podcast icon

Episode 74: Downside Risk in Primary Care

by Aledade

Dr. Darrin Menard is the physician owner of Scott Family Physicians, an independent primary care practice in Scott, Louisiana. He joins Josh and Joe to share some of the challenges of being an independent primary care physician and what it has been like to be a part of an Accountable Care Organization.

They discuss two-sided risk contracts and how and why the Louisiana 2016 ACO decided to take on downside risk.

Episode Transcript

Darrin Menard  00:00

Every decision that we make in our practice nowadays has to do with if it's going to be good for our patients. It's no longer about, is it going to make enough money to be able to pay for itself.


Josh Israel  00:15

This is The ACO Show, a podcast about value-based health care and the people who help make it happen. This interview is with Dr. Darrin Menard. Dr. Menard is a fantastic primary care physician in Scott, Louisiana. And he joined the show to talk about his experience in an accountable care organization; some of the challenges of being an independent primary care physician; and why an independent physician would enter into a risk contract where they could stand to make money or lose money, depending on how healthy they help keep their patients. Let's get right to it.


Joe Shonkwiler  00:47

Welcome to the ACO show. My name is Joe Shonkwiler and I lead adoption and training here at Aledade.


Josh Israel  00:53

I'm Josh Israel. I'm a physician, psychiatrist, and a medical director here at Aledade, and today we are joined by Dr. Darrin Menard. Dr. Menard is the owner of an independent primary care practice in Scott, Louisiana, called Scott Family Physicians, and he's been a local medical director of the Aledade Louisiana ACO, which started in 2016. Welcome, Dr. Menard. 


Darrin Menard  01:13

Thank you, Josh. It's good to be here with you guys.


Josh Israel  01:16

We wanted to talk about what it's like being an independent primary care physician. We know that independent PCP services are increasingly in demand. But it can be harder and harder to maintain independent status, to not become part of a larger clinical system or a hospital. What are some of the pressures that you experience trying to serve your community as an independent primary care provider?


Darrin Menard  01:38

In truth, the main challenge that most practices independently face is the lack of ability to be the advocate for themselves in the communities of the insurance programs that are out there because they won't listen necessarily to a single independent practice — insurance companies won't listen to independent practices independently. But when you're part of a group, they tend to listen more, they tend to give more. And when you're an independent, you have such an extreme amount of costs involved with expenses in your practice that it's really hard to justify staying independent because expenses become overwhelming, the older your practice gets. So you have to find different ways to pay those expenses throughout the years, busy-ness of medical practice just becomes overwhelming. And so you have to try to find different ways to meet those demands. And I think that's where value-based care has come into play for my practice, is to be able to do the things that we need to do, maintain those expenses, and profit from it as well.


Joe Shonkwiler  03:03

Dr. Menard, there are many different arrangements and contracts accountable care organizations, or ACOs, can make with Medicare. And many times people don't think about the opportunity to take what we call it downside risk, meaning where an ACO agrees to take, actually pay back money, if they don't reduce healthcare costs against a benchmark. And if they do that, if they do save money against that benchmark, they actually keep a higher percentage of the savings because they took on additional risk, and they were reducing those costs accordingly. That's a arrangement that you and your ACO have taken on, and I'd love to get some background on that. Why would a physician decide to take on that kind of risk?


