From Volume to Value: Cigna's collaborative accountable care programs

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Dick Salmon

Americans spend enormous sums of money on healthcare, but that hasn't resulted in a healthier population. Chronic conditions, such as diabetes and heart disease, continue to take a toll on millions of Americans, while healthcare costs continue to escalate. A large part of the problem stems from our ineffective system for rewarding physicians: we pay for volume rather than value. In other words, we pay doctors for performing more procedures, not for making people healthier.

What if we tried another approach and rewarded doctors differently? That's what Cigna has been doing since 2008 when we implemented our first collaborative accountable care program with Dartmouth-Hitchcock in New Hampshire. Collaborative accountable care (CAC) is Cigna's approach to achieving the same population health goals as accountable care organizations (ACOs)--the "triple aim" of improved health outcomes (quality), lower total medical costs and an enhanced patient experience. It's one of many approaches that Cigna is taking to help transform America's healthcare delivery system into one that's outcomes-oriented.

Since 2008, Cigna has implemented 14 CAC programs with large primary care physician practices, multi-specialty groups and fully integrated delivery systems, and many more are planned for 2012. We're moving ahead aggressively with this healthcare delivery model because of the promising results we've seen so far--results that lead us to conclude that a substantial portion of healthcare will be delivered based on this model within the next several years.

So what is collaborative accountable care? The principles of the patient-centered medical home are the foundation of these initiatives. That means the physician practice improves patient access to care, provides health education and other resources and becomes responsible for monitoring and coordinating nearly all aspects of a patient's medical care.

In many cases, the physician practices offer extended evening and weekend hours, improve appointment availability, offer case management and disease management services within the practice and use electronic medical records to better track medical history.

Cigna then builds on this foundation with a strong focus on collaboration and communication with the physician practice. We have a wealth of patient-specific data available that we can share with physician groups so they can better deliver on the triple aim, and we share this data daily to trigger action at the practice. For example, we provide a list of patients who are being discharged from the hospital who may be at risk for readmission. We also provide a list of patients who may have missed a prescription refill or may be overdue for important screenings or tests.

However, all of that information flowing from Cigna to the physician groups won't mean much if there isn't someone on the other end prepared to accept it and act on it. And that's why our CAC programs depend on embedded care coordinators--usually registered nurses within the physician practice--who pore over those lists and make outreach calls to their patients to ensure they get the follow-up care and resources they need.

These embedded care coordinators also know what benefits are available to their patients through the individual's Cigna health plan, and when appropriate, they can refer patients to Cigna's clinical programs (e.g., chronic condition management programs or health coaching programs for weight or stress management, nutrition or to quit tobacco). Our research shows that when the referral comes from the physician practice, the individual is more likely to engage because the individual sees the physician or care coordinator as a trusted adviser. This clinical collaboration between the physician practice and Cigna is a critical to achieving the triple aim.

Piedmont Physicians provides an excellent example of clinical collaboration. Piedmont relies heavily on Cigna's Coach Rx program, which helps individuals stick to their medication therapy. Cigna pharmacists are available for phone consultations with the Piedmont care coordinators, as well as Piedmont's patients. They provide guidance and assistance with medication compliance, suggest and facilitate switches to lower-cost alternatives and offer Cigna Home Delivery Pharmacy's services to help individuals stay compliant and save money on their regularly used medications. According to one of Piedmont's care coordinators, the Coach Rx program has helped her patients save hundreds of dollars by switching one or two medications. Removing barriers that prevent people from taking their prescribed medications is critical to helping people maintain or improve their health, and it's a key focus of Cigna's collaborative accountable care program with Piedmont.

Why do we do this? Cigna is more than an insurer or a claims payer. We're a health service company that's focused on helping people improve their health and well-being by helping them get the right care at the right time in the right place. Fundamentally, we believe that through better access to care, better coordination of care and proactive outreach to patients, especially to those with chronic conditions and those at risk, we'll be able to keep people healthier. And if people are healthier, they'll use fewer healthcare services over the long term, which will lower total medical costs.

What can we do to ensure success? An important step is to tie physician payment to results. Cigna's CAC initiatives are structured to reward the physician practice for improving patient health (quality) and for lowering total medical costs. It's important to note that the quality must come first. A practice that only lowers cost will not be rewarded. Patient health, measured through adherence to evidence-based medicine, must improve and total medical costs must be lowered relative to the market before a physician practice earns a reward. These programs don't transfer insurance risk to the physician practice. Financial targets are set after extensive case mix adjustment to adjust for changes in the illness burden of the population that the practice serves. This keeps the program focused on clinical accountability and health outcomes.

But does it work? Preliminary results indicate that it does. 

At Dartmouth-Hitchcock, collaboration and coordination has resulted in significant improvements in closing gaps in care--a 10 percent improvement overall, 16 percent for hypertension and 8 percent for diabetes--compared to other physician practices in the market that don't employ care coordinators.

At Cigna Medical Group, the Phoenix-based multi-specialty medical group practice division of Cigna HealthCare of Arizona, a strong focus on the patient and appropriate treatment, plus improved care coordination, has resulted in a 7 percent cost advantage and a 3 percent quality advantage compared to the market.

At Medical Clinic of North Texas (MCNT), enhanced care coordination has improved control of A1c blood sugar, cholesterol and blood pressure levels in diabetes patients, and MCNT outperformed the market by 7 percent for avoidable emergency room visits, while its hospital readmission rate declined 2 percentage points.

Where do we go from here? By the end of 2012, Cigna will have more than 30 CAC programs in various stages of development. We have selected the physician practices for these programs very carefully. Reshaping the healthcare delivery system isn't easy, inexpensive, quick or risk free. That's why it's critically important to find the right collaborative partners--clinical organizations in which the commitment to population health improvement starts at the top and permeates the entire enterprise--organizations that live and breathe the triple aim, organizations that believe that the current delivery and payment model is broken and needs to be repaired. We're confident that we've identified the right organizations--ones that are ready, able and willing to work collaboratively with us toward an outcomes-oriented system that rewards value, not volume.

Dick Salmon, M.D., Ph.D., is Cigna's national medical director for performance measurement and improvement.