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October 19, 2017
These health programs work. But in the rancor of Congress, they’ve been left in the lurch
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By  Erin Mershon@eemershon / October 19, 2017

WASHINGTON — She has inflammation in her gallbladder, frequent facial pain, and near paralysis on her left side ever since a stroke a few years back — but 74-year-old Sylvia Hollie is still living at home.

It’s a creaky but stately home in D.C.’s increasingly gentrified Mt. Pleasant neighborhood, with well-worn banisters and a wooden wheelchair ramp out front — and it means everything to Hollie. It’s the home where she took care of her ailing mother, and it’s been in the family for 50 years. It’s the home where she listens to daily Catholic Mass, propped up on pillows beneath a painting of the Last Supper one of her neighbors gave her. And it’s the home where she gets to visit, though never as often as she’d like, with her four grandchildren.

Hollie gets to stay in that home thanks to a house call pilot program aimed at many of Medicare’s sickest — and costliest — patients.

And while her immediate care isn’t in jeopardy, the federal support for the pilot program is, after funding and authorization for it and dozens of other health initiatives expired at the end of September. On their face, these so-called “extenders” — named because the policies they describe usually need to be reauthorized, reinstated, or extended at regular intervals — aren’t especially controversial. But in the midst of partisan tension over all things health-related, the programs are facing a more uncertain future than ever before.

In Hollie’s case, the program is Medicare’s Independence at Home Demonstration project. For patients who otherwise would be seeing multiple specialists, in and out of waiting rooms and hospital beds, the program instead pays doctors in 15 pilot practices — including her physician, Dr. Eric De Jonge at the MedStar Washington Hospital Center — to coordinate care and travel to the patient’s home, rather than the other way around. Hollie is one of about 10,000 participating patients.

When Hollie gets sick and needs X-rays, blood tests, or EKGs, for example, she calls De Jonge and his team instead of going to the ER. (“It took me a long time to get that in my head, that they were available for me 24 hours a day,” she said.)

The patients love it.

“To be here, as opposed to someplace else — you have no idea how wonderful that is,” Hollie said as De Jonge was zipping his bag after his last visit.

And perhaps counterintuitively, that coordinated concierge care actually saves Medicare money. Together, the 15 practices in the IAH program saved Medicare more than $34 million in their first two years.

But despite that statistic — and glowing reviews from patients like Hollie — the program’s future is mired in the partisanship that has consumed congressional efforts to reform health care since President Trump took office. The program — along with nearly two dozen other health-care related projects and funding streams — expired at the end of September.

Hollie won’t stop getting her care through MedStar’s broader house call program — but De Jonge can’t enroll anyone else in the Independence at Home program until it is reauthorized. Nor can MedStar count, with any real certainty, on getting any financial bonuses related to improving care for Hollie and the rest of her cohort.

The other expired programs run a broad gamut. They include higher-profile federal funding for the Children’s Health Insurance Program and community health centers.

Another program that lost funding helps seniors navigate the complexities of Medicare, still another gives payments aimed at keeping smaller, often rural hospitals financially afloat. Others offer grants to providers and other businesses working to address childhood obesity or improving abstinence education efforts.

In the past, Congress has reauthorized this slate of extenders with bipartisan support. Already this year, two House committees have approved tweaks or reauthorizations of many of the programs, teeing them up for further consideration from the full legislative body. The Senate also approved several of the programs, including a broad expansion of the Independence at Home program, as part of a bill aimed at improving care for individuals with chronic conditions. A handful of programs considered more urgently in need of funding were tucked into an unrelated Federal Aviation Administration package.

But the expired programs each cost the federal government somewhere between $100 million and $1.1 billion every two years. Though lawmakers agree generally on the policies, they are nowhere close to an agreement on how to offset those costs.

Hospital and health industry lobbyists said they have no reason to think that nearly all of the programs won’t ultimately be reauthorized. But lobbyists are nonetheless ramping up their visits to Capitol Hill as they field calls from hospitals and clinicians around the country who want some certainty about their funding as they make hiring decisions and set their budgets.

“These expiring programs must be extended, or it will have a crushing impact on many small and rural hospitals and the communities they serve,” said Erik Rasmussen, vice president of legislative affairs for the American Hospital Association. “These programs can mean the difference between a rural hospital maintaining or eliminating certain services for patients who rely on these hospitals as a vital — and often only — source of care.”

Most of the time, lawmakers lump these smaller Medicare and Medicaid policies in with a larger and more critical piece of legislation. For nearly two decades, Congress almost annually tackled the so-called “doc fix,” a constant legislative request from clinicians who wanted to avoid a major Medicare cut. The so-called extenders nearly always rode along.

When Congress passed its so-called “permanent doc fix” in 2015, however, lawmakers declined to make most of the extenders permanent, too.

Lobbyists across the health care industry have since suggested the programs could be reauthorized at the same time as the annual Children’s Health Insurance Program reauthorization. Congress missed its deadline to fund that program — considered vital to state children’s health programs across the country — in September, too. Congressional aides in both parties cautioned, however, that CHIP legislation might not be substantial enough to proceed on its own.

Negotiations on the program are stalled, as House Democrats push back against a series of overwhelmingly partisan cuts to Medicare and the Affordable Care Act that House Republicans have suggested as tradeoffs for their support for the children’s health insurance funding. Key senators have been working on a separate agreement for how to fund the program. It’s not clear either would include money for the extenders.

