The Exec: CMO Dr. Cathy Moffitt Talks UM at Aetna

The medical leader details how one payer practices utilization management.

For our series The Exec, Dr. Cathy Moffitt — SVP and Aetna Chief Medical Officer at CVS Health — talked 21^st century utilization management with HealthLeaders. The conversation included what UM involves, how it’s changed and how specifically it’s practiced at Aetna, a CVS Health company.

HealthLeaders: What is the role of utilization management in the healthcare delivery system?

Dr. Cathy Moffitt: I believe that utilization management absolutely has its place in securing the right care at the right time, for the right reason. My department is really guided by the Quintuple Aim — health equity and workforce well-being are our North Stars in addition to quality, experience, and cost. We all have a responsibility to be mindful of the enormous cost of care, especially low value or unnecessary care.

HealthLeaders: What are some UM examples that demonstrate how Aetna helps members receive the right care at the right time?

Dr. Moffitt: This is something I'm passionate about. I have been in the payer space now for more than 20 years, and I spent a lot of those years as a medical director actually reviewing utilization cases on a daily basis. I can give you a number of examples where we have really enhanced the quality of the care.

Let's focus on member experience. As a medical director reviewing cases for medical necessity on almost a daily basis, I found opportunities to communicate with the treating physicians. I remember a case where our member had a gastrointestinal bleed with coagulation levels that were abnormal. The patient had been in the hospital for a urinary tract infection, and they were given Ciprofloxacin at discharge which is usually a good drug for UTI.

The problem was, they were also on Coumadin, and there is a drug-drug interaction between Coumadin and Ciprofloxacin. As an infectious diseases doctor. I looked at that and immediately said, Oh no! I reached out to the prescribing provider and rather than receiving it as an annoying call from a payer, he was extremely grateful.

HealthLeaders: Talk more about the payer role in this . . .

Dr. Moffitt (continuing from above): Those are the kinds of things where we lean in, in the interest of the member and really try to enhance safety and improve quality . . . We don't practice medicine, and we don't directly give medical advice, but we're in a situation where we can help point out perhaps some care opportunities through that experience.

In the broader sense, utilization management does allow us to look at the case holistically: Does this person need discharge planning? Do they need home health? Do they need durable medical equipment to go home? Do they need care coordination? Do we need to refer them to one of our complex care managers? And if we weren't there to do this in real time . . .?

A lot of utilization management occurs historically post review, post service — which doesn't give you that sweet spot, that magic moment where you can get in there and get involved to help members receive appropriate care. A lot of people would not receive real-time care coordination [or] receive navigation services that we feel that we are able to provide . . . So rather than a retrospective review, pre-certification or pre-service authorization, we feel, enhances the safety and the quality of the care.

HealthLeaders: What are the components of Aetna’s specific approach to UM?

Dr. Moffitt: Overall, we feel that we bring the best medical evidence and clinical leadership that we can. During the decision-making process, our medical directors are not thinking of cost; they are only focused on whether something is medically necessary and in the best interest of the member. That is something that we do rigorously.

In terms of expertise, every medical director who renders a decision at Aetna is board-certified, currently and continuously, and in an ABMS or AOBMS medical specialty. We also have a number of subject matter experts who are specific to things, like spine surgery.

We also focus on evidence-based medicine. When a decision is truly aligned with the best medical evidence, we are able to render a determination that this is safe, effective for the member, and it won't be deleterious to them.

Finally, there are our regulatory, policy and research efforts. We do endeavor to help members receive appropriate care. In addition, healthcare spend is at least 72.3% of the country's gross domestic product. I think we have a role there, but the way we do is to look very, very diligently at the clinical evidence. We have over 800 clinical policies that we rigorously maintain. We update at least annually with peer-reviewed journal articles and the standards of practice, both regionally and nationally.

HealthLeaders: How has payer UM evolved?

Dr. Moffitt: [speaking to transparency and communication] We are very committed to transparency with both our providers and our members about the evidence that we bring to the decisions that we make. All of our policy bulletins are publicly available. They're published on the internet and anyone who needs to look at one can pull one out in just a moment and look at the standard evidence base that we are using to make decisions.

I think we are also working very hard in the industry to make sure that not just providers understand this, but that our members do too. We're constantly looking for opportunities to communicate our decisions to members. Clearly and transparently to help them get the best understanding of this and the best path to care.

HealthLeaders: How are you leveraging technology, including AI, to execute your UM strategy and serve members?

Dr. Moffitt: First, we are adamant that we never automate medical necessity denials. Any denial that comes through is always personally reviewed by a board-certified medical director. The only exception for medical necessity is an administrative denial for lack of information.

We need to optimize the experience that both providers and members have as they’re going through that process. We are looking continuously at ways to improve that experience through more automation of approvals. Things that can be approved, we are working diligently to try to make sure that more and more of them are approved and that providers for those services can go on onto their provider portals, get the necessary information, and receive an approval in real time. That is a very important aspect of optimizing the utilization management process.

By the end of the year, our intention is to automate about 30% of the services that come to us.

Here, using our historical data helps us understand when services are submitted but rarely denied. We call this provider differentiation, finding those providers who are aligned with the same medical necessity clinical evidence that we are using, which is standard evidence.

HealthLeaders: Provider differentiation and things like preventing negative drug interactions seem very relevant to not only UM but also to value-based care . . .

Dr. Moffitt: As someone who has been in this industry for over 20 years, I believe with all my heart that the best way to line up all of the priorities — cost, quality, access, equity, and workforce — is to have meaningful engagement with providers.

This is not idle theory and at Aetna, this has been proven out in a number of ways.

Dr. Moffit provided the following statistics for members under the care of VBC versus FFS providers in 2020:

• 57% more members achieved blood pressure control
• 8% fewer hospital admissions for commercial members
• 49% more diabetic Medicare members achieved HbA1c control and 7% had fewer hospitalizations

These are meaningful, meaningful tools that both payers and providers believe in, and we are very committed to expanding.