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://www.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://www.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://www.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://www.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.

Trust and good relationships with patients are essential in providing high quality healthcare. A key factor in this equation is being available for patients when they have questions or concerns. This availability is especially important for patients dealing with chronic illnesses or other health issues. Opening an avenue for these patients to have access to care, even outside the clinic, can greatly enhance the trust they feel and the relationship they share with their provider.

Like many others, our clinic is in a state of evolution as we make the transition from a traditional fee-for-service model into a more comprehensive care setting for our patients. We decided last January to begin offering Chronic Care Management as a resource to reach some of our most at-risk patients. Right away it became obvious the success of the program was going to hinge on finding the right person as a liaison between patient and provider. It had to be someone the patients felt comfortable talking to and someone I could trust. It was a very difficult leap of faith, but I decided there was no better choice than Susan Williams, my nurse of 15 years. Susan already has good relationships with all of my patients, and they trust her. I promoted her to the position of Care Manager, and we began enrolling patients.

With Susan leading the way, our patients immediately embraced the program, and we have seen many of our most in-need patients begin to manage their health more effectively and efficiently. We have over 80 patients under management, and only two have discontinued the program.

We launched a new cell phone line so patients in the program could access Susan directly. She carries the phone during office hours so that patients no longer need to speak to the receptionist. They no longer worry about not getting a call back or if their message is lost in translation. If there is a problem, Susan comes to me directly, and we decide whether the patient needs to come to the office or if we can handle the problem remotely.

It became immediately evident, once these patients knew they could get an answer quickly, their tendency to run to the emergency room decreased. Susan began keeping a list of patients who were seen in the office on the same day they called and spoke to her. While this is a number that never shows up in the data, we have counted over 40 occasions since last June where the patient called asking if they should go to the emergency room, and instead they were seen in the office. Even if they actually do need hospitalization, I can admit them to our hospital directly from my office, avoiding the time, stress, and extra cost of a trip to the emergency room.

A specific example of the effectiveness of the program involves a patient who had an outpatient procedure to replace his pacemaker battery. The following day he spiked a high fever and called the number provided by the cardiologist. He was unsuccessful at reaching any of the clinical staff and was told he would get a call back, which never came. Instead of going to the local ER, he called Susan. She informed me of the problem, and I had her call the Cardiology practice. She was quickly able to get the physician on the phone and direct admission was arranged under the care of the patient’s cardiologist. With a simple call, an ER visit was avoided and care was provided quickly.

Aledade ACOs emphasize the special relationships small practices have with their patients, and their guidance helped us launch this beneficial care management program. Our patients value the personal relationship they have with Susan, and we have direct evidence the program has led to better health outcomes and lower hospital and ER utilization by our patients.

President Trump’s administration has made it clear that they plan to greatly alter, if not repeal, the Affordable Care Act. To both sides of the political isle it may come as a surprise that altering the Affordable Care Act will likely have little impact on a core outcome of health reform: the fact that private insurance companies increasingly pay primary care providers for improved health outcomes. Since the presidential election, we have met with a dozen payers in both red and blue states: Arkansas, Florida, Louisiana, Mississippi, Missouri, New Jersey, Pennsylvania, Utah, and West Virginia. Not one payer has mentioned that they plan to stop their efforts, or pull back resources dedicated to moving physicians away from the fee-for-service paradigm and towards paying for outcomes. In fact, every payer we meet is intent to continue to innovate by paying providers in a manner that lowers cost and improves health.

A key piece of the Affordable Care Act created the Medicare Shared Savings Program, and private payers quickly followed with their own efforts to move physicians to shared savings contracts. Years later, private payers continue to dedicate significant resources to move providers away from fee for service and towards value payments. And payers have committed to move all of their providers, across all business lines (commercial, Medicare Advantage, and Managed Medicaid), to value. This investment has been significant. For example, Cigna established CareAllies, a service company that works with provider organizations of all types to focus on improved patient outcomes and better health care quality and affordability. Similarly, UnitedHealthcare (via Optum) has gone further and purchased providers in order to create high value networks and their own Accountable Care Organizations. Humana has a well-established value path (the Accountable Care Continuum) that moves its Medicare Advantage providers away from fee for service on a path towards global capitation. Each of these national payers have undertaken vast strategic efforts that require significant resources for staff and infrastructure, and a change in culture.

