Approximately four million adults in the United States are homebound, and many of them cannot access office-based primary care. They are among the most costly patients in the U.S. health care system, not because of a specific disease but because of a powerful combination of multiple chronic conditions, functional impairment, frailty, and social stressors.
- The full scope of their needs is not met by any of the existing formal health services – ambulatory, hospital, emergency department (ED), hospice, or skilled home health care.
- Their needs and their limited ability to access primary care commonly result in unnecessary ED visits, hospitalizations, and downstream health care expenditures.
- These patients account for approximately half of the costliest 5 percent of patients.
Bruce Leff, M.D., Professor of Medicine at the Johns Hopkins University School of Medicine, and co-author of “The Invisible Homebound: Setting Quality-of-Care Standards for Home-Based Primary Palliative Care” (Health Affairs 2014), describes the complexities of caring for the vulnerable patient population.
In his article, he shares the story of Alice, a homebound chronic care patient. Alice represents millions of patients across the U.S. who suffer from our current healthcare delivery gap in post-acute care. Alice’s hardships has many connections to current policy and reimbursement challenges. If we want less emergency room visits and more management and control of readmissions, we will need to address the gap existing today in post-acute care services.
Alice is an eighty-five-year-old former clerical worker whose two sons live in a different state. She lives alone, and her sole source of income is Social Security. Medicare is her primary health insurance. Alice’s income from Social Security is just above Medicaid eligibility requirements. She has long-standing chronic heart failure, type 2 diabetes mellitus, hypertension, chronic kidney disease, diabetic retinopathy, osteoarthritis, and depression.
For years Alice paid quarterly visits to her primary care physician at an ambulatory care clinic. As her arthritis and depression worsened, it became increasingly difficult for her to leave her home. As a result, she missed her scheduled primary care appointments but continued to call her physician’s office for prescription refills.
A year after her most recent visit to her primary care physician, Alice was hospitalized for a flare-up of heart failure and was then discharged home with Medicare Part A skilled home health care services that consisted of home nursing and physical therapy services, but no primary care medical services. Two weeks after her discharge, Alice was readmitted to the hospital for heart failure. This time she was discharged to a skilled nursing facility and then sent home with skilled home health care services.
Because of her functional impairments, Alice remained unable to see her primary care physician. Her recent hospitalizations resulted in accelerated functional decline: Walking around in her home became more difficult for her, and she had substantial difficulty with bathing and dressing. A neighbor brought her groceries, which consisted mostly of prepared foods that she could microwave. Her diabetes control deteriorated as a result of food insecurity, pain from her osteoarthritis, and worsening depression, which affected her physical activity and adherence to her medical regimen.
Alice remained too sick and functionally impaired to visit her primary care physician. Ironically, she was likely in greater need of medical attention than most of the patients that her physician saw on a given day. And there was an additional irony: From a care standpoint, Alice probably qualified for additional Medicare skilled home health services at this time. But because such services need to be ordered by a physician who sees a patient in a face-to-face clinical encounter, she could not receive them.
When Alice developed additional symptoms from her heart failure, diabetes, or other conditions, she called an ambulance to take her to the ED and was admitted to the hospital again. In the hospital, Alice was cared for by well-meaning providers, but they had limited knowledge of her medical conditions, goals of care, or care needs. A vicious cycle of repeated hospitalizations ensued, leading to further disability. Eventually, Alice was admitted to a nursing home.
Alice’s experience exemplifies that of millions of mostly homebound older adults in the United States.
Current Policies Impacting Alice
Can value-based care in post-acute services occur when existing policies don’t mesh? It’s time to look at the “cog” in the wheel hindering innovation. I’m referring to the existing “homebound” requirement in home health services.
