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Experts say home medicine is ripe for expansion

When results of the Medicare Independence at Home Demonstration are released this spring, advocates are hopeful that the data will go a long way to expanding the field and reimburse for it.

Between America’s retirement wave, the rise of consumer technology and the crisis of health quality and spending, home care medicine is “really at the sweet spot at where everything is going in healthcare,” said Constance Row, executive director of the American Academy of Home Care Medicine. Deploying teams of physicians, nurses and emergency care workers gives seniors healthcare “that anticipates their needs,” monitoring vital signs, diagnosing and treating small problems, helping with medications and also offering a meaningful social support on a regular basis.   

There is clear evidence for the benefits of home-based medicine and demand from seniors who are aging in place, Row said. “Patients do not want to be institutionalized. Hospitals are dangerous places, especially for the frail elderly. The field of geriatrics suggests that frail elderly should not be anywhere near the hospital unless they have to be. Nobody wants to go an ER or be hospitalized,” said Row, who previously led hospitals Maryland, including Calvert Memorial.

One of many Medicare pilot programs in the Affordable Care Act, the three-year Independence at Home demonstration was launched in 2012 to test the effectiveness of comprehensive primary care provided to high-cost, high-risk and home-limited seniors with comorbidities at home. Among the 15 participating providers were a mix of major hospital systems, and dedicated private practices, such as the Cleveland Clinic, North Shore Long Island Jewish Health Care, Housecall Providers Inc. in Oregon and and the Visiting Physicians Association, in Michigan, Wisconsin and Texas.  

As Row sees it, the federal government is catching up. But with the goal of value-based payments, that’s changing.

The Centers for Medicare & Medicaid Services put the providers in the Independence demonstration to the task of establishing a solid evidence base for home-based healthcare, in terms of reducing hospitalizations and high-cost interventions, and Row believes it will lead to dedicated Medicaid reimbursement.

The providers in Independence at Home are performing longitudinal home visits and reporting on quality metrics and patient satisfaction. The Independence providers are tasked with being self-financing, receiving no upfront payments that are used in some other demonstration programs. Those that save 5 percent or more of the patients population’s baseline pre-demonstration Medicare costs can share savings with Medicare.

Depending on the results of those demonstrations, and Row says early evidence is promising, Independence at Home could become a permanent Medicare benefit, if it were added by Congress. Or, it could be added by regulation specifically for Medicare ACOs. CMS could “encourage every ACO to have one of these programs for its high cost patients,” through either a direct incentive or by contract. The new chronic care coordination payment could also “bring in enough revenue to help these payments break-even.”

Some of the Medicare ACOs actually did have house calls programs, Row said, and “the results were very strong for these Pioneer ACOs,” including the Montefiore-North Shore-LIJ ACO, which saved $3.5 million in its first year.

A number of health systems are also offering good home medicine options, even under fee-for-service environments. In greater Chicago, the Cadence Physician Group, a part of Northwestern Medicine, is developing a comprehensive program to capitalize on the patient demand for more convenient care. Cadence primary care docs and NPs will visit seniors in homes and assisted living centers and provide everything from EKGs and ultrasounds to immunizations and palliative medicine for those at the end of their lives.

Health systems can get an ROI with home care medicine by capitalizing on readmissions reductions, whether in Medicare ACOs, Medicare Advantage contracts or with their own Medicare Advantage plans. But “unless there is some kind of managed care option or ACO option, they will have to find a way of cross subsidizing,” Row said. Medicare Advantage plans especially “need to take advantage of this model,” she argued. “They do have the flexibility,” and also the membership — some 17 million seniors, a third of Medicare beneficiaries, and growing.

“We’re in the process of evolving,” Row said of the state of American home care medicine. “We are now beginning to see the emergence of large companies and smaller practices. Larger companies are likely to play a real role in providing the infrastructure, and make the best practices more replicable.”

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