Two decades ago, I was fortunate to find myself at a company that revolutionized everything we knew about communication, media, technology, and by extension, almost every aspect of our lives; that company was America Online. In many ways, the same innovative spirit that brought me there is what brings me to Aledade now as our first Chief Commercial Officer.

The work Aledade is doing to put primary care at the center of medicine, accelerate the shift to value, and usher in this new era of health care is no less revolutionary than those first dial-up connections to the Internet 20+ years ago.

This is a time of great transformation in American health care. The combination of new technology plus new rules of the road, aided by growing consumer awareness of health care economics, means that this industry needs to reinvent itself. And as I saw in the early days of the Internet, those with outside perspectives and a commitment to embracing the future can be powerful agents of change.

It’s this state of change and the potential for positive impact that brought me to the health care industry seven years ago, first at WellBridge, then at Avalere Health, and now here at Aledade.

What makes Aledade so appealing is that for me, our mission is personal. Before he retired a decade ago, my father was a primary care doctor in Pittsburgh who cared passionately for his patients. I remember him answering late-night phone calls, taking the time to listen to his patients and their families, providing them his care and attention when they needed it the most. And, to this day, he continues to teach medical students the art of doing a physical and taking a medical history. He continues to receive letters and calls from people whose lives he touched – and even saved, not to mention the wonderful emails he still gets from his med school students.

Aledade’s model of primary care brings this same type of personal, high-quality medical care to hundreds of thousands of people across America. It’s that vision of what primary care was – and can be again – that motivated me to join Aledade. Because without a doubt, this company has the right team, the right care model, and the deep expertise in everything from technology to regulations to transform health care and improve the health of millions.

At Williamson Health and Wellness Center in West Virginia, we understand the importance of chronic care management for patients, our practice, and the health system. When not effectively controlled by providers and patients themselves, chronic conditions put a hefty burden on the health system by over-utilizing care services that generate sky-high costs.

To avoid this problem at our practice, we implemented a team-based Chronic Care Management program in 2012. With the Central Appalachian Health Alliance, we received a grant from Duke University’s CMS Health Care Transformation project to test the effectiveness of using community health workers to manage the care of high-risk diabetic patients. That program’s success led us to expand our care coordination network and provide community health workers to all high-risk patients with chronic conditions.

Our program has produced phenomenal results. We use the Aledade app daily to identify and prioritize high-risk patients. We’ve expanded practice hours and implemented an after-hours phone line. And, we’ve improved patient information and care coordination with the local hospital.

One recent example hit home as evidence that our Chronic Care Management program is making a real difference.

One of our patients with chronic obstructive pulmonary disease (COPD) had a habit of seeking care at the emergency department (ED) once or twice a week. This patient had serious anxiety about his COPD and saw emergency care as his only option when he had trouble breathing. Due to his condition and anxiety, we decided to enroll him in our Chronic Care Management program.

Once enrolled, the patient received additional care services, including weekly home visits from community health workers – who reduced his anxiety, taught him how to better manage his COPD with practices like breathing exercises, and helped him understand resources other than the ED that he could use when he needed outside help. Community health workers are absolutely vital to our program, working on the “front line” to deliver care, assess risks in patients’ daily lives and homes, and educate patients on self-management.

In addition to those visits, the patient received comforting check-in calls every Friday – when he typically went to the ED – from our practice staff. We also set-up a standing order of Solumedrol, which had proven effective for the patient, at the ED should he seek care there.

The good news: he hasn’t been back. His results have been stunning. The patient who previously went to the ED up to twice a week has now gone six weeks without returning. The Chronic Care Management program has had a huge impact on his life and avoided a dozen ED visits, also easing the strain on hospital providers and slashing the cost of care.

While this is an exceptional example of success, we’ve seen team-based Chronic Care Management work time after time for patients with all forms of chronic conditions. We look forward to sharing more turnaround stories with you!

As a physician in Mississippi, I am acutely aware of the health care challenges facing our state. Mississippi has one of the highest morbidity and mortality rates in the US while also being handicapped by the lowest saturation of doctors per capita in the US.

Together, this means that Mississippi has some of the sickest patients and fewest doctors. This is an incredible burden for the provider community.

