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!

I’m a Care Manager from Dixie Primary Care in Utah. I am responsible for contacting patients on a regular basis to monitor their care outside our practice. Our calls establish a reliable point of contact for patients with the greatest care demands. This allows us to stay on top of their health. Care Management shows our patients they have someone fighting in their corner, providing the support to make difficult lifestyle changes needed to turn their health around.

High-risk patients, often those with multiple chronic conditions, benefit most from Care Chronic Management (CCM) Program. Reflecting on the success of CCM, one patient comes to mind. This patient had chronic pain, COPD, A-Fib, Depression, Heart Failure, Hyperlipidemia, Hypertension, and Prostate CA, relied on a walker and cane for mobility, endured a number of breathing complications, weighed 265 pounds, and followed a pain medication schedule, when he began CCM in June 2017.

When first enrolled in the program, this patient was not ready to engage with me. After undergoing a knee replacement surgery, he recognized the importance of my team’s support in his recovery, and over time, my calls with him grew increasingly positive. I could begin to hear him smiling. Since his surgery, he is mostly pain free, only taking an occasional pain reliever as needed. Best of all, he is now walking freely, without dependence on a walker or cane.

The patient underwent an additional procedure on his nose that improved his O2 stats. He is able to breathe better and participate in more activities. In fact, he has started exercising and losing weight, thanks to both procedures and our partnership during his recovery. He joined a gym and works out with his wife three times a week. Now, he weighs 255 pounds!

After persistent follow up and unwavering support, this patient is engaged in his health. I am confident CCM and his increased participation in the program benefited him. When this patient and I began working together, we created a plan with the goal of exercising and losing weight. He is accomplishing his goals! Calling him a couple times a month, checking up on him, and providing accountability has catalyzed this process. This patient relishes the fact that he has completed his goals. I would even say he is overall less depressed as he now looks to the future.

If our practice wasn’t a part of an Aledade ACO, he would not have received this level of lasting, proactive support from someone on his team. Once he no longer needed follow-up appointments, he would have been off his doctors’ radars. But, because the patient had a CCM, he had support in reaching long-term goals, attaining holistic wellbeing, and addressing concerns that arose outside of the doctor’s office.

The support that Aledade has provided has given me tools that I can pass along to my patients. Helping a patient achieve their goals and take monumental steps towards wellness does not happen everyday and in every practice, which makes this story- a true success story- all the more exciting!

Every day, physicians are evaluated by a myriad of sources. Think of all the websites with provider ratings: Health Grades, Angie’s List, and even Yelp. These sites ask patients to review the quality of care provided by healthcare providers, and yet give no control to those who are being reviewed. Now, consider insurance companies and other payers who may provide scorecards based on patient metrics. As physicians, we may see a patient four times out of the year for 15 minutes, but we have no control over how they spend the other 8,759 hours of the year.

Also, take into consideration that no physician gets a perfect score across all of these scorecards. In today’s medicine, anything short of perfection is a “ding.” The reality is that dings are part of the new value-based world, and it’s important that we recognize them for what they are—opportunities for improvement rather than points of frustration.

Let’s face it, medical providers do not like to be judged. Many of us, as physicians, have succeeded in our professions due to our hard work and dedication. But, more importantly, our pursuit of excellence is what sets us apart. Perfection is the gold standard and anything less will not suffice. We believe that our patients’ lives depend upon it.

When we see scorecards produced by a payer and see that we do not meet or exceed all measures, many of us find this as being insufficient in the care we provide. As a medical director for Aledade, my conversation with primary care physicians in our national accountable care organization (ACO) network generally go like this:

The Over-Utilization Ding: Frequent Emergency Department (ED) Visits
“You mean to tell me I’m getting dinged for that guy? There is no way I can keep him out of the emergency room. He loves going there.”

The opportunity for over utilizers “frequent flyers” is to have them utilize you more. Less ED visits are a step in the right direction, so rather than trying to “fix” or “make perfect” one frequent flyer, we will instead attempt to reduce a few visits among all of your frequent flyers. We do this by helping practices expand same day access, teach patients to call the physician first, and add robust care management that targets patients who “love” the ED.

