A New Subspecialty? ‘Housepitalists’ Offer Complex Primary Care in the Home

HarmonyCares is a Troy, Mich.-based provider of home-based primary care services for complex patients. In a recent interview, Michael Millie, M..D, M.B.A. the company’s chief medical officer, spoke about the company’s shift to a team-based approach in a value-based care environment. 

HarmonyCares operates in-home primary care practices in 14 states, constituting a 150+ primary care provider group that delivers continuity-based primary care under an integrated, physician-driven model which includes ancillary services such as home health, hospice, palliative care, radiology, and laboratory.  In 2022, HarmonyCares announced a shared savings of $31.1 million through the Medicare Shared Savings Program, a savings rate of 10.9%, making it the best-performing ACO in terms of savings two years in a row.

In December 2021, Rubicon Founders acquired a majority stake in HarmonyCares. Although it has been in business for more than 30 years, the company recently announced that it has raised $200 million to bring its integrated, physician-led in-home care model to more patients nationwide. 

Healthcare Innovation: Before we dive into talking about HarmonyCares’ care model, can you tell us about your background. I saw that you had spent time at Everett Clinic in Washington state and then at Optum. What drew you to HarmonyCares from your experience there? 

Millie: First of all, it's a very bizarre story. I’ve been a surgeon in the greater Seattle area for more than 20 years. It’s very unusual that a surgeon is leading a complex primary care group as their chief medical officer. I've had a career-long interest in finding a better way to deliver healthcare. 

When I became a surgeon, I started thinking in population health ways from a surgical perspective, and started moving complex surgical care out of hospitals. I started thinking of different ways to satisfy both surgeons and patients, to deliver value in that space, and had a lot of success. 

When the opportunity came up to lead our entire population health program for the Everett Clinic, which is a very large multi-specialty group in greater Seattle, I took it. Then after 100 years of very proud physician ownership, our organization was purchased by Optum, mostly because we wanted to move deeper into the value-based space and needed capital. That’s why we decided to sell the company. I was serving as the chief clinical officer, which was functionally a chief of population health, and that job continued with Optum. As we grew our region across two states, we ended up with about 300,000 patients under full capitation in Medicare Advantage, an ACO, and capitated Medicaid. 

My holy grail was de-escalating care away from hospitals into offices, and away from offices and into the home. And that gap between office to home is really difficult to do, particularly if you're preoccupied with your brick-and- mortar infrastructure. The opportunity came up to consider the CMO position for this company, and the thesis was: what happens if we take this infrastructure that's existed for 30 years on a fee-for-service basis and we apply the resources that value-based care brings? That’s an experiment I want to be a part of. I did stop practicing surgery when I joined two and about two and a half years ago.

HCI: Have the services that HarmonyCares provides or the population it serves changed much, or is it just the contracting with the payers that's changed? 

Millie: We have always taken care of, by definition, seniors for the most part, with the exception of some very, very sick Medicaid patients, but mostly seniors and mostly complex patients. So while our patients aren't always homebound, we have a high proportion of patients who are truly homebound. We take care of patients who struggle to achieve primary care access in a brick-and-mortar setting. We take care of the patients who really struggle to find care in any other way, so we go to them, and we've always done that. That's always been our model. 

What has changed over the last two and a half years, largely as a result of the care model changes, is that we used to take care of the sickest 25% of the CMS population, and now our population is rising in its acuity level. So now we take care of about the sickest 15%. We admit sicker and sicker patients into our ACO as a function of the care model. It has to do with CMS rules and the mechanics of this, but that is our sweet spot. We do propensity matched pairing for our all of our patients, and then compare our performance across all other groups like us that take care of exact matches of our patients, and we are in the top quintile, so the top 95th percentile and above, particularly for advanced illness patients.  Now if you compare us to lower acuity patients, that’s not true, because we're a high-resource model.

HCI: How do you get your patients? How are they identified and made part of the ACO so that CMS tracks them through the MSSP?

Millie: We have this admission algorithm, for lack of a better term. Basically, we risk-stratify potential patients, and we do this in a really unique way. Other organizations that try to do what we do just do a polychronicity count. They count up the number of chronic conditions that a patient has; if they're above a certain number, they say, “This patient likely will fit our model.” The problem with that is that there is regression to the mean for a large proportion of those patients. We also count polychronicity, but a large proportion of our algorithm is looking at rising risk. We developed measures around frailty and other things that tell us which patients are likely to get sicker and progress over time. 

Patient acquisition comes in two ways. For our original Medicare patients who join one of our two ACOs in the advanced track for MSSP, those patients come to us largely via a community liaison team. We go out to the communities where these patients exist, and we just let them know that we have these services. Oftentimes it's during a transition. Discharge planners in hospitals who know we exist need a plan for a patient who likely isn't going to make it into their doctor's office. They call us, right? 

For Medicare Advantage, it’s largely contractual. What happens is a plan will say, I've got 3,000 patients in Houston who aren't accessing primary care for various reasons, and they're not doing well, so I need a team to go in and see them. Will you go engage the patient? So we do co-branded engagement campaigns with those patients. 

HCI: What about patients who are dually eligible for Medicare and Medicaid? 

