Provider Insider

Leadership Message

Winter 2022 | Issue No. 16

Colleagues, 

Let me begin our final newsletter of the year by saying thank you.  

It has been another busy year. You and your teams have been working nonstop trying to regain a sense of normalcy while still addressing the aftereffects of the COVID-19 pandemicproviding catch-up care for all the preventative screenings that lapsed; caring for patients whose chronic conditions were not addressed in the previous year; and managing new and acute health issues. It has kept our schedules and in-baskets overflowing.  

Your hard work is appreciated, and it does make a difference, as shown by what we accomplished this year.

2022 Accomplishments 

  • 18,079 completed mammograms, saving an estimated 125 patients from dying of breast cancer.1 
  • 6,834 completed colonoscopies, saving an estimated 164 patients from dying of colorectal cancer.2 
  • 36,290 diabetic patient visits, ensuring regular A1c testing, completed eye exams, renal disease screenings and medication adherence. 
  • 3,425 patients outreached by C3 care managers following an ED visit, and 1,500 patients outreached following hospitalization, making sure patients had what they needed at home to prevent readmission. 
  • 28,827 or 91.3% of medication adherence gaps closed, preventing potential clinical deterioration. 
  • 3 new value-based contracts negotiated, bringing the total number of value-based contracts we hold with payers to 10 for the coming year.   
  • More than $13 million in value-based payments made to C3 practices. 

With so much success behind us, what lies ahead in 2023? 

COVID-19 has inspired change and exposed fault lines in health care. It is increasingly evident that a fee-for-service system is not leading to the outcomes to which we aspire. Costs continue to increase; equity has not been achieved; and quality, as compared to other developed nations, does not measure up. Corporate giants like Amazon, Walmart and CVS are making massive investments in health care. New technologies are multiplying, and patients are asking for different types of carevirtual care, care at home and remote monitoring. The pace of change is dizzying. 

An Accountable Care Organization doesn’t protect you from the turbulence ahead, but it does offer a roadmap through it. As active members in C3, we are all agreeing to work together to ensure that patients get the “right care at the right time.” We are agreeing to think differently about patient care, and to transform our practices to support a new model that is proactive, not reactive, in nature. 

C3 now holds value-based contracts with all major insurance plans, and we are about to join the Medicare Shared Savings Program. That means for many of our network practices, a majority of their patients will be attributed to a value-based program in 2023. These contracts provide the opportunity to maximize the reimbursement and revenue for practices for the care given, and provides better care management for patients. But to win, we must adapt to the new environment. We must keep a laser-like focus on quality. We need to build and lead strong care teams. We must reduce the costs of care. We must make social determinants and behavioral health a larger part of the health care conversation. And we must empower and activate our patients to engage with us in staying healthy.

Our Commitment to You 

C3 continues to expand the teams who work in the background to support you, and we are always looking for ways to fill the “in-between spaces:”  

  • Data analysts focus on working with clinical and claims data so we can see the real “care gaps” and not the “data gaps.”  
  • Population health specialists outreach your patients, encouraging them to see their PCP and schedule preventative screenings.  
  • Care management nurses follow up with patients leaving the hospital to ensure they stay on the road to recovery.  
  • Coders audit charts and look for educational opportunities to help us improve on the nuances of effective documentation.   
  • Pharmacists work with your patients to help them understand their medicines better.

In closing, I am incredibly grateful to be a part of this network. You all are working so hard to give your patients the highest-quality, most equitable care for the lowest cost. And our central operations team is working just as hard to support you. Together, we will change health care. 

Thank you all again, and warmest wishes for a joyful holiday season. 

Amy Scanlan, MD 

  1. Biennial screening women ages 50-74 yields NNS of 144. https://www.researchgate.net/publication/221854638_Mammography_Screening_A_New_Estimate_of_Number_Needed_to_Screen_to_Prevent_One_Breast_Cancer_Death/citation/download
  2. 24 deaths prevented per 1,000 people screened every 10 years. Am Fam Physician. 2018;97(10):658-665