The CMS Innovation Center’s Independence at Home demonstration has worked with medical practices to test the effectiveness of delivering comprehensive primary care services to chronically ill patients at home. With that demonstration project coming to an end on Dec. 31, a panel of experts at this week’s Primary Care Transformation Summit discussed what it will take to scale up home-based primary care for the home-bound population.
Bruce Leff, M.D., professor of medicine and director of the Center for Transformative Geriatric Research at Johns Hopkins University School of Medicine, kicked off the panel by describing the population being served.
Leff said researchers estimate that there are 7.5 million older adults who are homebound to some degree. They are more likely to have poor self-reported health and more likely to have symptoms of depression. They are more likely to have dementia, less likely to be able to walk a few blocks and much more likely to have been hospitalized in the past 12 months.
“So you have older adults who are homebound, seriously ill and they are hiding in plain sight," he said. Pointing to research that shows the high mortality rates of this group, Leff said, “I think if we were to substitute a word like a disease state instead of the word homebound and recorded a 65 percent six-year mortality, people would be up in arms and ready to fund a few billion dollars worth of research.”
Eric De Jonge, M.D., section director for geriatrics at Medstar Washington Hospital Center, has been making house calls for almost 30 years and have been operating a house call program that has served over 4,000 frail elders in Washington, D.C.
De Jonge said that when you think about whether home-based primary care is effective, there are three perspectives to think about: one is for the patients and families, another is the health systems or providers, and the third is for the payers. "What's kind of cool about home-based primary care is in the last 10 to 15 years, there's been major study after major study that actually show it's effective for all three of those perspectives.”
For patients and families, there are large, well-controlled studies about how caregivers and patients find peace of mind from the access to care, in addition to being more affordable, because they don't land in the emergency room, De Jonge said.
Study after study, including Independence at Home, have shown a reduction in total costs for that frail, elderly population — 10 to 15 percent per year, consistently, up to 30 percent per year in some of the best programs, De Jonge added.
Also, there's actually lower or similar mortality for people who get home-based primary care compared to usual care. The end-of-life care is considered significantly better because patients and families report that they get more responsive care or they get 24/7 access to their medical team, and about 70 percent of the deaths that occur in these programs occur at home, as opposed to a nationwide average of about 35 percent, he added.
Robert Saunders, Ph.D., senior research director of Health Care Transformation at the Duke Margolis Center for Health Policy, said that the Independence at Home pilot, which has been going on for over a decade at this point, has been one way that home-based primary care has been supported by CMS, “but there are clearly other ways to think about how home-based care can be embedded in a variety of payment models and we're seeing successful ways of doing that in the field now. It may be that we don't have a one-size-fits-all but there may need to be multiple approaches recognizing the diversity of home-based care out there.”
Leff asked if research shows that home-based primary care delivers savings and better outcomes, why it gets overlooked. “It does feel a like little a Rodney Dangerfield we don't get no respect kind of thing.”
Christine Ritchie, M.D., M.S.P.H., professor of medicine at Harvard Medical School, said that dating back to the early part of the 1900s our health system has been very hospital-centric. “As long as we're hospital-centric in all of our processes and approaches to deliver supplies and resources and labor, it’s very hard to pivot to a different setting and to actually think about that setting as being the cornerstone for care as opposed to thinking of the hospital being the cornerstone for care. So this is a big paradigm shift. I do think there is a growing recognition of the feasibility of it and and increasingly, the value of it, as Eric mentioned. Now we have to figure out how to teach people to ride the backward bicycle, to think about how to provide care in a way that we just haven't set ourselves up systems-wise to do.”
The conversation turned to what it takes to get health system financial executives to make up-front investments in these programs. “When Independence at Home was really in full force, we would get a share of the savings that we produced for taking care of the most sick, high-cost patients — and it wasn't just cost avoidance, it was real hard revenues for the good work that home-based primary care teams were doing in D.C.,” said De Jonge. “Once we were in the black, based on that shared savings payment, the conversation changed, and all of a sudden we were able to get approval for new FTEs and we were talking about expanding to new geography. We did that and then when Independence at Home comes to an end next month, and that shared savings is less available, it’s been a harder conversation. So it does come back to having a longer term financial plan.”
De Jonge added that Independence at Home defined a good clinical intervention and it had a payment model that was okay, but it you have to wait for your savings for a couple of years, it is not a realistic cash-flow situation. He suggested learning lessons from Independence at Home, and then applying them in a permanent way within CMS. “Maybe it requires legislation, maybe CMS just does it as a long-term benefit to then adjust the incentives so that it can be a really sustainable payment model but still retain those values of identifying the highest-risk people and maintaining the quality of services and almost a certification of the home-based primary care teams so that you can't just have every schmo or Joe go out there and say I'm going to tap into this new Medicare payment model. It has to be, I think, a fairly high bar for people who are going to participate.”
The panelists saw some potential pros and cons of the rapid shift to Medicare Advantage. Julie Sacks, M.S.W., president and chief operating officer of the Home Centered Care Institute, said, “It makes it possible to sustain a practice and do what you need to do to take care of this really complex patient population. It allows the practices to have the resources to really take care of them in the way they need to. So I think it's a really good thing. I don't know that it has to be necessarily Medicare Advantage, but value-based care can come in different forms.”
De Jonge said that there are some potential positives, but also some real risks in the growth of Medicare Advantage. “What we've seen on the ground, honestly, is that there are barriers to care for the most sick and homebound folks who are in Medicare Advantage. We've had arbitrary limits on home care visits and post-acute rehab care and a lot more prior authorization and restrictions on care,” he said. “My personal belief is that this is due to the profit motive of Medicare Advantage companies,. They do have the freedom to make value-based arrangements with home-based, medical care organizations. And I think if they wanted to pay for that full continuum and pay the full cost of a really good home based medical care service, that could work well with the agreed upon metrics and outcomes.”