This week's expert is Randall Krakauer, MD, Medicare medical director for Aetna.

Question: How does Aetna's embedded case management complement the new accountable care organizations (ACO) models being developed?

Response: (Dr. Randall Krakauer) To some extent, these are ACOs, depending on your definition. Of course, the population is all Aetna Medicare Advantage. You might say in that context that they are not ACOs, but if you’ll accept that as a feature of the definition, you can say that we have a number of ACOs that are up and running and producing good results already.

In order to transition these to a fee-for-service (FFS) Medicare population, there are a few barriers. One is the data barrier: the data flow is probably going to be somewhat weaker in a FFS Medicare population than in our own. We are dealing with an enrolled population in a contracted network, which is certainly an advantage over a FFS Medicare population.

Also, we’re dealing with some metrics that we can follow and mutually agree upon. In the case of the federal program, there are some difficulties with the reporting requirements that could be costly; the infrastructure that’s going to be required. Frankly, the benchmarking issue is a serious problem; that is, if you’re using your own group’s previous three years’ experience as your benchmark in which to measure success, that means that any group that has already invested the time and effort and commitment into doing a good job now is to a very large extent excluded. And that’s a significant problem. Our very best groups that are doing the best for us are not candidates for the ACO program largely for that reason. But there are groups that we are working with that have potential for the regular CMS/ACO program.

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