By Jane Ehrhardt
By 2030, CMS aims to change most Medicare fee-for-service beneficiaries to a value-based care (VBC) program. That means Medicare will reimburse providers and insurers based on the benefits of the care given to the patient rather than the volume of services provided. “Value-based care is kind of a misnomer. It’s really about better care for the patient,” says John Farley, MD, medical director with Complete Health.
The primary care group’s VBC model centers on the 27 million or so people in the nation enrolled in Medicare Advantage plans. At their 16 practices, Complete Health works with the commercial insurers who offer the plans, such as Viva, United and Cigna, to take over the risk of managing the cost of care for those patient. For each patient, Complete Health receives 85 percent of the lump sum from Medicare designated toward healthcare. The insurers keep the other 15 percent.
Whatever monies remain after care, Complete Health can keep. If costs go over that 85 percent, it comes out of the company’s pocket. “The only way to have money left over is to take better care of the patients,” Farley says, because Medicare also pays based on whether parameters indicate better outcomes, such as hospital readmission rates, star ratings, and ordering preventive tests.
The extra monies are shared with all their providers and to pay for the additional services to keep the patients healthier. Those services focus on engagement and convenience for the patient. “We want to keep them out of the hospital,” Farley says. The nine Birmingham locations open at 8:00 a.m. with one offering Saturday hours along with an urgent care clinic in Pell City open on the weekends. All promote same-day and next-day appointments, with walk-ins at the urgent care clinic.
“You keep patients out of the hospital and emergency room by being available,” Farley says. “So we employ 45 care management nurses in Birmingham to engage with our sickest patients as frequently as they need to by calling or checking in on them. Patients seen in the clinics receive a call 24 hours after a visit to be sure they’re feeling better and have their prescriptions at-hand.
“Our motto is, see us first and we’ll get you seen, whether it’s virtual, personal, or a home visit. We send someone on house visits to certain patients every week, not only for their health, but so they don’t feel the need to visit the ER to seek companionship.
When specialists are needed, patients are referred to Complete Health’s preferred network of specialists. The network helps mitigate costs that have become a mainstay of the fee-for-service model specialists rely on for revenue. “For instance, do all patients need a chest x-ray before surgery? Science says no,” Farley says. “So we do less of those.
“All the money we earn comes from fixing the broken system. If a patient calls with UTI symptoms, they’re not sent to the ER because no appointments are available. We see them that day and dispense their medicine in the clinic or we have two nurse practitioners who can come to their house and see them. It’s about being proactive.”
Farley, who works out of the Florida headquarters, did a ride-along for a home visit in the west end of Birmingham. “The patients were so grateful to not have to come to the office,” he says. The company also perform mobile labs, ultrasounds, and x-rays.
The model has worked, and the resulting profits have created an additional revenue stream for their providers. “Our doctors typically make more than they did before they joined us, because we’re sharing the money with them that typically goes to the insurance company,” Farley says.
Three weeks ago, he distributed $1.5 million made by following their VBC model to their 25 providers in Daytona and 89 in Birmingham, including nurse practitioners. “Some doctors can make an additional $45,000 twice a year,” Farley says. “If you want to slow down, get paid better and focus on taking better care of the patients you already have, then you can do that.”
Between their Daytona and Birmingham locations, Complete Health now cares for more than 100,000 patients, of which 20,000 are enrolled in a Medicare Advantage plan with 6,500 of those under varied ACOs. The remainder are on traditional Medicare, Medicaid or are commercially insured patients. “Since we have these extra services, all of our patients benefit from them,” Farley says.
A fourth generation physician, Farley sees this value-based care model as a way to reinvent primary care. With its new revenue stream increasing income without increasing volume, it could help to end the primary care physicians shortage and lessen burnout. “Because we can pay our providers more based on managing a patient population well rather than on how many patients they see every day,” he says. “This is an evolution.”