A primary care model that specializes in serving older adults through a team-based approach and considers the physical, psychological, and social needs of this population.

Longer, frequent appointments with doctors and care team members. Appointments average around 40 minutes, as opposed to the standard 15- to 20-minute primary care appointments.

Use of interdisciplinary teams to coordinate care, educate patients, and proactively manage disease. Patients have more convenient, individualized access to physicians, nurses, social workers, pharmacists, and behavioral health therapists. The care team also may include community health workers or health coaches who can help extend care delivery to patients’ homes.

Delivery of care under a risk-based model as opposed to fee-for-service (FFS). Although there are some senior-focused primary care clinics that operate under FFS, the frequency of appointments and higher up-front costs lends itself better to value-based payment models. Some senior-focused primary care programs will serve only Medicare Advantage patients.

Use of data for better care delivery. Many senior-focused primary care programs will build their own tools, platforms, libraries, or frameworks to track and engage patients and identify those most in need of attention.

Ownership models

There are many senior-focused primary care models currently in the market. Generally, ownership of these models falls into the following categories:

• Provider-owned: Northwell HouseCalls, Geisinger Forward 65, etc.
• Payer-owned: CenterWell, CareMore, etc.
• Private disruptor/startup: Oak Street Health, Iora/One Medical, etc.

Despite the different types of ownership, senior-focused primary care programs largely operate their care models in similar ways. There are minor differences in how defined their target market is, whether they are predominately home-based or facility-based, and what kind of payment models they participate in (i.e., how much risk they take on).

Typical target market

While any adult over 65 could benefit from senior-focused primary care services, the higher cost of treating these patients means that most organizations focus on certain segments of the population. Individuals are often one or more of the following:

• Medicare Advantage beneficiaries
• Polychronic individuals
• Low-income, underserved populations (includes high-risk Medicare/MA/dual eligible patients

The average age for seniors enrolling in senior-focused primary care programs is 70 years old. Most of these programs are in suburban and urban areas, given the concentration of patients in those locations. Although many models are facility-based, some will target home-bound seniors.

The growth of the senior population has created greater demand and interest for senior-focused primary care services. However, seniors struggle to find providers who will take the necessary time to help them navigate their health care environment and increasingly complex needs. The combined lack of access, care coordination, communication, and compassion profoundly impact patients and their families. Senior-focused primary care is part of a larger, innovative effort to improve care for older adults. In general, the touted benefits or markers of success include:

• Lower costs and improved outcomes due to reduced hospitalizations and readmissions
• Higher patient satisfaction with personalized experiences and services
• Better care coordination through a team-based approach

While industry leaders understand the benefits of senior-focused primary care, it can be expensive and labor-intensive. These programs rely on a team-based model and typically operate under risk-based contracts. But it can be financially challenging for organizations to invest in extended care team members (e.g., social workers, pharmacists, care managers, etc.), or in the technology needed to track and use patient data.

Opinions about the future of senior-focused primary care generally fall on extreme sides of the spectrum. One side sees it as a niche offering provided by disruptors in the market and is wary of the ability to scale offerings due to the significant labor challenges. The other side sees it as a revolution for the way we can reduce costs and improve the care experience for those in Medicare. The truth lies somewhere in between those extremes.

Through our research on senior-focused primary care and conversations with thought leaders in the field, we uncovered the following four insights:

1. The expected increase in Medicare Advantage beneficiaries will create a growing market opportunity for senior-focused primary care.

Senior-focused primary care programs generally operate best under value-based payment models. It allows them the flexibility to innovate and better manage their patient population. This has led many operators to focus on the growing Medicare Advantage (MA) population. Medicare currently covers nearly 64 million Americans, and more new beneficiaries are opting for MA plans over traditional Medicare. The Chartis Group projects that the number of MA beneficiaries will surpass those in traditional Medicare by 2025. This will increase the number of seniors eligible for senior-focused primary care. However, there are large geographic differences in MA penetration, which may lead to differences in access to senior-focused primary care by geography.

2. Senior-focused primary care has the potential to transform outcomes for seniors—particularly the sickest, frailest seniors—under MA.

Operating a model under risk and using a team-based approach can have a significant impact on health outcomes for the most vulnerable seniors. We measured the potential impact of senior-focused primary care on beneficiaries ideal for senior-focused primary care (as outlined on page 7) by comparing utilization under fee-for-service. We found that hospitalization reduction rates ranged between 15 and 40%. And assuming all million eligible MA beneficiaries are in these models, we estimated that senior-focused primary care models could reduce overall Medicare spending on hospitalizations by up to $7.4 billion in 2021, rising to $11.5 billion by 2030.