Commercial payers believe, and have the data to demonstrate, that paying for value lowers their cost and improves the health of their members. For example, UnitedHealthcare has noted up to 6 percent lower medical costs across a range of value-based care programs, and overall, commercial ACOs have lower expenses per Medicare enrollee and slightly higher quality-of-care scores.

Despite the threat of repealing parts or all of the Affordable Care Act, our payer partners continue to move ahead with their payment reform efforts. The political battle over Obamacare has had no impact on payers’ dedication to reform provider payments; the future of primary care provider payment remains value-based. Though there is still much unknown about the potential repeal and replacement of the Affordable Care Act, the future of physician payment reform is clear.

In the primary care setting, physicians are constantly faced with the challenge and opportunity to care for patients who bring numerous and diverse needs into the clinic.

Behavioral health is one particular challenge that can make providing value-based care difficult. A recent report from the Commonwealth Fund highlighted this challenge and noted that high-need adults with a behavioral health condition struggle to receive adequate care, yet, at the same time, these patients have much higher health care costs.

Aledade understands the importance of integrating behavioral health care into the primary care setting. By striving to understand and meet all of the needs our patients have, we successfully help them receive higher quality care at a lower cost.

In fact, recently, I saw the importance of our behavioral health care coordination in action. A patient of Dr. Annil Sawh of the Orlando Medical Group in Aledade’s Florida Central ACO was utilizing the Emergency Department (ED) at a very elevated rate. This patient was abusing prescription opioids, and when she ran out, went to the ED to seek more medication.

Some people suggested Dr. Sawh should ‘fire’ the patient due to the high ED utilization, but Dr. Sawh was committed to providing her with the care she needed. Dr. Sawh tried setting up a “contract” with the patient, gradually limiting the number of pills she could receive. However, the patient ultimately continued drug-seeking behavior with other providers. She attended a drug rehabilitation program, but as is often the case with opiate abuse, she relapsed quickly after release from the program. Refusing to simply drop the patient from his care, Dr. Sawh turned to Aledade for some additional guidance.

The Aledade Central Florida ACO Executive Director, Sheila Fuse, suggested that Dr. Sawh request a consultation with me. I recommended that Dr. Sawh try treatment with Suboxone, an FDA approved medication for opiate dependence.

This intervention was highly successful. Before being treated with Suboxone, the patient conducted seven ED visits over the span of three months, but she has since avoided ED visits altogether over the past few months.

This patient broke the self-destructive and costly cycle of abusing opioids and making too many ED visits. She now works with Dr. Sawh to help a family member, with a similar set of problems, improve her life situation and break the cycle as well.

Aledade’s impact goes beyond the regular discussions we have with our physician partners.

Each month, I visit with care managers at the Green Spring Internal Medicine, one of our ACO partner practices in Maryland, to discuss psychiatric issues that come up in their care setting. During these visits, I provide advice and learn important lessons from the care managers at Green Spring that I can then take to Aledade practices across the country.

The Aledade depression toolkit is another example of how we help providers understand how to manage behavioral health conditions. This toolkit includes a comprehensive packet on how to treat depression, information on how to manage medicines, and guidance for care managers when psychiatric conditions arise.

Following the recent, serious flooding in Louisiana, Aledade was able to recommend resources for trained disaster relief counselors. Another small success was helping to facilitate better communication between a community mental health center and one of our Aledade practices in Kansas, to improve the referral process for primary care patients needing mental health treatment.

In the upcoming year, some upcoming initiatives involving behavioral health will include supporting our primary care providers in their efforts to offer advance care planning so that patients can face terminal illness in a manner consistent with their wishes and values, and we also aim to increase behavioral health-specific care management throughout our network of providers.

