Thread by @Farzad_MD

1/ We have a new study coming out today in @AJMC_Journal that I want to tell you about.

It’s about how @AledadeACO uses Medicare Annual Wellness Visits as a tool to engage patients, improve quality scores, and yes- reduce costs.

ajmc.com/journals/issue…
@AdamLBeckman

2/ Before I started @AledadeACO, I helped put together a public toolkit at @BrookingsInst on what physician-led ACOs need to do to be successful.

One of the key pillars for patient engagement was the Medicare Annual Wellness Visit

brookings.edu/wp-content/upl…
@jjseidman @jcolbertMD

@AledadeACO @BrookingsInst @jjseidman @jcolbertMD 3/ This was a new type of visit code that Medicare had created to encourage more time between primary care practices and their patients- Not a physical exam (which is a USPSTF D recommendation), but a talking visit where there is a fulsome discussion of #AllTheThings, w no copay

4/ "While Medicare Wellness Visits contribute to overall costs of care.. could be more than rewarded with valuable information gained from health risk assessments, accurate diagnosis coding and the opportunity to create stronger relationships w ACO patients”

#GoodFee4Service?

5/ Left unsaid, it could also be a waste of time and yet another opportunity to bilk Medicare. A check-the-box exercise by someone who has no ongoing primary care relationship with the patient, and just wants the FFS revenue

Sure enough, we saw vendors popping up to do just that

6/ there were also more earnest vendors just trying to help practices legally maximize revenue in a FFS world

"our providers average $1 million in revenue for every 3,000 AWVs performed at 60+% net profit margins”

But despite this, rates of uptake of AWVs have stayed pretty low

7/ Our business model @AledadeACO is carefully designed to shy away from FFS-maximizing incentives (“Golum’s Ring” says my friend Rick Gilfillan)- so unlike other ACO enablers we never take a piece of increased practice revenue from “good FFS"

We believed that AWVs were worth it

@AledadeACO 8/ we worked hard with our practices to not only increase the volume of AWVs, but to target them to the right patients, and do them better.

Everyone go read @mrsbrull writing about her experience in @aafp "Finding the Bright Spots in Value-Based Care”

aafp.org/fpm/2017/0900/…

@mrsbrull @aafp 9/ This is harder than it looks, with lots of challenges!

Our first @AledadeACO app was a tool to help call priority patients. We implemented EHR templates, provided data tools, supported performance monitoring, and shared best practices.

And lots of in-person workflow support

@mrsbrull @aafp @AledadeACO 10/ I’m saying all this because I don’t want the take-home from this study to simply be: “AWVs save money”

I don’t believe that they do, uncaveated

More primary care is good. More payments to primary care docs is great. But you don’t save money unless you are aiming at doing so

@AledadeACO 11/ So what did we accomplish?

Well, first off, quality scores improved a lot for things that require diligence (and documentation) like falls risk screening, but also improved for clinical quality measures like pneumonia vaccination and A1C control.

This makes sense to me

@AledadeACO 12/ But we really wanted to know what the impact would be on total cost of care for those who got AWVs c/w matched controls who didn’t.

We probably spent 90% of the time on this paper focused on whether we were just seeing selection bias.

After LOTS of work, I don’t think so.

13/ As an aside, maybe this is appropriate, but without an author who is a card-carrying member of the academic elite, the bar of getting past statistical review and skepticism at top journals is very very high.

Next time, I’m bribing @amitabhchandra2 with whiskey to help me

@amitabhchandra2 14/ If we anchor on the month when the AWV was conducted in one of our ACOs, and look at the costs for them and matched controls over the following 11 months, we found a big difference in costs, especially for inpatient care.

And the sicker the cohort, the bigger the impact

15/ As they say, there are limitation to our study, especially on generalizability.

The study population was ambulatory, could come to a PCP visit, not in hospice, etc.

And as I noted- this is within the context of primary care practices that are in an ACO and highly supported

16/ But I’m proud of this work, and unlike many academic studies, we have the opportunity to put our skin in the game.

If we didn’t believe it saved money in excess of the costs (in this case $480 vs $175), we would be idiots to pursue it as a central strategy in our business.

17/ If you prefer to read press releases to twitter stories, can go here, courtesy of our excellent friend @KennethBaer

“Annual wellness visits have been the cornerstone of many ACOs’ strategies …"

ajmc.com/press-release/… via @AJMC_Journal

Finally, many many thanks to our co-authors @AdamLBeckman
Adan Becerra
@anna_m_marcus
@AnnetteDuBard
@kllynch7
Emily Maxson
Jen King

And the 114 independent primary care practices in Delaware, New York, Arkansas, and Virginia who work hard for their patients every day.