Last week I had the opportunity to attend the National Association of Accountable Care Organizations Spring 2019 Conference in Baltimore, Maryland. Below are my top takeaways from the conference from sessions and speaking with other attendees.

1. Payment reform is a top priority.

CMS Administrator Seema Verma opened the conference with emphatic assurance that re-orienting our healthcare system around value, with a focus on payment reform, remains an urgent priority of the current administration. Strategies they intend to pursue include: promoting a multipayer environment by synchronizing models with private plans; encouraging states to align Medicaid with new payment models; improving risk adjustment and benchmarking methodologies; and empowering patients to choose high-value providers through greater transparency of cost and quality information.  

We can also expect continued efforts to promote interoperability and patient control of data, and to address regulations that are “barriers to value.” She specifically cited “outdated” aspects of Stark Law, and building on the progress of the Meaningful Measures Initiative which reduced the quantity of measures by 20% last year.

2. Primary care is a focal point for new payment models, but many questions remain.

Conference attendees were buzzing about the recent announcement of two new payment models under the CMS Innovations Center. The “Direct Contracting Model” envisions a capitated up-front payment for primary care services amounting to 7% of the expected total cost of care for the Accountable Care Organization’s (ACO) patient panel, while the ACO takes risk for 50% of savings or losses on total cost of care; or a full up-front capitation payment for total cost of care if the ACO takes risk on 100%. A third option is in development, where the ACO would take full risk and accountability for beneficiaries in a geographic region.

Separately, the “Primary Care First” model will be available in 26 regions across the country. In this model, primary care services will be funded through an up-front risk-adjusted population-based payment to primary care practices, alongside a flat rate reimbursement for each office visit (regardless of complexity), and a quarterly incentive payment based on acute hospitalization rates. A practice would have the opportunity to increase practice revenue by as much as 50% by keeping patients out of the hospital, or face a penalty of up to 10% if hospital use rises. ACO experts fear that the “devil is in the details” as we await further clarification of benchmarking methodology.  

3. The Value-Based Payment landscape is getting more complex.

CMS continues to pursue payment reform for specialty care as well, and representatives from the American Hospital Association and American Medical Association emphasized the importance of physician leadership in the design of new models. Interactions between models can be quite complex. For example, if a patient in an ACO has an episode of care covered under a bundled payment program, does one model win over the other for patient attribution? For partial costs or all costs? Do bonus payments made under one model count as costs to the other? One speaker described the need for a “patchwork of incentives to bind everyone together,” while acknowledging that getting the mechanics right is the tricky part.

Meanwhile, ACOs with specialist members are devising innovative ways to gain specialist engagement in the work of the ACO, incentivizing better referral communications, more efficient care pathways, and reduction of care variation or low value services. CMS Administrator Verma put it this way, “The road to value must have as many lanes as possible.”

4. ACOs are gaining traction and success in commercial markets.

Several presenters discussed expansion of ACO focus into self-insured populations and  commercial value-based contracts, with experienced ACOs taking on greater levels of financial risk and achieving financial success. Commonly cited challenges include: less visibility into historical performance to inform contract design; reliability and quality of payer data; misalignment of quality measures across contracts; and difficulties getting sufficient number of lives in the ACO for smaller payers.

Commercial pharmacy spend was seen as both a challenge and an opportunity. Some ACOs have been able to generate substantial savings through pharmacy management programs, while others felt that payers should not put providers at risk for drug costs when the payer has much more effective levers for controlling costs through drug price negotiation and benefit design. On the bright side, there were examples of commercial payers engaging ACO input on value-based insurance design, and making strategic investments to address social determinants of health.

5. Opportunities in Post-Acute Care

While some themes this year around optimizing post-acute care were familiar, such as managing skilled nursing facility (SNF) length-of-stay through use of preferred networks, others were more novel, such as use of SNF 3-day stay waivers to achieve lower hospital costs. Preferred network engagement tactics included the use of technology and ACO liaisons to collaborate in real time with skilled facility partners on individual patient care plans and discharge planning.