If lawmakers can’t reach a deal, both CHIP and the other programs might be reauthorized when Congress must pass legislation to finance the government, aides in both chambers and lobbyists said. The current authorization expires Dec. 8.

Several lobbyists suggested a new bipartisan Obamacare stabilization package, released this week by Sens. Lamar Alexander (R-Tenn.) and Patty Murray (D-Wash.) could include enough savings to help pay for the children’s health insurance program and the extenders, but that package has not yet been evaluated by the Congressional Budget Office, which makes those determinations.

For now, De Jonge and his team will keep visiting Hollie and the 620 other patients in MedStar’s house call program. And he himself will continue to push Congress to reauthorize his program and to expand it to more sites across the country.

“A lot of Medicare payment incentivize the wrong behavior, more procedures,” De Jonge said. “I know that if I do the right thing and keep Ms. Hollie out of the hospital, out of the ER, spend extra time on my visit, try to convince her to stop smoking, make sure she has her meds — if I take extra time with the patient — we will be rewarded by the IAH program. It encourages the right behavior, it encourages us to do the right thing.”

Full Article


September 14, 2017
Bringing Back House Calls to Cut Spending on High-Risk Patients
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A house call program for MedStar Health’s elderly, high-risk patients significantly reduced Medicare spending and hospitals costs, while improving primary care access.

By Jacqueline Belliveau

September 14, 2017 – Before the early 1960s, the majority of healthcare visits were performed in patient homes. But as healthcare evolved, providers could no longer fit their tools in a transportable medical bag and the proportion of visits made by house calls dropped to just 0.6 percent by 1980.

The reimbursement landscape also prompted more providers to settle into offices or hospitals. Under fee-for-service models, office visits presented a more efficient method for maximizing the number of patients seen and services performed in an hour compared to a personalized home visit that may take a full hour for just one patient.

But with payment models changing and new health IT becoming smaller, Maryland-based MedStar Health has brought back the house call for a select group of patients. The Total Care Elder program pairs the five percent of the patient population that accounts for over one-half of healthcare spending with a team of providers and community resources to provide constant, home-based primary care.

Co-founder K. Eric De Jonge, MD, explained that the program enrolls geriatric patients in the Washington DC and Baltimore area who suffer from a physical, cognitive, or mental health disability that prevents them from going to the doctor’s office. The patients must also have at least two chronic conditions.

K. Eric De Jonge, MD, MedStar Health's Director of Geriatrics, discusses his house call program for elderly, high-risk patients.
K. Eric De Jonge, MD, MedStar Health’s Director of Geriatrics Source: MedStar Health

“The reason for doing house calls is to really focus on these patients who have to call 911 and they land in the emergency room,” the system’s Director of Geriatrics said. “The program is there to really prevent 911 phone calls, prevent unnecessary hospital stays, and help patients stay at home for the rest of their life.”

READ MORE: Good Data, Better Value-Based Care Can Boost Population Health

Unlike traditional house calls for all patients, the program targets individuals who were being poorly served by office visits and, as a result, incur excessive hospital bills, he added. By preventing just one high-cost, high-risk patient from an unnecessary hospitalization the program could save about $12,200 for Medicare patients.

The house calls can also help reduce end-of-life spending, which accounts for one-quarter of all Medicare expenditures on beneficiaries 65 years or older. Providers can work with patients at home, rather than costly care sites, such as skilled nursing facilities or nursing homes.

In addition to monthly or weekly provider visits, the Total Elder Care program offers patients 24/7 access to a provider.

“They know they have a lifeline to talk to a live doctor who knows them, has their medical record in front of him or her, and can help them decide how serious the problem is, refill medications, start treatment over the phone, and send in prescriptions,” he explained. “We can say, ‘We’ll see you in a house call tomorrow.’”

With reassurance from a provider, patients are less likely to rush to the emergency department for immediate care, especially if their own provider can see them the next day.

READ MORE: Designing Care Models to Treat High-Need, High-Cost Patients

Under home-based primary care, MedStar Health providers saw healthcare costs drop for their most expensive patients. Medicare costs fell from an average of $50,997 for high-risk elderly patients to $44,455 in two years. Hospital costs also decreased by $4,291.

In addition, high-risk elderly patients received post-acute care at lower cost sites without experiencing negative outcomes. Home-based primary care resulted in greater home health and hospice care services, but skilled nursing facility spending declined by $1,277.

“We do more hospice work than the usual Medicare population gets,” De Jonge explained. “We may spend a little bit more on primary care, hospice, and home health, but we spend substantially less by preventing expensive hospital stays, which more than makes up for that.”

While house calls offer Medicare an effective method for reducing costs without sacrificing quality, De Jonge pointed out that the fee-for-service dominant industry does not fully support MedStar Health’s work with high-risk patients.

MedStar Health initially funded the Total Care Elder program in 1999 through some house call fees and Medicare fee-for-service revenue. But most of the funding came from philanthropists in their community.

READ MORE: What Is Value-Based Care, What It Means for Providers?

The health system covered the operating deficit at the at the end of each year, which was typically about 20 percent of the budget. System leaders justified the costs because the program filled a need in the community.

