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

Emma Lisec and Nadine Robin at the Aledade booth

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

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

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

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

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

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

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

Nadine and Matt Wheeler presenting at LAFP

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Sometimes, one of the most valuable members of the care management team isn’t in the practice at all.

For example, take a patient we enrolled in chronic care management in 2015. The patient was nearly 80, and living with a number of chronic conditions – starting with some pain in her ribs. We enrolled her in CCM so we could find the cause of this rib pain, control it, and hopefully help the patient stay independent.

Aledade teaches practices how to identify the patients who would benefit the most from the Chronic Care Management program. They encourage CCM for high-risk patients with multiple chronic conditions, high-risk factors, and poor symptom management. Most of all, they encourage practices to help patients improve their self-management skills, so they can live as independently as possible.

At the first appointment for our patient, I met one of her two daughters. We ran through all the preliminary steps, and set up a care plan. That’s when I learned that the patient lived with her other daughter. That daughter would be our point of contact.

From the beginning, this mom and her daughter called me with any needs they had. I helped the patient and her daughter set up studies, appointments with specialists, insurance referrals and communication with the patient’s primary care physician. I made sure that we had all of the communications and correspondence from specialists that we needed, and I kept the patient’s list of medications updated.

Aledade’s Care Management model emphasizes how important it is to have coordinated care, especially for high risk patients. They train practices on how to connect patients to the right care at the right time and for the right reason. Through this care coordination, we can close the gaps in care, making it simple and continuous for the patient.

In the process of our care management, I learned a lot about our patient.

But I was also learning a lot about her daughter. She was working three jobs at once – one full-time, and two part-time. Not to mention her fourth job as mom’s caregiver and main source of support. I knew how hard she was working. I could hear it in her calls and messages, which always came at the break of dawn or late into the evening. I made a point to respond to every single one.

Aledade’s Care Management holds the patient and their family at the center by emphasizing the importance of trusting relationships between the practice and our patients. The whole model encourages us to focus care around the patient’s needs and concerns.

One morning in June, my phone rang. It was the patient’s daughter – our care team MVP. I knew that they were on the search for an apartment that was just a single level, since it was getting tougher for mom to go up and down the stairs. Until then, every morning and every evening, the daughter would help her mom up the stairs and down – careful to avoid any falls, with all of the back and knee problems her mom had.

The night before, though, had been different. The daughter noticed it right away. She told me her mom had been “very winded” – much worse than normal. It took her a lot longer to recover from the walk. The daughter didn’t notice any chest pain or shortness of breath, but that morning, her mom was much more tired than usual.

I asked the daughter if they’d be able to come to the office that day. She said yes – she’d just need 30 minutes’ notice so she could leave work, pick up her mom and make the drive over.

Early that afternoon, our patient’s primary care doctor welcomed them in – the patient was diagnosed with new-onset congestive heart failure. We started her on a diuretic and scheduled an urgent follow-up with a cardiologist. By the end of it, we avoided what probably would have been a costly and frightening visit to the emergency room.

Aledade encourages care managers to proactively educate patients and caregivers on managing symptoms – not to wait until they become a problem. They advise practices to keep open lines of communication with their patients, so the patient can contact the practice as soon as a symptom becomes a concern. Quick and clear communication can help the practice and patient get the appropriate triage, ultimately reducing how often patients and their families have to visit the practice or a hospital.

There are a number of effective ways to do this. One way is to set up same-day appointments in the office. Another is to open a phone line for patients that’s available 24 hours a day, 7 days a week. Aledade always reminds us how important the relationship is between the practice and the patient.

Today, our patient’s follow-up is continuing. She’s getting better. And our care team all-star, her hardworking daughter, is our care management team’s key contact. Her mom is lucky to have her around. Our practice is, too.

Natanya 2

Natanya

At this week’s all-staff meeting, our CEO Farzad Mostashari repeated one phrase again and again. “At Aledade,” he said, “we’re thinking long term.”  

