Managing high-risk patients pays off
Group nets 4-to-1 return on investment first year
A partnership that provides an ambulatory case management program for patients at highest risk for resource consumption and poor outcomes has reaped big rewards for the Community Practice Network of the Lahey Clinic in Danvers, MA.
In just 15 months, the multispecialty group practice has seen a 4-to-1 return on its investment, saving about $4 million a year on patient care costs for its Medicare risk population, says Jerry Maliot, MD, MS, medical director of the network of 500 physicians at 32 sites.
When the program started, the per-member-per-month cost for the targeted population was $2,538. After 15 months, the cost dropped to $1,838. The hospital admission rate dropped from 18% per month to 13% per month.
Patients were asked to assess their own functional health status on a scale of 1 to 5 using the SF-12 outcomes measurement scale, with 5 denoting excellent health and 1 indicating poor health. During the first year, the patients’ perception of their health went from an average of 1.9 to 2.2, a statistically significant increase.
"Managed care means having programs in place to help the doctors do it right and to manage financial risk. We think the ambulatory side is something that has taken a back seat," Maliot says.
Lahey Clinic partnered with StatusOne Health Systems, a startup Internet company, to launch its ambulatory case management program focused on the highest-risk patients.
"Every organization needs to look at financial and human resources as a scarce commodity. We chose to partner with a startup dot com company that helped us jump start this process," Maliot says.
The practice already had disease management programs in place for a number of chronic diseases. These programs usually target the 5% of patients who account for 50% of medical costs. Usually, a single disease management strategy meets these patients’ needs, Maliot says.
The patients in Lahey’s high-risk care management program represent the 0.5% of patients who have multiple comorbidities and are taking many prescription drugs. These patients account for 25% to 30% of Lahey’s total costs, 25% to 30% of total admissions, and 30% to 45% of inpatient days.
"These patients with multiple comorbidities cannot be addressed with a single disease management program. If you refer them to several disease management programs, you get into the issue of managing care in silos and not in a system," Maliot says.
Many of the patients with the highest risk for revenue consumption have multiple psychosocial issues, transportation problems, and nutritional needs that can pose barriers to care, he adds.
StatusOne provided a predictive model to help identify at-risk patients and a software system that gave case managers guidelines and pathways online and allowed them to do only care planning.
Lahey hired eight case managers to manage its highest-risk population of patients. StatusOne conducted a training program for the case managers and other principals at Lahey and worked with them on a continuous quality improvement program.
It took a team from Lahey and StatusOne about six months to plan the program and another two to three months to roll it out.
The program takes a holistic approach to care management.
"In the traditional delivery of health care, we tell patients we are the doctor, the nurse, the case manager, and we’re going to do this for you. What we try to do in our program is to develop a partnership with the patient family and caregiver. We don’t assess just the medical problem but we look at the total environment," Maliot says.
The case managers develop a holistic plan that includes medical interventions as well as community and family resources.
For instance, if the patient is physically deconditioned, walking to the mailbox may be a goal. If the patient is not taking the medication correctly, the case manager examines the reason, which may be that the patient needs a way to get the medicine.
"We try to be proactive and holistic and look at the entire patient. Otherwise, you won’t get the right kinds of outcomes," Maliot says.
The population in the high-risk patient registry is fluid, with a turnover rate of 12% to 15% each month. This means that a case manager typically receives seven to 10 new patients each month.
About 80% of patients are put into the system through data analysis. The others are identified by doctors, nurses, case managers, or site managers who recognize them as being at risk for high consumption of resources and poor outcomes.
For instance, a new Medicare risk patient may not have a claim in the system but may meet the profile by having multiple comorbidities, receiving multiple medications, being noncompliant, or having a family situation that isn’t healthy.
The program has been so successful because it provides intensive services to the patients most likely to become seriously ill.
"If you have 100,000 patients, statistically, you can expect 5,000 of them to be chronically ill. It’s hard to get your hands around 5,000 patients but in my program, we’re looking at just .5% of the patients and that would be 500," he says.
In fact, the Lahey program goes a step further and concentrates on the patients who are most likely to be admitted to the hospital with six months.
When the case manager does an initial assessment, she rates the patients on how likely they are to be admitted to the hospital. For instance, a patient who is likely to be admitted within three months is rated an acuity level 1. Those who can expect to be hospitalized in 36 months are rated an acuity level 5.
The case managers give patients rated with an acuity level 1 and 2 the most attention but closely scrutinize the others.
"You’ve got to stratify your resources and target interventions to the population that is most in need and most actionable to get the best results," he says.
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