FutureFocus July 10, 2019 Payor and In-Home Physician Led Complex Care Model

Lisa Remington

This issue of FutureFocus highlights the innovation of an in-home, physician-led model working collaboratively with a payor to manage complex care. The results are impressive after one year.  The model stimulates team-based care, a physician housecall's program, and the delivery of patient-centered care in the home.

Lisa Remington, President, Remington Health Strategy Group

Adam Boehler is leaving his position as the deputy administrator and director of CMS and Medicaid Innovation (CMMI). President Donald Trump is expected to nominate him to lead the Overseas Private Investment Corp. OPIC raises private capital to help development of emerging economies.

His position at CMMI was important to home and community-based providers. His work created models to pay primary care physicians based on value, tie prices of drugs administered in a doctor’s office to the amount other countries pay, and a drive to move more people to get dialysis in their homes.

Prior to joining the Department of Health and Human Services in April 2018, Adam founded several businesses, including home-based group Landmark Health headquartered in Huntington Beach, CA. The business and clinical model at Landmark focuses on chronic care management. Today, Landmark has a collaborative program with Blue Shield of California and a comprehensive home-based care program and a physician’s house calls program.

The Blue Shield/Landmark Program

Landmark is a comprehensive home-based care program for Blue Shield of California members with five or more specific chronic illnesses has been widely embraced in its first 12 months. The program uses data-driven algorithms to identify members qualified to receive community-based, physician-led care in plan members’ homes so they can better manage multiple complex health issues such as kidney and heart diseases, diabetes, hypertension, and depression.

More than 3,500 members have enrolled in the program since it launched a year ago. Those members used Landmark’s 24/7 access to care, and received more than 15,000 home visits for medical, behavioral, and social support services as well as urgent and post-discharge care.

The Landmark service is available at no additional cost for eligible members of Blue Shield of California and its subsidiary Blue Shield of California Promise Health Plan. Landmark medical professionals do not replace a member’s primary care physician or specialists; they work collaboratively with members’ physicians to reinforce the doctor’s in-office care plan.

“We are heartened to see so many of our members who can benefit most participate in this program, which delivers the right care at the right time and in the right setting – their home, at any hour of the day,” said Terry Gilliland, M.D., Blue Shield’s Chief Health Officer. “The enrollment of eligible members has outpaced our first-year expectations, and we are delivering on our goal to help members with multiple chronic illnesses improve their quality of life by better managing their conditions.”

How The Program Works

Blue Shield uses data-driven algorithms to identify members who qualify for the Landmark program, then invites them to enroll through letters and phone calls. Primary care physicians of eligible members are also notified about the program.

Key Findings in the Program’s First Year:

  • 92 percent of the participating members are enrolled in a  Medicare, MediCal or Cal MediConnect plan offered by Blue Shield or Blue Shield Promise; the rest are Blue Shield’s commercial health plan members
  • Average age of program participant is 72
  • Top 10 chronic conditions addressed:

Hypertension

99 %

Chronic kidney disease

76%

Diabetes

69%

Peripheral vascular disease

66%

Coronary heart disease

65%

Pulmonary disease

62%

Depression

55%

Heart failure

53%

Atrial fibrillation

37%

Cerebral vascular disease

27%

  • 15,550 home visits by a Landmark provider
  • 33,317 phone contacts by a Landmark provider

Blue Shield’s Landmark program is currently available in the following counties: Los Angeles, Orange, Sacramento, San Diego, Riverside, San Bernardino, San Mateo, San Francisco and Santa Clara.

 About Landmark

Landmark Health and its affiliated medical groups (Landmark) partner with health plans and delivery systems to bring patient-centric, in-home care to complex and chronically ill populations. Landmark Health and its affiliated Landmark medical groups (Landmark) partner with care delivery systems, including health plans, to bring additional care to high-need patients. Patients qualify for the Landmark program based on their current health state, number of chronic conditions and complex health needs.

The company bears risk for more than 90,000 lives across 13 states. Landmark is available 24/7 to patients and their families. Its value-based model relies on fully-employed, local multidisciplinary care teams to help drive long-term outcomes for patients by bringing medical, behavioral, social and palliative care to individuals, where they reside and when they need it. Landmark is bringing back the house call. Learn more at www.landmarkhealth.org.

About Blue Shield of California


Blue Shield of California strives to create a health care system worthy of our family and friends that is sustainably affordable. We are a not for profit, independent member of the Blue Cross Blue Shield Association with care for four million members, 6,800 employees and more than $20 billion in annual revenue. Founded in 1939 and headquartered in San Francisco, Blue Shield of California and its affiliates provide health, dental, vision, Medicaid and Medicare health care service plans in California. The company has contributed more than $500 million to Blue Shield of California Foundation since 2002 to have an impact on California communities.