -- sets up public exchanges where individuals can buy health insurance. This has necessitated a marketing change for insurers, which need to expand their marketing efforts to target individuals, rather than employers or corporations.
"For payers who in the past have had to deal with brokers or employers, between the exchanges and generally, it's become much more of an individual market," Dr. Harry Greenspun, Senior Advisor for Health Care Transformation and Technology at the Deloitte Center for Health Solutions told MobiHealthNews. "They have to deal with individuals now. The tension is that in an individual market, you want to tailor your care to you and your needs and your belief system. But on a population level you've actually got to standardize care. How do we reconcile the two things? How do you manage a population at a statistical level, but also do patient centered care?"
That's where the other piece of Aetna's business going forward (according to Bertolini's keynote) fits in -- consumer engagement. And although Aetna wasn't championing its own engagement strategies as much as might be expected, other payor groups like UnitedHealth Group were. United announced at HIMSS that it's MyClaims Manager software, launched last June, has now been used to make more than $20 million in payments to more than 50,000 healthcare providers.
MyClaims Manager is an online tool that uses healthcare payment engine InstaMed to allow United members to pay their healthcare bills online. It also allows them to check on the status of claims and to track their deductible and out-of-pocket spending. The app is also an educational tool, using color-coded displays and easy to understand language to help explain to patients what they owe and why. Patients can also flag claims and make notes on them.
MyClaims manager is one of a number of digital consumer tools United offers its members. Others include myEasyBook, an appointment booking tool launched at CES in January, and Health4Me, a mobile application that includes a physician locator, a claims checker, and even a feature that lets them call and consult with a nurse.
These sorts of tools aim to help payers build up the patient trust that providers tend to have by default, according to Greenspun.
"The struggle that payers have is they don't enjoy a lot of trust from consumers," he said. "And in our own surveys of consumers, we ask who's the bottom of the barrel of trust for health information, and you've got payers, pharma, and your employer. Unfortunately those are the three biggest organizations sending health information out."
Providers have the trust of patients, but have historically not done much with it, because they don't have experience marketing to individuals as a business, the way stakeholders like pharma and payors do. Accountable care is changing that, Greenspun said.
"It's a new opportunity for providers to leverage the trust they have. They were never interested in it before because they weren't accountable," he said. "Now suddenly they've become accountable and then they'll get interested. So the good news is the people who need to do engagement and haven't done it in the past are well positioned to have it accepted. Then the question is, how does that get activated?"
One other group that has long been focused on pushing the boundaries of consumer engagement, as we wrote in our HIMSS coverage this week, is Kaiser Permanente, which represents a small class of payer-providers who are, according to Greenspun and Fera, ahead of the game because they have long-term experience with both population health management and patient engagement and individualized care.
"Kaiser has a tremendous advantage, I think they've got a great head start, they've been doing this for years and doing it very well," said Fera. "I think people are looking at them as an example [and many want to] replicate that kind of a business."
When talking about the evolving relationship between payers and providers, it's important not to forget the third, most important stakeholder -- the patient. Greenspun pointed out that a lot of patient engagement technologies mostly succeed in getting engaged patients more engaged. Instead, in order to meaningfully impact healthcare costs, it's important to get all patients engaged, especially those with preventable chronic diseases.
"Even if you have the best payer-provider collaboration and the best tools, you need the patient to be engaged," said Fera. "What's changing there is the financial burden on the patients. You do have to, to some extent, follow the money. If you look at the financial burden for patients, it is for sure going up."
He said that in the same way that getting patients to think about the cost of cigarettes will often get them to quit, even when warning them about health effects won't, financial incentives will help motivate patients to use the tools payers and providers set out for them.
"When individuals are faced with making financial choices, they're going to choose a lower cost product," he said. "They will more voluntarily enter into managed care products. Now I have patients engaged, because they have a financial skin in the game. I've got my payers engaged, I've got my providers engaged around the patient to help them make the best decisions."
