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!

Recently, I had dinner with some of my fellow family physicians and, typical for our group, our conversation ranged broadly. After discussing our favorite basketball teams’ odds of making the final four, we wound up talking about one of the biggest buzzes in health care today: the shift to value-based payment.

The conversation is moving beyond the fact of change to the pace of change acceleration.

Medicare is making this move because value-based care is improving patient outcomes. Increasing preventive medicine services, lowering hospitalizations and readmissions, and performing fewer unnecessary procedures means better medicine for both patients and their healthcare teams. The move to a value-based system is also saving money; in 2016, Medicare accountable care organizations (ACOs) generated more than $652 million in total savings. The private sector is not far behind, with a large coalition of health systems and insurers starting similar initiatives.

For primary care physicians, the implications of this shift are becoming clear. We understand the basic concept of value-based care: rewarding physicians for quality outcomes instead of volume. We are learning that providing value-based care empowers us to put the patients’ health first. A significant question remains: how can independent primary care doctors operate in this new environment?

While many of us feel we have the skills to be strong champions in leading this change, we lack the large-scale tools, regulatory fluency, and dollars to do so without sacrificing the qualities that make our practices our own. Negotiating with an insurance company or digesting volumes of government regulations aren’t skills often taught in medical school. Spending time learning those things in the midst of adopting new technology systems, adhering to regulatory requirements, and overhauling the practice payment structure distracts physicians from doing the job we love most: taking care of our patients.

The solution for independent practices may come from an unexpected direction: through innovative partnerships that don’t require geographic co-location or practice-based infrastructure. Three years ago, my practice made the decision to partner with an organization that believes patients must be at the center of value-based care, and that physicians are happiest and best utilized when providing that care to patients. I have served as the medical director for a Kansas-based ACO with Aledade, Inc. for three years.

I have seen the Aledade model provide support for the business, technological, administrative, and regulatory work of the ACO without placing a burden on my practice. The partnership allows each party to focus on what they know best: the practice takes care of the patient population and Aledade takes care of the infrastructure. The success of each partner is dependent on the other, which aligns priorities and goals across the organization.

Value-based care is the future of health care. From independent practices to large systems, we must adopt innovative strategies to accelerate the pace of change. Our physicians need it, our patients deserve it, and our healthcare system depends on it.

It was my second day at Aledade when someone told me to get out.

I thought it was a bit early to be fired, but the new colleague sounded convincing enough. I assumed they knew what they were doing.

Luckily, this wasn’t some drastic HR move. It was the first of many times that I’d hear, “You have to get out into the field. Go visit a practice.”

It’s a mantra here at Aledade. Everyone, even the current and former health care professionals on staff, seemed to have a story of the first time they visited one of Aledade’s partner practices. They all said that setting foot in a practice is the best way to find out what works, what doesn’t, and to get a sense of just how challenging and rewarding it is to work in an independent primary care practice today.

So when I first got the chance to visit Kansas, tagging along with New York Times columnist Farhad Manjoo as he worked on his new piece about Aledade’s work, I hopped on a flight to Wichita.

Before joining Aledade, I worked on the public affairs team at the U.S. Department of Health and Human Services. We promoted Open Enrollment for the Health Insurance Marketplace, talked about programs like Head Start, and got key messages out to the public about health threats like Ebola, Zika, and the opioid epidemic. But there was one story we kept coming back to – the future of health care.

We saw it every time we heard from doctors, and every time the Secretary visited a practice. Data had opened up new frontiers. Patients now had the tools to get engaged in their own care. And payment systems focused on value were starting to reward physicians who kept their patients healthy. There was a palpable sense that you could deliver better care and start to lower costs.

It seemed like everything was pointing down this path. Policymakers from both sides of the aisle saw the promise in this new approach. MACRA, the law that changed Medicare’s payment system into one that rewards the value of care, passed the Senate nearly unanimously and the House overwhelmingly. And down the street at HHS, the Department made a historic commitment – saying that, by 2018, half of all payments in Medicare would be payments that rewarded the value of care, not the old fee for service system.