As the program matured, MedStar Health received a Medicaid Elderly Persons with Disabilities waiver, which allowed De Jonge and his team to hire social workers to perform care management and keep patients out of the nursing homes if they did not truly need that type of care.

The health system also joined a Medicare alternative payment model supporting practices that deliver at-home primary care to beneficiaries with multiple chronic conditions. MedStar Health became one of 15 organizations in the Independence at Home demonstration to receive financial incentives for improving outcomes and reducing costs for the high-risk patient population.

The demonstration saved Medicare over $10 million by the end of its second year in 2016 and seven practices earned a total of $5.7 million in incentive payments.

“We’ve been able to be one of the successful sites where we have received payment from Medicare for total cost reductions, and that’s added some funding to our budget,” De Jonge said.

But even after about 19 years and proven cost reductions, the Total Care Elder program still relies on philanthropy and a mix of other revenue sources to support home-based primary care.

“It’s a diverse source of revenues between Medicare fee-for-service, Medicare shared savings payments, Medicaid, philanthropy, and then the state of Maryland,” he said. “And then all of that goes into the budget and MedStar Health, to their credit because we’re still striving to break even, covers any deficits that may arise.”

De Jonge noted that the industry still needs to shift away from fee-for-service for hospitals and health systems to sustain home-based primary care initiatives.

“There still needs to be a shift by payers, whether it’s Medicare, Medicaid, or Medicare Advantage, to pay hospital programs for results, then they’ll have the capital to hire new workforce,” he stated.

Medicare may answer MedStar Health’s call for value-based reimbursement for house calls. Four senators crafted legislation in February 2017 to make the demonstration a permanent Medicare payment model for practices across the country.

But until public and private payers make the switch to value-based reimbursement, health systems and hospitals may have little resources to grow the field, De Jonge said.

Despite a mixed bag of funding sources for now, MedStar Health stands behind its house call program. The system’s approach builds on the traditional house call model by targeting high-risk patients who could benefit the most of from home-based primary care.

“That’s the mission,” he said. “It’s good for the patient and family. It turns out as a wonderful side effect of reducing Medicare costs by caring for people in the home for both routine and urgent care.”

https://revcycleintelligence.com/news/bringing-back-house-calls-to-cut-spending-on-high-risk-patients


August 21, 2017
Perelman School of Medicine Joins National Initiative to Increase In-Home Primary Care
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Penn med students will learn the art of the old-fashioned house call.

By Haley Weiss  |  August 7, 2017

The Home Centered Care Institute (HCCI) announced last week that eight nationally recognized academic centers and hospitals, including the University of Pennsylvania’s Perelman School of Medicine, will soon offer the first and only comprehensive home-based primary care curriculum in the United States.

HCCI is a national nonprofit dedicated to expanding the availability and practice of in-home primary care visits. The organization estimates that there are only about 1,000 providers making the majority of home-based primary care visits nationally, a number it hopes will reach 6,000 in the next five years thanks to the new HCCI Centers of Excellence program. Additionally, the program and ensuing home visits made by Centers of Excellence physicians will allow the non-profit to build a new data registry to gain insight into in-home practices.

“HCCI is committed to inspiring, engaging and growing the next generation of home-based primary care professionals,” said Dr. Thomas Cornwell, founder and CEO, HCCI. “We are working to improve the lives of medically complex patients and preparing the nation for future pressures on the health care system as America’s aging population grows.”

Although the notion of increasing the numbers of doctors making house calls might seem regressive at first, in-home visits have actually become a dangerously overlooked element of our health care system.

While house calls made up 40 percent of physician encounters in 1930, the number plummeted significantly over the subsequent decades. By 1980, house calls accounted for less than 1 percent of physician encounters. The decline of in-home primary care visits made sense for the most part – not only would requiring patients to come into offices save physicians time and money, but new medical technologies quickly made it impossible for patients to receive the highest quality of care in the home.

But as optimal as office visits are for patients who can easily get there, house calls were soon all but forgotten even for patients for whom in-home care remained the only real option. And as the percentage of the U.S. population over the age of 65 has more than doubled since the 1940s, the number of homebound individuals who need practitioners to come to them has only grown. Groups like HCCI, which reports that only 11.9 percent of completely homebound individuals reported receiving any primary care in the home between 2012 and 2013, is now working to help providers realize that the last century’s decline in house calls was less of a solution than it was an overcorrection.

Thankfully for Philadelphia’s geriatric patients who require in-home care, the Perelman School of Medicine’s participation in HCCI’s new program is a welcome addition to existing efforts like the Truman Schnabel House Calls Program. The three-part HCCI Essential Elements of Home-Based Primary Care© curriculum consists of classroom learning, a short fellowship, and clinical field experience.

The curriculum will focus on four core components of in-home care (foundational principles, economics, operations and clinical care) and what they mean for the future of the modern house call.

The program is funded in part by the Bramsen Foundation and the John A. Hartford Foundation, which focus on improving care for end-of-life cases and older adults, respectively.

