1. 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

2. 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
APM with truly Risk-Adjusted PMPM
Hybrid – PMPM / At-risk Shared Savings
April 9, 2019

3. 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.”

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. Results- VA and FFS Results
VA (n = 9,425) (Oct JAGS)
Highest satisfaction in VA- 83% outstanding
Medicare Costs - 12% lower ($5,000/patient/year)
FFS Study- D.C. (722 cases, 2161 controls) (Oct JAGS)
Similar survival (16.2 vs months)
Medicare costs- 17% lower ($4,200 / patient /year)
Medicare - Independence at Home (IAH)
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

11. Results: Medicare Costs
April 9, 2019

12. 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

13. 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

14. Future Steps Enhance Clinical Model
Paramedics, Televideo, Acute/Hospital Care at Home
Centers of Excellence - Workforce (
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

15. References
SM Burwell. Setting Value-Based Payment Goals- HHS Efforts to Improve U.S. Health Care. NEJM,
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: Oct
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:
T Edes et al. Better Access, Quality, and Cost for Clinically Complex Veterans with Home-Based Primary Care. J Americ Geri Soc. 62: Oct