Bringing Medical Care Home: Landmark Health’s Risk-Bearing Journey Evolves
In the industry’s ongoing push toward a value-based care system, patient care organizations are continuing to find new ways to evolve and innovate to meet the demands of the new operational landscape. For instance, one key strategy to bend healthcare’s unsustainable cost curve is to reduce the number of patients with multiple chronic health conditions who too often rely on hospital emergency rooms as their primary source of care. In that context, in 2013, Landmark Health was founded to solve this core problem that exists in the U.S. for people at greatest risk.
The Huntington, Calif.-based organization assembled a team of leaders with experience in complex panel management, in-home medical care, and risk-based partnerships. The company eventually tapped Adam Boehler as its CEO before he went on to serve as director of the Center for Medicare & Medicaid Innovation (CMMI).
Today, Landmark is a $1.8 billion company bearing risk for more than 100,000 patients across 15 states and nearly 50 metro communities. Two of the company’s key executives—Nick Loporcaro, who is the present day CEO of Landmark Health, and Brandon Kerns, CFO—recently spoke with Managing Editor Rajiv Leventhal about how the organization has positioned itself as a leader in home-based medical care and how its value-based care journey continues to evolve. Below are excerpts of that interview.
What is Landmark’s precise mission and what core challenges are you looking to solve within the healthcare market?
Loporcaro: Our model in and of itself focuses on the elderly, frail, and [those with] complex chronic conditions; multi-morbid individuals who are either homebound or limited. That’s our typical patient and we affectionately refer to our patients as Joes and Josephines who are [usually] between 78- and 80-years-old. Today we take responsibility for approximately 115,000 of those individuals in 15 states and 50 markets that we serve. It’s a longitudinal, comprehensive, in-home medical home platform, but this is not home care or urgent care; it’s truly longitudinal primary care. Think of us as a mobile geriatrics practice as the 40,000-foot version.
How many health plans are you currently partnering with?
Loporcaro: We’re up to 16 plans; we just signed a large at-risk provider group as well as [a few] provider-backed or sponsored plans, so in total, about 20.
Kerns: Historically, it’s been primarily Medicare Advantage [MA]. About 95 percent of our membership is MA, with the balance being some commercial and some Medicaid. We are increasingly seeing traction with providers, but historically it has been health plans. Recently, though we have been migrating to integrated health systems and health plan relationships, as well as directly to capitated providers with our solution.
Which patients are eligible to be connected to your network and how are they chosen?
Loporcaro: At a high level, the filter is six or more chronic conditions, and how we code or score those chronic conditions varies a little bit. But we will go to an MA plan and take their MA membership. We typically run our algorithm and it yields about 8 to 10 percent of that [patient] population qualifying for our program, and once we agree with our MA partner, that population is basically handed over to us. We take responsibility for them immediately, so we’re at-risk for them right away, and then we have to engage them into the program with an opt-in [approach].
Kerns: On the front end, before Landmark engages, we look at the medical loss ratio (MLR) of that attributed population prior to our involvement. That sets a baseline MLR that oftentimes is around 100 percent or higher, and from there we guarantee savings. So we have that attributed membership, and every month people will either pass away or move off their health plan. They might move out of the area or go to hospice. So every month we run that same selection criteria across new claims that come in, and new members are being attributed to us every month, meaning it’s an open attributed population that is growing organically quite well.
In which ways have technology and data played an important role in accomplishing these goals?
Loporcaro: There are three discrete hard technologies that we’re leveraging. First and foremost, this organization decided from its conception that we’d have our own proprietary platform. We use the term ‘EMR’ because that’s the commercially recognized one, but it’s more than just that—it’s a comprehensive care platform. We have everything integrated into it, from the logistics of how we get a provider, to which patient and when, to scheduling, and routing—it’s all part of our comprehensive care platform, which we call Ubiquity.
The second piece is that we have an innovations team that is constantly looking at home monitoring and different therapeutic applications of different systems. And the third piece is telehealth. One thing we’re adamant about is that we embrace telehealth as a tool, whether that’s tele-phonic or video calls. When you look at our population, a lot of the [patients] have limitations, be it cognitive, hearing, or visual. Telehealth has been critical during the pandemic; we switched to virtual quickly, but today we’re back to over 90 percent in-person visits in most of our markets. The softer piece, which is just as important, is a lot of what Brandon’s data science team works on.