Read More About: Health Care, Home Centered Care Institute

Read more at http://www.phillymag.com/business/2017/08/07/perelman-school-of-medicine-hcci-home-visits/#cUGfrCdjHkQklCI0.99


August 21, 2017
AAHCM’s New Stand-Alone Conference Focuses on In-Home Primary Care for Healthcare Professionals
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October 12-14, 2017 – Chicago, IL

Released: 7-Aug-2017 2:05 PM EDT

Source Newsroom: American Academy of Home Care Medicine

Newswise — The American Academy of Home Care Medicine (AAHCM) announces its first ever stand-alone annual conference, focusing on the issues and challenges that face healthcare professionals who provide in-home primary care. Three tracks—VA, legislative, and clinical—will let participants customize learning to their specific needs while engaging with a health care professionals in the field of home care medicine. Students enjoy registration discounts, and can apply for travel grants to help cover expenses.

The AAHCM annual meeting attracts a broad range of attendees including doctors, nurses and nurse practitioners, physician assistants, and social workers, giving participants the opportunity to explore new approaches to providing quality in-home primary care in a cost efficient manner.

Sessions will include:

  • Interventions for Mental Health Problems in HBPC
  • Care of the Caregiver
  • Preparing the Next Generation of Home Health Providers
  • Continuity of Care: Using Telerehabilitation to Deliver Interdisciplinary Therapy Services
  • Improving Your Practice’s Quality Care in the World of MACRA
  • How to Implement and Get Payment for Interdisciplinary Team Members
  • What’s Next – Independence at Home and Other Health Policy Issues in Home Care Medicine
  • New Oral Anticoagulants Provide Another Option to Treat Venous Thromboembolism and Atrial Fibrillation in Home Patients
  • Evaluating Technology for Home Health
  • Strategic Tips for Administrative and Operational Success
  • Interdisciplinary Team Care Case Based Examples

Elaine Sanchez, author of the unflinchingly honest and surprisingly funny book, Letters from Madelyn, Chronicles of a Caregiver will be the keynote presenter. Ms. Sanchez is the co-founder of www.CaregiverHelp.com, an online support program for family and professional caregivers.

A preconference workshop will offer participants the opportunity to take the administrative and operational functions of their practice to the next level.

For those who can’t attend the meeting in person, the AAHCM Virtual Meeting makes the outstanding educational benefits of the annual meeting available to anyone anywhere.

Visit www.aahcm.org/page/2017_Annual_Meeting for a complete schedule, faculty and session information, travel and virtual conference details, and online registration, or call AAHCM Member Services at 877.375.4719. Participants may register by September 15 and take advantage of early-bird discounted rates.

AAHCM

AAHCM is a professional organization serving the needs of physicians and related professionals and agencies interested in improving care of patients in the home. AAHCM delivers on the promise of interdisciplinary, high value health care in the home for all people in need by promoting the art, science and practice of home care medicine. The AAHCM membership is comprised of physicians, medical directors, nurse practitioners, physician’s assistants, registered nurses, social workers, practice administrators, and residents/students working in the field of home care medicine.

http://www.newswise.com/articles/aahcm-s-new-stand-alone-conference-focuses-on-in-home-primary-care-for-healthcare-professionals


August 21, 2017
Home-based care proves more effective for elderly patients
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By: Emily Dieckman, Aug 10, 2017

Dr. Thomas Cornwell has made about 32,700 house calls in his career. In fact, he had eight last Monday alone, one involving a patient who had been in and out of the hospital from February to June. When she started receiving house calls from Dr. Cornwell, July became the first month of 2017 in which she spent no time in the hospital.

Seeing firsthand how beneficial home-based care is for patients and their families, Dr. Cornwell founded the Home Centered Care Institute in 2012. On Aug. 1, HCCI launched eight Centers of Excellence for home-based primary care across the U.S., at institutions like the Cleveland Clinic, Icahn School of Medicine at Mount Sinai and University of Arizona Center on Aging.

“We really are on an ‘A+’ list, and that’s because we are national leaders in the field,” said Dr. Mindy Fain, co-director of the center on aging; division chief of geriatrics, general internal medicine and palliative medicine; president of the American Academy of Homecare Medicine and board member of HCCI. “We really have been instrumental both in creating models of care and providing the education.”

Fain said all medical students completing their residency at UA receive some training in home-based care. The new, more extensive center is open to physicians and other medical professionals as well, and is offered free of charge to UA medical students and residents. The three-part training curriculum includes classroom education, group mentorship and a “mini-fellowship” program at an HCCI partner site.

“We need the Centers of Excellence not only to increase the workforce, but to improve the trained workforce,” Fain said.

Dr. Fain, along with Dr. Monica Vandivort and Dr. Corinne Self, both assistant UA professors, will teach the curriculum at the center.

“The three of us have a passion for home-based care for the elderly,” Self said, “As the three home-based care doctors, it was only natural that we would be the ones to teach.”

Like Cornwell, Fain initially became involved with home-based care because she wanted to help patients more effectively. But the icing on the cake, she said, was that home-based care has been shown to be extremely cost effective.

A Medicare demonstration program called the Independence at Home Act found that providing home-based care for eligible beneficiaries through participating practices saved participants approximately $32 million over two years, at an average savings of over $3,000 per beneficiary the first year and $746 per beneficiary the second year.

The cost-saving benefits of home-based healthcare are just one of the reasons Fain said she believes the Center of Excellence could boost the local economy. She also pointed out that offering assistance to family members acting as caregivers can allow family members to go back into the workforce. Physicians coming from out of state for the opportunity to learn at the center could be further additions the workforce.

