Aetna CMO Dr. Lonny Reisman

At the Digital Health Summit in Boston, Eric Murphy, President of Payer Solutions for Optum, and Dr. Lonny Reisman, Aetna's chief medical officer, talked about the changing role of the payer in healthcare. As the shift from fee-for-service to risk-sharing payment models occurs, Reisman and Murphy said payers need to step up how much they work with providers.

"As I interact with health plans and health plan leaders, there's an evolution happening," said Murphy. "Moving from a sponsored purchaser, risk aggregator, risk manager, to really an overall health manager, and getting to that nature of population health... Many health plans don't really know their own members on an individual basis until they file a claim or go through some sort of enrollment process. And oftentimes it's a very impersonal process. So the notion of health plans now driving toward heavy investments in data analytics and healthcare technology because of that notion of having to truly manage that whole population's health, if you will, I don't think there's anything more pronounced, and it's a really interesting transformation for healthcare."

Reisman said health plans have access to data that providers need to improve care, a goal which both payers and providers share.

"So if hospitals are being held responsible for readmissions, how many hospitals are aware of what drugs patients are taking not only from that hospitalization but from other docs?" Reisman asked. "Are they adherent? Have lab results emerged that would suggest certain drugs work better? On and on and on. There's a wide space, there's a continuum where most patients need to be tracked in order to prevent readmissions, complications, ER visits. To that extent, most systems don't have that ability. We do. We can analyze that data. We can provide workflow solutions."

Murphy and Reisman talked a lot about accountable care organizations and the role health plans can play in facilitating the change over from fee for service to value-based care.

"We're kind of flying the proverbial plane while we're building it," Murphy said. "You can't just turn off one system, historic fee for service, and then turn on a value-based, shared risk or fully capitated type model. You've got to keep them both going. But I can assure you there isn't a health plan in existence today that isn't talking about making dramatic changes. Whether it's cost reduction, whether it's improvement, driving transformational relationships with networks and delivery systems."

Changing healthcare is a matter of changing behavior, the speakers said, not just of patients but of doctors and insurers as well. Accountable care is about creating a system where all the incentives line up to create the best behaviors, rather than the current system where incentives can lead to overspending.

"As a doctor, people come to me with some form of chest pain and I immediately know its not significant," he said. "And I have a choice. I can say 'It's not significant', collect my 50 bucks or whatever it is and have the patient walk away thinking that I'm indifferent and calloused and fill out a survey saying I'm a bad guy. Or I can say 'You're probably ok but, after all, it is your heart, and I'd like to be 100 percent certain'. And then I do $20,000 worth of stuff to you and you walk out and say 'Boy, he's such a good guy.' I've got 20 grand, and now I've got a favorable survey. Until we change the incentives we're going to have a problem."

Reisman said that since the term originated, accountable care has evolved from "you're responsible for a population, here's a check, good luck" to a community collaboration between payers and providers to provide a set of tools and consistent standards for healthcare.

"We believe whether it's traditional care management capabilities, information technology, or Healthagen, ... if in fact we can create this constellation of capabilities and earn the trust of a community of providers -- not a small thing by the way -- then I think the ACOs have a real future," he said. "If we can't then someone will have to figure out another solution, but we're really quite optimistic."