Home-based primary care for these patients reduces the use of high-cost inpatient care and improves patient satisfaction, especially at the end of life.
The patient had multiple health problems and, over a 21-month period, 44 emergency department (ED) visits and 27 inpatient admissions, more than half of which included time in the intensive care unit.
Then Thomas Cornwell, MD, a house call physician, entered the picture. By seeing the patient in his home, Cornwell was able to understand and address his many issues holistically. In the first year under Cornwell’s care, the patient had one ED visit and one hospitalization.
“The following year, he had none,” says Cornwell (pictured at right), who founded Home Care Physicians in Wheaton, Ill., nearly 25 years ago. Now part of Northwestern Medicine Regional Medical Group in the Chicago area, he has made more than 32,000 house calls.
Based on the patient’s historical utilization pattern, he would have been expected to have 25 ED visits and 14 hospitalizations in a single year, racking up $176,000 in hospital charges. Those numbers hint at why, even though the delivery model has never gained widespread traction under fee for service, Cornwell thinks a tipping point is at hand.
Value-oriented payment strategies incentivize health systems to lower the cost of caring for a population of patients. Pointing out that 5 percent of patients account for 50 percent of healthcare expenditures, Cornwell sees home-based care as a way to make their lives easier while reducing their high-cost utilization of acute care services.
“When you are taking on financial risk, this 5 percent is where the greatest cost savings are,” Cornwell says. “That is where house calls really come in.”
Proving the Value
About 400,000 elderly Americans currently receive home-based primary care, Cornwell says. Programs vary widely in the scope of services provided and the mode of care delivery.
One of the longest-running and most-studied programs is the Medical House Call Program at MedStar Washington (D.C.) Hospital Center, started in 1999 by two geriatricians to reach patients who were too sick, frail, or disabled to travel to physician offices. The program, which serves an average of 550 patients a day, relies on philanthropic support and subsidies from the health system, in addition to insurance payments. Most patients are covered by fee-for-service Medicare, Medicaid, or commercial insurance; they are eligible for the house calls program if they are 65 or older, insured, have a functional problem that makes getting to the doctor’s office difficult, and agree to switch from their previous primary care provider.
About one-third of patients in the program are Medicare beneficiaries who receive home-based primary care through the hospital’s participation in the Independence at Home demonstration, sponsored by the Center for Medicare & Medicaid Innovation. Patient eligibility criteria for IAH include at least two chronic conditions, a non-elective hospitalization in the past 12 months, and problems with at least two activities of daily living.
The MedStar program’s success stems from a team-based approach to primary care, says co-founder K. Eric De Jonge, MD (pictured at right), a geriatrician and incoming president of the American Academy of Home Care Medicine.
A geriatrician conducts an initial at-home assessment that covers issues ranging from clinical and psychological symptoms to social and home-safety concerns. From there, a team that includes a nurse practitioner, social worker, and licensed practical nurse develops and implements a plan of care.
An analysis of 722 patients who were served by MedStar’s House Call program in 2004-08, along with a control group of 2,161 matched patients, found that patients in the program had 17 percent lower Medicare costs over two years of follow-up. They had significantly less hospital and skilled nursing facility (SNF) care than the control group, although their home health and hospice costs were higher. They had fewer subspecialist visits but more than double the number of generalist visits.
That study found no difference between patients in the program and the control group in either mortality rate or average time to death. But a different approach to end-of-life care is a likely reason that MedStar’s house calls program reduces high-cost inpatient utilization. About 60 percent of the program’s patients have the support they need to die at home with hospice care, while 25 percent die in a hospital and 15 percent die in an inpatient hospice facility.
In contrast, just 34 percent of Medicare fee-for-service beneficiaries died at home in 2009, according to an analysis of Medicare data. Nearly 70 percent had a hospitalization and 45 percent had a SNF stay in the last 90 days of life, and 29 percent spent time in an intensive care unit in the last 30 days before death.
Noting that most elderly patients say they want to die at home, Cornwell says home-based primary care increases patient satisfaction. His practice, HomeCare Physicians, cared for 230 patients who died in 2015; of those, 80 percent were at home and 76 percent were on hospice care.
Because house call programs generally require some form of subsidization, however, very few health systems provide the option to their patients.
“Most house call programs are not breaking even under fee for service because of the travel time and the staff costs,” De Jonge says.
But health systems could take a closer look at the ROI as the value movement takes hold. For example, Cornwell’s practice has received support from Central DuPage Hospital—now a part of Northwestern Medicine—for two decades. The hospital is now benefiting from the fact that house calls decrease 30-day readmissions—Central DuPage has never had to pay a penalty under Medicare’s Hospital Readmission Reduction Program. Similarly, because the vast majority of house call patients die at home, the hospital has a low mortality rate, which boosts its score in Medicare’s Hospital Value-Based Purchasing Program.
The financial equation for house call programs changes dramatically when the programs are rewarded for reducing costs to Medicare.
For the Independence at Home demonstration, MedStar is in a consortium with two other large health systems. In the first year of the demonstration, the consortium reduced Medicare spending by 20 percent, compared to expected spending for the patient population. That performance generated $1.8 million in shared savings.
Cornwell and De Jonge hope that results from the Independence at Home demonstration, now in its third year, will persuade Congress to make house calls a standard Medicare benefit. A Senate bill that would expand the demonstration and extend it for two years has bipartisan support.
Convinced that house calls for frail, elderly patients will eventually become the standard of care, Cornwell has started a nonprofit organization, Home Centered Care Institute, to help health systems and providers learn how to start and operate house call programs.
MedStar Health and seven other provider organizations—Cleveland Clinic, Icahn School of Medicine at Mount Sinai, Northwestern University Feinberg School of Medicine, Perelman School of Medicine at the University of Pennsylvania, University of Arizona Center on Aging, University of Arkansas for Medical Sciences, and University of California, San Francisco—were recently named to be the Institute’s first Centers of Excellence to spread home-based primary care best practices across the country.
Cornwell estimates the majority of primary care home visits are being made by only about 1,000 providers; he wants to train 5,000 clinicians and practice managers over the next five years.
“What’s the biggest roadblock to this becoming the norm?” he says. “It’s the work force.”
Lola Butcher writes about healthcare business and policy topics for several HFMA publications.
Interviewed for this article:
Thomas Cornwell, MD, physician, Northwestern Medicine Regional Medicine Group, Wheaton, Ill., and CEO, Home Centered Care Institute, Schaumburg, Ill.; K. Eric De Jonge, MD, co-founder, Medical House Call Program, MedStar Washington Hospital Center, Washington, D.C.