However, it is also a call to action for physicians in Mississippi to work together. Coordinating care is important no matter the circumstance, but in the demanding environment Mississippi providers face, it also becomes essential to deliver high-quality, cost-efficient care.

Let me give you an example in my own practice.

As a retina specialist, one of my primary focuses – perhaps surprisingly to some – is diabetes. Diabetes is the number one cause of blindness in Americans under the age of 70, and Mississippi has the second highest rate of diabetes per capita in the nation.

As a result, I work closely with primary care physicians to help manage chronic conditions like diabetes. A key part of this, are the often overlooked – but highly preventive – diabetic eye exams, which I perform daily.

When primary care physicians and eye doctors work together, we can save people’s eyesight, improve their health, and prevent skyrocketing costs. Moreover, since blindness severely affects not only patients’ lives, but also those of their friends and family, this type of care affects the entire community.

When I coordinate care with primary care physicians – like those in the Aledade ACO – I also report back to them what I see in my exams. For instance, eye exams routinely reveal the first signs of a patient’s risk for conditions such as vascular disease, kidney disease, and even a heart attack or stroke. When I see these signs during a patient’s eye exam, I can relay my observations to their primary care physician and recommend additional care or tests. At its best, it’s a two-way street of information between primary care doctors and specialists, and when that happens, those that benefit are the patients.

By coordinating care, we are easing the burden providers face, while ensuring our patients receive the highest quality, most cost efficient care possible.

The first year of our Aledade Louisiana ACO has been marked by excitement, growth, cooperation, and a deep commitment to population health. But, even as our network of providers and partners strives daily to improve quality of care through better coordination, we face a new challenge. This week, Louisiana experienced a 500-year flood in the areas surrounding our ACO. The Aledade family sends its heart out to our Louisiana ACO providers and patients affected by the flooding.

While no one can be fully prepared for the impact of a natural disaster, we are confident the primary care physicians in our Louisiana ACO are ready for the challenge ahead. The 2016 Aledade Louisiana ACO is made up of five leading practices in Acadiana committed to delivering the best possible care to the communities they have long served. In conjunction with our seven (and growing) new practices in our 2017 class, these providers will now serve as the first point of contact for thousands of patients who have been without medications, home monitoring, and even cell phone contact with their health care providers for the better part of a week.

One recent Aledade initiative has been particularly vital in helping the ACO respond to this disaster. This spring, Dr. Joshua Israel joined Aledade as the Mental Health Director. In this role, Dr. Israel leads Aledade’s efforts to integrate mental health into primary care practices. One in five American adults suffers from a mental health condition, and mental health treatment costs are $100 billion annually. Given this, ACO physicians who are responsible for their patients’ total health and cost of care must be prepared to manage their patients’ mental health issues. As the front line in a patient’s health care, primary care physicians are well positioned to identity, manage, and coordinate their patients’ mental health needs given their unique knowledge of and relationship with patients. In his first days at Aledade, Dr. Israel helped connect practices with behavioral health resources in a similar tragic flood in West Virginia, and he has helped us in Louisiana quickly provide our employees with tools to help our practices on the ground.

In addition to strengthening care capabilities through Aledade initiatives, the Louisiana ACO practices have benefited from local organizations committed to advancing value-based care. In particular, one local partner, iMedCORE, has become a great asset for their expertise in value-based care and the tools providers need to deliver it. In Louisiana, iMedCORE has led education efforts to support the shift to value-based care among Aledade providers and throughout the greater provider community. When expanding our network locally, we look for partners committed to helping our providers better serve their patients through care coordination, and iMedCORE has been working hard for our members to do just that.

That said, perhaps the biggest development for our Louisiana ACO this year is our partnership with Blue Cross and Blue Shield of Louisiana. As the first organization to bring a progressive group of independent physician practices to the Blue Cross of Louisiana Value Program/shared savings contract, Aledade has helped to align the payers and the practices as never before – setting the stage for future independent practice partners. We have also created a model for other Aledade ACOs to reach out to and better negotiate deals with the largest payers in their states.

The most effective piece of the partnership is Aledade practices’ access to Blue Cross patient data all integrated into the Aledade app. What this means is that rather than using two separate patient registry and care management platforms, the ACO primary care doctors can use the same technology for across their patient population – whether public or private payer. Not only does this reduce practices’ administrative and technology cost burdens, but increases practices’ ability to conduct population health management that leads to better health outcomes and lower costs.

