Personalized Preventive Care Leads to Significant Reductions in Hospital Utilization
Published Online: December 18, 2012
Andrea Klemes, DO, FACE; Ralph E. Seligmann, MD; Lawrence Allen, MD; Michael A. Kubica, MBA, MS; Kimberly Warth, BS, MPA; and Bernard Kaminetsky, MD, FACP
The high and growing cost of healthcare is a significant issue in the United States, with hospital care representing the largest component (31.1%) of national healthcare expenditures.1 In 2008, there were an estimated 39.9 million hospital discharges (131 per 1000 persons) in the United States, with an estimated total aggregate cost of $364.7 billion.2 Medicare was the expected primary payer for the largest number of discharges (14.9 million, 46.2%), followed by private insurance (14.1 million, 32.2%).2,3
Some hospitalizations for ambulatory care–sensitive conditions, such as diabetes and chronic cardiac and respiratory diseases, can potentially be prevented with timely and effective ambulatory care. Diabetes with complications was in the top 20 most expensive conditions requiring hospitalization for Medicare in 2008.3 In addition, coronary artery disease and acute cerebrovascular disease (stroke) ranked among the top 10, while congestive heart failure, heart attack, pneumonia, and respiratory failure ranked among the top 20 most expensive conditions for both Medicare and private insurance in 2008.3 In 2006, hospital costs for potentially preventable (ie, ambulatory care–sensitive) conditions were approximately $30.8 billion (1 of every 10 dollars of total hospital expenditures), and as many as 4.4 million hospital stays could possibly have been prevented with better ambulatory care, improved access to effective treatment, and/ or implementation of healthy behaviors.4 Therefore, reducing the frequency of potentially preventable hospitalizations would be an effective strategy for lowering costs while improving quality of care and outcomes.4
In 2001, the Institute of Medicine issued its vision for reinventing healthcare in the 21st century to foster innovation and improve the delivery of care, which included patient-centered, responsive, and timely approaches to care.5 One new model that has emerged in the United States that seeks to address this issue is personalized preventive care, which focuses on prevention and wellness while delivering a high quality of care. This model is based upon consumer/patient empowerment, greater focus on preventive services, increased physician availability, and access to other healthcare resources. MDVIP (MD – Value in Prevention) is the first company to establish a network of primary care practices that delivers personalized healthcare in this new way. The MDVIP model of comprehensive management focuses on personalized preventive healthcare by delivering a host of screenings (eg, depression, anxiety, sleep, nutrition, sexual function, vision, and hearing) and diagnostics (eg, expanded testing for diabetes, bone disease, and cardiovascular disease) for a membership fee of $125 to $150 per month. MDVIP practices limit the number of members in each practice (<600 patients per physician) to be able to logistically deliver the service, thus allowing physicians to provide more personalized attention to manage all relevant health issues including acute concerns, chronic disease, and preventive screening, not just the diagnosis and treatment of illness.6 Traditional practices have over 2000 patients7 and do not have the time to provide many preventive services.8 MDVIP founders calculated the amount of time it would take to deliver a comprehensive preventive wellness program yearly and be able to follow up with chronic issues, thus capping the number of patients at 600 for each physician. As a result of the smaller practice sizes required to be able to provide the services, MDVIP members also receive same-day or next-day appointments for urgent and nonurgent care and the ability to reach their primary care physician (PCP) 24 hours a day. This model is not a third-party payer, and the fee covers only the extended prevention and wellness services provided by the PCP; therefore, members still need traditional health insurance to cover the costs of inpatient and outpatient visits, services provided by specialists, and other medical services (eg, laboratories, Xrays).6 In this model, MDVIP believes that the focus on prevention and wellness and the additional attention and time (ie, high quality of care) will lead to lower hospital utilization and ultimately lower healthcare costs. In an early effort to assess the impact of the MDVIP model on hospital utilization, we compared the hospital inpatient discharge rates from MDVIP members from 5 mandatory reporting states to nonmembers within the same states over a 5-year period.
Comparative Utilization Methodology and Definitions
Hospital inpatient utilization data were purchased from Intellimed, an industry provider of hospital data. Intellimed reports utilization by state and payer (ie, for Medicare and non-Medicare). They also provided population data from the US Census Bureau and Claritas system, which were used to construct the comparator (nonmember) population against which the hospital utilization of MDVIP members was compared. In addition, members were identified by physician provider information since individual patient identifiers are not provided in the database.
Hospital utilization data were classified within the Intellimed database as being elective/ non-elective, emergent/urgent, and avoidable/unavoidable admissions. An elective admission was predefined in the IntelliMed database as the condition permitting adequate time to schedule the availability of a suitable accommodation. A non-elective admission was predefined in the IntelliMed database as the condition not permitting adequate time to schedule the availability of a suitable accommodation. Furthermore, non-elective admissions were classified as emergent or urgent. Emergent and urgent admissions were also predefined in the IntelliMed database. Emergent admissions were those that required immediate medical intervention as a result of a severe, life-threatening, or potentially disabling condition, and urgent admissions were those that required attention for the care and treatment of a physical or mental disorder. An avoidable admission was defined and validated by MDVIP physicians as an admission for inpatient care of chronic illnesses that could be averted if the patient had good quality outpatient care (eg, ruptured appendix, asthma, cellulitis, congestive heart failure [CHF], diabetes, gangrene, hypokalemia, immunizable conditions, malignant hypertension, pneumonia, pyelonephritis, perforated or bleeding ulcer) and included the following International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes: 032, 033, 037, 045, 055, 072, 250.1, 251.0, 276.8, 401.0, 402.0, 403.0, 404.4, 428, 437.2, 481, 482, 483, 485, 486, 493, 531.0, 532.0, 533.0, 540.0, 590.0, 681, 682, 785.4, inclusive of all sub-codes; whereas, an unavoidable admission could not be averted with good-quality outpatient care.
Of the 40 states and the District of Columbia in which MDVIP does business, only 5 states provide physician-specific data that could be used for this analysis. Therefore, MDVIP members were identified from MDVIP-affiliated physician provider information from those 5 mandatory reporting states: New York, Florida, Virginia, Arizona, and Nevada.
Since there is a lack of patient-level data within the Intellimed data set utilized for this analysis, MDVIP members were identified as any admission where an MDVIP physician was the attending physician. We established the comparator population using both inclusion and exclusionary measures. Using Claritas population data and collateral information available from the US Census Bureau, we established a comparison population matched by state of residence, age, and third-party payer coverage. We excluded from the comparator population individuals with attributes not found within the MDVIP cohort (ie, individuals under the age of 35 years were excluded from the commercial payer group, and individuals under the age of 65 years from the Medicare comparison group). We also excluded from the comparison group all payer groups not represented within the MDVIP membership (Medicaid, Medicaid HMO, CHAMPUS, Charity, Kid Care, state/ local government, self pay, underinsured, unknown, Veteran’s Administration, worker’s compensation, and other). In order to further ensure valid comparison, we excluded from the comparison group admission counts any admission types not represented in the population of MDVIP members (ie, newborn/ newborn premature, observation, unknown [including “info” and “NA”], semi-urgent, and trauma). MDVIP members were also excluded if their physician had a start date with the MDVIP network within the reporting quarter.
Hospital inpatient discharge rates per 1000 persons were used as the measure of comparison, calculated as: (discharges/ [days in reporting period/365])/(population/1000). Sensitivity analyses were also performed to assess the robustness of the data and to gain better understanding of systematic influences on the utilization differences between MDVIP and nonmember populations.
PDF is available on the last page.