Since 2003, teams of medical directors and other specialists at Aetna have analyzed claims data for specific medical conditions. Called “Condition Analysis,” and a part of Aetna Health and Clinical Services, the group works to identify ways to improve the quality of health outcomes for members while reducing wasteful spending in the health industry.
“We’re focused on improving quality of care while simultaneously controlling the cost of care,” said Phil Lerner, MD, MPH, Aetna’s national medical director, and head of Condition Analysis. One example is finding and managing miss-utilization of health care services, such as members who receive medically unnecessary or unproven treatments or when their providers may not be fully adhering to evidence-based guidelines pertaining to the evaluation or treatment of the member’s condition.
In 2015, the United States spent $3.2 trillion on health care, according to the Centers for Medicare & Medicaid Services. About one-third of the money spent on health care is wasted, according to a Health Affairs brief in 2012. Wasteful spending is one of many factors that leads to an unnecessary increase in cost, Lerner said.
Collaborating to gain insight
Condition Analysis is comprised of ten clinical teams covering various specialties, including cardiology, endocrinology, gastroenterology, genomics, musculoskeletal, neonatology, nephrology, oncology, preventive and women’s services. Each team is overseen by an Aetna medical director and is managed by a program manager. The teams include several medical directors and subject matter experts from a variety of departments across Aetna. They are supported by analysts who partner with the teams to use claims data to identify and evaluate opportunities to help our members obtain more cost-effective, evidence-based health care.
“Projects developed within our Condition Analysis teams improve the quality of care for members with specific conditions, without increasing health care costs,” said John Moore, D.O., FAAFP, Aetna’s medical director for the U.S. Northeast Region, who also leads the endocrinology team. “Everyone wins, especially the member who we hope remains healthier at home and avoids disease complications and unnecessary hospitalizations.”
Each team is actively working on a dozen or more projects at any given time, Lerner said, and uses a variety of information sources, including medical literature, data mining and medical director focus groups. Cost savings and improved quality of care can be realized through changes to clinical policies, claims payment processes, healthcare plan designs or by creating new condition-specific programs.
“The goal of each team is to look at broad issues around a particular topic. These issues may be related to how we contract with providers, how we make coverage decisions, what types of programs we implement,” said Dr. Krystal Revai, a medical director at Aetna and leader of the Neonatology Clinical Analysis Team. “It benefits the members because is enriches their coverage and may lead to the creation of an important program.”
Using data about kidney disease leads to savings, better care
Dialysis treatment for patients with chronic kidney disease is costly. Nationally, treatment of chronic kidney disease costs more than $48 billion a year, according to World Kidney Day.
With claims data, Condition Analysis could also see the mortality rate for patients with kidney disease was high. The analysis led to the creation of a new program, where Aetna partners with two dialysis providers to jointly manage and enhance the quality of life for members who have chronic kidney disease. They provide outreach and education with the goal of slowing the progression of disease.
The treatment does not cost anything for the plan sponsor or member. Patients were not only educated and supported, but the program helped identify, prevent and manage chronic kidney disease complications and associated comorbid costs. It also facilitated the transition to dialysis at participating facilities and avoided the cost of expensive emergent dialysis.
In addition to markedly better outcomes, the program provided significant savings for Aetna, as well as plan sponsors and members.
Finding new ways to save, improve care
As Condition Analysis continues to analyze data, the groups also examine how new technologies can be used to improve the quality and cost effectiveness of care.
“Medical technology advancements continue to have an impact on health care,” Lerner said. “These technologies include new pharmaceuticals, medical devices and diagnostic tests. Sometimes they involve expanded or new applications of existing technologies. These advancements have the potential to markedly improve health; however they tend to be expensive, especially when first introduced.
“We therefore work closely with Aetna Pharmacy, Medical Economics and Clinical Policy to monitor these new and emerging technologies to prepare for their impact, develop payment strategies and ensure that they are appropriately used to improve the health of our members in a cost-effective manner.”