At Aledade, our goal is to partner with primary care doctors to help empower them to deliver the highest quality care in a value-based health care system. While no community should have to deal with the terrible effects of a natural disaster, we are proud of our ACO providers in Louisiana who we know will fight through this challenge to support the communities and patients they care for so dearly.

Yesterday, Aledade announced that we are forming the first primary care physician-led accountable care organization (ACO) in Arkansas. We are proud to bring independent doctors in Arkansas a new model of primary care that will allow them to stay independent, focus on delivering high-quality care, and be rewarded for keeping patients healthy.

ACOs are part of a significant transformation in health care to value-based care – care in which doctors are reimbursed not for the number of tests or procedures they undertake, but in how successful they are in managing the health of their patients. In Arkansas, practices in the Aledade ACO will benefit from Aledade’s regulatory expertise, best practices from our nationwide network of primary care doctors, technology and data analytics, and in-person practice transformation support.

However, ACOs are not the only way for Arkansas doctors to participate in value-based care.

Earlier this year, the Centers for Medicare and Medicaid Services (CMS) announced a massive new pilot program called Comprehensive Primary Care Plus (CPC+). CPC+ is designed to help practices build capabilities and care processes to deliver better care by offering them greater financial resources and flexibility in care delivery. The goal of CPC+ is to strengthen primary care to enhance the quality of care patients receive, improve patients’ health, and spend health care dollars more wisely.

CPC+ does this by paying physicians monthly care management fees tiered to the patient’s level of need; different from the current “one-size fits all” Chronic Care Management fee that practices have been using to support comprehensive patient care. These payments provide physician practices with much-needed resources to invest in the capabilities and tools to effectively manage population health and the total cost of care.

The good news is that, as Aledade had hoped and proposed to CMS, CPC+ is open to physician practices that are also participating in the MSSP ACO program. Furthermore, CMS recently named Arkansas one of the regions in which CPC+ is being implemented. Together, this means that practices in the state can participate in both CPC+ and the Aledade ACO. The unique combination of CPC+ and the ACO gives both the resources necessary to improve patient care and the incentives to reduce the total cost of care. Upfront care management fees and support with the ACO’s primary care-led efforts to generate shared savings offers great promise in the goal of improving care quality and lowering costs. For physician practices, this means getting the upfront financial resources and support to improve care access, care management and coordination, and patient engagement, while also being rewarded for the resulting improved health outcomes through ACO shared savings payments.

Aledade will help its partner practices in CPC+ work to fulfill the program’s practice, reporting, and care management requirements, much of which align with the efforts Aledade practices are already doing as part of an ACO. Aledade also will continue to monitor what comes out of Washington so that its doctors can understand, adapt, and thrive under whatever new rules or programs are introduced.

A lot is changing in health care delivery, and Arkansas is no exception. With these models and with the right partners, I am confident it will mean better health care for Arkansans and thriving practices for their doctors.

 

Over the last eight months, my solo practice in Delaware has seen a 60 percent reduction in our monthly Emergency Department (ED) utilization rate. How have we accomplished this? We have undertaken a number of measures to reduce unnecessary ED utilization since joining the Aledade Delaware ACO, but clear communication – both with our patients and with other providers – has made a tremendous difference.

 

I have always put a focus on being available for my patients. Patients can contact someone from my practice 24 hours a day, seven days a week, and 365 days a year. I know the value – in health and peace of mind – access to a doctor delivers for patients.

 

As part of joining the Aledade Delaware ACO, my practice placed an emphasis on strengthening our communication with our patients to ensure they know they can – and should – contact my practice about any health need at any time on any day or night. I have reinforced this principle through clear communication during patients’ visits to my office, through my office staff, and with signs in our waiting room, provided by Aledade, reminding patients to call us before they go to the ED or hospital. I also proactively identify frequent ED users in my patient population with the Aledade App, which helps me create a dialogue with these specific patients, while better understanding their health concerns and needs.

