November 2, 2017 Home-Based Primary Care (HBPC) Value and Savings for High-Need Population Eric De Jonge, M.D. Director of Geriatrics Medstar Washington Hospital Center

Overview: Model of Home-based primary care (HBPC) Which Patients? How does it Work? What are Results? What Medicare Reform Needed? Independence at Home (IAH) demo- 2012-17 APM with truly Risk-Adjusted PMPM Hybrid – PMPM / At-risk Shared Savings April 9, 2019

MedStar House Call Team Founded 1999 Mission: Promote health and dignity of frail elders Share history Norman S. Hidle, “A group becomes a team when each member is sure enough of himself and his contribution to praise the skill of the others.”

Patient— Frances H. 86 yo woman- Congestive Heart Failure, Severe Rheumatoid Arthritis, Hypertension, Hip Fracture, Diabetes, Bedbound, Devoted Dtr. Pre-2007: 4-5 admissions / year  Medical House Call Program 2007–2016: Over 200 house calls  Urgent visits, X-rays, blood tests, Rx Social Work  Aides, Caregiver support Died March, 2016, with comfort care 5 admissions in 9 years

Why Important? U.S. Life Expectancy 1900 ? 2015 ? 49 years 79 years Fast-growing cohort: Elders w/ severe chronic illness/disability FY16 Medicare Medicaid Total $695B $574B $1.269 Trillion Affordable Skilled Care - Meet all needs of frail elders and families April 9, 2019

HBPC Model www.AAHCM.org HBPC for Patient / Family 24/7 Team MD/NP/SW ER Hospital Care Transport Social Services Aides, CG support, Home Safety, Legal Home PT/OT, Nursing, Hospice Medications and Equipment Home Labs, Radiology Mobile EHR Specialists, Rehab 6

What is Different? Longer Visits at home  Time to listen/learn 24/7 team-based care- Medical AND Social services Patient and Family Values  Known and Honored Continuity over time and setting 4/9/2019

Results? Outcomes that matter: % of Days at Home Patient/ Family Experience- 97% Outstanding Coordination of ALL services Less Hospitalizations/ER visits  Lower Total Costs 4/9/2019

Medicare IAH Demo Highly Targeted: 5% with severe, chronic illness (2M)  Expend nearly 50% of budget IAH - Focus on most ill and high-cost elders 2 or more permanent chronic illnesses Hospital admission and post-hospital services in past 12 months 2 or more deficits in Activities of Daily Life (ADLs) Payment Model- Shared Savings Meet 6 major quality metrics to receive full share Keep 80% of Savings AFTER 5% reduction in Total Costs Wait 1-2 years after service year ends Describe IAH; CBO report 2005

Results- VA and FFS Results VA (n = 9,425) (Oct. 2014 JAGS) Highest satisfaction in VA- 83% outstanding Medicare Costs - 12% lower ($5,000/patient/year) FFS Study- D.C. (722 cases, 2161 controls) (Oct. 2014 JAGS) Similar survival (16.2 vs. 16.8 months) Medicare costs- 17% lower ($4,200 / patient /year) Medicare - Independence at Home (IAH) 2012-17 Demonstration program – over 10,000 patients Successful (15 sites)- Most Met 6 Quality Measures Saved $32M in Years 1 and 2 Oct., 2017 – Bipartisan legislation to extend IAH program Evidence nationally of program model; Put years 1 & 2 together (make edits to reflect year 2); highlight satisfaction and similar outcomes; side effects (substantial cost reductions); poster child for where congress wants to take healthcare in the future

Results: Medicare Costs April 9, 2019

What are Barriers? Funding For Time-Intensive Activity Travel Family meetings and counseling Coordination of ALL needed services, equipment, paperwork House Call Programs Unable to Break Even Shortage of Physician Workforce Attitude, Team and Support, Compensation April 9, 2019

Keys to Success Serve the Right Patients Serious chronic illness with disability Staff Dedicated, compassionate and skilled staff for mobile teams 24/7 Access Payment Model to cover full program costs Responsible for care; accountable for cost MACRA is all about population health and team culture; moving volume into value It’s why IAH has such bipartisan support MTEC – meet needs of population and expand within system

Future Steps Enhance Clinical Model Paramedics, Televideo, Acute/Hospital Care at Home Centers of Excellence - Workforce (www.hccinstitute.org) Diverse Payment Model Risk-Adjusted PMPM for real-time capital- e.g. MA Plans Shared Savings- e.g. IAH Alternative Payment Models (APM) beyond FFS April 9, 2019

References SM Burwell. Setting Value-Based Payment Goals- HHS Efforts to Improve U.S. Health Care. NEJM, 2015 http://www.nejm.org/doi/full/10.1056/NEJMp1500445 http://kff.org/medicare/issue-brief/the-facts-on-medicare-spending-and-financing/ https://www.cms.gov/research-statistics-data-and-systems/statistics-trends-and- reports/nationalhealthexpenddata/nhe-fact-sheet.html KE De Jonge et al. Effects of Home-Based Primary Care on Medicare Costs in High-Risk Elders. J Americ Geri Soc. 62:1825-31. Oct. 2014 http://onlinelibrary.wiley.com/doi/10.1111/jgs.12974/full B Leff, P Boling. Comprehensive Longitudinal Health Care in the Home for High-Cost Beneficiaries: A Critical Strategy for Population Health Management. J Americ Geri Soc. 62:1974- 76 http://onlinelibrary.wiley.com/doi/10.1111/jgs.13049/full T Edes et al. Better Access, Quality, and Cost for Clinically Complex Veterans with Home-Based Primary Care. J Americ Geri Soc. 62:1954-61. Oct. 2014 http://onlinelibrary.wiley.com/doi/10.1111/jgs.13030/full