In this case study, we will tell you how Aetna, specifically the Aetna-GA market worked successfully with IPG, in conjunction with Kearny Street Consulting, Pinnacle Orthopaedics and several of their leading ASC partners to implement a targeted plan to shift outpatient procedures to an optimal cost and quality setting.
Health plans are faced with finding new ways to contain medical expenses on behalf of their membership. One key area driving those expenses is surgical procedures, more specifically those surgeries requiring an implantable device, such as knee replacement and rotator cuff surgeries just to name a few.
Not only has the utilization of those procedures gone up, but so have the relative costs. US demand for implantable medical devices is forecast to increase 7.7% annually to $52 billion in 2015, with orthopedic implants forecast to rise 8.8% annually. The spinal surgery device market is expected to grow at a Compound Annual Growth Rate (CAGR) of 4% from $6.5 billion in 2011 to $8.7 billion in 20181.
In addition, a mere 15% of implant procedures are performed in an ambulatory surgery center (ASC) outpatient setting. On average, there are over 2,000 unique Site of Care eligible procedures and almost 500 implant-related Site of Care procedures capable of being performed in an ASC environment2. Recently, more complex procedures such as total joint replacements and spine procedures are safely and more affordably being performed in ASCs. However, due to fee differentials, many of these procedures are redirected away from an ASC location to hospitals or HOPD’s. The higher cost associated with the procedure being redirected away from ASCs are passed onto the health plan, employers and members.
“The IPG-Pinnacle model is a great success story that we are replicating across Georgia and other Aetna markets to promote the appropriate coverage and reimbursement structure that supports eligible procedures, like total joints and spine cases to be delivered in the optimal cost and quality setting. Working with IPG allows us to identify those eligible facilities, surgeons and procedures that can be done in a more affordable setting thereby helping us manage our surgical costs to the benefit of our members.”
Director of Network Management