The top six types of providers who provided home-based medical care (non-podiatry) in both 2012 and 2013 were physicians in internal medicine, family practice, geriatric medicine, or general practice; nurse practitioners; and physician assistants – providers we termed primary care providers. Together they accounted for two-thirds of the providers of home-based medical care. In 2012, 4,832 primary care providers made about 1.7 million home visits; in 2013, 5,249 of the providers made roughly the same number of home visits. These providers accounted for 70 percent of all home-based medical visits in those years.
The increase in the number of providers of home-based medical care appeared to be greatest among health professionals who made no more than 500 home visits a year. The number of home visits made by these low-volume providers increased substantially, from 493,327 (29 percent of all visits) in 2012 to 559,489 (32 percent) in 2013.
“The United States faces a shortage of providers who care for homebound patients. About 5,000 primary care providers made 1.7 million home visits to Medicare fee-for-service beneficiaries in 2013, accounting for 70 percent of all home-based medical visits. Nine percent of these providers performed 44 percent of visits. However, most homebound people live more than thirty miles from a high-volume provider.”
In a study in Health Affairs, approximately 470 (9-10 percent) primary care providers made more than 1,000 home-based medical visits a year. These high-volume providers performed almost half of the 1.7 million home visits (47 percent in 2012 and 44 percent in 2013). On average, each of these providers made about 1,600 home-based medical visits annually and was paid about $167,000 by Medicare (averages of 2012 and 2013.
There were substantial variations in the spatial distribution of the primary care providers who made more than 500 or more than 1,000 home visits annually. By using 2010 census tract-level population data, the study found that at least 53 percent of Americans lived more than thirty miles from any of the high-volume, or full-time, providers of home-based medical care. Adding providers who made 501-1,000 home visits a year expanded the service areas of home-based medical care, but even then, Alaska, Hawaii, Maine, Mississippi, New Hampshire, Vermont, and many Midwestern states did not have any healthcare professionals who made more than 500 home visits a year. Some providers of home-based medical care drive within a radius of fifteen or twenty miles, such as providers in the house call programs of Virginia Commonwealth University and Cleveland Clinic.
The full-time home care providers who made over 1,000 home visits a year also sent about one million billings to Medicare annually during 2012–13 for medical services other than home visits. The top ten services outside of home visits accounted for about half of these services in 2012 and 2013.
For providers who made more than 1,000 visits per year, the top three services (by number of billings) other than the visits in both 2012 and 2013 were related to home-based medical care: skilled home healthcare supervision, recertification of skilled home health services, and certification of skilled home health services. In contrast, the top services for providers who made 501-1,000 home visits in the same year indicate that they provided more office-based care, domiciliary care, and nursing facility care, compared to the full-time providers of home-based medical care.
In the United States, an estimated two to four million vulnerable people need home-based medical care because they are frail, functionally limited, and homebound. They typically have high needs and costs associated with their healthcare. Through home-based medical care, healthcare professionals can focus on the needs of this population by visiting them at home (home visits) and at assisted living facilities or senior group homes (domiciliary care 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.
The Independence at Home Demonstration project of the Centers for Medicare and Medicaid Services (CMS) tests home-based medical care in the context of a shared savings payment model. The project saved CMS an average of $3,070 for each participant in the first performance year (June 2012–May 2013), compared to the calculated target expenditure – which is expected Medicare fee-for-service spending for each participant in the absence of the intervention. Home-based medical care’s potential for better care and cost savings may offer a partial solution to Medicare’s fiscal crisis.
Lisa Remington is president of the Remington Health Strategy Group and publisher of the Remington Report magazine and has worked with more than 6,000 organizations in both a consultancy role and educator. Lisa monitors the complex key trends and forces of change to develop a correct strategic approach to de-risk decision-making and create sustainable futures across the healthcare continuum.