Addressing the challenges of caring for dual-eligible Medicare/Medicaid beneficiaries

Americans who qualify for both Medicare and Medicaid benefits, rely almost entirely on government healthcare programs. They are characterized by low incomes and suffering disproportionately from multiple chronic conditions, cognitive impairments, low literacy and housing isolation.1 As a result, dual-eligible Medicare/Medicaid beneficiaries costs the US healthcare system more than $306 billion annually. Between 2006 and 2015, the total number of dual-eligible beneficiaries increased by 35 percent, from 8.5 million to 11.4 million.2 CMS reports that at least 60 percent of this population is diagnosed with three or more chronic conditions and requires relatively complex care.3

Health Systems must transform traditional care delivery methods and employ new tools to successfully care for this population. Caring for this co-morbid patient population presents numerous challenges. Innovative health systems have employed numerous strategies to control costs while maintaining high quality care, including the implementation of population health management tools, new payment models, care management initiatives, and the introduction of telehealth resources.

ConcertoHealth, a globally capitated medical group managing 22,000 dual-eligible patients, has developed innovative strategies to support the unique clinical needs of this population. Its care model addresses critical patient vulnerabilities by expanding access to personalized and high-touch primary care, enacting chronic condition management, and coordinating transitions between care settings. Central to its approach is a dedicated to deploying comprehensive clinical resources that extend the reach of primary care providers.

“Committed to providing comprehensive care to the communities we serve, by surrounding providers and their patients with the individualized support they need to improve health outcomes.”


Patient 3D

The ConcertoHealth proprietary population health platform delivers a single source of longitudinal patient data, population insights, and performance at the point of care.
• Point-of-care decision support and performance management
• Population health and predictive analytics, medical economics
• Customized and data-driven clinical program development
• Medical economics and network performance management analytics

The Challenge
ConcertoHealth faced challenges in providing its patients with appropriate access to timely and effective specialist consultations. Ensuring this access is essential to preventing unnecessary hospital admissions, reducing emergency department (ED) admissions, reducing anxiety for patients and caregivers, and mitigating the burden and strain for primary care physicians (PCPs).

Access issues for elderly and vulnerable dual-eligible patients, such as specialists not accepting insurance plans, exacerbate existing logistical challenges. As a result, these patients experience long wait times for appointments and deteriorating health while awaiting necessary specialist
consultation and treatment. Timely intervention is important to avoid costly ED admissions, especially for the 65% of the ConcertoHealth dual-eligible patient cohort diagnosed with behavioral health conditions. This complex-needs population also exhibits low healthcare literacy and follow-through, further jeopardizing the outcomes from referral-based specialty care.

ConcertoHealth Patient Population Breakdown:
• 38% cardiovascular disease
• 32% congestive heart failure
• 29% diabetes
• 52% with 3 or more co-morbidities

This high level of co-morbidity limits the ability of primary care providers to manage these complex patients without specialist support. Yet the need for specialist care is growing at a time when the nation is confronting a specialist shortage, which The Association of American Medical Colleges predicts to reach between 28,000 and 64,000 by 2025.4 Ultimately, the factors limiting specialty care access were having a negative effect on patient outcomes. ConcertoHealth assessed improvement opportunities and determined the most viable solution would be to empower PCPs to expand their scope of care by creating access to specialist insights without the need to transition care or for patients to travel.

Ultimately, the factors limiting specialty care access were having a negative effect on patient outcomes. ConcertoHealth assessed improvement opportunities and determined the most viable solution would be to empower PCPs to expand their scope of care by creating access to specialist insights without the need to transition care or for patients to travel.

Broken Process
Before AristaMD eConsults, ConcertoHealth used a manual process to identify specialists in-network for referring in-person visits. Primary care providers (PCPs) aimed to conduct appointments as follow-up to such specialist visits. Objectives were to review specialist visit results and reinforce compliance with the treatment plan. This process was imperfect for
several reasons:
• Patients would forget to go to their specialist consult;
• The consult would be scheduled too far into the future;
• The follow-up appointment with the PCP would take place before the consult with the specialist; or
• After specialist visit completion, patients would forget paperwork or have difficulty recalling or understanding the recommendations they received.

“Even when the ConcertoHealth team approached the specialist office directly, typically the patient would have missed the consult with the specialist, or the specialist office was not reliable in closing the information loop by forgetting to fax patient records, for example,” said Dr. Christopher Dodd, Chief Care Transformation Officer of ConcertoHealth.


