When Aetna starts work with delivery systems to form accountable care organizations, the insurer typically analyzes claims data to get a picture of a provider’s present status and guide creation of an efficiency model.

One ACO customer in particular had an unusually high rate of emergency department utilization, noted Charles Kennedy, M.D., CEO of accountable care solutions at Aetna, during a presentation at Health Data Management’s Healthcare Analytics Symposium in Chicago. Most interesting was that the high utilization was occurring during physician practice office hours.

Analysis found that all the excess utilization was coming from a single county with two poorly run offices where staff was so overwhelmed that they were routing calls to the answering service, which tells patients to go to the ER. “It’s these non-value-added and costly problems that we can take out of the system without changing everything else,” Kennedy said.

In a value-based care environment, providers that get more efficiency out of what they have rather than building more facilities and services will find that payers channel more business to them, Kennedy noted. Payers are ready to work with providers in multiple ways, he emphasized.

For instance, Inova Health in Virginia has 60 percent market share, yet realized that if it was to take on population health and value-based care, it also needed to become a payer. Consequently, the provider jointly developed a health plan with Aetna, “and now Inova looks a lot like Kaiser,” Kennedy said, with the lowest-priced products in the region and 100,000 members in the new health plan.

Providers and payers working together to develop ACOs each bring valuable components to the other, according to Kennedy. Providers have a community presence, patient experience, clinical expertise, and clinical/financial/operational data. Aetna brings a national presence with fixed costs, health insight, risk management expertise, insurance products and operations, population health management and data to benchmark an organization against peers.

Bringing together clinical and claims data is a key to population management as the combination of data helps identify two-to-three times more patients for intervention services. But what both organizations need to know most is that the other has integrity and can be trusted.

This story first appeared at Health Data Management.

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