Independent primary care providers get an inside look at the policy process while sharing their ideas for improvements to the value-based care landscape.
Aledade’s headquarters might be based just outside of our nation’s capital, but it isn’t every day that our partner physicians have a chance to meet one-on-one with their Congressional representatives on Capitol Hill to advocate for value-based primary care.
In early July, five independent primary care physicians from Aledade ACOs joined the company’s leadership team for a trip to Washington, D.C. and an opportunity to positively influence policymakers with real-world stories of patient care and practice transformation.
“One of the reasons why Aledade is very effective with influencing and informing policy is our ability to draw on the real-world experiences of practices who are really doing value-based care,” said Farzad Mostashari, MD, co-founder and CEO of Aledade.
Making policy and practicing medicine have a lot in common, he continued. Both demand the ability to make effective decisions in complex situations. Both can have immediate and long-term impacts on individuals and their families. And both require a personalized touch to be truly effective.
“Policymakers and regulators have to think about what’s best for a huge number of people,” said Mostashari. “They are operating on such a large scale, often with hundreds of billions of dollars running through their offices. When you’re in the middle of that, as I know from experience, you can start to worry about losing touch with what’s actually happening in the field.” “That’s why it was great to see that the people we met with were so receptive to hearing from physicians who are working in very real settings.”
For Dr. Karl Schwabe from PMA Medical Specialists in Pennsylvania and Dr. Richard Card, a solo primary care physician based in Virginia, going to the Hill for the first time was an eye-opening experience.
Most Americans only see the surface of the legislative process when they watch the news or read about political issues, said the two physicians.
While formal debates on issues of national importance certainly play a role in policymaking, much of the groundwork for new ideas is laid during quick walk-and-talk meetings, said Dr. Card.
“When you watch C-SPAN or the news, you see all these big rooms with dozens of Congresspeople talking and arguing with each other,” said Card.
“But the reality is that most decisions are made outside of that room. You get five or ten minutes in a hallway to plant your ideas with your representatives or their staff, and then sometimes it takes a couple of years before you see any fruit from it.”
Dr. Schwabe agreed that the process looks different from the inside.
“Everything gets done in little snippets,” he said. “You might have the opportunity for half an hour to make an impression on someone who works for your Congressional representative, and that’s it.”
However, a lot can be accomplished in half an hour. And these physicians didn’t waste a single moment.
During a packed day of meetings, the two doctors and their colleagues from North Carolina, Kansas, and Michigan met with legislators and staff to discuss issues that affect their communities, including hospital consolidation and appropriate utilization of healthcare services.
“When I met with the legislative assistant for Rep. Mary Gay Scanlon (D-PA), I started the conversation by explaining what an ACO was,” said Schwabe. “After that, we were able to have a great discussion about how we operate and what we do.”
Card also began one of his meetings with a little education about value-based care, he said.
“Congressman Morgan Griffith (R-VA) wasn’t very familiar with ACOs either, so we explained what they do and why they benefit the community,” said Card. “It turns out that he uses some independent practices for care, which was a good entry point for talking about how Aledade keeps PCPs independent.”
“It was also a segue into talking about industry consolidation and its negative effect on prices,” he continued. “The Congressman spent about 25 minutes with us, and we had a great conversation about these issues.”
Later that afternoon, Card and Schwabe joined Mostashari and the Aledade policy team for a sit-down with John Brooks, Principal Deputy Director of the Center for Medicare at the Centers for Medicare and Medicaid Services (CMS).
At the top of the agenda was the rural glitch, an issue with the way CMS calculates benchmarks for participants in the Medicare Shared Savings Program (MSSP).
Accountable care organizations allow multiple providers in a region to band together as one entity to tackle quality improvement and cost reductions. In sparsely populated rural areas with relatively few practices, many of those providers may be part of a single ACO. As a result, that ACO might end up serving a large proportion of the region’s patient population.
That gives rural ACOs a disadvantage in terms of calculating their cost improvements compared to the region, explained Card, because the formula currently includes an ACO’s own patient population in the benchmarking calculation.
“If those practices are doing very well for their patients and reducing costs, they are driving the changes in the benchmarks because they comprise such a big part of the calculation,” Card said.
“As a result, they are essentially competing against themselves in a way that is almost unfair compared to more populous regions where patients are divided more equally among more providers.”
The glitch has clear and significant financial impacts on ACOs in rural areas, added Travis Broome, VP for Policy and ACO Administration at Aledade.
“Let’s say I have an ACO in Washington, D.C. that accounts for 2 percent of the patients in the market,” Broome explained. “That ACO reduces costs by 5 percent by being truly excellent in delivering primary care. Under current policies, they get to keep nearly all of that money – 98 percent – as a reward for their work.”
“Now, let’s say there is an ACO in a very rural area where 20 percent of the patients are attributed to one ACO. That ACO also reduces costs by 5 percent. Because of the rural glitch, that group will only get to keep 80 percent of the reduction in costs compared to the 98 percent for the urban ACO.”
Removing a rural ACO’s own patients from the existing benchmarking rubric would solve this problem, show analyses from the Aledade policy team. That way, the comparison is more accurate and the ACO will not be financially penalized for doing well.
“We want to make sure that people who perform the same get paid the same. That’s all,” said Broome.
Mostashari was quick to point out that the rural glitch is not the result of some deliberate plan to put certain providers at a financial disadvantage.
Instead, it was simply a well-intentioned decision that has produced unforeseen results in an extremely complicated program that is constantly evolving to get better and better.
“People often forget that there are human beings on the other end of this who have been working their tails off every day trying to do the right thing,” said Mostashari. “Every day, they get 98 percent of it right, but people always seem to get mad about the other two percent of things that aren’t perfect.”
“One of the most important things, whether you’re a physician, an administrator, or whatever, is to be able to put yourself in the other person’s shoes. You need to thank them for the things they did right, because those things were hard. And you need to help them fix the other things by bringing solutions to the table, not just complaints.”
CMS and other policymaking entities regularly publish requests for information (RFIs) and open public comment periods when considering potential changes to programs like the MSSP.
Anyone can make observations or offer suggestions during these opportunities, and Aledade encourages all healthcare stakeholders to share their thoughts when policies are up for debate.
Actively participating in the process is the only way to enact the changes you want to see, said Mostashari. And getting involved does bring results.
“The government is not a nameless, faceless institution,” he stressed. “It’s a group of human beings making complicated decisions about complicated issues, and they are all trying to do the right thing for America.”
“Fundamentally, I believe in this process. I believe in bringing the best thinking and the best perspectives to the table. Change doesn’t always happen quickly, and it doesn’t happen in a straight line, but the system works.”