The ACO Show

185. Crossing the Chasm in Value-Based Care with Farzad Mostashari, M.D., and Geoffrey Moore

Aledade CEO, Dr. Farzad Mostashari, and best-selling author Geoffrey Moore explore how the concepts in Moore’s influential book, “Crossing the Chasm” can be applied to accelerate adoption of value-based care. In order to move to mainstream adoption, it’s crucial to focus on the niche market of “pragmatists in pain” who have an urgent need that the current system isn’t solving. Our co-host Sean Cavanaugh, chief policy officer at Aledade, points out that oftentimes in the traditional fee-for-service model, the pragmatists in pain are independent primary care clinicians. Moore and Dr. Mostashari also share insights and recommendations for the new administration from their recent article, including focusing on primary care, defining the competition and paving the way for simplifiers who can help clinicians navigate the complexities of value-based care. Using this framework, the Center for Medicare & Medicaid Services (CMS) could accelerate expansion of value-based care to the majority of the nation’s primary care clinicians as well as their patients.

Connect with us at acoshow@aledade.com or visit the Aledade Newsroom.

184. Bias and Equity with Artificial Intelligence in Health Care

Join us this episode as our guests from Aledade, Dennis Liubyvyi, Director of Artificial Intelligence (AI) Research, and Jette Henderson, Staff AI Researcher, explain the world of AI and machine learning and its potentially transformative impact on health care. Dennis shares how AI models at Aledade are reshaping patient care by analyzing vast amounts of patient data to predict critical health events such as kidney disease progression and congestive heart failure. The goal is to provide more timely, targeted interventions to patients who need them most. Jette also notes the challenges that exist in these predictive models, particularly regarding biases within data sets, which can lead to inaccurate predictions and how Aledade is developing tools to help identify and mitigate these biases.

Connect with us at acoshow@aledade.com or visit the Aledade Newsroom

183. Cardiology and Value-Based Care

Dr. Sameer Sheth, President and Co-Founder of Chamber Cardio, joins Josh and Sean to discuss the opportunities and challenges for specialists, particularly cardiologists, in transitioning to value-based care. Dr. Sheth notes that cardiologists have traditionally been slower to adopt value-based care because of a lack of financial incentives, but an increasing drive to remain independent is pushing more cardiologists towards value-based models. Dr. Sheth shares how he and Chamber Cardio are working to create a network of cardiologists, health plans, and tools to better incentivize their transition to value-based care.

Connect with us at acoshow@aledade.com or visit the Aledade Newsroom

182. Patient and Caregiver Experiences in Value-Based Care

Join Melanie Phelps, Senior Advocacy Advisor for Health System Transformation at the American Heart Association (AHA), to discuss her recent research which explores the impact of ACO-driven value-based care from the patient and caregiver perspectives. Melanie explores the overwhelmingly positive results of the study, which found that patients and their caregivers experienced better care, better support, and better patient outcomes as a result of their clinicians’ participation in an ACO. Dr. Julie Prosseda, Family Medicine Physician in Wilmington, DE and a participant in the AHA study, joins us to explore the reasoning behind these benefits of value-based care for patients, which is largely due to better relationships with their primary care physicians, as well as access to timely support and resources from an expanded care team. This more wholistic, patient-centered value-based care leads to enhanced patient engagement and a more trusting clinician-patient relationship. While it’s clear that patients should be demanding broader access to value-based care, Melanie and Dr. Prosseda also explore the challenges of expansion, including increasing educational opportunities and more alignment among payment models.

Learn more about the American Heart Association’s research: Understanding Patient, Family Caregiver and Health Care Team Member ACO Experiences

Connect with us at acoshow@aledade.com or visit the Aledade Newsroom

181. Nursing in Value-Based Care

Value-based care is a team effort, and nurses play a crucial role in coordinating care to achieve better and more efficient patient outcomes. Jacqueline Nikpour, Assistant Professor at the Emory University School of Nursing, and Kathy Samhammer, LPN at Cedar Ridge Family Medicine, join us to discuss the role of nurses in primary care, and how practices can maximize nurses’ contributions in the shift towards value-based care. Kathy’s role includes managing chronic conditions and preventing hospital readmissions, and she discusses the importance of ongoing, personalized communication with patients, especially after ER visits. This approach has led to better patient engagement and satisfaction, which is crucial for improving health outcomes. As Kathy demonstrates, expanding the role of nurses in value-based care is critical, but Jacqueline also notes the challenges in this expansion, including payment and recognition of nurses’ value. By addressing these challenges and better integrating nurses in patient care teams, we can ensure better care coordination and a more patient-centered health care system.

