Last week I had the opportunity to attend the National Association of Accountable Care Organizations Spring 2019 Conference in Baltimore, Maryland. Below are my top takeaways from the conference from sessions and speaking with other attendees.

1. Payment reform is a top priority.

CMS Administrator Seema Verma opened the conference with emphatic assurance that re-orienting our healthcare system around value, with a focus on payment reform, remains an urgent priority of the current administration. Strategies they intend to pursue include: promoting a multipayer environment by synchronizing models with private plans; encouraging states to align Medicaid with new payment models; improving risk adjustment and benchmarking methodologies; and empowering patients to choose high-value providers through greater transparency of cost and quality information.  

We can also expect continued efforts to promote interoperability and patient control of data, and to address regulations that are “barriers to value.” She specifically cited “outdated” aspects of Stark Law, and building on the progress of the Meaningful Measures Initiative which reduced the quantity of measures by 20% last year.


2. Primary care is a focal point for new payment models, but many questions remain.

Conference attendees were buzzing about the recent announcement of two new payment models under the CMS Innovations Center. The “Direct Contracting Model” envisions a capitated up-front payment for primary care services amounting to 7% of the expected total cost of care for the Accountable Care Organization’s (ACO) patient panel, while the ACO takes risk for 50% of savings or losses on total cost of care; or a full up-front capitation payment for total cost of care if the ACO takes risk on 100%. A third option is in development, where the ACO would take full risk and accountability for beneficiaries in a geographic region.

Separately, the “Primary Care First” model will be available in 26 regions across the country. In this model, primary care services will be funded through an up-front risk-adjusted population-based payment to primary care practices, alongside a flat rate reimbursement for each office visit (regardless of complexity), and a quarterly incentive payment based on acute hospitalization rates. A practice would have the opportunity to increase practice revenue by as much as 50% by keeping patients out of the hospital, or face a penalty of up to 10% if hospital use rises. ACO experts fear that the “devil is in the details” as we await further clarification of benchmarking methodology.  

3. The Value-Based Payment landscape is getting more complex.

CMS continues to pursue payment reform for specialty care as well, and representatives from the American Hospital Association and American Medical Association emphasized the importance of physician leadership in the design of new models. Interactions between models can be quite complex. For example, if a patient in an ACO has an episode of care covered under a bundled payment program, does one model win over the other for patient attribution? For partial costs or all costs? Do bonus payments made under one model count as costs to the other? One speaker described the need for a “patchwork of incentives to bind everyone together,” while acknowledging that getting the mechanics right is the tricky part.

Meanwhile, ACOs with specialist members are devising innovative ways to gain specialist engagement in the work of the ACO, incentivizing better referral communications, more efficient care pathways, and reduction of care variation or low value services. CMS Administrator Verma put it this way, “The road to value must have as many lanes as possible.”

4. ACOs are gaining traction and success in commercial markets.

Several presenters discussed expansion of ACO focus into self-insured populations and  commercial value-based contracts, with experienced ACOs taking on greater levels of financial risk and achieving financial success. Commonly cited challenges include: less visibility into historical performance to inform contract design; reliability and quality of payer data; misalignment of quality measures across contracts; and difficulties getting sufficient number of lives in the ACO for smaller payers.

Commercial pharmacy spend was seen as both a challenge and an opportunity. Some ACOs have been able to generate substantial savings through pharmacy management programs, while others felt that payers should not put providers at risk for drug costs when the payer has much more effective levers for controlling costs through drug price negotiation and benefit design. On the bright side, there were examples of commercial payers engaging ACO input on value-based insurance design, and making strategic investments to address social determinants of health.

5. Opportunities in Post-Acute Care

While some themes this year around optimizing post-acute care were familiar, such as managing skilled nursing facility (SNF) length-of-stay through use of preferred networks, others were more novel, such as use of SNF 3-day stay waivers to achieve lower hospital costs. Preferred network engagement tactics included the use of technology and ACO liaisons to collaborate in real time with skilled facility partners on individual patient care plans and discharge planning.

In one region, multiple ACOs have collaborated to develop uniform standards and protocols with preferred SNF partners. ACOs are leveraging cloud-based communication tools to share information with SNF partners (such as ACO patient identification and Physician’s Orders for Life-Sustaining Treatment (POLST) forms) and receive facility admission, discharge and transfer notifications. One presenter cited a 14% reduction in SNF spending and better care coordination resulting from these efforts.

SNF 3-day waivers allow ACOs to identify appropriate patients for skilled facilities admissions without the 3-day “qualifying hospital stay” that Medicare traditionally requires. ACOs have leveraged the waiver for patients in the emergency department to avert a hospital stay, or to achieve a shorter hospital stay. Several attendees voiced that use of the waiver has been lower than anticipated due to operational and engagement challenges. We have not seen outcomes data, and very few tactics or strategies were offered for using the waiver directly from the community or office setting to avoid the hospital visit entirely. Still, discussion of SNF waivers was generally enthusiastic and optimistic as groups gain experience with their use.   

I recently attended the 2019 National Association of Community Health Centers (NACHC) Policy and Issues (P&I) in Washington D.C. The energy at this year’s event was buzzing with positivity, as many advocates felt confident that the message is hitting the right hearts and minds, and that long-term stabilization of community health and affordable care will be a legislative priority in this country.

