*This is the full 3,600 word CMS response letter. A summary of our thoughts is available on our blog.

November 20, 2017

Seema Verma, Administrator

Centers for Medicare & Medicaid Services

7500 Security Blvd

Baltimore, MD 21244

 

Re:       RFI: Innovation Center New Direction

Dear Administrator Verma:

Aledade (www.aledade.com) partners with 272 primary care physician practices, FQHCs and RHCs in value-based health care. Organized into twenty accountable care organizations across 18 states these primary care physicians are accountable for over 240,000 Medicare beneficiaries. More than half of our primary care providers are in practices with fewer than ten clinicians. We are committed to outcome-based approaches to determine the value of health care. We are committed to using technology, data, practice transformation expertise and most important the relationship between a person and their primary care physician to improve the value of health care.

Future of Medicare and Medicaid Innovation in Value-Based Health Care

We appreciate the opportunity to respond to the Center for Medicare and Medicaid Innovation’s request for information (RFI) on Sept 20, 2017. We seek to share what physician practices have learned in the transition to value and our views on how to continue moving forward.

Physician-only ACOs face unique challenges in model participation while also outperforming other types of ACOs[1][2][3]. We view the RFI through the lens of models that are led by physicians.

Guiding Principles

  • Choice and Competition in the Market –Congress has taken initial steps to reduce regulatory incentives encouraging the merger of hospitals and physician practices, but more needs to be done. New models should further eliminate payments for physician practices to merge with hospital systems such as facility fees creating higher payment for the same services and the 340B program making drug pricing uncompetitive in private practice.

 

Competition is also key to success in value-based health care. CMS should prohibit anticompetitive behaviors such as data blocking and anti-tiering provisions that prevent the creation of financial incentives for using high-value health care providers.

 

  • Provider Choice and Incentives – A model that provides a business case for improving care will attract voluntary enrollment by physician practices. These models should, over time, put physician practices at financial risk, but that risk must be proportional to the finances of independent physician practice and not so large as to favor consolidation of practices. Models should move over time to a financial and evaluation structure focused on analysis of their local market. Physician practices should be able to accelerate the move to a difference-in-difference approach by taking on risk.

 

  • Patient-Centered Care – A strong primary care physician-patient relationship is the strongest tool available to create more value in health care. This proposition is strongly supported in the health services research literature and in the results of the MSSP.

 

  • Benefit Design and Price Transparency – Price transparency to model participants and to the consumer of health care creates competition by informing the choices of both beneficiaries and referring physicians. Benefit design should incentivize the building of the primary care physician-patient relationship and other cost-saving choices.

 

  • Transparent Model Design and Evaluation – Transparent design serves as a key component of voluntary provider choice. Uncertainty creates reluctance, but transparency promotes understanding and increases commitment. For evaluation, we favor difference in difference models of evaluation.

 

  • Small Scale Testing – All models should be designed with success and scalability in mind. We believe that Accountable Care Organizations can serve as unique test beds for innovation models due to ACO incentive to reduce total cost of care.

 

Focus Areas

  • Increased participation in AAPM – Three primary levers for physician practices:
    • Refine existing benchmarking methodology to better relate to local markets and reflect the health of the underlying population with accurate risk scoring
    • Calibrate risk to the finances of physician practices while still offering within-model reward for taking on risk for most models including all MSSP tracks
    • Create a new, more flexible, and sustainable version of Next Generation ACO for full risk taking with traditional Medicare
  • Consumer-Directed Care & Market Based Innovation Models – Allow Medicare beneficiaries to identify to CMS their primary care physician and create models that allow for beneficiaries to share in savings if their PCP participates in a savings model
  • Medicare Advantage Innovation Model – Facilitate innovative MA plans by allowing new physician-run plans to use existing Medicare infrastructure (e.g., MAC claims processing systems) so physicians can focus on population health management.
  • Physician Specialty Models – Focus on models that work within the framework of a total cost of care model as well as stand-alone models.
  • Prescription Drug Models – Test inclusion of Part D drugs in total cost of care models.
  • State-Based and Local Innovation – In addition to focusing on new models, CMMI can serve as a resource for physicians to learn about state and local innovation.
  • Mental and Behavioral Health Models – Use total cost of care models to test greater investment in mental and behavioral health.
  • Program Integrity – Allow physician practices, ACOs and other model participants to collaborate with CMS on surveillance and increasing transparency.

Increasing Participation in AAPM

Advanced Alternative Payment Models should be judged based on their ability to attract participants. The primary outcome measure for an AAPM should be how much value it created. The value is a combination of the percentage of savings or other outcome improvement measure times the number of people the model effected. There is no better way to encourage participation than a well-designed and well-understood model. This model relies on provider choice and transparency in development and is designed to attract willing physicians and other participants.

For physicians the crux of an advanced versus regular APM revolves around the phrase “more than nominal financial risk.” One of the first questions we get from our physicians is will the ACO qualify as an AAPM? Whether that risk is something that a given physician should undertakes revolves around how well the model benchmark separates risk due to the effective delivery of health care services and population health services versus risk that is due to uncontrollable circumstances or insurance risk. Aledade now partners with over 1000 primary care physicians who believe in population health and their role in it. However, they do not feel responsibility for events they can neither control nor influence. We have seen physicians and their staffs make great efforts to get the most non-compliant person into the office and out of the emergency department, on their medications and working towards their own health. However, no primary care efforts will influence whether that person develops unavoidable cancer. Nor will any primary care initiative account for regional differences in cost structures that have developed over decades. If you are financially responsible for whether a patient develops an unavoidable cancer you are an insurance company and that is a business that most physicians do not want to be in. All models should use risk scoring methodologies that accurately set targets, particularly advanced alternative payment models where the participant is taking risk. Models should acknowledge that changes in health will vary between model participants. This means that for a given model participant risk adjustment should be able to raise or lower the cost target. At the same time, we recognize that CMS has a vested interest in not rewarding model participants for changing their risk score more than the underlying health of the beneficiary population changes. At the program level this could take the form of either a cap in year over year change or a program wide adjustment factor. Regardless of the method CMS chooses to protect the program, an individual model participant’s cost target should track changes in their risk score (i.e. if the population is sicker the target higher, if the population is healthier the target lower) even if the magnitudes of the change are not 1:1 in order to protect the program at large.