The definition of homebound varies across studies, as have estimates of the size of the U.S. homebound population. Medicare, for example, uses its own definition to define eligibility for Medicare skilled home health services. The Medicare definition of homebound requires that a patient be “confined to the home.” That is, to leave the home the patient must need the aid of supportive devices or the assistance of other people or must have a condition that makes leaving the home medically contraindicated. In addition, there must exist a normal inability to leave home, and leaving home must require a considerable and taxing effort.
The Medicare definition may be too narrow to use as a definition of the population that may benefit from in-home medical services. Data from the U.S. census suggest that as of 2006, over 4.3 million older adults could be classified as homebound. (Health Affairs)
The presence of multiple chronic conditions and functional impairment among homebound people, especially older adults such as the fictional Alice, is common. Most homebound patients have multiple chronic conditions such as cardiovascular disease, diabetes mellitus, hypertension, and osteoarthritis, as well as other musculoskeletal diseases. A recent study demonstrated that over 70 percent of homebound patients had two or more chronic conditions.
The post-acute care “gap” occurs when the patient is discharged from home health (no longer qualify for homebound status), their illness still requires care management, and the patient is not ready for palliative care or hospice.
I refer to these patients as the “Black Hole Patient Population.” Patients still continue to need longitudinal care management for their chronic disease, but options are few based on current reimbursement and policy existing today. This is not a patient population that continues to improve. It’s quite the opposite. Taking a look at two current quality measures, we can see where the “gap” impacts the ability to make significant improvements.
1. Medicare Spending Per Beneficiary (MSPB)
Fixing the “gap” can impact cost per beneficiary. If 40.3% of spending that comprises the MSPB measure occurs outside the walls of the hospital, the healthcare delivery system must allow for continuous “uninterrupted” care for patients utilizing post-acute services. When options for care are not available because of the “gap,” the spend can only be controlled by the only services available for treatment.
The “gap” in post-acute care services, if addressed, can have a valuable impact on reducing readmissions and ED visits. The alarming number that CMS will penalize 2,597 hospitals for excessive readmissions rates for this coming year, withholding a total of $528 million in Medicare funding is a signal that change is needed.
Per Capita Spending for Medicare FFS Beneficiaries by Number of Chronic Conditions
Two relevant pieces of data make the point about MSPB. MSPB costs in post-acute services increases by type of service and age of the patient. (See Table 1). The cost of MSPB also increases with the number of chronic conditions. (See Table 2)
The question must be asked: Might the 40% of spend beyond the hospital walls be reduced if patients were placed in the right care, at the right time? If the post acute care “gap” was addressed, wouldn’t readmissions and ED visits be further reduced?
Examples of How the Post-Acute Care “Gap” is Being Addressed
High cost, chronic care patients are getting some relief through the Independence at Home Care demonstration (IAH) and through home-based primary care. Both models are promising ways patients can receive “uninterrupted” care management in their homes.
The Independence Act
The Independence at Home Demonstration (IAH) is providing solutions for patients like Alice and a tightening of the post-acute care “gap.” Legislation has been introduced in Congress to make the Independence at Home program accessible to all high cost, frail Medicare beneficiaries nationwide. (Independence at Home Act of 2016 (S. 3130). That bill has bipartisan support and has been supported by more than 70 consumer, practitioner and providers associations.
The IAH is part of the Administration’s broader strategy to improve the health care system by paying practitioners for what works, unlocking health care data, and finding new ways to coordinate and integrate care to improve quality. In March 2016, the Administration announced it reached its goal, nearly one year ahead of schedule, of tying 30 percent of Medicare payments to alternative payment models that reward the quality of care over the quantity of services provided to beneficiaries.
The Independence at Home Demonstration continues to provide high quality primary care services for chronically ill Medicare beneficiaries in the home setting while saving the Medicare program money, according to analysis by the Centers for Medicare & Medicaid Services (CMS).
“The Independence at Home Demonstration is a patient-centered model that supports providers in caring for chronically ill patients in their own homes,” said Dr. Patrick Conway, CMS acting deputy administrator and chief medical officer. “These results continue to support what most patients already want – the ability to have high quality care in the home setting”.
