Two Sides

By Laura Sander, MD MPH

“The blue side is what I display to people and the dark side is just that. The thoughts that race in my head are in yellow and white. Red is anger. The dark side of my mouth is because I say things I shouldn’t…”

SD is best able to express her emotions through art therapy. She is a 24 year-old mother, trauma survivor, and has been sick as long as she can remember. When we met in late 2014, she had an undiagnosed autoimmune condition; had not been in psychiatric care since age 18; had limited access to food, difficulty paying rent, and was on the verge of being evicted. SD was in need of intense attention to all aspects of health – medical, behavioral and social.

We are Priority Access Primary Care (PAPC), a primary care team dedicated to high-cost, high-needs Medicaid patients. In this unique partnership between Johns Hopkins Community Physicians and Johns Hopkins HealthCare’s Priority Partners Managed Care Organization, we identify patients based on disproportionate total costs, and the number of ER visits and hospitalizations. In the prior 6 months, SD went to the ER 27 times and had 2 admissions. Her healthcare costs reflected this high utilization: $82,000 in the prior 6 months, and over 7 times expected for her age and health conditions. Her costs were disproportionate as the majority of her care was inappropriately in the ER and hospital.

PAPC emphasizes primary care to combat high ER and hospital costs. Our patients encounter 45-minute visits with focus on care coordination; integrated behavioral health services via an embedded clinical social worker; and integrated social services via a community health worker. SD was connected to specialists, diagnosed and started on treatment for Crohn’s disease; diagnosed with bipolar disorder and engaged in group and art therapy; and has been connected to multiple social services.

Like all our patients, SD has 24/7 direct cell phone access to a provider for urgent needs, and we are notified immediately when she presents to ERs. We assist with care transitions, and do home visits for acute or chronic needs. By focusing on primary care, SD has had no hospitalizations, and her ER visits decreased by two-thirds, to 9, in the last 6 months. Her costs decreased by more than half – to $37,000.

Representing two sides of our health system – delivery and payer – PAPC has aligned financial goals with our duty to serve our most vulnerable Baltimoreans. As such, we deliver appropriate, high-quality care at a reduced cost. We have more than 50 patients who, like SD, have complex health needs and require extension of traditional biomedical models. In less than one year, by investing in and intensely caring for our sickest and costliest patients, we achieved a 20% return on investment. We have learned much from others engaged in similar work and are continually evaluating, improving and sharing. Benefits start at the individual and extend to the health system, affecting both sides of our health system and all aspects of our patients.


Laura Sander, MD MPH was a contestant in the 2015 Contest entitled “The Best Care, The Lowest Cost: One Idea at a Time.” She is also Medical Director, Priority Access Primary Care Program at Johns Hopkins.

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