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How Concierge Care for Low-Income Seniors Can Improve Outcomes and Reduce Costs
September 26, 2017

How Concierge Care for Low-Income Seniors Can Improve Outcomes and Reduce Costs

Christopher Chen, MD, is the CEO of ChenMed, a physician practice that aims to bring concierge-style medicine and better health outcomes to the neediest populations low-income seniors managing multiple complex chronic conditions. Under his leadership, ChenMed has grown from 4 senior medical centers in Florida in 2010 to the more than 40 locations in 9 US markets today. Raised in South Florida, Chen graduated from the University of Miami's Honors Program in medicine, and completed his medical training at Beth Israel Deaconess. He also held a specialty position studying cardiology at Cornell University Medical College.
We have found that investments up front—such as courtesy services, drop-in visits, and smaller patient panels—increase patient access to primary care. With this concierge-style model, doctors are able to spend a remarkable amount of time with each patient. When we examined our data, our physicians averaged 189 minutes in face-to-face appointment time with each patient, while the 2014 National Ambulatory Medical Care Survey (NAMCS) notes that U.S. patients are seen by general and family practice physicians for an average of 20.9 minutes each year. Increasing time between physicians and patients simply would not work under traditional Medicare fee-for-service.
We’ve found this increased face-to-face time makes a noticeable difference. It allows physicians to focus on preventative care, make earlier diagnoses and timely interventions. For our patients under this model, in 2015, rates of ER visits were 33.6% lower than the average among all Medicare beneficiaries in the counties in which we operate. The impact of up-front investments also applies to hospitalizations: our patients averaged 28% fewer hospital admissions and 25.7 fewer in-patient hospital days than average.
These significant reductions in care utilization ultimately reduced healthcare costs. ER visits are a significant expense for patients and the entire healthcare system. Patients who feel there is no other choice often resort to the ER, even when other healthcare options may be more appropriate. According to a National Center for Health Statistics report, in 1995, there were 97 million visits to the ER, but by 2010, there were 130 million visits to the ER, even as the number of ERs available declined by 11%. The report also found that an ER visit for people 65 and older resulted in an average expenditure of $1062 per visit in 2010—nearly a 50% increase from the average ER expense for seniors in 2000. The emergency care system is overburdened, and high-quality primary care is one way to reduce the overutilization of ER services.
Comparative 2015 CMS data indicate an average of 753 ER visits per 1000 Medicare beneficiaries. The average for patients in our model was significantly lower—one-third lower than the CMS rate—with just 500 ER visits per 1000 patients. In 2016, our average decreased even further, with just 458 ER visits per 1000 patients.
Using the latest data on the average cost of an ER visit ($1062) from 2012, assuming this amount did not decrease at all, and multiplying these average savings across 1000 patients, these reductions in ER visits conservatively saved $268,686 per 1000 patients in 2015. When extrapolating this across a larger patient population, one can see how the savings accrue. In a hypothetical value-based care practice of 5 doctors, each with 450 patients per panel, the savings from reduced ER visits alone would be more than $600,000 per year.
Reducing hospitalizations has similar cost-savings implications. Patients in our model averaged 1246 in-patient days per 1000 patients in 2015, while the average among Medicare beneficiaries was 1677 days per 1000 beneficiaries. ChenMed’s model led to 431 fewer hospital in-patient days per thousand patients and an overall reduction of 25.7%.
The American Hospital Association Annual Survey stated that the average in-patient hospital day cost $2271 in 2015. Multiplying these average savings across a larger population, a reduction of 431 in-patient days saved $978,801 per thousand patients. Similar to the savings yielded from fewer ER visits, a hypothetical value-based care practice with 5 doctors, each with 450 patients per panel, would save $2.2 million from reduced hospital in-patient days alone.
These findings are also notable in that CMS averages are not risk adjusted by disease burden, socioeconomic status, or ethnicity. Our patient population overwhelmingly draws from people who are older, with more chronic conditions, of lower socioeconomic status, and diverse minority groups. Roughly 30% of ChenMed patients are dual eligible; more than two-thirds belong to a racial minority group; and, on average, our patients are each managing 5 chronic conditions. These patients typically tend to have worse health outcomes than average and yet, with this “concierge-style” approach to value-based care, their outcomes were significantly better than average.
Our patient data indicate that delivering concierge-style, value-based care can work, even for the neediest—and costliest—patients. If we are looking for ways to effectively deliver high-quality care to those who need it most, we must embrace the significant, tangible results that can be achieved with Medicare Advantage.

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