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.

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.

In about two weeks, I’m joining the team at Aledade as Chief Administrative Officer – largely because three years ago, I went through a health scare.

It wasn’t me; it was my then 86-year-old father. And what started with a short-term crisis dragged out into a long-term battle with our dysfunctional health care system.

For two years, my dad bounced between doctors, hospitalists and specialists. We never got a clear picture of his health or the care he was getting. His doctors rarely talked to one another, rarely gave him much time and I couldn’t talk to them to understand it all.

At the same time, this was happening while I worked at the Centers for Medicare and Medicaid Services, tasked with running the entire Medicare program. I couldn’t help but put our situation into a broader context: if this frustrating and frightening ordeal could happen to my dad- a brilliant lawyer who was on the Law Review at Penn — and his son who ran the world’s largest insurer, what was it like for other families who didn’t have our resources and our knowledge of how to navigate this confusing health care system?

Fortunately, we were saved by a good quarterback – someone who could take a step back and look at the entire field of my father’s health. For an entire hour, a geriatrician sat with my father just to talk with him. He got a sense of his health conditions, what was giving him the most trouble, and the serpentine path he had taken to get help.

The doctor set up a care plan with him, and took a close look at his medications. When we focused on one drug in particular, my father pointed out that studies had shown it was relatively effective. “That’s true,” the doctor said, “until about 75 years of age.” My dad was taking medication that stopped being effective – and possibly became harmful to him — about ten years ago. In the end, we cleared out about half of my father’s prescriptions. It was as if a switch had been thrown. Over the next few months, my dad returned to the person we knew.

Value-based health care, directed by empowered, independent primary care physicians, is what my father and I needed then. Today, everyone agrees it’s what we all need now.

We need primary care physicians to be the stewards of care, guiding patients through this confusing health care system like the captains of a ship – always pointed to the north star of better health. We need a health care system that doesn’t focus on how many procedures or prescriptions patients get, but on how well their doctors keep them healthy. When those priorities are misaligned, that’s when our health care system doesn’t work. I know, because that’s what my father and I saw firsthand.

I’m joining Aledade because I know the team here is working with incredible physicians best situated to chart that path to value-based care. For years at CMS, I looked at the results and dove into the data – I saw that the future of health care will be led by primary care physicians with the autonomy to act in their patients’ best interests. I saw this potential for success across commercial plans, Medicare Advantage, and traditional Medicare – and Aledade’s covering all of these.

At Medicare, my focus was on the operational integrity of a program that provides insurance for more than 55 million Americans. I worked to ensure the program was run efficiently and responsibly for the taxpayers, and that we kept focused on our strategic goals of improving care and reducing costs. That’s what I’m most excited to do here at Aledade. My focus will be making sure the trains run on time – that our hardworking teams are valued and supported, and that we’re helping our partner practices along every step of this journey.

I’m also joining Aledade because there’s a unique mix of purpose and people in this place. I came from public service, and I wanted to join an organization with a mission that’s bigger than profits or short-term returns. Aledade lives its mission every single day.

I also was lucky to work at CMS with some of the most brilliant people in health policy who were also great colleagues. And I see those same qualities here at Aledade. Thanks to the hard work of so many people, Aledade partners with more than 200 primary care practices in 17 states to actively manage the care of nearly a quarter of a million patients. I can’t wait to be a part of the team that’s building the leading model for a health system that’s good for patients, good for doctors, and good for society.

There aren’t too many opportunities when you can get the present and the future of primary care in the same room. But that’s exactly what we found at the Louisiana Academy of Family Physicians’ Annual Conference.

Emma Lisec and Nadine Robin at the Aledade booth

On Wednesday afternoon, we arrived at the historic Roosevelt Hotel in downtown New Orleans – Nadine Robin, Aledade’s Southeast Executive Director, and me, Aledade’s Fellow for the Southeast. We were caffeinated, excited and ready to join a massive room full of displays from local hospitals, pharmaceutical companies, and specialty groups. We set up our booth, with Aledade’s slogan: “A New Model of Primary Care”, and we waited to see who would come through the doors.

Right on cue, as the conference’s main sessions took a break, the showcase room flooded with health care professionals from across Louisiana – independent doctors, curious hospital employees, even medical students from Louisiana State University. (Geaux Tigers!)

They dropped by a number of different booths, but kept lingering by ours, wondering what that “new model of primary care” actually meant. So Nadine explained: with MIPS, the new payment program created by the 2015 Medicare Access and CHIP Reauthorization Act (or “MACRA”), quality reporting was taking center stage.

