Rahul Rajkumar, M.D., J.D., gained experience in value-based care as former deputy director of the CMS Center for Medicare & Medicaid Innovation, chief medical officer of CareFirst Blue Cross BlueShield and Blue Cross NC, and chief operating officer of Optum Care Solutions. He recently spoke with Healthcare Innovation about how that experience shaped the company he has founded, Accompany Health, which partners with health plans serving dual-eligible and complex Medicare Advantage populations.

In a new white paper, Accompany Health describes how it surpasses industry averages by engaging 55 percent of attributed patients and sustaining those relationships year over year. The company adds that its care management program for high-cost populations consistently reduces medical spend by 36 percent and inpatient admissions by 49 percent.

Healthcare Innovation: You had considerable experiences at Optum Care Solutions, CareFirst and developing value-based care models at CMMI. How did that lead you to the idea for forming this company?  

Rajkumar: Let me take a step back. I'm a physician by training. I'm the son of two primary care doctors, and early in my life, I thought I was going to be an HIV doctor. That was my original path in medicine. I've been on this 15-year detour, you could say, which is a focus on value-based care and healthcare finance. The place where I have spent my career is the link between how we pay for healthcare and how we deliver care. How do we use the financing levers of healthcare to make healthcare better, to make it more affordable, to improve its quality? I cut my teeth at CMS, tried to replicate that in the commercial world, and then about four and a half years ago I decided that I wanted to take everything I've learned and apply it in the service of a population that really needs exceptional care in the home. That’s what led me to found Accompany Health.

HCI: Let's talk about the population you're serving —  dual eligibles and complex Medicare Advantage populations. What have been some of the challenges to overcome in serving that population well with a focus on total cost of care?

Rajkumar: I would say the main problem that we're trying to solve for this population is that they receive inadequate care at inadequate intensity — so a lack of access. And it's simultaneously paired with costs that are higher than they need to be and quality that is lower than it needs to be. Accompany Health provides intensive primary, behavioral and social care in an integrated model delivered to patients in their homes for Medicare, Medicaid duals, and highly complex populations. We hold ourselves to the standard of clinical excellence, and we want to treat patients as if they were members of our own family. We are providing care that we would happily provide to our own mothers, fathers, grandparents.

HCI: Have there been changes in payment models that match what you're trying to do, or that allow for what you're trying to do that weren't available a couple of years ago?

Rajkumar: I think you have to go back further than a couple of years ago. But the magic of this is risk. We are a risk-taking provider. We take full risk for outcomes and for the cost of care of the populations that we serve. And the magic of this is that by keeping people out of the hospital, out of the emergency room unnecessarily, we harvest those savings and we use it to power the model. And it's the intensive care that we provide that allows us to do that.

HCI: Do you mostly partner with Medicare Advantage plans?


Rajkumar: We partner with innovative, forward-thinking Medicare Advantage and D-SNP [Dual Eligible Special Needs] plans, a sub-variant of Medicare Advantage. The reason we have chosen to focus on that space is because it’s where you have the most flexibility to serve the population in the way that it needs to be served, and you can make the overall math work.

HCI: Are there challenges to overcome around getting access to the right kind of data about the patients from different types of providers that they're seeing? Is there fragmentation — for instance, if they have behavioral health issues and several chronic conditions?

Rajkumar: I would say one of the important foundational layers of the model that we provide is technology and assembling the right sources of data. We use an AI-enabled model to unify a complex, fragmented landscape. We synthesize medical data, which is really clinical EMR data, claims-based data, social data, demographic data, to form a unified and coherent picture of the patient that we're serving. This profile will be continuously refreshed as we get to know the patient.

We’re trying to turn our providers into superheroes before they knock on the door, so the chart is preassembled. They know what the gaps are. They know what the next best actions are, and this shows up in our results. We took our population in Detroit and Denver from 1.8 stars in the CMS composite stars measure set to 4.5 stars. Of all of the things I've done in healthcare, this is the one I'm the most proud of. We have achieved an 18 percent reduction in the medical loss ratio for the population that we serve. Medical spend is down 36 percent. This is driven by very high rates of engagement. We hold ourselves to a high definition of engagement, and that engagement rate is 55% of de novo engagement. And then, of people we have engaged, when we look at them from one year to the next, say from 2024 to 2025, 99% of them are continuously engaged with us.