Our work at Aledade helps physicians, patients, and society today, but we’re always looking ahead three years, six years, and even more. A focus on the future resonates in our values and the work we do every day.  In fact, the Aledade Fellows program is born from this long-term thinking. By joining the Aledade team as recent graduates or current students, we have the opportunity to learn what it takes to be the value-based health care champions of the future.

Dr. Ezekiel Emanuel’s new book, Prescription for the Future is similarly forward-thinking. In it, he argues for a positive prognosis for the U.S. health care system – but a prognosis that relies on disseminating a variety of transformational practices to raise the quality and lower the cost of health care.  

At Aledade, we partner with practices to implement these high-value practices every day.  Chronic care management that cares for a whole patient. Wellness visits that take into account a patient’s experience outside the doctor’s office. Referral management that steers patients to high-value specialists. And transitional care management that eases a patient’s discharge from the hospital. These are all initiatives that Aledade undertakes today. They’re practices we’ll keep improving on with an eye toward the future.

What Prescription for the Future offers us, as young people involved in the transformative work that Dr. Emanuel describes, is an understanding of Aledade within the greater context of the movement toward a value-based health care system. His book reminds us that the work we do is integral to that  movement, and that we are not alone in looking to the future.

But I wasn’t the only fellow who learned some valuable lessons from Dr. Emanuel’s work. Below are some additional insights from three Aledade fellows:

 

MargotMargot

In chapter eight, Dr. Emanuel asks the question, “Is transformed healthcare transferable?” In other words, can we replicate high-value care success stories across the country?

He points to factors such as cultural, social, and economic histories as the primary barriers to transferring care. Considering these barriers, it seems to me an organization like Aledade is uniquely positioned to transfer high-value care to patients across the country. With a large network focused on collecting quality data, Aledade is equipped to identify successful ideas and scale them among its partner practices. Coupled with this, and equally essential, is Aledade’s emphasis on local physician leadership.

Our partner practices have the independence and flexibility to adopt successful ideas in ways that fit their communities. Care management in Mississippi is not the same care management performed in New York. Ultimately, practices are accountable for the care of their patients, and practices have the grassroots knowledge to transform care for their patients.

 

Doug Streat1 - Edit

Doug

At Aledade, as in health care in general, we have a tendency to use industry buzzwords to describe what we do. Phrases like “value-based” and “patient-centered (and, scarier yet, our alphabet soup of acronyms like ACO, AAPM, CCM) dominate our conversations. This isn’t necessarily bad—we love our work—but it can be hard to explain exactly what is that we do, and why we do it. Dr. Emanuel’s Prescription for the Future is as much a formula for transformation as it is a chronicle of stories that clearly explain the future we are working to achieve.

The future we envision is good for patients. It is one where patients like Miss Harris in chapter one don’t need six providers to manage their care or, if they do, receive seamless care coordination among these providers. The future we imagine is one where patients have ready access to community interventions, like Mr. Downs in chapter six did. The future we are creating is one where primary care providers are so readily available, that their patients don’t need to go to the ED as often.

The future is good for providers, too. The future we are striving for stands on strong technological infrastructure that supports, but does not replace, the work of medical providers, as discussed in chapter seven. The future we seek is one where primary care providers can create improved care and improved bottom line at the same time, as one of our partners in West Virginia, Julie DeTemple, reported to us when she spoke at our all-staff retreat this May.

These transformations, and the others Dr. Emanuel writes about, will help stabilize health care costs and improve practices at a systemic level. In so doing, we hope to build a future that is good for society, too.

 

KellyKelly

As a widely-contested health care reform proposal dominates national news coverage, reading Dr. Zeke Emmanuel’s “Prescription for the Future” was both uplifting and insightful. Each day since I started at Aledade, I have gained a deeper understanding of the United States’ health care system. But arguably the most important thing that I have taken away is a new perspective on the future of health care.

Working alongside a passionate team dedicated to value-based care, a team that is growing every day, has shown me that health care providers are constantly innovating to improve the quality of care delivered nationwide.