I’m sharing five important themes from the conference, along with some examples of how health centers are making progress on critical issues.

Stabilization through Sustained Funding and Shared Savings

An announcement from George Sigounas, Administrator of the Health Resources and Services Administration generated a lot of excitement: a $200 million dollar funding opportunity will soon be available for health centers to focus on the integration of behavioral health and substance use disorder in primary care. Here’s a link to read more about this exciting news.

The 2019 Issues: Keeping Top of Mind

The key issues at the 2019 P&I Forum were focused on Health Resources and Services Administration (HRSA) and national health centers’ shared goals including reducing infant mortality rates, spending current resources on the opioid epidemic, eradicating HIV, and promoting healthier childhood nutrition and activity to reduce obesity. Health centers across the country are working on these key indicators of national health, with an eye on prevention. From grants to community programs, look for movement on these issues in the upcoming year.  

Community Health Centers are Meeting Patients Where They Are

When talking with other attendees I heard about health centers starting mobile services to better engage with communities and homeless outreach programs. One of the trends that got my attention is the expansion of school-based services. Some of the school-based services that are now available to students include behavioral health, primary care, and providing individualized services to help with issues students may face at home. Some health centers are also offering school-based dentistry programs, and often, these services are expanded to serve the entire family.

Leadership Is Moving from Volume to Value

Community health centers are making headway toward value-based care, whether or not they are a part of an Accountable Care Organization (ACO). Many of the health center leaders that I spoke with said that they’re very interested in taking the next steps to start generating more revenue for what they’re already doing. Health centers are beginning Care Management programs and training Care Managers to get up to speed and help high risk patients.

I also learned that many health centers have integrated behavioral health, dental clinics, and pharmacies to work together at the same location and provide “one-stop-shop” care for their patients. Because prevention is a key focus  (with the goal of keeping patients out of the ER), this “one-stop-shop” approach promotes self advocacy, better health and lower costs—the fundamentals of value-based care.

Sharing the Mission

The two core focuses of the conference this year were 1. reimbursement for services health centers are already doing, and 2. sustainability of funding. Transitioning to value-based care will allow health centers to get reimbursed for the care they are already providing. For example, comprehensive wellness visits and prevention, including head-to-toe healthcare and helping patients navigate their communities to meet their needs that are both health and socially related. Because value-based care is a more sustainable reimbursement model than fee-for-service,transitioning to the model can help health centers control costs and have more access to funds through shared savings.

Throughout the conference I learned so much about the key areas of focus for 2019, and I’m excited to see the ways that community health centers will continue to create programs that improve health in their communities. I believe that more health centers will enter into value-based care and will continue to expand the location and types of services they offer to better serve patients, while improving community health. I’m excited for next year’s P&I Conference to see what progress has been made and how health centers are incorporating value-based care in their communities.

Click here for more information about how Aledade partners with community health centers on value-based care.

Recently, Aledade announced a new agreement to expand value-based care in Delaware, West Virginia, and Utah. Aledade has now signed 24 value-based agreements covering commercial fully insured, self insured, Medicare Advantage, and Medicaid lives. Our providers now have over 260,000 attributed patients in these contracts (in addition to over 300,000 lives attributed through the Medicare Shared Savings Program). We are proud to be bringing high-value care to more people across the country.

PUTTING INDEPENDENT PRIMARY CARE PHYSICIANS FIRST

Aledade’s primary goal is to maintain independent practices as the foundation of our health care system. We help independent physicians succeed in value-based care arrangements. We start by enrolling them in the Medicare Shared Savings Program, but our physician partners want to provide high quality care to all of their patients regardless of their insurance. So, simply signing up for a Medicare ACO is not enough. We discuss with our physicians their goals and then find partnerships with other payers that align with those goals.

By taking a practice-centric approach, we ensure that the physicians in our network have a voice at the negotiating table with payers. Historically, primary care providers, particularly those in small and independent practices, have not had the opportunity to voice their opinions to national payers and, therefore, had little control over the design of  through value-based incentive programs. We’re changing that. And our payer partners welcome the opportunity to hear from primary care providers committed to transforming the care of their patients.

THE RIPPLE EFFECT

Part of what makes the Aledade approach to payer partnerships unique is the ripple effect of value-based care throughout the physician’s patient population. Every time we sign a contract, the payer agrees to share claims data with Aledade and our partner physicians; for the first time, our providers can see in the Aledade population health tool, our “App,” the opportunity to improve the health and cost of their patients. That’s important because it allows physicians to practice medicine the way they have always wanted to. When we establish ACO agreements with payers, we enable physicians to apply new workflows to these payer’s members. Providers can then use data-driven insights on more of their patients and be properly rewarded for all the value they are generating. This allows true practice transformation with benefits for payers, providers and patients.  

EVERYONE WINS

Our commercial contracts are good for doctors, good for patients, and good for society, because these contracts may generate revenue when patients get better care at lower cost. Aledade is proud to help align these interests in all of the work we do with practices and health plans.

