My post a few days ago complimenting Aetna on their progress in a number of areas struck a few nerves and elicited more than a few emails from ballistic providers (a couple of the printable ones are in the comment section of that post).
There’s a bit of conflation going on here – my comments were focused on the company’s overall strategy while several critics took the big healthplan to task for it’s poor contracting in workers comp (where the product is Aetna Work Comp Access, or AWCA).
Yet they have valid concerns, concerns that are consistent with problems experienced by Aetna’s WC customers, lousy provider directory data, providers refusing to accept WC patients, heavy handed contracting efforts.
I’ve posted on these issues months ago, yet these issues persist. One provider group in Pennsylvania is so frustrated that they contacted state regulators, only to find out that many other providers had the same problem. Now, they are banding together (albeit informally) and asking regulators to outlaw PPOs in the state.
Other complaints relate to Aetna’s practice of ‘negative affirmation’ (my term, but you can use it). Aetna sends their currently-contracted group health providers a letter stating that unless the provider responds within X days, they will be automatically enrolled in AWCA at their group health rates. In defense of Aetna, their contracts with the providers allow this, as does state law. And providers can opt out at any time, so the damage done is rather limited.
Aetna recently decided to use certified mail instead of regular post when sending these letters to providers – the last batch of letters, some 50,000 in all, went out certified about a month ago. When I discussed this with an Aetna exec, he agreed that the mailing of the negative affirmation letters likely contributed to the provider data issues; AWCA is hopeful that the new certified letter will help.
Still, it is a wonder that it took the big insurer this long. Two big payers view AWCA’s PA data as the worst they have ever encountered. Providers routinely get buckets of mail from networks, and it is certain that many of these ‘negative affirmation’ letters end up in the trash as junk. The WC payers get a contract load from AWCA, construct panels of providers, direct injured workers to these providers, who then either a) don’t accept WC, b) can’t spell WC, c) treat the injured worker and then scream when their bill is slashed and protest to the insurance commissioner et al.
Now that AWCA is the de facto network of choice (due to the Coventry deal), some payers’ concern is there may be little motivation for the company to clean up its act. Even less than it had before the deal was struck and AWCA was working hard to compete with Coventry – now it enjoys near-monopoly status in many states, a condition that some payers think makes it less likely it will invest in provider relations.
That’s not the case, according to AWCA. They are investing in the business – hiring more account managers and provider relations staff and continuing to work on their data issues. They have a ways to go, but appear to be committed to working at it.
If you are sensing a little ambivalence here, you’re right. Payers are notorious for blaming everything on vendors while accepting little responsibility themselves. Vendors suggest improvements in processes and systems that would improve results, only to be told its not a priority for the payer. And part of the negativity about AWCA is undoubtedly from payers that are not holding up their end of the deal.
Yet I expect more from Aetna. They should be better than CorVel and Coventry’s WC division. Here’s hoping they get there, and soon.

In my consulting practice, I work with large, really large, and small payers – insurers and self-insured employers, as well as managed care firms – on managed care, claims, and related issues.
One of the best claims-managed care programs I’ve come across is at a relatively tiny insurance company. They have (generally) excellent relations with providers, tightly integrated medical management, claims and bill review, a keen grasp of cost drivers, and highly effective specialty programs. Their network penetration (albeit in a network direction state) is just under 90%.
Their results are impressive.
Medical costs (on a per-claim basis) for lost time claims have dropped dramatically over the last two years. While the industry’s costs were going up by 7.5% (NCCI stats), their clients enjoyed a double-digit decrease in medical expense.
How is this possible? They don’t have access to the actuaries, statisticians, or clinical experts resident at larger payers. They can’t afford expensive IT initiatives, integration projects, and sophisticated rules engine-driven document management processes.
What they do have is focus, an open mind and willingness to try new things, a commitment to do the right thing, and very little patience for bureaucracy. They also have medical folks doing medical management – the adjuster has the final say, but it is rare that the clinician’s recommendation is overturned.
I’m convinced the reason this payer is as successful as they are starts with and is driven by their culture and commitment to doing the right thing. Too often big payers’ plans get bogged down in the cloying mud of committees, process, debate and discussion. Internal rivalries and turf battles suck the life out of promising ideas. Individuals are far more concerned with looking good and checking boxes off their annual goals than actually making sure the programs reduce costs and improve outcomes.
Meanwhile costs continue to go up and care is less than optimal.
What does this mean for you?
It doesn’t have to be that way.

One of the frequent questions from potential investors, regulators, and interested parties is why the group health payers are not doing more in workers comp. With the notable exception of Aetna and Wellpoint, the big group health players’ work comp activity is minimal (and in the case of Wellpoint, just a bit over that threshold).
Many group health execs consider entering into the comp business, figuring that if their company can do so well in group, they should be able to clean up in comp – which is in many ways still in the Dark Ages when it comes to medical management.
Superficially, they are right – but only superficially.
The primary difference is that in comp, the payer cares about the claimant’s functionality – if the injured worker can’t work, the payer is ‘on the hook’ for lost wages as well as medical care. This is not the case in group, where the payer couldn’t care less if the claimant returned to work or is sitting home.

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