Primary care practices act as the first line of defense against poor health for Medicare beneficiaries and other patients.  

In the value-based care environment, where shared savings depend on keeping patients healthier for longer, primary care providers can use a powerful tool for delivering proactive, preventive care: the Medicare Annual Wellness Visit (AWV).

AWVs are once-a-year office visits that allow providers to address a patient’s health issues and update information about the patient’s health status, including their clinical, psychosocial, and behavioral health risks.  

They differ from traditional “sick visits” in several ways, explained Greg Zorbas, Implementation Coordinator at Aledade.

“The Medicare AWV is designed as an opportunity for the patient and provider to have a proactive discussion about the patient’s ‘big picture’ issues,” he said.   

“It’s an important opportunity to strengthen the patient-provider relationship, and it allows providers to reinforce that they really care about their patients’ health and keeping them healthy.”

But for practices that often divide the day into fifteen-minute increments in order to keep sufficient revenue flowing, finding the time for a comprehensive review of every Medicare patient may seem like an insurmountable challenge.

Practices should start by making small, sustainable changes that take advantage of processes that are already in place, advised Zorbas.

“You don’t have to bring every single one of your patients in for an AWV within the next month – that’s not realistic,” he said.  “But you will be having patients come in every day for some reason, whether it’s a sick visit, a diabetes check, or a follow-up on a lab result.”

“Why not take advantage of that and start to integrate a few high-value screenings into those appointments, such as a depression screening or a falls risk assessment?  That will start to build the evidence that it’s important to start taking a more proactive approach to wellness.”

To learn more about how to incorporate AWVs into the daily schedule, download Aledade’s free white paper, Making Time for Medicare Annual Wellness Visits in an Independent Primary Care Practice.”



Aledade’s headquarters might be based just outside of our nation’s capital, but it isn’t every day that our partner physicians have a chance to meet one-on-one with their Congressional representatives on Capitol Hill to advocate for value-based primary care.

In early July, five independent primary care physicians from Aledade ACOs joined the company’s leadership team for a trip to Washington, D.C. and an opportunity to positively influence policymakers with real-world stories of patient care and practice transformation.

“One of the reasons why Aledade is very effective with influencing and informing policy is our ability to draw on the real-world experiences of practices who are really doing value-based care,” said Farzad Mostashari, MD, co-founder and CEO of Aledade.

Making policy and practicing medicine have a lot in common, he continued.  Both demand the ability to make effective decisions in complex situations. Both can have immediate and long-term impacts on individuals and their families.  And both require a personalized touch to be truly effective.

“Policymakers and regulators have to think about what’s best for a huge number of people,” said Mostashari. “They are operating on such a large scale, often with hundreds of billions of dollars running through their offices.  When you’re in the middle of that, as I know from experience, you can start to worry about losing touch with what’s actually happening in the field.” 

“That’s why it was great to see that the people we met with were so receptive to hearing from physicians who are working in very real settings.”

Gaining an inside perspective into the policy process

For Dr. Karl Schwabe from PMA Medical Specialists in Pennsylvania and Dr. Richard Card, a solo primary care physician based in Virginia, going to the Hill for the first time was an eye-opening experience.

Most Americans only see the surface of the legislative process when they watch the news or read about political issues, said the two physicians. 

While formal debates on issues of national importance certainly play a role in policymaking, much of the groundwork for new ideas is laid during quick walk-and-talk meetings, said Dr. Card.

“When you watch C-SPAN or the news, you see all these big rooms with dozens of Congresspeople talking and arguing with each other,” said Card. 

“But the reality is that most decisions are made outside of that room.  You get five or ten minutes in a hallway to plant your ideas with your representatives or their staff, and then sometimes it takes a couple of years before you see any fruit from it.”

Dr. Schwabe agreed that the process looks different from the inside.

“Everything gets done in little snippets,” he said.  “You might have the opportunity for half an hour to make an impression on someone who works for your Congressional representative, and that’s it.”

