It’s All About the Network

By Gregg A. Masters, MPH

2014 has kicked off to a challenging pace and doesn’t look to let up any time soon!

Over at Health Innovation Media where we follow health innovation from ‘idea to business model’ including accountable care platforms, ‘apps’ or infrastructure plays,  Dr. Pat Salber, CEO of early mover in the ‘rewards based’ crowd funding and innovation challenge space HealthTech Hatch and curator of The Doctor Weighs In and me are in workflow overflow from the mHealth Summit 2013 in National Harbor, VA.

If that wasn’t enough of a stretch for our new media startup, we just concluded the better part of the week in Las Vegas covering digital health developments at CES 2014 (see: Amidst the CES 2014 Firehose: Brands, Blogs & ‘PR’ Compete for Relevance in the Digital Economy) and it’s internally nested ‘Digital Health Summit‘, only to return to California challenged by the depth and breadth of the proceedings from both the JP Morgan Healthcare Conference and lesser known OneMed Forum.

One vetted message with relevant context to accountable care and the associated quest for the triple aim is sourced from the above JP Morgan Healthcare conference. The inspiration for this post’s headline and specifically it’s inherent ‘managed competition’ wisdom is courtesy of the CEO of the most ‘transformational ACO payor partner‘ – at least from the point of view of KLAS‘s ‘Accountable Care Payers: Partners in a Changing Paradigm‘. That player is Aetna or perhaps an attribution more holistically made to the aggregate activities of it’s fire-walled innovation sub Healthagen.

JPM14 KLAS transformer recognition

In his talk Mark Bertolini Aetna Chairman, President & CEO a man who’s career was forged squarely in the belly of HMO culture inside a traditional service vs. indemnity play,  via a rust belt domiciled ‘Blue plan’ competitor lays out the challenge not just for Aetna, but anyone in the accountable care space whether payor, provider or hybrids intent upon the co-creation of a sustainable future.

(NOTE: The entire series of JP Morgan webcasts including decks (where supplied) are accessible here. You’ll  need provide your email for a one time registration process to access all sessions, but the benefits are well worth it).

Back to Bertolini’s message, here are some note-able quotes from a very insightful and smart senior executive who sets the transformational imperative as follows:

This is how people feel about the healthcare system, it was designed in 1945 after WW2. It was funded by Hill Burton, and not much has changed over that time period in the way we run our healthcare system.

We leave the consumer to try and find their way through the system without much information, without much transparency.

So our goal is to change the system to align the incentives on the provider side [with the payor], give the consumers the tools so these questions can be answered and they can find a direct line of sight about how to use healthcare.

Our view is the system should work around the member, that it should be all about the member and  that it should be a personalized experience where all of these issues come together in one way… [i.e., the triple aim]

JPM14 Aetna healthier world

 

 

‘Line of sight’ what?

Heresy one might say from a once ‘all in’ little-to-no copay access to comprehensive health benefits HMO guy to now espouse a role for a marquee health plan operator to drive ecosystem integration between a tech enabled but evolving retail medicine (aka consumer directed or high deductible health plan world) segment and the costly, inflated, siloed and opaque sick care non-system.

But there’s more as the story is not so simple, nor easily analogized.

Bertolini continues and goes to the fundamental drivers of the Affordable Care Act and the enabling ACOs, ‘accountable care arrangements’ or their derivative plays that will ‘chop the wood and carry the water’ of this unprecedented transformation of a WW2 vintage legacy paradigm on life support.

If you’ve seen one ACO, you’ve seen one ACO, we do not call all of our value based contracting an ACO.

We have 100′s of value based contracting arrangements and various incentive programs in place, but for us, an ACO is an enabled provider network that’s at risk with us to improve the overall outcome for the patient and get rewarded as a result of making that happen.

Branded health plans is the next step [in the KLAS continuum noted above] and our most recent relationship with Inova we have launched Innovation Health Plans which is a branded private product of the Inova Health System in Northern Virginia.

This whole idea is to create transformational relationships with providers that let them be in the business of providing health plans to their community, allow them to change their revenue model by enrolling their patients and getting [Aetna] out of the middle of that relationship. We provide the risk mechanism, the technology and the intellectual property to allow it to happen, and that is what our ACO model is.

Bertolini then pivots to adding value in this expanding ‘retail’ market where Aetna enables informed choice via tools that empower members with the requisite ‘line of sight’ and thus gain share given projected enrollment of 75 million by 2020.

JPM14 Aetna retail projections

May I say, with the posting of this strategic glidepath the pivot of Aetna as a proxy for the legacy carrier health insurance business (including their forays into the HMO business) comes to an end. Rather re-skinned PPO’s, POS’s, and OWA’s morphed into ACOs of varying stripes intent upon passing increasing ‘skin in the game’ exposure to their members or insureds to vote with their feet and thus pocketbooks is now permanently enshrined as the defacto standard of ‘health insurance’ (whether ASO, fully or now retail/exchange based) in the U.S.

In this new model, health plans will morph into ‘utility companies’ who’s core competencies will center or transactional efficiency, member empowerment (to promote informed line of sight choices) and ecosystem stakeholder homeostasis largely as benefit solutions providers more and more with local or regional provider co-branding and sponsorship DNA.

Don’t get me wrong, I respect Mark and his chief architect Chuck Saunders, MD who’s assembling these consumer, informational and transactional empowerment capabilities inside the Aetna mothership via a ‘fire-walled’ Healthagen. From MediCity to iTriage and Active Health, this is precisely what the new zeitgeist requires of the legacy health insurance business.

Lets just call it as it is, AHIP and it’s member partners (principally the Health Insurance Association of America/HIAA constituency, exclusive of the Group Health Association of America/GHAA contingent) have failed at managing clinical risk and have effectively thrown in the towel, i.e., managed care was never more than mere contracting for discounted pricing, as armies of medical directors rarely denied more than 1% of referrals and/or admissions.

So today, surprise, surprise, it’s all about the network – as in ‘high value networks’ – tighter, smaller value based clusters of high performing provider collaborations.

Again, this is a fabulous pitch by Bertolini and one I highly recommend you listen to in it’s entirety.

Next up similar insights from AthenaHealth CEO Jonathan Bush followed by a somewhat anemic if not apologetic performance of Universal American’s CEO I’ll title ‘a not so healthy collaboration.’

As always, your thoughts, opinions or challenges are welcome.

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One thought on “It’s All About the Network

  1. Pingback: The Doctor Weighs InIt's All About the Network

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