After a decade, value-based healthcare is like buying a patient refrigerator

Health systems across the U.S. are questioning what value-based healthcare looks like in practice. When I meet Tim Curtin, vice president of community services at Memorial Healthcare System, he seems to get it—thanks in part to his work in theme parks and recreation during the crack epidemic of the ’80s.

Curtin was living in New York City at the time and was in charge of locking the gates of a small park in Harlem. The park would fill up with children after school let out, but when school let out time came, they didn’t want to go home. The children told Curtin that their parents and older siblings were abusing drugs and that they didn’t feel safe in their homes.

“So I said, ‘Well, if you guys want to hang out here, let’s open some books. Let’s do some homework,'” Curtin said. “I ran to the local bodega — I mean, it was so long ago, back then a Little Debbie was five cents and those little round bottles of the blue, juicy drinks were five cents each — so I bought about a half dozen of each. That was a snack. And we did our homework. And we talked about how not to end up like your older brother in the future.”

And then he accompanied the children home, “individually”.

It’s hardly surprising that Curtin pursued a career in social work and ended up at Memorial Healthcare System. The Hollywood, Florida-based organization has focused on value-based healthcare for about a decade and is nationally recognized for its work, including an Accountable Care Organization (ACO) that saved five times more than any other ACO organized in the health system in 2021 and a Social Determinants of Health (SDOH) Hub that has connected more than 900 patients with needed help in the past six months.

Curtin currently works at this SDOH center, leading a team of 322 staff who are employed by the health system but do not work in any of the six hospitals. Rather, these professionals work to improve access to care and outcomes in the community, beyond what is possible in a clinical setting alone.

Memorial’s community-based team – which includes social workers, mental health counselors and drug prevention specialists – leads initiatives for people of all ages experiencing all kinds of crises. The system operates senior centers and summer camps for children with special needs; it runs programs for new mothers overcoming maternal stress and for youth leaving foster care.

“Medical interventions are only about 20 percent of caring for a whole person,” Curtin said. “Their environment, their behavior, their access to healthy food, which they may not have, transportation options … all of these things make for a much healthier person. So we consider 20 percent of the work to be done in the hospital and the other 80 percent to be community issues.”

It’s similar to the philosophy Curtin followed in Harlem all those years ago. Children weren’t loitering in the park for the sake of loitering, but because there were no other safe places for them to be. Likewise, a patient who consistently misses appointments may not necessarily be forgetful – they could be lacking reliable transportation or childcare.

Memorial has been conducting population health needs assessments since 1994, but they weren’t made mandatory until the Affordable Care Act in 2010. The assessments provided information relevant to patient health, according to Curtin. For example, public housing in Florida in the early 1990s didn’t require air conditioning. Relentless heat can affect stress levels and sleep quality, which over time can even wear on patience – leading to an increase in domestic violence.

“Not only have we learned a lot about our community that we didn’t know at the time, but we’ve also learned to listen much better to our residents because they know what they need,” Curtin said. “We think we know, but they know.”

Today, when a patient arrives at a Memorial facility, a nurse or member of the admissions staff takes a medical history. If the patient indicates a need, it is flagged in Epic, the system’s electronic health record. The SDOH Hub is then notified and offers assistance to the patient.

Memorial maintains an extensive network of community partners to draw upon, including several food distribution sites and an organization that provides free new beds and bedding for children.

The system personalizes help wherever possible. In a recent case, a patient needed to refrigerate his medication after being discharged from hospital. Since he didn’t have a refrigerator at home, Memorial provided him with one free of charge.

These programs and donations are typically funded by grants and the system’s Memorial Foundation – and their results are paying off. From August 2023 to June of this year, 971 patients were referred to the SDOH Hub for food insecurity. After receiving the help they needed, the population experienced a 7.6 percent decrease in emergency department visits, a 13.9 percent decrease in admissions and a 5.3 percent decrease in readmissions.

Scott Wester, president and CEO of Memorial Healthcare System, also spoke about the cost savings from value-based care arrangements. Since forming an Accountable Care Organization with the Centers for Medicare and Medicaid Services (CMS), the system has saved nearly $70 million, which has been reinvested in the organization and its providers, according to Wester.

CMS has set a goal of putting all original Medicare beneficiaries and the “vast majority” of Medicaid beneficiaries in accountable care relationships by 2030. Participation is increasing—nearly half of people with traditional Medicare are enrolled in an ACO by 2024, a 3 percent increase from last year. According to a Jan. 29 CMS blog post, ACOs have “superior quality of care” over similar physician groups not participating in an ACO and have delivered year-over-year savings to the Medicare Trust Fund.

For Memorial’s high-performing ACO, the “secret sauce” is that “we drive analytics,” Wester said. “Then we make sure we’re doing things to drive down the cost of care. And that reduction in the cost of care is both price and utilization — we know you get more for your money on the utilization side.”

Like many ACOs, Memorial reduces dependence on costly emergency services by ensuring access to preventive services: primary care and a coordinated network of available specialists and pharmacists to ensure medication adherence.

The system is also increasing its use of technology to meet its value-based care goals, Wester said. It uses remote monitoring of patients to keep an eye on them after they are discharged from the hospital. So far, the system has seen a 48 percent reduction in hospital admissions, a 27 percent reduction in readmissions and a 28 percent reduction in emergency department visits in the cohort of about 1,000 patients who have used the technology.

“But the real kicker is a 47 percent increase in visits to the primary care physician,” Wester said. If a remotely monitored patient is found to have an abnormal vital sign, a care coordinator calls and tells them to see their primary care physician rather than go to the emergency room.

“We are all for value-based care,” Wester said. “For me, it comes down to something very simple: It’s about providing the right care for the patient.”

Curtin agreed, talking about the dozens of Memorial-sponsored fitness zones dotted around local parks. Every detail is considered. Sunshades protect the exercise equipment from the hot sun, and staff at the Hub are on hand to help people use it. If people don’t have transportation, the health system takes them there in a minibus. If they don’t have suitable exercise shoes, the health system buys them sneakers.

“One of our mantras here internally is ‘no barriers,'” Curtin said. “We’re going to break down every barrier, climb every mountain, and figure out how to drill a hole through that mountain if we can’t get through it. But we’re coming out the other side.”