I found the chapter on “Transforming Physician Office Infrastructure” particularly interesting and enjoyed reading the section about measuring and releasing unblinded physician performance data. Dr. Emanuel’s explanation of the effectiveness in releasing this data lies in the principle of peer comparisons, from behavioral economics. Physicians, like all humans, are wired to avoid embarrassment in front of their peers, so releasing unblinded data on their performance motivates changes in underperformance. In one story that Dr. Emanuel features, a physician notes:

“As soon as the system started generating data, I remember my own thought was, ‘This is silly. I know I am going to do great on this performance review.’ And then I saw my data. Holy cow, not nearly as good as I thought. Knowing made me realize, ‘Hey we’ve got to be sharing this data.’ But more importantly made me ask, ‘Who is doing the best?’ I need to look at that person and say, ‘What are you doing? How do you do it so well?’” (p.83)

By looking at positive outliers in performance data and assessing what exactly these outliers do better, providers can deliver better care as individuals and practices. That’s why, at Aledade, we analyze and provide quality metric performance and cost data to our providers, both at the ACO and the practice level. We take this one step further by providing practice support through a field team that works directly with practices to decrease their total cost of care and achieve higher quality performance.

My favorite part about working at Aledade is hearing provider success stories, like the one above that Dr. Emanuel features, shared by our field team after implementing Aledade’s resources in our ACO practices. They prove to me that health care professionals around the country are already making incredible progress, and building the future of health care today.

 

Natanya

Natanya

It is not always easy to explain Aledade’s work, and our work as Aledade Fellows, to our family and friends. With healthcare news dominating the airwaves and Twitter feeds recently, it can be tough to make clear how Aledade fits into all of these changes.  

While the answers to these questions are complex, the goal of everyone involved in the value-based transformation is relatively simple: We want to see a future with lower health care costs and higher quality care. At Aledade, we achieve that by partnering with practices and physicians to make that transition from volume toward value.

After all, an alidade is a device used for determining direction. In our case, we’re aiming our sights on a future with better outcomes for patients, providers, and society. Prescription for the Future has given us a peek into where others are aiming their sights. After reading it, I believe we’re not the only ones thinking long term, and that when we converge on the future, it’s going to be bright.

There has been no shortage of health policy news out of Washington in the past few weeks. Which means that one major announcement nearly slipped under the radar, but since this was the most relevant to Medicare, here’s our analysis.

Last week, CMS released a 1,058 page proposed rule to update the Quality Payment Program for 2018. The Quality Payment Program is the implementation of the Medicare and CHIP Reauthorization Act, passed in 2015 – one of the key pieces of legislation in the movement to a value-based health care system. We’ve talked about MACRA and CMS’s proposals to implement it before, so feel free to revisit our feedback on the Aledade blog.

Our key takeaway is that the rule is a win for small and independent primary care practices. That starts right near the beginning (page 9 to be exact), when CMS lays out the aims of the Quality Payment Program.

As the rule says:

“The Quality Payment Program aims to:

  1. Support care improvement by focusing on better outcomes for patients, decreased clinician burden, and preservation of independent clinical practice;
  2. Promote adoption of APMs that align incentives for high-quality, low-cost care across healthcare stakeholders; and
  3. Advance existing delivery system reform efforts, including ensuring a smooth transition to a healthcare system that promotes high-value, efficient care through unification of CMS legacy programs.”
    (emphasis ours)

“Preservation of independent clinical practice.” That new phrase guides not only this proposed rule, but should guide future program decisions as well. When CMS is looking at the best way to transition to value, they are committing to a key consideration of independent clinical practice.

Here’s how CMS puts that commitment into action in this rule: The rule sets up guidelines for virtual groups, allowing small practices to band together while keeping their independence. It preserves the excellent work CMS already did on the interaction between ACOs and MIPS, and adds some relief for small practices who are not yet ready for virtual groups or ACOs.