In one region, multiple ACOs have collaborated to develop uniform standards and protocols with preferred SNF partners. ACOs are leveraging cloud-based communication tools to share information with SNF partners (such as ACO patient identification and Physician’s Orders for Life-Sustaining Treatment (POLST) forms) and receive facility admission, discharge and transfer notifications. One presenter cited a 14% reduction in SNF spending and better care coordination resulting from these efforts.

SNF 3-day waivers allow ACOs to identify appropriate patients for skilled facilities admissions without the 3-day “qualifying hospital stay” that Medicare traditionally requires. ACOs have leveraged the waiver for patients in the emergency department to avert a hospital stay, or to achieve a shorter hospital stay. Several attendees voiced that use of the waiver has been lower than anticipated due to operational and engagement challenges. We have not seen outcomes data, and very few tactics or strategies were offered for using the waiver directly from the community or office setting to avoid the hospital visit entirely. Still, discussion of SNF waivers was generally enthusiastic and optimistic as groups gain experience with their use.   

On Monday, April 22nd Secretary Alex Azar stood at the podium of the American Medical Association and said

“This initiative will radically elevate the importance of primary care in American medicine.”

The initiative he was talking about comprises two new value-based primary care models collectively known as the CMS Primary Cares Initiatives. Aledade believes that excellence in primary care combined with excellence in population health leads to better quality and lower costs. Achieving excellence in primary care in today’s health care system means more primary care that meets the needs of patients, not less. Excellence is defined by how well a practice meets the needs of its patient, not how many 10 minute appointments a physician can fit into a day. Excellence is measured by improvements in quality and lower costs.

The models represent an opportunity to move payment of primary care services away from a 10 minute appointment to a more flexible payment structure giving practices more freedom to both meet the needs of their patients and run a financially successful practice. When coupled with accountability for total cost of care, they represent opportunities to make people’s lives better and reduce the burden on the Medicare trust fund. We believe Medicare took a big step towards value based care today.

Primary Care First

This 5-year model is an evolution of the current Comprehensive Primary Care Plus (CPC+) model. Track 1 and Track 2 of CPC+ augmented fee for service with additional payments to provide more comprehensive services, such as care management. In contrast, Primary Care First seeks to replace fee for service and provide enhanced payments based on performance. Traditional fee for service payments would be largely replaced with three payment streams:

  • Per-Visit Payment: A flat, per-visit rate for each traditional office visit
  • Population-Based Payment: A prospective, risk-adjusted payment for each attributed Medicare beneficiary.
  • Performance-Based Adjustment: Quarterly incentive payment for performance on risk-adjusted acute hospitalizations, with an upside of up to a 50% increase in practice revenue, and a downside of down to a 10% decrease in practice revenue.

Practices would still submit claims for purposes of calculating co-insurance and risk adjustment. But breaking the link between the claim and payment allows practices to redesign their patient interactions (e.g., extended, at home, telephonic, virtual, or group) without fear of financial ruin or compliance penalty. There is also a sub track in the model focused on hospice and palliative care.

Practices in 26 regions can apply for January 2020 this summer or January 2021 next summer (practices already in CPC+ can switch for 2021). The regions include all existing CPC+ markets plus new markets: AL, AK, CA, CO, DE, FL, Greater Buffalo region, Greater Kansas City, Greater Philadelphia, HI, LA, ME, MA, MI, MT, Northeast NH, NJ, ND,  North Hudson-Capital region, Ohio and Northern Kentucky, OR, OK, TN, RI, VA.

We believe that this model will be most impactful when it is coupled with participation in an accountable care organization (ACO) responsible for total cost of care. Given the great alignment between Primary Care First goals and Medicare Shared Savings Program goals, the payments enable the work of the ACO even more so than the current Comprehensive Primary Care Plus (CPC+) model. CMS has not yet detailed how the details of that combination would work. We urge CMS to allow the programs to come together as they currently do in CPC+. The ACO would be accountable for payments in Primary Care First as they are responsible for the total cost of care. There are many details about both models still to be released by CMS and we look forward to seeing these interactions soonest.

