House Calls Help Sickest Patients Avoid Hospital, Save Money

Laird Harrison

June 09, 2016

LONG BEACH, California — Doctors could care for their sickest patients more cost-effectively by treating them in their homes, researchers reported here at the American Geriatrics Society 2016 Annual Scientific Meeting.

Independence at Home — a program from the Centers for Medicare and Medicaid Services (CMS) — allows physicians to easily identify which of their patients are most likely to die or be hospitalized, said Bruce Kinosian, MD, from the University of Pennsylvania in Philadelphia.

By sending mobile teams of healthcare providers to the homes of these patients, the CMS saved $25 million in the program's first year. Of this, $11.7 million was passed on to the providers.

"It's a win for patients, a win for providers, and a win for the government," Dr Kinosian told Medscape Medical News.

The program started in 2012 with 17 practices and reached its cap of 10,000 beneficiaries in its second year. There are currently 15 practices in the program.

The mobile interdisciplinary teams are led by physicians or nurse practitioners, and include physician's assistants, pharmacists, social workers, and other staff.

The success of the program rests on three pillars, said Dr Kinosian, who participates through the University of Pennsylvania, which is part of a mid-Atlantic consortium.

 
It's a win for patients, a win for providers, and a win for the government.
 

The first pillar is paying providers to travel to the homes of patients to care for them there. This reduces the need for hospitals and nursing homes. "It's very effective because of the high trust that it generates," Dr Kinosian explained.

The second pillar is aligning financial incentives, which is achieved through the splitting of savings between the providers and CMS. A practice will qualify for an incentive payment if the cost of caring for a participating beneficiary is at least 5% lower than the CMS-estimated cost of treating the same patient outside the program. The nine practices that met this threshold received an average bonus of $9116 per beneficiary per year from CMS.

The third pillar is identifying the patients most likely to need expensive care. Qualifying for fee-for-service Medicare beneficiaries had at least two chronic conditions, needed assistance with at least two functional dependencies, had a nonelective hospital admission in the previous 12 months, and received acute or subacute rehabilitation services in the previous 12 months. These criteria were designed to be easy for clinicians to use, he pointed out.

Dr Kinosian's team estimate that 2.2 million Medicare beneficiaries fit the third-pillar criteria, which is 6.4% of the total fee-for-service Medicare population. In 2012, these patients cost CMS $3835 per month, which is more than four times the cost of the average Medicare beneficiary.

Forty-three percent of the patients who meet the third-pillar criteria are in the top 5% of the most expensive patients covered by fee-for-service Medicare.

Table. Independence at Home Program Annual Outcomes

Outcome All Program Participants, % Program Participants as a Percent of All Fee-for-Service Medicare Beneficiaries
Mortality 15 23
Long-term Institutionalization 12 38
Hospitalization 83 24
Readmission 28 46

 

This shows that the program successfully targeted the patients who cost the government the most, said Dr Kinosian. He said he was surprised by the results: "We didn't realize how high a risk group this was."

Although house calls appear to be a cost-effective way to care for this population, individual practices lose money if they take this approach in a fee-for-service program outside the demonstration program because CMS will not pay for the extra time these practitioners spend with each patient.

The findings suggest a huge potential to expand the program, but making it a nationwide program would require, literally, an Act of Congress, said Dr Kinosian. He expects such a bill to be introduced in Congress in the next few weeks.

Currently, Veterans Affairs Medical Centers are providing care at home for about 53,000 patients annually. It is estimated that this costs 12% less than standard care, he reported.

But it is worth testing whether other approaches could provide similar savings in the same population of high-risk patients, he said. "It's not that home-based care is the only way to treat them," he pointed out. "It's a good way, but there might be other models that are effective, too."

For example, the Massachusetts General Hospital in Boston showed that it could save CMS money by assigning nurse navigators to make frequent contact with patients, he pointed out. "It was very high-touch."

 
We have to go out there and care for people where they are.
 

After the presentation, one person in the audience wanted to know if electronic health records could help practitioners identify which patients meet the high-risk third-pillar criteria.

"We've done some of that already through the VA," said Dr Kinosian, who has worked on home-based care through the Corporal Michael J. Crescenz VA Medical Center in Philadelphia.

Another person in the audience wanted to know the percentage of patients in the program who died at home.

In the mid-Atlantic consortium, about 60% of the patients died over 3 years, Of those, 42% at home and 18% died in a nursing home, Dr Kinosian reported.

The results show that everyone benefits when care can be provided in patients' homes, said session moderator Ellen Flaherty, PhD, from the Dartmouth Centers for Health and Aging in Lebanon, New Hampshire.

"We have to go out there and care for people where they are," she said. "Having them live in facilities is just not sustainable in terms of cost, nor is it where people want to die. I think that's the real take-home message."

Dr Kinosian and Dr Flaherty have disclosed no relevant financial relationships.

American Geriatrics Society (AGS) 2016 Annual Scientific Meeting: Abstract P3. Presented May 19, 2016.

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