Focus on Sickest in Medical Homes Saves Costs in Pilot Test

Consulting firm Mercer has just wrapped up what it terms an intensive primary-care pilot project with a large unidentified Dallas employer.

Dallas was the third test of a concept Mercer calls an ambulatory intensive care, or A-ICU. The employer sent its highest-risk patients to Plano-based Village Health Partners (VHP) and Baylor Scott & White’s physician subsidiary, HealthTexas Provider Network.

Unlike traditional patient-centered medical homes, the A-ICU model matched a select group of high-performing physicians with chronically ill patients who required intensive, customized care.

The model was based on a group of medical-home innovators described in a 2009 Health Affairs article as ‘American Medical Home Runs.’

Eric Bassett, Mercer’s Dallas-based senior partner, said the DFW pilot netted 20 percent savings after program costs and physician incentive payments. He said the gross savings was 27 percent, compared to the anticipated costs for those patients.

The model’s creators believe the same methodology could produce savings between two and three times greater than that among patients 65 and older.

Bassett said the Dallas results were similar to those in the previous pilot tests. He said program participants were selected from among the 20 percent of employees who were expected to generate the highest healthcare costs for their employer. Bassett said the 20 percent most expensive employees typically represent 50-60 percent of a company’s medical claims costs. Employee participation was voluntary, and often encouraged by the use of incentives such a gift cards or a series of free office visits.

Bassett said patient-centered medical homes (PCMHs) have improved healthcare quality but have not produced adequate savings because care is too broad.

“We try to get the right person into the right setting, and get them the right services at the right time,” he said.

The three-year study of 32 small- and medium-sized primary care practices is believed to be the first U.S. multi-payer pilot to report results in more than three years. It found that the use of a PCMH model didn’t reduce hospitalizations, emergency department use, ambulatory services, or costs, according to a recent study in the Journal of the American Medical Association.

“It is time to replace enthusiasm and promotion with scientific rigor and prudence and to better understand what the PCMH is and is not,” Thomas Schwenk, MD, dean of the University of Nevada School of Medicine in Reno, wrote in an accompanying editorial. “Widespread implementation of the PCMH with limited data may lead to failure.”

Schwenk encouraged providers to focus more on high-need patients.

High-risk patients in PCMHs experienced lower costs and utilization rates while other patients did not, according to results of a three-year study published in The American Journal of Managed Care.

The study followed about 700 Independence Blue Cross of Pennsylvania patients with multiple chronic conditions treated in PCMHs.

Costs and utilization did not differ significantly between the PCMH and control groups among all patients, “suggesting that the benefits of the PCMH model are concentrated among high-risk, high-cost patients,” the authors wrote.

The top 1 percent of Americans consumes about 25 percent of medical care, according to the Agency for Healthcare Research and Quality. And nearly half is consumed by 5 percent of the population.

Christopher Crow, MD, VHP co-founder, said he made sure the A-ICU patients were assigned to care coordinators to ensure they got as much attention as they needed. Coordinators are more likely to recognize and deal with social determinants of health and ensure patients get medication reminders, transportation to physician visits, or perhaps home-care services.

Crow said the program was a success on three fronts. Patients liked the extra attention and communication. The accelerated primary care enhanced quality care management, and assured that patients were being treated comprehensively yet more cost effectively.

Michael Massey, MD, one of HTPN’s medical directors and chairman of its Best Care Committee, said 10 of HTPN’s 60 locations were involved in the project, based on proximity to the insurer’s selected patients.

“It is a really interesting idea, and a good one. The patients do well; they get extra health and get better care. The challenge was getting those patients to switch providers. Once they did, they liked (the program) and did well in it,” he said.

Steve Jacob is founding editor of D Healthcare Daily and author of the book Health Care in 2020: Where Uncertain Reform, Bad Habits, Too Few Doctors and Skyrocketing Costs Are Taking Us. He can be reached via email here.


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