More on Quality and Safety

PCMH paying off for Aetna and doctors

Patient outcomes improved, incentives were awarded and the insurer plans on widening the scope of the program

A patient-centered medical home program with a physician-owned, multispecialty group has been so promising that Aetna is extending the arrangement.

Last year, Aetna started a PCMH with WESTMED Medical Group, based in New York's Westchester County. Leaders from the organizations said that the medical home offers a good model for starting value-based payer-provider contracting, particularly with medical practices.

"Doctors often talk about quality, but don't measure it," said Simeon Schwartz, MD, president of WESTMED Medical Group, in a media release. "One of the key characteristics of the medical home is that it brings rigorous measurement and quality analysis to prove that the best care is being provided, resulting in fewer hospitalizations and medical errors."

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In the first year of the medical home contract, Aetna's 5,650 members being treated by WESTMED physicians saw a 35 percent reduction in hospital admissions and had relatively fewer ER visits and hospital readmissions. WESTMED doctors also met almost all of the 10 goals targeting cancer screenings and proactive management of diabetes and heart disease.

According to Aetna, those results earned WESTMED some $300,000 in incentive payments.

The positive results from the first year of the project have Aetna looking forward to expanding the relationship with WESTMED for Medicare, said Dave Kobus, the company's senior vice president for New York networks.

More than 650 Aetna Medicare Advantage members in and around Westchester County will now have access to WESTMED under the extended collaboration agreement, wherein Aetna nurse case managers will work with WESTMED doctors on coordinating care, focusing on patients with chronic conditions. 

In both the PCMH and the Medicare collaborative contracts, Aetna said it has found "careful tracking of quality metrics" to be critical, especially as it tries to expand these and other non-fee-for-service reimbursements. 

Nationally, about 1.5 million Aetna members are being served through an alternative reimbursement contract with providers. The insurer has been seeing medical practices like WESTMED as one main route to successful alternative reimbursement, but it's also nailing down similar arrangements with hospital systems.

For example, Aetna recently created its first commercial accountable care organization in greater Cincinnati, via an agreement Mercy Health, southwestern Ohio's largest hospital system. The Whole Health plan with Mercy's network of eight hospitals, 350 primary care physicians and 2,400 specialists, will be available to both fully-insured and self-funded employers in the counties of Butler, Clermont, Hamilton and Warren.

This story is based on an article appearing on Healthcare Payer News.