 

During a recent weekend, I received a call from a patient suffering from a cough. Comfortable the patient did not need to seek medical attention immediately in the ED, I arranged a convenient time to see him in the office the next day. Alternatively, I recently advised a patient with chest pain who called after hours to seek immediate medical attention. Given the severity of his medical issue, I called the hospital and had him directly admitted, bypassing what would have been a costly ED visit that would have resulted in a hospitalization.

 

As a solo physician, I know it takes support to provide this level of communication and service to my patients.  Dr. William Funk, a fellow member of the Aledade Delaware ACO, and I alternate our weekend on-call hours to benefit both our patients and our schedules.

 

Delivering high-quality care takes much more than clear communication. However, establishing communication between patients and providers goes a long way to increase the quality, timeliness, and cost of care. Ultimately, this benefits our patients’ health and well-being, and that’s what value based care is all about.

 

 

When CMS released its proposed MACRA rule in April, Aledade immediately dove in to understand how it would influence important issues ranging from health care market competition to the advancement of health IT. Overall, we believe the rule is a step in the right direction toward creating greater value in health care and encouraging the move of eligible clinicians out of fee-for-service and into advanced alternative payment models (AAPMs).

 

However, we believe there are some changes that CMS could make to help create a path for independent practices to thrive, deliver high quality care, and reduce costs. We highlighted these changes in a formal comment letter to CMS during the recently closed public comment period.

 

One of the primary changes we called for focuses on the “more than nominal risk” taken on by practices participating in AAPMs. Specifically, we believe that the level of financial risk needs to be more than nominal as it relates to the organization.

 

With nearly 50 percent of eligible clinicians still in small practices, health care organizations of all sizes must consider AAPMs a viable option. The proposal to base the determination of “more than nominal” on the benchmark of the APM will not succeed in moving more providers to financial risk. If left unchanged, the rule will create vastly different amounts of risk depending on the type/size of the organization and depending on the APM model.

 

Instead, as we said in our formal comment to CMS, we explained that we believe financial risk would be best measured as a percentage of revenue so that the risk is based on the size of each organization. We proposed:

 

“CMS should base the level of risk on how much revenue the organization and/or its members received from Medicare. This approach was appropriate for Medical Home Models and will also make sense for all APM entities at a higher threshold. We propose 15% of the APM Entity’s participant aggregate Medicare Parts A and B revenue.”

 

We told CMS this is the single most important policy change it could make for the implementation of MACRA and is absolutely crucial to encouraging eligible clinicians to embrace AAPMs.

 

We are happy to see that many of our peers agree with our assessment.

 

On the risk provision, the American Academy of Family Physicians (AAFP) said: “Entities of all sizes will be able to assume varying levels of risk. It is critical that CMS ensures the success of these entities by allowing for risk structures that will support this success.”

 

The American College of Physicians said a revenue-based risk level “would reflect significant nominal risk to the practices within the entity, but not place them in unreasonable financial jeopardy.”

 

Others voiced support for a revenue-based level of risk, including:

  • American Medical Association
  • Federation of American Hospitals
  • Health Care Transformation Task Force
  • Medical Group Management Association
  • National Association of ACOs
  • National Committee for Quality Assurance
  • Premier

 

Aledade hopes that when CMS reviews all of the comments and finalizes the rule, it considers making these small but important changes that will benefit patients, doctors, and the health care system overall.

At Complete Family Care, we’ve learned that a small magnet can make a big difference. Since the start of the year, we’ve been giving magnets to all our Medicare patients. The magnets have a simple message: “Call Before You Go.” It’s a reminder to our patients that we have a doctor on call 24 hours a day, and if they are feeling ill, they should call us first. In recent months, we’ve seen that the magnets have had an impact.

One story vividly illustrates how the magnets are helping patients avoid unnecessary Emergency Department (ED) visits. A Complete Family Care patient with a history of congestive heart failure started to have lower extremity edema late at night. This was the seventh time over the last several months he had swelling in his legs, and every time, the patient went to the ED. Each time the swelling was not a blood clot. After receiving the magnet, the patient decided to call Dr. McBratney. After reviewing his medical history, Dr. McBratney talked to the patient and recommended he take an extra Lasix pill. By morning, the swelling had gone down, and the patient avoided a costly and unnecessary ED visit. We believe that reducing unnecessary ED visits is both good medical practice and good business sense. Patients do not want to spend hours in an emergency room when there are better, less costly options.

