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After two years of experience with
their home-hospitalization initiative, leaders at Marshfield Clinic Health
System and its affiliate, Security Health Plan, are enthusiastic about the
Marshfield Clinic Health System is composed
of a large multispecialty medical group and three hospitals located in 34 Wisconsin
communities. In 2016, it partnered with a private company to start a program
that provides hospital-level care to patients in their homes.
Since then, Security Health Plan
members who require hospital care and who meet certain criteria are given the
option of being treated at home. The program has evolved as the partners have
gained experience, but they like what they have seen so far, says Marshfield
Clinic CFO Gordon Edwards (pictured at right).
In its first year, the program
reduced overall treatment costs by 30 percent for commercially insured patients—and
17 percent for patients in a Medicare Advantage plan—compared to similar patients
treated in an inpatient setting.
“The partnership is profitable, the
health plan is saving money, and the members are saving money,” Edwards says.
patient-satisfaction scores are high and clinical outcomes compare favorably to
those of similar inpatients, says Swetha Gudibanda, MD (pictured at right), a Marshfield Clinic
hospitalist who treats home-hospitalization patients. “I'm thinking this is
going to be the future of hospital medicine,” she says.
Hospital-at-home programs will work only
if payers are willing to support the innovation, Edwards says. Even though
pioneering programs have demonstrated good outcomes in quality, cost, and
patient satisfaction, most health plans are still on the sidelines.
That may change, however, if the
Centers for Medicare & Medicaid Services creates an alternative payment
model (APM) that supports hospital-at-home care. The Physician-Focused Payment
Model Technical Advisory Committee (PTAC) has recommended that the Center for
Medicare & Medicaid Innovation consider two bundled payment models—one
proposed by the Marshfield Clinic partnership, the other by the Icahn School of
Medicine at Mount Sinai—for home hospitalization. PTAC was established through legislation for the purpose of recommending physician-oriented APMs.
In June, Health & Human Services
(HHS) Secretary Alex Azar responded
to the PTAC recommendations by stating that HHS would explore “a model that
allows [Medicare] beneficiaries with certain acute illnesses or exacerbated
chronic diseases to receive hospital-level services in their homes.”
Marshfield Clinic’s Home Recovery
Program each month serves about 14 to 20 Security Health Plan members, most of
whom are referred into the program from the Marshfield Medical Center emergency
department. The program recently expanded to the health system’s new hospital
in Eau Claire, Wis.
“Home Recovery Care is all about
bringing essential elements of inpatient care to the comfort and convenience of
the patient's home,” Gudibanda says. “We see this as an opportunity to advance
our existing value-based care by extending it into the home.”
The program is staffed by:
The program accepts patients with
almost any diagnosis, with the following exceptions: surgery patients, pregnant
women, and patients who need intensive care or telemetry. If an ED physician
and Home Recovery Care coordinator agree that a patient is appropriate for home
care and the patient is amenable, a hospitalist is assigned to examine the
patient, discuss the care plan with the patient’s nurse, and place orders for
medication, medical equipment, and tests.
this is done, then we are set to send the patients home,” Gudibanda says.
the patient heads home—transported by a family member or hospital-arranged driver,
depending on the need—IV poles, a tablet used for video visits between patient
and clinicians, and other equipment are heading there as well. The patient’s
vital signs are monitored remotely. A registered nurse visits the patient at
home, and all clinicians—hospitalist, nurses, and therapists—interact with the
patient at home or via video technology as needed. Coordinators monitor vital signs, order medical equipment,
communicate with physicians, help with medication, provide patient education,
and help schedule follow-up appointments. A coordinator is available to
patients around the clock during their hospital-at-home stay.
Home Recovery Care partnership receives a bundled payment that covers the home
stay plus all necessary medical visits, lab testing, and medical equipment for
a 30-day period. Patients are admitted to and discharged from the
hospital-at-home program, but their stays are not categorized as hospital
admissions and they do not incur inpatient copays, Edwards says.
