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Service Delivery Innovation Profile

Advocacy Firm Assists Patients in Choosing Providers/Treatments and Coordinating Care, Leading to Quick Access to Services and High Satisfaction


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Snapshot

Summary

PinnacleCare, a private health advisory firm, provides individualized care management services that include an initial health assessment, an annual health plan/consultation, round-the-clock access to medical advocates and advisers, facilitated access to top specialists and medical institutions, and management of electronic medical records so they are available to patients and doctors instantly. Although no evidence is available on the program's impact on health outcomes, it has resulted in high satisfaction and renewal rates among members. In addition, anecdotal reports suggest that members are able to see specialists at leading academic medical centers quickly, usually within 1 week.

Evidence Rating (What is this?)

Suggestive: The evidence consists of post-implementation patient satisfaction surveys and renewal rates, along with anecdotal reports from members.
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Developing Organizations

PinnacleCare
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Use By Other Organizations

A growing number of for-profit patient advocacy and health care adviser firms are emerging, such as Patient Care of New Orleans and Health Advocate, Inc., of Blue Bell, PA. Some nonprofit organizations are also entering this field. For example, the Patient Advocate Foundation in Virginia provides free help to people with chronic, debilitating, and life-threatening conditions.

Date First Implemented

2002
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Patient Population

The average age of PinnacleCare members is 53 years old. Most are families, with 10 percent living outside the United States.end pp

Problem Addressed

Consumers face many challenges in selecting the best providers, coordinating their medical care and treatment, and making healthy lifestyle choices. With few resources to help, many consumers perform these tasks (often poorly) on their own, which takes up their valuable time and may undermine the quality of care they receive.
  • Few resources to help consumers: Most consumers have little professional help in choosing providers and in coordinating their care, and thus must rely on themselves and their family members to perform these tasks. Few resources exist to help them in identifying which provider or medical facility would be best.
  • Leading to lost time/income and suboptimal decisions: Spending time on these issues often results in a loss of income for patients or family members due to missed work. In addition, because patients and their families are not trained in how to choose providers or coordinate care, they may not be efficient or effective in doing so.
  • Putting patients at risk: Patients may be at risk of medical errors or substandard care because they choose inappropriate providers, and/or because providers and treatment facilities operate without the benefit of complete information about their condition and medical history, including which diagnostic or treatment services have been provided in other settings, and what medications have been prescribed by other clinicians.1

What They Did

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Description of the Innovative Activity

PinnacleCare provides individualized care management services that include an initial health assessment, an annual health plan/consultation, round-the-clock access to medical advocates and advisers, facilitated access to top specialists and medical institutions, and management of electronic medical records so they are available to patients and doctors instantly. PinnacleCare does not provide clinical services or medical insurance. Highlights of this patient advocacy service follow:
  • Thorough health screening and physician recommendation(s): On enrollment, each member undergoes a comprehensive health assessment to identify needs, risk factors, and goals. PinnacleCare then arranges a comprehensive, individualized physical examination, including appropriate biomarker screening and radiology studies or specialty consultations to identify or address existing health conditions and/or risks. PinnacleCare interviews and screens all providers to ensure that members will get the highest quality practitioners and expedited access to their services.
  • Annual plan and consultation: The team develops an annual plan for every member that is designed to proactively maintain good health and address any medical needs. Each member has one personal health consultation per year that focuses on relevant issues for the member and his or her family, such as nutrition counseling, sports medicine, physical therapy, or lifestyle coaching. The annual plan focuses on the need for prevention and early detection and sets specific goals to address the member's or family's health needs and goals.
  • Assigned advocate team: Each member is assigned an advocate team that includes a manager, several advocates (some of whom may specialize in a medical condition that affects the member), and support personnel who specialize in medical records management and research. One advocate serves as a member's key care manager, assisting with diet and prescriptions, accompanying them to medical appointments when needed, helping resolve problems with insurers, and consulting with the company’s staff physicians to get second opinions.
  • Researching and recommending best treatment and facilitating referrals: When a member faces a serious illness, PinnacleCare staff research the available treatment options, coordinate referrals for second or third opinions from top-level physicians in relevant specialties, and help identify the most appropriate institutions, clinicians, medical procedures, or clinical trials for the member, working within the member's insurance network if the member so desires. Through its network of senior-level contacts, PinnacleCare can expedite appointments so members receive treatment or see a specialist in a timely manner. PinnacleCare staff also write a 5-page report for the member that describes, in layman's terms, his or her condition(s) and treatment options.
  • Round-the-clock hotline: PinnacleCare provides 24-hour-a-day, 7-day-a-week access to a hotline staffed by advocates and an emergency physician. The service also provides domestic and international medical evacuations, international medical referrals for routine or emergency treatments, and assistance with prescription drugs when traveling.
  • Complex medical management: For members with serious, preexisting illnesses, PinnacleCare offers to help manage their complex medical needs, including coordination of second and third opinions, attendance at doctor's appointments, and multidisciplinary input from specialists with expertise in the condition(s). Members pay an additional fee for this service; please see the Funding Sources section for more information on member fees for various tiers of service.
  • Instant access to electronic medical record: The team organizes and updates members' medical records and stores them electronically so that they are accessible to members and their clinicians through PinnacleCare's secure Web site portal, which allows for rapid transfer of records to treating physicians anywhere in the world. All records are reviewed by a physician and are organized in a summary format that is useful to medical professionals in the event of an emergency.

Context of the Innovation

John Hutchins, PinnacleCare's founder, developed a program at Cleveland Clinic, marketing the clinic's services to affluent families around the world. He continued this work subsequently at Johns Hopkins University. Dr. Hutchins then decided to establish PinnacleCare as an independent patient advocacy service that would not be aligned with any particular medical institution but would facilitate access for clients with means to the best providers and institutions available nationally. It represents a model of how the health care system can work when resource constraints are largely absent. PinnacleCare currently serves 1,200 families, with a total of 3,400 members.