But it wasn’t until I visited Aledade’s partner practices in Kansas that I realized how far down the path these health care professionals already were.

On Wednesday, the New York Times’ Farhad Manjoo published his piece, and he captured this well. “Thanks to Aledade,” Farhad wrote, “the [Kansas] practices’ finances had improved and their patients were healthier. On every significant measure of health care costs, the Aledade method appeared to have reduced wasteful spending.”

Here’s an example of how they were keeping patients healthy:

For example, say you’re a doctor at a small practice in rural Kansas and one of your patients, a 67-year-old man with heart disease, has just gone to the emergency room.

“In the past, we’d only find out our patients were at the hospital maybe weeks afterward,” said Dr. Bryan Dennett, who runs the Family Care Center in Winfield, Kan., with medical partner, Dr. Bryan Davis. With Aledade, Dr. Dennett is now alerted immediately, so “we can call them when they’re at the emergency room and say, ‘Hey, what are you doing there? Come back here, we can take care of you!”

The care management team at Ashley Clinic talks with Farhad.

At Ashley Clinic in Chanute, I saw a larger care team tackle an even larger patient population. As one care manager said, “before, we had the doctor and the patient; a point A and a point C. But there was no one to serve as point B. That’s changed today.”

Two of Ashley Clinic’s patients – a husband and wife – agreed. Both said the care they got now was much better than anywhere they had been before. “We don’t know what an ACO is,” they said. “But we know we hear from our doctor more. And we like that.”

Most importantly, by talking to the care teams and doctors in these practices, I learned that I had been wrong. Value-based care isn’t some new future in the distance; it’s more of a homecoming. As one doctor told me, “This is why I became a doctor in the first place.”

But getting home isn’t always easy.

It’s taking new ways of thinking – focusing on finding the highest risk patients, keeping a close eye on them through chronic care programs, following up with patients as they leave the hospital, and ensuring that patients are going to the most efficient and effective specialists.

While it asks for more time and effort on the part of doctors and care teams, who already put in countless hours caring for patients, the destination is worth the jounrey. And thanks to Aledade’s technology, dedicated support staff in the field, and some inspiring health care professionals, you can find better health care right down a long stretch of Kansas road.

One day this past spring, I met with a patient for our standing care management appointment. She’s been coming to our clinic for 5 years, and during our conversation, I asked my usual questions. When I asked her how she was feeling, she told me something I didn’t expect.

The patient shared that her mobility was getting worse. She said it was getting hard for her to leave her home, because she couldn’t manage the step down from her porch. We continued the conversation, and I addressed her other concerns. But after the appointment, I got to thinking. How could we make it easier for her to leave her home?

I didn’t have to wait long for an answer. Later that week, my granddaughter was telling me about her day in school, when we suddenly had an idea. Her class could build a ramp for our patient!

I contacted Aaron Haselwood, the Industrial Arts teacher at Fredonia High School, about building a ramp. He joined in right away. He thought it was a great way for the students to learn and help the community.

Here’s Aaron’s story on how his students built the ramp:

When Tara reached out to me, I thought it would be a perfect project for my class. This is my first year teaching this class, and I can already see that the students are getting a lot out of it. They’re learning skills, gaining confidence, and earning certifications, all while giving back to the community.

The ramp was a class project, but five students took the lead on building and installing it. We spent about two class days on this project. On the first day, we met with the patient to discuss our plan, and then took measurements. We built the ramp in our workshop and installed it on the second day. The ramp didn’t cost the patient anything, because we used leftover materials.

My class already has projects lined up for next year, and we’re excited to continue helping more people in the community.

This ramp has helped my patient become more independent. She feels safer when she enters and exits her home. The ramp, combined with her exercise regimen, has reduced the patient’s risk of falling. She has not had a fall yet. I’m so glad that thanks to care management, our patient feels comfortable telling me her concerns. And I’m just as happy to know there are resources and people in our community eager to address them.