Darrin Menard  03:50

Well, that's a good question, Joe. I think the important aspect of this is, we didn't just make that decision overnight. That decision was made because of the fact of the three years of work that every clinic in the ACO has put into improving their primary care initiatives in their practices. So there was a group decision, and it was a unanimous decision to go to downside risk. Now, having said that, it took three years of transformation in these practices. I don't think every ACO is going to need three years to to transform like this, but it is definitely a good environment to learn in whenever you're not in a downside model. So when we first started our ACO in 2016 we started recording, we really had to develop the foundation of how we were going to improve the care that we needed to help our patients and to have the right staff in place. It definitely took a lot of initiative on the primary care practices, the providers out there, to say, 'Hey, look, we are going to commit to doing this because it is primary care at its best. It is what we went into our residency for and to family practice is to provide that primary preventative care at the highest level that we possibly could.' So we had to be really trusting of Aledade and their processes at that time, because it was going to take a significant financial investment for us, but we had to see a financial model, and we have to see a way to at least even out those expenses. And Aledade did a great job of explaining how we were going to do that over time, even if we didn't get the savings for a couple years, three years or whatever. There's still opportunity to improve revenue in the practice by doing the things that are most important in the patients' lives, like the preventive care, and then actually still continuing the chronic care but developing different strategies to improve that chronic care. So, you know, primary care physicians, independent primary care physicians, as I was growing up in the medical world, after medical school and going into residency, I realized that we were very territorial with our patients. We wanted to make sure that things were getting done for our patients that were done the right way, not just being done because it could be done. And that's the care that we have been providing to our patients for 20 years. And we wanted to make sure that even when we did send patients over to a specialist, that they had some financial responsibility on their end to make sure that the patient was taken care of in an efficient way. That's the way I looked at how I would send patients over to other specialists. So that made such a big difference. And the practices that Aledade recruited, most of them, I knew who they were. And we were all the same way: we all took very thoughtful care about how we would send patients to other physicians. And we did not try to overutilize sources in this just to create financial gain for people.


Josh Israel  07:20

You know, you make it sound like it was an easy decision after three years with it being unanimous. But I imagine that a lot went into that final vote and discussion. Were there any concerns you had to address that the doctors and the ACO had? Were there worries at that point, about going to two-sided risk, or were there some earlier that had just gone away because of the success that your ACO was having?


Darrin Menard  07:47

Absolutely. There were concerns there were worries. Again, our ACO did a great job of preparing for those outcomes. And in those discussions, we had multiple different options. They wanted to share that there were several different tracks that we could potentially go on at the time when it was time to make a decision after those first three years. And so it was it was actually about a 3-6 month process of clinical calls with other physicians, answering questions that they had, looking at the different options that Aledade is proposing to us. And then it was it was a good 3-6 month process at board meetings to discuss with everybody in attendance because it was a critical decision that everyone needed to make. Because it was obviously meaning that we were going to have to put some skin in the game and really make a difference with financial incentives on the upside potential. So there was going to be tremendous upside potential for us as compared to the downside risk and Aledade did a great job of giving us the opportunities to look at different pathways to be able to do that by helping us in several different ways. So it was not an easy decision. I think everybody made their decisions together, and for the good of the whole ACO, we made the decision to go to downside risk in the way that we did.


Joe Shonkwiler  09:08

Sounds like it took a lot of work and trust and relationship-building across the providers and the board of the ACO, which totally makes sense, given the complex dynamics involved in these kinds of decisions. One question I have is what does it look like building the team within an individual office to get this done?  I imagine everybody had to be on board when you are taking on additional risk, but with the potential for additional reward and the upside scenario, so, you know, how did you prep focusing in your office, how did other folks prep folks in their office for this, this heightened relationship?


