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

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

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

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

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

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

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

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

We started Aledade with the goal of building a new model of primary care – one that’s good for patients, good for doctors and good for our society. In just three years, we have brought this new model to more than 200 practices across 17 states – practices who collectively care for more than a million patients. We have brought it to the Medicare Shared Savings Program (MSSP) as well as other payers including Medicaid, Medicare Advantage and commercial health plans.

Our model isn’t easy. It combines both on-the-ground support and a cutting-edge technology platform – one that works with over 60 electronic health records. But it also requires sweat equity – investments of valuable time and effort by our dedicated partner practices and Aledade staff. So, it’s important that we take a close look at how we define success. To us, it’s always been a clear but challenging metric: is what we are doing good for patients, good for doctors, and good for the health system?

For patients, Aledade emphasizes more personal, preventive, and coordinated care – the quality of care that you’d want for your own mother or father. In 2016, both of our ACOs from 2015 improved their quality measures for things like controlling blood pressure and ensuring vaccinations and screenings. Our ACOs, overall, are improving their quality scores, and their patients are taking note. In a recent Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey, Aledade physicians were rated by their patients at an average of 9.3 on a scale of 0 to 10 – above the average for the over 400 MSSP ACOs.

Our practices are doing the right things. They are delivering many more preventive and primary visits, they are reaching out to patients to help them with transitions from hospital to home, they are, for the first time, hiring care coordinators who help those who need extra help. And it works. In every Aledade ACO– not just those that earned shared savings—avoidable emergency room visits dropped, readmissions plummeted, preventable hospitalizations from congestive heart failure, pneumonia, and pulmonary disease fell. Collectively, our ACOs prevented more than 1,500 hospitalizations. Aledade ACO practices are giving their patients better care – and we hear it in their stories, and we see it in the data.

Second, we want to make sure that what we’re doing is good for health care providers. Being part of an ACO has to be valuable, and sustainable, for our partner practices. In a time of increasing consolidation and a health care market that often doesn’t foster real competition, our goal is to help independent primary care practices thrive, and our partner practices succeed in value-based care.

Aledade ACO practices provide more – and more intense – primary care. By conducting more annual wellness visits, helping patients through transitions of care, and implementing chronic care management programs, our practices are seeing a return for their work. By implementing value-based care and practices transformation initiatives, our ACOs redirected health care dollars toward primary care and away from hospitals and emergency care. That is, our practices delivered better care and kept people healthier. The health of their practices did not suffer; in fact, they thrived.

And it’s important to note that they saw these returns in health and the bottom line while also lowering costs for society as a whole. That’s our third target for success.

During the 2016 performance period , Aledade’s ACOs – comprising 142 practices with over 80,000 patients in 11 states (Arkansas, Delaware, Florida, Kansas, Louisiana, Maryland, Mississippi, New York, Tennessee, Virginia and West Virginia) – saved Medicare more than $9.3 million. Five of our seven ACOs came in under the benchmark set by Medicare, and one was right at benchmark. Two of these – in West Virginia and Florida – exceeded the savings threshold so that Medicare will be sending them a shared savings check. We couldn’t be happier for those practices and the teams that support them, and we’re proud to be their partners.

Proud, but not satisfied.

If not for historically-low rates of inflation nationwide and the idiosyncratic way Medicare measures savings, many more of our ACOs would have earned savings. In Delaware, for example, we reduced costs by a whopping 3.3 percent over last year, and we’re on track to do even better in 2017. In fact, research shows that the savings from ACOs are generally undervalued. ACOs should be rewarded based on whether they improved care and lowered costs more than their local competitors – not a nationwide average. We’ve already proposed some improvements to the way that ACOs are measured.

Medicare also offers a regional inflation update to ACOs in their second three-year contract, which means young ACOs face uncertain market dynamics, but ACOs like many of ours, approaching that second contract, will have more accurate benchmarks. The combination of regional inflation for historical costs and regional benchmarking for this year’s costs reward ACOs that have bent the cost curve persistently in their regions, and have the patience and resources to plan for the long term.

The simple answer is that transforming health care just isn’t a simple thing. It takes a lot of work, a lot of creativity, some patience, and some time. But it works. Studies show that the proportion of ACOs that earn savings nearly doubles from year one to year four. We already have data that our ACOs are performing well in their regions. And with our new partnerships with commercial payers and Medicare Advantage, we’re finding new ways to promote value-based care for independent, primary care practices.

We’re on the right track. Our partner practices are taking the right steps. And the data for 2016 proves it. Despite all you hear about our broken health care system, Aledade practices and our staff are working day in and day out to transform health care in our country so that it delivers better care and lowers costs. That’s why Aledade exists. It’s why we’re so committed to our work. And I’m thrilled to see it’s bearing fruit.

The Affordable Care Act (ACA) has created a movement to change the way doctors can be paid; now physicians get paid if they can put in place processes to improve the health of their patients and proactively reach out to their sickest patients. Gain share contracts allow physicians to share in the “gains” of keeping their patients healthy and their cost down. Physicians’ salaries increase now when their care improves the health of their patients. And this payment reform has happened both for Medicare and private insurance payers.