Let’s walk through some of the changes that are proposed:

  • The creation of a virtual group option for practices
  • Another year-long delay before cost performance becomes part of the MIPS score
  • Bonus points in the MIPS score for small practices (small defined as 15 clinicians or less)
  • Another year-long delay in the requirement to use 2015-edition certified EHRs
  • A significant increase in the low volume threshold to exclude clinicians from MIPS

The Stepping Stone of Virtual Groups

Virtual groups are a completely new option for physicians in 2018. The move to value-based care isn’t immediate. Not every practice can immediately leap into an ACO that puts them on the hook for any higher costs, especially if they want to stay independent. Some need a longer runway, and virtual groups create that option.

Here’s the proposed criteria for virtual groups:

  • A virtual group will be a combination of a solo practitioners or practices (defined as a single TIN) with 10 or fewer eligible clinicians who band together for at least one-year performance period. As of now, there are no geographic, size or specialty limitations on the groups (though CMS is open to comments on this).
  • The group’s participants need to send a written agreement to CMS by December 1, before their performance period starts.
  • At least one member of each participating practice needs to be eligible for MIPS, and the entire group will be assessed as a group on every MIPS category.
  • As the formation requirements are relatively light, these groups will be much easier to form and operate than a typical ACO with fewer responsibilities.

The purpose of creating virtual groups is to create a better path to valued based care. We believe it is worth taking a moment to review the current pathway, compared to the proposed pathway.

Here’s how the runway currently looks as providers move from the old fee-for-service system to two-sided risk:

MACRA Blog 1 pt2

 

In there are at least two major hurdles, especially for small, independent practices. First, the initial step out of fee-for-service and into one-sided risk. Practices want to band together in high-value networks, especially if there’s a chance to share in savings. But many practices don’t want to sacrifice their independence for a hierarchical ownership structure. That’s why we called for CMS to create “virtual groups” last year.

Second, the jump from one-sided risk to two-sided risk can be devastating to practice revenue. If a small, independent practice faces headwinds in one year, losses based on the total cost of care could be devastating. This is why the rule contains practice-revenue based risk. CMS created Track 1+ ACOs to take advantage of this revenue-based risk and they should roll that principle out to all two-sided risk ACOs.

Here’s what the proposed path looks like:

MACRA Blog 2

We’ll dive into this pathway more in a future post. Virtual groups are a key component to making the hardest transition between fee for service and accountability for total cost of care.

Delaying the Cost Factor in MIPS

CMS is proposing to delay the cost category in MIPS for another year. In the vacuum of a single year, this is no big deal. However, MACRA requires a certain transition to the cost category. So every year the transition is delayed, the cliff gets steeper. Right now, CMS is proposing to go from 0 percent cost in 2018 to 30 percent cost in 2019, trying to catch up to the law. There are consequences to kicking the can down the road.

Bonus Points for Small Practices

CMS is proposing 5 bonus points to the total MIPS score for small practices. Small practices are individual practices (defined by Tax Payer ID or TIN) with 15 or fewer physicians, nurse practitioners, physician assistants and other MIPS-eligible clinicians in the practice. The minimum threshold is 15 points, to ensure a practice is not penalized for 2020 based on 2018 performance. So these 5 points immediately get a small practices a third of the way there. This means that a small practice can avoid a negative adjustment in 2020 simply by reporting on at least two quality measures.

Delaying the Required Use of 2015 Edition Certified EHR Technology

Practices will be able to report on the advancing care information category with either 2014 or 2015 edition EHRs. While there are very important improvements to EHRs in the 2015 edition, we have seen firsthand the delays in rolling out 2015 edition EHRs to practices. CMS is proposing that rather than penalizing practices who don’t use the 2015 Edition, they would award 10 bonus points if practices do. As only 100 points are needed for full credit in the ACI category, this is a significant bonus. 

Increasing the Low-Volume Threshold – How Much is Too Much?

In this new proposed rule, CMS suggests they might raise that threshold even higher – from an initially proposed combination of $10,000 in Medicare revenue and less than 100 patients to this year’s proposal of either $90,000 of Medicare revenue or 200 patients. That means nearly half of all physicians could be exempt from this requirement. In other words, more than one out of every ten dollars spent by Medicare Part B. By significantly increasing the low-volume threshold, CMS risks slowing the transition to value-based care and, worse, create a two-tiered system of physicians moving forward opposed to those who are exempt and doing what they can to stay that way.

