Site of Service
This edition of the newsletter (and some to follow, too) addresses an important concept in value-based care (VBC) – site of service. Our innovator this month is an organization that renders care in the home to proactively avoid the high costs of emergency departments and acute care facilities by optimizing the management of chronic diseases.
Site of service cost discrepancy was in the news this past week. This is one of the issues addressed in the recently passed House Bill HR 5378 (Lower Costs More Transparency Act of 2023). Specifically, the bill addresses the price differences between receiving a medicine in a hospital or hospital-owned facility (Hospital Outpatient Department – HOPD) versus a free-standing clinic. The bill would take away a health system’s ability to charge more for medication administration done on one of its properties, introducing so-called site neutrality.
I don’t want to argue the political or fiscal rationale for a hospital or health system to charge more for a service, even when it’s done outside of an acute care facility. However, from a practical standpoint and a VBC perspective, this is an issue that physicians and providers need to pay attention to.
If you are in a risk contract with a payer, either shared savings or premium risk, site of service considerations are very important in impacting overall medical expense, and therefore driving VBC revenue.
Radiology studies and outpatient surgical procedures done in a hospital or HOPD setting cost significantly more than the same tests and procedures done in a free-standing diagnostic center or ambulatory surgery center, respectively. The reasons are multiple and varied, with their validity dependent upon your point of view in healthcare delivery. (Shout out to Orlando Health who, last I knew, was not charging higher prices for many of their HOPD sites of service!)
Likewise, medications administered (usually by injection or infusion) in an HOPD carry a greater cost than the same drug given in a clinic not owned by the hospital. That’s what this House Bill attempts to address. (Never mind that many of the same hospitals and health systems have been getting the drugs at a greatly discounted price through the government’s 340B plan – different topic for another day.)
Decreasing medical spend through lowering HOPD reimbursement could possibly help those in VBC contracts. However, if the hospital or HOPD is your patients’ only alternative for their medication administration, tests, or procedures, limiting the allowed price might push the HOPD to close its doors. At least that is the argument from the hospital associations, and it may be accurate in some instances (eg., rural locations).
Point being, know your local alternatives for similar treatments, tests, and procedures and use the ones that will render the same quality at a lower price. Have your office staff prioritize those lower cost alternatives when scheduling and engage your specialist network in the same mindset. Look into the possibility of offering the service yourself, outside of hospital ownership. If enough lower cost alternatives exist, the site neutrality issue will likely solve itself.
Plus, in thinking about how to manage chronic conditions, look to alternative sites of services like the one discussed in this month’s innovation article. Happy Holidays!
Tried & True
This month, in the VBC foundation article, we’ll focus on Risk Stratification. From a VBC perspective, it’s really like preparing to make a meal – you need to do it to survive, but how it’s done can vary greatly based upon your budget of both time and resources.
Your risk strat process can be gourmet or can be making toast and boiling water, depending on your means. I’ve seen practices spend a lot of money on predictive analytics tools with high C-scores to determine which patients are at risk or are rising risks for health decompensation and a high utilization of resources. These tools, though costly, can help tremendously in determining which patients need your focused efforts. I like a shrimp escabeche with avocado aioli, red onions, and fried plantain chips as much as anyone!
If that’s out of your price range, though, you still need to prep your care management “meal.”
The point of this stratification process is you need to consider the risks of your individual patients, so you know where to prioritize your outreach efforts. You probably can’t afford to be everything for everyone; they call that boiling the ocean. So, find the patients who are at the greatest risk that you can impact the most on your budget, and boil the ocean one bucket at a time. (This concept is discussed in my book “Value in Healthcare: what is it and how do we create it.”)
That is risk stratification. It’s basically triage for your clinical programming.
If you can’t afford a fancy predictive analytics tool, don’t just pick your Top 5% patients based on historic claims cost from last year for a standard care management intervention group. I see too many organizations do this, and it’s not particularly effective. The majority of these Top 5% spenders either have conditions* that you’re not going to have appreciable effect on with typical clinical programming or their catastrophic medical needs from the prior year will be followed by a regression to the mean without intervention, i.e., their spend would decrease anyway, without care management.
An inexpensive yet effective alternative to the Top 5% approach is what I call “The Ven of Risk.” You’ll need the ability to pull reports from your EHR for this approach.
[*Conditions like these would be End Stage Renal Disease or Oncology cases. There are opportunities to impact the care of these patients, but this is typically through a specialized Care Management program. The more bang for the buck still comes from other conditions unless you exclusively deal with is kidney disease or cancer.]
First, find all your patients with the chronic fragile conditions – Diabetes, Heart Failure, and/or COPD – those with a BMI over 30, and those with diagnoses of depression or anxiety. The area of intersection of these three circles of patients is a good place to start in outreach to support patients.
This technique won’t rank within the cohort of high risk, but these are the people that are going to get into the most medical trouble without intervention. Hopefully their number will be small enough for you to work them all as a starting point. If not, you’ve got some serious managing of care to do!
An alternative to help you identify high utilizers with potentially rising risks is to prioritize reaching out to your patients with frequent Emergency Department (ED) visits. A typical cutoff is 2 in the past 6 months or 3 in a year. This is especially powerful when the patient has more ED visits than office visits. Too many for your resources? Filter based on diagnosis from the ED (acute illness or injuries vs exacerbation of chronic conditions) or by those with the fragile chronic conditions mentioned above. This is a great place to start to control your ED per 1,000 cost and utilization if that’s a primary driver of your out-of-control costs.
