Return of the House Call

A Breakfast ForumHousecall ProvidersJune 4, 2014

The Mission of House Calls1. Improve the quality of life of homebound patients2. Improve the quality of life of caregivers3. Decrease health care costs by enabling patients to remain at

home and avoid expensive emergency departments, hospitals and nursing homes

Three Reasons for the Decline of the House Call

1. Increased office/hospital based technology2. Fear of increased liability3. Financial disincentives

Technology is Not a Barrier

Liability is Not a Barrier

Medicare House Call Codes/Payments1997 New 1997 1998 New (Min) 1998 2014 IDPA2

99341 $62.51 99341 (20) $57.53 $58.99 $27.95 99342 $77.71 99342 (30) $77.58 $85.34 $37.40 99343 $101.62 99343 (45) $110.19 $139.16 $54.90

993441 (60) $140.50 $193.94 $70.55 993451 (75) $166.24 $233.70 $85.55

1997 Estab. 1997 1998 Est. (Min) 1998 2014 IDPA2 99351 $46.66 99347 (15) $45.43 $59.39 $24.25 99352 $59.37 99348 (25) $65.54 $89.64 $31.30 99353 $74.80 99349 (40) $94.92 $135.18 $47.50

993501 (60) $136.00 $189.15 $68.85

1 Additional 1998 higher level Medicare house call codes2 IDPA: Illinois Department of Public AideShaded payments are most frequently used house call codesNote: Medicare Payments vary by locality. These are for Locality 15.Place of Service Code for Home = 12

The Return of the House CallWhy?• Demographics: Aging of Society• Health Care Reform: The Affordable Care Act

1. Readmission Reduction2. Accountable Care Organizations3. Independence at Home

• Medicare and Medicaid Fiscal Crisis• Recent evidence of the value of house calls

Demographics: Aging Society

Exploding Homebound Population!

For half of the patients readmitted within 30 days, there was no bill for a physician visit during that time.

0-3 Months 3-6 Months 6-12 months$0

$100,000

$200,000

$300,000

$400,000

$500,000

$600,000

$236,144

$145,581

$205,528

$489,420

$358,472

$218,035

Intervention Control

Transitional Care of Older Adults Hospitalized with Heart Failure: A Randomized, Controlled Trial (Naylor, M.D. et al. 2004. JAGS 52:675–84.)

Resource Use Among Elderly Congestive Heart Failure: Patients Who Received a Transitional Care Intervention or

Usual Care, Six Philadelphia Hospitals, 1997–2001

5/14/09 – 2/18/11 (1 year, 9 months (645 days)) 44 Emergency Department Visits (avg 16 days between visits) 27 Hospitalizations—over half required ICU days (avg 25 days between stays)

HCP First Visit 3/2/11 (365 Days) 1 ED visit + 1 Hospitalization (May 2011)

Expected: 25 ED visits, 15 Hospitalizations

Following Year: 0 ED, 0 Hospitalizations

1/1/12-12/5/12 17 Emergency Department (ED) Visits 13 Hospitalizations (69 Days) Multiple rehab stays

HCP First Visit 12/5/12 1 ED Visit/1 Hospitalization 12/18/12 (4 days) 0 ED Visits/0 Hospitalizations in 2013 Passed away at home 7/22/13 on hospice

End-of-Life CareHomeCare Physicians Patient Deaths 2003-2013

Number Percentage

Total 2049 100%

Home 1,521 74%

Hospital 389 19%

Nursing Home 102 5%

Unknown 37 2%

HomeCare Physicians and End-of-Life Care• 9/1/12-8/31/13 215 deaths

– 79% died at home– 71% where on hospice– Average length of stay 2.1 years– Median length of stay 0.56 years– 25 died in first 30 days

• 23 (92%) died at home

• 25.1% of the $556 billion Medicare dollars goes to care in last year of life Riley, Lubitz; Health Services Research 4/2010

Average Traditional Medicare per capita Spending, 2009

Bottom 90% Top 10% Average $-

$10,000

$20,000

$30,000

$40,000

$50,000

$60,000

$4,584

$55,763

$9,702

Source: The Kaiser Foundation

Independence at Home Demonstration1. Focuses on the highest cost Medicare beneficiaries (10% of

Medicare beneficiaries with ≥ 5 chronic conditions account for 2/3rds of Medicare spending)1. ≥ 2 chronic conditions2. Emergent hospitalization in past year + post acute care services3. Functional dependence (≥ 2 ADL deficiencies) and frailty

2. Holds IAH provider organizations strictly accountable for three performance standards

1. Minimum savings of 5%2. Good outcomes commensurate with the beneficiary’s condition3. Patient/caregiver satisfaction

Independence at Home Demonstration

• Savings beyond 5% are split 80% / 20% with Medicare thereby creating an incentive for greater savings and generating revenue that can be invested in new mobile technologies that generate further savings such as decisional support, point-of-service diagnostic testing and portable therapeutic devices.

Medicare/Medicaid Crisis

• Medicare facing insolvency• Medicaid increased from 8% of state spending in FY1985 to

22% in FY2004 overtaking K-12 education as the largest component of state budgets

• Most rapidly increasing Medicaid cost is for long term care

Costs of Care Before vs During HBPC for 2002(per patient per year) *includes HBPC cost

Before HBPC

During HBPC

Change

Total Cost of VA Care

$38,228 $29,136* -$9,092 (- 24%) P < 0.0001

Hospital $18,868 $7026 $11,842 (- 63%)

Nursing home $10,382 $1382 $9000 (- 87%)

Outpatient $6490 $7140 $650 (+ 10%)

All home care $2488 $13,588* $11,100 (+ 460%)

N=11,334$103,048,728