Aetna targets costs, expands tiered network of specialists

Aetna is planning to expand the availability of a "tiered" insurance product that rewards patients for choosing physician specialists who are classified as being cost-effective and clinically superior.

The Hartford, Conn.-based insurer's Aexcel product will be offered to employers in Connecticut, Atlanta, Houston, Los Angeles, the Washington, D.C., area and metropolitan New York, starting in January 2005. Since last January, it has been available to employers in Dallas-Fort Worth, northern Florida and western Washington state, including Seattle.

The range of specialists in the Aexcel network also will be expanded for 2005. The company said the network will be comprised of cardiologists, cardiothoracic surgeons, gastroenterologists, general surgeons, ob-gyns, orthopedists, otolaryngologists, neurologists, neurosurgeons, plastic surgeons, vascular surgeons and urologists. Aetna will analyze specialists' claims data using its own database to create a sub-network of doctors whose cost-efficiency and quality both are deemed to be best. Clinical performance measures are based on rates of hospital readmissions, rates of unexpected adverse events, and total cost of care in and out of the hospital.

The reimbursements to doctors in the Aexcel network are not any higher than to doctors in other Aetna networks. But Aetna subscribers who select doctors from the Aexcel tier do get financial rewards, which depending on the plan design, could be lower deductibles and/or co-pays, higher coverage levels, or a combination of incentives, the company said.

Since Aexcel was rolled out to plan sponsors in the original three markets, 64,000 employees working in 10 companies have enrolled, said Don Liss, MD, Aetna's senior medical director. That represents less than 1% of Aetna's total membership of 13.3 million. The product is being marketed to large, self-insured companies, Dr. Liss said. In almost all cases, the companies that have adopted Aexcel have offered it as one insurance option and not as the sole plan available.

Primary care doctors are not being separated into an Aexcel tier. Aetna believes much of the recent escalation in health care costs stems from technology and medications employed by specialists, Dr. Liss said.

The Aexcel approach has been "fairly well-received by doctors," he said, adding that Aexcel has prompted some physicians to ask questions about how Aetna measures their performance relative to peers. "It's pretty eye-opening," he said. "Doctors in practice get very little feedback regarding their performance."

Although Aexcel is being marketed as a tool for employers to reduce their health expenditures, Dr. Liss said it's too early for Aetna to have any specific information on whether employees enrolled in the plan actually are spending less.

Manzoor Abidi, MD, president of the Medical Society of New Jersey and a neurologist in Maple Shades, N.J., said a plan such as Aexcel might not be appropriate for northern New Jersey, which already is experiencing a shortage of doctors due to high liability insurance rates. "It's going to reduce access to physician choice in certain areas," he said. Aetna, however, says it allows specialists to be part of the Aexcel tier if their exclusion would lead to a scarcity of specialists within a geographic area, even if they normally wouldn't qualify under cost-effectiveness and quality standards.

Dr. Abidi also said he has not yet seen details about the product from Aetna, and is concerned that it might create undue pressure on doctors to keep down the cost of care.

"If reduction in the cost means reduction in the quality of care, I'd be totally opposed to it," he said. "The question becomes how much are you going to push cost-effectiveness."