Decreasing avoidable utilization, improving patient outcomes, and reducing costs: small panel high risk primary care programs in Johns Hopkins Medicine

From the 2021 HVPAA National Conference

Michael Albert (Johns Hopkins Community Physicians)


Primary care in the United States is chronically underfunded, leading to a system that overvalues high visit volumes and undervalues efforts required to care for high risk patients. Investing resources in primary care has been shown in other countries to improve outcomes and reduce overall cost of healthcare delivery.


Over the past 7 years, Johns Hopkins Community Physicians, a geographically distributed, heterogeneous network of primary care sites, has collaborated within Johns Hopkins Medicine to support several small panel, high value, provider-led patient care teams that systematically address the needs of high risk patients. Key collaborations were forged with partners, payers and hospitals within Johns Hopkins Medicine to advance these models, which target specific cohorts of high risk patients. The models include a Medicaid high utilizer practice, a geriatric high risk practice, a home-based primary care program, and an advanced practice provider led program that co-manages high risk patients along with existing PCPs.


After 7 years of data, the Medicaid program has shown 52% inpatient utilization reduction, and 60% ER utilization reduction relative to baseline, with an overall ROI of 4.45:1 for the payer. After 3 years, the geriatric program has shown 49% inpatient utilization reduction, 50% ER utilization reduction, and greater than $1.5 million annual total cost of care reduction on an active panel of 125 patients. In its first year of partnership with the Johns Hopkins Medicare Advantage plan, the home based primary care program is showing significant total cost and utilization reduction compared to a matched cohort, yielding a 3.6 ROI for the payer that helps fund the intervention. Early results for the advanced practice provider programs show they appear to help their practices meet system utilization goals in aggregate.


These models have succeeded in protecting enrolled patients from avoidable ER and hospital utilization. In addition to increased quality and safety for patients, the programs significantly reduce total health care costs, and show an impressive return on investment.

Implications for patient care

Incremental investment in high value primary care results in improved outcomes and reduced costs

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