Since Post Rock Family Medicine began our care management program in May, we’ve seen first-hand the direct impact it can have on our patients and our practice. Care management has proven to be incredibly valuable because it allows our practice to improve so many aspects of our patients’ health and care.

In leading our care management program, two recent cases come to mind as standout examples of how care management can comprehensively improve patient health and wellness.

One summer Friday, I received a call from a patient with diabetes who was enrolled in our care management program. She called our 24-hour care management hotline to notify the practice that her glucometer was broken and that she would not be able to take blood sugar readings until her new one arrived – scheduled to be delivered a whole week later. She could not afford to get one rush shipped or from another source.

The patient knew she could reach the practice – due to the hotline – and wanted to let us know she would not be providing blood sugar information to her telemedicine monitoring program throughout the week. Concerned about her stability without a way to monitor and report her blood sugar, we jumped into action to get her a glucometer right away.

I reached out to the director of nursing at our local hospital, and she found an available glucometer for the patient to use. As the patient was without transportation, I picked up the glucometer and was able to deliver it to her home the very same day. Instead of being without a critical tool she needed for upwards of a week, the patient had it – free of charge and right away after contacting us.

By providing her with a replacement glucometer until her new one arrived, we offered peace of mind for the patient and for ourselves – knowing that we could monitor any abnormal blood sugar measurements and take appropriate actions, and possibly prevent an unnecessary hospitalization.

Another case study emphasizes the role of the home visit that we conduct anytime a new patient enrolls in our care management program. During these visits, we introduce the program and begin to develop a personal connection with the patient.

On one of these such visits, while I was doing our standard pharmaceutical review, a patient expressed worry about the expensive cost of her medications. This cued me to walk through her health insurance information, and in doing so, I discovered that she had recently become dual-eligible for Kansas Medicaid as well as Medicare, but was unaware and not utilizing it.

I was not only able to explain this to the patient, but also helped get her Medicaid information to the pharmacy, local hospital, our practice, and her DME supplier – significantly reducing her monthly health care expenses. Without the personal connections developed and information gathered during our care management home visits, this patient would have had more out-of-pocket expenses, and the stress that comes with higher health care costs.

In both of these cases, our care management program improved patient care. However, each case also highlights how care management comprehensively encompasses all aspects of patient health – from preventive care to financial wellness. Using the Aledade app, we’ve been able to identify high-risk patients, prioritize them for our care management program, and better monitor their health and care. So far, we’ve seen outstanding results – and heard complementary feedback from patients – and I look forward to seeing the successes to come.

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.

Ashley Clinic Sees Immediate Impact of Proactive Preventive Care
Chelsea Buck, RN, BSN, Case Manager, Ashley Clinic

The Ashley Clinic has been committed to providing the highest standard of care to residents and families of our community in southeast Kansas for over 75 years. In order to continue to uphold this mission, our clinic must always look for ways to improve our care. Last fall, we began an initiative that’s already made quite the impact at our practice.

Beginning last year, the Ashley Clinic began working with our Aledade ACO in Kansas to put a renewed focus on Annual Wellness Visits (AWVs). In the past, we had not emphasized AWVs, which resulted in only conducting a handful in 2014. In 2015, that changed. Aledade helped our team build a template and process for our AWVs. The Aledade team worked with us to ensure that both our patients and clinic could get the full potential out of AWVs. Now, our AWV process is in full swing, and as Case Manager I lead the team to coordinate patient identification, patient outreach, and administration of these visits

Our new goal is to conduct 75 AWVs a week to meet our target of about 4,000 in 2016.

What has motivated this ambitious AWV initiative?

Put simply, results. Within two months of formalizing our AWV process last year, we saw clear evidence of its value for our patients. Specifically, two patient stories stand out as exemplary cases for how AWVs can influence a patient’s health – and they only occurred a few weeks apart.