Direct Provider Contracting

This model is an evolution from the Next Generation ACO model. It is much more complex than the Primary Care First and most of the crucial details (It’s all about the benchmark) are still to come. Here is what we know.

There are two versions of the model

  • Primary care services for ACO participants are paid for with fixed, capitated payments  to the ACO equal to 7 percent of the total cost of care and the ACO is responsible for 50 percent savings and losses on total cost of care.
  • Primary care services, plus other services for which the ACO can negotiate contracts, are paid for under capitation, and the ACO is responsible for 100 percent of the savings and losses on total cost of care.

The first version is not immediately interesting to us today because we can already get 75% of the savings and only 40% of the losses under Enhanced. However, we will be sure to look at the details as they become available.

The second version does offer more of the savings, but with a vastly increased downside. There is also the possibility of capitation for improved cash flow, even if most of it is passed on to other health care providers (this is a feature that was included in the Next Gen ACO, which allows the ACO to negotiate payment rates with providers/services outside of the ACO). The details of how much money, how you contract, how you pass it on to providers are all as of yet unavailable.

What little we know about the benchmark is that it will be a blend of historical and regional benchmarking, similar to MSSP. However, the regional methodology will be driven by more established Medicare Advantage (MA) rate setting methodology rather than the methodology used for MSSP.

The model is based on MSSP-like attribution methodology but CMS has also placed a heavy emphasis on supplementary voluntary alignment. CMS expects that most organizations would seek out voluntary alignment where a beneficiary chooses a physician in the ACO on To allow for that to occur, ACOs apply to be in the model this summer for January 2020; however, 2020 is Performance Year 0. The responsibility for total cost of care (and Advanced APM status) begins 2021.

Giving the ACO responsibility for paying for primary care creates even more options for excellence in primary care and population health. With that responsibility also comes accountability for total cost of care in the model itself. When taking on that accountability for total cost of care, an ACO must understand how that total cost of care is calculated. It does indeed become all about the benchmark as we explained when we considered the Next Generation ACO model. We are intrigued by the idea of using MA rates for at least a portion of the benchmark. We encourage CMS to be flexible and supportive of different mechanisms to pay for primary care and to maintain tight links to MA policies wherever possible. We are eagerly looking forward to learning more about this model.

CMS Primary Cares

In conclusion, we have always acknowledged that we are building value based health care models on a fee for service chassis. There is massive infrastructure already in place for fee for service that allows for the trillions of dollars in health care to flow between people and organizations in health care. These models do not replace that infrastructure nor do they really bypass it. What the models do is give primary care physicians the financial flexibility to put the needs of the patient ahead of what the code description thinks the patient needs. At Aledade, we look forward to putting that flexibility to work for better quality and lower costs supporting practices in the move to value as we have over the last 5 years for more than 400 practices.

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.

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.

Growing up in the Appalachian Culture of rural southwest Virginia was challenging, but until I began working with Aledade, I did not realize that my community and circumstances were unique. As a child, I did not aspire to be a nurse. I presumed I would follow the same path as my mom. She worked as a seamstress in our local sewing factories, which were essentially sweatshops. She did not graduate from high school, she was widowed at an early age and she had two children to raise. We knew we were poor but we couldn’t escape the circumstances because it was all we knew.

Survival was hard work, ingenuity, and poverty “smarts”. We knew how to stretch a meager income, grow our own food, and treat ailments, injuries, and illness naturally. Our house was always in need of repairs. A leaky roof with buckets and pots strategically stationed to catch the water, no air conditioning and only a wood stove for heat. Our clothes were hand me downs therefore I never was stylish in the 70s and 80s designs. We didn’t have an indoor bathroom until I was 16, I never had my hair cut in a salon, rarely did I even get to go inside a grocery store, and the nearest mall or shopping centers were, in my mind, lightyears away, although it was a mere 35 miles. Our car was lucky to make it 5 miles before it puttered out or we didn’t have money for gas. This is what I knew, who I was and, to me, everything was normal in this environment.