The other way to increase the accuracy of model benchmarks is to relate them to local health care markets. Finally, since insurance risk cannot be completely eliminated the risk to which physician practices are exposed to must be more than nominal, but never ruinous. The goal of downside risk is to motivate the model participants and give the payer assurance that the ACO’s interests are aligned with the payers or in the case of Medicare society’s interests. Rather than setting downside risk in its current mostly symmetrical fashion just because it feels fair, CMS and other payers should set downside risk to accomplish the goal of motivation. Models like Track 1+, that relate risk to the finances of the participants instead of the model benchmarks will greatly encourage AAPM participation, particularly if those models offer rewards in the model for taking on risk, which is not currently the case with Track 1+.

Finally, we recommend that CMS dramatically reduce the timeline for when a physician is rewarded with the 5% bonus created by MACRA. Under the current timeline, a physician who makes a decision to join an AAPM in July of 2018 (most AAPMs have July deadlines) for 2019 participation will not see their 5% bonus until May 2021, nearly three years later. The physician could receive payments or pay losses based on their performance in the AAPM in September 2020 or nine months earlier than the bonus they get just for participation. This timeline is serving as a drag on AAPM participation. For AAPMs that require full year participation CMS could assume participation for 2019 as early as the finalization of the model participant list in December 2018 and then retroactively look at 2018 claims to determine whether the physician is a qualifying professional. This would allow CMS to move the MACRA AAPM bonus payment forward two years to spring 2019 and serve as a much better incentive for physicians to join an AAPM this summer. Principally, CMS should always be looking for ways to shorten the time frame from when physicians take action to when the outcomes of those actions are rewarded.

In conclusion, to encourage greater AAPM participation for 2019 we recommend:

  • Design new models and refine all existing models to focus on value creation that is within control of physicians and patients through local market benchmarking and accurate risk scoring as no incentive payment will ever overcome significant transfer of insurance risk from payer to provider
  • Require risk, but make the risk motivational and rewarding, not ruinous
  • Dramatically shorten the MACRA AAPM bonus timeline and continually seek to shorten the timeline between action and outcome
  • Create a new, more flexible, and sustainable version of Next Generation ACO for full risk taking with traditional Medicare

Consumer-Directed Care & Market Based Innovation Models

We believe one of the strongest tools to create value in health care is the relationship between primary care physician and patient. We suggest centering consumer-directed care around that relationship. CMS should create a mechanism for beneficiaries to select their primary care physician and encourage, but not require, them to do so. If a beneficiary selects a PCP who is an alternative payment model and that PCP succeeds in the model, the beneficiary should share in that success.

We suggest that this be in the form of reduced deductible and/or Part B premiums in the next year. We believe that by the patient should get the benefit automatically and that the ensuing discussion between patient and PCP on the success of the model will align incentives and create loss aversion on behalf of both parties that will benefit all involved. We are missing out on an opportunity when we only align incentives between health care providers and health care insurers. By creating an opportunity for Medicare beneficiaries to realize savings as well, we engage all parties in the effort.

In addition and not necessarily in conjunction, we recommend that CMS streamline the waiver process and expand it to allow model participants to offer reduced cost sharing to Medicare beneficiaries and to allow model participants to invest not just in health care related services such as home monitoring equipment, but also social services such as accessibility to the home and nutritional needs.

Medicare Advantage Innovation Model

Medicare Advantage is an excellent opportunity to align incentives, but it suffers from a lack of competition[4]. Since 1997, Medicare Advantage has tested the premise that the private sector can compete with Medicare in providing health care to seniors. Through its many iterations and refinements, two aspects of the program have never changed: First, to compete with Medicare, private companies must take over claims processing from the Medicare administrative contractors (MACs). Second, those companies must also create their own provider contracts. Twenty years since the program began, health care plan competition consists of much more than efficient claims processing and provider contract negotiations. Yet these capabilities are still two of the main barriers to entry into Medicare Advantage, blocking efficient and innovative providers from participating in the program. We propose removing these barriers by opening up Medicare Advantage to health care providers without a dependency on legacy plan capabilities such as claims processing and network contracting. We believe that the two greatest drivers of health care value are increasing and maintaining competition and aligning incentives of physicians and other health care providers with Medicare and with Medicare beneficiaries. Our proposal will do both by building a network on top of Medicare participation—not instead of it—and leaving claims processing in the highly experienced, efficient hands of the MACs. Making this change will shift the conversation about provider networks from price concessions and market power to creation of truly patient-centric, quality-based networks led by primary care. This will result in better care for patients, while allowing traditional Medicare to realize deeper savings through competition and aligned incentives. By removing traditional plan operations as a barrier to entry for Medicare Advantage, Medicare can create a path for successful provider groups to move into Medicare Advantage. This increase in competition will benefit both Medicare beneficiaries and health care providers. We discuss this proposal in greater details in Health Affairs[5]

CMS should also review current Medicare Advantage regulations to ensure they encourage participation in value based contracting. For example, the Performance Based Incentive Payment regulations have not been updated since the emergence of accountable care and other models.

Physician Specialty Models

CMS should explore models for specialists that integrate with total cost of care models and models that stand alone. As CMS works on physician specialty models, we recommend that it always consider the effects on other models. We further recommend that in cases where models do overlap that the model with the most risk would receive precedence in assign the financial outcomes of the model. In all cases, overlap should never result in a situation where costs are assigned to one model due to another model that are higher than historical costs for the model participant. For example, if a joint replacement model overlaps with a total cost of care model the joint replacement could be assigned the price of $20,000. So the total cost of care model gets assigned $20,000 no matter what the actual cost is. However, if the participants of the total cost of care model historically have an average cost of just $18,000 for a joint replacement, then the overlap is creating an artificial $2,000 loss. This situation must be avoided as it creates animosity rather than collaboration.

Mental and Behavioral Health Models

Total cost of care models are unique opportunities to test further investment in mental and behavioral health. When health care providers are responsible for total cost of care it removes incentives to cost shift and creates an incentive to maximize the volume derived from additional investment in mental and behavioral health.

