Aetna and ProHealth Physicians Provider Collaboration Model Leads to Fewer Hospitalizations for Certain Patients

HARTFORD, Conn.--(BUSINESS WIRE)-- As groups throughout the health care system work to develop Accountable Care Organizations (ACOs), Aetna (NYSE: AET) today announced results of a collaborative relationship with ProHealth Physicians (ProHealth), a physician-driven primary care organization based in central Connecticut. Since 2007, Aetna and ProHealth have worked together to accomplish two of the main goals of ACOs through the Aetna Medicare Provider Collaboration program – improving quality of care and lowering health care costs.

ProHealth physicians provide care to more than 900 Aetna Medicare Advantage members through Aetna’s Provider Collaboration program. To date, more than 97 percent of these Aetna Medicare Advantage members visited their health care provider in 2011 to receive preventive and follow-up care. In addition, compared with Medicare beneficiaries residing in the state of Connecticut who are enrolled in Original Medicare, this Aetna Medicare Advantage member population has experienced 37 percent fewer inpatient hospital days on a risk-adjusted basis and 35 percent fewer hospital readmissions.

“By working more effectively and efficiently with outstanding health care providers like ProHealth, we have demonstrated that we can help improve the coordination and quality of care and reduce health care costs,” said Randall Krakauer, MD, FACP, FACR, Aetna’s national Medicare medical director. “Aetna believes patient-centered collaboratives can serve as one stepping stone to the creation of Accountable Care Organizations which further align financial incentives with high quality, more efficient care. We will continue to improve our Provider Collaboration program and expand the program to other health care providers across the country that deliver services to Aetna’s Medicare Advantage members.”

Coordinated Care Helps Improve Health Outcomes

One of the major components of the collaborative relationship with ProHealth is the Aetna nurse case manager who helps coordinate care for Aetna Medicare Advantage members. With this program, the Aetna nurse case manager is dedicated specifically to working with the designated clinical coordinator at ProHealth and with their shared Medicare members.

The Commonwealth Fund described Aetna’s work with a similar “embedded” nurse case manager model in a recent case study (Sept. 2010). Aetna's data on the model suggests that the model has decreased duplicate or unnecessary services and improved health outcomes. For example, compared to unmanaged Medicare, Aetna Medicare Advantage members required 43 percent less acute (critical) hospital care in 2010.

Aetna nurse case managers also use advanced technology to monitor the care and health progress of Aetna Medicare Advantage members. The technology is supported by the ActiveHealth CareEngine® System. The CareEngine continuously monitors all available information on patients, compares it to current medical evidence, and identifies and alerts members and doctors to possible urgent situations and opportunities to improve the patient’s care.

ProHealth has its own clinical performance program that seeks to improve clinical outcomes and enhance preventive care across all of its patients. Through their own adoption of innovative technology, providers are able to identify areas that need to be addressed at the point of care, based on each patient’s particular clinical condition. As a result, ProHealth’s quality results under the Aetna Provider Collaboration program have consistently exceeded targets for each of the following quality metrics:

  • Increasing the percentage of Aetna Medicare Advantage members who have an office visit each calendar year;
  • Encouraging office visits every six months for members with chronic heart failure (CHF) or diabetes;
  • Encouraging HbA1C (blood glucose) tests each calendar year for members with diabetes; and
  • Confirming that members schedule follow-up visits within 30 days of being discharged from an inpatient stay.

“We are very proud of the results we have achieved under the collaboration model. The value of having our own designated care coordinator, who is the lead point of contact for the Aetna nurse case manager, is evident in our outcomes. Together, the team enjoys a unique focus on the patients we share. We communicate, we coordinate and we work hard to meet the healthcare needs of our patients. Optimizing the expertise of each organization, we can ensure that our patients receive the right care, at the right time,” said James Cox-Chapman, ProHealth’s Chief Medical Officer.

Aetna is working with a number of health care organizations to develop products and services that support value-driven, patient-centered care. The Aetna models and capabilities are described on the company’s new accountable care website at

About Aetna

Aetna is one of the nation’s leading diversified health care benefits companies, serving approximately 36.3 million people with information and resources to help them make better informed decisions about their health care. Aetna offers a broad range of traditional, voluntary and consumer-directed health insurance products and related services, including medical, pharmacy, dental, behavioral health, group life and disability plans, and medical management capabilities and health care management services for Medicaid plans. Our customers include employer groups, individuals, college students, part-time and hourly workers, health plans, governmental units, government-sponsored plans, labor groups and expatriates. For more information, see

About ProHealth

ProHealth Physicians is the state’s largest physician-owned delivery system, based in Farmington, Connecticut. Formed in 1997, the company has grown to include more than 270 primary care providers, and offers select specialty and diagnostic/therapeutic services such as ENT, pediatric gastroenterology, imaging, physical therapy, sleep medicine centers, ADHD expertise, a hearing center, and five extended-hours locations to meet our patients’ needs for access and convenience. ProHealth serves about ten percent of Connecticut’s population.


Ethan Slavin, 860-273-6095
[email protected]

KEYWORDS:   United States  North America  Connecticut

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