INDEPENDENCE AT HOME A 20 YEAR OVERNIGHT SUCCESS Eric DeJonge, MD Director of Geriatrics, MedStar Washington Hospital Center

INDEPENDENCE AT HOME A 20 YEAR OVERNIGHT SUCCESS Jim Pyles & Peggy Tighe Powers, Pyles, Sutter, & Verville NOVEMBER 23, 2015

IAH ATTRIBUTES 1. “TARGETED, IMMEDIATE AND PROVEN” 2. REDUCES MEDICARE COSTS: Cost reduction where costs are highest by $21-$35 billion over 10 years. 3. SELF-FUNDING: Funded entirely by savings it achieves. 4. VOLUNTARY: Participation is totally voluntary for patients and practitioners. 5. WIDESPREAD BIPARTISAN SUPPORT  3-year IAH Demo was added to the Medicare Act with strong bipartisan support  2-year extension was added with unanimous bipartisan/bicameral support on July 30, 2015.

IAH ATTRIBUTES 6. SAVINGS SUCCESS: 15 programs with approximately 8500 high cost beneficiaries saved over $25 million, an average of over $3050 per patient. Years 2 & 3 likely better. 7. QUALITY, COST IMPROVEMENTS: Reduced hospitalizations, 30- day re-hospitalizations, ER use, & improved medication management and transitions to and from hospitals. 8. CMS ASSESSMENT: Consistent with goals of “tying 30% of Medicare payments to quality & value through alternative payment models by 2016 and 50% of payments by 2018.” 9. SCALABLE: Home-based primary care is already taking off across the country. Providing financial incentives will propel more growth. 10. PROVEN: A large body of evidence spanning > 20 years & all 50 states & D.C., including 2 major peer-reviewed studies, shows that Home-Based Primary Care enhances quality of care & reduces cost for chronically ill patients.

2-YEAR EXTENSION TIMELINE APRIL 21, 2015  IAH two-year extension passes on Senate floor MAY 31, 2015  IAH demonstration expires JUNE 2, 2015  Ways and Means committee votes to pass two year extension, approved by unanimous vote JUNE 24, 2015  Energy and Commerce committee waives jurisdiction for IAH extension JULY 15, 2015  IAH two-year extension passes on House floor JULY 31, 2015  President signs two–year extension of IAH demonstration

CONVERSION TIMELINE JUNE 22, 2015  AAHCM submits comments to Senate Finance Chronic Care Working Group (CCWG) AUGUST 20, 2015  AAHCM leaders present IAH conversion draft legislation, savings estimates to Senate Finance CCWG AUGUST 26 & 27, 2015  Fly-in for IAH leaders on Capitol Hill Sent shared savings estimates to Senate Finance committees staff upon CCWG request (Oct. 15) NOVEMBER or DECEMBER 2015  SENATE FINANCE CCWG to release plan??

CONVERT MEDICARE IAH DEMO INTO NATIONWIDE PROGRAM The Independence at Home (IAH) Medicare Demonstration is a targeted, proven, bipartisan success that is backed by decades of evidence from all 50 states, meets the Senate Finance committee’s Chronic Care Working Group’s goals, and can produce significant savings if converted from a demonstration into a Medicare program that is accessible nationwide. MAKING THE CASE FOR CONVERSION

With bipartisan, bicameral support, Congress recently extended the 3-year IAH demonstration (1866E of the Medicare Act) for more two years; the extension became law on July 30, The IAH Demonstration, and requested conversion, focuses initially on the 5% of beneficiaries with multiple chronic conditions who account for more than 50% of Medicare costs and can encompass 25% of high cost beneficiaries who account for 85% of costs. CMS found that IAH practices saved over $25 million during the first performance year – an average of $3,070 per beneficiary – while delivering high quality patient care in the home. Year 1 cost savings are 8% annually for over 8,000 ill elders (savings range: $2,676 to $12,804/patient year). BIPARTISAN SUPPORT/PROVEN SUCCESS

RESEARCH 1.A large body of evidence spanning > 20 years & all 50 states & D.C., including 2 major peer-reviewed studies issued in 2014, shows that Home-Based Primary Care, as applied in the IAH demo, enhances quality of care & reduces cost for chronically ill patients. 2.The VA’s HBPC program reduced costs by 12% ($5,000/ patient- year) and achieved an 83% positive patient satisfaction rating among 34,000 patients in all 50 states. 3.A study in fee-for service Medicare showed a 17% annual cost reduction ($4,000 / patient-year) with similar mortality outcomes to usual care. “Better Access, Quality and Cost for Clinically Complex Veterans and Home-Based Primary Care”, Journal of the American Geriatrics Society 62: , “Effects of Home-Based Primary Care On Medicare Costs in High Risk Elders”, Journal of American Geriatric Society, 62: , 2014.

IAH MEETS CCWG GOALS 1.The IAH model meets the three major bipartisan goals enumerated by the Senate Finance committee’s Chronic Care Working Group. 2.Increases care coordination: interdisciplinary primary care, mobile EHRs, & 24/7 access. 3.Promotes appropriate levels of care for the most complex beneficiaries and discourages overuse of services with the shared savings incentives. 4.Provides better outcomes and improved patient/caregiver satisfaction.

COST SAVINGS 1.The current IAH Demonstration shows that even more significant cost savings to the federal government could be achieved if the IAH Demonstration were converted to a Medicare program accessible nationwide. 2.IAH could benefit nearly two million more high cost Medicare beneficiaries with multiple chronic conditions and disability, the fastest growing segment of the Medicare population. 3.Given first year IAH results and national published data, conversion could bring $21-35B in total savings over 10 years, to be divided between programs and the federal government.

CAPACITY