Our experience with the Comprehensive Primary Care Plus (CPC+) program, specifically its Track 2, shows the difficulty in enabling behavioral health care in the primary care setting. Primary care physicians view this work as distinct and specialized requiring dedicated staff and specific expertise. To fund these activities, behavioral health is not served well by wrapping its funding into other funding streams. It is better for it to be clear to physicians what resources are dedicated to behavioral health. We recommend that CMS clarify CPC+ Track 2 behavioral requirements and consider a new model for behavioral health within total cost of care models.

For CPC+ Track 2, we recommend CMS issue a white paper or other education that ties a specific amount of the increase between CPC+ Track 1 and Track 2 to the behavioral health integration requirements. This would give practices much needed information to inform investment levels in behavioral health. This need not be a requirement, but simply filling an existing knowledge gap that we believe is holding back investment and participation in behavioral health integration with primary care.

For a new model of behavioral health, we recommend that CMS launch a behavioral health model that will provide new payment models within total cost of care organizations like ACOs and their participants. Structured around a predictable payment schedule, this investment can test behavioral health specific resources within the context of an organization that is responsible for the total cost of care. CMS could also test the effects of varying payment levels of existing behavioral health payments within a total cost of care organization. By allowing the organization to decide on how best to deploy the resources, either at the practice level or the organizational level, CMS creates flexibility for organizations of different make-ups to apply behavioral health integration as it best relates to their local health care market.

Increasing Value in Health Care through Innovation

We believe there are three main drivers of increased value in health care: competition, aligned incentives and professionalism. Competition increases value; however, it must be encouraged and even protected. Unlike professionalism and aligned incentives, competition does put downward pressure on health care provider’s margins creating an incentive for health care providers to find ways to reduce competition. CMS must always be aware of the effects that new models will have on competition. These effects are not always intuitive. It is possible for a model to both encourage further consolidation among large health care providers and also provide an avenue for independence for smaller health care providers. For example, the accountable care model is an opportunity for independent practices to take advantage of today’s advances in technology and data to help their patients navigate the whole health care system without needing to vertically integrate. It can also be a catalyst for a large integrated delivery system to complete their vertical integration efforts. To understand these sometimes competing effects, markets must be critically evaluated for competition and the make-up of model participants should be understood and categorized by type of provider physician practices, hospitals, other facilities, and integrated delivery networks. This does not always present itself as classical consolidation. For example, non-compete clauses in hospital employment contracts (eg that bar medical practice within 50 miles for 5 years) could be an anti-competitive abuse of market power that would not show itself in a traditional market analysis. Finally, models must also consider that health care providers do not just compete among each other they also compete with insurance companies for share of health care dollars. Models should consider the effects on competition with health insurers as well as competition among health care providers.

Aligned incentives is the most recent addition to value driven health care. It is a challenging task. In health care rarely is the need for a service known in advance by the consumer of that service. To address this and other uncertainties, consumers transfer risk to health insurers thereby created a three party transaction between the health care provider, the health insurer and the consumer of health care services. Further complication exists in the third-party administrator situation where the health insurer (the party that bears the uncertainty) and the party that contracts with health care providers are different. Finally, the quality of the health care service provided is hard to measure and the definition quality itself is subjective. These complications can create disparate incentives where a physician may be incentivized to perform more tests, while a health insurer wants fewer tests, a third party administrator gets a percentage of the tests and the patient has no idea how many tests they really need. Our challenge is to align incentives in such a way to maximize the value of a dollar spent on health care. In order to do so we should create models that reward health care providers for increasing the value of the health care dollar and ensure that health care consumers also receive that value through lower premiums over time or even through direct payments to consumers.

Medicine has always been blessed with a high level of professionalism. That professionalism must be respected as we seek to increase value through competition and aligned incentives less we lose the value it brings to health care. Physicians, and indeed most health care professionals, feel their autonomy is under threat from nearly all quarters. Poorly designed quality measures that either do not help a physician provide better quality or impose unjustified burdens for data collection distract from the physician/patient relationship. Pressure on the margins for physician services combined with ever-increasing administrative burden to document physician services assault private practice from both the revenue and cost side decreasing competition as physicians seek negotiating power to increase revenue and scale to spread out the administrative burden. As we align incentives and increase competition, we should do everything we can to ensure we do not lose value that is created by professionalism.

Conclusion

We appreciate the opportunity to comment on the future direction of CMMI. We believe there is incredible opportunity for CMS to continue to lead the movement towards value based payment in health care.

As CMS conceives of and evaluates new models we summarize our thoughts as:

  • Models should be attractive enough to independent physicians that they choose to participate and to take risk
  • Competition creates value as well and CMMI should consider the competitive effects of all models
  • Professionalism of health care providers creates value as well and should be preserved and respected

We look forward to continuing to work with CMS to increase the value of the health care dollar. Please contact me or Travis Broome (travis@aledade.com) if you have any questions about our submission and/or we can be helpful to you and your staff as you explore new directions for CMMI.

 

[1] http://www.nejm.org/doi/full/10.1056/NEJMsa1600142#t=article

[2] http://www.nejm.org/doi/full/10.1056/NEJMp1709197?query=TOC

[3] http://www.ajmc.com/contributor/travis-broome/2017/10/cms-releases-medicare-shared-savings-program-2016-results

[4] http://www.commonwealthfund.org/~/media/files/publications/issue-brief/2015/aug/1832_biles_competition_medicare_private_plans_ib_v2.pdf

[5] http://www.healthaffairs.org/do/10.1377/hblog20170706.060925/full/

As the new administration continues to chart their course in value-based health care they have formally asked for the public’s input. We shared with CMS what we and our partner physician practices have learned in the transition to value and our views on how to continue moving forward. Below is a summary of our full letter which can be found here.

We believe there are three main drivers to increase value in health care:

  • Competition
  • Aligned incentives
  • Professionalism

First, competition increases value; however, it must be encouraged and even protected. Unlike professionalism and aligned incentives, competition puts downward pressure on health care provider’s margins. This creates an incentive for health care providers to find ways to reduce competition. Due to this, CMS should evaluate the competitive effects of new models. Second, aligning incentives creates the greatest opportunity for value creation; however, it is a challenging task and our primary subject today. Third, medicine has always been blessed with a high level of professionalism. As we align incentives and increase competition, we should do everything we can to ensure we do not lose value that is created by professionalism.