The CMS analysis found that, for the second performance year, Independence at Home participants saved Medicare more than $10 million – an average of $1,010 per beneficiary – while delivering higher quality patient care in the home. CMS will award incentive payments of $5.7 million to seven participating practices that succeeded in reducing spending while improving quality.
In the second performance year, 15 practices served more than 10,000 Medicare beneficiaries. According to the CMS analysis, all 15 practices improved quality from the first performance year in at least two of the six quality measures for the Demonstration. Four practices met the performance measures for all six quality measures.
These quality results mean improved care for Medicare beneficiaries who are participating in Independence at Home practices. On average, beneficiaries:
- Have follow-up contact from their provider within 48 hours of a hospital admission, hospital discharge, or emergency room visit;
- Have fewer hospital readmissions within 30 days;
- Have their medication identified by their provider within 48 hours of discharge from the hospital;
- Have their preferences documented by their provider;
- Use inpatient hospital and emergency room services less for conditions such as diabetes, high blood pressure, asthma, pneumonia, or urinary tract infection.
Home-Based Primary Care
Through home-based primary care, health care professionals can focus on the estimated four million vulnerable people in need of home-based medical care because they are frail, functionally limited, and the homebound. In home-based primary care, patients ideally receive comprehensive longitudinal primary medical care at home from an interprofessional team of physicians, nurse practitioners, or both, together with nurses, social workers, and skilled therapists.
In some cases, all team members are employees of a given practice. In other cases, practices may work collaboratively with home health agencies to provide skilled home health services, such as physical or occupational therapy or skilled nursing services on an episodic basis, for patients who qualify for them. Some programs, such as those operated by the Department of Veterans Affairs (VA), may also incorporate telehealth.
The shortage of providers to care for this patient population is challenging.
Recent data from the Medicare fee-for-service program, found:
- The majority of Americans live more than thirty miles from any of the 475 primary care providers who made 1,000 or more home visits in 2012.
- Collectively, about 5,000 primary care providers made 1.7 million home visits to Medicare fee-for-service beneficiaries annually in 2012–13 accounting for 70 percent of all home-based medical visits.
- Approximately 9-10 percent of these providers performed almost half of these home visits, making them the highest-volume providers of home-based medical care in the country.
The study (Health Affairs) provides one of the first descriptions of the provision and use of medical care at home in the United States. It sets a baseline for future evaluation of the workforce providing home-based medical care, use of that care, and geographic variations in both the workforce and the utilization.
Another pertinent point about the study is the importance of shifting away from the traditional “mindset” of fee-for-service to solutions for value-based care. There are at least two million homebound frail people and fewer than two million nursing home patients in the United States. However, about seven times more primary care providers (34,000 of them) visited nursing facilities than visited patients at home. The volume of nursing facility visits also greatly exceeds that of home visits. For example, internal medicine physicians made about eight million nursing facility visits but only about half a million home visits in 2012, and Medicare paid those providers $500 million for nursing facility visits but only $50 million for home visits.
Using home-based medical care appears to shift care from specialty care to generalist care, and from the inpatient to the outpatient setting. This shift reduces overall high-cost medical utilization and provides high levels of satisfaction among patients and caregivers. It also fills the “gap” in the post-acute care continuum.
Growth of the aging US population will fuel the nation’s demand for home-based medical care. The full scope of needs of homebound frail Americans are not best served by the current fragmented model of health care, which results in large expenditures because of hospitalizations and visits to the emergency department.
Homebound older adults have been a relatively invisible patient population from a quality and care delivery standpoint. The inability of homebound patients to access usual medical care because of multiple chronic conditions and both functional and social challenges requires a medical care delivery model that sees them on their terms in their place of residence. It also requires valid quality measures to improve care delivery and linked financial models that are appropriate and accountable.