Another inexpensive option is a Risk Stratification algorithm provided by the American Academy of Family Physicians (https://www.aafp.org/news/practice-professional-issues/20210505rscmtools.html). It’s free to members and $50 for non-members. It gives a good framework for assigning risk. If you have someone in your organization that’s handy with data, they could possibly automate it for you with information fed from your EHR. Otherwise, it’s a patient-by-patient, hand-completed tool.
Here’s an important takeaway point on risk stratification: Whatever method you use to prioritize your patients for outreach and programming, the main issue is following through and actually engaging these patients. Too many practices use their fancy risk strat tools, stratify their patients, and then do nothing effective or impactful to change the patients’ health trajectory. Follow-through is essential.
Value-based care is the applied cousin of population health. One definition of population health is changing the health of a population, one person at a time. To do that, you need to know the risks facing your patients – medical, social, mental, etc. – who has the most risks, and whose risks are readily impacted for positive change.
How you build your list of patient priorities will vary based upon the time and money available to you. There are cheap alternatives to fancy pop health risk strat tools, though they are certainly not as exact or robust. The point of the whole list-building process, though, is not to have a great list. If you don’t follow through by engaging patients where they are with clinical programming that they need, you’ve basically stopped with your grocery list or your prep work and failed to complete the meal and provide the sustenance for survival, much less thriving.
Identify your patients at risk. THEN, engage them in clinical programming to enhance their health and well-being in their healthcare journey.
Innovation
Throughout the content platform of The Business of Primary Care, in our articles, podcasts and newsletters, we have repeatedly said that effective value-based care of patients extends beyond the halls and walls of the PCP practice. Any opportunity for a practice to connect with patients between those brief 10-20 minutes in the office supports better outcomes and healthier patients. In this newsletter’s innovation section, we will look at extending the reach of the PCP, physically and virtually, into the homes of some of the highest risk patients.
Eyes, ears, hands, and feet in the home enhance the care of patients, especially those with fragile chronic conditions like diabetes, heart failure, and COPD. Inna Plumb, COO of MedArrive notes many powerful aspects to visiting a patient at home. “First, it is a more comfortable environment for the patients, so they tend to open up more to the provider. Second, there is greater information around auxiliary influence on patient health in the home – for instance what they keep in their fridge, what kind of fall hazards exist, etc.”
Inna Plumb
COO @ MedArrive
Powering care programs into the home with EMS at the core.
She goes on to note the augmented effectiveness of medication reconciliation in the home and assess social risks, “It’s much easier to walk through all of a patient’s medications, by looking directly at the bottles rather than basing a review on often faulty patient memory or records. There is also meaningful information around social determinants of health (SDOH) impacts to health, such as financial, housing, transportation, and other challenges.” This type of interaction is especially beneficial to patients who for one reason or another are not able to get to care outside their home.
Which patients get the most benefit from this type of service? According to Plumb, MedArrive’s “core focus tends to be with patients who are high utilizers of the emergency room. These folks are typically not able to access care in the right way and find themselves in the hospital much more often than needed. Underlying conditions could be chronic conditions like diabetes or COPD, but are often behavioral as well.”
These patients do not need to be homebound, though, like a conventional Home Health Care model requires. The main issue is they have medical needs that need extra attention, and frequent contact with them can proactively address existing and rising risk in patients through this model, providing enormous opportunity for cost savings through a VBC care and payment structure.
Why EMS personnel? Plumb says they’re actually better suited for this type of work than other medical providers who are used to patient interactions in the office or the hospital.
She explains, “The EMS workforce is enormously comfortable in the home -, that’s one of the most amazing aspects of their skillset. Not only are they broadly scoped, but once they get into the home, they’re able to help a patient relax and quickly build a trusting relationship with the provider. Our EMS staff are inspired by the opportunity to serve patients by keeping them healthy in their own homes rather than previously bringing them to the hospital. They serve as the key connecting force in our care plan, building an in-person relationship with the patient while being supported by our virtual providers.” (There’s the R-word, again – relationship – for those of you who are following our podcast!)
Communication with the patient’s PCP is essential. Additionally, someone needs to be available to answer questions from the boots on the ground in the home if something is amiss with the patient. This is where solid protocols are necessary for when to contact the PCP, a physician covering for the PCP, or get a telemedicine visit urgently online.
Specifically, with MedArrive, their team has used AI to develop cutting edge mechanisms to optimize our routing and scheduling, support note taking and summarize complex patient histories and claims data for shared context across a multi-provider care team.
Plumb admonishes that patient engagement can be a challenge for initiating this type of work, especially “hard for patients currently over-utilizing the ED, as they are already not engaging with the healthcare ecosystem correctly.” MedArrive has had to hone messaging and engagement strategies to build trust and show that the home visit program has great benefit to the patient more rapidly.
Again, the point of pursuing an initiative like this is to optimize care of chronic conditions through more frequent touch-points within a patient’s home, thereby improving outcomes and lowering costs. To date, after engaging thousands of patients, MedArrive has achieved statistically significant reduction in total cost of care, ED utilization, IP admission and behavioral health admission which have led to meaningful savings for their partners as well as outsized improvements in health outcomes.
When it comes to managing patients with fragile chronic conditions, multi-modal, frequent, meaningful touches can improve engagement, adherence, early identification of decompensation, and overall care, all leading to better outcomes and lower overall costs. Consider adding home visits to your VBC toolbox.