SAN FRANCISCO — Aetna's performance-based physician networks are a way to keep costs down and let patients know which physicians offered the best, most cost-effective care, according to Dr. Gerald Bishop, senior medical director for Aetna's West division.
Preferred provider networks have been the subject of legal challenges around the country. Physicians have claimed that the networks use inappropriate methodology to rate performance.
In 2007, New York Attorney General Andrew Cuomo struck a settlement with several insurers in which they agreed to publicly disclose rating methods and how much of the ratings is based on cost, and to retain an independent monitoring board to report on compliance. Aetna was one of the first insurers to sign on, and has continued to comply, said Dr. Bishop at the AHIP Institute, at a conference sponsored by America's Health Insurance Plans.
He noted that Aetna reviews and updates its provider list every 2 years and notifies each physician if there has been any change in status. Physicians have the opportunity to appeal if there is an error—before any data are made public, he said.
Aetna also encourages physicians to submit relevant information from medical records if they have a question.
Aetna first began developing its Aexcel network in 2002 to mitigate rising costs, ensure patient access to specialists, and find a way to recognize the variations in costs and practices in each market, said Dr. Bishop. Aetna found that 12 specialties represented 70% of spending on specialists and 50% of overall spending: cardiology, cardiothoracic surgery, gastroenterology, general surgery, neurology, neurosurgery, obstetrics/gynecology, orthopedics, otolaryngology, plastic surgery, urology, and vascular surgery.
When considering which physicians were eligible, Aetna looks at the number of Aetna cases managed over 3 years and uses nationally recognized performance measures to gauge clinical performance. Physicians who score statistically significantly below their peers are excluded.
The company also uses the Episode Treatment Group methodology to evaluate 3 years of claims for cost and utilization patterns. A physician is considered efficient if his or her score is greater than the mean for that specialty and market, said Dr. Bishop.
The network now exists in 35 markets, covering 670,000 members. Aetna members in most areas can log onto a secure patient Web site and see costs for various procedures and information on why his or her physician has been designated a preferred provider in the network. Dr. Bishop said Aetna has determined that physicians in the Aexcel network perform 1%-8% more efficiently than their peers. A client could save 4% of annual claim costs if its covered workers used the network, he said.