Small, independent practices are the key to that focus on quality. As our CEO Farzad Mostashari has pointed out, small, physician-owned practices offer more personalization for patients. They have lower average costs per patient, fewer preventable hospital admissions, and lower readmission rates than larger, independent- and hospital-owned practices. In other words, they’re in the best position to succeed.

Nadine explained how Aledade helps their independent partner practices report these quality measures all while maintaining their independence. I noticed that a few physicians’ ears perked up at this – the prospect of having a helpful guide through MACRA and MIPS seemed to be integral to their practices staying independent.

I remember one doctor in particular who pulled us aside. He felt like his clinic was short-staffed, and the pressure to sell his practice was only growing. Nadine and I listened to him, and explained that the whole purpose of Aledade is to help small, independent physicians like his stay independent – and thrive. But to do that, we have to start with an honest relationship. We weren’t going to pressure him into joining Aledade if it wasn’t going to be in the best interest of his practice and his patients. We agreed to pull his QRUR report and follow up to see if a partnership with Aledade would be his best step.

We also spoke with some of the physicians of tomorrow. A few medical students from LSU dropped by our booth, wondering what an ACO was. To many of them, the idea of opening their own independent practice seemed out of reach. The concept of a comprehensive approach to primary care, one where the independent practice is in the center of a high value network, sounded promising. They asked us if they could reach out to us later to get a better understanding of an ACO and value-based care.

Nadine and Matt Wheeler presenting at LAFP

That Friday morning, Nadine and Matt Wheeler, one of our inspiring Office Administrators from Bossier Family Medicine in Bossier City, gave a presentation about the new world of alternative payment models. They laid out the idea of value-based care – that physicians should be empowered to provide quality care, and rewarded for helping their patients stay healthy.

They explained what an ACO is – basically a group of health care professionals committed to the health and well-being of a specific group of patients. And they explained why this future – better health care at lower cost – was inevitable. It’s good for doctors, good for patients and good for society.

Nadine with Dr. Jose Mata, a family medicine doctor in New Iberia, LA

Nadine and Matt weren’t the only ones making the case for value-based care. A number of Aledade’s partner physicians in Louisiana were there too – each of them explaining to other doctors why value-based care works.

This whole move to a better health care system isn’t being led by any single practice or any single company, like Aledade. It’s a partnership – a network of practices who want to keep their patients healthy, and organizations working to help those practices succeed. Value-based care is the best model for today’s primary care physicians here in Louisiana, and tomorrow’s too.

Are conversations between doctors and patients the key to good health care? How well do doctors and patients actually talk to one another? In a 1984 study, Howard Beckman and Robert Frankel surveyed 74 practices and recorded how doctors listened and interacted with their patients. 77 percent of the time, physicians prevented their patients from completing an opening statement by asking questions about a specific concern. On average, it happened 18 seconds after the patient began talking.

Beckman and Frankel’s study was conducted in 1984, but the results resonated in a larger study by Lawrence Dyche and Deborah Swiderski in 2005. Physicians in that study asked a question during a patient’s opening statement in 72 percent of the visits, on average in 23 seconds. A quarter of doctors did not solicit patient questions at all.

The average doctor spends between 13 and 15 minutes with a patient. In only 15 minutes, the doctor and patient are supposed to discuss a full patient history, treatment plan and questions. The question at the root of this problem is why do doctors feel the need to rush?

The current fee-for-service system does not reward doctors for having long, detailed conversations with their patients. It incentivizes them to provide more treatments, because payment depends on quantity of care rather than quality of care. Understandably, this system is infuriating to both doctors and patients. However, the fee-for-service system is not the only healthcare model available to doctors.

At Aledade, we focus on helping doctors do their jobs the way that they want to – so that they can listen longer, ask deeper questions, and get more complete answers from patients without needing to rush through diagnoses and treatment plans. As you may have seen in some of our success stories on our blog we do this in many ways, most often by helping our partner practices effectively conduct Annual Wellness Visits (AWVs), Chronic Care Management (CCM), and Transitional Care Management (TCM). These stories highlight how value-based care and a patient-centered approach improves the patient-provider relationship and improves health outcomes.

Communication is the cornerstone of patient care. A report by the Joint Commission, an organization accredits healthcare programs and organizations,  found that  “communication failure was at the root of over 70 percent of serious adverse health outcomes in hospitals.”  Aledade partner practices have learned the value of good communication between a doctor and a patient.

In 2015, Aledade’s ACOs decreased emergency department (ED) visit rates by 6 to 7 percent. The ED visit rate for the Medicare Fee-For-Service (FFS) population increased by 2.4 percent. Hospitalization rates decreased by 5 to 7 percent, while hospitalization rates for Medicare FFS populations increased by 2.4 percent. And Aledade’s ACOs decreased readmissions by 7 to 11 percent. Across Medicare FFS, readmissions increased by 8 to 9 percent.  

