ACO Niche
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ACO Niche | Primary Partners, Dr. Cara Jakob, Dr. Memory Crowley, Sheila Fusè, ACO

Dr. Memory Crowley
Trio of females – CEO, two MDs – collaborate to grow grass roots ACO to sustainable model of restored “old-fashioned” patient care 


CLERMONT, FLA.— Lake County physicians Cara Jakob, MD, and Memory Crowley, DO, are making “old-fashioned” patient care hip again – improving quality and aiming to be profitable.

Primary Partners was on the short list of 27 inaugural Accountable Care Organizations (ACOs) nationwide – only three physician-led in Florida – selected by the Centers for Medicare & Medicaid Services (CMS) on April 1 for Medicare Shared Savings Program participation. 

Since the ACO was approved, Primary Partners has doubled from 22 to 44 independent physician practices that are now clinically integrating. The new model of care under the ACO framework is bringing all healthcare elements under one roof to create new efficiencies, resulting in better healthcare management and outcomes.

“Physicians have really liked the model we’re building for the ACO – an overall coordinated system of care that puts the patient first – and we’ve grown quickly,” said Crowley. “Patients have also liked the streamlined changes. We considered the opt-out response of 1.7 percent of the patients as very positive.”

Among the physician-led ACO benefits: patients receive better access to staff, expertise and technology; communication improves between healthcare systems and healthcare providers; physicians share best practices; and all members of the healthcare provider team are accountable.

CMS deputy administrator Jonathan Blum said the reasoning for branching into physician-led ACOs rather than all hospital or healthcare system ACOs was the expectation of strong post-acute care systems.

“We know that one of the best ways to improve quality of care is to better manage patients once they leave the hospital and go into post-acute system,” he said. “To me, any ACO that’s going to be successful has to be proactive in providing care for those patients in a post-acute setting to avoid rehospitalizations.”

Even though it was part of the Patient Protection and Affordable Care Act, and even if the law was to be struck down, industry leaders widely believe the ACO and bundled payment model signal the future of federal reimbursement.

“The celebration of being selected as an ACO came when we realized that we had the advanced funding because primary care providers, without having a hospital or insurance company affiliation and the deep pockets that go with it, couldn’t necessarily afford to build an ACO,” said Jakob. “We give CMS a lot of credit for having the advanced payment model (APM) that wouldn’t be approved if (the physician-led ACO applicant) had one of those affiliations or a large outpatient clinic. It was designed for rural areas, independent practices, or high Medicaid populations.”


Getting There

Jakob and Crowley had separate practices in Clermont when they began collaborating last August on building a physician-led ACO.

“When the regulations kept changing, we realized there was an opportunity for advanced payment with an April start date, which bumped up our timeline dramatically,” said Crowley. “So in September, we decided to try for the April start date. However, we knew that we may be great physicians with great concepts, but we needed a leader and that’s where Sheila came onboard as an advisor.”

At the time, Sheila Fusè, now CEO of Primary Partners, was working for a 150,000-person global bank.

“I couldn’t have come from a different background or size organization,” said Fusè, who had focused on risk management and new initiatives in the financial services industry. “But I was so motivated and moved by the questions they were asking. They whole-heartedly understood the commitment and the vision, and spent almost every waking moment between patients and at home, weekdays and weekends, to get the application completed in time.”

From the start of the process, Crowley and Jakob discussed how being a physician-led model that includes four counties – Lake, Orange, Osceola and Polk – and works with assorted hospitals and assisted living facilities, would allow them to follow patients through adult life transitions.

“We’re on the front line,” said Jakob, “and we saw an opportunity to build a much less fragmented front line for improved patient care.”

Jakob knew they were moving in the right direction after a patient with a debilitating muscle disease asked her: “What will happen to me when I’m unable to come to your office?”

“With our healthcare system so fragmented, I wasn’t going to be able to provide care for her in an effective manner and she was worsening,” recalled Jakob. “It’s not just providing care where patients are located, but also eliminating the duplication of services, improving the coordination, and improving communication. That’s part of what we’re able to do now as an ACO.”

Fusè said she’s convinced the Primary Partners ACO application stood out to CMS “because it was the voice of the physicians and their real aspirations for what they wanted to do.”

“As the application was being written, they were talking to their patients, asking their opinion about the healthcare process,” she said.  


Reverse Engineering

While most PCPs are focusing energies on getting Patient Centered Medical Home (PCMH) certified and then mulling ACO options, Primary Partners took the opposite approach.

“We’re now clinically integrating, which is challenging in itself with so many different practices using various processes including for medical records, and moving toward PCMH certification,” said Fusè. “I consider what they’re doing is reverse-engineering the system and really focusing on the patient-centered approach, which is what the (PC) medical home model wants to achieve. It was a natural fit.”

Jakob and Crowley continue to host routine committee meetings that include representation from every facet of healthcare, including Medicare beneficiaries.

“We want to lower readmissions,” said Jakob. “Patients don’t want to be in the hospital and we want to improve patient care. We’ve looked at all the different ways the system can break down. It’s amazing how many elements have to be correctly in place to get a patient in the hospital, for us to be notified, to get the patient on the correct medication, and back into our office. For example, we were wondering why some patients were reluctant to take medication recommended by hospital staff, and our volunteer Medicare beneficiary committee member told us why. She said it’s because she has trust in her primary care provider, and if the primary care provider isn’t advising her to take a particular medication, she’s not sure if she should. Hearing the influence of the patient makes such a difference. That’s invaluable.”

Also, when PCPs from independent practices in the Primary Partners ACO gather around the table, magic happens, said Crowley.

“It’s been very exciting to see them brainstorming, going over ideas, and implementing better processes,” she said. “Now we’re hearing from consultants and specialists, asking us how to make improvements. It’s rewarding to see physicians wanting to improve patient care instead of complaining about the current system. That’s been an enjoyable part of the process.”

Also beneficial: Practice leaders now have access to a bird’s eye view of population health.

“This is an important point that most folks don’t realize,” said Fusè. “Physicians love clinical data, but never get to view population health on an aggregate basis. It’s exciting to have data to support decisions to make better clinical decisions. I’ve done operational bank mergers and this is the same thing – protecting and identifying the patient population and enriching the patient experience while eliminating redundancies.”



ACO, Dr. Cara Jakob, Dr. Memory Crowley, Primary Partners, Sheila Fusè

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