View Aetna’s Strategies
Overview
Aetna has been a leader in the insurance industry throughout the company’s 160-year history. The company is still a leader today but is evolving from an insurance carrier to a health solutions company that helps empower people to live healthier lives and aims to improve the overall health care system. With more than 44 million members, and nearly 47,000 employees around the world, the company remains on the leading edge of innovation when it comes to the health of the American workforce, including its own.
Aetna uses a multifaceted approach to improving the health and wellness of individuals, including initiatives that focus on identifying and addressing Metabolic Syndrome, harnessing technology to empower consumers, and stress reduction.
Aetna’s Strategies for Improving the Health and Wellness of Individuals
Identifying and Addressing Metabolic Syndrome
One of today’s fastest growing health issues is known as Metabolic Syndrome, a grouping of five risk factors including large waist size, high blood pressure, high triglycerides, low HDL (“good”) cholesterol, and high blood sugar. An adult with three or more of these risk factors is considered to have Metabolic Syndrome. An estimated one-third of American adults have Metabolic Syndrome, and many are unaware that they have it.1 Those with it are twice as likely as those without it to develop cardiovascular disease and five times more likely to develop diabetes.2 In addition, health care costs increase 25 percent with each added risk factor.3 The good news about Metabolic Syndrome is that lifestyle changes can reduce or eliminate the risk for these conditions.
Through a voluntary program, employees and spouses or partners can be screened annually at no cost. Those who test and are in a “desired” range for at least three of five risk factors each receive a $300 annual medical plan premium credit. To help higher-risk employees address Metabolic Syndrome, Aetna recently introduced two technology-based programs designed to help.
Aetna offers employees a holistic program called Metabolic Health in Small Bytes, to which employees can self-refer. This evidence-based online program is designed to help reduce or reverse the risk factors associated with Metabolic Syndrome. Developed through a collaborative effort with Duke Diet and Fitness, Duke Integrative Medicine and eMindful, Small Bytes offers weekly or monthly classes conducted through a real-time, virtual, online classroom where participants can interact in real time with the instructor and each other.
In addition, Aetna offers its employees an interactive tool—a Metabolic Health Advisor called “ALEX®.” A virtual host, ALEX is designed to motivate users to participate in the screening to increase identification of employees at risk, explain the results and give personalized feedback about the risk of Metabolic Syndrome, and encourage them to participate in lifestyle changes and Aetna intervention programs to reduce their risk.
Harnessing Technology to Empower Consumers
Mobile technology is a powerful tool to deliver more contextual and personalized health care and health information. Consumer use of these tools and information is driving changes in the way care is accessed and delivered and shows promise for bending the national cost curve as well. Aetna’s most popular health-related mobile application is Itriage®, which helps consumers choose health care providers. This decision support tool, founded by two emergency room physicians, is designed to help consumers answer two common medical questions: “What could be wrong?” and “Where can I go?”
Using iTriage, consumers can check symptoms; research treatment options, procedures, costs and complications; get information about medications; determine appropriate actions; locate and compare nearby care options; check in digitally, make appointments or phone calls, and get directions; and manage personal health records and information. A customizable employer enhancement helps users understand the cost implications of using in-network versus out-of-network providers, guiding users to the most clinically appropriate, lowest-cost care option. This feature increases in-network compliance and helps employers reduce costs while still providing employees with appropriate treatment options.
Stress Reduction. Stress can exacerbate or open the door to a range of health problems. Highly stressed individuals are at greater risk for multiple health conditions, including coronary heart disease, cancer, diabetes, depression and anxiety, fatigue, obesity and musculoskeletal pain. An international labor association estimates that 30 percent of all work-related disorders are due to stress, accounting for $6.6 billion of losses in the United States alone.4
To address this, Aetna piloted two innovative programs designed to help its own workforce manage stress. Both programs were developed in collaboration with Duke Integrative Medicine, eMindful, and the American Viniyoga Institute. Both were part of the “Mind-Body Stress Reduction in the Workplace” clinical trial, the results of which were published in the April 2012 edition of the Journal of Occupational Health and Psychology.5 Based on the success of the pilots, the programs are now offered to Aetna customers.
Mindfulness At Work™
This mind-body stress management program is based on the principles and practices of mindfulness meditation. Developed and offered by eMindful, the program teaches relatively brief (five to fifteen minutes) mindfulness practices that explicitly target work-related stress and work-life balance, and are specifically designed to be used at work.
Offered through an online, virtual classroom, the program teaches evidence-based mental skills, including mindfulness awareness, breathing techniques and emotions management. The program also helps participants discover and use their inner resources for bringing awareness, balance, and peace of mind to their lives. The goal is to improve mental performance, focus, and productivity, as well as enhanced quality of life.