By placing a focus on quality behavioral health care, Aledade is giving providers and patients the tools necessary to manage these issues in the primary care setting. It’s a pleasure to work with physicians like Dr. Sawh and the providers at Green Spring as we all strive to ensure our patients receive the best possible care. Together, we will continue to develop effective ways to keep patients engaged and give them the health outcomes they deserve, while reducing the challenge of treating behavioral health issues in a primary care setting.

For over twenty years, I’ve been blessed to receive exceptional care from Dr. Chiarito, my primary care physician at Mission Primary Care Clinic in Vicksburg, MS. I’m a retired English professor, I’m a minister of the Presbyterian Church (USA), and I’m someone who’s had plenty of engagement with the health care system over the last few years. This includes having my hip joint replaced and, recently, having surgery on my shoulder. With the help of Dr. Chiarito, I have also recently lost a significant amount of weight.

I remember meeting Dr. Chiarito, when she was still in medical school, observing at the Mission Clinic. In the years since joining the practice, Dr. Chiarito has been someone I depend on for my medical care. I have never had a better relationship with a doctor. Dr. Chiarito’s warm, outgoing personality helps me know that my medical needs will be supported, and her personal touch with patients is noteworthy. Once, when I was in a skilled nursing facility, Dr. Chiarito came by to check on me, and she brought me some delicious figs from her garden!

In addition to Dr. Chiarito, I’ve also grown close to one of the nurses, Melody, who helps me take proactive measures to prevent future health problems. Examples of these measures include the flu and pneumonia shots I receive and the Prolia shots Dr. Chiarito prescribes for osteoporosis prevention.

I am enrolled in the Mission Clinic’s Care Management Program. Mary, the Care Manager, helps address my unique health concerns and works in partnership with me to identify and implement ways I can positively impact my own health. She calls me once a month to check in, and we have a conversation about changes in my health as well as any health-related questions I may have. Her monthly phone call is a source of confidence and peace of mind. If there is something bothering me, Mary arranges an appointment for me right away.

One example of Mary’s dedication to managing my health stands out. After my shoulder surgery, my physical therapist had a few questions for my surgeon. Unfortunately, my physical therapist had trouble reaching him. Mary called the surgeon every day for a week, and she was able to get the answers needed to continue my physical therapy. Without getting the right physical therapy in a timely manner, my recovery could have been severely impacted.

I encourage everyone to have a primary care physician and build a relationship with their doctor and the rest of the practice staff. The Mission Clinic team has greatly improved my health, and they have positively impacted my life. Because of the relationships I have with everyone at Mission Clinic, I feel confident asking questions, and I know I am receiving the best care. Dr. Chiarito, Mary, and Melody are partners in my care, they help me get all the right information, and they determine the best plan for me. Mission Primary Care Clinic gives me a great sense of being personally looked after, and, with their help, I am confident many healthy years are ahead!

Dr. Salvatore Volpe, MD, FAAP, FACP, CHCQM, a member of the Aledade Primary Care ACO, was selected by the Patient-Centered Primary Care Collaborative (PCPCC) as the 2016 recipient of its National PCMH Practice Award. Dr. Volpe is the chief medical officer at the Staten Island Performing Provider System and has run his own primary care practice in New York for more than 25 years. Below he explains his unique approach to running a primary care practice and how it’s changed over the years.

For me, a primary care physician and Staten Island “settler,” being recognized at the same ceremony as Dr. Paul Grundy and Dr. Edward Wagner is like being on stage with the Mickey Mantle and Joe DiMaggio of my profession.

Dr. Grundy is the godfather of patient-centered medical homes, or PCMHs, while Dr. Wagner wrote the book on Chronic Care and Care Coordination.

I am honored to receive PCPCC’s award, as I see it as a lifetime achievement award (even though I’m still practicing). And, I am humbled to be recognized, because all I ever set out to do was run a solo-physician primary care practice in my home town. Lastly, I am proud of the award as it marks how far my practice has come since its founding 25 years ago – especially our advances in care delivery, quality, and technology.

