Primary care for the sickest of the sick: A model to consider

Part of a series.

“It is all about vigilance and caring. Our aim is to put the caring back into health care and we are serious about that. Our standards are not how many patients did you see today but how much quality did you dispense today,” Dr. Greg Foti told me about the clinic where he works in downtown Baltimore, MD.

Individuals that have 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). For the most part, they convert an ongoing practice of 2,500 to 3,000+ plus patients to a new model that encompasses about 500 patients. Their patient group usually spans a wide range of ages and spans the spectrum of some with serious chronic illnesses to many who are basically healthy. I wrote earlier in this series of 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. There are a number of companies that 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 percent of individuals for whom 40 percent to almost 50 percent of all medical dollars are expended.  The company opened a second program in Baltimore: a 17,000 square foot primary care clinic in a new building to manage the care of  “the sickest of the sick” whose average annual claims approach $80,000 per year. Their model has one PCP or NP per only 300 patients working with a team of a case manager, medical assistant, and nurse.

Other onsite professionals include a mental health therapist, psychiatrist, social workers, and nutritionists.  In addition to medical care, they address social issues that may be impacting on health status such as food, clothing, housing and transportation. For example, they will pick up the patient and bring him or her to the clinic and return afterward. In essence, the clinic 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 these individuals are on Medicaid or in a Medicare Advantage plan for those in economically stressed areas, both through Amerigroup.

The Baltimore clinic, which I have visited twice, is notable for its ambiance, cleanliness, the 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, social situation; are they living alone, do they have transportation, are they having difficulties with rent, phone, heating bills?

Same day visits are the norm; basic blood tests are done on site, IV therapies are available as is an in-house pharmacy. General radiology is transmitted to a nearby tele-radiologist. The clinic has a cadre of specialists that they tend to call upon for referrals — chosen not only for their expertise but for their willingness to work in close coordination with the care team.

As medical director 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 be sure they actually 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 too new to have health or cost data yet. But the Atlanta office has demonstrated a sharp reduction in hospitalizations, ER visits and total costs of care by perhaps a third, a remarkable reduction for these very challenging patients.

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 with this clinic and others like it is to offer expanded primary care with heavy use of resources in a way that improves health and lowers total costs. 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 requirements.

The result is the patient becomes not only much healthier but will be using many fewer medical system resources especially those that are exceptionally expensive like ER visits, procedures, imaging, specialist visits and hospitalizations.

Note: I have toured AbsoluteCARE’s Baltimore clinic and talked at length with the company president and the medical director. I have no financial relationship with this company; it is used for illustrative purposes and is not meant to be an endorsement.

Crisis-2 jpegStephen C. Schimpff is a quasi-retired internist, professor of medicine and public policy, former CEO, University of Maryland Medical Center, and senior advisor, Sage Growth Partners.  He is the author of Fixing the Primary Care Crisis: Reclaiming the Patient-Doctor Relationship and Returning Healthcare Decisions to You and Your Doctor.

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