Payers, physicians, patients, and Aledade all want the same thing—the best possible care at the lowest possible cost. We are excited to partner with Aetna so our providers in Delaware, West Virginia, and Utah are paid for health and cost improvement and not volume. Now begins the fun work of applying our analytics and practice transformation support so the patients who need extra support and care receive it.

For more information about how to join an Aledade ACO, please email us at outreach@aledade.com.

Our healthcare system has evolved to pay for sickness rather than health. Prevention and proactive chronic disease management are reimbursed modestly in primary care, while the majority of costs are accrued in emergency rooms and hospitals after patients have already fallen very ill.

To contest the current ‘wait until you’re sick’ model, Medicare created the Annual Wellness Visit, or AWV, which emphasizes upstream care and enables a more intimate understanding of the patient’s personal circumstances and risk factors.

Rather than focusing on a particular complaint or physical exam, the patient and provider dedicate the AWV to a variety of conversational topics including screenings for depression, cognition, and falls-risk, reviewing medications, optimizing the care team, and understanding end of life wishes. At the end of the visit, the patient receives a personalized care plan with an emphasis on preventive services that will maximize their health outcomes.

Despite this unique opportunity to enhance the patient-provider relationship and prevent future adverse health events, adoption of AWVs has been slow, with only 16 percent of Medicare beneficiaries receiving the service in 20141. In an effort to help the health care community understand the potential impact of these visits—and the need to do more of them—Aledade released a study that quantifies the effects of AWVs on both cost and quality among Medicare beneficiaries in Aledade’s Delaware and Primary Care Accountable Care Organizations (ACOs). The study found that AWVs were associated with both improved performance on clinical quality measures and an annual cost savings of approximately $418 per beneficiary.

We are immensely proud of our Delaware and Primary Care ACO partner practices, and encouraged by the practices who have followed in their footsteps, optimizing their workflows to enable these high-quality visits.

“For me, an Annual Wellness Visit provides the perfect opportunity to step back momentarily from chronic disease management and problem-focused interactions with my patients so that we can engage instead in critically important conversations about prevention and safety.” said Dr. Mathew Weimer, a physician at Valley Health Systems and participant in the Aledade West Virginia ACO.

“While I have always woven these discussions into office visits, I rarely had the chance to focus on these matters clearly, comprehensively, and in a single visit with Medicare patients before I started doing Annual Wellness Visits,” continued Dr. Weimer.

As our population ages, it will be crucial to not only bend the cost curve and improve the quality of care, but to recognize the importance of building a trusting relationship between patients and providers. Solidifying this relationship through AWVs paves the way for patients to be vulnerable and express their healthcare needs—ultimately enabling clinicians to deliver high-value care.

We are hopeful that the experience of our two ACOs, and broader community of physicians, serves as a call to action for primary care practitioners to more rapidly adopt the use of AWVs and encourages policymakers to expand funding for preventive care interventions among the Medicare population.
__________________________

Footnotes

1. Ganguli, I., Souza, J., McWilliams, JM., Mehrotra A. Trends in Use of the US Medicare Annual Wellness Visit, 2011-2014. JAMA. 2017;317(21):2233–2235.

As a care manager, I’m a patient advocate and the first line of defense for keeping high risk patients healthy. My regular calls help build a trusting relationship with these patients so that I can help them control their chronic conditions and prevent any new issues from becoming serious. During my monthly calls with patients, I quickly assess their health concerns and start evidence-based protocols to divert avoidable emergency room visits or unnecessary hospital admissions until they can be seen by their provider. Beyond that, I get to connect with individual patients in a personal way to help them along each step of their health journey.

What follows is a story about the power of these relationships. It’s a story about how I was able to help a patient get through a high-risk situation, in the middle of the ocean, because of the trusting relationship we’d built over time.

Recently, one of my care management patients began experiencing symptoms related to his heart failure while on a cruise ship in the Bahamas – a cruise he was advised not to go on by his cardiologist. Throughout the day the patient had been experiencing dizziness and shortness of breath. During dinner on the formal night of the cruise his symptoms worsened. In a panic, he and his wife called me from the next port.

Building Trust
I wasn’t always the patient’s first call for any healthcare concern. I had been working with this patient since I started at this practice eleven months ago, and it took us time to establish our rapport. We enrolled him in our care management program and began a monthly call to discuss how he was doing and talked through his challenges that could negatively impact his health. When I first met with him his wife was on a month-long visit with their grandkids. One day he came to the office and, very upset, he explained he could not afford his medications and that he was all alone at home. I worked with his primary care physician (PCP) to switch his insulin to a less expensive brand and told him to call me anytime, not to hesitate, and reinforced that I’m here to help him in any way that I can. During these initial conversations about his care, he thanked me over and over again for listening to him and helping him make good decisions about his health. That’s when I knew we were making a connection.

Staying Connected
Three months later, I noticed during our monthly call that he sounded a little off. I called his wife to make sure everything was ok and that’s when she told me what was going on. He was not taking his medications correctly, sometimes forgetting a dose and he had started to increase his alcohol consumption. Right away, I made an appointment for him to come to the office so that we could discuss these new concerns with his PCP. Because of my trusting relationship with the patient we were able to have an open and honest conversation with his care team and develop a plan of care to address the impact of his alcohol use.

