In this follow-up conversation, Dr. John Pagan welcomes back Dr. James Galasso to dig deeper into the quality and shared savings programs that have defined his approach to independent practice. Drawing on firsthand experience with Pennsylvania's Governor's Chronic Care Initiative and his current role on PACN's ACO Oversight Board, Dr. Galasso offers a practical, ground-level perspective on what it actually looks like to deliver high-quality, data-driven care in a small independent practice — and why it pays off for physicians and patients alike. Haven't heard Part 1? Start there for Dr. Galasso's full story — his path to medicine, his community, and why he chose independent practice over the large health systems that surround him. Key Highlights Roots in the Governor's Chronic Care Initiative Dr. Galasso's experience with value-based care predates PACN. Under Governor Rendell, he was selected to participate in the Governor's Chronic Care Initiative — a statewide pilot program that partnered practices with Blue Cross to identify high-risk patients, particularly those with diabetes, and improve their outcomes through proactive management. Practices were organized by region, competed against each other, and learned from one another's approaches. The results were striking: in his first year, Dr. Galasso received a check from Blue Cross of over $100,000 — from his practice alone — simply by identifying uncontrolled diabetic patients, bringing them in, and hitting established clinical guidelines. Hospitalizations dropped. Costs dropped. The model worked. How PACN Amplifies What Works The Governor's Initiative gave Dr. Galasso a foundation, but PACN gives him scale. Where he once relied on one nurse to manage outreach, he now has an entire team behind the scenes scrubbing charts, generating reports, and flagging patients who have fallen out of care. His EMR system — MedEnt — is integrated with a red diamond alert that populates before each visit, telling him exactly what needs to be addressed before he walks into the room. The work that once required significant manual effort now happens largely in the background, freeing him to focus on patient care. PACN's ACO and the "Big Five" Dr. Galasso serves on PACN's ACO Oversight Board and helped shape the network's focus on five key care touchpoints that drive shared savings under the Medicare ACO program. PACN documented significant savings in its first year of ACO participation in 2022. The five focus areas are: Annual Wellness Visits — A cornerstone of preventive care and chronic condition capture. Dr. Galasso's entire patient panel is tracked for annual wellness visits, with staff trained to identify gaps at check-in and complete screenings — mini mental status exams, depression screenings, diabetic foot exams — as a matter of routine. Patients have come to expect and look forward to these visits. Critically, the annual wellness visit also allows practices to capture and revalidate all active chronic diagnoses, which directly affects risk adjustment and reimbursement. Transitional Care Management — Dr. Galasso identified this as one of the highest-impact opportunities in value-based care. When a patient is discharged from the hospital, he gets them in as quickly as possible — ideally within the week. Post-discharge visits catch medication errors that are surprisingly common when hospitalists reconcile discharge meds against admission lists, identify new diagnoses the patient may not fully understand, and ensure follow-through on referrals, home health, and rehab. This is also where the continuity advantage of independent practice shines: Dr. Galasso already knows the patient, their medications, their support system, and their history in a way no hospitalist can replicate. Chronic Care Management, Advanced Care Planning, and Behavioral Health — Dr. Pagan noted these remaining three elements of the "Big Five" will be explored in a future episode. The Case for Complete and Accurate Coding A recurring theme throughout the conversation was the importance of capturing the full complexity of each patient's health through accurate, specific diagnosis coding. Risk adjustment models used by Medicare and other payers assign higher resource allocations to more complex patients — but only if those conditions are properly coded each year. Conditions identified through specialist notes, ER visits, or hospitalizations that don't make it back into the primary care record represent missed opportunities. PACN's team actively surfaces these gaps, prompting Dr. Galasso's practice to code more completely and ensuring the network's population complexity is accurately recognized. An Open Invitation Dr. Galasso closed with a characteristic generosity: any physician who wants to know how Galasso Family Practice approaches these programs is welcome to reach out. He's not afraid to share what's worked. Key Takeaways Proactive chronic disease management — particularly for diabetic patients — is one of the highest-return activities in value-based care, as Dr. Galasso demonstrated with over $100,000 in shared savings in a single year under the Governor's Chronic Care Initiative.PACN's behind-the-scenes infrastructure multiplies what a small practice can accomplish, replacing manual outreach with systematic, data-driven support.Transitional care management is one of the most impactful and underutilized touchpoints in primary care — catching patients quickly after discharge prevents medication errors, readmissions, and gaps in follow-up.Accurate, complete chronic condition coding is not just a billing issue — it ensures that the true complexity of a practice's patient population is recognized by payers, supporting both fair reimbursement and shared savings.Annual wellness visits are a win on multiple levels: preventive care, chronic condition capture, risk adjustment, and an additional billable service — all in one visit.
