Health care payers across the country are shifting away from paying providers for the number of doctor visits and tests they perform and towards paying for healthy patient outcomes.
Delaware Public Media’s Nick Ciolino has more on a group of primary care practices in Delaware who say they’ve been able to successfully use this payment model to both save money for Medicare and improve their patient outcomes.
Jessica Marker and Linda Darling meet each other in person for the first time at the Southern Delaware Medical Group, a primary care practice in Milford.
But they’ve known each other over the phone for years.
Jessica is a Chronic Care Management Nurse at the practice and Linda is a chronic care patient.
“When I’m really concerned, I want to call the doctor’s office and talk to Jess. So that’s been very helpful for me,” said Darling.
Darling herself is a retired nurse. She is also a diabetic receiving medical insurance through Medicare.
Marker's job is to stay in touch with patients like Linda, making sure they’re following up with doctor recommendations and are staying out of the emergency room.
“I’m here. I encourage them to call me anytime with any questions. I can schedule appointments just as well as I can answer questions. I call, make their specialist appointments for them, follow up, make sure they’ve gone. I try to collect everything so we can coordinate the care for the patient,” said Marker.
But this wasn’t always Marker's role at Southern Delaware Medical Group. The practice made changes to the way it follows up with patients when it joined an Accountable Care Organization, or ACO, in 2015.
The group it joined was the Delaware branch of the Maryland-based ACO called Aledade. The group includes 23 Medicare primary care private practices across all three Delaware counties.
Through Aledade, the Southern Delaware Medical Group is now incentivized to save money for Medicare and create positive health outcomes for its patients.
So, Marker follows up with patients to try to reduce costly duplicative tests and trips to the ER.
She schedules annual wellness visits to check the patient’s overall health, and transitional care management visits to follow up with the patient after a hospitalization to try to reduce readmissions.
“Before this program, we’d see a patient maybe every three to six months, where now we’re connecting with this patients at least on a monthly basis," Marke noted. "Sometimes with these patients I’m weekly or even daily on the phone with them.”
This is commonly called value-based care. Its effectiveness relies both on the work of care managers like Jessica and the use of data to keep track of the patients.
Marker and others at Southern Delaware are assisted by the Aledade app.
“I’ll show you what it looks like from the very beginning...” said Sarah Marshall, Aledade’s Delaware Market Coordinator, as she shows us that the app keeps track of data previously unavailable to most doctors.
It displays all patient diagnoses which factor into the patient’s risk score. And it shows all of the patient’s Medicare claims including emergency room visits and visits to specialists.
“So that helps for a couple reasons. It increases visibility so the doctor knows what’s going on with the patient, because we all know memory is not always the best way to convey information—so this puts it right there," Marshall explained. "It also can alert the doctor to if there’s something going on that they didn’t know about, or if there’s something going on the doctor themselves can help to manage.”
Doctors know from the app what medications the patient takes so they don’t make duplicate prescriptions. They know what vaccines the patients have not received and which specialist the patient is due to visit.
“So we’re pretty much filling in the blanks and making sure we have complete comprehensive care instead of fragmented care,”said Dr. Beshara Helou of Georgetown Medical Associates, another member of the Delaware Aledade ACO.
He’s been practicing in Delaware for just over 21 years and joined Aledade in 2014.
He says he got into value-based care hoping to improve the quality of life of his patients while reducing the cost of care. But he says it did not pay off right away.
“From a financial point in the beginning, it was not a very good investment—I’ll tell you that. It was a big learning curve," said Dr. Helou. "For the first six months in 2014 everybody was just volunteering their time and effort and energy”
Aledade charges a monthly fee to its members and additional staffing is often required for a practice to get started with Aledade’s follow up initiatives.
The practice also needs to keep electronic medical records to use to Aledade app. Some Delaware practices still use pad and paper.
And Aledade is the first of Delaware’s four ACOs to adopt a two-sided risk contract. So if the ACO saves money for Medicare it gets to share in the savings, but if it ends up costing more the ACO pays money back into the system.
It wasn’t until 2017 Dr. Helou saw a return on his investment.
“If you’re committed, you’re committed, and that’s when you have to have a conscientious effort. It’s not about the money, it’s about the quality of care, but you want to be rewarded for doing a good job,” said Dr. Helou.
In 2017, the Delaware Aledade Acountable Care Organization reduced hospitalizations by 13 percent, saved Medicare more than five and a half million dollars, and earned a quality score of 96 percent.
This evidence supports the case for value-based care as an overarching model for health care going forward.
But there still is some skepticism.
C. D. Casscells is Director of the Health Policy Sector at the Caesar Rodney Institute, a free market think tank.
He says value-based contracts might discourage providers from taking on patients with high risk scores.
But Linda Darling, the diabetes patient at Southern Delaware medical group says she has noticed improvement in her care since the practice adopted a value-based contract.
She says her follow up calls with Jessica Marker helped her manage her medication as she recovered after a heart attack.
“That saved me a couple of trips into the doctor and we were able to manage this part of a chronic issue I’m going to have to live with in a very efficient way that made me feel really supported and that I had someone I could connect to very quickly,” said Darling.
To start the year the state of Delaware changed its Medicaid contracts to include value-based incentives and many of the state’s major hospitals have done the same with private insurers. Delaware is also incentivizing private practices with one-time competitive grants to take steps towards shifting to value-based care.
Aledade officials say theirs is the only Delaware ACO thus far to receive shared cost savings with Medicare.