A Call During Crisis
It was this relationship that enabled me to extend him a lifeline, even from far away.
When we connected from the cruise port, the patient and his wife were both scared and nervous and had no idea what to do. I reached out to the provider who recommended diet modifications to the patient and to stay on the ship for the remainder of the time. I also made an appointment for him to see his PCP immediately after he and his wife were back on land and I followed up to make sure he attended that visit.

During that appointment, we addressed ways to help get his health back on track. After following the new plan, his health improved!

Lasting Impact
This story is so impactful because it reminds me that Aledade’s care management program works. With support and training from Aledade, care managers across the country are able to help build relationships that keep patients healthier and out of the hospital. That’s what we’re here for – to help patients, even if they’re stuck on a boat in the middle of the ocean.

In communities across Mississippi and Tennessee, a group of primary care doctors are changing health care for their patients, their practices, and society: they are practicing the kind of patient-centered care that inspired them to go into medicine and their efforts are creating measurable value.

The work started in January of 2016 when 16 independent primary care offices across Mississippi and Tennessee took a chance on improving quality outcomes and lowering costs for their patients. These practices teamed up with Aledade to form the Aledade Mississippi Accountable Care Organization (ACO) that is now composed of 22 participants. Aledade partners with independent practices, health centers, and clinics across the country to build and lead ACOs anchored in primary care. As a part of the ACO, member practices work collaboratively and share in the savings they create.

The work paid off. The Aledade Mississippi ACO was successful in earning a quality score of 95% while saving Medicare $9.8 million in 2017. We reduced hospital admissions by 9%, cut unnecessary home health spending by $4.8 million and decreased hospital readmissions by 3%. We were also able to increase the number of office visits performed by primary care providers by 33% and increase the number of transitional care visits performed by 7%. These numbers mean healthier patients receiving higher quality care from their local primary care doctors – doctors who are now better-positioned to sustain their independence.

Utilizing Aledade’s combination of resources, technology, and local support, the practices in the Mississippi and Tennessee ACO have influenced a change in the health care system in our region. Dr. Katie Patterson, of Indianola Family Medical Group in Mississippi, recently stated that the ACO work has allowed her to better care for her patients with the knowledge of what’s happening outside of the office walls. “It’s provided me with greater knowledge of total patient care versus just the snapshot we are given in the office.”

Dr. Stephen Hammack of Premier Medical Group in Mississippi also vocalized the impact on his practice: “I am able to be more proactive about my patients’ needs…and identify patients with needs that may have gone unnoticed previously.”

We are achieving these results through a number of initiatives, such as “Home for the Holidays”. There is often an uptick in illness as well as emergency room visits around the holidays and this program helped practices to educate their patients and keep them healthy. This program included proactively calling patients, mailing postcard reminders, and focused conversations during office visits. Practices used same day appointments and twenty-four hour call lines to help patients avoid spending their holidays in a hospital waiting room.

Another initiative we pursued related to managing transitions of care through timely health information sharing with inpatient facilities. We work closely with a few local hospitals and utilize innovative strategies for gathering additional information from others. One clinic hired a nurse to follow patients from admission to discharge, ensuring the patient’s needs were met and that they received timely follow up. Another clinic assigned a nurse to use the local hospital’s health record to monitor the daily patient census, identifying when patients were discharged and then following up with them promptly.

While the revenue generated from savings is a great incentive to keep doing the work, one of our local medical directors, Dr. Syed Zaidi, points to a broader benefit: “We’re able to be a better practice now. We can help our patients more efficiently and provide a higher level of quality care.” That is the goal: efficient, quality care.

The holidays are fast-approaching. For some it is a celebratory time with family and friends, while for others it is more difficult.

Many patients with chronic diseases struggle to stay healthy during the holidays. Some tend to eat or drink too much during the holiday season and unfortunately, holiday foods are usually high in fat, salt, or sugar. Traveling and change in routine can lead to skipping or missing important medications. Additionally, holidays can increase stress and depression. Unfortunately, during this time, the hours for primary care clinics and pharmacies are reduced and patients are not always able to get the support they need.

As you gear up for the holiday season, here are our top five tips for helping your patients to stay healthy and “Home for the Holidays.”

1. Focus on high-priority patients. In many Aledade ACOs, partner practices are reaching out to high-priority patients via phone call, email, or mail. High-priority patients are those who frequently visit the Emergency Department (ED), have been recently hospitalized, or are on the chronic care management worklist. Many ACOs are running phone banks, where Aledade staff or contractors call high-priority patients to inform them about their practice’s hours around the holidays. They also remind the patients about same day/next day appointments, the availability of an on-call provider 24/7, and the flu shot. Almost all of our partner practices are hanging Home for the Holidays posters and mailing postcards or emailing high-priority patients. These materials are customized with the practice’s office hours and holiday closures, as well as any specific after-hours information.

2. Reach out to high-risk patients under care management to make sure they have everything they need to avoid a visit to the local hospital. If they are frequent ED users, consider bringing them in for a visit, especially if they lack social support.

3. Take the time to update voicemail with holiday closing and on-call coverage information so patients and families know when you will be available for them. Try to avoid recordings that advise patients to go directly to the ER, rather, encourage them to call the on-call provider and if necessary, go to urgent care.