However, a lot can be accomplished in half an hour.  And these physicians didn’t waste a single moment. 

During a packed day of meetings, the two doctors and their colleagues from North Carolina, Kansas, and Michigan met with legislators and staff to discuss issues that affect their communities, including hospital consolidation and appropriate utilization of healthcare services.

“When I met with the legislative assistant for Rep. Mary Gay Scanlon (D-PA), I started the conversation by explaining what an ACO was,” said Schwabe.  “After that, we were able to have a great discussion about how we operate and what we do.” 

Card also began one of his meetings with a little education about value-based care, he said.

“Congressman Morgan Griffith (R-VA) wasn’t very familiar with ACOs either, so we explained what they do and why they benefit the community,” said Card.  “It turns out that he uses some independent practices for care, which was a good entry point for talking about how Aledade keeps PCPs independent.”

“It was also a segue into talking about industry consolidation and its negative effect on prices,” he continued.  “The Congressman spent about 25 minutes with us, and we had a great conversation about these issues.”

Fixing the rural glitch to equalize rewards for quality improvement

Later that afternoon, Card and Schwabe joined Mostashari and the Aledade policy team for a sit-down with John Brooks, Principal Deputy Director of the Center for Medicare at the Centers for Medicare and Medicaid Services (CMS).

At the top of the agenda was the rural glitch, an issue with the way CMS calculates benchmarks for participants in the Medicare Shared Savings Program (MSSP).

Accountable care organizations allow multiple providers in a region to band together as one entity to tackle quality improvement and cost reductions.  In sparsely populated rural areas with relatively few practices, many of those providers may be part of a single ACO. As a result, that ACO might end up serving a large proportion of the region’s patient population.

That gives rural ACOs a disadvantage in terms of calculating their cost improvements compared to the region, explained Card, because the formula currently includes an ACO’s own patient population in the benchmarking calculation. 

“If those practices are doing very well for their patients and reducing costs, they are driving the changes in the benchmarks because they comprise such a big part of the calculation,” Card said.

“As a result, they are essentially competing against themselves in a way that is almost unfair compared to more populous regions where patients are divided more equally among more providers.”

The glitch has clear and significant financial impacts on ACOs in rural areas, added Travis Broome, VP for Policy and ACO Administration at Aledade.

“Let’s say I have an ACO in Washington, D.C. that accounts for 2 percent of the patients in the market,” Broome explained.  “That ACO reduces costs by 5 percent by being truly excellent in delivering primary care. Under current policies, they get to keep nearly all of that money – 98 percent – as a reward for their work.”

“Now, let’s say there is an ACO in a very rural area where 20 percent of the patients are attributed to one ACO.  That ACO also reduces costs by 5 percent. Because of the rural glitch, that group will only get to keep 80 percent of the reduction in costs compared to the 98 percent for the urban ACO.”

Removing a rural ACO’s own patients from the existing benchmarking rubric would solve this problem, show analyses from the Aledade policy team.  That way, the comparison is more accurate and the ACO will not be financially penalized for doing well.

“We want to make sure that people who perform the same get paid the same.  That’s all,” said Broome.

Enacting change by bringing a positive perspective to the table

Mostashari was quick to point out that the rural glitch is not the result of some deliberate plan to put certain providers at a financial disadvantage. 

Instead, it was simply a well-intentioned decision that has produced unforeseen results in an extremely complicated program that is constantly evolving to get better and better.

“People often forget that there are human beings on the other end of this who have been working their tails off every day trying to do the right thing,” said Mostashari.  “Every day, they get 98 percent of it right, but people always seem to get mad about the other two percent of things that aren’t perfect.”

“One of the most important things, whether you’re a physician, an administrator, or whatever, is to be able to put yourself in the other person’s shoes.  You need to thank them for the things they did right, because those things were hard. And you need to help them fix the other things by bringing solutions to the table, not just complaints.”

