To succeed in value-based care, practices need to help patients get the right care at the right time in the right setting. At Aledade, we help practices do just that by reducing unnecessary emergency department (ED) use, improving care coordination with specialists, and managing chronic conditions.

Another way we improve quality is by engaging home health providers as key partners. Home health care accounts for eight to ten percent of total spending across our ACOs.

A primary care physician (PCP) can order home health for a patient in a hospital or another setting. Every 60 days after that, the physician needs to recertify the services as medically necessary for the patient. In the past, PCPs had limited insight into home health quality. They might not know when patients started home health care. They might not have clear communication during the recertification (or recert) process. This often leads to significant care gaps, and risks for the patient.

Our partner practices in Arkansas grew frustrated with the recert process, so they decided to revamp it. When a home health agency submits a recert request to the PCP, the practice’s care manager reviews it right away. The care manager checks if the patient is improving, and calls the home health agency to learn more. The office then schedules the patient for an appointment to review their progress towards their health care goals. Together, the PCP and the patient decide if the patient should continue with home health care. Sometimes another service, like Chronic Care Management, social support, transportation, or education, is more appropriate.

One patient in the Arkansas ACO had received home health services for diabetes management for more than a year. Both the patient and the PCP were frustrated. The patient’s A1C hadn’t improved and their ED utilization had increased. The practice stopped home health, and enrolled the patient in an in-office diabetic education program. There, the patient learned about triggers and how to manage insulin levels. The patient was also able to meet with the practice’s nutritionist for help with planning groceries and meals.

According to the team at Dr. Walker’s Clinic in De Queen, Arkansas, the new home health workflow ensures the practice reviews “all patients prior to admission to home health and performed at every recertification. We have a nurse that manages this population and meets with our home health agencies bi-weekly to discuss goals, recerts, and discharges.”

In West Virginia, our partner practices worked with home health agencies to reduce preventable admissions and readmissions. The home health agencies created a Collaborative Performance Review. They identify the hospital utilization of home health patients and find out how many hospital admissions were readmissions. They also look at patients who screened positive for depression, falls risk, and ED overutilization. This summary finds gaps in patient care, showing how the practice could have prevented a patient’s admission or readmission.

According to Dr. Tom Bowden of Charleston Internal Medicine in the Aledade West Virginia ACO:

“The transition from hospital to home is a critical step in the well-being of our patients. Partnering with home health agencies that can assist us in this process is vital. Finding the home health agencies that are willing to work with us, make changes, provide the care our patients need and track quality metrics will certainly help reach the triple aim of improving health outcomes, improving the patient experience and lowering health care costs.”

All of this starts with a question: “What information from would be most helpful when making a recert determination?”

By focusing on this question, we’ve developed a form for home health agencies. We found home health agencies were eager to provide the necessary information, as were the PCPs. This summary, and the conversations that came with it, are still in the early stages. However, we expect that more communication will identify the most necessary recerts.

Better home health care means patients get the right, high quality care. We work with our home health partners to transition patients from skilled nursing facilities, nursing homes, and hospitals safely and sooner when possible. Home health also helps to proactively keep high risk patients safely out of the hospital. This requires close partnerships with home health agencies, and the communication to paint a full picture of the patient’s health. Armed with this, Aledade’s partner practices can ensure their patients get coordinated care in the right place at the right time.

The 2016 results are in and Aledade Accountable Care Organization (ACO) practices saved Medicare more than $9.3 million! The Aledade West Virginia ACO not only reduced costs 5% below the Medicare benchmark, but also received a shared savings check. In 2015, we brought together a unique group of 11 independent primary care practices that understood the importance of collaborating on improving health. Together, our partner practices have created a strong network that have reduced unnecessary hospital visits and kept patients safely at home, managed high-risk patients through a robust care management program, and provided better coordination of patient care with specialists and other providers in the medical neighborhood. We are very proud of our partner practices’ incredible progress and dedication in these key initiatives that have helped improve patient outcomes. “Teamwork and quality are always a winning combination. None of us are as smart as all of us together, and that is why we joined the ACO, said Dr. Jonathan Lilly, a Vice Chair of the West Virginia ACO. “We’re so proud of the ACO’s work in improving care and reducing costs in West Virginia.”

At Aledade, we know the value data offers to primary care physicians (PCPs) in helping them to deliver high-quality, coordinated care. We believed that if doctors receive practice workflow support, technology, and analytics, they are in a better position to deliver the highest-quality care while reducing unnecessary costs. In West Virginia, our physicians get a real time report when their patients show up at the hospital. With this knowledge they have been able to coordinate with hospital providers and support patients coming out of post-acute setting, reducing hospital readmissions, unnecessary days spent in ERs and the number of days patients spend in skilled nursing facilities. Dr. Ghali Bacha, an ACO member, said, “By joining the ACO and utilizing Aledade’s technology and support, our practice has significantly reduced our patients’ unnecessary emergency department visits and hospitalizations in 2016. Helping our patients get the right care in the right place at the right time has been a major accomplishment.”

