This is the 12th article in a series on America’s dysfunctional healthcare system.
“It is all about vigilance and caring. We aim to put the caring back into healthcare, and we are serious about that. Our standards are not how many patients you saw today but how much quality you dispensed today,” Dr. Greg Foti told me about the comprehensive care center, AbsoluteCare, where he works in downtown Baltimore, MD.
Individuals with multiple chronic illnesses compounded by socioeconomic issues are perhaps the most difficult to treat, and the annual expenses can be exceptionally high. Success with these patients would be a story worth telling. Here it is.
Individual doctors and doctor groups have embraced the direct primary care approach with either a fee per visit (direct pay) or a fee per month or year (membership, retainer, and concierge). Mostly, they convert an ongoing practice of 2500–3000+ plus patients to a new model that encompasses about 500 patients. Their patient group usually spans a wide range of ages and the spectrum of some with serious chronic illnesses to those who are basically healthy. I wrote earlier in this series about the advantage of an all- gerontology practice that maintains a patient panel per PCP of about 400.
But what about a panel of patients that all have serious illnesses, who are socio-economically disadvantaged and cannot afford to pay a membership? A number of companies are addressing this need with a focus on the medically most needy; here is an example.
An infectious disease practice in Atlanta initially dedicated to HIV patients later expanded to a broad primary care program for those with multiple serious chronic illnesses — just those who are among the 5% of individuals for whom 40% to almost 50% of all medical dollars are expended. The company, AbsoluteCare, opened a second program in Baltimore — a 17,000-square-foot primary care office in a new building to manage the care of “the sickest of the sick,” whose average annual claims approach $40,000 per year.
Their model has one PCP or NP per only 300 patients working with a team of case manager, medical assistant, and nurse. Other on-site professionals include a mental health therapist, psychiatrist, and social interventions. They also deploy a community-based team that cares for patients in their neighborhoods and homes. In addition to medical care, they address social issues that may impact health status, such as food, clothing, housing, and transportation. For example, they will pick up the patient, bring them to the office, and return afterward.
In essence, the center staff is providing dramatically enhanced primary care at a substantial additional cost over typical primary care but with the aim to improve health and thus lower total costs. Most of the initial patients were on Medicaid or in a Medicare Advantage plan and lived in economically stressed areas. AbsoluteCare now also has contracts with both local and national health plans and has operations in 6 cities, and continues to grow.
It is important to be repetitive here. This type of primary care costs much more than traditional primary care but the result, besides for much-improved patient health and wellness, is a major reduction in total health care costs. That’s why health plans representing Medicare and Medicaid are willing to be supportive. Good for them to have opted to give it a try, and it is working in multiple cities.
The Baltimore office, which I have visited twice, is notable for its ambiance, cleanliness, exceptionally courteous staff, the sense of fun yet seriousness, and the clear message that everyone really cares about the patients and is determined to develop a trusting healing relationship with each. Not exactly what one might expect in an inner city medical office that caters to the socially-economically disadvantaged.
A major focus is on the family and social situation — are they living alone, having transportation, or are they having difficulties with rent, phone, and heating bills?
Same-day visits are the norm; basic blood tests are done on-site, and IV therapies are available, as is an in-house pharmacy. General radiology is transmitted to a nearby tele-radiologist. In addition, the center has a cadre of specialists they tend to call upon for referrals — chosen not only for their expertise but also for their willingness to work in close coordination with the care team.
As Chief Medical Officer Dr. Greg Foti told me: “It is all about vigilance and caring. We must call the hospitalist if the patient is admitted. We must follow up with skilled nursing if needed. We must transport them here to ensure they get the care they need. We want to fully wrap our arms around all the factors that affect their health. We don’t have any magic bullets, but we can give true love and care to our ‘members.’ That will make the difference in both quality and costs.”
The Baltimore office is focused on ensuring that they provide quality care as measured by some standard parameters. “Before AbsoluteCare intervention, our traditional member population scores in the lower 30th percentile with most quality- and value-based purchasing outcomes. After Absolute Care intervention, our members have increased their quality- and value-based purchasing outcomes [such as blood pressure control, HbA1c control, etc.] into the 75thth-95th percentile. Our culture demands that success be tied to quality- and value-based purchasing performance.”
For the payor, these numbers are impressive: a sharp reduction in hospitalizations (down 50%), ER visits (down 34%), reduction in specialists visits (24%), and total costs of care by perhaps a third, a remarkable decrease for these very challenging patients.
But most important, patients have, probably for the first time, found compassionate, thorough, comprehensive, meaningful care that has had a positive impact on their health and their lives.
Many pressures are driving the need for alternative approaches to providing primary care. Enterprising physician entrepreneurs are often the drivers of paradigm change. The fundamental concept of this center and others like it is to offer expanded primary care with heavy use of resources to improve health and lower total costs. As Dr. Foti noted, “We cannot always cure these individuals of their chronic diseases, but we can make a big difference in each person’s health, in their ability to enjoy life and be productive.”
The patient gets extensive primary care not just with a doctor or nurse practitioner but also with a team including attention to social needs as well as medical and mental health requirements. The result is that the patient becomes much healthier and will be using fewer medical system resources, especially those that are exceptionally expensive, like ER visits, procedures, imaging, specialist visits, and hospitalizations.
It is time for insurers to recognize and support this type of care. It changes the payment model but will lower their total care costs.