Another example highlights how the magnets can aid transitions in care management. A Complete Family Care patient was having a hypoglycemic event, again late at night. His wife called 911, but then, triggered by the magnet, remembered to contact the on call doctor as well. She told the on call doctor that her spouse was on the way to the ED, enabling the doctor to contact the ED and provide background information on the patient. That one-minute phone call helped the ED better prepare to receive the patient and our office was able to follow up with the patient upon discharge.

At Complete Family Care, we believe patient communication is paramount. Having a doctor on call reinforces that we care about our patients and will respond to their needs and concerns all hours of the day. We take pride in providing high quality care, and we recognize that an important aspect of quality care is peace of mind. Patients take comfort in knowing they can reach a doctor at any hour, even if they never need to.

While the magnet isn’t the answer to everything, even in this digital age of emails, texts, and smartphones, sometimes a reminder posted on the fridge next to photos of the grandchildren can be the best medicine.

One of the keys to ACO success is ensuring that patients get the right care in the right place at the right time. 95 percent of Aledade’s physician partners provide 24 hour-a-day, seven-day-a-week patient access to an on-call doctor.  But what happens if a patient has an urgent health need after hours that can’t be addressed over the phone? Is the Emergency Room the best option?

Urgent care clinics offer an additional care option for patients, which significantly/crucially/measurably expands access to care. These clinics offer patient-friendly hours and a quicker, less costly care option than hospitals, when a primary care physician is not available. When urgent care centers are too far away or closed, patients resort to going to the ED. At the ED patients face chronically long wait times, expensive and often unnecessary care. It also may be difficult to reconcile patient records after a visit to the ED.

Effective urgent care clinics exemplify the key to coordinated care:  getting the right care at the right time in the right care setting. Urgent care centers can also make significant strides in reducing the strain on overcrowded hospitals, decreasing the wait for care, and shortening the distance patients travel for care – all while achieving the value-based care goal of high-quality care at lower costs.

For physicians, urgent care clinics ensure their patients are getting the care they need when they need it. And, by partnering with urgent care clinics, primary care physicians can be notified of when their patients receive care, get clinical notes and records, and coordinate transitional or follow up care. This informational sharing partnership is especially important for ACO physicians – as this care coordination updates physicians on pertinent information, helps keep patients out of the ED and hospital, limits unnecessary or repeated tests, and reduces overall costs.

Aledade’s Delaware ACO recently established a care compact with a large group of local urgent care clinics. This care compact enables data and record sharing between the urgent care clinics and Aledade ACO partner practices, improving patient care at the clinics and rounding out/filling in ACO practices’ knowledge of their patients’ care. To ensure patients are receiving the highest quality of care in an urgent care setting, Aledade has instituted a monthly case reviews with the urgent care center’s clinical team. In addition, Aledade plans to monitor key quality measures over time, ensuring the urgent care center is a good alternative for patients to obtain access to care as an alternative to the emergency department.

The Delaware urgent care clinic agreement is an important example of one the many ways Aledade is working to encourage and improve urgent care throughout our ACOs. Urgent care centers play a vital role in an effective, value-driven health care system. In each of our ACO markets, Aledade is looking for ways to model Delaware’s care compact, which both coordinates care between our ACO practices and urgent care centers, as well as expands access to urgent care for our ACOs’ patients.

However, in some areas where Aledade’s ACOs operate, urgent care clinics are few and far between.  In these cases, Aledade and our ACO partner practices have to get creative – finding the best ways to expand PCP availability to patients in order to compensate for a lack of other nearby providers.

Recently, physicians from one of Aledade’s Primary Care ACO  partner practices, the WVVA Health Care Alliance, came together to form their own urgent care clinic, providing access to care for the communities of western Virginia and southeastern West Virginia. Known as Alliance Express Urgent Care, this new clinic has not only expanded access to care for the community, but lightened the care load for the local hospital by seeing up to 50 patients per day. As an urgent care facility run by the local primary care physicians, Alliance Express is in full communication and coordination around patients’ care. After each patient visit, the urgent care provider calls the patient’s primary care doctor to fill the physician in on the patient’s health and health care needs.