The Solution
After a thorough evaluation process of available technologies, ConcertoHealth partnered with AristaMD, whose Smart Care Platform facilitates communication between PCPs and specialists by leveraging eConsults.

An eConsult is an asynchronous, digital consultation between the PCP and the specialist that provides timely access to high-quality clinical guidance through a seamless, secure online communications and information exchange. The HIPAA-compliant Smart Care Platform connects PCPs to a national, board-certified panel of specialists, who represent more than 70 specialty and subspecialty areas and return eConsults, often delivered within a few hours.

Additionally, AristaMD’s Smart Care Platform offers ~400 clinical work-up checklists originally created by clinicians at the University of California at San Francisco (UCSF). These condition-specific guidelines include recommendations for clinical assessments, labs, and diagnostics, ensuring the appropriate workup is completed every time.

ConcertoHealth initially launched a pilot of the Smart Care Platform at three Puget Sound Care Centers with six PCPs. The pilot’s goal was to provide answers to two questions:
1. “Is the AristaMD Smart Care Platform capable of equipping a PCP to deliver more comprehensive care?”
2. “Is turnaround time and clinical workflow sufficient for PCPs to incorporate specialist guidance into treatment plans?”



ConcertoHealth leadership was thoroughly satisfied with how the pilot met its program goals; and decided to expand implementation of the platform into the entire Detroit-metro market for further evaluation and testing. Following more positive results, ConcertoHealth now makes the AristaMD Smart Care platform accessible to PCPs in all its locations throughout Michigan and Washington.

AristaMD eConsults provided timely and actionable feedback for ConcertoHealth providers. It is extremely difficult to get patients with behavioral health diagnoses to attend specialist consults in Washington. Instead of waiting for a specialist to become available, ConcertoHealth PCPs are now empowered to engage a specialist through eConsults within hours in order to receive the information and take appropriate treatment action.

The immediate and tangible impact of eConsults for ConcertoHealth is the ability to avoid unnecessary referrals, while the long-term benefits include avoiding unnecessary admissions and readmissions. In these ways, AristaMD’s platform was able to support the ConcertoHealth PCPs’ ability to maintain the health of their patients with an increase in quality of care–at a lower cost.

“The immediate and tangible impact of eConsults for ConcertoHealth is the ability
to avoid unnecessary referrals, while the long-term benefits include avoiding unnecessary admissions and readmissions.”

In addition, eConsults were shown to deliver value across a broad spectrum of conditions. For example:
• Endocrine specialists consulting on insulin-dosing regimens as part of diabetic medical management as well as pain management.
• Orthopedic specialists consulting on patients’ report of pain. Instead of going to the ED for imaging, patients visit ConcertoHealth PCPs first, who are then equipped to address these situations by using eConsults and often avoid unnecessary imaging.

Overall ConcertoHealth has seen a 17.1% drop in readmissions year-over-year* thanks to the AristaMD platform, along with other implemented resources. Further, the AristaMD Smart Care eConsults platform and clinical workup checklists resulted in:

  • 73% replaced need for in-person specialist visit
  • Increased patient satisfaction, as patients gain greater access to specialty care without having to leave the comfort and familiarity of their own PCP’s office, further sparing them the time and expense of transportation to a specialist’s office
  • Increased PCP satisfaction, with providers able to evolve relationships with specialists, and work in a “virtual multispecialty group practice,” which improves practice scope, enhances real-time learning and enriches the professional experience
  • Downward trend of inpatient medical cost from pre-pilot to current state, while professional cost has remained stable

“Today, ConcertoHealth providers actively notify the patient when they use eConsults. This is a selling point for care providers. PCPs are not afraid to indicate when they don’t have an immediate answer; but are confident in declaring that they have a specialist on-hand through eConsults and are equipped to provide an answer in a timely fashion.”

Learn more about the value AristaMD can provide your health system to achieve quadruple goals. Contact us at


1. Prindiville K and Burke G. MEDICARE AND MEDICAID ALIGNMENT Challenges and Opportunities for Serving Dual Eligibles. Aug 2011.

2. CMS Medicare-Medicaid Coordination Office. Data Analysis Brief: Medicare-Medicaid Dual Enrollment from 2006 through 2015. Dec 2016.

3. Centers for Medicare & Medicaid Services. Physical and Mental Health Condition Prevalence and Comorbidity among Fee-for-Service Medicare-Medicaid Enrollees. Sept 2016.

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