CareMore, an insurance plan based in southern California, has reduced costs and improved outcomes by providing direct care for its frailest elderly patients.
Published Online: June 12, 2015
Christine A. Sinsky, MD; and Thomas A. Sinsky, MD
Staffing varies by factors such as geographic concentration of members and maturity of the market. In general, a CareMore team of 2 extensivist physicians, 2 to 4 NPs, 2 to 3 case managers and 14 MAs, along with a nutritionist, social worker, and pharmacist provides the hospital and intensive outpatient management for the sickest quintile of patients within a “neighborhood” of 4000 to 5000 covered patients. At any given time, an NP typically has a panel of approximately 400 patients and an extensivist has a panel of 100 patients; panel size varies based on network composition, market maturity, and disease burden.
Physicians and their teams are provided data to modify their practices. For example, on a monthly basis, readmission rates, hospital length of stay, wounds, and urinary tract infections are reported to the provider. In addition to the HEDIS measures, CareMore also tracks 114 clinical measures quarterly, such as average A1C and low-density lipoprotein levels, amputation rate, heart failure patients on ACE inhibitors, percentage of anticoagulated patients within therapeutic INR range, percentage of patients with heart failure enrolled in a heart failure program, and the percentage of patients with optimal A1C range after enrollment in a diabetes clinic.
On-site Exercise Facilities
Patients enrolled in any of CareMore’s insurance products have free access to the “Nifty after Fifty” exercise facility, located in a building adjacent to the center. Patients receive a customized exercise plan, prescribed by an exercise physiologist, programmed into their “key.” Patients place their key in each exercise machine, and the key triggers their individualized program; it also records their workout, which is later downloaded and sent back to their PCP. Nifty after Fifty also includes a physical therapy facility.
Preliminary data suggest better outcomes at lower costs for CareMore patients: 42% fewer hospital admissions than national average; an amputation rate for diabetic patients 60% lower than national average; a 4% pressure ulcer rate in institutionalized patients compared with an average of 13% for the state of California. Per member per month (PMPM) spending is less than expected under a CMS model for similar risk patients: for patients in the intermediate risk category the actual cost is $1000 compared with an expected cost of $1500 PMPM. For the highest risk group the cost is $2250 PMPM compared with an expected cost of $3500 PMPM (Figure 2).
What is it Like to Work at CareMore as a Physician?
CareMore physicians are not the downtrodden, overworked, under-supported PCPs so typical in many organizations. CareMore physicians work 40-hour weeks and spend the majority of their time caring for sick patients. CareMore extensivists are paid a base pay between $200,000 and $220,000 annually. With bonuses and other benefits, the average compensation by year 2 of employment is greater than $300,000. A typical CareMore physician schedule is in Figure 1.
What is Missing?
CareMore provides an impressive array of support services for patients. The model would be stronger with utilization of devices to increase medication adherence, such as a pharmacy-filled “med buddy” that reminds patients to take their medications at the appropriate time. CareMore staff members also look forward to having mental health counseling on site and to having interoperative records between the hospitals, PCP offices, and the CareMore center. Currently, for example, care manager extenders (MAs) manually transfer data from hospital systems to CareMore’s electronic health record. Some network PCPs would prefer not to receive voluminous notes and are sent summaries of the key interventions and findings.
The CareMore model may be ideally suited to markets where existing care is splintered. While it has also been successful competing in markets with existing integrated networks, such networks may themselves be able to deliver similar care within their existing organization. The CareMore leadership also identifies the initial investment costs, and the requirement for smaller, well-organized PCP and subspecialty networks as a limitation.
While CareMore is a delivery arm of an insurance provider, there are lessons for the rest of the country in its model. For patients there is wrap-around care, and details are not left to chance. For example, the patient isn’t just advised to get a scale to do daily weights, the MA brings a scale to the home, sets up the remote monitoring system, and a nurse monitors the results.
For the physicians, there is remarkably less waste of physician resources than in a typical primary care practice. Whereas most generalist physicians in the United States are teamed with 1 MA, and devote a substantial portion of their day to lower-value documentation, billing, and clerical functions, CareMore physicians are each part of a team with an average of 2 NPs, 2 nurse case managers, and 7 MAs per physician. This larger but still socially integrated team extends the physicians’ reach. To the authors’ observation, CareMore physicians’ morale was higher than that of most generalist physicians. We suspect this comes from their working in a setting that allows them to spend most of their effort on physician-level work.
CareMore has much to teach the rest of us about the care of complex, chronically ill elderly: frequent contact, home monitoring, NP and case manager run protocols, and a culture that promotes aggressive, low-cost interventions over expensive, high-tech interventions.
Conclusion: The Way Forward
Many hospitals and clinics are oriented toward attracting relatively healthy patients for high-cost, high-margin services such as radiation therapy, orthopedic procedures, or interventional cardiology. Physicians delivering these high margin services are paid well and are typically surrounded by a team of support staff to help maximally leverage their skills and training.
Yet in most communities, services for the frail elderly are delivered on a limited budget, sometimes in crowded, unattractive settings, by physicians who are paid the least among their peers. Physicians providing this care often work without much clinical support, and consequently, spend much of their day on non–physician-level work (ie, locating information, calling payers for prior authorizations, and typing the visit note). This is not a formula for optimizing the clinical outcomes and financial health of the US healthcare system. Burnout is common and coordination with other points within the healthcare system is spotty and inconsistent—a complex patient is a liability to be avoided.
CareMore, by contrast, actively seeks out the sick and vulnerable, and has built systems to coordinate their complex care. CareMore is delighted to enroll the homebound, fragile 78-year-old with emphysema, diabetes, and chronic venous ulcerations. CareMore wants the confused 84-year-old who cannot keep track of her medications, has little social support and who has been hospitalized twice within the past year. CareMore is not a low-budget, charitable organization. Rather it is a highly successful, entrepreneurial enterprise in a setting where the financial incentives allow them to do well taking good care of sick people. As an insurance company, it is a risk bearer that has invested heavily in upfront chronic illness care to reduce the total global costs of care for its population. The CareMore experience highlights some of the dysfunctions in the current reimbursement system and points the way toward a model of care that benefits patients, is sustainable for the physicians and staff providing the care, and cost-effective for those who finance the care.
Medical Associates Clinic and Health Plans (CS, TS), Dubuque, IA.
Source of Funding:
Dr Christine Sinsky serves on the advisory board of healthfinch, where she has a minimal stock option; she is also the vice president of Professional Satisfaction at the American Medical Association. Both authors have consulted with healthcare organizations on practice redesign and have received honoraria for grand rounds presentations.
Concept and design (CS, TS); acquisition of data (CS, TS, and CareMore staff); analysis and interpretation of data (CS, TS, and CareMore staff); drafting of the manuscript (CS); critical revision of the manuscript for important intellectual content (CS, TS); statistical analysis (CareMore staff).
Address correspondence to:
Christine A. Sinsky, MD, Medical Associates Clinic and Health Plans, 1000 Langworthy St, Dubuque, IA 52001. E-mail: firstname.lastname@example.org
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