Choice and Competition in the Market and in Models

Congress has taken initial steps to reduce regulatory incentives encouraging the merger of hospitals and physician practices, but more needs to be done.  New models should further eliminate payments for physician practices to merge with hospital systems such as facility fees creating higher payment for the same services and the 340B program making drug pricing uncompetitive in private practice.

Competition is also key to success in value-based health care. The administration should prohibit anticompetitive behaviors such as data blocking non-compete clauses in physician contracts and anti-tiering provisions that prevent the creation of financial incentives for using high-value health care providers.

Provider Choice and Incentives – Increasing AAPM Participation

A model that provides a business case for improving care will attract voluntary enrollment by physician practices.  Principally, these models should, over time, put physician practices at financial risk that is proportional to the finances of independent physician practice and not so large as to favor consolidation of practices. Models should move over time to a financial and evaluation structure focused on analysis of their local market. Physician practices should be able to accelerate the move to a difference-in-difference approach by taking on risk. These principles will increase advanced alternative payment model (AAPM) participation.

For physicians the decision of whether to participate in an advanced versus a regular APM revolves around the phrase “more than nominal financial risk.” One of the first questions we get from our physicians is will the ACO qualify as an AAPM? Whether the answer should be “yes” is decided by how well the model benchmark separates risk due to the effective delivery of health care services and population health services versus risk that is due to uncontrollable circumstances or insurance risk. Aledade now partners with over 1000 primary care physicians who believe in population health and their role in it. However, they do not feel responsibility for events they can neither control nor influence. We have seen physicians and their staffs make great efforts to get someone into the office and out of the emergency department, on their medications and working towards their own health. However, no primary care efforts will influence whether that person develops unavoidable cancer. Nor will any primary care initiative account for regional differences in cost structures that have developed over decades. All models should use risk scoring methodologies that accurately set targets, particularly advanced alternative payment models where the participant is taking risk. Models should acknowledge that changes in health will vary between model participants. This means that for a given model participant risk adjustment should be able to raise or lower the cost target

The other way to increase the accuracy of model benchmarks is to relate them to local health care markets. Comparing the ACO or other model participant to other health care providers around them not to themselves. Finally, since insurance risk cannot be completely eliminated the risk to which physician practices are exposed to must be more than nominal, but never ruinous. The goal of downside risk is to motivate the model participants and give the payer assurance that the ACO’s interests are aligned with the payers or in the case of Medicare society’s interests. Models like Track 1+, that relate risk to the finances of the participants instead of the model benchmarks will greatly encourage AAPM participation, particularly if those models offer rewards in the model for taking on risk, which is not currently the case with Track 1+.

Completing the Glide path in Value Drive Health Care

Medicare Advantage is an excellent opportunity to align incentives, but it suffers from a lack of competition. We believe there is an opportunity to create health care value through a new model of Medicare Advantage. Our proposal will allow physicians to build a network on top of Medicare participation—not instead of it—and leaving claims processing in the highly experienced, efficient hands of the MACs. Making this change will shift the conversation about provider networks from price concessions and market power to creation of truly patient-centric, quality-based networks led by primary care. This will result in better care for patients, while allowing traditional Medicare to realize deeper savings through competition and aligned incentives. By removing traditional plan operations as a barrier to entry for Medicare Advantage, Medicare can create a path for successful provider groups to move into Medicare Advantage. This increase in competition will benefit both Medicare beneficiaries and health care providers. We discuss this proposal in greater detail in Health Affairs.

We appreciate the opportunity to engage with CMS on the future direction of value based health care. We believe there is incredible opportunity for CMS to continue to lead the movement towards value based payment in health care.

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

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

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

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

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

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

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

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

Proud, but not satisfied.

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

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

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

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

It was my second day at Aledade when someone told me to get out.

I thought it was a bit early to be fired, but the new colleague sounded convincing enough. I assumed they knew what they were doing.

Luckily, this wasn’t some drastic HR move. It was the first of many times that I’d hear, “You have to get out into the field. Go visit a practice.”

It’s a mantra here at Aledade. Everyone, even the current and former health care professionals on staff, seemed to have a story of the first time they visited one of Aledade’s partner practices. They all said that setting foot in a practice is the best way to find out what works, what doesn’t, and to get a sense of just how challenging and rewarding it is to work in an independent primary care practice today.

So when I first got the chance to visit Kansas, tagging along with New York Times columnist Farhad Manjoo as he worked on his new piece about Aledade’s work, I hopped on a flight to Wichita.

Before joining Aledade, I worked on the public affairs team at the U.S. Department of Health and Human Services. We promoted Open Enrollment for the Health Insurance Marketplace, talked about programs like Head Start, and got key messages out to the public about health threats like Ebola, Zika, and the opioid epidemic. But there was one story we kept coming back to – the future of health care.

We saw it every time we heard from doctors, and every time the Secretary visited a practice. Data had opened up new frontiers. Patients now had the tools to get engaged in their own care. And payment systems focused on value were starting to reward physicians who kept their patients healthy. There was a palpable sense that you could deliver better care and start to lower costs.

It seemed like everything was pointing down this path. Policymakers from both sides of the aisle saw the promise in this new approach. MACRA, the law that changed Medicare’s payment system into one that rewards the value of care, passed the Senate nearly unanimously and the House overwhelmingly. And down the street at HHS, the Department made a historic commitment – saying that, by 2018, half of all payments in Medicare would be payments that rewarded the value of care, not the old fee for service system.

But it wasn’t until I visited Aledade’s partner practices in Kansas that I realized how far down the path these health care professionals already were.

On Wednesday, the New York Times’ Farhad Manjoo published his piece, and he captured this well. “Thanks to Aledade,” Farhad wrote, “the [Kansas] practices’ finances had improved and their patients were healthier. On every significant measure of health care costs, the Aledade method appeared to have reduced wasteful spending.”

Here’s an example of how they were keeping patients healthy:

For example, say you’re a doctor at a small practice in rural Kansas and one of your patients, a 67-year-old man with heart disease, has just gone to the emergency room.