In my view, my practice has always been a PCMH in principle. However, it’s been a long-term, step-by-step process: achieving PCMH status, becoming the first solo-practice to achieve PCMH NCQA Level 3 in the nation, becoming chief medical officer of State Island Performing Provider System, and joining an Aledade ACO.

Through this, I have come to appreciate three keys to running a high-performing PCMH primary care practice: technology, care management and communication, and patient relationships

When I founded my practice there was no EHR. I used a medical manager practice system for billing and appointments, and that was it. However, I took advantage of a little-known feature in the system called notes, a place to leave details similar in length to a tweet today. With this, I could keep track of test results, reports, and patient information. I saved a lot of health care spending and improved patient health by having access to these notes whenever I got a call – during or after office hours.

When I finally got an EHR system in 2005, it was both a commitment and a risk. Not only was it a hefty investment for my small practice, but it would require hours of learning and workflow adjustment until my staff and I were fully comfortable with its utilization. The investment was worthwhile though, and many EHR system updates and other IT tools later, today I have technology that empowers my practice with data, insight, and analytics never before imagined. Due to this, I’ve become an advocate for EHRs and health information technology, which has lead me to many advocacy roles, including at the NYS Medical Society HIT Committee, the New York Chapter of HIMSS, and assisting Dr. Mostashari and the Aledade team in developing population health technology tools.

One area that improved technology has helped significantly is care management and communication. Through our EHR, HIE, and population health tools, my practice can better collect, manage, and analyze the patient information we need. A good example of this – involving both patient-to-provider and provider-to-provider communication – occurs when one of my patients is admitted to the hospital. Once notified, I call the hospital to speak with the ED doctor or hospitalist to coordinate care – by sending patient records, explaining health history, requesting a discharge summary, and letting patients know to follow up with my practice.

Today, population health management is driven by patient data and technology tools. I can use the EHR and care management tools to assess which patients are at risk due to chronic disease, recent ED or hospital visits, or even flu season, and ensure we are managing the risk. This means communicating with the patient via the phone, to check in or schedule a visit; during a visit, about health needs or prevention; or, for my practice, throughout our community.

Modernization and technology has certainly impacted my practice greatly, but it can only do so much. Primary care, like many professions, still comes down to the people. I pride myself on personal communication and relationship with my patients. My inspiration comes from the lesson of my parents, who, rather than being physicians, were blue-collar workers, but that took care of their friends and neighbors in the community. This example is how I operate my primary care practice. My patients are part of my community, as I live 15 minutes from my practice, and see them at church and the grocery store. Patient relationships like this are important for improving care as they build trust, as well as encourage open communication about health concerns – both mental and physical.

I consider primary care physicians to be the project manager of health. It’s through this approach, including my continued focus on advancing technology, care management, and strong patient relationships, I have been able to successfully lead a solo-physician primary care practice for over 25 years. Recognitions are always a gratifying surprise, and they only further motivate me to improve my practice and care for what matters most – my patients.

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.

Since Post Rock Family Medicine began our care management program in May, we’ve seen first-hand the direct impact it can have on our patients and our practice. Care management has proven to be incredibly valuable because it allows our practice to improve so many aspects of our patients’ health and care.

In leading our care management program, two recent cases come to mind as standout examples of how care management can comprehensively improve patient health and wellness.

One summer Friday, I received a call from a patient with diabetes who was enrolled in our care management program. She called our 24-hour care management hotline to notify the practice that her glucometer was broken and that she would not be able to take blood sugar readings until her new one arrived – scheduled to be delivered a whole week later. She could not afford to get one rush shipped or from another source.

The patient knew she could reach the practice – due to the hotline – and wanted to let us know she would not be providing blood sugar information to her telemedicine monitoring program throughout the week. Concerned about her stability without a way to monitor and report her blood sugar, we jumped into action to get her a glucometer right away.

