Aetna Scales Clinical Collaboration Program

Aetna, a CVS Health Inc. company, announced its plan to scale the Aetna Clinical Collaboration (ACC) program to ten hospitals by year-end 2025. This strategic expansion is underway with major medical institutions including AdventHealth Shawnee Mission, Houston Methodist, and WakeMed Health & Hospitals. The initiative comes as the healthcare sector prepares for significant regulatory changes, particularly a new Centers for Medicare & Medicaid Services (CMS) rule, effective fiscal 2027, which will count Medicare Advantage members in hospital readmission penalty calculations.

Program Details and Objectives

The ACC program integrates Aetna nurses directly with hospital staff, fostering a collaborative environment to support Medicare Advantage members during the vulnerable post-discharge period. The primary objectives are to enhance care outcomes for Aetna Medicare Advantage members, specifically targeting a reduction in 30-day readmission rates and emergency room visits. Concurrently, the program aims to alleviate the administrative workload for hospitals and their clinical personnel.

Hospital readmissions are a persistent challenge, particularly among older populations, with nearly 20% of Medicare-insured patients experiencing readmission within 30 days of discharge. Early program indicators show substantial member engagement, with approximately one in four participating members actively collaborating with an Aetna care manager. Once operating at full scale, the ACC program is projected to achieve a five percent reduction in year-over-year 30-day readmissions and hospital length of stay.

Market Positioning and Financial Implications

Aetna's proactive expansion of the ACC program strategically positions the company within the competitive Medicare Advantage Market. By assisting partner hospitals in mitigating the risk of substantial financial penalties under the forthcoming CMS rule, Aetna aims to fortify its long-term financial performance and expand its market share. For hospitals, the new CMS rule presents a considerable financial exposure, potentially leading to payment reductions of up to 3% for higher-than-expected readmission rates. Programs like Aetna's are designed to alleviate these pressures.

Data from fiscal year 2023 indicates that 74.7% of eligible hospitals faced penalties under the Hospital Readmissions Reduction Program (HRRP), totaling $320 million and averaging a 0.43% payment reduction. The inclusion of Medicare Advantage patients in future calculations is projected to increase both the percentage of penalized hospitals (estimated at 75% to 82%) and the average penalty to 0.44%.

Expert Perspective

Dr. Ben Kornitzer, Senior Vice President and Aetna Chief Medical Officer, underscored the critical nature of the discharge process:

"Hospital discharge is one the most important—and vulnerable—moments in a patient's journey. Patients may be managing new diagnoses, complex medications, and follow-up needs, all while coping with the stress of transitioning back home or to a new facility. By embedding Aetna nurses within hospitals, we're partnering with care teams to ensure that members are supported every step of the way and have the right services to stay well and avoid complications that could lead to readmission."

This sentiment highlights the program's focus on comprehensive patient support during a crucial period.

Outlook and Future Expansion

As a leading Medicare Advantage health plan provider, serving over 4 million members aged 65 and older, Aetna plans to continue expanding the ACC program across its network through 2026 and beyond. The company is also implementing a similar model for its Commercial business. This sustained investment indicates Aetna's commitment to enhancing care coordination and its strategic foresight in adapting to an evolving regulatory landscape within the Healthcare Sector.