One of the first tenets of our work at Aledade is that all patients benefit from the combination of a strong primary care relationship and population health. Delivering higher quality of care at a lower cost is beneficial for everyone and the quicker payers recognize primary care physicians as partners in that value equation the better for patients, the better for physicians, and the better for society.

Aledade helps independent providers navigate the complexity of commercial contracts, obtain gain share contracts for all their patients, and allows providers to improve their workflows so they can drive down the cost of commercial patients while improving overall health.

This week, we are pleased to announce that Aledade and our partner physicians now have nearly 50,000 commercially insured patients in value based contracts. We are announcing the completion of four gain share contracts with payers in states across the country: West Virginia, Florida, Louisiana, and Kansas. These contracts include Blue Cross and Blue Shield organizations, as well as a state employee self-insured group. Understanding how we got to this point and accelerating accountable care adoption is key to increasing the value of health care for everyone in the country.

Accountable care is at the heart of the transformation of health care promoted by the ACA. The ACA created the Medicare Shared Savings Program and turned Medicare into an accountable care leader. The impact of Medicare embracing accountable care has been profound. In January 2015, the federal government established a 50/90 initiative: a set goal to have 50 percent of Medicare patients in alternative payment models and 90 percent of Medicare fee-for-service payments in value-based purchasing by 2018.

Many commercial payers quickly followed with their own announcements: In March 2015, Cigna committed to the value-based payment goals set forth by HHS, and UnitedHealthcare currently delivers $49 billion in care annually through value-based contracts, or one-third of its total payments, with a goal to raise this amount to $65 billion by 2018. Today, every major national payer has established corporate goals to move their fee-for-services payer contracts to value-based contracts.

In the effort to translate the high-level goals into detailed gain share contracts, payers have developed gain share contracts that bear little resemblance to each other. Our providers are driven by the singular desire to improve their patients’ health, but most of the commercial gain share contracts we review typically have disparate quality measures. It is near impossible for small, independent providers to monitor their performance across quality measures that differ for each patient in their busy schedule. For example, one contract we reviewed included nearly 30 quality measures, yet another contained only nine measures. In addition, most payers use validated HEDIS quality measures, but many payers use “home-grown” measures that are not validated.

There is also significant variation among the key financial terms of each commercial payer contract. This lack of alignment of contract terms presents a barrier to providers negotiating gain share agreements with commercials payers. Add to that the complexity of gain share contracts – and it makes it difficult for an independent primary care provider to negotiate directly.

Yet, when we meet with commercial payers we are almost always met with a willing partner; private payers also want to empower primary care providers to drive down the cost of improving the health of their patients. Aledade offers a unique partnership opportunity, working with independent primary care physicians on workflow, population health and whatever they need to succeed in creating value. Research shows that independent physicians are the provider type most likely to keep costs down (as compared to providers aligned with health systems). At the same time, we are committed to working with the broader payer community to optimize and standardize accountable care design in the commercial space.

Our independent providers are hungry to move all of their patients, not just their Medicare patients, into gain share contracts that can account for patients’ total cost because at the end of the day they are all their patients. Nearly every week we connect with a new payer partner who shares the same goals for better value for the nation’s health care dollar. We look forward to continuing to work across the country with physicians, payers and patients to improve health and health care value.

When Aledade launched in June of 2014, we were a small, passionate staff fundamentally committed to a big idea: that independent primary care providers were uniquely positioned to help lead the biggest shift in the American health care system in more than a generation. We believed that if these doctors received practice support, technology, analytics, and regulatory expertise from a true partner, they could reassume their role at the center of their patients’ care – delivering the highest-quality care while bringing down costs across the health care system.

By the beginning of this year, we had partnered with 80 primary care doctors across four states, taking accountability for the care of more than 20,000 Medicare patients. Throughout 2015, we helped these physicians increase vaccinations and preventive care for their patients, decrease hospitalizations, and make investments that will keep patients healthier for years to come. We equipped these doctors with customized platforms that tie together EHR and Medicare claims data, enable them to connect with their high-risk patients, and provide instant notifications when their patients are admitted, discharged, or transferred between care facilities.

But we knew that 2015 would simply be the start.

So today, we are proud to announce that the Center for Medicare and Medicaid Services (CMS) has officially recognized five new Aledade ACOs:

• A Kansas-based ACO contracting with Kansas Foundation for Medical Care, Inc. for practice support
• A West Virginia-based ACO, centered around Charleston, in partnership with the West Virginia Medical Institute
• A Central Florida-focused ACO, partnering with Primary Health Partners LLC
• A Louisiana-based ACO, in partnership with the Louisiana Health Care Quality Forum
• A Mississippi and Tennessee-based ACO, partnering with the Mississippi Academy of Family Physicians, Arkansas Foundation for Medical Care, and Q Source

Beginning January 1, 2016 – less than 18 months after we started this journey – our team grew to include more than 700 physicians in over 110 practices, Federally Qualified Health Centers (FQHCs), and Rural Health Centers (RHCs) across 11 states. We are now responsible for nearly 100,000 Medicare patients, and more than $1 billion in health care expenditures.

