A Nashville-based medical group called Imagine Pediatrics is partnering with health plans on a value-based payment model that brings 24/7 medical, behavioral, and social care and support into the homes of Medicaid-eligible children with medical complexity and special healthcare needs. The company’s CEO, George Boghos, M.B.A., recently sat down with Healthcare Innovation to describe the problem his company was formed to solve.
Prior to joining Imagine Pediatrics 14 months ago, Boghos co-founded and led AIM Clinics, which delivered evidence-based applied behavioral analysis services to children with autism and their families who are from communities that experience health inequity.
Healthcare Innovation: Could you talk about some of the access issues in pediatrics that your company is working to solve?
Boghos: Pediatrics generally is one of the last places for innovation in healthcare. My mother is a pediatrician, so I've grown around pediatrics my whole life. My observation is that pediatrics hasn't evolved one iota since I remember my mom practicing. It’s set up well to serve kids who are generally healthy. You go to a pediatrician a few times a year and you're spending maybe 10 minutes with your pediatrician, and that works for most kids. Who it doesn't work for is kids with chronic complex medical conditions. What that's led to is children and their families utilizing the emergency room at a very, very high rate – and unfortunately oftentimes being admitted to the hospital for completely preventable reasons, because they've got nowhere else to go.
What we are saying is, let's wrap around kids with medical complexities and their families a 24/7 virtual first, in-home care model by complex care pediatricians, by nurse practitioners, by therapists, dietitians, paramedics, and social workers — a full interdisciplinary care team that is really investing time to get to know these kids and their caregivers, and catch things preventatively through daily or weekly touch points, but also be there 24/7 for these families when they need the support. So in a nutshell that is what we are here to do.
HCI: What kinds of conditions do these children tend to have?
Boghos: It is the 1 to 2 percent of kids who have these complex chronic medical conditions such as severe unmanaged asthma or diabetes, cystic fibrosis, cerebral palsy, and they often have mental health comorbidities to go along with that. So that's who we're trying to solve this access problem for.
HCI: And what is the business model? Do you partner with payers?
Boghos: The way we do it is an entirely value-based population health model. We partner with Medicaid managed care organizations. We take full risk on the total cost of care for these children who qualify into our program, and we are here to manage their entire experience and care journey. We're not replacing anybody that they're working with. Our kids have PCPs. They've got specialists. They've got a ton of support, but we are there to fill the gaps. And our primary aim is to keep kids healthier and happier in their homes and out of the hospital when they don't need to be there.
HCI: You're explaining that this supplements but doesn't replace their existing doctors. But do your providers need to coordinate care with those traditional doctors they already have — and how is that information about what Imagine has done get shared with the child's regular doctor's office and vice versa, so that everyone is on the same page?
Boghos: That is a crucial point, because a lot our kids and families have five to 10 different healthcare providers involved in their care, and the last thing we want to do is be an extra layer in that journey and complicate things further. So we've invested a ton in our technology backbone. We work with our families through our patient app. We've got a population health tool that we've developed internally. We utilize an EMR and we are plugged into health information exchanges in the markets we're in. We’ve got ad-hoc one-on-one data integrations and connections with the big providers, pediatrics groups and complex care clinics where we're practicing. We are sharing that data on a daily basis. Whenever we've got an encounter with a child where we're looking at the care plan that their specialists or pediatrician developed, we are consulting with that pediatrician, and we are sharing information so everybody's in the loop.
HCI: I read that your company is working in Florida and Texas currently. Can you name a couple of the managed care organizations you work with?
Boghos: We are working with Superior Health Plan, which is Centene’s managed care plan in Texas, as well as UnitedHealthcare Community Plan of Texas and UnitedHealthcare Community Plan of Florida.
HCI: Is there a particular reason you are in those two states first?
Boghos: There's a lot that goes into it. A lot of the value we bring to our plan partners is helping them innovate and solve a need for a population that's difficult to manage historically. So it's based on states where the plans have had difficulty caring for children with medical complexity, and those states rose to the top. Secondarily, we become, an important part of the differentiation in the market for health plan partners, because they're looking to win bids or expand their market share in those states, and this could become an important differentiator for them.
HCI: Do you expect that in 2024 you'll expand and scale up into other states?