The Appalachian Culture is difficult to leave because of the deep sense of place and pride. I was fortunate to have a mother who emphasized education. Without my education, I may have remained poverty stricken. Thankfully, I was led to a career in nursing through a choice I made to attend the high school vocational-technical school. Once I started nursing, I couldn’t stop. I started as a licensed practical nurse and eventually became a master’s prepared registered nurse.

I began my nursing career in 1988. Since then, I have seen incredible changes in health care. In those 30 years, I have worked in hospitals, home health, school nursing, community health, management and quality/patient safety. In November 2015, I stepped out of my box and accepted a Practice Transformation Specialist position with Aledade. Initially after joining the Aledade team, I felt intimidated by the “city folk”, the city, and the impressive educational and career backgrounds of our team. I thought, what does this country girl from southwest Virginia have to offer? As I soon found out, Aledade impacts the health care of my community and I play an integral role.

I always remember my mom telling me “you don’t go to the doctor unless it’s broke or you’re dying”. This mindset was driven by the lack of health insurance with the lack of adequate finances, poor health literacy, and a health care system built on the premise of reactive instead of proactive care. The history of medical care was based on treating illness and injury and lacked public health maintenance. It wasn’t until 2002 that the Institute of Medicine issued a report entitled “Who Will Keep the Public Healthy?” which concluded that public health professionals must develop a plan that identifies the impact of multiple determinates affecting health and address health for the 21st century.

Amazingly, it was just a few short years ago that we realized the need to change health care to improve the health of our people through prevention. Aledade wants to change health care across the nation and we are making a huge impact by working with our primary care providers to help them gain control of the health of their patients. Our team at Aledade HQ provides me data to help the providers in my community identify patients who have health risks and proactively address ways to prevent disease or injury. Aledade’s cutting edge technology gives providers insight to the patient’s medical care from all care transitions and sources including specialists, pharmacies, and hospitals. We also help them navigate end of life for patients who need quality instead of quantity of life planning.

I lost my mom suddenly 4 years ago. She was a smoker and had uncontrolled hypertension. She died unexpectedly of a massive heart attack at the age of 63. As I look back on her medical care now, I think about what I would have given for her provider to have been working with Aledade. Aledade would have worked with her doctor’s practice to implement Annual Wellness Visits to determine her risk factors and addressed smoking cessation, exercise, EKGs, diet and cholesterol control. Her provider would have been able to see, in the pharmacy data that Aledade provides, that she was not getting her blood pressure medicine filled consistently. Her hospitalizations for accelerated hypertension would have been evaluated through transitional care visits and a chronic care manager would have helped her if she couldn’t afford her medication but didn’t want to tell people because of her pride. This provider would have been equipped to proactively address her impending heart attack by educating her on the symptoms of a myocardial infarction. She would have known that the left arm pain she was having was not from overuse of carrying in wood to keep her fire going. If Aledade could have been there sooner, my mom could potentially still be here enjoying her grandson’s ballgames and watching him grow.

This is why I work for Aledade. I am part of a shift in health care delivery in our nation but most importantly, I can personally impact my community and my family. My mom always gave me this advice….”an ounce of prevention is worth a pound of cure.” She was so right.

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.

I’m an independent internal medicine physician with my own practice, Advanced Internal Medicine, in Paducah, Kentucky. My practice has served patients in Paducah for three and a half years. Paducah is a changing medical community. We have two competitive hospitals in our town that employ many of the specialists and physicians in our area. There’s still a good number of independent primary care doctors, like me, who run our own practices.