Kerns: Our front-end data analytics [entail] who we select, how we engage them, and what frequency we visit them. We then have our Ubiquity operating system with our predictive analytics fed into it. The first thing we do is an opportunity assessment. When we go into a new market, we offer guaranteed savings, so health plans are seeing the value proposition; the super complex [patients] are not getting better from an MLR standpoint. So the value proposition [for them] is real.
For example, say we get pulled into the Phoenix market; a health plan there tells us assess the plan’s population that would qualify for our services. Then they give us their data, our data and analytics team looks at that and looks at visualization—so for instance, the number of patients admitted to a hospital per 1,000 health plan members; skilled nursing facility days; and overall, some 30 categories of service. Then we look at PMPM [per member per month] medical spend as well as medical loss ratio. There’s a lot of granularity to it and we see if the juice is worth the squeeze. In almost every case the answer is yes, and in some cases, it’s already very well run, so the health plan wouldn’t have a great ROI with us.
Once we get an attributed population, we’re at risk for that entire group so it’s incumbent upon us to engage those members. We [believe] that we engage them at levels higher than any other in-home medical provider or vendor that you will see. Data and analytics play a really important role in that. We look to sort of ‘reverse cherry pick’ those who are in need of our services the most. So we have an outreach model—a score we determine by individual that predicts the likelihood they will say yes to engaging with Landmark services. We know that those who are at highest risk also have the highest propensity to engage with Landmark, and that enables us to ramp up our engagement very quickly for data science and analytics.
Once they are an engaged member, how does it all come together? We have a 15-person team that is constantly re-running, on a monthly basis, our predictive analytics across claims criteria amongst other data we receive, such as lab and pharmacy data. There are four components that come out of that: who we touch, with what frequency do we touch them, with what provider type, and what will we emphasize on that visit? All of that is pushed through our Ubiquity mobile EMR system that can be right on the doorstep of a patient. What I mean by that is we risk stratify our population, and for the sickest people, they are getting a doctor visit weekly in the home. [Comparatively], the least sick on the risk stratification model are receiving maybe two to four in-person touches a year, and the rest might be via telephonic, social services or behavioral health. So it’s a lighter model [for those patients].
Our clinical model determines which type of provider is best for that patient: a doctor, nurse practitioner, or social worker, for example. We have ‘healthcare ambassadors’ going into the home all the time. What’s really important is we may have 30 different predictive models running in the background, but we can’t inundate our providers with 30 different PDFs. They need to know those two or three really important things that are [necessary] for the patient visit. These models feed into Ubiquity and the provider can see what they need to accomplish on that visit.
Loporcaro: Married into that, let’s say we have a provider visiting Josephine today and he or she needs to schedule an appointment. The system, based on the data that’s being fed, will know when they will be next in that vicinity and prioritize that visit. They are literally taking the provider by the hand virtually and guiding them through where they are going, what the intervention needs to look like, and truly supporting them. Candidly, that is what has enabled us to be able to scale nationally and as successful as we can.
What do you believe have been the most noteworthy outcomes of this model?
Loporcaro: Reduction in utilization helps lower the MLR, and those are the metrics we’re scoring so what we can show value to the health plans. More importantly, we are reducing mortality and have evidence of that. Our patient satisfaction scores are consistently in the mid-90s, so we know we are delivering value. To do that as well as lower costs is very gratifying.
Kerns: A lot of risk-bearing providers will be successful in one location because they have an exceptional clinical team. We have that, too, but as we continue to grow, now being in 15 states, it’s really special that we can do the same level of care and performance both from a quality standpoint, but importantly, financially, too, all across the U.S. The technology provides that standardization and allows us to have a lower standard deviation on clinical and financial outcomes across the country.
Loporcaro: I’d be remiss if I didn’t mention the amount of time and energy we invest in training and continued education. Our interdisciplinary teams take a half day every week to group up together to get familiar with their files. Each one of our providers [goes through] 175 hours of training before they get to their first visit. We have our own Master’s Academy; we refine the system, and we’re continuously training and educating.