4. Ask your team to ensure that prescription refills are up-to-date for patients on your “worry list” and or reach out to local pharmacies who may be willing to fill your patients’ prescription by protocol for a short time if your office is closed.

5. Share your closing message about holiday plans through waiting room posters, mailings, website/patient portal, social media, or better yet with a friendly reminder in person with each office visit. The materials mentioned above can be a great place to start!

We know that the holidays can be stressful for some of your patients but hope that you will find a way to help them stay safe and at home while you and your staff enjoy some well-deserved time with your own families.

Download Customizable Poster & Flyer Template

Deborah C. Stamps, Marcella L. Carr, Holiday Season for a Healthy Heart, Critical Care Nursing Clinics of North America, Volume 24, Issue 4, December 2012, Pages 519-525, ISSN 0899-5885, http://dx.doi.org/10.1016/j.ccell.2012.07.007.

David P. Phillips, Jason R. Jarvinen, Ian S. Abramson and Rosalie R. Phillips Cardiac Mortality Is Higher Around Christmas and New Year’s Than at Any Other Time: The Holidays as a Risk Factor for Death Circulation. 2004;110:3781-3788, http://dx.doi.org/10.1161/01.CIR.0000151424.02045.F7.

One of the stated policy objectives for the ACO rule is to encourage more ACOs to take higher levels of risk, but a little-noticed provision in the notice of proposed rule-making would severely restrict the ability of physician-only ACOs to enter into the higher risk ENHANCED track. This relates to the required “repayment mechanisms” that ensures that ACOs entering downside risk models will pay CMS back if they incur shared losses. A small policy decision here can make a large difference in the amount of cash ACO would need to sequester, and the investments they can make in care improvement.

The repayment mechanism amount required for two-sided risk contracts is significant and can range from $100,000 for an ACO with 5,000 assigned beneficiaries under the BASIC track, to $5,000,000 for an ACO with 50,000 assigned beneficiaries under the ENHANCED track. While the data show that physician-only ACOs can be most successful at reducing cost, few would be able to put away millions of dollars into escrow, while simultaneously investing in the additional technology and services needed to generate savings.

Fortunately, there is an approved repayment mechanism that is well-designed for this purpose- surety bonds. An issuer like Swiss Re would provide an assurance that the obligation will be paid if incurred, in return for a small fee. They would also require a cash collateral depending on the level of risk assumed, and on regulatory requirements and the availability of reinsurance. While complicated, these financial instruments are a key part of the smooth functioning of financial institutions and businesses throughout the economy.

A key factor in an issuer’s calculation of the cash collateral required is is the time period of the bond. A bond with a 3-year term, renewed annually, has a dramatically different profile for an issuer than a 7-year bond. When CMS proposed to lengthen the contract periods for ACO contracts from 3 to 5 years, they also proposed to lengthen the time period for repayment mechanisms from the current 5 to 7 years.

However, surety bonds are nearly always issued for a maximum of 5 years, due to reinsurance and regulatory complications surfacing beyond this time frame.  Most notably, reinsurance treaty prohibits insurers from writing bonds with terms exceeding 5 years. Aledade has brought CMS’s proposal to the attention of One Beacon Surety Group and Swiss Re. After discussion and analysis both organizations came to the conclusion that if the proposed  7-year term is finalized, all surety bonds would require 100% cash collateral, defeating the purpose of the surety bond!

This would impose a significant liquidity and capital burden, limiting a ACO’s ability to invest in innovations that deliver higher quality care at lower cost.  This would be especially problematic for physician-based and small, rural ACOs, neither of which have access to low-cost capital.

Therefore, Aledade strongly urges CMS to set the Pathways to Success repayment mechanism duration to 3 years, with a required annual renewal with the appropriate updated repayment mechanism amount. This approach would allow CMS to (1) continue to protect the financial integrity of the program by ensuring that all continuing and renewing ACOs will remain capable of repaying losses, and (2) preserve the viability of surety bonds so physician-led and small, rural ACOs access capital and liquidity.

We greatly appreciate the thought and analysis CMS has put into the proposed Pathways to Success program. Thank you for your consideration and we look forward to contributing to the continued success of the program.

Today, we submitted to CMS our comments on the proposed changes to the 2019 Physician Fee Schedule. This year was more exciting than most with CMS proposing significant changes to how physician’s bill for evaluation and management services i.e. the traditional office visit. We worked with our partner physicians and analyzed over 700,000 claims to inform our comments on this proposal. Below is our full comment letter and analysis to CMS.

Dear Administrator Verma:

Aledade (www.aledade.com) partners with 272 primary care physician practices, FQHCs and RHCs in value-based health care. Organized into twenty accountable care organizations across 18 states, these primary care physicians are accountable for over 240,000 Medicare beneficiaries. More than half of our primary care providers are in practices with fewer than 10 clinicians. We are committed to outcome-based approaches to determine the value of health care. We are committed to using technology, data, practice-transformation expertise and, most important, the relationship between a person and their primary care physician to improve the value of health care.