I reached out to the director of nursing at our local hospital, and she found an available glucometer for the patient to use. As the patient was without transportation, I picked up the glucometer and was able to deliver it to her home the very same day. Instead of being without a critical tool she needed for upwards of a week, the patient had it – free of charge and right away after contacting us.

By providing her with a replacement glucometer until her new one arrived, we offered peace of mind for the patient and for ourselves – knowing that we could monitor any abnormal blood sugar measurements and take appropriate actions, and possibly prevent an unnecessary hospitalization.

Another case study emphasizes the role of the home visit that we conduct anytime a new patient enrolls in our care management program. During these visits, we introduce the program and begin to develop a personal connection with the patient.

On one of these such visits, while I was doing our standard pharmaceutical review, a patient expressed worry about the expensive cost of her medications. This cued me to walk through her health insurance information, and in doing so, I discovered that she had recently become dual-eligible for Kansas Medicaid as well as Medicare, but was unaware and not utilizing it.

I was not only able to explain this to the patient, but also helped get her Medicaid information to the pharmacy, local hospital, our practice, and her DME supplier – significantly reducing her monthly health care expenses. Without the personal connections developed and information gathered during our care management home visits, this patient would have had more out-of-pocket expenses, and the stress that comes with higher health care costs.

In both of these cases, our care management program improved patient care. However, each case also highlights how care management comprehensively encompasses all aspects of patient health – from preventive care to financial wellness. Using the Aledade app, we’ve been able to identify high-risk patients, prioritize them for our care management program, and better monitor their health and care. So far, we’ve seen outstanding results – and heard complementary feedback from patients – and I look forward to seeing the successes to come.

As our network grows, so does its value. Aledade’s growth is a learning process, and as we help primary care practices understand how to thrive in a value-based health care system, we continue to learn about the real-world issues that primary care doctors encounter, what they need to deliver the highest quality care, and what our 200 like-minded primary care practices across 15 states can learn from their peers.

This is an important strength of Aledade’s primary care physician-led ACOs. While there is no one-size-fits all solution to improve primary care, we have experience developing and implementing strategies that work across a diverse group of practices. Each independent practice faces its own unique set of challenges – whether driven by geographic, patient population, technology, or policy factors. But, between Aledade’s team, experience, and network of partner practices, together we can empower the delivery of high-quality, coordinated care.

Two members of the Aledade Mississippi ACO (which also includes practices in Tennessee) are leading examples of innovating solutions to their particularly challenging conditions. In both cases, the Mississippi practices have developed successful approaches to Transitional Care Management (TCM). These are valuable solutions as TCM is an effective way to lower hospital readmissions, hospitalization rates, and identify patients needing additional attention. In fact, Aledade has found that for every eight high risk patients who receive TCM, practices can prevent one readmission.

The foundation of TCM is knowing when patients are admitted to and discharged from local hospitals. And one of the easiest ways to acquire that information is through electronic admission, discharge, transfer (ADT) notifications via health information exchanges (HIEs) or from hospitals directly. The Aledade Mississippi ACO has experienced numerous challenges getting electronic ADT data from local hospitals, but the ACO practices haven’t let this technical hurdle stop them. Several practices have adopted their own method of getting critical ADT data in order to implement TCM.

The Indianola Family Medical Group has provided care to patients in Indianola and the South Sunflower County area for over 60 years. In order to get the information they need, Indianola sources directly from the local hospital’s EHR. The practice staff can log-in directly to the hospital’s system and identify which of their patients received care, why the patient was at the hospital, and when the patient was discharged.

Each and every morning, at the same time, their care manager conducts her TCM calls to patients. Indianola has had great success with TCM because, as the care manager describes, “it’s like starting a cup of coffee in the morning.” It’s the first thing she does when she arrives at 8:00am. And, since implementing this TCM process, it has become a tool for identifying patients for Chronic Care Management (CCM). Identifying patients who need a TCM visit, or should be enrolled in the CCM program, is a great way to improve patient health and reduce health care costs.

