An Innovative Approach to Engaging Patients and Primary Care Physicians Enhances Performance of an Accountable Care Organization

From the 2019 HVPAA National Conference

Dr. Michael Kiritsy (LifeBridge Health), Ms. Tiffany Wandy (LifeBridge Health), Dr. Jonathan Ringo (LifeBridge Health), Mr. Jonathan Moles (LifeBridge Health), Dr. Daniel Durand (LifeBridge Health)


Patient engagement is critical to high quality care. For that reason, health systems across the nation are continually trying to improve with regard to “activating” their patients. Since primary care providers (PCPs) are often the “quarterbacks” in managing the care for patients, LifeBridge Health (LBH) attempted to devise a way to more directly connect patients with these providers. Moreover, effective primary care helps keeps patients healthy and prevents costly hospital and emergency department visits.

LifeLink is an innovative approach that aligns value-based care with fee-for-service payment models. LifeLink is the LBH contact center that is based in Manila, Philippines, and is staffed 24/7 by nurses with excellent English-speaking skills.

Beginning in 2016, LBH, in collaboration with the LifeLink, has conducted yearly Medicare patient outreach campaigns. These campaigns were based on patients of Medicare age identified through our hospital EMR data. Any patient of Medicare age was targeted for outreach. The primary goals were to increase visits to LBH PCPs, “activate” patients to engage in their healthcare, conduct telephonic fall-risk screenings, outreach to diabetic patients with a high HbA1c, and other activities


LBH sought to assess the value of our outreach campaign and its impact on ACO success.


We assessed the number of lives contacted and the proportion that were attributed to the ACO (based on Q4 reports). We also determined how many new patients we brought into the ACO who were not attributed in 2017, and what was their effect on our overall performance. CMS claims data, through February 2019, were used to calculate total costs. To assess the impact on ACO performance, we performed a counter-factual analysis based on the fourth quarter performance data provided by CMS, and recalculated our per-member per-year (PMPY) expenditures without the new patients and their associated expenditures. We also compared the total costs of all patients we contacted to our CMS reported average, on a risk-adjusted basis. We calculated an ROI on these campaigns based on the difference between the newly attributed population’s PMPY compared to the PMPY of our population, multiplied by 50%, the amount kept by our ACO in the event of achieving shared savings.


In 2018, the outreach program aided LifeBridge to contact 3,809 Medicare beneficiaries. 2,634 of these patients were ACO patients, which accounted for 13.5% of our population. 283 were new patients for whom claims were available. These patients were not attributed to our ACO in 2017, but had previously been seen at a LifeBridge facility. These patients had an average cost of $10,102.36 PMPY. On a risk-adjusted basis by Medicare enrollment type, which are ESRD patients, patients eligible based on age (Aged Non-Dual), patients eligible for Medicare and Medicaid (Aged Dual), and patients eligible for Medicare based on disability (Disabled), all beneficiaries’ expenditures were lower compared to our ACO average as shown in Table 1. Our overall PMPY would have been $36.56 higher without these patients attributed to us. The ROI for the campaign in 2018 was 217%, assuming we would have achieved savings without these patients.

Clinical Implications

Patient engagement is paramount to an ACO’s ability to achieve their intended goal. Primary care physicians are a key component to this. By engaging patients through a call center, we are able to keep patient’s healthier, reduce overall healthcare costs, and improve our ACO performance.


What are academic medical centers across the country doing to improve healthcare value?

Value improvement guides: Published reviews in JAMA Internal Medicine coauthored by experienced faculty from multiple leading medical centers, with safety outcomes data and an implementation blue print.

Review article detailing 25 labs to refine for high value quality improvement | July 2020

MAVEN campaign: Free 4 year high value care curriculum online.

Join the Alliance! Membership is free with institutional approval and commitment to improving value in your medical center.

Learn more about HVPA on Health Affairs Blog