PHILADELPHIA -- Don't give up on the sickest patients -- your organization can make a difference, Alan Cohn, MD, said here at Thomas Jefferson University's annual Population Health Colloquium.
"Don't give up. You can have an impact. But it takes creating real trust," Cohn, president and CEO of AbsoluteCARE of Singer Island, Florida, a healthcare company focused on medically complex patients, said Tuesday.
Cohn's firm was one of several presenters at a session on companies that are disrupting the way patients are provided with primary care. Much of the discussion centered on the importance of providing ancillary services, such as transportation, food, and temporary housing, to help patients get their life -- and their health -- back on track.
A Different Payment Model
"If you want to make the biggest difference, the first thing you'd do to lower hospitalizations and deliver care is give access to primary care," said Griffin Myers, MD, co-founder and chief medical officer of Oak Street Health in Chicago. Oak Street currently runs 25 primary care centers in six markets nationwide, serving 42,000 patients, of which half are "dual eligibles" on both Medicare and Medicaid and 25% are in Medicare Advantage. The company's model is to go into communities where there is little primary care access, build a brick-and-mortar health clinic, and ensure that the clinic meets strict quality-of-care criteria.
Unlike many other primary care offices, however, "we don't do fee-for-service medicine," said Myers, noting that the company is instead fully capitated for Medicare parts A and B across the 11 health plans it works with. "The way we cover the costs of all the ancillary services [we provide] is through taking full risk, investing up front, and keeping people happy, healthy, and out of the hospital."
"We take care of a really sick population ... The big opportunity is addressing health disparities and social determinants of health," he added. "One man's health disparity is another's opportunity."
So far, that model seems to be working: while the hospital admission rate for male dual eligible beneficiaries in the Chicago area is 770 per 1,000 patients per year; Oak Street's is 200, Myers said. And when Oak Street patients are admitted, the team at the health center meets every morning "to look at who the inpatients are, where they are, and what's their length of stay," he said. The team is alerted via a computer program to which of those patients meet criteria for having a high risk for readmission, and is guided by the program to decide which evidence-based measures would reduce the chances for readmission.
The result: a 15% year-over-year reduction in 30-day readmissions, a number that Myers said he expects will get better because Oak Street has since added more in-home visits as well as an onsite pharmacy that does medication reconciliation lists.
One large expense for Oak Street is its fleet of 85 vans that bring patients who qualify to and from clinic appointments at no cost, said Myers. The company also has a 24/7 nurse line for patients; "the best thing was ... nurse access overnight, and evening and weekend hours, especially [in cases] where caregivers and family members need to be involved," he said. Other features to help with access include practicing in seven languages and the fact that 83% of the physician staff and 80% of the clinic staff live within 5 miles of the center.
One-Stop Care
AbsoluteCARE's focus is similar but a little different: it's on "the 3-4% of the population responsible for 30-40% of all health spending," Cohn said. "We don't want acute situations; we want members year in and year out who constantly have high-cost care," with the average member generating about $50,000 per year in claims expenses prior to becoming an AbsoluteCARE patient.
These patients "have multiple chronic conditions and major behavioral and social issues," he continued. "We're not open to the public; our model is by referral only. We contract with health plans, insurers, and self-insured employers to help them identify those members where our model would be appropriate for their care ... We see [those members] constantly -- we provide pharmacy, radiology, transportation, all behavioral services, nutrition, and so forth."
The company's setup gives it extra resources to provide services they don't have to bill for, said Cohn. For example, if a patient was vomiting and went to a hospital emergency department for rehydration, they might be billed $800 for the visit, whereas the same service at AbsoluteCARE would cost $10 for the bag of IV fluid, with staffing costs already built in.
The staffing model is very egalitarian; "no one is more important in our model than anyone else," said Gregory Foti, MD, AbsoluteCARE's executive vice president for innovative medical operations. For example, the company's van drivers attend the morning staff meeting, and often provide valuable input.
"Lance, our regular van driver, knows [our patient] Mrs. Smith more than we know her," said Foti. "Mrs. Smith may tell us, 'I haven't smoked crack in a week' and [Lance will say] 'Actually, she told me she did smoke.' Or Lance knows when that she runs out of cell phone minutes she'll be at her sister-in-law's house, and when she's [there], watch out because she is on crack and when she takes crack she has a COPD [chronic obstructive pulmonary disease] exacerbation and she ends up in the hospital for a week. We need to get in front of those stories."
Foti agreed with Myers that "transportation is incredibly important. Members could get from A to B, but they don't, and van drivers will help them out of their house."
The Value of Health Coaches
Health coaches are part of the approach used by Iora Health, a primary care company in Boston with practices nationwide. "These are people from the community; they speak the language of the people they serve," explained Rushika Fernandopulle, MD, MPP, Iora's CEO. "The only thing they need is empathy -- connecting to another human being." As a result, one of Iora's health coaches used to be a food and beverage server; another was previously a yoga teacher.
Iora also works to make patients feel at home, he said. Exam rooms include tables with chairs in addition to the exam table, and patients are invited to sit in whatever chair they prefer. The company puts video screens up on the exam room wall so patients can see their medical record being worked on. Only 60% of care is provided through inpatient visits, with the rest done by email, text message, and video chats.
Iora also uses lots of patient groups -- "no one wants to be in a 'group', so we call them 'clubs'," said Fernandopulle -- to get patients to engage with each other. If patients are having trouble with their diets, staff members will take them grocery shopping to show them what to buy. They also do in-home visits.
He told the story of a patient from California who was widowed and moved to suburban Seattle -- where she didn't have any friends -- to live with her daughter. Her daughter offered to drive her wherever she wanted to go, but she didn't want to be a burden, so she didn't go out very much. The patient became isolated and her health started getting worse.
When the Iora team in Seattle discussed the patient, her physician wondered if she needed more medicines, but her health coach said, "No, she's isolated; we need to get her engaged." So they decided to have her join the practice's 'It's My Story' club -- where patients tell each other their life stories. The health coach went to the patient's house the next day and showed her how to ride the bus to get to the club, which was having a meeting that day.
"She started coming to the group, and more importantly, she started having coffee with the people she met ... and guess what?" said Fernandopulle. "Her health started to get better."
"Why does no one do this?" he asked, referring to teaching the patient to ride the bus. "Because there is no CPT code for 'Teach Patient to Ride the Bus.' Our job is to do what's right for the patient, whatever it takes."