CMS and other policymaking entities regularly publish requests for information (RFIs) and open public comment periods when considering potential changes to programs like the MSSP.

Anyone can make observations or offer suggestions during these opportunities, and Aledade encourages all healthcare stakeholders to share their thoughts when policies are up for debate.

Actively participating in the process is the only way to enact the changes you want to see, said Mostashari.  And getting involved does bring results.  

“The government is not a nameless, faceless resistance,” he stressed.  “It’s a group of human beings making complicated decisions about complicated issues, and they are all trying to do the right thing for America.” 

“Fundamentally, I believe in this process.  I believe in bringing the best thinking and the best perspectives to the table.  Change doesn’t always happen quickly, and it doesn’t happen in a straight line, but the system works.”


The healthcare industry is in the midst of a shift from fee-for-service reimbursement to value-based care, putting pressure on physicians to make significant changes to their processes and workflows. While value-based models have shown promise, the transition can be intimidating for independent practices, especially when resources are scarce and success seems uncertain.

Adopting a value-based approach to patient care requires significant investments in workflow changes and practice transformation.  However, with the right support and an actionable roadmap for success, independent practices can thrive in this space and work effectively to provide more proactive, holistic care for patients while simultaneously bringing benefits to the practice itself. 

Dan Bowles, SVP of Growth & Network Operations, Aledade

“An independent physician practice that is participating in value-based care can significantly increase its income by keeping patients healthy,” says Dan Bowles, SVP, Growth & Network Operations for Aledade. 

While many independent and small practices want to move into value-based care and achieve these gains for themselves, doing so can be a challenge. Navigating this transition – while retaining independence – requires the right strategy, technology, data and workflows.

Providers should start by clarifying their motivation for moving to accountable care, advised Bowles.  Some practices may be feeling more financial pressures; some may be looking for better strategies for addressing a specific issue facing their community, such as substance abuse or high rates of diabetes. Others may be focused on maintaining their independence in a rapidly consolidating market.

No matter what the impetus for exploring value-based care, practices should take the time to be certain about what they are hoping to accomplish.

Once practices are clear about what they hope to achieve, they should take the time to engage in an open dialogue about current procedures, such as how the practice rooms a patient, how the EHR system works, which staff members handle which tasks, and other important factors that govern day-to-day activities. 

This conversation should result in an action plan that identifies any weak spots, such as high emergency department utilization or a large number of nursing home admissions. Taking stock of current processes will allow primary care practices to make the adjustments necessary to thrive in the value-based environment.

Setting clear goals and assessing existing procedures can help practices move forward quickly into the next steps for success with accountable care.


To learn more about how to make the transition into the value-based care environment, click below to download our white paper, “A Value-Based Care Roadmap for Primary Care Providers.



Five years ago, The Medicare Shared Savings Program (MSSP) was in its infancy, with a handful of optimistic accountable care organizations (ACOs) experimenting with the challenging idea that an innovative incentive structure could successfully contain spending and produce higher-quality results for patients.

Over the past half-decade, that idea has certainly taken off.  Now in 2019, there are more than 560 MSSP ACOs across the United States, providing care to over 10.5 million Medicare beneficiaries, CMS says.  And although it’s a little harder to track the numbers, commercial insurance companies are investing in ACOs at a similarly brisk rate, bringing millions more lives under the value-based umbrella.

Getting to this point hasn’t been easy, acknowledged Mark McClellan, MD, PhD, currently a professor and the director of the Duke-Margolis Center for Health Policy at Duke University.

As a former FDA Commissioner and former CMS Administrator who served during the genesis of the value-based care movement, McClellan has a unique perspective on the ACO origin story and what it takes to succeed with accountable care today.

Taking the time to get accountable care done right

Patience, persistence, creativity, and the ability to adapt to the unexpected are all key traits of providers who have made the most of their early entry into value-based care, he told Aledade staff recently at a special 5th year birthday celebration for the company. 

