Nov 02, 2018

Road to Risk: Teaming Up to Hurdle Medicare Challenges in Our Community

With more than a decade of experience in creating and evolving a patient-centered medical home model, Austin Regional Clinic (ARC) knows very well about using data to proactively care for "fragile", more medically complex patients. Our “experience” has improved patient access to care, led to better patient outcomes and reduced total medical costs for patients, employers, and health plans. And we've known, for quite some time, that expanding this model to more Medicare patients is something we could and should do.

But, before investing more resources into growing a Medicare patient base (when most others are shrinking theirs) we had a lot to consider.

ARC doctors take care of more than 470,000 people in Central Texas, and Medicare patients have always been an important part of our practice. Unfortunately, the trend across the country shows more and more physicians “opting out” of Medicare, because federal payments have not kept up with actual costs or because practices cannot keep up with the increasing paperwork burden specifically around Medicare. In Central Texas, an overall doctor shortage contributes further to the problem and seniors are being left with fewer choices.

Austin Regional Clinic is known for overcoming obstacles and doing what’s right for our patients and for the community. We founded the organization on a patient-centered medical home model in the 1980s when that term still barely existed in healthcare. But, from our almost 40 years in health care, we knew we couldn’t invest in Medicare the way we wanted to by pursuing it alone. So, we looked for the right teammate to help build something different.

We found that in another local well-respected primary care medical group — Premier Family Physicians (Premier). Two multi-specialty primary care groups in the same region joining forces may seem unlikely teammates yet, like us, they saw great opportunity — a new type of Medicare Advantage program that would simply be too effective for health plans and Medicare beneficiaries to NOT sign on.

Build It and They Will Come

Together we’ve agreed to take on the financial risk (“full-risk”) where we receive a monthly fixed payment from the Medicare Advantage plans versus payment for each patient visit (typical of “fee-for-service”). At the same time, we are ensuring timely access for patients, enhanced coordination of care by an expanded care team, shared data and analytics, and a focus on improving patient health while controlling member cost-sharing wherever possible. It’s a high bar, but we know we can achieve it.

Our next step was to find a partner that had the same vision along with the needed financial, experience and technology support. agilon health became that partner.

Now, after several years of searching for the right like-minded medical, financial and technology partners, that vision is a reality — a newly unveiled Medicare Advantage program called Connected Senior Care Advantage. The program has the needed resources to meet our shared mandate, allowing us to offer more Medicare Advantage patients the great care our groups have historically provided in Central Texas.

Under this full-risk model and new reimbursement structure with health plan partners, our medical groups are choosing to take complete responsibility for quality and cost of care. Because we are paid a fixed monthly payment per member, we have the needed resources to ensure access and coordinate care for our Medicare Advantage patients. For example, Nurse Navigators will call patients to make sure they are taking needed prescriptions; Patient Outreach Coordinators will ensure patients have their needed follow-up visits; Advanced Nurse Practitioners will spend extended time with patients at the Medicare Wellness Visits; and doctors will continue to focus on patients’ healthcare and lifestyle needs while quarterbacking their care.

We’re building it, so we can design it.

We are building a network of primary care and specialty doctors and facilities throughout the community that will be part of the Connected Senior Care Advantage network. The network will reach beyond both of our groups to include the full suite of healthcare services our Medicare Advantage patients need.

To date, Humana, Aetna, and WellCare have “signed on” to Connected Senior Care Advantage via their Medicare Advantage plans. We expect more plans to sign on for 2020 plans.

‘Opting’ In

It’s the right time to roll out such a program. So far, local seniors are selecting the more organized care of Medicare Advantage options at a record pace. Enrollment in Austin is growing at 12 percent annually – three times faster than that of traditional Medicare.

Besides the care coordination aspect, they are drawn to benefits such as prescription drug coverage, vision and dental coverage, and even gym membership coverage not provided through traditional Medicare.

We know from national survey data, as well as our own patients’ feedback, that seniors are actively seeking programs where care coordination is a priority. Enrolled patients want their physicians in the quarterback position, coordinating their care in a way that enables better patient outcomes.

ARC and Premier are physician-led medical groups building a comprehensive organized system of care for Central Texas. For now, this new partnership is focused on Medicare Advantage. But, this is just the beginning. We believe it’s imperative to preserve the role of organized and physician-led primary and specialty care in the Central Texas market – and nationally, for that matter— to bring excellent, affordable care to communities.

We live and breathe care coordination.

With Connected Senior Care Advantage we are reimagining care for seniors. We are building and designing more infrastructure that appropriately aligns incentives. We will be able to get full transparency to the quality, frequency and cost of care for our patients. We will be able to resource capabilities that are not typically provided through a primary care practice but are critical to managing the quality and cost of patient care, such as disease management programs, home care, data analytics, network design and engagement, and the list goes on.

Being a healthcare leader in the community, means enhancing access to care and raising the bar for quality of care. It’s our unwavering focus. That’s why we are positioning ourselves to respond to healthcare needs for the growing number of seniors in Austin and surrounding communities.

We owe it to our patients.

Dr. Anas Daghestani is CEO of Austin Regional Clinic.