The Over-Budget Ding: Costs More Than Expected
“So what you’re saying is that I am getting dinged for his liver transplant? How am I supposed to control his costs? I am just his primary care physician.”
The opportunity for high cost patients is to start thinking ahead. Ask yourself the “surprise question” are the high costs due to a specific medical condition, like cancer? Would it surprise you if the patient died in the next six to 12 months? If the answer is no, has the patient or family received an end-of-life conversation? If this is not an end-of-life situation, is chronic care management appropriate? Are the costs episodic? If so, there might not be much that you can do besides embrace the ding.

The Quality Measure Ding: Failure to Meet a Seemingly Arbitrary Content Management System Defined By Quality Measures that Make No Sense Clinically
“You mean to tell me I’m getting dinged by a patient with diabetes, who refuses to take my medical advice? I am going to dismiss that patient from my practice so I never get dinged again.”

This particular ding can provide the opportunity to improve quality measure performance for an entire population. Can the measure be addressed across the entire population? Are you leveraging standing orders? Are you seeing poorly controlled patients more frequently until they reach a specific goal? Do you recognize the opportunity to improve your risk coding for these complex patients?

It’s time to rethink the ding. It can feel frustrating to have someone tell you that you are not doing your job well, but embrace the ding and let it be your call to action. Keep providing the best quality care to your patients, always with positive outcomes in mind. If you get dinged, then you will know where you need to get better. Focus on providing better care at affordable costs.

Four years ago, enticed by the vision of a better healthcare system in the hands of empowered and elevated primary care providers, I joined my longtime mentors, Farzad Mostashari, MD and Mat Kendall, on our third collective adventure – Aledade.

Since that fateful day, I’ve served in a handful of roles – teacher, learner, confidante, road warrior, doctor, and mediator. I could write of the way our incredible mission has motivated me, kept me centered and determined, driven me to keep learning. I could explain the feeling I get when one of our Aledade physicians relays to me an a-hah moment, having realized that the Annual Wellness Visit they just conducted just saved a patient’s life, simply by opening up a conversation about the patient’s circumstances and risk factors. I could tell of the pride and exhilaration born of gaining momentum, of extending our reach to new patients across the country.

Instead, I want to share the story of Aledade’s four years through its people.

Year One introduced me to our Chief Technology Officer Edwin Miller, fabled builder of Electronic Health Record systems and incredible humanist, who literally feels the pain of our providers in a way I never thought possible. He shares his passion for working on old cars with his son and has quietly amassed the most incredible t-shirt collection I have ever seen. Edwin taught me what it means to serve our providers, to put their needs first, to dive in and do whatever is necessary to reach our goals.

In that first year, Edwin and I both got to meet Becky Jaffe, one of our original Delaware family physicians, a tireless advocate for the independent primary care provider, and the doctor I would choose for myself or any one of my family members. Becky and our indomitable physician partners in Delaware, Maryland, Arkansas, and Staten Island pushed us to be better and helped us build this incredible rocket ship without an instruction manual (and while flying it). Our first Delaware Practice Transformation Specialist, Robin Senft, taught me that you can accomplish anything with a smile – and a homemade, hand decorated cake pop.

In our second year, we blossomed. I was lucky to get to know so many new members of the Aledade team as our company grew, including Christine Dang-Vu, Golden State Warriors’ number one fan and tenacious, brilliant practice advocate and implementation strategist (and executor). A veritable One-Woman Band, Christine exemplified for me the discipline and work ethic necessary to move the needle in this complex ecosystem.