For our comments on the 2019 proposed physician fee schedule, we focus on those issues closest to value-driven health care and to independent physician practices, including:

  • Changes to evaluation and management (E&M) documentation and payment
  • New codes for physician time spent with patients that is not face to face
  • Updates to the Quality Payment Program (QPP)
  • Changes to the quality measures in the Medicare Shared Savings Program (MSSP)

E&M Documentation and Payment

We are pleased that CMS is seeking to reduce the burden of E&M documentation. Despite being outdated and misvalued, E&M codes have remained largely unchanged in the last twenty years. This is mainly due to a lack of consensus on the best way to revise the documentation guidelines and payments in the physician and payer community. We evaluated the proposed changes with a belief that reducing physician burden is a worthy and long overdue goal.

Deciding which E&M Level
We support CMS’s proposal to allow for two new, streamlined approaches to determining the E&M level.

  • Basing the level of E&M solely on the complexity of the medical decision making required
  • Relying on time as the deciding factor for the level of visit without the focus on counseling or care coordination

By providing two alternative methods of documentation, CMS would allow physicians to match their choice to their practice style and patient population. CMS would also gain experience with the different methods that will inform future efforts to improve documentation focused on worthwhile medical record keeping and care coordination.

However, our partner physicians have given us important feedback that the impact of CMS changes are limited. CMS documentation requirements are not the sole driver of the current level of documentation in most practices. Commercial payers or malpractice concerns would continue to necessitate documentation even if CMS finalizes these proposals. We encourage CMS to continue to work with the AMA CPT editorial panel to revise the guidelines at their source to minimize unnecessary documentation across the entire patient panel.

E&M Single Payment Rate
We cannot recommend that CMS finalize the single payment rate for level 2 through 5 E&M visits, even with CMS’s efforts to use G codes to minimize the variance that a single rate would cause. This decision informed both by feedback from our partner physician practices and from our analysis of the effects the rate and G-codes would have on practice revenue. Specifically, we analyzed 771,011 2017 claims of 213 Aledade practices. We provide details of that analysis and detailed feedback from our partner physician practices in the appendix. Our key takeaways are:

Neither the documentation not the single payment rate can be evaluated with consideration of interaction with other Medicare policies and with policies outside of Medicare from other payers and regarding liability

  • Without the G-codes, the practices would lose 2.3% of their revenue from E&M
  • With the addition of the primary care-focused GPCX1, the practices would gain 3.2%
  • Practice level effects vary widely with a range of -19% to +41% (see graph below)
  • To eliminate the negative effects on 99% of the practices, the extended time code, GPRO1, would have to be billed on 29% of Level 4/5 visits
  • Beneficiary risk scores do not significantly account for practice level differences in utilization of level 4 and 5 visits versus level 2 and 3 visits

 

The graph below shows the distribution of change at the practice level:

This variation creates substantial revenue uncertainty for practices. Considering Medicare’s limited effect on overall documentation requirements faced by a practice and this uncertainty, we do not believe that payment rates are an appropriate tool to reduce physician documentation. We are also concerned about introducing harmful incentives. A single payment rate combined with the MPPR policy (discussed later) incentivizes frequent limited visits that inconvenience Medicare beneficiaries, at a minimum, and possibly create less cohesive care. While the G codes mitigate this to some extent, the incentive remains both to shorten visits and to prefer patients who can be well cared for in a short visit and patients who can easily make multiple trips to the office.

Home Visits
We support the CMS proposal to remove the requirement to justify the medical necessity of a home visit. Given the challenges of providing a home visit and the obvious convenience to the beneficiary, requiring justification is an unnecessary step.

Reducing the Least Expensive Procedure by 50 Percent
We cannot recommend that CMS finalize its proposal to require modifier 25 when a procedure is combined with an E&M visit. The savings from these policies are applied to the single payment rate by CMS, but the cost that they impose on our practices are not included in our analysis. This means that if both policies were finalized then the impact on practices would be more variable and more negative than in our analysis. However, we do not recommend this proposal for more than its interaction with the E&M single payment rate.

We disagree that there is significant enough overlap between resource use of procedures and E&M to justify a 50 percent reduction. The main overlap is in physical location of the office and administrative components that do not make up 50 percent of the RVUs for most procedures and E&M services. Nothing we have experienced with our partner practices would indicate that the savings to the practice for doing multiple services in a single visit would account for the 50 percent of the costs. Finally, this adds yet another financial incentive to the practice shorten visits. Even if CMS were to finalize the single payment rate for E&M we encourage CMS to not finalize these proposal in conjunction even if it means making adjustments to the single payment rate.

Non-Face-to-Face Physician Time

Chronic Care Management Services by a Physician or Other Qualified Health Care Professional
We support the creation of a separate code for CCM that focuses on and is valued on physician time. The lack of this code creates a disincentive for physicians to step into the care coordination process. By creating this physician valued code, CMS continues its movement to supporting comprehensive chronic care management that began with 99490.

Brief Communication Technology-Based Service
We support the creation of this code because we believe that this service falls between those which are obviously incidental and those which are defined and require direct financial support. However, we acknowledge that the low reimbursement of this code combined with the high administrative cost of the claims process creates concerns. In particular, we are concerned that the collection of the minimal beneficiary coinsurance could result in administrative collection costs that exceed the amount of the coinsurance. To the extent allowed by statute, we encourage CMS to allow practices to routinely waive the coinsurance for this code due to the high financial cost for the practice to collect it.