Economic benefits aside, most terminally ill patients indicate a preference for dying at home, according to a 2005 study published in the Journal of Palliative Medicine. Cornwell spoke about the relief that professional home-based care can offer families, who are trying to do the job of medical nurses with little to no training.

“Everybody wins,” he said. “The patient gets what they want, the family gets support – they actually get a year of bereavement support after the patient passes away–and it saves a lot of money.”

Fain agreed, saying that a movement toward home-based care is “a no-brainer.” So why did the healthcare system move away from this model in the first place? Cornwell cites the rise of technology.

When innovations like X-rays were first developed, Cornwell said doctors couldn’t carry the equipment around to make house calls. But, today’s technology allows physicians making house calls to offer services comparable to most standard doctor’s offices, including running X-rays on portable machines, diagnosing conditions like pneumonia and blood clots and even starting treatments for those conditions.

“This is not just your typical black bag with your stethoscopes,” Cornwell said.

Within his modern toolkit, a device manufactured by AliveCor allows him to take patients’ EKG readings using an affordable, pocket-sized device and a smartphone application. In fact, he used it just the other day to detect an atrial defibrillation in a patient.

“She was from Italy, grew up in the war, had a beautiful garden, but she couldn’t get out [of the house],” he said.

Cornwell said that the vast majority of his patients suffer from chronic conditions such as ALS, MS, cervical spine injuries or muscular dystrophy. A smaller number are what he called “high-utilizers.” For example, one patient had 44 emergency department visits and 27 hospitalizations (half of which were in the ICU) in a 21-month period. In the first year of receiving home-based care, the patient was only hospitalized once. In the second year, the patient was not hospitalized at all.

“I always enjoyed taking care of what I call disenfranchised patients,” Cornwell said. “[These patients] are disenfranchised from the healthcare system because they can’t get to it. So instead of having them come to their office, which they can’t do, we bring the office to them.”

http://www.tucsonlocalmedia.com/news/article_195f5e1e-7c87-11e7-a1d9-f33b38566ce6.html


August 21, 2017
New Directions in the Doctor Patient Relationship
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A past, present and potentially forward look at physician house calls and home health
by Liz Carey

People have been talking about revisions to the home health care industry for years. The basic storyline runs a little like the classic soap opera. You can be away for a while, tune back in, and discover a big chunk of the dialogue has stayed the same: cost, quality, waste, fraud.

When home health diabetes care costs soared in Miami-Dade County, Florida, to an unusual degree compared to the rest of the United States, rules were established to limit suspected, undeserved profiting. Outliers—the term used to signal possible abuse—were said to be just one of the industry’s challenges, along with basing payments on historical averages; understanding the balance of companies with big healthy profit margins and those operating at a loss; and making sure patients truly receive the (appropriate) care being billed.

Points of Interest

2016 Physician Fee Schedule Regarded as economically significant
2017 Physician Fee Schedule Proposes to add codes to list of covered telehealth services, including health risk assessment and care planning for chronic care management (CCM)2016 Hospice Payment 2.1 percent ($350 million)
2017 Hospice Payment 1.0 percent ($180 million)

2016 Home Health Completion of rebasing effort required by Affordable Care Act, payment rate update –$130 million (–0.7 percent)
2017 Home Health Proposes 0.4 percent decrease (–$80 million) for 2018, 30-day rather than 60-day, reliance on clinical drivers for 2019

Source: CMS

As of July 29, 2017, the Centers for Medicare & Medicaid Services (CMS), HHS extended the temporary moratoria on new enrollment of home health agencies, subunits and branch locations in Florida, Illinois, Michigan, Texas, Pennsylvania and New Jersey, as applicable, to prevent and combat fraud, waste and abuse in these states. Also in July 2017, the new home health proposed payment system rule rang some alarm bells too.

Throughout Industry Upheaval, People Still Need Care

Gaining traction is a new care model that is not really new—that potentially sets the stage for changing the way the home health agencies and hospices could be working with doctors and hospitals in the future. Policy and payment incentives appear to be giving homebased primary care (HBPC) a lift.

Meet Dr. Thomas Cornwell in Chicago, one of the thought leaders behind the HBPC movement. Cornwell has made more than 32,000 house calls over the past 24 years. Today, he is one of the practicing leaders in the shift to more medical care at home.

Cornwell directs the Home Centered Care Institute (HCCI) based in Schaumburg, Illinois, and, with the partnership of eight medical institutions around the United States, launched a new comprehensive home-based primary care training and curriculum program in August 2017. The program is largely supported by organizations including the John A. Hartford Foundation, a private national organization dedicated to improving the care of older adults.

Cornwell envisions a shift toward more primary care at home as part of Medicare’s value-based payment design.

The Power of Partnership

Home-based primary care presents a new kind of partnership between the doctor and other in-home providers, such as the home health agency, HME providers and hospice, to better align with the needs of patients. It also factors in the need for specialists and potentially other home-based clinical services such as X-rays and ultrasounds, Cornwell said.

“There is so much we can do in the home now. Home-based primary care can improve the quality of life for homebound patients and caregivers, and decrease health care costs by enabling patients to remain at home and avoiding expensive emergency department visits, hospitalizations and nursing home care.”

CMS, by way of the new home health prospective payment system, is looking to change the home health payment structure to a more clinically based system. The changes are set to start in 2019, and are meant to align the highest payments with the highest-cost, sickest patients.

Does This Model Make Sense?