Boghos: Yes, that is our plan. We've got a lot of conversations going on with a variety of health plan partners in Texas and Florida, as well as in a variety of other states. Our goal is to be in a couple more states next year.
HCI: It seems like sometimes startup companies have a chicken and egg problem where a payer would want to see proof of quality and ROI before agreeing to a partnership, but it's challenging to get there when you don't have that initial contract. How do you show them the value of it before you've actually done it with an organization of that size?
Boghos: In two ways. One is that part of our founding team had done this very thing. We're talking about a virtual-first, high-touch model for children with medical complexities within a hospital system in the Midwest, and they saw great results doing it. Not only in terms of the satisfaction in the engagement of the families, but also in terms of reducing dramatically the unnecessary emergency room and hospital visits. So we had proof and data points, and published work being done. But more importantly, because the model is value-based in nature, we are truly putting our money where our mouth is. We are taking full risk. If we're not able to deliver outcomes, in terms of improvement on quality measures and preventing unnecessary hospital visits and reducing costs, the plan is no worse off. So that's the beauty of a full-risk model. Some of the plans are willing to trust us with that because they know we're perfectly aligned in doing the right thing for the patients.
HCI: Did Imagine get venture capital investment to start up?
Boghos: We were founded out of a group called Rubicon Founders, which is a Nashville-based venture incubator group made up of very experienced healthcare entrepreneurs and operators, who are trying to solve big problems in healthcare primarily through value-based care models.
HCI: Could you talk about any results you've seen early on in working with these managed care organizations?
Boghos: We’re still early. We launched with our first plan partner in January of 2023. What we've been able to accomplish is a pretty high engagement rate of the population we're serving. So we're currently taking on risk on close to 20,000 patients across those two states, Texas and Florida. We've been able to engage a very large percentage of them in a pretty short period of time. We touch base with our families, on average, about four times per month. That's anything from a chat on our app to a virtual visit to an in-home visit. We've done north of 50,000 patient interactions just in the first 11 months.
More importantly, we've got early claims results, so we're tracking healthcare claims data post-engagement with Imagine versus pre-engagement, and what we're seeing is approximately a 15 percent reduction in impatient volume, and about a 20 percent reduction in the total cost of care for these families, primarily driven by prevention of unnecessary emergency department visits, which oftentimes turn into lengthy admissions into the hospital.
HCI: Is one of the challenges finding the clinical teams to support scaling this up?
Boghos: I thought it would be our biggest challenge, but I've been pleasantly surprised with how well we've been able to attract really amazing teammates here. And a big part of the reason is this is very different from anything in pediatrics, right. We've been able to attract awesome teammates out of the PICU or NICU in a hospital or out of traditional pediatrics practices who really are yearning for the opportunity to develop very, very long-term, deep relationships with families and caregivers in a virtual-first model where they're really able to drive impact. Instead of a transactional type of relationship in a hospital where you're seeing a family at their worst, and then they're discharged, and you don't see them again, it's a really nice value for our care teams to be able to care for these families on a longitudinal basis and form those really, really deep relationships where you're not constrained by time limits of the 10-minute appointments.
The other beauty of our model is because it's virtual first, we are serving kids in very rural areas as well. We're able to have a team that's based in Houston serve children across the entire state of Texas, for example. So in terms of improving access and health equity, but also allowing us to hire the right talent and the best talent and be able to serve kids and not necessarily within driving distance is a really nice way for us to scale.
HCI: Do you think these virtual-first models are going to continue to evolve and be highlighted as ways to address shortages and target resources at patients who traditionally are underserved?
Boghos: I think so, and I hope so. You know, we spent a lot of time on our philosophy that virtual care is never going to completely replace in-person care. But it can dramatically augment it and dramatically improve the access issues. If you think about a small PCP practice in a rural part of Texas, we're augmenting their ability. We’re able to be there 24/7 for these families within minutes of when they need us. Improving that access issue is of huge importance to us and I think a lot of virtual-first models are going to be able to do that to the betterment of the families, the patients and really the entire healthcare system. So my hope is that we'll see a lot more of these, not as a replacement for in-person care, but as a way to dramatically augment the impact of in-person care.