Leaders from CIGNA, Dartmouth-Hitchcock share about their ACO success

Dick Salmon

Dick Salmon

Accountable care delivery seems to be on everyone's radar, but many healthcare leaders are scratching their heads over the many details involved in this coordinated care initiative. To gain a real-world perspective on many of the nitty-gritty details of ACOs, FierceHealthcare recently invited Dr. Dick Salmon, CIGNA's National Performance Improvement Medical Executive, and Dartmouth-Hitchcock Medical Center's Sheila Johnson, who heads up her organization's ACO project with CIGNA, to share their experiences during a one-hour webinar. 

The following are excerpts from the Q & A portion of the webinar, Accountable Care Pilots: Lessons Learned from Multi-year Demonstrations. Both speakers shared how their ACO improved care coordination and, in some cases, outcomes, for Dartmouth-Hitchcock's 19,000 patients.

The role of care coordinators
FierceHealthcare:  One of the key roles to making the ACO work is the health coach in your partnership model. Do CIGNA coaches receive any type of certification?

Dr. Salmon: We have over 3,000 nurses, mental health professionals and home health professionals who serve as our health coaches and provide lifestyle and chronic disease, complex case and transplant management services. Many of those nurses are certified in case management, and they all receive a great deal of training, both in the specialty areas but also the general areas of motivational interviewing and so forth to be effective coaches at the end of the day.

FH: Information sharing is obviously an integral part of any ACO's success. Are the Dartmouth-Hitchcock and CIGNA health records integrated or separate? 

Sheila Johnson: The records are not integrated. At Dartmouth, we do not have the ability to see the CIGNA health records, and CIGNA does not have the ability to see our electronic health records. But we [discuss] what we see in our own respective records.

FH: How much time passes between patient admission and when providers are notified of it?

DS: We are now giving our partners, including Dartmouth, a census on a daily basis. We get it out within a 24-hour basis when we know [about the patient admission]. We usually know it because of the notification process within 12 hours or so of when the patient is actually admitted to the hospital. Certainly, in most cases, it's timely enough to engage with the individual before he or she is ready for discharge.

Price transparency for patients
How does your program provide cost transparency so that patients understand the total cost of a proposed treatment (e.g., surgery, facility, labs, radiology, pharmacy) and can understand the costs of treatment A versus treatment B?

SJ: We have a calculator on our website where people can [see] how much a case is going to be. It does not, though, afford the opportunity for one to see [the price differences between] Dartmouth versus another community hospital.

DS: We actually do on MyCigna.com, which is available to customers or individual members who have CIGNA products. They can actually look up these calculations and do that kind of comparison. Sometimes, we have enough data that you can do it at the individual physician or the individual hospital level. If our data is not robust enough, we at least give the information at the community level so people understand that end-to-end cost that they are possibly being exposed to. 

The nice things about these tools is that they interact with exactly where the individual is on their benefits so it tells them not only what the total costs are, which might be of interest, but what the individual really wants to know is what is the cost out of their pocket. All of this interacts with their benefit so they understand the different levels of insurance of copay, as well as deductibles of the shared savings account.

'Risky' patients
One of the criticisms of ACOs is that some patients are risky patients. Can you remove these so-called "bad" patients from the group if they don't eat right or exercise regularly?

SJ: We don't remove any patients from our care for that [reason].

DS: We compare the performance of Dartmouth to the rest of the community. Every group has its share of patients who may be difficult to motivate at the start. Certainly, when you think about the science and the art of medication, it begins with knowing the right course of action. And the true difference between clinicians may be when those who are able to motive individuals to see it and feel it intrinsically in their own self-interest take that right course.

Our stance is, no, we would not remove those individuals because we want everyone on the clinical team to ask themselves, "How can I get to the next level with that challenging patient? How can I motivate someone who seems un-motivated today? How can I help motivate them in the future?

'Bad' physicians
Similarly, can you remove physicians from the group that continue to bill volumes of unnecessary tests and procedures?

DS: I suspect that's an extraordinarily rare [situation].

We have several [arrangements] with primary care groups, where a number of the specialists and the hospitals that are providing care to their patients are actually not part of their formal organization. Physicians can start exercising judgments--maybe more careful judgments, maybe putting a little more thought into it than they have historically--about where they refer patients. These initiatives are still done like the CMS [Physician Group Practice Demonstration Project] in an open-access environment. Patients can ultimately go wherever they want, but many patients do organize their care through their principle physician. In those instances, the physician has the ability to direct patients to those [referrals] he thinks provide the highest value care.

SJ: We would like our physicians and providers to send our patients to the treatment center and utilization areas for X-rays, PET scans and orthopedics, wherever it be that we trust and feel we are going to get good outcomes from.

To answer the question, no, we do not let physicians go for overutilization. From what physicians tell me ... they don't necessarily believe they're over-utilizing different things. They believe they are providing good care to their patients.

An approach that seems to work, and is not widespread at Dartmouth, is to show our physicians data that's specific to them and the patients they care for, and when you look at it and say "Dr. Smith has a higher use of MRIs than Dr. Jones," then they have a clinical discussion together. What we are finding is that [the doctor will say,] "I thought that when a patient presents with this symptom, we always get an MRI." It goes back to using some of the clinical practice tools that helps drive decision making.

The challenges ahead
ACOs especially target chronic conditions. What diseases or conditions will be most challenging moving forward?

SJ: I don't think the disease or the condition is really the challenge. It's the person and if he or she is motivated to take lifestyle changes and also take medications and treatments. We see that we have great success in many of our disease conditions with people that want to make a change in their lives. 

DS: I encourage everyone to think about patients with challenging diseases the same way that we've looked at other areas of healthcare improvement. For instance, hospitals used to think that central-line infections were seen as a fact of life. Now, they're a rare event because people have worked to find out what you need to do to make it a rare event. We need to continually ask ourselves with the challenging patients we serve, "What do we have to do so that a diabetic hospitalization is a rare event, or that a congestive heart failure hospitalization is a rare event? We all just want to keep moving toward that lofty goal.

This interview has been edited and condensed for clarity. You can view the free webinar on-demand