As Medicare Advantage insurers show increasing interest in moving physicians down the path toward value-based care, Irvine, Calif.-based ConcertoHealth is taking a two-pronged approach to supporting the network needs of its health plan partners across a variety of settings. Originally a provider-led MA plan called Fidelis Secure Care, the company under new ownership was renamed and divested its MA assets in 2014 to focus on the provider side. ConcertoHealth began entering value-based payment arrangements with MA and other insurers with the types of chronically ill, vulnerable members it was already equipped to serve via its existing primary care clinic model.
Operating on the “extreme end of the value-based care spectrum,” Chief Development Officer Colin LeClair says the organization serves more than 98% of its plan partners’ members through globally capitated arrangements. This means the company is fully accountable for the patient’s total quality and cost of care, regardless of where that care is delivered. And the full-risk payment arrangement allows clinic physicians to use medical funds at their discretion and enables the organization to invest in “resources that directly and immediately impact patient outcomes,” LeClair explains in an interview with AIS Health.
This could mean time and money spent on arranging transportation, coordinating medication deliveries and collecting health information from across the delivery system — all activities that can impact a patient’s care but aren’t billable in a traditional fee-for-service model. And many of these activities support MA plans’ star ratings goals, which is one of the foremost reasons they choose to engage with ConcertoHealth clinicians, says LeClair. The company’s core markets are the greater Detroit area — where it has partnerships with Centene Corp., Blue Cross Blue Shield of Michigan, Meridian Health Plan’s MeridianCare and Molina Healthcare, Inc. — and the greater Seattle area.
Value-Based Pact Supports Models of Care
“MeridianCare and ConcertoHealth have an amazing partnership, which lends itself to a value-based relationship focused on quality of care for our members as well as better outcomes for our members,” weighs in Shawn Holt, senior vice president of MeridianCare, which operates multiple Medicare products in the state of Michigan. And while it’s too soon to share outcomes from the year-old partnership, Holt adds that the value-based pact includes goals that “meet or exceed the government standards” for the required Special Needs Plan and Medicare-Medicaid plan Models of Care.
Primary care resources are assigned in one of two ways. First, the company operates seven Americans with Disabilities Act-accessible ConcertoHealth Care Centers that are staffed with primary care physicians, nurse practitioners, nurse case managers, pharmacists, dietitians, nutritionists and social workers and feature an in-house lab. In other words, an “entire interdisciplinary team is on-hand” to manage a chronically ill population. Those team members may also conduct field-based visits that range from acute care (i.e., facilitating a safe discharge from the hospital) to preventive care (e.g., visiting a high-risk patient in the home to perform diagnostics, a comprehensive evaluation or health risk assessment). There are currently three Care Centers in the greater Seattle area and four in the greater Detroit region.
That, LeClair explains, is the model that was built by its predecessor, but a second component that was developed by ConcertoHealth is a wrap-around model that allows the plan partners’ other network physicians to provide the same clinical supports without having to directly hire social workers or additional staff members. Through this primary care support platform, which it began offering two-and-a-half years ago, ConcertoHealth will “embed” resources in an independent practice, like a field-based dietitian or nutritionist.
For providers to take full accountability, however, they also need broader access to patient data to enhance their decision making, argues LeClair. A critical component of the ConcertoHealth platform is access to an array of data gathered from laboratories, e-prescribing vendors and pharmacy chains — as well as health plans via utilization management requests that are processed by ConcertoHealth medical directors. “Primary care physicians historically have had very limited access to the complete care experience of their patients, [and that] is a huge impediment to their ability to move to value-based payments and value-based incentives,” he contends. “If you can’t see what’s happening to your patients outside of your office, how can you take accountability for their outcomes and take a true population health approach? You just can’t.”
So as not to overwhelm physicians with “reams of data,” ConcertoHealth attempts to “boil down” the information so that clinicians can easily use it at the point of care via a portal and view, for instance, all the medications a patient has been prescribed, all of the prescriptions that patient has filled at the pharmacy and all of the scripts the patient has actually told the care manager they’re taking. In addition, ConcertoHealth provides the physicians with data on how they’re performing in terms of quality and medical improvements.
On a more proactive basis, however, the company sends alerts about patient care, such that if there’s a change in the patient’s status or they’ve been admitted to the emergency department, the physician will know about it “as close to real time as possible so that they can act,” he adds. “The goal is to close the communication gap between the primary care doctor and every other stakeholder in the system, so that the primary care doctor can remain the patient’s care quarterback.”
All these elements combined have led to improved outcomes that LeClair says demonstrate that the model is working. In the first 18 months of partnering with ConcertoHealth, three health plans observed a doubling in primary care visits and saw both hospital admissions and readmissions drop by more than 30%.
In addition, ConcertoHealth has identified the skilled nursing facility network in each of its markets that is best equipped to handle its vulnerable patients and channeled more than 80% of SNF stays to the highest performing 30%. By consolidating those SNF referrals, plans have also seen fewer readmissions and less “bouncing back and forth” from the SNF to the hospital, he explains.
Company Is Exploring Additional Markets
Having increased its patient base by 300% in its core markets over the last 12 months — driven by demand from its existing partners — ConcertoHealth is now in a critical stage of its growth strategy. The company is in the middle of securing growth capital financing, and in January 2018 will expand into Illinois and Ohio with existing partners under global risk agreements. In addition, the company is in advanced discussions with new and existing payers about expansion opportunities in “a number of additional markets from coast to coast,” discloses LeClair. “Most of our partnership discussions have been with Medicare Advantage and managed Medicaid health plans; however, we’re fielding increasing interest from large integrated delivery systems that are interested in accelerating their transition to value-based care,” he adds.
When asked if the organization would ever consider going back to the insurer side of things as provider-led plans dominate the startup MA market, LeClair offers a firm no. “ConcertoHealth’s mission is to bridge the chasm between health plans and their primary care providers,” he tells AIS Health. “Having shed many of the traditional health plan responsibilities — benefit design, sales and marketing, claims payment, network contracting, etc. — ConcertoHealth is now exclusively focused on enveloping primary care practices with the clinical resources and enabling technologies that will produce better patient health outcomes.”