HCI: I could imagine other people in this field saying, "Well, I'd love to engage with people more, but it doesn't cost out. That high-touch approach costs more, so we can't do it.” How do you manage it? 

Rajkumar: It's a combination of two things. We are able to assemble and synthesize data to form a persona of the people that we are reaching out to. This is smart outreach, where we are able to tailor the scripting and speak to the needs of that individual human being. Some of this, though, is pure elbow grease, boots on the ground. We are in communities, on the streets, in Dollar Stores, churches, community centers. We do visits on the street. We spend an enormous amount of energy and mind share on this. 

HCI: Is telehealth part of the equation, too?

Rajkumar: We always start in the home. We think it is important to build trust to start in the home. Over time, we do some care virtually as is clinically appropriate, but we see people in the home as often as they need to be seen. We try to serve people in the most efficient way possible, in the way that is clinically appropriate.

HCI: Have there been any challenges in care coordination? For instance, if you have behavioral health specialists or psychiatrists — first, finding the people to do that work — and then coordinating their care with primary care?

Rajkumar: About half of our patients don't have a primary care provider, and we play that role. For the other half of our patients, we build a bridge to the primary care provider. What is unique about our model is that we do that in person. We send a health advocate or a community health worker with the patient to the primary care office. It is almost as if they are a member of the patient's family, and this is quite different than sending a letter to the primary care provider or calling the office.

HCI: We’ve written about community health workers in other settings, but do you see this health advocate role as slightly different or you've tailored it a certain way?

Rajkumar: This is our version of the community health worker role. This idea of drawing people from the community who are motivated and can help improve the health of their communities exists in many organizations in many countries. Our version of the role is tailored to our model and the unique needs of the populations that we serve. We call it a health advocate.

HCI: You mentioned working in Detroit and Denver. What makes particular D-SNP or MA organizations attractive partners for you?

Rajkumar: We work with multiple payers in all of our geographies, and we go to new markets where we find an innovative payer that is long-term- oriented and partnership-oriented. We’re also looking for unmet need, where there's a population where we can make a difference.

HCI: Do those tend to be large payers or small community plans, or a mix?

Rajkumar: It's a mix. It could be either. We operate in dense urban areas, but also serve less dense areas. We're statewide in Massachusetts, for example, including Western Massachusetts.

HCI: What's your next step for scaling this up?

Rajkumar: We are growing rapidly. Our goal is to grow in a disciplined way, where we can do the greatest good for the greatest number of patients, so we we will go where there is need, where we find great payer partners. We're currently in three states: Michigan, Colorado, and Massachusetts. We will serve about 50,000 patients by the end of this month, and our goal is to bring this model to many more states in the future, but to do it in a structured and disciplined way.

HCI: Does the market for this vary by state? Do state regulations or regional insurance markets influence whether you'll find the partners that make sense for you?

Rajkumar: A little bit. I think that there are probably opportunities in almost every state. Because we serve Medicare/Medicaid duals, there are unique elements of state policy that could make certain states different, but I think our model is adaptable to to different circumstances in different states.

HCI: Is there any kind of regulatory uncertainty at the federal level? Or things you'd like to see happen that would bolster the work you do?

Rajkumar: There's always regulatory uncertainty in healthcare, as you know, David. As a former CMS official, I understand that the goals of the federal government are to get the most value for every taxpayer dollar —  value being the best care and highest quality at the lowest cost. Our model is aligned with that. There's a wonderful team at CMS now that's very aware of this. We are the little guys. We are not large health plans. We negotiate with large health plans in the service of our patients, and I think we hope for federal policies that lift up and recognize the work that we do on behalf of CMS beneficiaries.

HCI: Within the ACO REACH model, there was a high-needs ACO segment, and now that's moving over to LEAD. Would your company fit that definition, or are you seeing a different population than those ACOs?

Rajkumar: I think there's quite a bit of overlap there. We're currently not in the CMS ACO models, but we are definitely taking a look at them.

HCI: We’ve spoken about the impact of your enhanced focus on engagement and retention. Is there anything else that you want to stress about your model?

Rajkumar: We want plans to bring us their hardest problems, and we want to knock the cover off the ball for them. We want to be judged on our numbers and our results, and that's what we're proud of.