Aledade equips PCPs with direct practice support and tools to utilize data to deliver high-quality, coordinated care. Taking data from multiple sources helps doctors keep patients healthier and out of the ER, makes it easier to prioritize their time and their practice’s time for patients who benefit the most from programs like Transitional Care Management (TCM), Chronic Care Management (CCM), and Annual Wellness Visits (AWVs). By implementing care management programs in our practices, both providers and patients have seen significant benefit. In a recent blog, ACO partner physician, Dr. Beckett talked about how improving patient information and care coordination with the local hospitals has made a real difference. He shared a success story about “the patient who previously went to the ED up to twice a week has now gone six weeks without returning.” While this is only one exceptional example of success, this is fortunately a trend we are seeing across all our West Virginia practices and plan to continue to share future success stories.

As Aledade West Virginia ACO’s Medical Director, Dr. Tom Bowden put it, joining the ACO “helped better foster our relationships with patients and other health care providers and helped form that bridge to other doctors and hospitals.” And we have done just that. Practices have worked with local specialists in improving communication to make the patient experience as seamless as possible. Kanawha County specialists have worked closely with our PCPs on referral management to better coordinate and manage patient care. Whether, it’s meeting in person to strategize referral processes or getting systems aligned virtually to get real time data on their patients, the dedication to improving care coordination has driven unnecessary spending down and quality of care up.

In our first performance year, we have established a strong network of providers who have been able to remain independent by driving down costs all the while improving quality of care for their patients. The ACO strives to get every person the right care at the right time in the right place. The proof is in the numbers. 368 fewer West Virginians needed to be admitted to the hospital, 136 of those were readmissions that were prevented by reducing complications. Over 400 West Virginians ended up in their physician office instead of the emergency room. They spent 566 more days at home instead of in a skilled nursing facility and saw their primary care physician 10% more often to help make all this happen. In 2016, the ACO achieved a total savings of $3,197,252, with shared savings of $1,566,654. With continued dedication and hard work on ACO initiatives, we are moving in the right direction for bigger and better things this year and the coming year. We are excited for the future of our ACO in helping create a better health care system and better care for West Virginians.

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

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

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

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

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

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

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

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

Proud, but not satisfied.

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

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

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

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

Aledade’s growth is about more than adding new practices or forming new ACOs. To us, true growth represents strengthening our network of primary care practices by giving physicians new insight into their patient populations.

This is made possible by creating access to one of the most vital resources primary care practices need – data. Access to timely, relevant data is empowering to practices and impacts everything from workflow to quality of care.

Since our founding, Aledade has emphasized the importance of getting data flowing to – and from – our ACO partner practices. And Aledade’s model is designed to focus on equipping primary care doctors with everything they need to utilize this data and 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.

That’s why Aledade is excited about connecting our ACOs with four new HIEs: Clinisync of Ohio Health Information Partnership, Healthix New York, Louisiana Health Information Exchange (LaHIE), and Mississippi Health Information Network (MS-HIN). Together, these HIEs will connect our partner practices in Louisiana, Mississippi, New York, and West Virginia with more than 130 hospitals.

Across all of Aledade’s ACOs, practices are connected to more than 500 hospitals through our HIE partnerships. The data that physicians access through these connections allows them to see a more holistic view of the care their patients receive, extending well beyond the four walls of their practice.

For instance, Admission Discharge Transfer (ADT) data from local hospitals lets primary care doctors know when their patients have been hospitalized. This allows them to coordinate with hospital providers and support patients with Transitional Care Management (TCM), proven to reduce hospital readmissions.

Connecting our ACOs to HIEs is only the first step in strengthening primary care through data. In addition to HIE data, Aledade ACOs pull together data from a number of sources such as Medicare claims and private payer data – all integrated in the Aledade app. The integration of data from multiple sources allows doctors to effectively manage population health by identifying and prioritizing patients for TCM, Chronic Care Management (CCM), and wellness visits – listing patients by their risk level or time since last appointment.

Aledade knows the value data offers to primary care practices. But, we also know that it is a three step process to use data to improve care. First, practices need to get the data. That’s why we focus on connecting to HIEs to deliver data to practices. Next, practices need to derive insights from the data. The Aledade app integrates all of practices’ clinical and claims data, giving doctors a full picture of patients’ health and care. Finally, practices need to act on the data, as it guides them to deliver high-quality, coordinated care.

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.

At Williamson Health and Wellness Center in West Virginia, we understand the importance of chronic care management for patients, our practice, and the health system. When not effectively controlled by providers and patients themselves, chronic conditions put a hefty burden on the health system by over-utilizing care services that generate sky-high costs.

To avoid this problem at our practice, we implemented a team-based Chronic Care Management program in 2012. With the Central Appalachian Health Alliance, we received a grant from Duke University’s CMS Health Care Transformation project to test the effectiveness of using community health workers to manage the care of high-risk diabetic patients. That program’s success led us to expand our care coordination network and provide community health workers to all high-risk patients with chronic conditions.

Our program has produced phenomenal results. We use the Aledade app daily to identify and prioritize high-risk patients. We’ve expanded practice hours and implemented an after-hours phone line. And, we’ve improved patient information and care coordination with the local hospital.

