In communities across Mississippi and Tennessee, a group of primary care doctors are changing health care for their patients, their practices, and society: they are practicing the kind of patient-centered care that inspired them to go into medicine and their efforts are creating measurable value.

The work started in January of 2016 when 16 independent primary care offices across Mississippi and Tennessee took a chance on improving quality outcomes and lowering costs for their patients. These practices teamed up with Aledade to form the Aledade Mississippi Accountable Care Organization (ACO) that is now composed of 22 participants. Aledade partners with independent practices, health centers, and clinics across the country to build and lead ACOs anchored in primary care. As a part of the ACO, member practices work collaboratively and share in the savings they create.

The work paid off. The Aledade Mississippi ACO was successful in earning a quality score of 95% while saving Medicare $9.8 million in 2017. We reduced hospital admissions by 9%, cut unnecessary home health spending by $4.8 million and decreased hospital readmissions by 3%. We were also able to increase the number of office visits performed by primary care providers by 33% and increase the number of transitional care visits performed by 7%. These numbers mean healthier patients receiving higher quality care from their local primary care doctors – doctors who are now better-positioned to sustain their independence.

Utilizing Aledade’s combination of resources, technology, and local support, the practices in the Mississippi and Tennessee ACO have influenced a change in the health care system in our region. Dr. Katie Patterson, of Indianola Family Medical Group in Mississippi, recently stated that the ACO work has allowed her to better care for her patients with the knowledge of what’s happening outside of the office walls. “It’s provided me with greater knowledge of total patient care versus just the snapshot we are given in the office.”

Dr. Stephen Hammack of Premier Medical Group in Mississippi also vocalized the impact on his practice: “I am able to be more proactive about my patients’ needs…and identify patients with needs that may have gone unnoticed previously.”

We are achieving these results through a number of initiatives, such as “Home for the Holidays”. There is often an uptick in illness as well as emergency room visits around the holidays and this program helped practices to educate their patients and keep them healthy. This program included proactively calling patients, mailing postcard reminders, and focused conversations during office visits. Practices used same day appointments and twenty-four hour call lines to help patients avoid spending their holidays in a hospital waiting room.

Another initiative we pursued related to managing transitions of care through timely health information sharing with inpatient facilities. We work closely with a few local hospitals and utilize innovative strategies for gathering additional information from others. One clinic hired a nurse to follow patients from admission to discharge, ensuring the patient’s needs were met and that they received timely follow up. Another clinic assigned a nurse to use the local hospital’s health record to monitor the daily patient census, identifying when patients were discharged and then following up with them promptly.

While the revenue generated from savings is a great incentive to keep doing the work, one of our local medical directors, Dr. Syed Zaidi, points to a broader benefit: “We’re able to be a better practice now. We can help our patients more efficiently and provide a higher level of quality care.” That is the goal: efficient, quality care.

Here at Aledade, we talk a lot about getting out beyond the four walls of the practice – because that’s how you get a window into the real challenges that a patient faces every day. They might be challenges we couldn’t have seen if we kept doing business the same old way. And sometimes, if we fix those, everything else can fall into place.

One of our partner practices proved this not too long ago. Dr. Syed Zaidi has been working in the town of Ripley, Tennessee for the past 20 years – providing care to the families around Ripley through his independent practice. And thanks to Aledade, he was able to care for them with some new tools.

In 2016, Dr. Zaidi started offering Chronic Care Management to some of his Medicare patients. This meant that a care management team would check up on his patients with more complex chronic conditions, making sure they had their medications and to try to get ahead of anything that could go wrong.

One patient had been in care management for a while, but Dr. Zaidi and his team weren’t seeing any changes. Neither he nor the patient felt like they were really making progress.

Then one day, the family opened up, and shared the real challenge they were living with every day. They were homeless. For several weeks, the entire family had been living out of their car – joined by a few animals they had adopted as pets. Their home had been infected with mold, making it uninhabitable, and they didn’t know where to turn.

That’s where the care management team and Dr. Zaidi’s whole practice jumped in. They helped the family find a safe place to live. Through community resources, they secured donations and raised money to provide the family everything from new mattresses to new clothes. And, since the family’s new home couldn’t take pets, Dr. Zaidi’s team even found good homes for every one of the animals. Today, the family’s healthier, and the patient’s chronic conditions are under much better control.

Chronic diseases are only going to get more challenging in the years to come. In 2012, the CDC estimated that one out of every two adults in the U.S. had at least one chronic condition. One in every four U.S. adults had two or more. And 86 percent of all of U.S. health care spending in 2010 was for people with at least one chronic medical condition. Chronic care management – by actually connecting patients with an active and engaged care management team – can tackle a daunting challenge for our health care system, and open up new possibilities in lowering costs.

But most of all, CCM helps our patients live better lives. Thanks to CCM through Aledade, we found out about this family’s situation. And thanks to the compassion and drive of Dr. Zaidi and his care management team, this family got back on their feet and back on the road to better health.

Since joining Aledade last year, I’ve worked towards our mission of empowering doctors on the front lines of medicine with cutting edge technology to help them deliver high-quality care, while bringing down health care costs. Specifically, as Executive Director for Mississippi and Tennessee, I’ve focused on forming a new primary care physician-led Accountable Care Organization (ACO) in these states.

Today, I am proud to announce Aledade and I have a new partner in this initiative. We have begun a first-of-its-kind partnership with the Mississippi Academy of Family Physicians (MAFP), a statewide professional association of approximately 1,016 members, including physicians, residents, and medical students. At their very core, both Aledade and the MAFP are organizations with the mission of advocating for primary care physicians and their patients.

Aledade ACOs are made up of carefully selected physicians identified for their dedication to and delivery of high-quality care. Our Mississippi ACO is a group of top-level physicians from throughout all of Mississippi and the Memphis area, combined with leading physician members from MAFP.

With this partnership, Aledade continues its work with state-wide physician associations, including several other AFP chapters, focused on helping primary care physicians succeed in a value-based healthcare system. We will work with the MAFP and physicians across Mississippi and the Memphis area to operate a Medicare Shared Savings Program ACO. Our focus is on delivering the highest-quality care to patients, with an emphasis on preventative care, high-value referral networks, customized technology, and unmatched analysis of patient claims and electronic health record (EHR) data to identify patients who need help before serious medical problems arise.

This Aledade ACO means Mississippi and Tennessee patients can continue to see their local family physicians, with whom many have personal relationships. But, these family physicians will be more empowered than ever to manage patient care. Our ACO provides physician partners with the technology and network needed to better assist patients as they navigate a complex healthcare system. Patients can expect improved services as a result of the Aledade ACO, including after-hours care, transitions of care coordination, and long term care coordination. The bottom-line for patients is more personalized, high-quality care from physicians who operate in a system that rewards them for positive health outcomes, not simply services delivered.

For physicians, our partnership with the MAFP will enable the new ACO to provide in-person support throughout the entire setup and operation of the organization. MAFP will provide direct support to help practices within the ACO implement and enhance wellness services and care coordination. MAFP staff will also offer educational resources to help its members understand the benefits of ACO participation and population health, and will serve as a strong presence to aid in creating health policy conducive to empowered primary care.

The combination of top-level practices, MAFP’s resources, and Aledade’s custom technology, policy and regulatory expertise, and practice transformation experience will give independent primary care physicians the opportunity to be leaders in the healthcare transformation to value-based care.

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.