UpStream Health Prepares for Expansion, ACO Reach

As his company works to help more primary care practices participate in alternative payment models, Sanjay Doddamani, M.D., CEO at UpStream Healthcare, said the company is preparing to participate in the ACO Reach model and expand from North Carolina into Virginia and South Carolina.

UpStream has created a model of integrated team-based care, clinical and retail pharmacy programs, and two-sided risk-bearing capabilities for primary care physicians to be successful in value-based care. It provides physicians with the support and systems they need to provide chronic care management services to their Medicare and Medicare Advantage patients.

“We do three key things,” Doddamani explained in a recent interview with Healthcare Innovation. “One, we embed highly specialized care teams, including pharmacists, into each doctor's office, and we have a set of virtual concierge and other non-licensed folks following through on the work.” The second thing is the business model that pays “GAP-Q” monthly incentives to physicians based on quality during the performance year. “We don't believe in paying doctors one and a half years later,” he said. “In traditional ACOs, they wait for reconciliation. We have eliminated that. We give physicians more certainty, by de-risking not just their downside by putting up the reserves necessary to participate in advance payment models, but we also guarantee their upside in a very unique way, tying doctor payments to quality achievements.”

“Finally, we could not do this without a technology strategic partner. We don't call Innovaccer a vendor; they are our strategic partner in building a layer of technology applications on their already superb platform,” he said. By using the Innovaccer Health Cloud, UpStream can equip care teams with unified patient records that provide a centralized, longitudinal view of the patient.

UpStream has just under 100,000 lives in full-risk contracts and is in relationships in North Carolina with several clinical partners. In November 2021, Cone Health, Triad HealthCare Network and UpStream agreed on a five-year affiliation to work on value-based care. In February 2022, Community Care Physician Network (CCPN), the largest independent primary care physician network in North Carolina, announced it had selected UpStream as a partner for advanced, full-risk Medicare program for network physicians.

“We stratify that population and we find the 30 percent of patients who account for over 65 percent of all healthcare spending, and it's really all hospitalizations,” Doddamani said. “We've worked on some of this with ClosedLoop.ai and Innovaccer. We lead with a highly skilled pharmacist to improve medication adherence. With a pharmacist embedded in the office, nurses in the home, and concierges who are acting either virtually or at the point of care, we're able to drive very significant improvements in clinical outcomes. We are extremely systematic and modular in our approach in terms of consolidating the care plans, having patients complete a pharmacotherapeutic workup, and making sure their medications are appropriate, effective, safe, and accessible.”

“We're not some virtual service,” he said. “We're physically embedded in each of these doctor's offices,” Doddamani said. “We consolidate the specialty care plans. We reach out to the transplant nephrologist or to the neurologist and we work across the specialties and consolidate the care plans.”

A cardiologist by training, Doddamani’s career has prepared him well for his position leading UpStream. Prior to joining UpStream, he was executive vice president, chief physician executive and chief operating officer at Southwestern Health Resources’ accountable care network, where he oversaw the strategy and implementation of operations, quality, clinical programs, and population health. In 2019, he served as a senior physician advisor at the Center for Medicare and Medicaid Innovation working with teams on alternate payment models that test and measure value-based payment innovation. Prior to joining CMMI, he was chief medical officer of Geisinger at Home, a home-based model of care for medically complex patients, and concurrently, he led the Keystone ACO.

Doddamani noted that Upstream works with all kinds of practices regardless of where they are on the spectrum of infrastructure and capabilities. “We have not turned away physician practices, regardless of size,” he said. “It adds more challenge for us when they are very small, but we really want to hold out the promise of encouraging more and more doctors to embrace full financial risk in value-based care models. This should not be an elite preserve. The average U.S. primary care physician should be included in in any such opportunity, and UpStream makes it possible for them to do it. We're not asking them to do more work. We're putting in all the resources, we're putting the infrastructure, we're paying for it, and we're letting all boats rise.”

UpStream is looking forward to working in the ACO Reach program, he added. “We have three ACO Reach entity applications approved. We are very fortunate because only 47 percent of these applications for ACO Reach were approved, and all three of ours were approved. And we feel very fortunate Belinda Rutledge on our team is the co-chair of the National ACO Reach Coalition. We've got the infrastructure and capabilities to drive performance in ACO Reach as well as in Medicare Advantage.”