Read Jacqueline’s article in Health Affairs: To Improve Outcomes Under CMS’ ‘Making Care Primary’, Focus On Registered Nurses

Connect with us at acoshow@aledade.com or visit the Aledade Newsroom

180. Transforming End-of-Life Care with Comprehensive Advance Care Planning (CACP)

Comprehensive Advance Care Planning (CACP) supports individuals in understanding and sharing their values and goals for medical care at the end of life. Kerri Petrin, Vice President and Head of Operations at Aledade Plus, joins us to explore how the CACP program allows patients and their loved ones to have guided, personalized conversations with clinical facilitators and generate legal documents so that patients and their care teams can make health care decisions that align with the patients’ values. We are also joined by Marissa McNichols, who shares insights into her role as a CACP facilitator, especially the importance of having open-ended conversations that include family members, allowing everyone the opportunity to ask questions and make decisions outside of a crisis moment. Tune in to learn more about how CACP is transforming end-of-life care planning, ensuring alignment with patient values and reducing unwanted, unnecessary care.

Connect with us at acoshow@aledade.com or visit the Aledade Newsroom

179. From Residency to Value-Based Care: Lessons from Aledade FIRST

Graduates of the Aledade FIRST Program, Dr. Boone Marois and Dr. Breanna Heard-Pinho, reflect on their experiences in the program and how it helped prepare them to practice value-based medicine. Dr. Heard-Pinho, Family Medicine Physician in Vicksburg, Mississippi, shares how Aledade FIRST taught valuable practice management skills, as well as held in-depth discussions of value-based care not taught in traditional residency programs. While Dr. Marois, Family Medicine Physician in Asheville, North Carolina, reflects on the importance of taking a preventative approach with each patient. Listen as they share unexpected joys and challenges of practicing value-based care in their communities.

Connect with us at acoshow@aledade.com or visit the Aledade Newsroom

178. Challenges and Opportunities in Caring for Dual-Eligible Beneficiaries

In this episode, Sean Cavanaugh and Josh Israel discuss the complexities of caring for patients who are dually eligible for Medicare and Medicaid. They are joined first by Melanie Bella, whose prior roles include former Director of Indiana Medicaid, Director of the CMS Medicare-Medicaid Coordination Office and EVP at Cityblock, and are then joined by Aledade’s Mohamed Arif, and Lahila Pitts. They explore the unique challenges these patients face, including fragmented care and high social needs. They also highlight how value-based care and data-driven solutions are improving outcomes for this underserved group. Tune in for insights into better care coordination for dual-eligible beneficiaries.

177. What’s New for ACOs in 2025?

Casey Korba, Director of Policy at Aledade, walks us through regulations that were announced along with the 2025 CMS Medicare Physician Fee Schedule, including updates to the Medicare Shared Savings Program. Casey and our host Sean Cavanaugh, who is the former Director of the Center for Medicare, explain policy changes that will support value-based care, including changes to payments for some preventive care services and a new health equity benchmarking adjustment. While there is bipartisan support for CMS’s goal of moving towards value-based care, they also explore ongoing challenges like the rebasing process and benchmarking standards.

176. Healthcare During a Devastating Hurricane

In this episode, we sit down with Traci Spence, the Chief Operating Officer of Blue Ridge Community Health Center in Hendersonville, North Carolina. Traci shares her  experience managing a health center during a catastrophic hurricane that left the region without power, water, or infrastructure. Despite these overwhelming challenges, Traci and her team found creative solutions to continue serving their community in the midst of chaos. This conversation highlights themes of improvisation, community, and resilience when the healthcare system is pushed to its limits.