Did It Work?

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Results

Although no evidence is available on the program's impact on health outcomes, it has resulted in high satisfaction and renewal rates among members. In addition, anecdotal reports suggest that members are able to quickly access specialists at leading academic medical centers across the United States.
  • High satisfaction, renewal rates, and membership growth: In surveys, 93 percent of members report being highly satisfied with PinnacleCare's services, and 90 percent would recommend the program to a friend. The annual membership renewal rate is 89 percent, and membership growth has reached 50 percent per year.
  • Quick access to specialists at leading medical centers: PinnacleCare staff report that their members are able to see specialists affiliated with leading medical centers and gain admission to those centers for needed procedures within 1 week, on average.

Evidence Rating (What is this?)

Suggestive: The evidence consists of post-implementation patient satisfaction surveys and renewal rates, along with anecdotal reports from members.

How They Did It

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Planning and Development Process

Key steps in the planning and development process include the following:
  • Forging relationships with world-class institutions and physicians: PinnacleCare approached top physicians and medical centers in the United States about participating in the program, securing informal agreements from them to provide facilitated access to PinnacleCare members (as they typically already did for wealthy domestic and international patients). Because Pinnacle's affluent members may refer other patients from nontraditional referral locations, and because, in some cases, they may have such positive experiences that they wish to make donations, many medical centers decided to join PinnacleCare's network.
  • Forming advisory board: PinnacleCare recruited specialists, including department chairs at many leading academic medical institutions, to serve on the company's Medical Advisory Board.

Resources Used and Skills Needed

  • Staffing: The company has 130 employees, consisting primarily of the following:
    • Patient advocate teams: Patient advocates are nurses or clinical social workers with master's degrees and experience in health care management, geriatrics, hospice care, and/or other chronic care specialties. Other team members include medical doctors, hospital international program specialists, and concierge specialists.
    • Physicians and other clinical staff: One adult emergency physician and two adult and pediatric emergency physicians are available to support the patient advocate teams, while two part-time physicians regularly review medical records.
    • Medical researchers: A team of physicians and doctorate-level researchers performs research on treatment options and interviews clinicians and hospital administrators.
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Funding Sources

PinnacleCare
The program is funded by member payments, as these services are not typically covered by health insurance policies. PinnacleCare offers three tiers of membership, each with varying intensity of medical management services. Within each category, members can purchase additional sessions or consultations.
  • Live Well: This level, designed for healthy members, includes care coordination and other basic services. The initial setup fees are $3,000 for an individual and $7,000 for a family, with annual fees of $7,000 and $10,000, respectively.
  • Circle of Care: This level includes research on specialized care or disease management and opinions from the Medical Advisory Board. The setup fee is $4,000 for individuals and $6,000 for families, with annual fees of $12,000 and $16,000, respectively.
  • Vital Advantage: This individual-only membership offers intense medical management support for those with serious illnesses. The setup fee is $5,000, and the 6-month fee is $25,000. The member can renew this service or drop to a less intensive tier once the medical condition has been resolved.
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Adoption Considerations

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Getting Started with This Innovation

  • Define services, service area, and target clientele: Determine the range of care management and support services to be provided and whether the service will focus on a specific city or region, be open to everyone regardless of insurance affiliation, or align with a single health plan to serve its members.
  • Recruit staff clinicians and a medical advisory board: Recruit physicians and specialists to be advisers and to review charts, as needed. Hire nurses, social workers, medical researchers, and others who are capable of researching treatment options, arranging health care in the coverage area, and providing care management and coordination services to members.
  • Establish relationships with expert clinicians and medical centers: Establish relationships with primary care clinicians, specialists, and medical centers in the service area. Formalize what level of access members will have to their services.
  • Develop a system to provide electronic access to records: Create an electronic system that makes medical records easily accessible to patient advocate teams, members, and participating providers and that can be easily updated by authorized users.
  • Determine degree of interaction with health insurers: Decide if the service will negotiate with health insurers on behalf of members to resolve claims. PinnacleCare, for example, subcontracts with another firm to resolve insurance claims and disputes.

Sustaining This Innovation

Set fees according to members' severity of illness: For example, PinnacleCare finds that managing the health of the frail elderly requires more time and resources and therefore charges a higher fee to these individuals.

Use By Other Organizations

A growing number of for-profit patient advocacy and health care adviser firms are emerging, such as Patient Care of New Orleans and Health Advocate, Inc., of Blue Bell, PA. Some nonprofit organizations are also entering this field. For example, the Patient Advocate Foundation in Virginia provides free help to people with chronic, debilitating, and life-threatening conditions.

More Information

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Contact the Innovator

Miles Varn, MD
Chief Medical Officer, PinnacleCare
250 West Pratt St. Suite 1100
Baltimore, MD 21201
Phone: (443) 874-5982
Fax: (410) 400-7082
E-mail: mvarn@pinnaclecare.com

Innovator Disclosures

Dr. Varn has not indicated whether he has financial interests or business/professional affiliations relevant to the work described in this profile.

References/Related Articles

More information about PinnacleCare is available at http://www.pinnaclecare.com.

Footnotes

1 Committee on Quality of Health Care in America, Institute of Medicine. Crossing the quality chasm: a new health system of the 21st century. Washington, DC: National Academy Press; 2001. Available at: http://books.nap.edu/html/quality_chasm/reportbrief.pdf (If you don't have the software to open this PDF, download free Adobe Acrobat ReaderĀ® software External Web Site Policy.)
Comment on this Innovation

Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: September 29, 2008.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: August 13, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: March 10, 2011.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.