We believe that American health care needs to avoid a bifurcated or two-tiered system – one in which some providers are paid for improving quality and outcomes, and other providers stay in the old fee-for-service model with different incentives.

This proposed rule estimates that 70 percent of Medicare Part B dollars will flow either through MIPS or Advanced Alternative Payment Models.

That number can never go down.

Every patient deserves to be in a system of better care and lower costs, and every provider deserves to be rewarded for high value care. Instead of kicking the can down the road on cost and exempting more physicians, CMS should concentrate on making the program itself better. They make good strides in that endeavor with this proposed rule.

We will be working closely with our physicians and with other stakeholders to submit complete comments on the regulation in the weeks to come. We look forward to working with CMS on its commitment to move to value, and its clear commitment to preserve independent clinical practice.

One day this past spring, I met with a patient for our standing care management appointment. She’s been coming to our clinic for 5 years, and during our conversation, I asked my usual questions. When I asked her how she was feeling, she told me something I didn’t expect.

The patient shared that her mobility was getting worse. She said it was getting hard for her to leave her home, because she couldn’t manage the step down from her porch. We continued the conversation, and I addressed her other concerns. But after the appointment, I got to thinking. How could we make it easier for her to leave her home?

I didn’t have to wait long for an answer. Later that week, my granddaughter was telling me about her day in school, when we suddenly had an idea. Her class could build a ramp for our patient!

I contacted Aaron Haselwood, the Industrial Arts teacher at Fredonia High School, about building a ramp. He joined in right away. He thought it was a great way for the students to learn and help the community.

Here’s Aaron’s story on how his students built the ramp:

When Tara reached out to me, I thought it would be a perfect project for my class. This is my first year teaching this class, and I can already see that the students are getting a lot out of it. They’re learning skills, gaining confidence, and earning certifications, all while giving back to the community.

The ramp was a class project, but five students took the lead on building and installing it. We spent about two class days on this project. On the first day, we met with the patient to discuss our plan, and then took measurements. We built the ramp in our workshop and installed it on the second day. The ramp didn’t cost the patient anything, because we used leftover materials.

My class already has projects lined up for next year, and we’re excited to continue helping more people in the community.

This ramp has helped my patient become more independent. She feels safer when she enters and exits her home. The ramp, combined with her exercise regimen, has reduced the patient’s risk of falling. She has not had a fall yet. I’m so glad that thanks to care management, our patient feels comfortable telling me her concerns. And I’m just as happy to know there are resources and people in our community eager to address them.

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.

As the Care Manager at the Winston Clinic and a Nurse Practitioner by training, I’ve taken the lead in working with our high-risk patients, as well as those with uncontrolled chronic diseases.

When a patient is identified as “high risk”, whether that’s by Aledade or by a provider, we place the patient’s name on my desktop, and add it to our list of patients who should receive care management. Usually, these are patients who need support for a hospital discharge, or have had a new diagnosis. Sometimes, they’re patients who will need support over a longer time period. One of our new programs is to place patients with uncontrolled chronic disease onto care management before we even refer them out to a specialist.

I have multiple patients who say they benefit from care management, and their clinical numbers show the same thing. But there are two patients who stand out the most.

One was placed on care management for her diabetes. In the past three months, she’s made huge steps forward. She had been diagnosed as diabetic for more than a decade, she’s been on insulin and Metformin for some time and her HgBA1C level hit 15.3. Our clinic was just about to refer her to an endocrinologist, until I asked specifically if she could be referred to Care Management services instead.

On our first care management call, I started by just asking her why she thought her sugars were high. The patient told me that she didn’t know – she wasn’t eating any sweets or white bread. She had no idea that different fruits, vegetables and drinks were driving her sugars up. When I asked what her providers had taught her, she said she felt stupid for asking them questions, and they had assumed she already knew.

I also asked her why she wasn’t taking her insulin. It turns out she had been placed in the hospital once before for hypoglycemia because she had taken too high of a dose of insulin. She was worried about putting herself through that again.  Over the course of several phone calls and an office visit to train her how to manage her diabetes, the patient told me she feels much better about her ability to manage her diabetes.