Aledade believes that urgent care clinics play a vital role in the health care ecosystem, and Aledade is committed to partnering with and increasing access to urgent care clinics across all of our ACOs where possible. By connecting primary care practices with other health care stakeholders, we can help deliver coordinated, high-quality care.

 

The two strongest external forces for creating value are aligned incentives and competition. As the largest payer of health care in the world, the federal government is in a unique position to promote both. With the incoming Baby Boomer generation putting continued fiscal pressure on Medicare, creating greater value in health care is imperative to Medicare. How CMS sets up the new payment system under the MACRA law is critical to accelerating the transition from volume to value. As CMS considers the final rules for how to implement this law, we believe that there is an opportunity to use this new payment structure to increase aligned incentives for small physician practices and foster robust competition among health care providers. Both are critical to hasten the move of eligible clinicians out of fee-for-service and into advanced alternative payment models (AAPMs), a goal that the drafters of MACRA, the President, and many in health care agree on.

Of course, aligning incentives and fostering competition can conflict. Yet, one thing both goals have in common is the centrality of the independent, primary care physician practice. Responsible for a patient’s overall health and health spending, primary care doctors play a critical frontline role in controlling spending and delivering care[i]. In such a world, the independence of primary care physicians is important because any pressure to serve a larger health care system could run counter to these goals. These physician-led ACOs may lack the capital and resources of their hospital-owned brethren. However, they have the ability to act more nimbly with no internal conflicts between a business model predicated on hospital admissions, and a different one based on preventing them[ii]. This is why it is essential that independent primary care physicians are supported, not squashed, by these new rules.

To both move every physician who is ready towards aligned incentives and to foster competition, we encourage CMS to evaluate the MACRA implementation using these principles:

  • With nearly 50 percent of eligible clinicians still in small practices, health care organizations of all sizes must see themselves in AAPMs. Specifically, for MACRA implementation, the level of financial risk needs to be more than nominal as it relates to the organization, otherwise CMS policies will inevitably favor one type of organization over another.
  • Competition plays a key role in value creation even in health care. This is particularly true in the private health insurance market in which CMS now is a major participant through the Exchanges. CMS along with the FTC and DOJ must be vigilant in preserving competition.
  • Beneficial network integration does not have to be sacrificed to preserve competition. Through health information technology and aligned incentives, independent health care organizations can come to together to create beneficial networks that do not rely on hierarchical ownership structures. These groups go by many names — such as accountable care organizations, conveners, or virtual groups. CMS should support the concept that clinicians can be integrated in their delivery of health care without being in the same corporate structure.

In particular, if CMS creates AAPMs that favor larger organizations, further consolidation will occur, thereby eroding competition. The goal should be that no one will be able to claim that “MACRA forced me to consolidate.” To ensure this does not happen CMS should

  1. Define “more than nominal financial risk” such that smaller practices are motivated but do not face an existential threat. We propose basing financial risk on the participating APM Entity’s Part A and B Medicare revenue, and a pathway for making it available in time for 2019 payments.
  2. Allowing independent practices to come together in “virtual groups” now for all aspects of MIPS reporting, and rewarding their clinical practice and health IT advances as they work towards participation in APMs (like gain share only ACOs) and on to AAPMs.
  3. Providing administrative flexibility for these small businesses by comparing their performance under MIPS to that of their peers by practice size.

By making these small, but important, changes to the implementation of MACRA, we believe that CMS will create a path for independent practices to thrive, deliver high quality care, and reduce costs. This will benefit patients, doctors, and the health care system overall.[iii]

[i] Mostashari F, Sanghavi D, McClellan M. Health Reform and Physician-Led Accountable Care: The Paradox of Primary Care Physician Leadership. JAMA. 2014;311(18):1855-1856. doi:10.1001/jama.2014.4086.

[ii] The Paradox of Size: How Small, Independent Practices Can Thrive in Value-Based Care Ann Fam Med January/February 2016 14:5-7; doi:10.1370/afm.1899

[iii] J. Michael McWilliams, M.D., Ph.D., Laura A. Hatfield, Ph.D., Michael E. Chernew, Ph.D., Bruce E. Landon, M.D., M.B.A., and Aaron L. Schwartz, Ph.D. N Engl J Med 2016; 374:2357-2366 June 16, 2016 DOI: 10.1056/NEJMsa1600142