In the year and a half since we founded this company, the health care system has accelerated its shift towards outcome-based health care. Early last year, the U.S. Department of Health and Human Services (HHS) set a goal of tying 50 percent of fee-for-service Medicare payments to quality or value through alternative payment models by the end of 2018. It was the first time in the history of the Medicare program that HHS has set explicit goals for alternative payment models and value-based payments. In April, the Medicare Access and CHIP Reauthorization Act set a foundation for Medicare’s outcome-focused future. Today, seven in 10 Americans live in an area served by an ACO.

As policy tailwinds have delivered additional momentum, we’ve continued to grow our team and doubled (and tripled) down on our emphasis on preventive care, our development of customized technology for Aledade practices, and the uniquely aligned financial partnership we have with our physicians.

In 2016, we will continue to expand initiatives that have already helped improve our doctors’ practices:

• Care management interventions for specific chronic conditions.
• Behavioral health interventions to support patients battling depression and anxiety.
• Tools and approaches to help ensure patients get the care that aligns with their personal goals at end of life.
• Skilled nursing facility (SNF) transition strategies to ensure patients receive effective care in a SNF and safely return home.

In 2014, Accountable Care Organizations saved Medicare nearly a billion dollars while improving on 80 percent of CMS quality measures – and most observers agree that both the quality and savings effects of these organizations will only grow as ACOs mature. Recent surveys have confirmed what doctors across the country already know – the health care industry’s move towards value-based payment is now inexorable. The question for most physicians – especially those in small, independent practices – is how to navigate this new health care economy.

Aledade was founded to provide an answer – and a resource – for these very doctors. Today’s CMS announcement proves that the appetite for our model, our team, and our services continues to grow. So too does our commitment to our practices and their patients. As we move into next year, our greater scale will enable us to draw more insights about the best way to keep health care costs down and the health of our patients up.

Five years ago, I sat in an imaging center in southern Florida as a group of independent physicians discussed the newest – and one of the most unfamiliar – concepts in the world of health care: Accountable Care Organizations (ACOs). What were they? What were shared savings? Would ACOs force all of these doctors to give up their independent practice and be subsumed by hospitals? As lively discussion escalated to more heated conversation, I was struck with one thought.

If ACOs had the potential to be this disruptive to the status quo, I needed to be involved.

I decided then to learn as much as possible about ACOs and the Medicare Shared Savings Program (MSSP). As one of the doctors said to me at the time, “We – physicians – want to be part of the solution.” But too many of these doctors had no idea how. With ACOs, I saw a chance to empower independent physicians, and place them back at the center of their patients’ care.

Months later, the organization I co-founded – Palm Beach ACO – received the first number in the history of the Medicare Shared Savings Program: A1001. When our program year began on July 1, 2012, we were one of the only ACOs to be physician-led; 78% of our doctors were solo practitioners. When our year one performance results were tallied, we generated $39 million in savings for Medicare – including $19 million for our own doctors.

Since then, I’ve helped build successful physician-led ACOs – leading my own firm and consulting physician-led groups,while also working with CMS to identify the parts of MSSP that are working, and those can be improved.

So today, I’m ecstatic to announce I am joining Aledade as a Senior Advisor and Executive Director of the Florida Division.

ACOs present a unique opportunity for primary care physicians to be at the forefront of positive, industry-wide change – I’ve been fortunate to work with other visionary physicians who share the mission, values, and passion for that transformation.

But I joined this company for two specific reasons.

First, Aledade has assembled an all-star team of health care policy, technology, and operations experts unmatched anywhere else in the field. With Farzad and Aledade, I’ve found a home that enables me to share this vision for health care with the widest possible audience. Over the last four and a half years, I’ve spoken with around 2,000 doctors – they’ve told me what they need to succeed in providing the highest quality care while improving outcomes and lowering costs. Aledade shares that understanding, and instead of spending time and energy simply fighting rules, this team has embraced them – and wants to work within those rules to maximize the impact and efficiency of independent doctors.

Second, Aledade couples that vision and passion with the most sophisticated approach to creating and operating ACOs that I’ve seen anywhere in the field. Aledade is able to understand the intricacies of electronic health records, health information technology, and interoperability – because members of the team here were integral in creating the rules that govern this technology. Our success in South Florida was predicated on empowering physicians. But integral to that strategy was using data to drive strategic decisions about patient outreach and intervention.

In my time with Aledade, their approach to the same problem is miles ahead of where most ACOs are. Aledade’s understanding of interoperability enables them to mine data from public domain or outgoing billing claims (instead of waiting for returned claims); the team’s analytic capability turns this raw data into actionable information for their partner doctors – highlighting patients at the highest risk, those in need of more outreach, and those in need of intervention before serious health problems develop or worsen.

No other team combines Aledade’s commitment to the triple aim of health care improvement with the technology capable of empowering independent physicians to lead the way. As I embark on my first assignment – recruiting primary care physicians to form an Aledade ACO in Florida – I couldn’t be more confident about this team’s ability to help physicians lead the way in transforming medicine, or more excited for the work ahead.