Viniyoga Stress Reduction
This ten-week therapeutic yoga-based program was developed by American Viniyoga Institute founder Gary Kraftsow. Participants receive instruction for managing stress including physical yoga postures, breathing techniques, guided relaxation, and mental skills. The classes also provide coping strategies for dealing with stressful events and promote the use of home and office strategies for reducing stress through yoga. The program offers weekly in-person classes, home practice handouts, and yoga break handouts for home and office use.
Benefits and Impact
Identifying and Addressing Metabolic Syndrome
Aetna employees who participated in the Metabolic Health in Small Bytes program showed statistically significant improvements in all five risk factors, as shown in the following chart.
| Test Results | % in Appropriate Range Before | % in Appropriate Range After |
| Triglycerides (Appropriate range less than 150 mg/dL) | 74.0% | 85.5% |
| High Blood Sugar (Glucose) (Appropriate range less than 100 mg/dL) | 76.3% | 84.7% |
| Low HDL (‘good’) cholesterol (Appropriate range more than or equal to 50 mg/dL for women and 40 mg/dL for men) | 61.8% | 76.3% |
| Blood pressure (Appropriate range lower than or equal to 130/85) | 77.1% | 93.9% |
| Waist Circumference (appropriate range less than or equal to 35 inches for women and 40 for men) | 9.2% | 21.4% |
| Body Mass Index (appropriate range lower than 30) | 21.7% | 28.3% |
In addition, Aetna employees who participated in the program showed improvements in a number of other areas:
- Greater Productivity. The average number of minutes per week of lost productivity decreased from 61.2 to 21.6
- Increased Physical Activity. The number of participants performing at least 20 minutes of aerobic exercise at least three days per week increased 22.3 percent (from 47.7 percent to 69.9 percent).
- Stress Reduction. Participants reported statistically significant improvements such as being less upset in unexpected situations, being more in control of the important things in their lives, being better able to cope with all the things they needed to do, and feeling more “on top of things.”
Harnessing Technology to Empower Consumers
iTriage has been downloaded more than ten million times, with 50 million user sessions each year. The app is driving more appropriate and more efficient care: When iTriage users search for providers based on non-acute conditions, they select emergency departments 40 percent less frequently. The app also boosts engagement and health literacy, which lowers costs: 63 percent of users search symptoms, 17 percent learn more about medications, 13 percent read news and alerts, and 53 percent review conditions and procedures.
This innovative electronic consumer tool improves employee engagement in their health; guides employees to the most appropriate level of care; encourages the use of more cost-effective, in-network providers; increases network compliance; and reduces unnecessary ER visits.
Stress Reduction
Participants in the “Mind-Body Stress Reduction in the Workplace” clinical trial, which looked at the impact of both mindfulness and Viniyoga, showed significant improvements in perceived stress with 36 and 33 percent decreases in stress levels respectively, compared with an 18 percent reduction for the control group as measured with the Perceived Stress Scale. Participants in the mind-body programs also saw significant improvements in various heart rate measurements, suggesting that their bodies were better able to manage stress.
To date more than 13,000 Aetna employees have participated in one or both programs. Since the pilot study showed statistically equivalent results for Mindfulness At Work participants who attended in-person sessions as well as those who accessed content through a virtual online classroom, the program is now offered online to all employees. The Mindfulness at Work program is helping participants gain an average of 62 minutes per week of productivity.
Lessons Learned
Identifying and Addressing Metabolic Syndrome
Getting employees to participate in the biometric screenings and then enroll in the program interventions, if appropriate, requires effective communication as well as incentives. Implementing a successful Metabolic Syndrome testing program requires a multi-year strategy to build a culture of health and well-being in your organization. Some of the high-level steps include:
- Understanding your employee demographics
- Establishing a wellness baseline
- Building employee awareness around the importance of screenings and health assessment completion
- Driving action and engagement in relevant tools and program resources
- Refining your strategy for optimal results.
Stress Reduction
It can be difficult to quantify the value of reducing stress. Aetna’s pilot program found that among all individuals who were screened for the study, those reporting the highest stress level (top quintile) had nearly $2,000 higher medical costs for the preceding year than those reporting the lowest stress level. Reducing stress can help reduce the risk for associated health conditions and points to the potential to help reduce overall health care costs.
Key Take-aways for Employers
Changing behavior is ultimately up to each individual. However, employers can make a big difference by helping their employees see the value of adopting healthier behaviors so they can live healthier lives.
The employer’s workplace culture sets the tone for their employees. A supportive work environment, where managers reinforce the wellness strategy, can keep employees motivated and engaged. Support and commitment from senior management is critical to the success of the strategy. Senior management support also helps ensure that the resources needed to follow through effectively are obtained. One option is to have senior leaders play specific roles in announcing and reinforcing the strategy throughout the year. For example, senior managers can kick off the campaign or can be the first to have their onsite health screening.