Mark McClellan, MD, PhD

McClellan has served as a member of Aledade’s Board of Directors, but recently turned over his chair to Dr. Patrick Conway, President and CEO of Blue Cross Blue Shield of North Carolina.

“It’s really important to remember that revision is a necessary part of creating something new,” said McClellan, who is currently a professor and the director of the Duke-Margolis Center for Health Policy at Duke University.

“The important thing is to stick with the right concepts and revise the technical details as you go along until you get it right.”

Farzad Mostashari, MD, CEO of Aledade and former National Coordinator for Health IT, also believes that policymakers need to be responsive to the fact that putting a big idea like value-based care into practice can result in some unexpected curveballs. 

Sometimes the technical details about implementation, when you really get down to doing it, have to influence policy decisions,” Mostashari observed.

Not sometimes – I’d say all the time, in healthcare,” responded McClellan.  “Better outcomes and lower costs through better access to innovative care is a pretty good north star to keep following.  That’s always what we’ve tried to do.”

A fateful question: “Why can’t we do that?”

About five years before Aledade opened its doors, policymakers and healthcare innovators were starting to mull over the details of launching ACOs and putting value-based care into practice at scale.

At the Brookings Institution, a non-profit think tank, McClellan was preparing to recruit a handful of ACOs for a “competition” to see if the idea of ACOs could really work.

“There was no money involved – no prizes. It was really just a Tom Sawyer approach to healthcare reform,” McClellan admitted with a smile.  “We wanted to see what they could do and study how they did it.  There was a lot of interest from people across the country.” 

One of those interested people was Mostashari, who was working at the New York City Department of Public Health to bring health IT tools, informatics, and quality improvement support to more than 1200 primary care providers in the region.

“I was sitting there in a room with Mat Kendall, who would later co-found Aledade with me, listening to this pitch from Mark on the phone and getting excited about the possibilities,” said Mostashari.  “But we were a group of primary care providers. I asked if we could apply, but Mark said, ‘No, you have to have a hospital.’”

“And I said, ‘We don’t have any hospitals.  We want to be an ACO, but we only want to have independent primary care providers.  Why can’t we do that?’”

Farzad Mostashari, MD

Mostashari was “crushed” when McClellan repeated that they would not be eligible without a hospital as part of the ACO.

But the question and its implications stuck with McClellan.  Even the earliest ACO prototypes stressed the importance of primary care for preventive care and coordinated patient management. So why not let primary care physicians lead their own ACOs?  

McClellan carried this idea with him as he helped to shape components of the Affordable Care Act, which subsequently established the Medicare Shared Savings Program.  

He credits Mostashari’s feedback for the provisions in the landmark law that allow physician-led ACOs to exist.

“That call in 2009 really did help us reexamine what is critical for an accountable care organization,” said McClellan.  “It turns out that in order to implement the program effectively, we needed to connect it to primary care providers, and we needed to let them lead the way in ACOs. Primary care utilization is also the best foundation for patient attribution, so it just made much more sense.”

Use what you have to get to where you want to go

As the MSSP program started to ramp up in 2012, the first crop of Medicare ACOs had to get creative in order to deliver coordinated, high-quality, cost effective care, McClellan and Mostashari recalled.  

Many of these ACOs found that relatively small and simple changes could be very effective for providers and their patients, said Mostashari.  

“I asked Rio Grande Valley ACO in Texas about their secret to success,” he said.  “Turns out, it was that the physicians gave patients their cell phone numbers.”  

“They would take the patient’s phone, dial their own personal cell numbers so it’s in their contacts, and say, ‘Here’s my number.  When you need me, just call me.  We’ll help get you whatever care you need.’  That’s the kind of thing you weren’t going to hear anywhere else at the time.”

Other early ACOs around the country were taking similar approaches, turning their new ideas into the best practices that now help save tens of millions of dollars for the health system every year.

“These ACOs were very scrappy, in a good way,” said McClellan.  “There would be groups where five physicians would get together on the weekend and figure out how they were going to make things work.”  