One recent example hit home as evidence that our Chronic Care Management program is making a real difference.

One of our patients with chronic obstructive pulmonary disease (COPD) had a habit of seeking care at the emergency department (ED) once or twice a week. This patient had serious anxiety about his COPD and saw emergency care as his only option when he had trouble breathing. Due to his condition and anxiety, we decided to enroll him in our Chronic Care Management program.

Once enrolled, the patient received additional care services, including weekly home visits from community health workers – who reduced his anxiety, taught him how to better manage his COPD with practices like breathing exercises, and helped him understand resources other than the ED that he could use when he needed outside help. Community health workers are absolutely vital to our program, working on the “front line” to deliver care, assess risks in patients’ daily lives and homes, and educate patients on self-management.

In addition to those visits, the patient received comforting check-in calls every Friday – when he typically went to the ED – from our practice staff. We also set-up a standing order of Solumedrol, which had proven effective for the patient, at the ED should he seek care there.

The good news: he hasn’t been back. His results have been stunning. The patient who previously went to the ED up to twice a week has now gone six weeks without returning. The Chronic Care Management program has had a huge impact on his life and avoided a dozen ED visits, also easing the strain on hospital providers and slashing the cost of care.

While this is an exceptional example of success, we’ve seen team-based Chronic Care Management work time after time for patients with all forms of chronic conditions. We look forward to sharing more turnaround stories with you!

At Charleston Internal Medicine we know that high-quality care also means seamless care. This is particularly important when it comes to patients being admitted or discharged from a hospital. Transitions of care can be a vulnerable time for patients, as they face an array of challenges.

For instance, when a patient is discharged from the hospital, he or she may need to understand and follow new instructions, take new medications, use new health tools or equipment, or need to schedule follow up care. And, we must ensure that all their other providers are updated on these changes. If not managed correctly, transitions of care can lead to hospital readmissions, health complications, or a decreased chance of long term improvement.

That’s why our practice has made closing the gaps created in transitions of care a priority. Just over two years ago, Charleston Internal Medicine brought on our own Hospitalist to care for all of our hospitalized patients. With a Hospitalist on staff, our patients have a physician from the primary care practice they trust on hand and caring for them during hospitalizations – which can be trying and difficult times. And, our practice has a direct line of communication and insight into our patients’ health and care. Our Hospitalist lets the practice know what she needs and sees in the inpatient setting, while we keep her informed on our patients in the outpatient setting.

Right away, we saw the impact of our Hospitalist program. Most notably the open communication through our Electronic Health Record allows full access to patients’ record and the ability to connect with a patients’ Primary Provider at any time. The outcomes have been significant: Charleston Internal Medicine patients’ average length of stay in the hospital is almost two days less than other patients at the local hospital.

Even so, we believed more could be done. So we added a Nurse Practitioner to work alongside the Hospitalist and manage patient communications. She communicates with the patient, family, and caregivers as to the changes in care and what is needed at and after discharge. The Nurse Practitioner also personally calls each patient within 48 hours of discharge to ensure the patient is managing the transition properly.

The follow up calls have had a clear impact. In talking with the patient after they’ve been discharged, our Nurse Practitioner invariably, finds a missed care gap, a change that needs to occur, or another issue to be corrected or communicated to the doctor. For example, twice in recent months, she has called patients after they’ve been discharged from the hospital to discover that their oxygen tanks were not delivered. She was able to follow up with the oxygen supplier to ensure immediate delivery to meet this critical need. This example illustrates that while a transitional care visit 4-5 days after discharge is standard, many issues can arise and cause serious health decline that lead to readmissions even before that visit, so reaching out to the patient within the first 2 days is vital.

Given our practice’s emphasis on transitional care management, joining the Aledade West Virginia ACO last year was an easy decision for us. We knew that Aledade shared our mission to focus on keeping our patients healthy, out of the hospital, and in their homes. We also knew Aledade would provide us with even more resources such as policy expertise, data and technology to continue this vital work. Participating in a value based program, like the ACO, gives us even more reason to focus on our patients’ full spectrum of health and wellness.

One of the major benefits of joining the ACO has been the ability to share innovative ideas that benefit our patients across other practices in our region. Our efforts around care transitions have worked so well that another Aledade ACO practice recently asked us to handle all care for their patients in the hospital as well. This assures our fellow ACO practice that their patients receive quality care, gives them direct communication with the hospital staff, and immediate communication upon discharge about pertinent issues that need to be addressed in outpatient setting.

The ACO has helped us to think even more creatively about key issues like transitions of care. Recently, we’ve also begun another initiative that helps improve transitions of care, reduce readmissions, and post-discharge health complications. We partnered with a local pharmaceutical school so that every Charleston Internal Medicine patient that is discharged sees the pharmacist and does a medication reconciliation. This ensures that any changes or new medications will not adversely affect the patient.

Patient satisfaction has skyrocketed since we have implemented these new systems. We have received many calls from patients, families, and caregivers expressing their gratitude for this added care that they have never received before. Knowing that we’re focusing on keeping our patients healthier while easing the minds of their caregivers has been extremely rewarding for our physicians and staff, and most importantly, better for our patients.

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.