1. House Calls Medicine for High-Risk Pioneer Beneficiaries
Alan Abrams, MD, MPH
Medical Director, BIDCO Pioneer ACP
American Academy of Home Care Medicine
May 14,2014
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2. Former United Health Medical Director
Disclosures
Former United Health Medical Director

3. Agenda About BIDCO High-risk case spend House Calls Medicine
Program analysis
Summary
Questions

4. About BIDCO
BIDCO is a value-based, physician and hospital network and an Accountable Care Organization (ACO)
Located in Westwood, Mass
Employs more than 80 staff members
Contracts with 2,300 physicians, including nearly 550 PCPs and more than 1,750 specialists
Contracted by Centers for Medicare and Medicaid Services as a Pioneer ACO
Our highest level goal is to promote the best quality and value of care to patients, providers, health insurers, and employers

5. BIDCO Membership 5 Community Health Centers
Academic Medical Center Primary Care
Hospital supported large group practice
Solo Providers in Family Practice
Concierge Practices
5 Hospitals
Extends from Cape Cod to New Hampshire border
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6. What is a Pioneer ACO?
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7. Pioneer ACO Shared Savings: How it works in Pioneer
Pioneer ACO organization must have at least 15,000 beneficiaries aligned to their budget
Alignment is imprecise but based on a claims based method looking back 3 years
Aligned beneficiaries calculated to have an average per capita per year cost
Average cost is then adjusted for mortality and for health care cost trends during the program year in a reference population
Final average cost target is determined at the end of the program year

8. Pioneer ACO Methodology
Final average per capita annual cost is then compared to the actual costs for the aligned population at the end of the year
Calculated savings or deficits determined when you compare the actual Medicare expenses to the predicted/adjusted Medicare expenses for the aligned population
Shared savings are determined by the difference and the threshold for achieving savings which is contract dependent

9. High Cost Patients
Historically high cost patients increase your baseline budget
Historically high cost patients can contribute to your savings disproportionately if you manage their care more effectively
High costs are often the result of multiple acute care and post-acute care expenses, ER visits, and the inability to manage complex patients with multiple chronic illnesses

10. Disproportionate expenses for complex, chronic illnesses
13%
46%
23%
32%
28%
Centers for Medicare & Medicaid Services. (2013). Chronic Conditions Among Medicare Beneficiaries, Chartbook: 2012 Edition. Baltimore, MD: Centers for Medicare & Medicaid Services.
32%
19% 7%

11. Beneficiaries with disproportionate Medicare spend
Over 65 year of age
Multiple chronic conditions
Functional limitations
DM, OA, HBP, heart disease, mood disorder
Fair or poor reported health status
Most likely to be hospitalized in next year

12. House Calls Medicine Targets high-risk Pioneer patients
Enrolls top 1 – 3 % highest risk Pioneer population
Utilized when PCP office-based care is unable to meet all care plan needs

13. Who is High Risk and Referred for House Calls Program
Pioneer Beneficiaries with a high probability of hospitalization as determined by OPTUM iPro algorithm
Patients recognized by PCPs to be at high risk d/t to advanced illness, self-management challenges, functional and social/behavioral issues

14. Referrals
Pioneer ACO patient lists with hospitalization probability risk scores provided to PCPs
Patients with > 50% probability of hospitalization highlighted on patient lists
PCPs can refer any patients to House Calls Medicine, encouraged to consider high-risk patients

15. Patients unlikely to benefit from House Calls Medicine
Patients on dialysis
Patients with primary uncontrolled major psychiatric illness
Patients being actively treated for malignancy
Patients being actively treated for HIV-related infections and complications

16. Patient participation
Patients categorized as:
“House Calls” — Referred and enrolled, receives House Calls Medicine intervention
“Control” — Referred and refused intervention, receives usual care

17. “House Calls” intervention
Active patients receive NP collaborative practice model in coordination with referring PCP*
PCP pre-determines MD-NP communication strategy
Monthly visit schedule
One NP home visit
Two telephonic check-ins
PRN visits as needed
24/7 NP call number for off-hours, urgent telephonic triage
* BIDCO subcontracts with OPTUM Health for the NP services

18. “Control” intervention
Usual care

19. Determining ROI
Patient Total Medical Expense (TME) for one year prior to “House Calls” or “Control” cohort assignment determines baseline cost
First nine months of patient experience following assignment has been analyzed
Nine months post-assignment, T.M.E. PM/PM cost compared to baseline costs to calculate medical expense decline for each group

20. Referral Numbers 1200 of 35,000 beneficiaries referred
Only 600 contacted to enroll d/t geographic constraints and FTE
Of the 600 contacted about 50% accepted the Housecall Program NP
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21. Cases
Cohort
Total cases
Month 9
House Calls
385
202
Control
249
133

22. House Call and Control Group Characteristics
Gender
Age
Mortality
Risk Score
House Calls
67% Female
83.5 yrs.
6.6%
5.2
Controls
71% Female
80.3 yrs.
7.7%
4.7

23. Baseline Expenses of House Calls and Control Groups at Referral

24. Results at nine months of finalized claims
Reporting category
House Calls (A)
Control (B)
Difference (A)-(B)
INPATIENT
-33.9%
-13.6%
-20.3%
OBSERVATION
-28.2%
-53.2%
25.0%
OP PROCEDURES
-2.2%
-1.6%
-0.6%
EMERGENCY
-15.9%
-20.8%
4.9%
RADIOLOGY
-18.3%
21.1%
-39.4%
VISITS
-10.4%
-4.7%
-5.7%
DIAGNOSTICS
-11.4%
-12.1%
0.6%
LAB
-22.0%
-18.0%
-4.0%
PT/AT/ST/OT
32.4%
-5.8%
38.1%
ANCILLARY
-17.6%
-13.8%
-3.8%
Total
-24.9%
-11.7%
-13.2%

25. Summary
Total Medical Expense reduction for “House Calls” cohort significantly greater than “Control” cohort at nine months experience
Most significant medical expense reduction for “House Calls” cohort is hospitalization cost and post-acute care cost

26. Questions

27. ©AAHCM