“That level of physician engagement is very powerful.  These are people who know their patients, and now, with the MSSP, they were starting to get access to a mechanism that would let them give those patients better lives.”

A bold new idea for primary care

The healthcare industry was on the edge of something truly transformational, McClellan said, and interest was starting to build to a fever pitch.  But something was missing.

“I would take a look at the landscape, and I felt that if primary care providers could just get a bit more capital into their hands and a bit more support, they could make enormous strides to actually transform care,” he said.

McClellan wasn’t the only one who was starting to think that primary care providers could benefit from a true partner in practice transformation.  

Mostashari was seeing the same patterns and formulating his own ideas about how to bring those critical capabilities to primary care providers while helping them maintain their independence.

In what McClellan called “one of his favorite papers,” they published the economic calculations that could underpin the creation of a business model to fund primary care transformation.

I remember the math we came up with that was first written on a white board at the Brookings Institution,” he said.  “If you take 100 primary care doctors with 2000 patients between them, then multiply that by an average of $5000 in medical expenses per patient per year, you’d find that those 100 doctors are managing a billion dollars in medical spend every year.  A billion dollars!  You get 100 PCPs to work together on that…imagine the possibilities.”

“I said to myself that someone should start a business.  I kept waiting for someone to do it, but no one did.”

I think you knew it was going to be you,” laughed McClellan.

No, I didn’t,” Mostashari insisted.  “I thought it might be, but I didn’t know.  But I’m glad it was.”

Five years later, that business is Aledade.  The company now has hundreds of primary care partners in 25 states and is still growing fast.  

Aledade helps independent primary care providers succeed in all types of value-based contracts, helping participating providers earn more than $25 million in value-based care revenue since its inception.

A promising future for accountable care organizations

This is just the beginning for Aledade, Mostashari predicted, and for ACOs in general.  As value-based care continues to gain traction over the next half a decade, the healthcare industry is bound to keep changing in many respects.  

But community-based primary care providers will still be the essential glue that holds the nation’s health together.  And there will still be opportunities for primary care practices to thrive without giving up their independence.

McClellan also sees change over the next five years, and is equally optimistic about the continued importance of independent primary care providers.  Success will come to those who stay flexible about implementation while keeping their patients at the center of all they do, he said.

“It’s going to take innovation and leadership to keep going and keep seeing results,” stressed McClellan.  “Whether you’re an MD or not, you need to understand and empathize with people and their needs.  And then you have to layer in the economics and the policy context around how you actually build out capabilities behind meeting those needs.”

“To me, that’s a very exciting and encouraging prospect, and I can’t wait to see what the next few years will bring.”

At Stonecreek Family Physicians in Kansas, a rocky EHR replacement, skepticism about value-based care, and prior disappointments with participation in an accountable care organization (ACO) could have forced this 10-physician practice to close its doors.

But strong commitment from staff members, a willingness to invest in new ideas, and partnering with Aledade brought a new focus on care management as a way to boost care quality and earn shared savings that kept this family practice afloat.

With support and guidance from Aledade, practice leaders at Stonecreek decided to hire a dedicated care manager to spearhead the expanded programming.

“All day, every day we work with patients with chronic conditions who are in need of chronic care management,” said Marian Darnell, RN, Stonecreek’s care management leader. “Care coordination must invest in creating smooth collaborative relationships with resources outside their practice so patients can get support that will make it more likely for them to remain compliant and see improvements.”

“We do find that patients become more engaged after we start working with them, even if we just let them know that we’re available if they need us. We’ll give them a phone number to call, and it can really turn opinions around when they get an answer and get help quickly after calling us.”

To learn more about how Stonecreek developed their care management program and achieved commercial shared savings, download our case study by clicking here.

Five years ago, I joined the Aledade Delaware Accountable Care Organization (ACO) because I saw value-based care as the future of medicine and the best option for my patients. Being a part of the ACO has helped me grow closer to my neighboring physicians and has allowed me to take better care of my patients thanks to better information.

