Value-based care support provider UpStream Healthcare raises $140M

Steven Loeb · December 2, 2022 · Short URL:

The company provides services and technology solutions for physicians offering value-based care

While the majority of primary care physicians are, at least in part, moving away from a fee-for-service payment model, and toward value-based care, there are still barriers they face, including not having the resources or technology to fully make that transition.

That's where UpStream Healthcare comes in: the company, which announced$140 million Series B funding on Thursday, provides a suite of services and technology solutions for physicians operating under full-risk, value-based arrangements who are providing care to seniors on Medicare. 

There are three specific problems that physicians operating under value-based arrangements run into when providing care to seniors on Medicare, Dr. Sanjay Doddamani, UpStream's co-founder and CEO, told VatorNews, the first being financial risk.

"Physicians have opted to take lower risk settings such as the Medicare Shared Savings Program, especially earlier tracks, rather than taking steeper, two-sided risk, despite the opportunities for greater access to savings and the ability to fund more services and programs, as well as regulatory flexibilities within full-risk payment models. Physicians have extensive training in the craft of caring – not being bankers or insurance experts," he said.

The second problem is burnout due to the administrative burden being placed on physicians, which includes activities such as gap closures, or completing a series of patient assessments, in order to satisfy a requirement, things that don’t even necessarily require a physician, but can be completed by a member of the care team. By having someone else do these routine activities and perform follow-ups, it can free up the physician to perform more complex tasks.

Finally, there's a lack of technology, which means physicians don't have insights that can help them identify of high-risk patients, or actuarial data to attach costs to specific conditions, procedures, and medications, which Doddamani likened to "performing surgery in the dark."

All of these barriers can ultimately have adverse effects on patients, since they can result in unplanned hospital admissions and emergency room visits, which increases the risk of blood clots and hospital acquired infections. 

"There is a better way – we call it going UpStream, preventing these poor outcomes, by navigating and coordinating better access to care and having access to affordable medications that are optimally dosed," said Doddamani.

UpStream helps physicians overcome these barriers by assuming the financial risk associated with advanced payment models.

"In other words, physician partners see upside opportunity that scales with their quality achievements, known as the GAP-Q (Guaranteed Advanced Payments for Quality) program rather than financial uncertainty and the threat of financial hardship or ruin. To achieve this, UpStream sets aside the necessary capital reserves and enters into durable partnerships with primary care physicians creating a more robust system for value-based payments," Doddamani explained. 

The company also helps by bringing together a clinical support platform that embeds pharmacists, nurses and other care coordination teams, who are then powered by AI-driven insights. For patients with greater social needs, the health concierges help to coordinate care by addressing access, out of pocket costs, scheduling appointments, setting up medical transportation and patient reminders, and any other support as the situation demands.

Finally, UpStream provides each primary care practice with technology that connects to the data platform, so they can do advanced analytics and apply machine learning algorithms to establish a risk stratification of the highest risk patients, provide intel on the likelihood to be hospitalized or identify care gaps and opportunities to improve quality and clinical outcomes.  

All of this ultimately results in better health outcomes for the patient, Doddamani said.

"We embed clinical teams that become part of the practice’s team. A prescribing pharmacist tackles prescription services, while coordination nurses streamline the various facets of care delivery. Off-site teams provide scheduling support," he explained.

"Our multidisciplinary team then consolidates this information to produce a tailored care plan that becomes the road map the primary care physician has outlined for the patient. It really is individualized medicine that improves the patient's health outcomes. Those patients on the platform have a 20% lower cost related to hospitalizations and post-acute spend."

On the physician's side, UpStream frees up the their time, which allows them to expand their panel, remove administrative obstacles, and ensure that their senior patients receive a better whole person care experience.

"In addition to this, our Guaranteed Advanced Payments for Quality (G.A.P.-Q.) is a proven economic and quality focussed solution for physicians. It recognizes the value physicians bring to primary care. By maintaining a higher-than-average quality CMS-Star performance for contracted seniors, physicians can receive a higher premium and overall payment for the care they deliver," Doddamani said.

UpStream current has over 1,000 primary care physicians contracted for 2023 across Virginia, North Carolina, and South Carolina. There are 180,000 Medicare eligible seniors in its risk arrangements and it has a total of over 2,900 overall doctors, meaning specialists and PCPs, in value-based care.

The company's new funding round, which brings its total raised to nearly $185 million, was co-led by technology and global growth investors Coatue and Dragoneer with additional participation from other top healthcare and technology investors, including Avidity Partners, Define Ventures and Mubadala.         

The money will be used, in part, for geographical expansion, launching into new markets in the coming year. In 2022, the company was in four counties in North Carolina; in the coming year, its physician partners will across the whole state. It has also partnered with physician groups in North Carolina, Virginia and South Carolina, including Community Care Physician Network, Tidewater Medical Group, and Medical University of South Carolina Health Alliance, as well as independent physician association Primary Care Associates.

The money will also go toward expanding the team, as well as continuing to invest in its IP so it can further define the patient population, develop a more accurate risk stratification engine, improve efficiencies, and develop more solutions related to optimizing patient’s prescription medications.

"As adoption of value-based care models continues to spread across the healthcare industry, we plan to use the Series B funding to scale our model to physicians nationwide. But ultimately, the total addressable market is over $60 million; even if we get five times bigger, there are still 59 million other senior patients," said Doddamani.

"We want a vibrant primary care driven patient-centered healthcare system. Compared to their specialty peers, PCPs are paid less, have greater practice risk, risk greater burn out and have fewer resources. We aim to change all of that."

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