“In the past, we’d only find out our patients were at the hospital maybe weeks afterward,” said Dr. Bryan Dennett, who runs the Family Care Center in Winfield, Kan., with medical partner, Dr. Bryan Davis. With Aledade, Dr. Dennett is now alerted immediately, so “we can call them when they’re at the emergency room and say, ‘Hey, what are you doing there? Come back here, we can take care of you!”

The care management team at Ashley Clinic talks with Farhad.

At Ashley Clinic in Chanute, I saw a larger care team tackle an even larger patient population. As one care manager said, “before, we had the doctor and the patient; a point A and a point C. But there was no one to serve as point B. That’s changed today.”

Two of Ashley Clinic’s patients – a husband and wife – agreed. Both said the care they got now was much better than anywhere they had been before. “We don’t know what an ACO is,” they said. “But we know we hear from our doctor more. And we like that.”

Most importantly, by talking to the care teams and doctors in these practices, I learned that I had been wrong. Value-based care isn’t some new future in the distance; it’s more of a homecoming. As one doctor told me, “This is why I became a doctor in the first place.”

But getting home isn’t always easy.

It’s taking new ways of thinking – focusing on finding the highest risk patients, keeping a close eye on them through chronic care programs, following up with patients as they leave the hospital, and ensuring that patients are going to the most efficient and effective specialists.

While it asks for more time and effort on the part of doctors and care teams, who already put in countless hours caring for patients, the destination is worth the jounrey. And thanks to Aledade’s technology, dedicated support staff in the field, and some inspiring health care professionals, you can find better health care right down a long stretch of Kansas road.

When we founded Aledade in June of 2014, it was with a tangible goal: to help independent primary care physicians succeed in leading the shift to a value-based health care system.

When we marked our first birthday we had stood up two Medicare Shared Savings Program ACOs with about 20,000 lives under management, and we announced a round of funding that would finance the growth of our model. We said that we would expand in geographies, but also in our capabilities, and in the patient populations we serve.

Since then, we celebrated our company’s second birthday, and it’s been a busy, busy time for the Aledade team. I’m proud to say we have surpassed another measurable benchmark in reaching our goal. It’s an incredible feeling to know that we are helping more than 1,100 physicians across 15 states deliver high-quality, coordinated care to their patients. Aledade’s ACOs now include over200 independent, physician-led practices who are accountable for the care of more than 200,000 patients and responsible for nearly$2 billion in health care spending.

But numerical growth is not the only marker of our progress. The past 18 months have seen our company take important steps as a business and as a network, with demonstrable results.

We got our first results.

While we did not realize shared savings in our first year, the two ACOs in our 2015 cohort delivered top-quality care and set us on the path to success. Last year, Aledade Primary Care ACO – with practices in Maryland, New York, and Arkansas – was in the 98th percentile of quality scores across all 327 ACOs that began in 2012 and 2014, and the Aledade Delaware ACO was in the 88th percentile. We cut down on avoidable emergency department visits, readmissions, and prevented hundreds of hospitalizations. Our primary care partners transformed their practices for value-based care and implemented Aledade’s model of primary care – and have seen the success of their efforts.

table

We are adding to our capabilities.

Our tech-enabled interventions to improve access, quality and care transitions are by now well developed, reproducible and scalable. But we know there is still much work to be done, and much to learn. We are developing additional core capabilities in care management and referral management that were recently highlighted in an excellent two-part series by Marketplace. I believe that our proprietary Aledade Technology Platform, is already the best tool on the market for embedding population health insights into practice workflows, and it continues to evolve and improve. We are closer to the problems than any software vendor could be, and have added over a dozen developers who use the real-world feedback from our partners to update and improve the tools that we and our practices use every day.

We expanded beyond Medicare.

We founded Aledade with an initial focus on the Medicare Shared Savings Program (MSSP), as Medicare led the way in encouraging value-based payment models. But our goal is to provide the best care possible to all of our practice’s patients, not just a portion. As we approached other payers, we have seen clearly that the shift to value over volume is being embraced and expanded across the country . We have already established commercial risk-sharing agreements with Blue Cross Blue Shield of Kansas, Blue Cross Blue Shield of Louisiana, Florida Blue, and West Virginia Public Employees Insurance Agency; and the pace of our commercial agreements are accelerating, with several important announcements still to come.

We strengthened our company.

Supported by funding from Venrock, ARCH Venture Partners, and Biomatics, Aledade has established our team, technology tools, and expertise across the company. We have added talent like Dr. Mark McClelland to our Board; our first Chief Commercial Officer, long-time tech exec Danny Krifcher, and Vice President of Finance and Operations, Molly Hill Patten. Aledade is now over 100 employees strong, and with amazing partners on the ground in each of our local markets.

We stayed at the forefront.

Aledade’s model of primary care and our network of ACOs rely on some key factors: the strength of the Aledade team, the commitment of our partner practices, and the direction of the health care marketplace. With deep confidence in the first two factors, we must continue to inform and anticipate the third. The past year has seen an unprecedented series of policy supports for our core concept of primary-care centric networks of independent practices taking accountability for the total cost and quality of care for their patients. In June, the MSSP Regional Benchmarking Rule created long-term sustainability for efficient ACOs, and the Comprehensive Primary Care Plus and 2017 Physician Fee Schedule created a path for smaller practices to deliver more intense care management to their patients who need it the most. But the grand-daddy of them all was the Medicare Access and CHIP Reauthorization Act (MACRA) rulemaking. By combining persuasive data and perspectives with practical regulatory solutions we helped ensure that the final MACRA rules included a pathway to advanced alternative payment models that leveled the playing field for smaller practices who are leading the wave of health reform.

Aledade’s growth in such a short amount of time demonstrates the real demand for a new model of primary care, one that empowers physicians to succeed. This appetite extends across the nation from providers, to both public and private payers. As we enter this next phase of Aledade’s growth, we will look for more opportunities for Aledade to enter new markets through public as well as private payers and partnerships that help our doctors deliver better care to patients, better health outcomes, and lower costs.

The trillion dollar shift in healthcare payment “from volume to value” is well underway with both public and private payers and purchasers pushing provider organizations to participate in outcome-based risk contracts, stepping up from pay-for-performance and medical home models to a variety of accountable care and bundled payment programs.

