When Cigna announced a few weeks ago that it added 10 new accountable care organization (ACO) initiatives in seven states to its existing 12 ACO programs, it officially became a central ACO player in the insurance industry. Cigna now has 22 ACO programs, which it calls "collaborative accountable care," in 13 states, covering about 270,000 customers.
Curious about how the company is able to recruit so many providers and establish such successful programs, FierceHealthPayer spoke with Dick Salmon, Cigna's national medical director for performance measurement and improvement. He provides medical leadership and oversight for Cigna's ACO programs and offered insight into the company's achievements, thus far, and why its pay-for-performance program is a marathon rather than a sprint.
FierceHealthPayer: In announcing the 10 new ACO programs, CMO Alan Muney said Cigna's existing programs are making "excellent progress." What positive results have the programs demonstrated?
Dick Salmon: Dartmouth-Hitchcock has had excellent results closing gaps in care, in particular, for people with high blood pressure and diabetes. Cigna Medical Group has had superior cost and quality measures compared to their market peers. Medical Clinic of North Texas has improved control of A1c blood sugar, cholesterol and blood pressure levels in diabetes patients and has outperformed the market by 7 percent for avoidable emergency room visits, while its hospital readmission rate declined 2 percentage points. We are now evaluating results from the mature programs and expect to publish results later this year.
FHP: How does Cigna select physician practices to participate in the program? What factors determine eligibility?
DS: First and foremost, the physician practice has to share Cigna's commitment to achieving the triple aim, starting at the top of the organization on down. This is critical, and it must be ready and willing to accept accountability for improving the health of the population it serves. Although we work with several types of organizations--large primary care practices, multi-specialty groups, fully integrated delivery systems, physician hospital organizations--the group must have a substantial focus on primary care. The physician practice should also have a significant number of Cigna customers (people with a Cigna health plan) among its patients. This patient threshold will vary geographically.
FHP: Cigna's collaborative programs rely heavily on patient care coordinators. What specific benefits do they provide for the program's overall success?
DS: Better care coordination is critical to achieving the triple aim. The care coordinators reach out to patients to ensure they get follow-up care after hospitalization; get the screenings or preventive care they may be missing; have access to educational materials, especially for people living with a chronic health condition; provide health coaching or refer their patients to Cigna's health coaching programs, such as coaching to quit tobacco, manage stress, manage weight; and refer patients to high quality/high value specialists in Cigna's network.
FHP: What type of claims data does Cigna share with participating doctor groups?
DS: Our claims data indicates which patients might need outreach. For example, we have claims data when someone visits the emergency room or is admitted to the hospital. We send that information to the physician practices to follow up. Our claims data will also show that someone hasn't had a mammogram, colonoscopy or other screening, or that someone hasn't refilled a prescription. It will also indicate if patients with chronic kidney disease or other health conditions have missed important blood tests. We alert the physician practice about these types of situations and the care coordinator uses that information for patient outreach.
FHP: What benchmarks must doctors meet to receive pay-for-performance rewards?
DS: The practice must meet specified targets for improving quality (following evidence-based medicine) and lowering total medical costs compared to its peers in the local market. It must meet both targets; there is no payout if the practice only lowers cost or only improves quality. It must meet both targets. Some practices have achieved the targets, others have not. We see this is a marathon, not a sprint. We expect to see steady improvement over time, and some practices will achieve results sooner than others. If a practice isn't meeting its targets, it's an opportunity for us to learn what is or isn't working in the program and make adjustments. We provide each physician group with a Cigna consultant who helps the group understand the best practices of well-performing groups, and each year we also convene several "learning collaboratives," where participants from the practices share their experiences with one another.
FHP: What has been the overall benefit of these collaborative programs for Cigna?
DS: It's important to keep in mind that Cigna's mission is to improve the health and well-being of our customers so the "benefit" to Cigna comes when people are living healthy and productive lives, in particular, when people with chronic conditions like diabetes or heart disease are able to manage their condition, keep their health from deteriorating and avoid hospitalization.
Editor's note: This interview has been edited for length and clarity.
From Volume to Value: Cigna's collaborative accountable care programs
ACOs must be ready to manage populations with tech, staff
The care coordinator role at Dartmouth-Hitchcock, Cigna's accountable care model
Leaders from CIGNA, Dartmouth-Hitchcock share about their ACO success
ACO rule: Good, bad or ugly for payers?