A Payer and a Partner Make the Case for Extensivists

Advocates for the extensivist model say it doesn't replace primary care, but provides additional oversight and resources needed to prevent gaps in care. Older, sicker patients in particular, have been shown to benefit.

This article was originally published on February 10, 2016.

"Capitation is not risk. It's freedom."

5 Ways to Ensure Extensivists Improve Outcomes and Cut Costs

Sachin H. Jain, MD, chief medical officer of Cerritos, CA-based CareMore Health System, a subsidiary of Anthem, says that's a saying around his organization.

Jain contends that being followed by single a physician throughout a continuum of care during and after a hospitalization is beneficial for the patients, especially older ones.

His recent piece in theJournal of the American Medical Association, "Delivery Models for High-Risk Older Patients: Back to the Future" argues that inpatient and outpatient care shouldn't be so heavily siloed. He believes that if a patient is admitted for a routine procedure, the model of being followed by different doctors throughout the care continuum might work just fine, but people with chronic conditions need something more.

"What you really need is someone who can follow you from the inpatient to the outpatient, what we call an 'extensivist,'" he says.

In his JAMA piece, Jain highlights two systems that use this kind of model: The University of Chicago Health System and his own, CareMore.

The University of Chicago Health System's Comprehensive Care Physician (CCP) model, which launched in 2012, aligns inpatient and outpatient care for high-risk Medicare beneficiaries. In the CareMore model, high-risk patients in its Medicare Advantage plans are identified through risk assessments, predictive algorithms, and physician referrals.

When these patients are admitted to the hospital, CareMore extensivists, who are re-trained hospitalists, provide care throughout the admission and lead a care team that includes nurse practitioners, case managers, medical assistants, a social worker, and a nutritionist.

Extensivists also oversee discharge planning, and continue to provide direct care when patients are discharged to post-acute sites. Patients who go home, follow up with their extensivist at a CareMore outpatient clinic.

"What we're really focusing on is design for purpose," says Jain. "We are designing our healthcare delivery system for the purpose that it serves."

He says this model is about driving the health of patients, rather than utilization, and "doesn't happen in a fee-for-service environment."

"You have to commit to the primary objective being health instead of healthcare delivery," he says.

Jain says funding for the CareMore model, "really comes from the clinical outcomes." As he wrote in JAMA:

"Early observational data (based on internal analysis of CareMore Health System data) from 67,424 patients in 2012 points to substantial reductions in hospital length of stay (31%, from 5.2 days to 3.7 days) and 30-day readmission rate (20%, from 18.4% to 14.7%) compared with traditional Medicare despite caring for a higher acuity population."

In addition, he writes that these models remove "the need for supplemental care coordination and transition management capabilities. As a result, the resources required to develop extensivist and CCP capabilities should be substantially less than those required under past Medicare demonstration projects and pilots for high-risk elderly patients."

But, Jain says, it's not enough to "nibble on the margins" when implementing a program like this. Instead, organizations must commit to "total system transformation."

"That's about taking all of the pieces and making them work better together," he says.

In Practice
One health system that's working with CareMore to do that is the Emory Healthcare Network in Atlanta.

"CareMore's relationship with us is not as a payer, but as a partner, as they teach us, using our staff, to execute their model, and it's focused on Medicare Advantage patients," says Richard Gitomer, MD, president and chief quality officer of the Emory Healthcare Network. "We have a partnership with CareMore for financial responsibility for this effort."

Using the CareMore model, Emory, too, risk stratifies patients, and provides additional oversight to ones who are complex and fragile. Extensivists see the patients, both throughout their stays at hospitals and skilled nursing facilities, as well as at care centers.

Emory's two coordinated care centers opened in August of 2015 and have a team lead by nurse practitioners who execute 30 different clinical programs for conditions such as diabetes, heart failure management, and wound care.

"They do a lot of high-touch outreach to these clinically vulnerable patients," Gitomer says. "All of these resources are in addition to the primary care relationship that the patient already has with their primary care doctor."

Extensivists also follow these patients when they're in the hospital, into a skilled-nursing facility, and also typically see them at least once for follow-up in the care center.

The patients also get plugged into one of Emory's 30 clinical programs, if applicable. He says the model doesn't replace primary care, but acts as a kind of "sidekick" to the primary care "superhero," to "provide the additional oversight and resources" needed to prevent dropped balls and gaps in care.

Moreover, it focuses resources on the most vulnerable population. According to CareMore, the "chronically ill comprise 15% of Medicare beneficiaries, yet they account for 75% of costs," and this model aims to address that.

"This is a radical system change," Gitomer says. "It's allowing us to make a transformational step as opposed to the incremental steps."