Part of being a successful ACO is providing better quality care to your patients. In the most recent reporting year my practice team earned scores of 100% on all of our MSSP Quality Reporting Measures. This is what we strive for as a practice: we want to always deliver the best possible care. However average scores can vary, so I’m sharing the strategies my team has honed over the last several years, to deliver quality care to our patients.  

Make sure everyone gets a Medicare Annual Wellness Visit (AWV)

Getting patients scheduled for AWVs has helped us to be successful with our MSSP Quality Measure Reporting and a key part of building trusting patient relationships is getting Medicare patients scheduled for their Medicare Annual Wellness Visits (AWVs). The AWV worklist in the Aledade App lets us see who is eligible for an annual visit and prioritizes patients based on their risk factors and eligibility. From August until December, we work especially hard to get eligible patients in the door.  We work from a list of patients attributed to our practice, marking off who has been scheduled and who still needs to be seen. We schedule patients for next year’s AWV before they leave this year’s AWV. Patients now see these visits as a regular part of their care, and I get the opportunity to sit down and discuss important issues with each patient every year.

Provide flu shots to high-risk patients

We typically start with a list of people who had flu shots last year and see who we can bring in or give shots to when they are in the office. The practice staff and I review this regularly and run a list from our EHR at the end of December and try to get the remaining patients vaccinated. We focus on high-risk groups such as those who are 65 years and older and those with asthma and diabetes. We do whatever it takes to get our patients into the office for their flu shot, including sending them reminder cards and calling them at home.

Embrace preventive care

Our approach to preventive measures such as colorectal cancer screening, breast cancer screening, or even HgA1C monitoring is to check each person’s health maintenance list in our EHR. We do this for all visits. We start by checking the Daily Huddle in the Aledade App to see preventative services that have occurred outside of our office, which allows us to update our records. If they are due for their mammogram or bloodwork for diabetes, I give them a prescription and set a reminder.

We bring our diabetic patients into our office every four months for a checkup. Each time they come in, they know they will get their lab slip for their HgA1C so that we have that lab done prior to the next visit. It’s important to make sure patients are getting what they need while they are in the office. Convenience is key for making sure that patients receive the right services – we know that patients will not always get everything done if it isn’t convenient for them.

We have also started to proactively reach out to everyone when they turn 50 years old. We schedule patients for a physical, Prostate-specific antigen (PSA), colonoscopy, mammogram and other preventive care recommended based on the patient’s medical history and risk factors. This approach helps prepare patients for the routine services they will need as they age, and helps them get on a schedule for appropriate preventive measures.

Generate buy-in and create success
As you make these changes to patient care, don’t forget your own team! At my practice we take a team approach to tackling quality. Our practice manager, Michele Weiss, and Karen Green RN have been essential in developing and carrying out these processes to manage and document our quality efforts. Make sure to identify who plays a role in reporting and emphasize the importance of quality reporting and its impact on patient care. Then take time with your team to identify any pain points or particularly low scores and discuss ways you can improve them.

We’ve found success with increasing patient outreach activities, including making calls, sending cards and scheduling next year’s yearly appointments at the patient’s next office visit.  Changing the way you manage patients might seem overwhelming, but you don’t have to do everything at once. Focus on improving one area at a time and building other processes as you go. And remember, the heart of quality reporting is supporting and engaging your patients to provide better quality care.

For this small-town, southern Mississippi gal, it is hard to believe that I work for a nationwide company based in Bethesda, Maryland filled with talented people from all over the country. I have never, in my 35+ year career, worked for a company that is so invested in what they are doing—and in their employees.

I was born in New Orleans and spent the first 3 months of my life in the Baptist Children’s Village orphanage there. I was quickly snatched up by the two most loving parents a girl could ever ask for. I landed in the rural Delta town of Cleveland, Mississippi where the land is flatter than a pancake and the people, music, and food all blend together to make it a very unique place to live.

