Oak Street Health announced the opening of its sixth center in Michigan this week. The network of health centers—which uses a value-based model of primary care for Medicare enrollees—has teamed up with Health Alliance Plan (HAP) and other payers at its new Burton location to offer a more holistic approach to healthcare for the most vulnerable populations.
“Together, we will serve our Medicare members with a fresh approach to healthcare that addresses both physical and social issues to help improve their quality of life,” HAP Chief Medical Officer Michael Genord, M.D., said in a statement.
The new location offers supplemental services such as transportation to and from appointments, classes on Medicare and behavioral health guidance in order to address all of a patient’s primary care needs.
To address other social determinants of health (SDOH), Oak Street offers social activities and physical classes to keep patients, especially seniors, from feeling isolated and inactive. The center also offers post-visit care including an around-the-clock patient support phone line and home nursing visits.
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Currently, Oak Street has a 94% retention rate. Since its inception in 2012, the centers have helped reduce its population’s hospital admission rate by 44% and emergency room visits by 46%. A majority of Oak Street’s patients are dually eligible for Medicare and Medicaid and pay zero dollars downstream for any healthcare services.
So, how has the company been so successful in helping vulnerable populations while still turning a profit?
One of the founders, Griffin Myers, M.D., chief medical officer of Oak Street Health, credits sticking to the company’s mission to rebuild healthcare to be personable, equitable and accountable. Myers left his work in emergency medicine and research six years ago to follow this mission and change the disturbing medical finding that as many as 80% of mortalities having nothing to do with a person’s quality of healthcare.
What’s unique is that Oak Street has been investing in social determinants since before it became an industry buzzword, Myers said.
“There was a gap in understanding what people need and what people were getting,” Myers told FierceHealthcare. “I think a majority of the healthcare systems are getting it intellectually, but a majority don’t have the financing mechanisms to do what’s right.”
Oak Street starts by engaging the population through 20,000 community events, which invite strangers to do free screenings that validate the need for SDOH opportunities. Some resources made available through Oak Street include behavioral health support, transportation and food benefits.
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Myers credits a big part of Oak Street’s success to its model. The model is being embraced by many in the industry, including the Centers for Medicare & Medicaid Services (CMS), so Oak Street is excited to be on the ground floor of this expanding national agenda. The center services managed Medicare and Medicaid patients by taking their full premium payments upfront, but then Oak Street pays for all services down the line from doctors visits to surgeries and even transportation.
“We don’t want to thrive until after the patients thrive,” Myers said. On average, the primary care system sees patients nine times a year, while the national average for Medicare beneficiaries is three primary care visits per year.
But meeting these needs efficiently and with limited resources means utilizing the best technology available in artificial intelligence and machine learning. While Myers notes that collecting as much data as possible is important, it’s useless if the business can’t generate insight.
Oak Street has its own proprietary software called the Canopy technology suite. It collects information from hundreds of data sources—from CMS claims to demographic output—and combines it with information collected specifically by Oak Street. So when a patient visits the center, Canopy walks the provider through evidence-based testing that is specific to the patient on that day. The questions could lead to a screening or follow-up then and there, at the point of care.
Myers notes that even with their concierge support and scheduling, 50% of referrals are not carried out by patients. Plus, seeing a specialist can be quite costly, so the center tries to handle the problem immediately through myriad resources.
Now, 80% of the time Oak Street patients are able to avoid seeing a specialist. So what’s changed in the past six years for Myers and his team?
While Oak Street has always believed that value-based care was sustainable and profitable, it seems the greater public is now starting to understand that this model is achievable on a larger scale. And when it comes to advanced technology, the company now has the ability to provide better outcomes for patients in hospitals.
For example, there were 50 factors named in the Annals of Medicine that give a patient the best chance of avoiding re-hospitalization. So Oak Street built these processes into its app to help patients make follow-up appointments, compose a medications list, coordinate care and all of the other factors necessary to avoid readmission. Since implementing this change in Canopy, Oak Street has seen a 15% year-over-year reduction in readmissions.
“I want our patients to have the highest expectations in America, because they deserve it,” Myers added.
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CMS’ recent announcement of direct contracting initiatives is connecting Oak Street’s team with folks who have similar goals. And no matter where one falls politically, Myers believes the people at the Department of Health and Human Services and CMS have good intentions and are making headway on the value-based system.
“It’s not going to be easy for anyone, but its about aligning Medicare problems with the resources that we have,” Myers said, saying that there is enough funding to make value-based care for all achievable. “Value-based models are the future.”
Oak Street Health will open a second location in Genesee County, Michigan, later this year in Flint, on top of the existing locations in Southgate, Hazel Park, Inkster and Detroit. Outside of the state, Oak Street has centers in Illinois, Indiana, Pennsylvania and Ohio.