What could account for the difference? For starters, AWV, TCM, and CCM all help  practices catch problems earlier, and provide more consistent care. Annual Wellness Visits help to decrease ED visit rates by helping physicians identify high-risk patients and give them the tools they need to avoid a trip to the emergency room, saving on costly hospital bills. Transitional Care Management lowers readmission rates by helping patients stay out of the hospital when they’ve been discharged from the hospital.he Chronic Care Management program provides high risk patients with intensive ongoing care management support that decreases adverse health events, decreases readmissions and improves self-management skills.

If a provider has the space and time to listen to their patients, they can lay the foundation for mutually trusting and beneficial relationships. This trusting relationship is a key component in providing value-based care as it improves patient satisfaction and health outcomes. It all starts with a conversation, and it is more important than ever to really listen.

In a Health Affairs blog post yesterday morning, Donald Fisher and Chet Speed from AMGA took a hard look at some of the obstacles on the path to value-based care. Building off a survey of their membership and a close look at the Billings Clinic in Montana, Wyoming, and the Dakotas, they found that it’s often tough for practices to get the right data at the right time. They worry that commercial payers aren’t moving as aggressively toward value-based payments – especially in local markets. And they say that reporting requirements are too burdensome.

They’re taking a clear-eyed look at many of the challenges that primary care doctors are facing every day as we move to a health care system that rewards high-quality care. But if we look too hard at the obstacles, we can miss some opportunities.

Here’s what we’re seeing at Aledade:

Commercial Payers are Gearing Up for Value-Based Payment

https://aledade.com/moving-ahead-with-payment-reform-in-commercial-markets/

Commercial contracts around value-based payments aren’t everywhere just yet, but they’re on the move. Take this recent analysis from Leavitt Partners –  Medicare may get the most attention, but a larger proportion of lives covered by an ACO come from commercial contracts, and they’re growing at a rapid pace.

Take two examples:

  •  Cigna established CareAllies, a service company that works with provider organizations of all types to improve patient outcomes and raise the quality and affordability of health care.
  • Humana has a well-established value path called the Accountable Care Continuum that moves its Medicare Advantage providers away from fee for service towards global capitation.

Right here in Aledade, we’ve been working with commercial partners – like Highmark and Blue Cross Blue Shield, covering more than 70,000 lives, to connect them with high-quality care through the physicians in our ACOs.

This kind of movement across the market empowers purchasers as well. Now they’re empowered to push their payers towards value-based contracting.

Reporting Requirements Absolutely Need Standardization

https://aledade.com/the-importance-of-quality-measures-for-accountable-care/

Just as important as standardization is a shift in focus. We and our partner physicians must focus on getting value out of measurement. Asking ourselves the question “How can we use this measure in our practice to ensure better outcomes for our patients?” No doctor wants to be filling out multiple, confusing and often duplicative quality reporting requirements and there is a lot of work to do in standardization. However, we need to do our part and shift our mindset from compliance to outcomes.

Data Access is a Solvable Problem

https://aledade.com/aledade-gets-the-data-flowing-to-pcps/

Fisher and Speed focus on accessing data, but that’s only the first step. We agree that practices need to get the data. That’s why, at Aledade, we focus on connecting to HIEs to deliver data to practices. But practices then need to derive insights from that data. At Aledade, we developed an app that integrates all of a practices’ clinical and claims data, giving doctors a full picture of their patients’ care. And finally, practices need to act on the data, as it guides them to deliver high-quality, coordinated care.

As we grow, Aledade continues to develop relationships with stakeholders throughout the national and local health care markets to equip our ACOs with the data they need. A big part of this is working with Health Information Exchange networks (HIEs) in the communities our ACOs serve.

They can even partner with other practices. One idea that’s started to take shape here is the idea of a virtual group – a group of physicians who can band together online to improve the quality of their care, and be scored as a group for the purposes of the Merit-based Incentive Payment System under MACRA. Our experience has been that these efforts do benefit from the economies of scale and a data “utility” that serves virtual groups and physician practices is an idea whose time has come.

Aledade is here to navigate these obstacles

https://aledade.com/growing-together-and-learning-from-our-partner-physicians/

We agree that these obstacles are real. We hear about them from our own partner physicians every day. But they don’t necessarily need to slow our journey toward a value-based payment system. Everybody needs a partner in this era – and a key part of the transition to value is that partnership doesn’t have to be driven by ownership, but can be driven by shared values and centered around the patient.

Whether it is a partner like Aledade who is transitioning practices from volume to value right now or partners like the recently announced support for the Quality Payment Program who help practices get ready for the transition to value, practices are not in this alone.