Our third year introduced me to the miracle of motherhood and the challenges of being a working mom. My daughter Nina became the light of my life on October 21, 2016, and even after an extended maternity leave, I was just not ready to suffer being away from her. My Aledade family rose up around me and held my hand, gracious, gentle and patient. Countless colleagues – friends – counselled and supported me and helped me see that there was a balance and serenity to be gained through persistence, self-love and incremental progress. My eyes were opened to so many awe-inspiring examples of Aledade parents – Candice Cortes, Spring Lane, Joe Neumann, to name a few – who have navigated this complex and often heart-wrenching dance. I can’t imagine going back to a time without Candice’s incredible EHR and practice workflow knowledge, Spring’s enthusiasm, can-do-it attitude and results-orientation, or Joe’s quiet progress behind the scenes to get us the data we need to promote practice change.

In our fourth year, our ranks continued to swell with the most inspiring individuals, personally and professionally. We count among us Peace Corps volunteers, foster parents, mountain climbers, church leaders, yoga instructors, acupuncturists, chefs, world travelers, and rodeo athletes. Every day, my colleagues carry our core values of Grit, Service and Inclusion to their communities. I am so proud and grateful to work alongside this incredible team and I cannot wait to see where, and to whom, Aledade’s fifth year takes us.

Earlier this year, my mom was hospitalized with bilateral multifocal pneumonia and the flu. For most patients her age, these infections would have been unpleasant but ultimately manageable. For my mom, though — a patient with a complicated medical history and multiple chronic conditions — the confluence of these illnesses was devastating. She was having trouble breathing and barely getting enough oxygen into her blood to survive. Doctors and nurses gathered in her room, poking and prodding, dripping and injecting, questioning and documenting. But their interventions failed. She decompensated. As she was rushed to the Intensive Care Unit, I rushed back to Connecticut from Washington, DC to be by her side.

Sitting in her hospital room in the days that followed, I met at least a dozen providers, all of whom introduced themselves to me as “her doctor,” as if saying it aloud would somehow make it true. The reality is that although my mom has been passed among specialists like a prized specimen for years (perhaps ever since her first mitral valve replacement), no physician has been truly “her doctor” for as long as I can remember. She has no primary care champion.

She’s not alone. Nationally, 17 percent of women report having no personal doctor, and among those who share my mom’s Hispanic ethnicity, 32 percent (nearly 1 in 3!) have no health care provider.[1] The statistics are even higher for men. These numbers terrify me: primary care is eroding as independent practice gives way to corporate consolidation. This paradigm shift means that there are millions of patients in the United States who have no healthcare quarterback, whose care is not coordinated, who suffer the acute failures of our fragmented healthcare delivery system alone. Working at Aledade, we are lucky to get to whittle away at those statistics. Aledade partners with independent primary care physicians in 18 states, providing exceptional care and acting as the champion for over 200,000 Medicare patients and more than 100,000 patients with commercial health plans.

I’ve gotten to visit some of these primary care champions as part of my work here over the past year. One of my most salient memories is visiting a practice in Collegeville, PA, and shadowing Dr. Fiorillo, one of Aledade’s partner physicians, as he visited with his patients. I knew from having seen his schedule that his calendar was packed with back-to-back 15-minute visits and no breaks, but the moment he entered a patient room and closed the door it was as if he had all the time in the world. He listened intently as patients described their ailments. He asked about birthday parties and Little League baseball games. He knew them personally, and they trusted him. As a healthcare professional, this was my first experience seeing primary care done the right way.

By the fifth day of my mom’s hospital stay, one of “her doctors” began to start making small talk. We learned his name was Dr. Balboa, and that he was a hospitalist. And though he’d spoken only English on days one through four, on this day he asked her in her native language: “¿De donde eres tú?” Where are you from? “Medellín, Colombia,” she replied proudly. He laughed sheepishly. As it turned out, he was Colombian too. Over the next few days, he got to know her personally and she began to trust him. I was reminded of my visit to Dr. Fiorillo’s office.

As we talked with him, we learned that he used to be in primary care. “But, as a primary care physician, every year you work harder and you make less. And everyone says that primary care matters, but the powers that be have not prioritized primary care. I couldn’t afford it anymore. I had no choice; I left to work for the hospital.” Never had my work or our mission at Aledade felt more personal than that moment. By partnering with independent primary care docs, Aledade helps relieve the pressures of decreasing primary care compensation and increasing regulatory complexity, and in so doing helps keep top-notch primary care physicians like Dr. Balboa independent, allowing them to do what they do best by taking care of patients in their communities.

