National at-home primary care initiative saves millions

An Affordable Care Act payment model is showing that chronically ill patients can be better taken care of in their own homes while bringing down the long-term cost of care.

This Centers for Medicare & Medicaid Services (CMS) initiative, the Independence at Home Demonstration, was created in 2012 as a new delivery model linked to a Medicare shared savings payment incentive program connected to quality measures. The model uses home-based care teams targeted to the most complex, highest-cost and highest-risk patients.

The first year of implementation yielded successful results-saving $25 million, while improving care, according to CMS.

Virginia Commonwealth University (VCU) Medical Center has taken a lead role in the creation and design of the Independence at Home (IAH) initiative to test the advantages of home-based medical care, also known as house calls, for elderly patients too ill or disabled to visit their physicians.

During the Advanced Payment Models in Healthcare Conference 2016, held in Orlando, Florida, March 17 and 18, Peter A. Boling, MD, professor and chair of geriatric medicine at VCU Medical Center, shared VCU’s case study during his presentation, “Independence at Home-Insights from Virginia on a Shared Savings Model in Home Based Primary Care.”

Boling, MD explored some of the key insights from the design, implementation, and lessons learned for moving forward with implementation the IAH program on a larger scale.

How the model works 

The IAH program’s medical team provides home-based medical care and personalized care coordination to Medicare beneficiaries that have decreased mobility and high illness burden.

House calls provide the opportunity for providers to spend more quality time with patients, gain a much better understanding of the care environment and the patient’s goals, then match the care plan to actual needs. 

“The demonstration has shown great success to date,” Boling told Managed Healthcare Executive. “It is well targeted and has identified a pool of high risk of high-cost patients, and has a unique delivery model.”

In its first year, IAH has shown more savings than other demonstrations, along with high quality of care, according to Boling.

“Patients and families love house calls as an alternative to usual care, the teams understand patients’ and families’ needs and capabilities better than do providers who are office-based or hospital-based and the team can make more timely response to changes in condition,” he said. “The payment model supports home-based primary care teams and allows providers the time they need to manage the care of their patients instead of concentrating exclusively on maximizing the number of billed visits, as is the norm in fee-for-service care.

Next: Lessons learned through participating in the initiative

Lessons learned

VCU is one of 19 sites nationwide to participate in the initiative. The most successful sites created systems to track key data such as enrollment, utilization, and quality metrics.

Boling has recognized the value of this national learning collaborative to help teams improve and standardize processes, as well as having timely utilization data trends, which are generated internally by sharing information across sites. 

“We have also met unexpected delays in receipt of incentive payments, which has been difficult come budget time, as our programs incurred extra costs to participate in the demonstration,” he said.

However, he said, “There is always room for improvement. We learned a lot about risk adjustment for this very sick patient group. We have experienced problems with slow growth in markets with high-managed care penetration. Surprisingly only a few managed care organization have embraced this model so far, perhaps finding it difficult to conceptualize and integrate with their systems which are built on a facility-based, fee-for-service care model.”

Boling offers these lessons learned:

• Timely access to utilization data and strategic use is critical to manage care more effectively.

• There is a high value in sharing lessons through a learning collaborative.

• It’s important to develop an accurate risk-adjustment method that will allow timely payments of shared savings incentives.

• It is critical to ensure a cultural shift occurs from a team concentrating on fee-for-service income to one focused on patient outcomes; since everyone contributes substantially to success, teams are more collegial than hierarchical.

Next: Key factors critical to success

Key factors critical to success

“The key to home-based primary care [HBPC] is the team,” Boling said. “The providers need to enjoy making home visits, be dedicated to holistic comprehensive continuous care; have a broad range of clinical capabilities; communicate effectively with patients, families and other professionals; work well with the core HBPC team; and be able to use systems of care approaches effectively.”

The successes come from small local teams, who know local care systems and who can form close, trusting relationships with patients and families, he said.

Along with home visit providers, having a strong office support team is key to managing dispatch and routing, triaging clinical calls coming in during the day, and managing new referrals, Boling said.

“Social work support is also critical; the social circumstances surrounding these patients are often very complex and the social support systems are critical to staying at home,” he said. “Advanced skills in the community resource domain are vital to success.”

Like other clinical care models, there are myriad operational details that must be addressed, as well, according to Boling.

“Having a data local acquisition and management process are a critical component to success and this needs to be baked into the team model,” he said.

Next: Reimbursement models best suited for IAH integration

Reimbursement models best suited for IAH integration

The IAH clinical model is ideally suited to being a component of an accountable care organization (ACO) or MCO strategy, Boling said.

“In working with ACOs and MCOs the rules of engagement must be established from the start,” he said. “Which patients will be referred and managed, and how will the IAH team be compensated? There are a number of options, which should not rely too heavily on fee-for-service payments, but likely include a substantial monthly PMPM.”

Shared savings is another appealing option, he said. “This requires advanced actuarial processes to be fair. The patients have costs skewed far to the right of the distribution, and compensation will never be sufficient if based on models such as unadjusted HCC scores and related concepts such as the Medical Loss Ratio or the Medical Expenditure Ratio.”

IAH experience suggests that the enrolled population meeting IAH criteria has average annual costs of $50,000 to $60,000 and average Medicare savings in the range of $12,000 per year-about $1,000 per month-are attainable under IAH, said Boling.

“This advanced health home model works best when managed as a carve-out, to take full advantage of the income under shared savings,” he said. “The HBPC team needs financial support, likely in the range of $4,000 per patient-year in present circumstances, in addition to credit for fee-for-service billings.”

Boling said that he believes that IAH is poised to become a permanent part of the Medicare program, and should be supported.