Millie: More than 65% of our current patients are dual eligible, so that is part of our sweet spot. We know that as much as 70% of healthcare outcomes are a function of the social determinants of health. One of the four core pillars of the care model is focusing on eliminating social barriers to health. We have a care management team that includes social workers, but every single clinician on our team is, in addition to being a clinician, a social worker. We solve problems in real time.

In fact, let me describe my very first home visit after I joined the company. I'm in Detroit. I go with this doctor who's been with the company for 15 years, and we see a patient and it is kind of cold in the house. The patient's bed-bound in a hospital bed in an under-resourced living room. I thought he was going to ask her if she needed help paying her heating bill. She said, ‘Well, I can actually afford my heat bill, but I can't afford to have my furnace fixed.’ And he said, ‘Where's your furnace?’ She said, ‘Down in the cellar.’ I pulled out my iPhone flashlight. We went into the basement, and he fixed her furnace. Now that's the only time I've seen furnace repair on a ride-along visit, but that's the kind of thing that our teams are doing every day. 

HCI: Obviously going into people's homes is different than the traditional primary care office visits. But does it also require kind of a quarterbacking, team-based approach by the physician? 

Millie: The answer to that is absolutely yes. I quickly realized one of the reasons why I wasn't wildly successful in building this with all of the resources I had at Optum is because this isn't just routine primary care. I refer to our providers as sub-specialists of primary care. 

We have a term we use. It started as a joke. They do basically complex primary care in the home, and we started calling them “housepitalists,” which was a play on the term hospitalist, but it actually is really analogous to exactly what they are. They’re the eyes and ears of primary care for complex patients in the home, just like a hospitalist is for a sick patient in a hospital. So we call them housepitalists. A very significant portion of our clinicians are internal medicine-trained. A large proportion actually have geriatric training. 

We design our teams as pods. There is a physician who's the leader of a pod, and they have individual contributing providers, no more than four, who are either physicians or nurse practitioners, who work on their team. And that pod leader has full accountability for the performance of the entire team. The maximum number of patients in a pod would be 1,000 patients, or roughly 250 per individually contributing provider. 

Then we wrap that team with care management nurse that's embedded in the team. This is very important. It cannot be a box-checking centralized function. They have to be in the team. These people have to be on a first-name basis. I often say, if you aren't on each other's speed dials, this will never work, and they're calling each other constantly. 

The care management team is part of that. We have a care navigator and a community health worker who's out in the field helping them out. And then there is the outer layer of this circle: hospice, palliative care, home health. Even if those teams aren't touching a particular patient, they're showing up at our interdisciplinary care team meetings, and I call this the halo effect. They're providing their expertise, just in general, to the team on every single case that we discuss, even if they aren't consulting on it.

HCI: Would a lot of the things you're describing be tough to deliver in the fee-for-service world?

Millie: None of it existed before two and a half years ago. We had individual primary care providers just out doing their thing, and they were doing it well. We have long-tenured clinicians in the organization, and it's proof that just good, thoughtful access to primary care can bend the curve. I would say 50% of what we do is just provide amazing, thoughtful primary care. But going the extra mile beyond that requires all of these things I'm describing with team-based care. 

We have four pillars that really bend the curve on total cost. The first one is just thoughtful, meaningful primary care access, and we provide proactive access. We risk-stratify our patients. The sickest get more. Those less sick get slightly less. Our very sickest tier of patients is 5% of our patients, and they're seeing a minimum of every two weeks by a provider

The second one is something I've already mentioned, and that is that we recognize that 70% of outcomes has to do with the environment in which our patients live. And a very significant portion of them are dual eligible. Many of them have area deprivation index scores that are very, very high, so we are helping every day to remove the barriers to health that are socially determined. 

The third is that the type of admission that we have the most control over and when our patients are most vulnerable is during a transition. So we focus on transitions of care to decrease our readmission rate. CMS considers any all-cause 30-day readmissions a failure of the system, and so, do we. We reach out to them quickly. Within 24 hours of a transition, somebody from our care management team is reaching out and setting up a cadence of solving problems from them. We try to see them with an in home visit, in person with a primary care provider within one week of discharge. We do med reconciliation and medication education within one week.

The last main pillar of our approach is recognizing that around 25% of our very, very ill senior patient population passes away every year, so we focus on their values and how they want to transition through the last stages of their lives. We focus on compassionate value-based end-of-life care.

If we know that it seems like common sense that a primary care group would do these four things; well, nobody does these four things well. We're constantly trying to improve on them, and we are maniacal about making those things better every single day, and that's how we're bending the curve. 

HCI: HarmonyCares just got this infusion of capital pretty recently. What can that enable? Expansion to a lot of other states? Or is there infrastructure you need to build or clinician recruiting? 


Millie: All of the above. The biggest things it's enabling is technology and better tools that make it easier for our frontline teams to do the work. 

HCI: And is that something you would build in house, or work with vendors on or both? 

Millie: Both. We've been trying value-based care since the ‘70s and ‘80s, and in the '80s everyone failed miserably, right? One of the differences between then and now is the availability of metadata. So if you don’t invest heavily in knowing your patients and knowing your populations with great data reporting and analytics, you aren't going to be successful in this space. So we are investing heavily in data reporting and analytics. We're also looking at ways to make EMRs work better for us to manage populations of patients, and not just individual patients.