At an early age, my parents instilled in me a desire to serve others who are less fortunate and taught me what selfless love and service meant. My mother volunteered to teach inmates how to read at Parchman State Prison, and my father taught Bible study to the male prisoners there once a week.

They weren’t the only ones who went above and beyond in their devotion to others.  One time, in the middle of the night, our family physician made a house call to check on my high fever.  I can still see his black leather ‘doctor’ bag, straight out of Norman Rockwell, and hear his calming, reassuring voice.

I like to compare what we do at Aledade to that memory. Value-based care means going the extra mile for your patients and really wrapping your arms around them. That’s the family medicine I remember from my childhood and long for as an adult. It is a great privilege to get to do work day in and day out that transforms practices from the fee-for-service mentality back to providing care that brings value and better health.

As a Practice Transformation Specialist, my job is to help physicians achieve the goals of bringing value and better health to their patients.  I do this by creating workflows to implement preventive-based annual wellness visits, timely hospital and emergency department follow-ups, and better coordination of each patient’s overall care. I’m so fortunate to be able to travel back to my Delta roots every week to practices that have embraced value-based care.

Much of the Delta has changed, but there is still a lot that hasn’t. The poverty level is extreme. Mississippi is ranked first in the country in obesity, which only compounds the chronic conditions that most of these patients have.

Education is so important when it comes to these patients’ health. The practices I work with are able to use Aledade’s tools to help teach these patients how to better take care of their chronic conditions. The support from our team in Bethesda is mind-blowing when it comes to educating our Care Managers on how to take care of these patients.

The Care Managers can use data from the Aledade App to see which patients need to be engaged first and what health issues they might be dealing with. This App also allows them to see a current snapshot of their patient’s healthcare via our Daily Huddle, which is full of pertinent information on one page. For example, a physician can see what specialists their patients are seeing, any recent hospitalizations, and which preventive services are recommended for them, such as colonoscopies and mammograms.  

I also love that the staff at Headquarters are continuously working to make the information more useful and seek input from us out in the field to improve the data and how it’s presented. I could not do my job without the tireless effort and constant support from these dedicated co-workers. Getting to teach practices about value-based care, which mirrors my up-bringing, and working for Aledade is a win-win!  

Approximately 2,400 years ago, Hippocrates stated, “It is more important to know what sort of person has a disease than to know what sort of disease a person has.” As biomedical science and technological innovation advance the discipline of medicine, we must not forget the importance of knowing our patients and building relationships.

To emphasize the importance of patient-centered care, the Institute for Healthcare Improvement (IHI) started a “What Matters to You?” campaign. “What Matters to You?”  is an initiative to encourage and support more meaningful conversations between those who provide health and social care and those who receive health and social care. The IHI has created a toolkit entitled What Matters” to Older Adults?  

The toolkit presents a 4-part framework that focuses on what Matters, Medications, Mentation and Mobility. It also contains a 2-page multicultural tool to help the clinician better understand the person in front of them, as well as other useful resources.

The Ottawa Personal Decision Guide, a shared decision-making tool, is another resource that assists with patient-physician collaboration in the care of the patient. 

Additional readings include an AMA blog post on how a health system is identifying and prioritizing patient’s concerns and a 2017 article written by Dan and Chip Heath in Behavioral Scientist recounting personal stories that emphasize why the work we do day-to-day is important.

Despite the 2,400 year difference, Hippocrates’ words are more valid than ever before. Providing value-based and innovative care begins when we look up from our charts/computer screens and really work to understand the person sitting in front of us.

The evidence is slow in its production, but the rewards of the caring collaboration are priceless. 

Additional readings: 

Seidman J, Anderson M, Masi D et al. Measuring Value Based On What Matters to Patients: A New Value Assessment Framework. Health Affairs. May 23, 2017 Health Affairs

DiGloia A, Clayton S, Giarrusso M. “What Matters to You?”: A pilot project for implementing patient-centered care. Patient Experience Journal. Vol3 (2), 2016 PXJ

In 2015, my wife and I had just driven across 10 states, from Colorado to Washington, D.C., so that she could start a new job. At the time, I was working remotely as a programmer. But soon, the opportunity arose to help improve healthcare in America by joining a company called Aledade.

