12 Points on Private Payor CIGNA's Plans for ACOs

CIGNA has been experimenting with accountable care models in pilot studies with physicians in Connecticut, New Hampshire and Texas during the past two years. In July, the nationwide health insurer started a new pilot with Piedmont Physicians Group, a 100-member primary care practice. It is part of Atlanta-based Piedmont Healthcare, which runs five hospitals.

Here Dick Salmon, MD, national medical director for CIGNA, explains how the company works with its ACO pilots, what it expects of them and how the model might evolve.

1. Seeking more ACO pilots.
CIGNA is hoping to launch more pilots in partnerships with large primary care groups, multispecialty groups and integrated delivery systems of physicians and hospitals. The organization would need to have substantial number of primary care physicians and be willing to be responsible for total population health. There would have to be a sufficient number of CIGNA members. For example, the Piedmont pilot covers 10,000 members.

2. What Cigna is looking for. CIGNA wants hospitals and physician groups that are "committed to a mission of quality, affordability and patient satisfaction," Dr. Salmon says. "The group has to be willing to take on accountability." An ACO requires integrated teamwork, so "there needs to be a cohesiveness," he says. "Whether it’s a hospital and physicians group or just a physicians group, they would have to work together as an integrated group."

3. Moving away from negotiating clout. Large hospital systems have been able to leverage higher reimbursements from insurers, but with the ACO model, CIGNA is expecting large systems to produce savings by introducing efficiencies. In the future, ACOs might bring together independent groups, but "if separate groups come together in a single negotiating unit, they would have to add value," Dr. Salmon says.

4. Freedom to find savings. It is up to the ACO to decide how it will achieve savings. "Each ACO has to choose its own pathway," Dr. Salmon says. "I want to emphasize that each organization might choose different pathways to the ultimate goal." For example, when patients have a high ER utilization rate, a group practice might decide to improve access by extending operations to evenings and weekends.

5. How patients are assigned. Members in all types of products, including PPOs, could be assigned to the ACO. To decide which patients would be assigned, CIGNA uses an "attribution" model, in which the company reviews a patient's claims history, identifies the primary care physician who last treated the patient, and assigns the patients to that physician. However, patients are free to get their care at other providers. Therefore, ACO physicians need to attract their patients to them. "Provider have to offer extraordinary care so that the patient comes to them," Dr. Salmon says.

6. Centered on primary care physicians.
Primary care physicians follow their patients, but in most cases, they would not be "gatekeepers" and would not be deciding on access to specialists. Ninety percent of CIGNA members do not have a gatekeeper.

7. Outreach efforts. Nurses funded by CIGNA conduct outreach efforts, focusing on patients who are most likely to benefit from enhanced care coordination, such as patients with chronic conditions and those who are at risk for readmission. To avoid readmissions, nurses call these patients after discharge to make sure they get a follow-up appointment, that medications are reconciled and that patients are aware of warning signs indicating health problems.

8. ACOs get enhanced data. CIGNA has given providers some claims data on quality in the past, but the ACO pilots are getting a much richer flow. For the first time, providers at Piedmont are getting affordability information, and quality measures have been expanded. The quality data are mostly HEDIS process-of-care measures. CIGNA also provides prescription data, showing physicians, for example, where they prescribed brand name drugs instead of less expensive generics.

9. Identifying gaps in care. CIGNA's ACOs are using informatics to identify gaps in care, such as patients not filling medications or not getting a required test. The nurse makes an outreach call to resolve the situation. "The practice has to determine how patients are receiving care and identify improvements," Dr. Salmon says.

10. Setting payments. In the Piedmont model, primary care physicians get the usual payment for medical services they provide, plus an additional fee for care coordination and other extra services. Then, through a "pay for performance" structure, they will be rewarded extra payments for meeting targets for improved quality and lower medical costs. "To get bonuses, they have to excel in both quality and savings," Dr. Salmon says.

11. Penalties to be introduced later. The payment model starts with a reward, but Dr. Salmon says CIGNA eventually expects to add a penalty for ACOs not meeting targets.

12. Evolving models. Cigna wants to learn from its pilot and launch ACO models that would probably evolve in different ways in different markets, Dr. Salmon says. he company will evaluate results from the Piedmont program in a year. "It's a little too early to know if it will work," Dr. Salmon says, but he points to successes of some practices in CMS' Medicare Physician Group Practice Demonstration Program, which ended this spring.

Read a news release on the Piedmont ACO pilot.

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