From the 2024 HVPA National Conference
Pouya Afshar MD, MBA (Presidium Health), Armin Arbab-Zadeh MD, PHD, MPH (Johns Hopkins University School of Medicine)
It has been well documented that the top 1% of America’s highest cost patients consume over $160,000 in annual health expenditures and account for nearly 30% of the country’s $4.5 trillion healthcare budget (1). The landmark “Hotspotting” article suggested that it was not possible to improve healthcare outcomes while simultaneously reducing costs for these superutilizers (2). Despite this precedent, a San Diego-based medical group (Presidium Health) entered into a value-based pilot program targeting a cohort of 93 medically and socially complex Medicaid members who had a baseline of 535 hospitalizations per year and annual healthcare costs of $17.9 million. To minimize the effect of mean reversion, these 93 members were chosen based on a 3-year average where their claims data showed consistent high utilization.
The health plan provided the medical group with only basic demographic information and the cost of care for each member. Once the member’s location was verified, a field-based medical team was deployed and services where rendered wherever the members resided. The care team consisted of an integrated group of clinicians that provided the following longitudinal services: 1) primary care, 2) acute care, 3) behavioral health, 4) substance use support, and 5) social services. The initial visit consisted of a face-to-face encounter with a primary care provider who onboarded the member. Thereafter, subsequent visits included both in-person and telehealth encounters. All members received 24/7 access to a medical triage line, backed by acute-care trained medical providers with the ability to deliver mobile imaging, labs, and other diagnostic modalities. Unlike the conventional hospital-at-home model, members who activated the triage line and met inpatient criteria were managed at home without a predicated encounter in the emergency department. In certain acute care cases that warranted additional oversight, members were transferred directly from home to a skilled nursing facility (SNF) where they received short-term inpatient care (“hospital-at-SNF”).
The value-based agreement provided fee-for-service reimbursement for any professional services, a “no-prior authorization” clause for any orders or referrals made by the primary care team, and a shared savings component. At the conclusion of the one year pilot, there was a significant improvement in clinical metrics and a 53% reduction in hospitalizations. The fee-for-service charges throughout the year totaled just over $300,000, representing more than a ten-fold increase from the baseline, capitated primary care payments. Despite the relatively higher costs allocated toward primary care services, the total cost of care for these 93 patients decreased from a baseline of $17.9 million to $11.9 million (34% year-over-year savings).
Given the unprecedented success of the pilot program, Presidium Health was awarded a second value-based agreement for 419 members with annual healthcare costs of $53 million. Preliminary metrics for this cohort show similar improvements in clinical metrics, reduced inpatient utilization, and an estimated $16 million reduction in total healthcare costs (30% year-over-year savings).
Beyond the services component, Presidium Health has leveraged over ten years worth of use cases and user stories to build a technology platform that houses the proprietary clinical and social algorithms and automates the logistics of its field-based services. The proven track record, combined with their technology platform and a centralized support team, have now positioned Presidium Health to scale their model across the United States.
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