But what are we to take away from the mixed results of these programs — from the lack of savings in the Comprehensive Primary Care demonstration, to the dropouts from the Pioneer program, the recently released underwhelming results from the first year of the Bundled Payment for Care Improvement Initiative, or the 2015 results from the Medicare Shared Savings Program?

One approach would be for partisans for each of these approaches to search for positive nuggets in the results from their preferred program, while heaping scorn on the other “competing” reforms.

Another would be to retreat altogether from the aspirations of achieving better care at lower cost, towards either resignation towards ever-escalating health care costs or more likely to (altogether regretful!) rationing of access to good healthcare for the most vulnerable in our society.

A third path would be to acknowledge that there is no magic bullet for “transforming healthcare” overnight, and that the work of redesigning our delivery systems to meet the expectations of the outcome-based payment models will be slow, hard, and uneven. We would accept that there are likely multiple payment reforms that will need to be implemented alongside each other, targeting different healthcare markets and different participants. (Capitated payments for truly integrated delivery networks. Mandatory bundled payments for proceduralists and hospitals. Accountable care for independent physician networks). And each model will need to be iterated and tweaked and incrementally improved.

That is what I choose to believe.

We are publishing today in the new issue of the American Journal of Managed Care, “A Report From the Field,” the detailed description of what our two ACO “freshman” accomplished in 2015, and openly discussing the challenges we faced, what we are doing differently now, and some policy changes that can put more wind to the backs of those in these trenches.

Here are a few of the key findings:

In the two of our ACOs that were part of the 2015 cohort, we successfully increased primary care utilization (and revenue). We saw significant quality improvements. We achieved rates of aspirin use for patients with ischemic vascular disease of 87 percent, screening and follow up for elevated blood pressure at 90 percent, and tobacco use screening and cessation at 93 percent.

Our independent primary care practices decreased emergency department (ED) visits by being more available and accessible to their patients and educating them about appropriate ED use. They increased contact with their patients after discharge (sometimes with the active help of hospitals, sometimes despite its absence), and substantially reduced readmissions and acute hospital utilization. (see table)

table

There are regulatory headwinds that ACOs in the MSSP program face. For instance, the calculated “benchmark” used to determine savings is a flawed measure of the counterfactual. By using national trends rather than regional comparators, MSSP program success is an inaccurate reflection of what costs would have been for ACO patients in the absence of the ACO (“difference in difference”). Regional trends (eg. in hospital coding, whereby utilization decreased but cost increased) will not be reflected in some ACO results, while others will benefit simply from downward regional trends. In addition, we (and I suspect many other ACOs) saw millions of dollars of savings evaporate due to downward risk adjustment, as a peculiar feature of the MSSP, wherein risk adjustment can decrease the benchmark, but never increase it. Aledade has the resources to understand and accommodate to these factors, but many ACOs do not. These are the sorts of regulatory tweaks that can make a true difference in health care delivery innovators staying with the program over the long run.

While physician-led ACOs do not have to contend with the “demand destruction” that stymie hospital-led ACOs, they need to pay particular attention to specialist costs. In particular, specialist practices that have been reclassified as hospital outpatient settings can double the cost to Medicare for visits and procedures. As we move forward, we are bringing more focus – and scale—to influencing downstream care through specialist tiering, referral management, and compacts.

There is a lot more detail in the full article. Overall, we have learned that given the right support and incentives, independent primary care practices can deliver better outcomes to patients, boost quality across the health care system, and lower costs. Achieving savings on the total cost of care takes time, but the benefits of the program to patients and taxpayers are not limited to those ACOs that received shared savings distributions. The movement “from volume to value” in payments must co-evolve with the delivery system’s ability to transform itself to deliver better care at lower cost. For the health of patients and the health of the health care system, we cannot retreat.

Yesterday the leadership at CMS wrote a blog entitled “Focusing on Primary Care for Better Health” and we couldn’t agree more. Administrator Slavitt and Dr. Conway articulated four principles for CMS:

• Improve how we pay for care that we value.
• Provide more opportunities for primary care providers to practice the way they think is best.
• Reduce practice expenses associated with operating a primary care or other small practice.
• Explore and encourage far-reaching innovations to connect people with primary care in new ways.

Achieving these principles while ensuring the independence of primary care practice is what Aledade is all about. We are very pleased that the leadership of CMS is aligned with these goals and look forward to continuing to work with CMS on achieving them. So for the first time we post another blog in its entirety on Aledade.com.

Focusing on Primary Care for Better Health
By Andy Slavitt, CMS Acting Administrator (@aslavitt) and
Patrick Conway, MD, MSc, CMS Acting Principal Deputy Administrator and Chief Medical Officer

In the United States, we have historically invested far more in treating sickness than we do in maintaining health. The result of this imbalance is not only poorer health, but more money spent in institutions, hospitals, and nursing homes.

The road to a better health care system means correcting this imbalance. We should reinvest in what we value — primary care — as a practice, as a profession, and as an abundant resource for patients. In recent years, we have begun taking a number of meaningful steps to begin this reinvestment process. Today, we are proposing significant actions to improve how we pay primary care physicians, mental health specialists, geriatricians, and other clinicians. By better valuing primary care and care coordination, we help beneficiaries access the services they need to stay well. In addition to keeping people healthy, health care costs are lower when people have a primary care provider and team of doctors and clinicians overseeing and coordinating their care.

There are four parts to our strategy to emphasize primary care:
1.We are improving how we pay for care that we value. Today, through the Medicare physician fee schedule proposed rule, we are announcing an important set of changes that would improve how Medicare pays for primary care, care coordination, and mental health care. We conservatively estimate that these changes would result in approximately $900 million in additional funding in 2017 to physicians and practitioners providing these services. Over time, if the practitioners qualified to provide these services were to fully provide these services to all eligible beneficiaries, the increase could be as much as $5 billion in additional funding for care coordination and patient-centered care. These changes build on the work we’ve done to improve access to care in Medicaid by finalizing long-anticipatedrules that help support state delivery system reform efforts, and strengthening new policies to align payment with better, more cost-effective care and ensure that access to care is sufficient in key specialties.

