A sustainable Medicare payment for home-based medicine is on the horizon, and some insurers are already major backers of the service. But health plans could be doing more, especially in Medicare Advantage.
Later this spring, the results of the Medicare Independence At Home Demonstration will be released, and home medicine advocates are hopeful that the data will go a long way to expand the field and reimbursement for it.
Between America's retirement wave, the crisis of health quality and spending and the rise of consumer technology, home-based 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. "Patients do not want to be institutionalized. Hospitals are dangerous places, especially for the frail elderly," said Row, the former CEO at Calvert Memorial Hospital in Maryland. 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."
On the flip side, deploying teams of physicians, nurses and emergency care workers gives at risk 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.
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 in their homes. Among the 15 participating providers are a mix of major hospital systems, like the Cleveland Clinic and North Shore Long Island Jewish Health Care, and dedicated home medicine practices like 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 to the needs of Medicare's most at-risk seniors. But now that's changing.
The Centers for Medicare & Medicaid Services put the providers in the Independence demonstration to the task of establishing an solid evidence base for home-based medicine, 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 ACO and Medicare pilot 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 a direct incentive or by contract. The new chronic care coordination payment might 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 sve $3.5 million in its first year.
A number of health systems are also offering good home-care medicine, 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.
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 of health systems and practices trying to launch a home-based medicine program.. 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.
So far, some Medicare Advantage insurers have embraced home-based primary care, including the largest, UnitedHealthcare. United was "an early adopter," Row said. In 2011, UHG's Optum subsidiary purchased Inspiris, a Tennessee-based in-residence direct care company serving medically complex, chronically ill, frail and elderly patients across 20 states.
In 2013, Cigna also acquired a home medicine company, Chicago-based Alegis Care, with the goal of deploying the service for its most-at risk seniors in Medicare Advantage plans.
"The rising numbers of frail elderly, the highest cost patients who need to be cared for in the community not in institutions" means that home-based primary care is a "great attraction to everyone from managed care organizations to accountable care organizations," said Row.
"We're in the process of evolving," she added. "We are now beginning to see the emergence of large companies," who "are likely to play a real role in providing the infrastructure and make the best practices more replicable."