Her last A1C reading was 11.5. That steady decrease is a win for the practice, and a win for our patient! But we’re not stopping there – we are still working together to lower these numbers this even more!

The other patient who stands out to me was diagnosed with prediabetes. She was due for an Annual Wellness Visit (AWV), so we brought her in. I gave her a health risk assessment, where she remarked that she felt unwell today. But she wasn’t very specific. Then I saw that her PHQ9 – a depression health questionnaire – was off the charts. I put the diabetes aside for a second, and started using some of my coaching skills to help her to open up.

She told me that she was suicidal on most days. Her mother had died three weeks before, and often she would lay in bed and cry all day. She had missed her previous day’s counseling appointment, and wasn’t scheduled to see her outpatient counselor for another several weeks.

I determined that she was not suicidal at that moment, and began to use some of our health coaching strategies. I asked her if she could picture herself happy. She said she could not. She said the only reason she hadn’t killed herself is because she didn’t want her girls to lose their grandmother and their mother in the same year.

Needless to say, we talked a lot. In the end, she decided that she could commit to one change. She would spend time each day trying to picture herself happy. And during the few times a week that she felt happy, she would write down what she was grateful for. As soon as the patient left, I called the counselor, and she called the patient for a phone visit immediately. She’s visited her counselor multiple times.

I have spoken with the patient every week over the course of several weeks. She felt that I wasn’t judging her during the first visit, that I actually cared about the “other stuff”, even though she was there to discuss her diabetes.

Just recently, I asked her how she was feeling.

She responded, “I think I can be!”

I said, “You lost me. You can be what?”

“One day,” she said, “I think I can be happy!”

She has had several bad days since then, and several good days. Through the ups and the downs, I think I’m getting as much from her as she’s getting from me. And I know I would have missed out on this experience if we were not making the effort to reach out to our patients.

I believe in the power of the AWV and care management calls, because I’ve seen it in these two patients, and many others. Here at Winston Clinic, we will continue to support our high-risk patients and patients with uncontrolled chronic diseases through care management and having open, honest conversations.

Drew Brees, the quarterback of the NFL’s New Orleans Saints, the first quarterback to bring home a Super Bowl trophy to the Pelican State, has a pretty simple formula for success: “When you wake up,” he says, “think about winning the day. Don’t worry about a week or a month from now – just think about one day at a time. If you are worried about the mountain in the distance, you might trip over the molehill right in front of you.”

Every morning, not far from New Orleans, there are a few more Louisianans who wake up thinking about how to win the day. They’re the team at the practice run by Dr. Bryan LeBean – a primary care physician who’s been serving in the community of Lafayette for 23 years. And they have a name an NFL quarterback would appreciate – “Team LeBean.”

Just recently, Dr. LeBean’s practice joined the Aledade Louisiana Accountable Care Organization – to find new ways to provide better care to the families in Lafayette, while keeping the practice’s independence. Working closely with other practices in the area, Team LeBean shared some of the tactics and strategies that worked for them – how to properly conduct an Annual Wellness Visit, some ideas for good care management.

They also borrowed a few good ideas, one of which has paid off every morning. Before starting each day, Team LeBean sits down for a Daily Huddle. The entire care management team runs through a few standard questions, and then covers any other topics that came up.

They start by looking at how many AWVs have been scheduled for the day, and how many patients are in the hospital or recently visited the Emergency Department – information that they can find right on the Aledade app.

They then take a look at a few patients with chronic conditions – like diabetic patients, especially those in need of an eye exam, and patients enrolled in tobacco cessation. After running through a few other items, they wrap up by focusing on any particular patient complaints or concerns – always keeping an eye on how today can run even better than the day before.

That’s how you win the day. By working closely together – practices like Team LeBean, their patients, and Aledade are winning the day. And they’re well on their way to a better health care system with strong, independent primary care practices suiting up in the quarterback role they were always meant to play.

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

http://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

http://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

http://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

http://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.