Updates to the Quality Payment Program
Promoting Interoperability
We support the proposal to apply the individual or group-level score for Promoting Interoperability (PI) for purposes of MIPS score even when the MIPS-eligible clinician participates in MSSP. Even in our more homogenous ACOs (same state, independent primary care), we have seen significant variance in the practice level-PI scores. As with any measurement program, high levels of measure performance requires not just good process and use, but a focus on measure monitoring. Some practices monitor their measures and seek to perform high on the measure. Other practices implement processes focused on workflow, not measure performance. Unsurprisingly the former scores better than the latter. Using the ACO average hides these differences and disincentivizes high scores. By moving the the score to the individual or group level, the choices made by the practice are accurately reflected in the MIPS score of the practice.

Qualifying Professional Determination
We support CMS’s proposal for making the QP determination at the TIN level in addition to the AAPM level. This is a particularly acute issue as the threshold rises to 50 percent. Even primary care-only ACOs receive attribution for only 60-75% of their patients, depending on ACO characteristics such as geography (rural areas have higher attribution than urban). The inclusion of specialists in the ACO, particularly specialists who do not drive attribution, quickly moves the ACO close to the 50 percent AAPM threshold. Having the 50 percent threshold at the AAPM level discourages additional inclusion of specialists in the ACO because it is difficult to predict whether a given specialist will take the ACO below the threshold and therefore remove the AAPM bonus for all ACO participants. We do not believe it is desirable for the QP determination to solely dictate whether an ACO includes a specialist. By moving the QP determination to look both at the TIN and AAPM level, CMS’s proposal to use an -and- methodology removes this disincentive to include specialists while maintaining the attractiveness of the AAPM bonus to ACO participants.

Quality Measurement in the Medicare Shared Savings Program
We support all the measure changes that are being proposed by CMS.
The table below is our measure-by-measure reasoning for this support.
Web Interface Changes

As we continue to look towards outcome measures over process measures, we urge development of a “time spent at home” (https://catalyst.nejm.org/time-spent-at-home-a-patient-defined-outcome/) or “days spent at home” (https://www.nejm.org/doi/pdf/10.1056/NEJMp1607206) patient-centered outcome measure using administrative data.

CAHPS Measures
We support both the inclusion of measuring ACO-45, “CAHPS: Courteous and Helpful Office Staff” and ACO-46, “CAHPS: Care Coordination” and the movement of ACO-7, “Health and Functional Status” to pay-for-performance. While it was not a proposal by CMS, we want to call attention to the increasing weight of CAHPS scores in accounting for differences between ACO performance. As an increasing number of Web Interface Measures top out (only three are not topped out) and as the claims-based measures are reduced in this proposal, the remaining measures for an ACO to distinguish themselves are in CAHPS. We are supporters of CAHPS measurement and do not believe CMS needs to take action in the final rule. However, it is something that CMS should monitor as the program progresses.

We look forward to continuing to work with CMS to incentivize more value creation in health care. Please contact me or Travis Broome (travis@aledade.com) if you have any questions about our submission and/or if we can be helpful to you and your staff as you consider the finalization of this regulation.

Sincerely,
/s/
Farzad Mostashari, MD, ScM
CEO and Co-Founder
Aledade, Inc.

Appendix: E&M Payment Rate Effects Data Analysis
To inform our views on the proposed movement to a single payment rate for E&M levels 2 through 5 and the addition of new G codes we analyzed billing data of 213 practices that were in ACOs participating in the Medicare Shared Savings Program in 2017. There were 771,011 claims that would have been affected by the proposed changes and, therefore, were included in the analysis. We used the 2019 conversion factor to value the RVUs of the 2017 claims in 2019 dollars. We then replaced the RVUs with the proposed RVUs of the single payment rate for the comparison. We adjusted for geography using the Geographic Adjustment Factor File included with the proposed rule. Finally, we applied GPC1X and GPRO1 to variable percentage of the 2017 claims to finish the comparison between 2017 revenue in 2019 dollars to 2019 revenue under the proposed rule

We were interested in the following questions:

  1. What was the mean effect of the policies on the 213 practices accounting for different use of GPC1X and GPRO1?
  2. Does the mean vary by geography?
  3. What were the practice level effects and what was the variation in the mean?
  4. Does practice risk score explain practice utilization of level 4 and 5 visits?

Mean Effect on the 213 Practices
For this first analysis we calculated the mean payment without GPC1X and with full use of GPC1X, by state. Later, we looked at the effects of GPRO1. It is unclear to us at what level GPRO1 would have been used in 2017 had it been available and therefore we account for it separately.


The effect of the practice level distribution with no G codes is negative with state level variation ranging from -$28,377 to gaining $23,104.

As these are primary care practices we ran the analysis assuming 100% of established visit claims use GPC1X.


As CMS expected the addition of the primary care focused G code moves the mean. For the practices in the analysis this means a now positive 3.2%. The geographic variation is essentially unchanged.

