From Medicaid to Medicare: Lessons in managed care from Aetna's chief medical officer

Cathy Moffitt, MD, has been a senior vice president at CVS Health and chief medical officer at Aetna since late 2022. She sat down with Becker's to discuss the organization's medical strategy as older adults seek services post-pandemic and the cost of care continues to rise.

Question: Aetna saw major growth in its Medicare Advantage segment in the last few months. How would you describe the value of managed care in 2024?

Dr. Cathy Moffitt: We are very excited about our growth and the opportunity to provide older adults with affordable and convenient care. We made significant improvements and investments in member experience over the last year, which is evident in our strong 2024 Star Ratings — 87% of Aetna's Medicare Advantage members are now in plans that are four stars or higher. In addition to providing all the benefits that traditional Medicare allows, we overlay that with good initiatives to improve care management, especially in our dual eligible space. We are serious about managing care and identifying needs through utilization management, customer service and member communications. We help with discharge planning after the hospital, needs around getting medications and durable medical equipment, and we help address gaps in care — especially now that CVS is affiliated with Signify Health and Oak Street Health.

Q: You began your career in managed health overseeing Medicaid and long-term care programs. What lessons have you brought to Aetna?

CM: Before managed care, I used to be a pediatric emergency physician treating a large Medicaid population in South Florida. Children come to the emergency department when there are gaps in care that need to be addressed or when they need episodic rescue therapy, such as asthma. Young patients would come into the ER repeatedly, but they were never managed outside the ER by either a primary care provider or an asthma specialist. They were never put on regulator therapies or medications that the NIH would recommend. One of the first things that I did when I got to the managed care environment was working on disease management that aligns with evidence-based guidelines so that we can help people get the right care. I fundamentally believe that helping people adhere to evidence-based guidelines will improve their health and improve the cost of care. It's one of the fundamental things that I brought to this job. The difference now is that I'm not just working with one patient at the bedside anymore, but literally working with millions to try to improve the care that they receive.

Q: How do you strike the balance between controlling care costs and not overburdening providers with administrative processes?

CM: Not all services should be automatically approved. It's in the best interest of the patient that the care prescribed be reviewed and be based on medical evidence and safety. At the same time, a lot of stakeholders, providers and patients see the process as cumbersome. We've invested a lot in this through new technologies (EHR- and automation-based efforts) to try and get the best of both worlds that ensures our members receive safe, evidence-based care at the right time and for the right reason. We also try to limit the hassle factor by reducing the burden of prior authorization requirements, which we're lighter on than some of our industry colleagues. Nevertheless, we're trying to be very thoughtful and intentional about things such as uncommon services or providers that have a strong track record of having services approved. We fundamentally believe that this brings value, safety and enhances the quality of clinical care, but we're very aware that we also have a responsibility to try to mitigate the administrative burden to our constituents. 

Q: Can you share an overview of Aetna's medical affairs strategy and top priorities for the remainder of this year?

CM: After the pandemic, I think most healthcare experts worry about the basic average health needs of our population, especially Medicare members and people who went without care for a couple of years. In some ways, they now present sicker than they used to, and they also are in need of catch-up services, both preventive and therapeutic. We are extremely committed to helping them close those gaps in care. I also want to mention behavioral health specifically because almost all of the segments that we serve have an increased need for behavioral health services. We're working hard to enhance access through brick-and-mortar providers and telemedicine; Signify and Oak Street are essential in this journey.

Q: Is there a member's story that has stuck in your mind recently?

CM: I have many such stories, but one notable example happened when I was a medical director. I was reviewing an inpatient case for someone who came in with a GI bleed. I looked back at their previous admission and saw they had been placed on a certain antibiotic for a urinary tract infection. This patient was also on a blood thinner that has a bad drug interaction with the antibiotic, so I called the hospital and spoke to the attending physician to stop one of the drugs. It wasn't a gotcha moment, and I think the provider was very grateful. I felt good about that because it's representative of how we partner with doctors and patients every day and how the healthcare delivery system can be another set of eyes for evidence-based care and making things better for everybody.

Q: Final advice for industry colleagues looking to improve clinical quality and integrity for members?

CM: It's a very noble venture, and I encourage them to keep it up because we badly need it. Aetna is regularly reviewing and updating all of our clinical policies and procedures. We measure ourselves through HEDIS, Stars and other outcomes to target gaps in care, and we feel that updating, adjusting and improving our clinical practices is critical to ensuring patient safety and quality of care. We're happy that many in the industry are very thoughtful and intentional around this, too.

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