I am in awe of the work that Aledade’s field staff, my colleagues across the country, do each day, acting variably as advocates, healers, coaches, mentors, counselors, and friends to our providers and to our patients. I am lucky to get to contribute to this work myself as part of our tech team, helping to develop tools and reports that provide insights to our docs and their staff members at the point of care. Together, in partnership across our organization, Aledade delivers insights and knowledge that ensure patients all over the country are getting better care every day.

My mom is out of the hospital now and doing much better, but she still doesn’t have a primary care champion. I worry about her every day. I wonder if her various treatment regimens for multiple chronic conditions are being coordinated, or if there might be an adverse drug-drug interaction hidden within her cocktail of more than a dozen medications. As her son I try to help, but I’m no substitute for a primary care provider. If Dr. Fiorillo were her doctor, I would have nothing to worry about; surely he’d be able to keep track of it all. But alas, for now she’s navigating her healthcare journey alone, as she travels from neurologist to cardiologist and many -ologists in between. I can only hope that one day Aledade might expand into Connecticut — the moment we do, I’ll be sure to take her to visit an Aledade partner physician.

Happy Birthday Aledade. Here’s to many more years of health — for Aledade, and for its patients.

[1] https://www.kff.org/disparities-policy/state-indicator/no-personal-doctor/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D

As a primary care physician in a small, independent practice, my focus has always been on doing what is best for my patients and community. Over the past twenty years, I’ve continued to come back to this idea. My practice, Scott Family Physicians, has become a trusted, connected part of the community. Being an independent physician offers many benefits to my patients.  One example is the freedom to have open scheduling in my practice, allowing patients to set same day appointments, instead of an expensive, unnecessary visit to the ER. It also allows me to serve my community as the high school football team’s doctor every Friday in the fall.

But, running an independent primary care practice also comes with challenges and tough decisions. As the shift to value-based care gained traction, it became clear that this new model was a great way for primary care practices to be rewarded for the attentive, personal care we provide our patients.

That’s why, two years ago, I decided to join the Aledade Accountable Care Organization (ACO) with other local Acadiana primary care physicians. I knew what this meant for my practice, as the transformation to value-based care is an investment of time, staff, and finances, but was confident that we could succeed with our partner independent physicians in the ACO and with Aledade.

And, I am proud to say, now as the Medical Director of the Aledade Louisiana ACOs with over 30 of the highest quality primary care practices in Louisiana, my practice’s decision to embrace value-based care is showing returns in a big way.

Through the Aledade ACO, our group of local, independent primary care practices partnered with one of the largest payers in Louisiana, Blue Cross and Blue Shield of Louisiana. In our first year providing value-based care to our patients covered by Blue Cross in its value program, Quality Blue, we saw great results. Not only did our patients receive better quality care, our ACO achieved significant savings.

Through our clinical initiatives, population health management, and increased ability to access and share data, we reduced our patients’ total cost of care by 8 percent. But, more importantly, we kept them healthier. Our ACO kept patients out of the hospital and ER, reducing admittances from 65 to 57 per 1,000 patients. By focusing on chronic disease management, we helped increase our patients’ rate of control of diabetes (up 13 percent) and hypertension (up 20 percent) significantly. Through improved visibility into our patient population, we could proactively reach out to high-risk patients, identify patients in need of a PCP visit, and conduct more preventive care – such as mammograms, which we saw rise 5 percent across the ACO.

For my fellow physicians and I in the ACO, this is a sign of our hard work paying off. Many of our practices had been delivering this kind of care for years, but in Aledade’s ACO model we now have the technology, access to data, and ability to participate in value programs, like Blue Cross’ Quality Blue program, to see the benefits and results for our patients and practice. For my practice this means we kept our patients healthier and the savings we achieved let me breathe easier as a small business owner. The savings we shared in, can be the difference between keeping clinic doors open and remaining independent or having to close a practice.