2.We are providing more opportunities for primary care providers to practice the way they think is best. Medicare is transitioning to policies that reduce burden on both patients and clinicians by better rewarding coordinated, quality care. We’ve recently launched a new advanced primary care Medical Home model called CPC+, which will be broadly available across the country and will support primary care doctors’ and clinicians’ efforts to spend more time with patients, serve patients’ needs outside of the office visit, and better coordinate care with specialists.

3.We are finding ways to reduce practice expenses associated with operating a primary care or other small practice. We have been convening meetings with physician practices across the country to find ways to reduce reporting and compliance burdens, while at the same time increasing support to their practices. This spring, we proposed to streamline how Medicare pays for quality and value through the new Quality Payment Program, which includes features intended to reduce the reporting burden for clinicians. Through this new program, we’ve moved beyond meaningful use to the new Advancing Care Information category, which supports the vision of providers leveraging health IT to promote efficiency and clinical effectiveness based on their unique needs. In addition, the Transforming Clinical Practice Initiative supports more than 140,000 clinicians in sharing, adapting, and further developing their comprehensive quality improvement strategies.

4.We are exploring and encouraging far-reaching innovations to connect people with primary care in new ways. We have included telemedicine in a number of care models. The Rural Health Council is also helping to promote a strategic focus on access, economics, and innovation issues across rural America.

Today’s Proposals for Primary Care Payments in the Physician Fee Schedule

•With today’s primary care payment proposals, Medicare continues to move toward a health care system that encourages teams of doctors to work together and collaborate in order to provide more personalized care for their patients. Doctors will be compensated for spending more time with their patients, serving their patients’ needs outside of the office visit, and better coordinating care. These changes will deliver improved health outcomes that matter to the patient. Some examples of today’s proposals include:

•Increasing payments for routine office visits for treating patients with mobility-related disabilities. Currently, Medicare pays approximately $73 for these visits, even though the patient might need to spend more time with the physician or require more physical and staff support during the visit. Under today’s proposal, Medicare would pay approximately $119 for the visit.

•Increasing payments to geriatricians or family practice physicians – specialists who provide core services for the Medicare program. Under our conservative assumptions, we anticipate that these clinicians could receive a two percent increase in their payments for providing the care we propose to recognize under the Physician Fee Schedule. Over time, if all of the practitioners that can provide these services provide them to all eligible patients, we estimate that the payment increase could be as much as 30 and 37 percent respectively to these specialties.

•Proposing to pay for care using the behavioral health Collaborative Care Model. The Collaborative Care model supports mental and behavioral health through a team-based, coordinated approach involving a psychiatric consultant, a behavioral health care manager, and the primary care clinician and which extends beyond the scope of an office visit. Payment for care using this model will help address access issues for behavioral health and improve care for patients. This model, increasingly used by primary care practices, has demonstrated benefits in a variety of settings to improve patient outcomes. CMS is also proposing to pay for other approaches to behavioral health integration.

Strengthening Primary Care Beyond Medicare

As more people age into the Medicare program, we know that access to primary care is an essential tool for their health and wellbeing. We know that effective primary care, care coordination and planning, mental health care, substance use disorder treatment, and care for patients with cognitive and functional impairments can improve outcomes and result in smarter spending. Today’s efforts aim to better value primary care to ensure continued – and strengthened – beneficiary access to these valuable services.

We expect to see the impact of this proposal far beyond Medicare beneficiaries and hope that it will help strengthen the fabric of primary care throughout the country.

For more information, please visit: https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2016-Fact-sheets-items/2016-07-07-2.html.

This company started two years ago, on a set of beliefs.

We believed that health care payment was going to undergo a fundamental shift “from Volume to Value”- that there would finally be a business case for those who could deliver better care at lower cost. Since that time, the Secretary of Health and Human Services announced a commitment to this transition- to goals and dates- the first of which (30percent value based by 2016) has already been exceeded. The number of Medicare beneficiaries in ACOs has risen from 5.6 million to 8.9 million, and just as significantly, a near-consensus among private payors and employers has embraced this goal as their own.

We believed that high-performing independent primary care practices would want to take accountability for the total cost of care, and would want the technology-enabled services we would offer. Within 6 weeks we had signed up more than 100 hand-picked physicians who believed in our vision, and wanted to help us make it a reality. Last year, we grew to over 400 primary care physicians in 11 states, and we are on track for reaching nearly 1,000 physicians by the end of this year. These proud community leaders are drawn to a model where our interests are aligned with theirs, and we are neither employers nor vendors, but partners. Together, we are taking accountability for over 100,000 patients’ care, and nearly a billion dollars of annual medical costs.

We believed that with the right support, small and independent primary care practices would embrace change and achieve results. Our practices have opened their doors to same-day visits and accepted patient calls 24-7 access. We have seen jaw-dropping rates of quality with preventive screenings soaring, immunizations tripling, and diabetes and blood pressure brought under control for thousands of patients. Preventable emergency department visits and avoidable hospitalizations dropped by 7percent, and readmissions fell by 11-13percent. And now we are extending our network to high-performing and high-value specialists, rehab facilities, and home health agencies. We are getting extra help to patients who are most at risk- identified by computer algorithm, and cared for by their primary care practice who knows them best.

We believed that we could hire an amazing team who share our passion and wish to serve. We have grown from our initial founding team to more than 90 individuals who are world-class at all the multiple disciplines needed to succeed- regulatory and policy, technology and analytics, population health, and practice redesign—and have instilled a common sense of purpose and a dedication to the “North Star” of Aledade. On a recent staff survey with 96 percent participation, 99 percent of Aledade staff said that they were proud to work at Aledade.

We believed that it would be hard, and that we would make mistakes, and we would learn. And we have. We have learned that we can’t roll out initiatives in lock step; we must prioritize interventions for each practice based on their greatest opportunity for improvement. We have learned that we can’t expect the same primary care staff to take on all the additional work required of population health. We have learned that we must continually listen for where we can improve the value of our data and technology to our practices. We have learned that not all patients benefit equally from extra touches, and our practices’ bandwidth is limited, and must be prioritized for those who need it the most. We have learned that there is much that we don’t know, and we must ruthlessly question and evaluate our assumptions by measuring what we are doing, what works, and what doesn’t work.