Aledade was founded on an ambitious optimism that fuels the team to this day. We believe that what we do matters. Our work helps patients—parents, grandparents, siblings, and friends—stay healthy and happy. We help independent primary care physicians stay focused on caring for the communities that they serve. We serve those who serve society, and that mission speaks to all of us.

This is true no matter where in the country my colleagues live and work—and that is just about everywhere. Aledade embraces talented, empathetic people across America and supports a remote-friendly culture to help them contribute to our larger goals. Supporting a remote workplace certainly takes effort to get right.

As we brought on more employees, it became clear that we needed to invest not only in the right technology, but more importantly, we needed to invest in making sure that our whole team continued to feel like a team despite the lack of physical proximity.

Over the years, we’ve learned to communicate clearly in text and to assume good intentions in our communications so that everyone feels connected to the work. We use video calls for meetings to make sure that we don’t miss out on those non-verbal communications that are so important for working well with others.

That focused work paid off as our talent pool grew. Work-life balance isn’t just a buzzword here: there are opportunities for flexible schedules, and there is a real “family-first” approach for all Aledaders, whether they’re in the office or working remotely.

Now, in 2019, I am delighted to have coworkers all across the country, from California to Florida to New York to Michigan. Insights and ideas from West Virginia and Utah are just a Slack message away. We now operate in 8 of the 10 states that I drove through on my way to D.C.—and many more beyond.

Aledade has assembled a diverse team of hardworking people all focused on helping our partner practices treat their patients better while taking cost out of the healthcare system—all focused on improving the state of healthcare in America.

So Aledade, congratulations on a successful fifth year. Year six begins now: let’s keep up the good work!

In my experience as a practicing pediatrician and a leader of health care organizations, I’ve found that some of the most positive changes  to our health care system happen when we invest in primary care. When primary care physicians and clinicians are leading the care team, and when they have the resources to put patients truly at the center of care, we see improvements in patients’ health and experience.

This investment of time and resources is core to the pioneering work Aledade is doing to support independent primary care.

Primary care has a rightful place in leading health care transformation. More than half of all physician office visits are to primary care, yet it accounts for only about 8 percent of commercial medical spending in the U.S. This shows the incredible value we get out of primary care. But it also illustrates how little we as a nation invest in the physicians, physician assistants, nurses and office professionals who are on the front lines of helping patients get the best care possible.

I’m excited that Blue Cross and Blue Shield of North Carolina (Blue Cross NC) is working with Aledade to help independent primary care practices across our state transition to value-based care. We saw a need to work closely with these practices as we develop new payment models. By sharing more data and resources with these physicians, we can improve the quality of care for patients, better manage chronic diseases, and ultimately reduce health care costs. Aledade has the experience and knowledge to help us strengthen independent primary care in these areas.

So far, we’ve made good progress in North Carolina. A lot of eyes are on Blue Cross NC as we work to become a model of what’s possible in health care. 

Independent primary care is very much a part of this progress. For example, more than 50 practices serving 50,000 Blue Cross NC customers have enrolled in Aledade’s North Carolina ACOs since the start of the year.

We are proud of our partnership with Aledade and primary care clinicians. We share Farzad Mostashari and his team’s vision for helping independent primary care make the transition to value and lead the way to better care and lower costs.

That is why I have joined the Aledade Board of Directors. Working with the team at Aledade, we can make great progress in providing independent primary care practices with the resources they need to thrive in our value-based health care system.

Patrick Conway, MD, is President and CEO of Blue Cross and Blue Shield of North Carolina and is the former Deputy Administrator for Innovation and Quality at the Centers for Medicare and Medicaid Services. He is also a member of Aledade’s Board of Directors.