What’s Next at MetaPhy: Scaling Impact and Shaping the Future of Patient Management

In our last blog post, we celebrated a significant milestone: over one million patient encounters delivered through MetaPhy Health’s MyCare Program. Each encounter represents a connection, education, encouragement, and support for a patient managing a chronic condition. 

But one million patient encounters isn’t the finish line for us—it’s just the beginning. The next chapter for MetaPhy Health is about scaling our reach, leveraging advanced technology to support patients, providers, and our internal team, and helping shape the future of patient-centered virtual care nationwide. 

With major industry changes on the horizon, such as the Centers for Medicare and Medicaid Services’ (CMS) proposed Ambulatory Specialty Model (ASM), the expectations for chronic care management are evolving faster than ever. MetaPhy isn’t just keeping up—we’re setting the standard, helping provider teams deliver exceptional care and drive better patient outcomes. 

How the Future of Patient Management is Changing

Healthcare providers today face increasing challenges:

• Workforce shortages are stretching already overburdened teams.

• Chronic conditions like heart disease, diabetes, and obesity continue to rise. 

• Health systems are under pressure to deliver better outcomes, serve more patients, and control costs.

In response, CMS is advocating for earlier intervention, more consistent patient engagement, and the use of technology to streamline communication.

The Ambulatory Specialty Model (ASM)

Recently, CMS proposed the ASM—a mandatory payment model focused on high-cost, high-need conditions, such as heart failure and lower back pain. The payment model aims to move care upstream, where earlier detection, better patient management, and timely interventions can reduce hospitalizations, unnecessary procedures, and overall costs.

If finalized, AMS would reward specialists who:

• Detect early signs of worsening chronic conditions and intervene.

• Enhance patient care and prevent avoidable hospitalizations.

• Use technology to share data and communicate seamlessly with patients and primary care providers.

The AMS is a clear signal that the future of chronic care must be proactive, connected, and technology-supported. It’s also exactly what MetaPhy Health has been building and perfecting for years. 

Why Patient Management Works

The value of proactive patient management is clear. Multiple studies have shown that high-touch chronic care management and remote patient monitoring deliver significant results, including:

• Reduced hospital readmissions: North Carolina’s Transitional Care Program reduced readmissions by 20% in the first year for Medicaid patients with complex chronic conditions, compared to similar patients in usual care.

• Fewer inpatient admissions and ED visits: Some programs saw a 43–56% drop in inpatient admissions and an 11% decline in ED visits within six months of implementing chronic care management.

• High-impact population reach: North Carolina found that aged and disabled Medicaid beneficiaries make up only 25% of enrollees but account for 40% of admissions and 80% of costs. Reaching these patients with better management changes the game.

At MetaPhy Health, our results echo this data. We’ve supported over 90,000 patients through more than one million encounters in our MyCare Program, delivering measurable, positive patient outcomes and ROI for our provider partners.

What’s Next: MetaPhy’s Vision for the Next Million Patient Encounters

As we look to the future of MetaPhy, we’re focused on four key areas: expanding our reach, leveraging cutting-edge technology, driving continuous improvement, and deepening provider collaboration.

Expanding Reach

We’re building new partnerships with practices and health systems across the country, helping providers better manage patients with chronic conditions without increasing their workload. Some of our recent partnerships include Atlantic Medical Group, Louisiana Gastroenterology Associates, San Diego Gastroenterology, St. Thomas Medical Group, and more. 

Today, MetaPhy supports more than 620 providers across the country, helping them support patients with the tools, resources, and personalized care they need to live healthier lives.  

Leveraging Cutting-Edge AI Technology

Meet Cara, Our AI Nurse

At MetaPhy, we believe technology can enable more streamlined and personal care. That’s why we developed Cara, our AI-powered nurse. Cara works alongside our Virtual Care Team to:

• Streamline workflows by routing patient calls and generating detailed clinical notes after virtual encounters.

• Flag urgent patient needs in real time, helping our team resolve issues quickly and keep patients on track.

• Send automated patient reminders for appointments and health check-ins to ensure patients stay aligned with their care plan.

• Scoring patient interactions to measure and improve the virtual care experience we provide. 

Cara reduces the workload on our Virtual Care Team, allowing them to spend less time on routine tasks and more time connecting with patients. For patients, Cara enables a more streamlined, personalized, and responsive care experience.

Advanced Remote Patient Monitoring (RPM)

Our RPM device, branded as the MyCare Device, monitors weight fluctuations in real-time. Our care team can identify subtle changes in weight, activity, or symptoms that may indicate a problem before it becomes a serious issue. Earlier interventions prevent hospitalizations and support the proactive care model the industry is striving for. 

Data-Driven Continuous Improvement

Every patient encounter is an opportunity to learn. We score every patient interaction, track trends, and share actionable insights with our provider teams. This allows us to:

• Refine patient education and engagement strategies.

• Collaborate with providers to address problems before they become serious issues. 

• Identify trends that inform preventative care strategies.

Providers receive clear, timely patient updates, allowing them to see precisely how the MyCare Program is impacting patients and their bottom line. 

Deepening Provider Collaboration

MetaPhy’s partnership goes beyond providing a service. We understand the day-to-day needs of practices and patients, so we act as an extension of the provider’s team, helping them:

• Deliver more value to patients with limited resources and time.

• Reduce administrative burden while improving patient engagement.

• Stay aligned with evolving CMS quality and cost benchmarks.

The Bigger Picture: Shaping the Future of Patient-Centered Virtual Care

The healthcare industry is moving toward value-based, personalized care, where outcomes, quality, and cost-effectiveness are critical. Patient management, when supported by technology and delivered at scale, fits perfectly into this model.

MetaPhy bridges the gap between office visits, ensuring providers meet growing CMS expectations for more high-touch, preventative care, without adding to their workload.  

More importantly, we manage the whole patient, not just their condition. That means:

• Helping patients understand and follow care plans.

• Providing motivation and emotional support.

• Identifying red flags early and supporting timely intervention.

• Supporting lifestyle changes that improve long-term health.

When patients feel heard, supported, and empowered, they’re more engaged in their care plan, and outcomes improve. That’s the future CMS is pushing for, and we’re delivering it now.

Why Partner with MetaPhy Now

Our first million patient encounters demonstrate what’s possible with the combination of a skilled Virtual Care Team, thoughtfully designed technology, and a human-centered approach. We’re proud to help shape the future of patient management and help providers deliver exceptional, personalized virtual care. 

Want to learn how we can support your team, patients, and growth goals? Contact us today.