We believed that we would have many competitors. And we were wrong. While there are many fellow-travelers who we respect and learn from- there is yet no national company that is doing what we are doing- truly partnering and aligned with independent primary care physicians, with cutting edge analytics in the cloud, and helping hands in the practice. We are single-mindedly focused on our Aledade mission: good for society, good for doctors, and good for patients.

We feel this as a humbling responsibility. We are not as good as we will be next month, and next year. But our success will be a marker and a model for whether it’s possible to return control of healthcare to doctors over corporations, if quality can triumph over size, and whether less spending can come from better care not less care.

Forward.

 

 

As a Federally Qualified Health Center (FQHC), Hudson River HealthCare’s mission is to increase access to comprehensive primary and preventive health care and to improve the health status of our community in New York’s Hudson Valley and Long Island, especially for the underserved and vulnerable. We are proud to be a part of the Aledade value based care network, because we share the belief that primary care is the foundation of an effective health care system.

We work hard to coordinate the full range of care our patients receive, including outside of our health centers, to monitor, assess, and manage our patients’ full health and wellness needs, not just care for them when they’re sick. As part of an Accountable Care Organization (ACO), we are quarterbacking our patient’s health care.

One of the ways we do this is through our care management program, which focuses on a team-based, holistic approach to care. This allows Hudson River HealthCare to help patients achieve optimal wellness – from their physical and behavioral health needs, to social services and basic living needs.

As we see every day, low income or underserved patients can experience multiple barriers to care – from transportation challenges to lack of resources to follow up on care options. That’s where Care Managers play an important role, talking with patients individually to understand their specific situations and how they can help. We have seen many examples of how our approach to managing patients’ full-spectrum of health and wellness has made a big difference.

In one recent case, a Care Manager, making a routine check-in call with a patient, learned that the patient had recently canceled a medically necessary surgical procedure she was supposed to have on her eye. After inquiring with both the patient and the surgical center, our Care Manager discovered that it was due to the patient’s inability to afford the required insurance co-pay.

Our care manager took action and helped the patient find a community resource to help cover the co-pay, and ultimately the patient was able to get the surgery thanks to this additional support. Without a pre-surgery check-in call, our practice would not have known about the cancelation, and the patient would have likely skipped the surgery, with disastrous results.

A second case demonstrated the Hudson River’s team-based approach to care. One of our physicians learned during a patient visit that the patient did not have a place to live and was “couch surfing” at multiple friends’ apartments. We knew that without adequate housing, the patient would not be able to focus fully on taking her medications or monitoring her health conditions. Upon relaying that information to the care management team, we worked to get the patient an expedited appointment with a local housing organization. A Care Manager accompanied the patient to the housing organization interview and subsequent lease signing. Because of the swift work of our care management team in addressing an issue outside of basic health care, our patient’s quality of life was greatly improved.

We’ve learned that often, when caring for patients with limited resources, even the smallest barrier to care can become a serious issue, and that’s why we take the time and effort to check in often with our patients. As primary care providers, we know that in order to help keep our patients healthy, we need to focus on what happens beyond the walls of our health centers, from issues like housing or financial wellness. This keeps us up-to-date on our patients, coordinated with other providers, and providing the highest-quality care possible.

Participating in an ACO has allowed us to put even greater emphasis on keeping our patients healthy, and that’s our mission.

The Aledade Delaware ACO is gaining momentum on several fronts in our mission to usher in a new model of primary care. Last year, our ACO doubled in size, and we continue to recruit top independent primary care practices across Delaware that are ready to embrace change by participating in value based programs. Last month, we started participating in the state’s Practice Transformation Services Program in partnership with Remedy Healthcare Consulting. And this week we are excited to announce a new set of agreements that will benefit providers and patients across the state.

Aledade is committed to closing the gaps in health care – coordinating patient care more seamlessly and effectively. In order to do that, primary care physicians need to know what happens to their patients when they see specialists and get treatment outside the four walls of their office. These new arrangements in Delaware will help us do just that – shed light on the care patients receive outside of their primary care practices and empower our Delaware ACO practice partners to deliver coordinated, high quality care.

First, we have recently formed a new partnership with one of the largest groups of hospitalists in Delaware, IPC Healthcare. This will give our ACO practices the ability to share patient data, advise on care, and coordinate with the hospitals where their patients receive care. Partnerships like this are important to value-based care as they reduce unnecessary tests, ER visits, and hospitalizations while improving the care patients receive with provider data access. Aledade’s ACO practices can now also directly admit patients to local hospitals when appropriate, instead of first going to the ER. Doing so, when appropriate, will reduce cost and the time patients spend getting the care they need.

Second, we have upgraded our agreement with The Delaware Health Information Network (DHIN), the state’s health information exchange. While they have long provided patient data on a twice daily basis to our Delaware ACO, the DHIN has now taken the next step, and is providing Aledade ACO practices with real-time patient update. This means primary care physicians will be notified right away if their patient is admitted, discharged, or transferred from a care facility. With real-time data from DHIN, ACO practices will be able to provide more timely follow up with their patients during transitions of care. Transitions of care management are an important focus for Aledade’s ACOs, and an important aspect of providing seamless care.

Another development in Aledade’s data connection with DHIN is that Aledade now receives notifications and data from MedExpress through the health information exchange. MedExpress is a large network of walk-in clinics throughout Delaware, so having real time data from these clinics gives our ACO practices more detailed understanding of the care our ACO patients receive outside of their primary care practices. This too is an important aspect of providing seamless, coordinated care, and we are in the process of arranging further partnerships with walk-in clinics throughout the state.

Lastly, we now have a care compact with The Heart and Vascular Clinic, PA (HVCA) in Delaware. While Aledade believes primary care is the core of a coordinated, effective health care system, we also know that high-quality specialists are a critical piece of the puzzle. That’s why we work to arrange care agreements with high-quality specialists, such as our cardiology referral management program with The Heart and Vascular Clinic, PA (HVCA) in Delaware. These agreements focus on improving care coordination, access, and effectiveness through communication and information sharing, including test outcomes and consultation notes. For patients, this means they can see an HVCA provider within 48 hours for an urgent visit and receive more seamless care.

Taken together, these new agreements and updated services will strengthen the Delaware ACO’s ability to coordinate care, resulting in improved quality and lower overall costs.