Marshfield Clinic is among a group
of hospital-at-home pioneers that also includes Presbyterian Healthcare
Services in New Mexico, which launched its program in 2008. An analysis
of its early results—patients served by the program between Jan. 1, 2009, and
Dec. 31, 2010—found comparable or better clinical outcomes compared with
similar inpatients, higher patient-satisfaction scores, and 19 percent lower
costs. The lower costs were attributed to a shorter average length-of-stay and
the use of fewer lab and diagnostic tests.
More recently, researchers reviewed
the performance of the hospital-at-home program at New York City’s Icahn School
of Medicine at Mount Sinai, the recipient of a federal Health Care Innovation
Award to demonstrate the clinical effectiveness of hospital-at-home care
bundled with a 30-day post-acute period of home-based transitional care. The study—295
patients enrolled in the hospital-at-home program—is believed to be the biggest
of its kind.
The research team compared the
experience of hospital-at-home patients with a control group of patients who
qualified for the program but either refused at-home care or were evaluated in
the emergency department during weekends and weeknight hours, when
hospital-at-home clinicians were unavailable to enroll them.
The study documented that more than
half of patients with hospital-at-home qualifying conditions were served by the
novel program. (Of 406 patients who were approached by the hospital-at-home
team, 19 were ineligible because of clinical instability or home factors and
146 refused.) The four most frequent admission diagnoses were urinary tract
infections, community-acquired pneumonia, cellulitis, and congestive heart failure.
Patients treated in their homes with
30 days of post-acute transitional care had shorter acute-care length of stay,
lower odds of hospital and emergency department readmissions and skilled
nursing facility admissions, and higher patient ratings of care compared with the
control group of inpatients. Total costs of care were not analyzed.
Health Plan sees hospital-at-home care as a high-value proposition because it
lowers the patient’s out-of-pocket costs and the total cost of care, while
delivering high patient satisfaction and good clinical outcomes, says Eric S.
Quivers, MD (pictured at right), chief medical officer.
example, in the first year of the Marshfield Clinic program—from September 2016
to September 2017—11 Security Health Plan members were treated for cellulitis
in the hospital-at-home program, and the health plan’s cost per episode was
roughly $11,000, which included physician fees, readmissions, and all other
related costs. Inpatient treatment of that diagnosis would have cost nearly
$13,000, not including the additional costs related to the 30-day episode.
Home Recovery Care costs to historical inpatient costs, the insurer saved about
$1,600 per episode, or nearly $18,000 on those 11 patients, Quivers says.
total, the health plan saved $101,732 in the first year of the program, which
got off to a slow start because it was limited to a handful of DRGs: congestive
heart failure, chronic obstructive pulmonary disease, deep vein
thrombosis/pulmonary embolism, urinary tract infection, cellulitis, and
In the second year, the list of
conditions was expanded—to 151 DRGs —and the health plan saved $129,122 in the
first 3.5 months.
cost savings are partially attributable to improved outcomes. In the first
year, patients enrolled in the home-hospitalization program had a 57 percent
lower 30-day readmission rate, and the mean length-of-stay was 34 percent
shorter than for comparable inpatients.
patient satisfaction scores for the Home Recovery Care program are around 93
percent since its inception. Patient satisfaction with the program is consistently
higher than that of traditional inpatients, Edwards says. “That makes sense
because you don't wear funny gowns, you've got your own bed, you've got your
family support around you,” he says. “Receiving care at home rather than a
hospital setting can be a more comforting environment.”
Lola Butcher writes about healthcare business
and policy topics for several HFMA publications.
Interviewed for this article: Gordon Edwards, CFO, Marshfield Clinic, Marshfield, Wis.; Swetha
Gudibanda, MD, hospitalist, Marshfield Medical Center,
Marshfield, Wis.; Eric Quivers, MD, chief medical officer, Security
Health Plan, Marshfield, Wis.
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