- The spread of delivery innovations has been limited by lagging payment models.
- Some providers have found commercial health plans to support innovative care delivery and others are becoming “payviders.”
- Medicare is expected to drive a big shift toward home-based care.
Where the future in healthcare already exists
Science fiction author William Gibson once said, “The future has arrived — it’s just not evenly distributed yet.”
Susan Dentzer, president and CEO of the Network for Excellence in Health Innovation, told attendees June 26 at the HFMA Annual Conference that the sentiment accurately describes certain innovative pockets of healthcare, from which the broader system could learn.
For example, the “hospital at home” concept was pioneered more than 20 years ago by Johns Hopkins Medicine but remains relatively rare. A 2012 Health Affairs study compared outcomes for patients who chose the hospital at home option — mostly elderly patient diagnosed with pneumonia — with a group of similar hospitalized patients and found the first group had slightly lower hospital readmission and mortality rates, and almost 10% higher satisfaction scores.
But the model’s use has been limited by the realities of the healthcare financing system.
“If you’re an institution structured around filling beds, this doesn’t seem attractive,” Dentzer said.
But Mount Sinai Hospital in New York has found success using the model under shared-saving arrangements with multiple commercial health plans, Dentzer said.
Widespread use of telehealth includes the Veterans Affairs Department’s more than 2 million patient encounters throughout its health system, which importantly is not subject to state scope-of-practice and clinician licensing requirements.
Alternate sites of care
In the commercial sector, Walgreens stores in New York City have installed kiosks that provide widely distributed telehealth access to emergency department (ED) clinicians. That has reportedly resulted in reduced costly ED use by those patients.
“It was much easier to walk into the kiosk right down the street,” Dentzer said.
She noted that among specific disease areas, researchers found success in remote care for Parkinson’s patients, according to a 2017 study in Neurology. Specifically, they found the approach received 94% satisfaction from physicians and 94% satisfaction from patients. Additionally, 74% of participants were interested in receiving future care through virtual visits.
When told by a conference attendee — a provider — that health plans were rarely willing to offer the payment models that would reward the use of such lower-cost sites of care, Dentzer urged them to keep searching because an increasing number of health plans are offering such arrangements.
“Go find the payer that will do this because they are out there,” Dentzer said.
Alternatively, an increasing number of health plans are purchasing providers, and providers are launching or partnering with health plans to launch their own health plans. Such “payviders” are increasingly using payment arrangements that are not volume-based, Dentzer said.
Medicare home-care shift
Dentzer noted one payer moving aggressively toward home-based care for kidney disease patients is Medicare, which spends about one-quarter of its outlays on such patients.
In a March address to the National Kidney Foundation, Alex Azar, secretary of the U.S. Department of Health and Human Services (HHS), said he is pushing to test “significant payment changes to boost home dialysis.” Currently, 88% of Americans with end-stage renal disease (ESRD) start treatment with center-based dialysis, while just 12% start treatment at home with hemodialysis or peritoneal dialysis.
“Improving this situation dramatically, as we ought to do, will mean examining the payment incentives in our programs today, while expanding access to new technologies,” Azar said.
Azar said HHS’s Center for Medicare and Medicaid Innovation is developing new models for patients not just with ESRD, but also stage 4 and 5 kidney disease.