“Home-based primary care providers are great partners for home health agencies, because they fully understand and utilize the skills of the home health personnel to safely care for patients at home,” says Cornwell, who discussed a recent patient where the home health nurse called to report that a heart failure patient had increased shortness of breath, leg swelling and had gained four pounds over two days. Rather than calling 911, he had the nurse adjust the medication and offer guidance to call if symptoms worsened, with follow-up the next day. The following day the shortness of breath was gone, the patient was down two pounds, and a hospitalization was averted.

“Often when a home health nurse calls a busy office practice, they are told to call 911. This is why there is such a high rate of readmissions associated with home health.”

Cornwell adds that home-based primary care providers are also good home health partners because they know the importance of good documentation to enable home health agencies to bill and to help DME companies get paid for the equipment that patients need.

He works alongside others envisioning the expansion of medical care at home. Icahn School of Medicine at Mount Sinai, which appears on the list of HCCI’s Centers of Excellence, pursues the Hospital at Home Plus (HaH-Plus) physician-focused payment model for the provision of acute hospital hospital-level care and 30 days of transition services in the homes of carefully selected Medicare beneficiaries.

Not Possible Through Traditional FFS Medicare

Dr. Dennis S. Charney leads the way for HaH-Plus at Mount Sinai. “Although the acute hospital is the standard venue for providing acute medical care for serious illness, it may be hazardous for vulnerable older persons, who commonly experience functional decline, iatrogenic illness, and other adverse events during care, and it is expensive,” Charney stated in a February 2017 letter to the Physician-Focused Payment Model Technical Advisory Committee (PTAC) and the U.S. Department of Health and Human Services (HHS).

Mount Sinai’s mobile acute care team hospital at home services are for beneficiaries with qualifying diagnoses and an acuity level that would otherwise require hospitalization. It involves an integrated team of mobile providers. Services such as these cannot be billed with traditional fee-for-service (FFS) Medicare, the letter states.

What Are the Challenges?

“We’re in a period of innovation and experimentation” says healthcare markets and regulation expert Michael Chernew, professor of Health Care Policy at Harvard Medical School. “The challenge is to find an efficient way to get the physicians to the patients. It’s execution: getting the right resources to the right patients at the right time. A lot depends on the condition of the patient.” And he adds, “Throughout the health care system, the portion of care that’s paid by Medicare is subject to all the pressures that Medicare faces.”

Cornwell is hopeful. “The new Medicare program for this decade could be house calls, and this could be an incredible benefit to the population, but they need both house calls and home health and hospice.”

CMS, which directed a hospice pay increase of 2.1 percent ($350 million) in 2016 for 2017, delivered another hospice pay increase of 1.0 percent ($180 million) in 2017 for 2018, as of an August 1, 2017 statement—and new quality measures with both.

Policy Developments Are Moving Targets

Policy developments help to scale such operations. Of direct impact, for examples, have been the Independence at Home Act and MACRA, known as the Medicare Access and CHIP Reauthorization Act of 2015.

MACRA, regarded by some as “quietly transforming health care” behind the scenes, is in its first year of implementation in 2017. Under MACRA is the Quality Payment Program, which for those opting into the Advanced Alternative Payment Models (APMs) offers incentives for participating and for those opting into the Merit-based Incentive Payment System (MIPS) offers a performance-based payment adjustment. The first payment adjustments based on performance go into effect January 1, 2019.

For the 2018 performance year, CMS estimates that more than 125,000 clinicians will participate in Advanced APMs and qualify for the 5 percent incentive payment. Working with such clinicians is Dr. William Mills, a home-based primary care physician at Kindred Healthcare, where he was also chief medical officer of Kindred At Home, sits on the board for the American Academy of Home Care Medicine and leads his own company, Chronic Care Management, LLC.

Mills has practiced home-based primary care for about 10 years. Primary care in the home, which includes physician house calls and visits by physician assistants and nurse practitioners, can be practiced in traditional Medicare fee-for-service, as well as advanced alternate payment models, like Accountable Care Organizations or CPC+ (Comprehensive Primary Care Plus), a five-year model that started January 1, 2017.

Kindred House Calls is a CPC+ participant, one of more than 2,900 primary care practices nationwide participating in a partnership between payer partners from CMS, state Medicaid agencies, commercial health plans, self-insured businesses and primary care providers. The physician house call arm of Kindred fledged in 2013 when Kindred At Home launched.

“Kindred is currently utilizing this innovative program to provide additional longitudinal care management support for some of its sickest primary care patients. The level of engagement and resources that are now made possible with CPC+ and other programs, such as chronic care management, can provide patients “in-between visit” resources that were often impossible to provide in traditional fee-for-service,” Mills said.

“I have long viewed my clinical practice and the practice of home-based primary care as being the quarterback of the care team, a coordinator of the types of care and services that homebound patients need. Those services include home health care, therapy, DME, private duty and hospice.”

Mills spent several years in hospice practice through the company he founded, HopeBridge Hospice in Cleveland, that is now part of Kindred and operates under the Kindred Hospice name. He adds that hospice continues to be underutilized in the United States. By activating hospice sooner for patients with terminal illness, many patients have a better chance of staying out of the hospital or a nursing home in their last month of life, a point Cornwell makes too.