Next we looked at the practice level variation. This was the biggest area of concern raised by our analysis and directly led to our decision to not recommend that CMS adopt the proposal.

The above graph should the distribution of % change in practice revenue with 100% GPC1X use. Each block is a practice. As you see the range is dramatic from -19% lose to 51% gain.

While variation has its own costs it is the negatively impacted practices that are most affected. Whether a practice is positively or negatively financially impacted is a direct relation to the ratio of level 4 and 5 visits to level 2 and 3 visits.

We believe it stands to reason that the use of GPRO1, the prolonged visit code would be more likely to be used in level 4 and 5 visits and therefore would disproportionately and positively affect practices who without GPRO1 are negatively impacted financially.

The next graph assumes 15% of Level 4 and 5 Claims with Prolonged Visit Added On

As you can see this greatly reduces the number of practices negatively impacted from 93 to 25 while not increasing the range on the positive side of the graph. However, it does shift the mean from a 3.2% gain over 2017 to a 9.1% gain. We were not able to determine whether that shift can be adjusted for without increasing the number of negatively impacted practices. The ratio of visits with GPRO1, the value of GPC1X and the value of the single payment rate can be tweaked to create a variety of results. We are unable to estimate the rate GPRO1 would have been used in 2017 so the 15% of this graph is illustrative purposes only.

In another distribution we found that it would be necessary to have a GPRO1 use rate of 35% of Level 4 and 5 Claims to eliminate any practice with a loss. This would move the mean to 17.0%.

The final question we attempted to answer was whether HCC risk score controlled for differences in level 4 and 5 variation and could therefore be used to vary the single payment rate in a way that did not require documentation. While risk did reduce some variation (see three graphs below) it did not control for level variation enough to be a viable solution.

In addition to our analysis, the other driver of our decision to not recommend the proposal was feedback from our partner physicians. Below is a summary of the key points they provided to us. The feedback did include both support and concerns; however, unlike the revenue impacts which overall were favorable, the overall feedback was unfavorable.

  • If a physician is paid the same for 10 minutes as for 30 minutes and needs to maintain positive margins as a business owner, the incentive is to limit the volume of complex patients and maintain a practice that leans towards low acuity patients
  • Proposal adds yet more change without addressing the chronic underfunding of primary care
  • Malpractice concerns are the main driver of documentation levels not billing
  • Many visits that should be level 4 and 5 go out as 3s because the documentation is so onerous on a solo practitioner. This levels the playing field between small practices and large practices with billing departments.
  • If CMS can figure out how to level the reimbursement differences, the same principles apply to home visits (CPT 99341-99350) and CMS should do the same for those codes
  • As much concern for the 50 percent reduction in multi-service visits as for the single payment rate combined with G codes. Certainly that the 50 percent policy will reduce revenue, but the effects of the single payment rate on revenue is uncertain so lots of concern that the combined policies will reduce revenue

After attending University of Kansas for undergrad and medical school, I knew I wanted to stay in Kansas to practice medicine. Rural Kansas isn’t a resource-rich environment, but the patients here deserve the best care. I began an independent family practice to provide my community with the full-spectrum care so many lacked.

Soon after starting my practice, I knew the transition to value-based care was inevitable. As a new, forward-looking physician, I wanted to lead that movement, but I didn’t know how. Aledade equipped me with invaluable technology, tools, and guidance to navigate the transition.

Aledade’s app prepares me for patient appointments so I can play the offensive in my patients’ care. The app lists preventive services for which my patients are eligible. This allows me to monitor their health before something goes wrong. It also includes critical information to help me coordinate patient care, such as other doctors my patient is visiting, additional medications they’re taking, and new diagnoses they may have received. Most importantly, Aledade recommended my practice hire a Care Manager. Our Care Manager acts as an accessible point of contact who has reduced emergency department utilization, provided additional assistance to patients with chronic diseases, and improved communication with the large number of Spanish-speaking patients at my practice.

Aledade’s support has led to positive outcomes in my practice and throughout the entire Aledade Kansas ACO. Our ACO has been able to participate in a quality program with Blue Cross and Blue Shield of Kansas. We recently received the exciting news that our ACO reduced the total cost of patient care by 5.8 percent. As a result, practices in the Kansas ACO received a shared savings check! We did this all by working to keep our patients healthy. We decreased ED utilization by 8 percent and reduced inpatient admissions from 73.6 to 70.3 inpatient admits per 1,000. We also focused on preventive care services. For example, we increased breast cancer screenings by 17.9 percent and annual well child checkups by 31 percent.

After my staff saw the impact Aledade’s best practices had on our work, they become even more excited to utilize the Aledade app. They check the app every morning and recommend preventive care options at every opportunity!

I know Aledade will be critical to my practice’s future. Demand is the biggest problem we face. Rural Kansas has so few primary care physicians, my practice faces a challenge of more patient requests than we can serve. By offering shared savings, enhanced patient outcomes, and the opportunity to put primary care doctors back in charge of their patients’ care, Aledade incentivizes doctors to practice primary care. Redirecting doctors to primary care will improve the healthcare system and country as a whole. In this way, Aledade not only betters my practice and the care my patients receive, but leads to a brighter future in healthcare in Kansas and beyond!