3. Recruiting and retaining a sufficient workforce for senior-focused primary care may exacerbate existing labor challenges across the rest of the industry—particularly for the non-physician workforce.

The finite supply of labor is a huge challenge for senior-focused primary care programs. To support our estimated 9.5 million eligible seniors (as outlined on page 7)—where panels range between 300 and 500 patients—the industry would need 15,000 PCPs (7% of the PCP workforce) by 2030.

Senior-focused primary care programs require more than just PCPs. The bigger constraint will be the need for advance practice providers (APPs), nurses, social workers, pharmacists, and behavioral health therapists. Attracting the workforce for these programs will create greater competition for labor across the rest of the industry, where there are existing shortages. It will also be difficult to train physicians and other staff to deal with older and more complex patients.

4. Entering the senior-focused primary care market is not easy, and it can take a long time to yield cost and quality results.

Many senior-focused primary care models take on full risk. Setting up risk-based payment models takes time and is a long-term commitment. And it can take time to see a return on investment, since organizations need to be able to prove quality outcomes—like reduced hospital admissions—in their patient population over time. Additionally, there are significant up-front costs in starting a senior-focused primary care program. Organizations will need to find capital to train and recruit labor, build technological capabilities, and create facilities. They will also need to determine how to penetrate the market and target eligible seniors willing to participate in their model.

To achieve the outcomes outlined in the previous section, new and existing senior-focused primary care programs will need to expand their offerings. This could include:

• Increased membership in existing markets
• Access to new markets and network partnerships
• Expanded services, new populations, or care delivery channels
• Increased margins or volumes

In the following sections, we’ll look at three strategies to grow senior-focused primary care.

As participation in senior-focused primary care increases, there will be several ripple effects across the industry.

1. Better connections between older adults and community-based services

As senior-focused primary care providers gather data on the social determinants of health for patients, they will be better able to identify needs and make connection to community organizations. As providers measure and evaluate these referrals, they’ll also be better able to determine how these community-based services can close gaps in care.

Stakeholder considerations

• Patients: Will see more seamless connection with organizations that will reduce their gaps in care.
• Health plans: Will need to identify and develop ways to manage and evaluate increasingly larger lists of community partners.
• Health plans and providers: Will need to decide what services to partner with in communities versus offering in-house.

2. Changes to downstream utilization

Senior-focused primary care changes where and how patients receive primary care, and may also impact downstream hospitalizations, post-acute care utilization, and specialty care needs. Many organizations report how their models decrease hospitalizations and ED use, since they inherently prevent the escalation of health care needs. For specialty care, private startup models have no ancillaries and no specialists and must partner with leading health systems to provide longitudinal care. In this case specialist volumes might not change, but networks might.

Stakeholder considerations

• Hospitals: Will see reduced hospitalization and ED visits, which may relieve capacity. But, given the types of hospitalizations avoided through senior-focused primary care, it’s unlikely this will have a significant impact on hospital margins.
• Physicians and hospitals: May see changes to specialist/hospital referrals from senior-focused primary care organizations. Better managing chronic care in older adults can reduce the need for downstream care. Also, senior-focused primary care providers may change referrals patterns to providers who can better meet cost/quality metrics.

3. Competition or partnership opportunities

The number of stakeholders in the market demonstrates that there is a lot of interest in senior-focused primary care across the industry. This is unsurprising, given the greater push toward value-based care, especially in Medicare. Physician groups and hospital providers can build their own models, or they can appeal to disruptors by partnering with them or earning their specialty referrals. Players in this space will need to know who is in the market and what specific value proposition they can offer patients and payers.

Stakeholder considerations

• Physicians and hospitals: Depending on the market, may be forced to decide if they want to buy, partner, or cede the space.
• Health plans: Will need to decide if they want to acquire or build their own senior-focused primary care arm or rely on contracts with other providers.

This report explores new and better ways to deliver care to older adults—and understand how industry stakeholders can play a role in setting up, partnering with, or supporting these efforts. Looking forward, leaders should keep in mind the following:

• The growth of the senior population, and their current lack of quality primary care options, will put pressure on the health care industry to deliver more personalized and holistic care.
• The rapid growth of the senior population alone won’t guarantee success in senior-focused primary care. There is a lot of competition within the space, there are significant upfront costs, and it is hard to attract and retain the workforce needed to care for high-risk individuals.

For additional information about caring for an aging population, check out www.advisory.com/seniors.