Three years ago, other independent doctors and I joined a local Accountable Care Organization (ACO). We were excited about the opportunity to come together to offer better care for our patients and leverage our size to compete with hospital employment. However, we didn’t see significant progress in our move to value-based care or a clear vision for how we would get there. At the end of our relationship with our prior ACO, after doing some research, we decided to partner with Aledade.

Working with Aledade has been a completely different experience.  From our first kick- off visits we could see that Aledade was different.  Aledade had a plan to address our local pain points and worked with us to get things right. Before Aledade, for example, our group of doctors didn’t have a plan for Annual Wellness Visits (AWVs) or HCC coding. We were all trying to tackle them separately without insight into an optimal workflow. With the Aledade App we have actionable data and can target our highest priority patients, to keep them healthy.

I have found that it is possible to participate in value based care and remain independent. I was the solo doctor figuring it out on my own, and it was time consuming and hard. When you partner with Aledade you don’t have to figure things out on your own. Having support in moving to the next level of value-based care has made all the difference. We now have someone from Aledade in our office every single week. They help us stay on track and keep in touch between visits. They’re there to help us break down barriers, so we can provide our patients the best care.

I’m looking forward to the next three years working with Aledade. The changes I’ve seen already in my practice are unparalleled.

For nurse practitioner Kirt Greenlee, it started out as a routine visit at the local nursing center for a ripped toenail. Casually, the patient asked if he could also look at what seemed to be an ant bite on his elbow. Greenlee quickly identified that the small raised bump was not the result of a bug bite, but an abscess caused by Methicillin-Resistant Staphylococcus aureus, commonly known as MRSA. He immediately started the patient on a course of antibiotics to get the condition under control. Had Greenlee not caught this early, the patient could have suffered serious complications, potentially leading to a hospital admission. The bacteria could have also spread to other residents, causing even more harm.

Situations like this are typical in Greenlee’s role as a nurse practitioner at Premier Medical Group. Unlike most providers who work in one clinic all day, Greenlee spends the first part of his morning visiting patients at the local nursing facility, Attala County Nursing Center, and goes into the clinic afterward. On a typical morning, he sees about three to eight patients with a variety of ailments, including congestion, urinary tract infections, COPD exacerbations, and upper respiratory tract infections. Greenlee then goes into the clinic where he sees more patients and is available to the nursing center by phone.

Setting up this workflow took a lot of collaboration with Attala County Nursing Center. Previously, they were hesitant to contact providers for fear that they were bothering them. With this partnership, we set clear expectations upfront so they know when and how to communicate with the practice. Patients receive the best care when we all work together, rather than in individual silos.

Going to the nursing center daily is important. It allows Greenlee to catch conditions early that could otherwise snowball into debilitating illnesses, like a cough that could turn into pneumonia. Greenlee can take simple steps, like prescribing steroids or antibiotics, to keep the patient healthy and prevent an unpleasant and stressful trip to the emergency room.

This work is also important because as a member of an accountable care organization (ACO), Premier Medical Group takes responsibility for the quality and cost of its patients’ care. By catching minor conditions early on, Greenlee prevents expensive emergency room visits and hospital stays.

Greenlee says “my favorite part of my job is taking an active role in protecting the quality of life of my patients.” Once a patient ends up in the hospital, they often lose some of their independence and freedom, and are at risk of contracting additional infections. The care that Greenlee provides truly helps achieve the goal of reducing costs while improving quality, which aligns with the goals of the Aledade Mississippi and Tennessee ACO. Premier Medical Group and the other partner practices are making huge differences in patients’ lives and bringing better value care to their communities through their ACO work.

A few weeks ago, we had a patient call around 9:00 am. She had been recently diagnosed with the flu, and was struggling to keep down any food or fluids. We were able to get her an appointment at the office within two hours of the call and administered IV fluids to prevent dehydration. If the patient hadn’t called us first, or if we didn’t have open-access scheduling, she would have likely ended up in the emergency department.