Darrin Menard  09:53

So essentially, our office staff does not necessarily know that we were going to downside risk. Our office staff is so ingrained in doing the work of what we're doing as an ACO because they see the results that we've been noticing over the past three or four years of how we're taking care of our patients much better than we ever have. And, you know, if a patient goes to the hospital, it's not like we say, we used to say, 'Okay, well, the patient's in the hospital, okay, well we'll see him when they get out whenever they get a chance.' Now, they're really involved in making sure that that patient, a lot of times, they're calling patients in the hospital, see how things go on. And then as soon as we get the discharge notification, they're calling those patients right away. So the staff is really a vital, key component to making that decision to go to downside risk, because if you know that your staff is a well-oiled machine and they are doing all the work, all the fundamental basics that need to get done for an ACO, then that's what you need to be successful in an ACO, then you can make that decision to go to downside risk a lot easier. So the staff is a critical component because if your staff is new and your staff are not working on the same page already, then downside risk is not an option at that point. But you really want to help your staff to understand the needs of your patients on the preventive care side. So as far as I said before, we can prevent 30 heart attacks in patients' lives. But nobody's ever going to notice that. But if a patient has a heart attack and somebody comes in with a stent in that artery, then that patient saved their life for the rest of their lives. Well, the independent primary care doctors, you know, saved 30 other patients from having a heart attack before that. That's part of being an independent primary care provider, is the fact that you have to be humble, you have to understand our role is to prevent those things from happening. And that's for the good of humanity, and it's good for our patients. So while we're also saving some costs, that is allowing us to improve the care of our society. And then once we do that, then financially we'll be taken care of on the back end. And that's part of that whole risk scenario. And I think our whole staff understands that, and they understand working hard and taking care of patients is, I tell them this all the time. I'll tell them, 'How would you want to be treated when you walk into the doors of that clinic?'


Josh Israel  12:47

So Dr. Menard, do you think it helped your accountable care organization to start in one-sided risk at first, where you got the hang of it? It sounds like that's the case. Would you say there would ever be a case where somebody would just start an ACO and go right to two-sided risk, or is it something that takes time and support to get there?


Darrin Menard  13:07

So yeah, that just depends on the practice and how much risk a person wants to take. You have to have a certain amount of patience to be in an ACO. So you have to be very confident and trusting of every other practice that's in your ACO to make sure that you're already very good at saving costs If you want to take that downside risk initially. One of the issues for us was that none of us really knew what value-based care was about When we first started in the ACO. We all knew about preventative care, But to take it to the level of where we are now was unheard of before when we were looking at our entire population of patients. So that has been the biggest shift. And once we realized that all the practices wanted to do this, it was an easy decision. But we had to, we all had to trust each other and make sure that every one of us were doing the same thing, and improving the care that we needed to in our own practices. For us, it was kind of the decision we needed to make on that upside risk and downside risk situation. We had three years of experience, and we all knew that everybody was doing the work already. At the time, we hadn't made savings yet, but we could tell just from the practice data that we were receiving, everyone was doing the work that they needed to. So downside risk practices that choose to go to that model right away straight into an ACO, they obviously have had some experience and in a value-based care type of model at some point. So they're really heavily ingrained into doing the quality in their patients' care. So they're confident with the fact that they're going to save dollars. As long as they have the data to back it up, they're going to make that decision on their own. Everybody has their own free will to make that decision. But if they know that they're doing well in a certain region, in a community, and in whatever state, they are free to make that decision and take that risk. You know, it just depends on the practice. If you're doing that quality at a high level, it's easier to move into downside risk.


Joe Shonkwiler  15:27

Dr. Menard given that you've been working in this area and had some very clear successes, I'd love to hear some of the things you're most proud of, that you've been able to transform at your practice or even that you've seen throughout the ACO.


