HFMA report highlights: Banner|Aetna's payvider model realigning care and coverage

The following are key takeaways from a Healthcare Financial Management Association (HFMA) report on the new frontier of value-based care, which includes insight from Banner|Aetna chief executive officer Tom Grote.

The new value-based care landscape includes a growing contingent of insurers and health systems integrating coverage and care in different ways, including Arizona-based commercial payvider Banner|Aetna.

Since launching in 2017 as a joint venture between Banner Health and Aetna, a CVS Health company, Banner|Aetna has become the fastest growing health insurer in Arizona. As 50/50 equal partners, both parent companies share financial rewards and risk. And their payvider model has demonstrated some distinct advantages over traditionally adversarial payer-provider contracts.

“By having a joint venture, you can leverage where each entity has the underlying expertise,” said CEO Tom Grote. For Banner|Aetna, this means Aetna manages the operational aspects of the health plan like paying claims, billing, and customer service. Banner Health is responsible for utilization management as well as the joint venture’s “performance network,” which is a group of contracted providers who have demonstrated track records of delivering high-value health care.

“With 100% aligned incentives, we can turn over utilization management responsibilities to Banner to get the care decisions closer to the care delivery,” Grote continued. Because Banner already has access to the medical records needed to justify a request, providers get fewer upfront denials.

Banner|Aetna has also been able to quickly implement impactful wellness programs and other member-centric innovations, like a Type 2 diabetes reversal program that helps people manage their condition without medication. “We piloted it, saw immediate results and stood it up within nine months,” Grote said. “The joint venture presents that opportunity because we are smaller and more nimble.” While Aetna has more than 20 million members across the entire country, Banner|Aetna has 415,000 members in one market.

A key benefit of the payvider model is demonstrated improvement in cost and quality metrics, thanks to its performance network, which generates up to 14% savings among enrolled members. Grote attributes these results to metrics such as better member compliance with using medications like beta blockers, and a higher percentage of members with Type 2 diabetes getting their hemoglobin A1C levels below 8%.

Even though Banner|Aetna’s results are impressive, Grote says the payvider model is not a one-size-fits-all solution to address continued issues with a lack of quality, accessible care in the U.S. The key requirements needed to form a successful joint venture insurance company are rare — both companies need capital to invest in a long-term venture, they must build on a foundation of deep trust and collaboration, and truly commit to population health and value-based care. “It can’t be just window-dressing,” he said. “You really have to believe in it. And it can’t just be the value-based care the leader believes in, but the CFO has to believe in it, and the system has to believe in it.”

Grote notes that internally, “there are going to be people who run a service line or have responsibility for driving revenue through certain avenues, and the things we do in value-based care are not going to necessarily align with their goals.”

Looking ahead, Grote predicts the value-based care movement will advance primarily through contracts between payers and providers rather than joint ventures. Still, a payvider model like Banner|Aetna shows that collaboration between payers and providers is possible and can drive a better member experience in health care.