1 D.M. Boudreau et al., “Health care utilization and costs by metabolic syndrome risk factors,” Metabolic Syndrome and Related Disorders, August 2009. 7(4):305-14. http://www.ncbi.nlm.nih.gov/pubmed/19558267
2 “About metabolic syndrome,” American Heart Association, Last updated July 24, 2014. http://www.heart.org/HEARTORG/Conditions/More/MetabolicSyndrome/About-Metabolic- Syndrome_UCM_301920_Article.jsp
3 “Why metabolic syndrome matters,” American Heart Association, Last updated July 24, 2014. http://www.heart.org/HEARTORG/Conditions/More/MetabolicSyndrome/Why-Metabolic-Syndrome-Matters_UCM_301922_Article.jsp
4 Yoshio Mino et al., “Can stress management at the workplace prevent depression? A randomized controlled trial,” Psychotherapy and Psychosomatics, 75(3): 177-182. DOI: 10.1159/000091775.
5 Ruth Q. Wolever et al., “Effective and viable mind-body stress reduction in the workplace: A randomized controlled trial,” Journal of Occupational Health Psychology, Vol 17(2), Apr 2012, 246-258. DOI: 10.1037/a0027278 http://psycnet.apa.org/journals/ocp/17/2/246/
Overview
Health insurance companies can play a powerful role in improving the health care system by collaborating with health care providers to develop new models of care that help their members and patients. Aetna is working to build a new health care system model for the future that reorients insurers’ traditional focus by redefining customers to include providers, consumers, and employers. By aligning economic incentives between payers and providers, Aetna is working to create a health care system that provides consumers with superior outcomes and a better patient and consumer experience that is affordable and sustainable. Aetna’s Medicare Advantage Provider Collaboration program, and its work to create accountable care organizations (ACOs) with provider organizations across the nation, are examples of this new model that is improving the quality of care and health outcomes while also reducing costs.
Aetna Strategies for Improving the Health Care System
Medicare Advantage Provider Collaboration: NovaHealth
Through this program, Aetna has collaborated since 2008 with NovaHealth, a medical group (Intermed), and an independent physician association based in Portland, Maine, that provides care to approximately 1,600 Aetna Medicare Advantage members. The collaboration functions something like an accountable care organization, but for a Medicare Advantage population, using shared data, financial incentives, and collaborative care management to improve the health of the population.
The program embeds Aetna’s nurse case managers with NovaHealth, where they help develop care plans, monitor adherence to plans, educate patients, and coordinate care to build continuity and improve health outcomes. The role of the Aetna nurse case manager is a major component of the collaborative relationship with NovaHealth. Aetna’s nurse case managers serve as a single point of contact and work directly with NovaHealth’s clinical staff to help coordinate care and enhance adherence for Aetna Medicare Advantage members.
Aetna’s program with NovaHealth was one of its first Medicare Provider Collaboration arrangements. Aetna currently has more than 100 Medicare Advantage Provider Collaboration arrangements with health care providers across the country.
The combined work of the physicians, Intermed/NovaHealth, and Aetna has resulted in dramatic impact on quality and cost compared with unmanaged Medicare populations in Maine, as published in Health Affairs, a leading health policy publication.1
Accountable Care Organizations: Banner Health Network
ACOs use technology and a team-based approach to care for a population of patients. Doctors and hospitals assume accountability for the outcomes and are rewarded financially for achieving higher quality, greater efficiency, and an overall better patient experience.
In these arrangements, Aetna works with the provider organization to assess their readiness to take on risk and manage populations. Aetna then works with the organization to build the health information technology (IT) and clinical infrastructure that allow the providers to transform their delivery system, focus on coordinating care for patients, and accept financial risk.
Aetna has more than 30 such arrangements, including with Banner Health Network of Arizona to support its accountable care organization. Banner Health Network is one of the Medicare Pioneer ACOs, but it also has commercial ACO relationships. Banner Health Network is a patient care and business venture between Arizona Integrated Physicians, the Banner Medical Group, the Banner Physician Hospital Organization (BPHO), and Banner Health. The Banner Health Network currently has more than 2,000 employed and private practice physicians located in the Phoenix metro area serving four million residents.
Together, Aetna and Banner’s goal is to achieve the triple aim of accountable care (better care, better health, and better cost) through population health. Banner is at the forefront of change as the overall reimbursement structure of health care services is changing.
Aetna and Banner Health Network collaborated to deploy product, technology, and care management capabilities to deliver patient-centered, accountable care across multiple populations, including the Pioneer ACO (Medicare fee-for-service), Aetna’s commercial membership, and Banner’s employees. In addition, Aetna and Banner are jointly offering health plan products that incent and motivate members to seek care within the ACO network.
