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Aetna, data, and care management

Aetna’s acquisition of ActiveHealth Management is part of a growing trend wherein large health plans are seeking to mine their data for better ways to manage cost and care and enable their providers to better utilize “evidence-based medicine”. ActiveHealth has strong assets in these two primary areas, both based on their CareEngine technology.
In part, the acquisition reflects an understanding and appreciation on the part of Aetna senior management that the present use of medical guidelines and pathways is not working. Companies such as Interqual/McKesson, Milliman and Robertson, and IDG all promote their clinical guidelines, and most providers and payers use some form of guideline in the delivery or management of care. However, payers are noting:
– the health care inflation rate is twice that of overall inflation;
– provider practice pattern variation continues to frustrate regulators, academics, providers, and payers alike:
– providers continue to voice their displeasure with what they perceive to be overly-intrusive “management” by “bureaucrats”;
– the chief complaint from providers is the present guidelines are “cookbook” medicine, which treat all patients alike regardless of individual characteristics; and
– the “return on investment” of utilization review and case management continues to diminish (in general).
In addition, payers are finally starting to understand that one of their key assets is the data resident in their claims and managed care information systems. Leaving aside the (rather significant) issues of data accuracy, consistency, and completeness, one of, if not THE key asset of most payers is their database of information on how providers treat, which providers have better outcomes for which types of patients and diagnoses, billing practices, and the like. This asset has been underutilized, to say the least.
If managed care companies/health plans/HMOs are going to be successful, they are going to start utilizing their data to determine the best way to deliver care, and utilize technology similar to ActiveHealth’s to assist in that care delivery.
What does this mean for you?
If Aetna, UnitedHealthGroup, and others are starting to finally take meaningful steps, perhaps you should too. If you are a provider, you would do well to follow this trend carefully, because there is no doubt you will be affected by it.

Joe Paduda is the principal of Health Strategy Associates



A national consulting firm specializing in managed care for workers’ compensation, group health and auto, and health care cost containment. We serve insurers, employers and health care providers.



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