As I mentioned here, not all is bleak in the world of care delivery. Forbes recently ran two articles on how things are changing rapidly. The first, found here, is about how Aetna is  reformulating itself as a consequence of the Affordable Care Act and other pressures/ From the article:

Aetna recognizes the transition from the “do more, bill more” generation to the value/outcome-based generation is going to happen regardless of whether the Supreme Court overturns the health reform. The employers picking up the largest portion of the healthcare tab are fed up with the “get less for more” story they are told every year. In fact, IBM itself is a leader amongst large employers that pushed for facets of the health reform that included an emphasis on primary care.

From afar Aetna , it appears there are at least four key insights driving Aetna’s behavior:

  1. Traditional health insurance business profits have been capped so they are pursuing complementary businesses that are unregulated.
  2. Simply going through traditional channels of employers and providers won’t allow them to reach all of their target market. They have to create new pathways to the ultimate consumer. For a bunch of reasons, healthcare is becoming a more consumer-driven market so they must build or acquire that skillset.
  3. The devastating Medical Loss Ratio (MLR) requirements mentioned in the Health Insurance’s Bunker Buster article demand that 80-85% of premium dollars go to patient care (vs. administrative overhead). I believe the aggressive acquisition spree will be for services that can be classified as patient care and thus help them with their MLR requirements.
  4. An onslaught of new requirements are being placed on healthcare providers. Smaller providers are especially ill-equipped to handle these on their own. Thus, Aetna wants to provide backoffice services for these organizations.

The second item of interest, also in Forbes, is the use of the Direct Primary Care Medical Home (DPC) provision of the ACA by primary care docs. While the details are a little complicated (and found in the article) the results are not:

Because DPC models are a more pure form of primary care not having to worry about how to weave in cumbersome insurance-driven processes, they have shown an even more dramatic impact than the aforementioned PCMH. While garnering customer satisfaction scores higher than Google or Apple, achieving more 5 star ratings on CitySearch than any other business DPC practices such as Qliance, Iora Health and WhiteGlove Health have reduced expensive downstream costs (surgical, emergency department and specialist visits) by 40-80%. I predict some of the PCMH models being piloted will shift to DPC as payment reform continues.

In the words of Forbes, good primary care (mostly Family Medicine) is sexy:

Utilizing a collaborative care model, the patient becomes a valued member of the care team — more than just a vessel for billing codes. Patients win. Physicians Win. Employers Win. Even forward-thinking insurance companies win. In fact, most major health insurance companies have major efforts to make primary care the foundation of their plans and it’s not a moment too early.

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