2 min read November 2022 — Raleigh-Durham’s healthcare landscape is as dynamic as its demographic and economic growth. James Day, market leader and general manager for the Carolinas of global health services company Cigna, spoke with Invest: about its work in three particular areas: healthcare affordability, strengthening the mental and physical health connection in the provision of care and access to care.
What successes has Cigna achieved over the past year?
We are incredibly well positioned to accelerate our accountable care organizations (ACOs) in Raleigh and in Durham. This is not new to Cigna; we have had our ACO arrangements since 2008 and we were the first to market them. We are proud to announce that WakeMed, Duke and UNC are all in collaborative partnerships with Cigna, which means all of the hospitals in the Triangle and 97% of the primary care physicians in the Triangle are in a value-based relationship with us. It is a true differentiator from our competition. In parallel, we have a proven track record in lowering the cost of care and improving quality.
Even though our healthcare landscape is ever changing, Cigna focuses on being flexible and shifting its lens to the various needs of the provider, the health system, the community and, most importantly, our members. Throughout the pandemic, our value-based programs did not remain stagnant. We made those necessary shifts in growth expectations through COVID and beyond. We made it a priority to keep our finger on the pulse of the healthcare environment around us, not forgetting or alienating our partners, but focusing on how we can grow with them. Our growth in this market would not be what it is without our hospital systems partnerships.
Why are ACOs important in today’s healthcare landscape?
ACOs are a partnership between the insurance company and the hospital system or the primary care physicians themselves. We take industry data and provide information to those systems on the members that we cover at their facility. We have an embedded care coordinator, somebody who works within the hospital system reviewing and analyzing Cigna patients, to ensure that those individuals have higher quality, lower costs and better outcomes at those facilities compared to the rest of the market. We incentivize and create different programs with those providers to ensure they focus not only on Cigna-covered members but how they are accessing care and readmissions. Each ACO is different because we need to meet our hospital partners where they are, to ensure they provide the best care and lowest cost to our customers. It is an authentic movement away from the fee-for-service structure we previously had in the industry and toward better health outcomes.
Have you seen more of a deliberate effort to create an equitable healthcare system in the Triangle?
We are constantly innovating to offer new technologies and capabilities to our clients and customers to drive health equity. One of the challenges that we see around diversity, equity and inclusion (DEI) is making sure that they are not just talking points – this is part of what we do and we are dramatically innovating in this space. We had a large local government that went to RFP and scaled DEI 25 percent of their grading criteria. We scored 100 percent on that test and their current incumbent care scored zero. Through our diversity and inclusion efforts, we aim to advance an inclusive culture that powers diversity, strives for equality and shows the values and differences of talents that we bring as part of our mission.
How is Cigna tackling controlled costs to foster healthcare affordability?
There are three key forces that are fundamentally changing the healthcare landscape. First, the acceleration of pharmaceutical innovations: if you ask every client that we have, not only in the Carolinas but across the country, what they are most excited about and what they are most concerned about, they’ll tell you it’s costs, which are primarily pharmacy-based. When I started in insurance over 15 years ago, pharmacy spend was between 5% and 10%. It is bumping up to over 30% in 2022. With gene therapy medications already approved and more coming down the pipeline with several that have just been approved this year, we know pharmacy costs – especially specialty pharmacy and gene therapy medications – have fundamentally changed. Our healthcare environment is exciting because you have disease states that are now actually curable through these pharmaceuticals and therapies.
The question for employers becomes how to cover these medications without bankrupting your company. Some of these medications cost from $1 million to $2.5 million. Anticipating the rapid increase in pharmacy innovation and expense, in 2018 we purchased Express Scripts, the industry’s best specialty pharmacy management company. With this acquisition, we created a program called Embarc Benefit Protection® which allows access to three FDA-approved gene therapy medications. We subsidize the cost across our entire portfolio of clients, only charging them 99 cents per employee per month.
Second, we have recognized the need for greater recognition of the connection between mental health and physical health. Healthcare is not in a silo. For example, someone with a condition like diabetes is far more likely to have a mental health condition than individuals who lack a physical ailment. The inverse can be true as well. An individual with a mental health condition is far more likely to have a physical condition. Moreover, our diabetic populations are far more likely to ration their insulin, which is why we have created programs and services that cap the cost of insulin for our customers at $25 for 30 days’ supply. We were the first in the industry to do that.
The third way we’re tackling costs is by responding to the rapidly changing ways customers access care, not only with telehealth or virtual care, but also with specialty pharmacy management. We have some key initiatives that we are going to be launching in 2023, specifically addressing access to specialty medications and ensuring our customers have the most collaborative and best care for their specialty medications.
What is your outlook for Cigna and the healthcare landscape in the Triangle over the next couple of years?
It really comes back to a couple of key tenants in our core goals of making healthcare affordable, predictable and simple, and improving the health, well-being and peace of mind of the people we serve. How individuals access care today is very different than prior to the pandemic, which makes our coordinated approach to whole person health with a specialized focus on behavioral health all the more important. We recently launched Your New Growth Plan to differentiate us as a partner of choice. We see this acceleration now more than ever, especially with the focus from an organizational standpoint to continue to grow with the Carolinas. We will continue working with our provider partners and our clients to create innovative solutions to cater to their needs.
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