Over the past couple of years accountable care organizations (ACOs) have become an increasingly important part of the evolution of health care delivery and financing. While the concept started with the Patient Protection and Affordable Care Act (PPACA) and Medicare, there are now more beneficiaries in commercial ACOs than in Medicare ACOs (more than 17.2 million in commercial ACOs versus 14.6 million in Medicare ACOs). And, in some states—Oregon, Massachusetts, and Colorado, among others—Medicaid ACOs are changing the landscape.
The question we’ve been contemplating is how do ACOs address the needs of complex consumers? I had a chance to learn more about this at the recent 2018 OPEN MINDS Executive Leadership Retreat, during the keynote address by William Lopez, M.D., CPE, Senior Medical Director for Behavioral Health at Cigna, Key Issues Shaping The Market For Complex Consumers: A Health Plan Perspective On What Executives Need To Know To Succeed.
He talked about Cigna’s version of ACOs, the Cigna Accountable Care (CAC) model, and specifically the latest pilot program which encourages behavioral health integration for the management of complex customers. Cigna originally launched its CAC program in 2008. Thus far, over 200 provider organizations have participated in some fashion, taking on financial risk and/or gainsharing related to total medical cost and quality. The behavioral integration pilot began in February 2018 after the Centers for Medicare & Medicaid Services (CMS) approved the new Collaborative Care Model (CoCM) codes the prior year. The purpose of the pilot is to demonstrate the value of the CoCM in a commercial book of business. The model has four key components that affect consumer care in general, and consumers with complex needs in particular.
Care coordination support – In order to assist provider organizations in transforming care to a population-based approach, Cigna funds at least one embedded care coordinator (ECC) in each CAC. The number of ECCs in each CAC depends on the size of the aligned population. Additionally, those organizations participating in the behavioral health integration pilot have an additional care coordinator to support the ECC. These care coordinators assist in managing care for consumers and connect them to outside programs in order to serve the whole person.
Clinical consultation – Cigna supports organizations participating in the CAC by acting as a clinical partner. Cigna provides organizations with clinical best practice resources, offers a learning collaborative, and a behavioral health toll-free hotline. The hotline is staffed by a masters-level behavioral health specialist who can assist with referrals, help providers to better evaluate the best clinical course, connect the consumer with Cigna’s coaching programs, and provide clinicians access to Cigna’s behavioral health medical directors for direct consultation.
Data sharing – As part of the CAC, provider organizations receive extensive reports from Cigna with the information needed to maintain a value-based arrangement. Organizations participating in the behavioral health integration pilot also receive a predictive report that identifies members with chronic conditions who may also have a co-occurring behavioral health disorder. This report can be used by the provider organization to reach out to the consumer and help get them needed services. It also allows them to identify individuals who may have higher than usual medical spend.
Gainsharing – The model supports a full spectrum of value-based payments from gainsharing to capitation. The risk arrangement is tailored to the provider organization’s current capabilities with the goal of slowly increasing risk acceptance over time. Cigna supports the provider organization in this process and will help them move between different risk arrangements as needed. Payments are tied to cost and quality. Cost is based on the total medical cost of the aligned population compared to the non-CAC population in the market. The program also tracks true reduction in care consumption such as a reduction in emergency department visits and improvements in quality of care, such as well-child screenings.
For executives of provider organizations, I think there is one major takeaway from Dr Lopez’s talk. Health plans like Cigna are tackling consumer needs mostly from the primary care side and behavioral health provider organizations are going to have to develop partnerships with these organizations in order to be successful.
To learn more about the Cigna model, join us at The 2019 OPEN MINDS Performance Management Institute in Clearwater Florida on February 14 for the session, “Implementing A New Model Of Integration: The Cigna Collaborative Care Model” featuring Lisa Kay, Clinical Program Manager, Cigna.