In the same week, another patient contacted us and said that she didn’t feel quite right. Again, we leveraged our open-access scheduling to get her into the office quickly. This patient was also scheduled for a knee replacement surgery within the next two weeks. She was concerned that her current condition would prevent her from proceeding with the surgery. I evaluated her and determined although she was without a fever, she had pyelonephritis, an infection of the kidney. At the visit, I gave her intramuscular antibiotics to treat the infection and contacted her orthopedic surgeon to provide a report on her visit and treatment plan.

Through the rest of the week, I saw her every day at the office to monitor her progress and keep her surgeon informed on her course of care. She was very anxious about the surgery but trusted that since I was monitoring her closely, I wasn’t going to let her go through it if I felt she wasn’t ready. Thankfully, she was able to make a full recovery in time to have the knee replacement. This could have resulted in significant perioperative complications had she not called us first.

At Dixie Primary Care, our patients know that we can be available if they reach out to us when they experience health concerns. If a patient can contact us before they go to the emergency department, there’s a good chance we can care for them at the office immediately, thereby saving them an unpleasant, lengthy, and expensive visit to the ER. Each of our providers keeps four acute appointments open every day which create 16 same-day consultation slots for the whole practice.

When I tell other doctors about our scheduling process, they often ask whether it is difficult to fill all of the same day appointments. Our response is that this is a conscious choice in an effort to serve our patients, regardless of whether we fill the slots. In some instances, we have used these appointments to reconcile medications after patients get discharged from the ER, hospital or rehabilitation facility. We have decided that it is more important to be available for our patients than to overbook our providers’ days.

This scheduling process parallels our mission to provide value-based care as it leads to remarkably low rates of ED utilization by our patients. Our rates are among the lowest in all of Aledade’s partner practices, which are already lower than many primary care practices across the country. It helps our patients get the right care, at the right time, for the right reason, thereby improving patient experience and compliance and decreasing costs.

A patient’s fears and concerns can be enough for them to turn to just anyone for help. For my family and friends, I would want them to see a doctor who knows them well and whom they can implicitly trust. This is what being a primary care provider is all about.

It’s hard to stay healthy if you don’t have a place to call home.

That’s what we learned firsthand, when one of our patients came in for his annual wellness visit.

Thanks to Aledade, we’ve been doing a lot more of these AWVs. They give us a chance to have a conversation with our patients that’s not just about the test or procedure or illness they came in for that day. They help us see the full picture of the patient’s health. Thanks to Aledade’s care management trainings and real-time data and analytics from the Aledade app, we know which patients we need to see for an AWV, and how to work with them when they arrive.

Our patient that day was wheelchair bound, so we asked how his social situation was. Sometimes patients in a wheelchair can get to feeling a bit lonely. In the course of the conversation, though, this patient told us that he had recently lost his home. The waiting list for housing assistance stretched out for three years. In the meantime, the only place he could stay was a shed in his friend’s backyard.

As a care management team, we knew we had to do something.

Housing is such an important part of good health. The National Council on Health Care for the Homeless covers a few reasons for this. A clean, dry and safe environment supports good personal hygiene, the storage of medication, and safety from people and the weather. A private space lets a patient establish stable personal relationships, and have good social interactions with other people. Importantly for us as health care professionals, a patient with a place of their own is more likely to stick with a treatment plan, eat meals regularly, and show up on time for appointments. And housing reduces anxiety and the impact of stress-related illnesses.

Aledade’s practice transformation specialist Connie Perkins and I knew that a three-year wait was too long. So we spent countless hours on the phone with the state’s resources for homeless and disabled persons. Tooele is a rural community. We don’t have that many resources for housing, but after a lot of work and some persistence, we did it.

We were able to find housing for this patient in Wendover. Even though Wendover’s a two hour drive away from our town, the patient was thrilled to have a home of his own. He even started looking for work around his new place.

Thanks to an annual wellness visit – supported by the training, technology, and partnership of Aledade – we helped our patient get healthier, by finding a place to call his own.