New program aids high-needs patients, reduces health expenses

About 5% of patients account for half of the nation’s healthcare expenditures in any given year, says Alan Glaseroff, MD.

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 “It may vary slightly according to the population you are serving, but the rule of a small number of people costing the bulk of the money is true in every population in the U.S,” explains Glaseroff, co-founder of the Stanford Coordinated Care Clinic and clinical professor of medicine at Stanford University.

To help doctors more effectively care for their high-needs patients, the Intensive Outpatient Care Program (IOCP) embeds care coordinators in medical practices.  According to Glaseroff, a family physician who created IOCP with colleagues, this model not only reduces health expenditures, but promotes patient empowerment by addressing the reasons why they haven’t been doing well.  

IOCP was further developed by Boeing, the California Public Employees Retirement System and Pacific Gas and Electric Company, members of the Pacific Business Group on Health (PBGH), a coalition of 65 employer purchasers. PBGH coordinates programs including the Purchaser Value Network, an organization that promotes value-based purchasing of healthcare.

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IOCP recently concluded a three-year demonstration pilot funded by the Center for Medicare and Medicaid Innovation involving 23 practices, 500 physicians, and 15,000 patients. The program is now being adopted by PBGH members.

Next: How to setp up an IOCP

Setting up IOCP   

“Because it is difficult for any one physician or practice to set up these services, the services are paid for by an IPA or medical group, or integrated delivery system.” says Diane Stewart, MBA, senior director of the California Quality Collaborative, an organization administered by the Pacific Business Group on Health. “So one care coordinator might work with 10 practices or 20 clinicians. It is offered as a support to the practice.” The medical group or IPA hires, trains, and supports the staff and works with providers to identify patients using predictive risk modeling and a prospective risk score based on claims histories.  

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Stanford incorporates the IOCP model

At Stanford University, every patient is assigned a care coordinator, who takes notes when patients are in the room. “The physician’s role is more consultative and supportive,” Glaseroff says.  

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This team approach may be unworkable under a traditional fee-for-service model, according to Glaseroff, but payment reforms such as Medicare Option B can enable even small practices to hire a robust team and work under capitation, sharing in  any resulting savings. 

“I think anyone in any practice, regardless of the size, would enjoy that environment.” says Glaseroff. “But it takes payment reform to fund it. And it comes under the name of value-based payment. I think it is where primary care is going.”

According to Glaseroff, nationally, primary care gets about 5% of the health insurance premium dollar. The IOCP model is closer to 10%, but it is balanced by fewer unnecessary hospital admissions, emergency department visits and fewer visits to specialists. Since incorporating care coordinators at Stanford, emergency room visits declined 59%, and admissions declined 29%. Even with a rising fee schedule, the program saved 13% in costs and achieved the 90^th percentile for most quality measures.

Next: Real world example 

Scottsdale Health Partners

Scottsdale Health Partners (SHP), a clinically integrated network and accountable care organization in Scottsdale, Arizona participated in the IOCP pilot. “It was definitely the foundation for our care management program,” says Karen Vanaskie, DNP, MSN, RN, care management program director. SHP counts 35,000 members, including 17,000 Medicare fee-for-service, 5,000 in Medicare Advantage plans, 7,000 commercial and 5,000 employer-based self-insured. Of its 715 physicians, 118 are primary care physicians.

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Primary care physician practices with embedded care coordinators can take advantage of the new Medicare chronic care management and transitional care management billing codes. SHP’s Medicare Advantage plan had a 10% cost reduction in 2013 and a 4.5% cost reduction in 2014.  

SHP embeds care coordinators in medical practices, training them to listen to patients, conduct assessments and in behavioral modification interviewing techniques. Physicians don’t pay for the care coordinator but pay a one-time fee to join the network.

Care coordinators contact patients at least once a month, track their medical data, make appointments, and help patients achieve personal goals such as losing weight. In addition, they refer patients to community services such as transportation.  “Many of these elderly deal with a tremendous amount of loss.” Vanaskie says. After six months in the program, the numbers of patients seen with moderate to severe depression went down by 62%, and according to Vanaskie, about 65% of physicians in the SHP network, now have embedded care coordinators. “As a nurse, what moves me is how frustrating it must have been for patients before care coordinators,” she says.