The difference between CPC+ and the home-based primary care that Cornwell speaks of is that the CPC+ model is applicable to a variety of different practice sites including traditional office settings, whereas Independence at Home is focused on patients who receive primary care at home.

The Independence at Home Act, through the at-times maligned Affordable Care Act, propelled a demonstration project that tested if and how primary-based care in the home helped to reduce hospitalizations, save health care dollars and improve outcomes for frail elderly patients with multiple chronic conditions and chronic care management (CCM) needs. Obamacare earmarked millions of dollars to help test new care models, including home-based primary care.

Both the Independence at Home and the CPC+ programs help to support and strengthen Medicare providers who care for chronically ill patients. Additionally, Medicare’s Chronic Care Management (CCM) program is currently helping practices across the country transition to value-based care models. The CCM program—which is referenced in the recent Physician Fee Schedule proposal, specifically to add codes to covered telehealth services—is helping practices of various degrees of sophistication utilize it to perform comprehensive care planning for patients, while providing new revenue to participating practices. Taken together, CMS views CCM as a bridge to value-based care.

New Directions in the Doctor Patient Relationship

“What used to be a 7-minute visit every six months is moving toward the physician being better connected with the patient,” Mills says. “The areas that CMS continues to invest in are largely those efforts that provide more holistic, goal-directed care—and person-centered care planning is a pivotal part of chronic care management. All of these developments are moving us in the right direction.”

Question:
As a stakeholder in the coordination and service of care, how will a more formal adoption of home-based primary care and/or hospital care at home work for you?

We welcome your predictions, thoughts, concerns, questions and comments: Send an eLetter to HomeCare Editor Liz Carey at ecarey@cahabamedia.com, or comment via Facebook.

More Information
Home-Based Primary Care Education Program
Medical institutions in Ohio, New York, Illinois, Pennsylvania, Arizona, Arkansas, California, Maryland and Washington, District of Columbia joined the HCCI Centers of Excellence rollout. The program focuses on four core components of home-based primary care—foundational principles, economics, operations and clinical care.
https://www.homecaremag.com/news/new-program-launches-increase-quality-primary-care-home

CY 2018 Physician Fee Schedule Proposed Rule, Comment Deadline
This proposed rule updates payment policies, payment rates, and other provisions for services furnished under the Medicare Physician Fee Schedule (PFS) on or after January 1, 2018. In addition to policies affecting the calculation of payment rates, this proposed rule proposes potentially misvalued codes, adding procedures to the telehealth list, and a number of new policies. CMS will accept comments on the proposed rule until September 11, 2017, and will respond to comments in a final rule.
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices-Items/CMS-1676-P.html

Hospice Center Spotlights
See short snippets of major developments.
https://www.cms.gov/Center/Provider-Type/Hospice-Center.html

Extension Moratoria, Home Health Agencies
Document support for the rationale for the moratoria extension, indicators of fraud, waste and abuse, outliers; Provider Enrollment Moratoria Access Waiver Demonstration; (81 FR 51116); (82 FR 35122).

Quality Payment Program – Fall 2016 Developments, CMS
This document also references APMs, Medical Home Model, Transforming Clinical Practice Initiative (TCPI), Quality Innovation Network (QIN)-Quality Improvement Organizations (QIO).
https://qpp.cms.gov/docs/Quality_Payment_Program_Overview_Fact_Sheet.pdf

https://www.homecaremag.com/cmsmedicare/new-directions-doctor-patient-relationship


August 14, 2017
Telehealth Remains a Top Priority for Advancing Quality Health Care
  • Posted By : Emily Whiteman/
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By Faegre Baker Daniels

Even with the prospect of Obamacare repeal and replace on the backburner for now, the federal government continues to focus on health care. Following August recess, Congress will have less than four weeks to work through must-pass legislation that would fund the Children’s Health Insurance Program (CHIP). Currently, federal funding for the program — which covers nearly 8.5 million low- and moderate-income children — is set to expire on September 30, 2017.

Amidst this hard-stop deadline for program funding, this must-pass legislation could become a vehicle to attach other party priorities such as pieces of the repeal/replace language or expansion of telehealth services for Medicaid beneficiaries. In light of the Department of Veterans Affairs’ plan to expand telehealth services for our nation’s veterans, it’s clear the federal government has begun to recognize the importance of these services in ensuring widespread access to health care throughout the country. The Department of Health and Human Services (HHS) Office of Inspector General (OIG) has also announced a Medicare telehealth services audit as a supplement to OIG’s 2017 Work Plan. The report is expected to be issued in 2017 and will review Medicare claims to ensure patients received care from an eligible originating site and that all appropriate conditions have been met for reimbursement.

Likewise, technology giants such as Amazon, Apple and others are dedicating significant amounts of money and resources to advance the technological components of health care, including greater interoperability of electronic health records (EHRs) and associated telemedicine technologies. A late July 2017 report from CNBC announced the creation of a special program within Amazon, dubbed ‘1492,’ that would be responsible for the development of opportunities to advance telemedicine functionality and consumer navigation of the health care delivery system.