Kosciusko Medical Clinic has also found a way to coordinate with its local hospital to get the patient data it needs for TCM. However, whereas Indianola used the hospital’s technology to access data, Kosciusko has enlisted their own office support staff. Every day – at least once – a practice employee picks up the paper discharge records from the hospital and walks them across the street to Kosciusko’s desk staff. Originally, the practice only got the triage sheet, limited to names of patients who were discharged, but now they receive a more comprehensive record with the full who, what, when, and why information on their patients who sought care at the ER or were admitted to the hospital.

Kosciusko’s team of care managers uses this information to conduct their TCM outreach every day. The practice brought on a nurse care manager to support each of its providers. This has resulted in a successful work flow to identify high-risk patients who need TCM, and others who should be prioritized for care.

Aledade is proud to help leading primary care practices – like Indianola and Kosciusko – design and utilize the unique solutions they need to deliver high-quality care. It’s entrepreneurial primary care practices like these that join and are successful in Aledade ACOs – helping transform primary care to deliver better care at lower costs.

After months of practice visits with physicians across the country, another round of recruitment has come to a close for Aledade. Aledade recently submitted our Medicare Shared Savings Program (MSSP) applications the 2017 start year.

The results are astounding. Aledade has doubled in size. Our ACOs now include over 200 total practices, spread across 15 states, responsible for over 200,000 patients. This is an incredible accomplishment for our young company, and a huge opportunity for the independent physicians we partner with to thrive in the new value-based health care system.

But, for us, and the rest of the Aledade team, crisscrossing the country over the last 12 months speaking with physicians offered an amazing opportunity to get to know and learn from primary care doctors and their staff. We have learned a great deal about what independent physicians value, how they operate their practices, and how they view the great transformation taking place in health care.

First and foremost, the primary concern for all of the physicians we speak with is the same: delivering high-quality care to their patients. Primary care physicians know their patients best. Patients, and the community, trust their primary care practice to deliver personal, attentive care. Unfortunately, the current fee-for-service system makes it difficult for them to deliver that. The result is a system that costs a lot, but delivers less than the best. And no doctor wants to settle for anything less than the best for his or her patients.

Second, from Salt Lake City, UT to West Chester, PA and from Bay City, MI to Rockledge, FL, one common theme emerged as we spoke to primary care doctors across the country – they see great potential in the new value-based payment models, and are eager for a system that pays them to keep people healthy. However, they are concerned about how to get there. Can they stay independent or will they have to go work for a hospital or health system? What options do they have, and of those out there — ACOs, hospital employment, IPAs, and other management groups – which are best? What does all of this mean for their future?

Third, if they take the plunge, how can an independent physician make the changes necessary to thrive in a new payment model? They understand that the shift to advanced payment models comes with adjustments across the board for primary care practices. Technology, workflows, quality reporting, and keeping up with payer and regulatory requirements all need attention. As a solo-physician in Sulphur, LA explained to us, physicians know they must take action, but also need the guidance and tools to do so. This is a complex, if not overwhelming, task for many independent physicians leading their own practice. Whether through help updating practice technology or understanding health policy, practices need a supportive partner to help them navigate the transition.

Our mission at Aledade is to be that supportive, knowledgeable partner for physicians throughout their journey adapting to a value-based health system. Aledade’s on-the-ground staff provide hands-on help for physicians as they implement new technology and workflows. Our policy staff can walk physicians and their practice team through new reporting and reimbursement structures. Our technology gives physicians visibility, for the first time, into what’s happening with their patients outside of the four walls of their practices. And, our network of like-minded physicians across 15 states shares best practices from the field.

This is how Aledade has grown so much this past year, and this is how we are going to deliver the high-quality care patients deserve this year – and for years to come.

To our newest 2017 practice partners, we welcome you to the Aledade family. We’re committed to working tirelessly on behalf of your practice and your patients. And we will advocate for you every step of the way.