Why did you decide to co-found Landmark Health? Can you describe its model and how it’s different?

I grew up in small-town Massachusetts where I watched my dad, a physician, do house-calls. After I became a hospitalist, I saw patients that would get better under my care in the acute settings, but invariably some would come back to the hospital a few weeks later despite extensive post-discharge office visits. The reason for these readmissions were not clear, so I thought, why don’t I go see these patients in the home like my father did? It is very eye opening going into the home, and you can see all the hoarding, the fall risks, the empty refrigerators, the medications not being taken, and then it really makes sense. This is the real root cause of why they couldn’t stay out of the hospital – it is just that no one ever gets to see this in a short office visit. It’s about addressing these social and behavioral determinants of health as well as the medical.

The Landmark model is a completely mobile medical group that is available to patients 24/7 in their homes. The business started when Adam Boehler (WUGR alumni, now running the Center for Medicare & Medicaid Innovation), and the three other Co-Founders came up with this model to bring care to the patient 24/7 and take risk from health plans. We offer an alternative to the ER and can triage and stabilize patients by doing a lot of procedures in the home – checking labs, starting IVs, administering IV fluids and meds, and checking X-rays, to name a few. We fully employ doctors, nurse practitioners, psychiatrists, nurse care managers, social workers, pharmacists and dieticians. It’s an intensive model and we can support this robust team by taking risk from our health plan partners or other risk bearing entities. Landmark receives a per member per month amount to cover our direct cost and guarantee that we’ll generate savings on these riskiest patients. If we cannot achieve total cost of care savings on this cohort, we’ll pay them back ensuring they are no worse off than before.

What sorts of improvements have you seen with this model?

Landmark targets the top 5-10% of a health plan’s most chronically frail and high-risk patients. These are typically money losing patients for the plans – the expenses required to care for them are more than what they get reimbursed for by the government – and the biggest driver of that cost is inpatient care. We have reduced hospitalizations by 20-40%, which translates into a significant reduction in the overall cost of these patients. From a quality standpoint, we can help improve the health plan’s CMS quality star ratings by bringing testing to the home. In addition, providing free 24/7 in home concierge-level care for patients is a huge patient satisfier and they become very sticky with Landmark. Patients receiving Landmark services have a 10x higher retention rate with health plans, so plan membership grows, and health plans have a way to brand themselves as innovators in the marketplace. We’ve also seen over 50% reduction in mortality rates in the first 12 months of care under Landmark services from propensity matched cohort analyses. From a documentation standpoint, we help patients get better coordinated care and help health plans accurately capture revenue on a risk adjusted basis. Finally, it’s a very satisfying program for patients. Our net promotor score is 90 or higher for 3 years running. That translates to the health plans and is a big competitive differentiator.

It seems like Landmark has recently expanded into more rural states (e.g., Louisiana, Mississippi, etc.). How has your business model had to shift to adapt?

For more rural areas, we’ve looked to have more telemedicine and remote monitoring. In a home-based model, if it takes an hour to drive to see a patient, it becomes less efficient and video visits combined with in-person visits helps in more rural settings. We’ve also leveraged ambassadors, or non-clinical staff, to do screening, either telephonically or in-person. Ambassadors go through a series of questions to identify triggers of need to escalate to a clinical team member. This helps us to most efficiently leverage our clinicians and their time.

Tell me more about behavioral health and social determinants of health.

We know that for the sickest and frailest patients, especially those with multiple chronic conditions, a very high percentage suffer from some sort of social or behavioral condition that is often undiagnosed and likely undertreated because of the scarcity of behavioral health resources in the community. From the very beginning, we brought on a psychiatrist, Dr. Chris Dennis, our Chief Behavioral Health Officer, to integrate the medical side with the behavioral side. He oversees a team of psychiatrists, addictionologists, psychiatric nurse practitioners and social workers that address the social and behavioral side, which often impacts utilization just as much as the medical condition. If patients have schizophrenia or bipolar disorder that is not being addressed, they will be non-adherent to medications and their medical conditions exacerbate.

What are some of the challenges in providing this behavioral health care model to patients?

There is a shortage of behavioral health providers. Attracting those providers to join Landmark is a challenge as it is for any medical group, but we have several unique benefits to offer. Instead of a clinic where a provider may see 30+ patients a day, on average a provider for the Landmark Behavioral Health Team is seeing 6-7 patients a day, and they have time go more deeply and thoroughly into issues. They are also supported by a full team – the medical, nursing, social work, pharmacist and dietician – which allows them to focus on their own area of expertise knowing that others are addressing the other issues. We also leverage quite a bit of tele-psychiatry visits, so that they can expand their reach.

From a patient standpoint, there is still some stigma around talking about behavioral health. We train our behavioral teams on motivational interviewing to get patients more comfortable with discussing this. We also mandate screening for behavioral health for all our patients to ensure we catch conditions early when more easily treated.

Outside of behavioral health, are there any other challenges with executing on the Landmark model in today’s environment?

For the existing community of physicians, there’s always a little bit of resistance to new things coming into the marketplace. ‘Am I going to lose revenue’, or ‘Why is this new provider seeing my patients?’ We educate PCPs that we view ourselves more as a specialist: our expertise is seeing all of the valuable information in the home and communicating that back to them. We do not replace the PCP and often get these patients plugged back with their PCPs and into the system. In addition, of the, say 2,500 patients on a PCP’s total panel, Landmark typically comprises only 4-5 patients, and they are probably some of the most challenging. After clarifying the model, primary care physicians are very happy to be able to have this sort of partnership that extends care and their visibility into the home.

You mentioned telehealth. How else do you use technology?

We have an Innovations Team that is actively exploring and innovating in terms of technology. There is a lot of testing that we can bring into the home, to close quality gaps and diagnose in real time, so that we can better triage patients. For example, we can capture secure images of wounds, send them back to our employed wound expert and get instructions on how to best manage the wound. We are also in the early stages of evaluating voice recognition. There are studies showing that voice recognition can be effective in diagnosing depression or even heart failure.

From a machine learning and AI perspective, this is also exciting technology that can help us to stratify our patients even more granularly. Right now, we have four stratification levels that drive different algorithms of touch frequency. We’re looking at how we can leverage machine learning and AI to create infinite stratification levels to more efficiently allocate our resources and clinical assets.

Do you see any changes to your business model in the horizon?

Any changes that drive more towards value-based care and away from traditional fee-for-service will benefit any organization that is involved in population health. We are seeing more traction towards this, so we view this as a positive overall for healthcare and for our business. With this trend, we see a lot of need and opportunity still in our current space and will likely stay fairly focused on our core risk business while still exploring some adjacencies around the edges.