Humana Value-Based Care Syracuse

Family Care Medical Group is a primary care practice serving the greater Syracuse, New York area, with 45 partners and more than 60 physicians. Like most practices, it struggled to keep up with the follow-up work that quality scores depend on: cancer screenings, A1C checks, blood pressure control, and patients who don't come back.

We produced this piece for Humana in 2019. A physician and Humana's care coordinator describe the same partnership from both sides: a coordinator working inside the practice's EMR, reaching out to patients and getting them in for care they would otherwise skip. Over that stretch, the group's overall star scores rose significantly.

Value-based care is hard to explain in the abstract. Hearing the doctor and the coordinator tell it together does most of the work.

About This Project
Client: Humana
Practice: Family Care Medical Group
Type: Healthcare video, value-based care, provider testimonial
Location: Syracuse, NY
Services: Production, interviews, editing

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Video Transcript:

Family Care Medical Group is a family practice, a PCP-driven practice that also has a wonderful complement of specialists. And they serve the greater Syracuse area.

I joined this group 20 years ago. We have 45 partners, 60, 65 docs.

Personally, as a primary care physician, I've found there are lots of patients who do not say things to the doctors when they're here. They don't follow up for appointments, they don't follow up for tests, and this has really been the primary care physician's responsibility, and there's not much compensation to do it, and it kind of gets left in the cracks.

All the HEDIS measures: screening for colorectal cancer, hemoglobin A1C measurement, your diabetes control, your blood pressure control. If you're really not doing well on these measures, you're probably not doing such a great job on everything else.

We do know that we need boots on the ground in the offices. We need somebody to help out. We need somebody to help coordinate these screenings and just get in the office and get into the EMR and be able to really make an impact.

When I initially started, the goal wasn't really to do any kind of miracle work. It was just focusing on patient outreach and care coordination in regards to preventive screenings like mammograms and colonoscopies. Let's just get patients in and get them healthy.

So we pick certain things. We have priorities. In our electronic medical record, we have a disease management, health management screen that automatically appears when you start, and we have a list. The idea is, if you haven't done it, it's in red, and if you do it, then it goes away and it's clear. A lot of it is just finding out whether the patients have had it done.

She'll come to me and say, "Hey, do you mind if I do outreach to this patient? Can I email the provider directly, so that between the office and Humana we can get a patient in for a service?"

Sometimes they don't want to go to the doctor, even though there's a little problem. But if they're talking to a care coordinator, all of a sudden they'll say, "Hey, you know, something's going on," and they'll mention it. And that way, the care coordinator can translate that back to the physician and say, "Okay, maybe we need to bring that patient in," when they really wouldn't have come in for something.

So having that extra level of care coordinator really, I think, is benefiting the patients. It keeps them out of the ED and the urgent cares, because you're really encouraging them to come into the office.

Since I started here at Family Care, there's been a significant increase in their overall HEDIS star scores, and ending last year they actually reached a four for their overall star score.

I was in this very room having a meeting with Dr. Brodey, and we were viewing data, and you could see the improvement that was happening over time. He looked over at me and said, "You know what? We should really enjoy this partnership." And I think that was one of my highlights in my six years working for Humana.

Insurance companies, for once, are willing to actually pay for what doctors have complained about for many years: they don't have enough support staff, enough time to do all this stuff. And if you can get your organization to do it, I think it can be very beneficial for patients. It keeps people out of the hospital. It keeps people going to their appointments.

And I think it's very helpful when we get our report card from the insurance company. We'd all like to be five-star institutions, and it's very hard to get that. It takes a lot of work.

It's a lot of collaboration, a lot of effort between the providers' offices and myself, and really Humana as a whole, to make sure that we're able to take all the hard work we're doing and have it benefit the providers. Because they're really the ones that are doing all the hard work. We're just giving them the tools to be successful.