Caring for the Sickest Patients: A Calling and an Opportunity

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Don't give up on the sickest patients -- your organization can make a difference, Alan Cohn, MD, said here at Thomas Jefferson University's annual Population Health Colloquium.

"Don't give up. You can have an impact. But it takes creating real trust," Cohn, president and CEO of AbsoluteCARE of Singer Island, Florida, a healthcare company focused on medically complex patients, said Tuesday.

Cohn's firm was one of several presenters at a session on companies that are disrupting the way patients are provided with primary care. Much of the discussion centered on the importance of providing ancillary services, such as transportation, food, and temporary housing, to help patients get their life -- and their health -- back on track.

"If you want to make the biggest difference, the first thing you'd do to lower hospitalizations and deliver care is give access to primary care," said Griffin Myers, MD, co-founder and chief medical officer of Oak Street Health in Chicago. Oak Street currently runs 25 primary care centers in six markets nationwide, serving 42,000 patients, of which half are "dual eligibles" on both Medicare and Medicaid and 25% are in Medicare Advantage. The company's model is to go into communities where there is little primary care access, build a brick-and-mortar health clinic, and ensure that the clinic meets strict quality-of-care criteria.

Unlike many other primary care offices, however, "we don't do fee-for-service medicine," said Myers. "We are fully capitated for [Medicare parts] A, B, and D across all of the 11 health plans that we work with ... The way we cover the costs of all the ancillary services [we provide] is through taking full risk, investing up front, and keeping people happy, healthy, and out of the hospital."

"We take care of a really sick population ... The big opportunity is addressing health disparities and social determinants of health," he added. "One man's health disparity is another's opportunity."

So far, that model seems to be working: 

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