How Does the Shift to Home-Based Care Affect Quality and Cost?

Many health systems are seeking to move care into the home as an alternative to hospitals and skilled nursing facilities. A panel convened by the Leonard Davis Institute (LDI) at the University of Pennsylvania last week discussed how this shift could affect the quality and cost of care.

“The widespread use of home-based care is uncharted territory, and there are many questions about how to achieve the goal of shifting more care out of institutions and into people's homes and potential barriers to successfully doing so,” said Rachel Werner, M.D., Ph.D., executive director of Penn LDI. “These include our continued reliance on fee-for-service hospital-centric payment arrangements in most cases, and unequal access to the technologies needed to successfully transition to care at home to name just a few.”

With acute hospital-at-home programs, there is a lot of evidence to suggest that there's better patient, family and caregiver experience and that home care is high quality by pretty much any quality metric, said Bruce Leff, M.D., director of the Center for Transformative Geriatric Research and a professor at Johns Hopkins University School of Medicine. For instance, he said, a national demonstration study involving Medicare Advantage plans in the early 2000s saw a 75 percent reduction in incident delirium — acute confusional states which can contribute to long-term cognitive decline in older adults.

Noting that this is a conversation about home-based care in general, Leff said that when you think about hospital at home in the context of a home-based care ecosystem, “you can start to do some very interesting things and keep people out of the facilities. SNF [skilled nursing facility] at home is a newer kid on the block with less data, but very promising. Early data suggests you can have good functional outcomes. And it seems like no one wants to go to a SNF, especially these days.”

Craig Samitt, M.D., founder and CEO of ITO Advisors, and former president and CEO of Blue Cross and Blue Shield of Minnesota, said the conversation about home care brought to mind the notion of working at the top of one's license. “What if we looked at optimizing care settings through a similar lens if our goal is to deliver more convenient, cost-effective, and quality care in the optimal setting? Wouldn't we want to drive a complete reconfiguration of where and how we receive care? If we would want to do that, I would envision that beyond just hospital at home, we should build an ecosystem that would deliver primary care, modern surgical specialty care, and chronic disease management via the home, mobile and retail or the cloud. It's not just hospital and not just SNF, and it's not just urgent care, although I think those are the three that are getting a lot more of the attention recently. In fact, to Bruce's point, if we redesigned toward the right ecosystem, I would think we would also include a focus on wellness, prevention, avoidance and cure in the home. It’s not just about shifting the old hospital system into houses, but significantly reducing the need for hospitalization in the first place.”

Werner asked Reed Tuckson, M.D., managing director of Tuckson Health Connections LLC and former executive vice president and chief of medical affairs at UnitedHealth Group, to discuss some of the issues related to health equity the shift to home-based care brings up.
People of color, and disadvantaged and marginalized communities do not very often have the resource base at the community level that migrates into the home to be able to help dissipate some of the challenges of managing patients in this environment, Tuckson said. Also, he said, “clinicians sometimes make decisions about appropriateness of care based upon their assumptions of the social environment, so many people who might benefit from this kind of care may not be offered it because of the assumptions that, in fact, it can't be done in that environment.”

Finally, he said, there are areas of the country where the patient base’s needs are very high but the hospitals’ capacity to be able to offer this type of service is very low. “As we start to identify workforce training needs, we're going to need to be able to use this as another spur to recruit people from underserved communities to not only be the primary care clinicians and nurse practitioners, but also the care managers, social workers in in-home support system that are needed.”

Meena Seshamani, M.D., Ph.D., director of the Center for Medicare at the Centers for Medicare & Medicaid Services (CMS), said that beyond its acute hospital-at-home waiver, CMS’ value-based care programs, such as its accountable care organizations, have leveraged the innovations of telehealth and being able to move care upstream to better coordinate care and manage health and social needs. She stressed that an important aspect of the federal government’s work is going to involve public/private partnerships. “As we do take care upstream and start thinking more holistically about what people need, that requires bringing together various pieces to build the capacity in communities, and not using an infrastructure of a hospital anymore, but you have an infrastructure of a home and the caregivers that are in that person's environment and addressing social needs.”

Home health and value-based care models

How does the shift to care at home connect to the shift to value-based care models? “The bigger concern that plans struggle with is whether we'll see appropriate and efficient utilization of hospital at home or care at home when it sits on a fee-for-service chassis,” Sammit said. “One of the hopes for care at home and telehealth is that care in those settings should arguably cost less than in the traditional care setting,” he added. “My concern, though, is if compensation for care at home or telehealth is paid at traditional rates, margins will be higher for the provider per home admission or visit, which could frankly incentivize an increase in utilization and drive an overall increase in costs, not a decrease. We solve for that by being more forceful in driving to a shift in payment to value-based arrangements. As we were developing value-based arrangements in Minnesota, it gave us the freedom and the opportunity to completely redesign the relationship between payer and provider so that we were more likely to waive prior authorization requirements for system partners that took capitation. I think payers are very rapidly going to be more likely to fully endorse the use of care at home if systems and payers are jointly accountable for the total cost of delivering care, regardless of setting.”

From the Medicare perspective, their authority is limited with the Medicare payment system, Seshamani said, adding that the acute hospital-at-home waiver is only in effect for the duration of the public health emergency. “But certainly there are opportunities for the innovations that we've seen during the pandemic to further all of our goals around improving outcomes, improving access, addressing equity, and also making care more affordable and sustainable.”

Leff said he agrees that more value-based approaches are needed for hospital-at home payment. “My read of the acute hospital-at-home waiver was a desire to move something out quickly when the administration was concerned that hospital capacity in the context of a COVID surge and to make it the least complicated for implementation,” he said. “But I do think there are more value-based approaches to thinking about hospital-at-home payments.” He mentioned “payviders” such as Humana are now getting very interested in the home space.
Leff added that he and colleagues submitted a proposal to the Physician-Focused Payment Technical Advisory Committee that was a 30-day bundled payment for hospital at home plus 30 days that was at risk with quality assurances as well. “So there are examples of payment mechanisms that could be a bit more value-based for future use.”

Sammit said it is important to align incentives to focus on total cost of care. “I don't think we want to create incentive systems that merely encourage or incentivize the shift of care delivery or hospitalizations from inpatient to outpatient,” he said. The benefit of more advanced payment arrangements that really look at the total cost of care is that if a health system were equally accountable for the total cost of a population, then they would think about the optimal use of settings for each clinical condition. “Frankly, if hospitalization isn't needed, whether it's inpatient or at home, then a hospitalization should not occur.”

Sammit said he advocates for a population health perspective and aligning health systems and physicians within a global payment system. “That is likely to achieve both of the things we want: care in the optimal setting and reduction of unsafe and unnecessary care that, frankly, we're still seeing too much of.”

In wrapping up the panel, Werner asked where the panelists saw this movement trending in five years.

“While I am excited about all of these movements, I am very concerned about what we have learned about this nation over the last couple of years,” Tuckson said. “Too many of us are out for me. You cannot assume that the resources at the community level to do some of the things that we've been talking about are going to be more robust.  In fact, you may have to assume that they may be less robust.”

More churches and community and social organizations are going to try to fill the breach, Tuckson added, and the question will be how successful those entities will be in filling the gaps. “Ultimately, in the political environment that we have today, and the sense of selfishness that we are seeing today, those are fundamental rate-determining steps here, in addition to all the wonderful things we have talked about, which include moving forward on payment design, payment delivery, and all those other blocking and tackling issues.”