Aetna worked with Banner to build a health IT framework and clinical infrastructure. The clinical model focuses on patient and member experience. Patients have a virtual care team that includes nurses, doctors, and other providers supported by the technology infrastructure that allows any member of the care team to see and communicate through the full patient record. Information is exchanged electronically; there is no hand-off of paper copies or reliance on notes from phone calls. Aetna and Banner work together to pilot new ideas and concepts to improve the care for Aetna members in the ACO through more coordinated care.
Benefits and Impact
Medicare Advantage Provider Collaboration: NovaHealth
Together, Aetna and NovaHealth have achieved two main goals of ACOs: improving quality of care and lowering health care costs. Results from 2011 that were published in Health Affairs show that:2
- Patients in the program had 50 percent fewer inpatient hospital days, 45 percent fewer hospital admissions, and 56 percent fewer readmissions than unmanaged Medicare populations statewide.
- More than 99 percent of these Aetna Medicare Advantage members visited their doctors in 2011 to receive preventive and follow-up care.
- NovaHealth’s total per member, per month costs for its Aetna Medicare Advantage members were 16.5 to 33 percent lower across all medical cost categories than for other Aetna Medicare Advantage members not cared for by NovaHealth.
Through the Provider Collaboration Program, NovaHealth has met a number of clinical quality metrics agreed upon by both sides, including:
- 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), chronic obstructive pulmonary disease (COPD) 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.
Accountable Care Organizations: Banner Health Network
Aetna members within the Banner Health Network pay less out of pocket; benefit from a focus on wellness; receive more coordinated care and greater assistance with managing their chronic conditions; and have access to Aetna’s online tools.
Aetna and Banner Health Network implemented a risk-sharing agreement that compensates and rewards Banner Health based on achieving certain quality, efficiency and patient satisfaction measures. The measures include, but are not limited to, the percentage of Aetna members who receive recommended preventive care and screenings; reductions in hospital readmission rates; and expanded access to primary care physicians.
Across all patient populations served by the Banner Health Network ACO, results from 2012 showed the following year-over-year improvements:
- 0 to 5.5 percent medical cost savings over prior 12 months
- 0 to 8.0 percent increase in PCP visits
- 0 to 8.0 percent reduction in hospital admissions
- 5 to 1.0 percent reduction in hospital readmission rate
- 0 to 7.0 percent reduction in high-tech radiology utlization.
Lessons Learned
Medicare Advantage Provider Collaboration: NovaHealth
Getting a high level of physician buy-in is one key to a successful collaboration. This requires physician-to-physician communication and the provision of data and other tools to help providers measure their performance and improve. In a successful collaboration, ideas, recommendations and suggestions flow in both directions. Nurse case managers, particularly case managers embedded in physicians’ offices, can be invaluable to health care providers as they become valued and trusted members of the overall care team.
Accountable Care Organizations: Banner Health Network
Strong working relationships are critically important to the development of accountable care models. Employers and their insurers should work with providers to create arrangements that advance the interests of each stakeholder and of patients. Effective communication with employees about the value of more coordinated health care is an essential element in driving quality up and costs down. Patients who are educated about the importance of selecting doctors and hospitals whose reimbursement is based on quality, cost and patient satisfaction, rather than on volume, will be empowered to make choices that support this shift.
Key Take-aways for Employers
Aetna believes that patient-centered collaboratives are a stepping stone to accountable care organizations, which further align financial incentives with high-quality, more efficient care, says Randall Krakauer, MD, FACP, FACR, Vice President, National Medical Director of Medical Strategy for the Office of the Chief Medical Officer.
“By aligning our clinical goals and sharing data, we can help improve health outcomes for the members that we serve. Working together, we can help confirm that our members are receiving the right care at the right time and support them as they try to be as healthy as possible” says Krakauer.
“Value-based, patient-centered care models such as accountable care organizations or ACOS, bring employers, providers and insurers together to help drive much-needed change to the quality, delivery and cost of health care in America,” says Charles D. Kennedy, MD, chief executive officer of Accountable Care Solutions for Aetna.
1 Thomas F. Claffey et al., “Payer-provider collaboration in accountable care reduced use and improved quality in Maine Medicare Advantage plan,” Health Affairs, September 2012. 31, no. 9, 2074-2083. http://content.healthaffairs.org/content/31/9/2074.abstract
2 Thomas F. Claffey et al., “Payer-provider collaboration in accountable care reduced use and improved quality in Maine Medicare Advantage plan,” Health Affairs, September 2012. 31, no. 9, 2074-2083. http://content.healthaffairs.org/content/31/9/2074.abstract
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