Darrin Menard  15:43

So we're definitely excited about the fact that every decision that we make in our practice nowadays has to do with if it's going to be good for our patients. It's no longer about is it going to make enough money to be able to pay for itself or be able to pay the staff to do the things that we need to. I recently purchased some equipment to kind of help predict if a patient is going to have a heart attack, just primary care-type things, preventative-type things. And it wasn't about the financial aspect of it, but when I thought about it, I was like, 'Okay, will this help me save dollars, and will this help me decrease the cost of care for our patients?' That was the first question I asked myself, I said, 'Absolutely, it's going to make a difference. Because I won't have to send so many patients to a cardiologist where we don't really know, we'll be able to identify things quicker.' That decision has made, has been impacted because of the things that we're doing nowadays and in the ACO. It's good for those patients because they don't have to spend thousands of dollars on things that we know that are good. The most proud thing that I think the proudest achievements that we've had in our ACO and the world that we've been living in for the last four years, is the fact that we've been able to reduce ER visits by almost 11% over the last couple of years. We've been able to reduce hospitalizations about 15%. And how do we do that? It's just by doing the primary care work that we're doing as effectively as we are. We're getting more patients into the office having open-access scheduling to allow patients to come in and be seen when they're just getting sick instead of waiting until they're already, you know, beyond the point of return. So that open-access scheduling has made a big difference in reducing hospital costs, reducing the ER burden costs to our ACO. That's an exciting initiative that we really put into place that has made a big difference, where we could actually see the outcomes that in our practices, patients are healthier, they're not having to spend time in the hospital as much anymore. We've also increased our quality scores to almost 97% in 2018. And that was just a fantastic number that we saw to be able to help improve the quality of care in our in our entire ACO in Louisiana, 16,000 patient lives. That's pretty remarkable. To make such a change in all these lives, those are really high accomplishing goals that we all had. And we've really exceeded the efforts that we were trying to achieve with that.


Josh Israel  18:30

And one of my favorite things about doing this podcast is all the stories Joe and I get to hear about the sorts of changes that are going on across America, in health care. And when we think about the idea of an ACO not a very old idea, just a few years old at this point, and you know, sort of bold idea that by keeping people healthy, we could bring down healthcare costs. And as you describe it, it really sounds like it's working, where your practice is getting more revenue, you get to stay independent, and you're keeping people out of the hospital. Are you surprised that this seems to be working?


Darrin Menard  19:06

I am surprised in a way, these are things that we've been taught in residency and in medical school, that we needed to prevent things from happening in patients' lives. And so we were taught that and we thought we were doing a good job of that up until we started with the ACO and we realized that all these people didn't get the wellness visits that they needed to get. When I first started the ACO, I think we maybe had like 10 to 15% of our population that had a wellness visit done within the last three years. I mean, that's just, it's amazing how and now we're at 82% of our population. It's amazing the transformation that's had in our population. One of the main initiatives that we've worked on, we're still working on today, but it's controlling high blood pressure. We've really worked hard on making sure that our patients are having their blood pressure controlled as good as possible, as efficient as possible. Making sure that they're getting their blood pressure checked at home on a regular basis. And we improved our blood pressure numbers, controlling blood pressure numbers from, I think it was probably in the 65% range to 92% control over a year's time. And only because we started paying attention to that, as an entire staff, every person in the staff made it a goal to make sure that their patient's blood pressure was under control. And when you have a whole team that can start working on an initiative like that, results become tremendous. I noticed that because of that control that high blood pressure we've seen the results, we're getting paid extra by our insurance companies in the state for controlling blood pressure. And it's one of their initiatives is to control blood pressure, it is probably the biggest initiative that the Blue Cross program has here is to make sure that blood pressures are controlled. Well, we started getting some reimbursement from doing that, but the biggest reimbursement that we noticed is the fact that less patients are having strokes, less patients are having heart attacks in my practice. I've noticed that over the last couple of years, that I'm not seeing patients on follow-up from the hospital for heart attacks and strokes anymore. It's more other etiology things that are causing other, different problems, rather than their blood pressure being out of control. So I was pretty impressed about the fact that yes, we got blood pressure under control. And yes, we're producing outcomes by decreasing heart attacks and decreasing cardiovascular disease in these patients' lives. And overall, what happens, the patient care gets better, they don't really notice the difference. But they just you know, I don't see those patients, I used to see patients, you know, once or twice a month they were having heart attacks in my practice, I think it's probably been, it's probably been a few months since I had a patient with a heart attack. But I think once or twice a year now we're having patients with heart attacks. We're getting to the patient's care earlier. It's making such a big difference.


Joe Shonkwiler  22:15

Dr. Darrin Menard, owner and independent primary care practitioner at Scott Family Physicians in Scott, Louisiana. Thank you for joining us on The ACO Show.


Darrin Menard  22:25

Thank you, Joe. Thank you, Josh.