The first case is one in which our practice identified a patient as due for an AWV and contacted her to come into the office. If not for our phone call, she may not have set up an appointment to come into the office for months or more. As part of the AWV, we discovered the patient had not had a mammogram in six years. Additionally, as is part of every AWV, we assessed the patient’s medical and family history and found there was risk of breast cancer in the patient’s family. With this information, we explained the importance of regular mammograms to the patient and immediately got her scheduled for one.

The mammogram turned out to be abnormal and the patient was scheduled for a follow up sonogram, which revealed that the patient had early stage breast cancer. Thanks to our clinic proactively bringing the patient in to be seen for an AWV, the cancer was discovered during a treatable stage. The patient is now receiving the care she needs, having had a lumpectomy in March and moving forward with radiation therapy this month.

Another recent case demonstrated the impact AWVs can have not just on a patient’s health or health care, but on their general wellbeing. In December, during the course of an AWV, a patient explained to our staff that she lived in a home without running water or electricity – and had been for quite some time.

Concerned for the patient, and knowing that she could not operate the medical tools she needed in these living conditions, our team took action above and beyond providing medical care. Clinic staff helped the patient get assistance from the Kansas Department for Children and Families. Due to this, the patient now has both running water and electricity in her home. And, she is using the care tools she needs to maintain her health.

In just the few months after putting a greater focus on AWVs and implementing a workflow, our clinic has seen first-hand the impact they can have on our patients. That’s why, with the tools and continued help from Aledade, we are making AWVs such an integral part of the care we deliver. It’s important that our clinic not only provide high-quality care to our patients when they’re sick, but to take advantage of all the preventive services we can deliver to promote their health and wellbeing.

We are excited to announce the latest development in our efforts to expand and provide quality, coordinated, patient centered care in Kansas.

The Aledade Kansas ACO is partnering with one of the only two approved Health Information Exchanges (HIE) in the state of Kansas, the Kansas Health Information Network, for the benefit of our patients and their caregivers.

KHIN – the largest HIE in Kansas – is an industry leader in establishing secure networks that enable real-time data flow to health care providers, and we are proud to partner with them in order to better coordinate patient care and provide actionable information to our primary care doctors.

Quality health information exchanges like KHIN play an important role in value-based care.

Starting this month, Aledade Kansas ACO doctors will automatically receive near real-time admission, discharge, and transfer (ADT) notifications for their patients. This information is vital to coordinating care and establishing effective transitional care management (TCM) programs for their patients. Studies have shown that if a patient has been contacted by their doctor within 48 hours of discharge, the patient is more likely understand their discharge instructions and less likely to be readmitted to the hospital.

In fact, something as basic as the primary care doctor calling their patient just to talk after they have been discharged can have a big impact. In the past, primary care doctors didn’t make the phone call because they didn’t know their patients had been discharged, let alone admitted.

In essence, they were operating blind when it came to the care their patients received from other doctors. And with the help of KHIN, we are taking the blindfold off for primary care physicians. With this partnership, Aledade’s primary care doctors will also have electronic access to information about the range of care their patients are receiving from specialists and other providers.

Real-time information helps primary care doctors assess a patient’s situation, make informed care decisions, and help coordinate their care, leading to better outcomes – for patients and their families and caregivers.

At Aledade, our more than 700 physicians are focused on delivering the highest quality, health IT-enabled and patient-centered care possible, with an emphasis on preventive care. Our partnerships with leading HIEs like KHIN will allow us to continue to provide that care and serve our nearly 100,000 patients nationwide.

As a provider-led organization, KHIN is one of the leading health information exchanges (HIE) in the country with more than 1,200 participating hospitals, clinics and other health care related facilities. KHIN’s mission is to improve health care quality, coordination and efficiency through the exchange of health information at the point of care utilizing a secure electronic network, provided by a collaboration of health care organizations. For more information about KHIN visit www.khinonline.org.

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.