Understanding the clear public- and private-sector interest in advancing access to telehealth services, Congress has begun debate on several bills introduced with the intention of maintaining and expanding access to health care for vulnerable populations throughout the country. While the fate of the Affordable Care Act (ACA) remains uncertain, passage of these bills — whether standalone or in a package alongside other legislation — would improve access to quality and timely care for all Medicare and Medicaid beneficiaries. Recent data shared from the Centers for Medicare & Medicaid Services (CMS) now notes that in 2016 alone, Medicare spending on telehealth services totaled $28.75 million over nearly 500,000 patient claims. These numbers reflect a 1,143-percent and 977-percent increase in spending and individual claims for telehealth services, respectively, over the past decade, and a 28 percent jump in the last year alone.

Each of the bills listed below has either been recently introduced or noted as a potential addition to the CHIP reauthorization; all are designed to improve acceptance and access to telehealth services.

  • CHRONIC Care Act (S. 870) – The bill would amend Title XVIII of the Social Security Act to implement novel Medicare payment policies designed to improve the management of chronic conditions, streamline care coordination, and continue to balance cost and quality for health care services. The CHRONIC Care Act would, as also outlined in several of the bills below, allow for Medicare Advantage plans (beginning in 2020) and Accountable Care Organizations (to utilize telemedicine services for tele-stroke and end-stage renal disease (ESRD) patients. This would eliminate the geographic component of originating site requirements and allow for beneficiaries to receive home care. The CHRONIC Care Act also extends the Independence at Home Model of Care outlined in the ACA for home-based primary care for chronic conditions until September 2019 and would increase the cap to 15,000 participants.
  • CONNECT for Health Act (S. 1016) – Many of the sections in S. 1016 fall in line with the Senate Finance Committee’s CHRONIC Care Act regarding home dialysis, tele-stroke services and Medicare Advantage coverage. The revised provisions address concerns around increasing the ability to classify locations as legitimate origination sites (e.g., rural clinics, federally -qualified health centers and Native American sites). This bill would also provide coverage for remote patient monitoring with certain chronic diseases and increase access for Medicare beneficiaries with appropriate reimbursement, in line with agency goals reducing costs while maintaining or increasing quality of care.
  • Medicare Part B Improvement Act (H.R. 3178) – H.R. 3178 was introduced by Representative Kevin Brady (R-TX) and Frank Pallone (D-TX) and passed quickly through the House Committee on Energy and Commerce and subsequently passed in the full House by voice vote on July 25, 2017. Section 202 of this bill would allow for the use of telehealth services for ESRD-related visits on a monthly basis for Medicare beneficiaries, going into effect on January 1, 2019. Telehealth services will be covered only in the instance that the beneficiary also receives periodic face-to-face consultations. Telehealth and remote patient monitoring would be allowed for qualifying participants in alternative payment models and would also become a benefit for Medicare Advantage plans.
  • Telehealth Enhancement Act (H.R. 3360) – H.R. 3360 would work to add urban critical access hospitals, sole community hospitals, home telehealth sites and counties with fewer than 25,000 people as eligible for Medicare payments for telemedicine services. It would also recognize telehealth services and remote patient monitoring within bundled payments for services rendered at Accountable Care Organizations or for Medicare Advantage plan coverage.
  • Evidence-Based Telehealth Expansion Act (H.R. 3482) – This bill would allow the Secretary of Health and Human Services to review the existing services offered within the Medicare program and identify those for which telehealth would be appropriate. For those identified, the Secretary of HHS would have the authority to waive existing restrictions in the instance these services would either reduce spending while maintaining quality or improve quality without increasing associated costs.

With these bills, the federal government would catch up with, but not exceed, the efforts of leading states. Most recently, Texas and New Jersey passed legislation that broadens the practice of telemedicine, and nearly all large employers are beginning to offer these services.

http://www.jdsupra.com/legalnews/telehealth-remains-a-top-priority-for-63675/


August 4, 2017
New push to train more docs to provide in-home care
  • Posted By : Leif Brierley/
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A new program to train doctors to provide primary care right in a patient’s home launches today. There are only about 1,000 physicians in the U.S. who work as home-based primary care docs, according to the Home Centered Care Institute. But home care experts say that providing care in the home, particularly to elderly and medically complex patients, can reduce health care costs and improve the experience for those patients. Eight medical centers and schools — including the Cleveland Clinic, University of California San Francisco, and Northwestern — are participating in the program, which aims to grow the workforce by 5,000 clinicians in five years.

Source: http://us11.campaign-archive2.com/?u=f8609630ae206654824f897b6&id=c4088a01fd


August 4, 2017
MedStar joins seven institutions in new home-based care initiative
  • Posted By : Leif Brierley/
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By Morgan Eichensehr, Reporter, Baltimore Business Journal

MedStar Health is joining seven partner institutions across the country to launch a new home-based primary care training program.

The nonprofit Home Centered Care Institute works to ensure homebound patients have access to high-quality primary care in their homes nationwide. It’s establishing eight new Centers of Excellence, including MedStar’s Medical House Call Program, to offer its home-based primary care training and curriculum in major cities across the U.S.

MedStar has had its own home-based care program in Washington, D.C. since 1999. The program expanded to Baltimore last year. Dr. Eric DeJonge, executive director of MedStar Total Elder Care, said he served on the Home Centered Care Institute’s initial board to develop a national training program. Their goal was to identify organizations with experience that could help teach a workforce around the country to build a successful house call program.

“There is a huge unmet need in almost every community in the U.S. for home-based medical care,” DeJonge said. “About 5 percent of Medicare patients who are very sick or disabled could benefit from this kind of program…We really want to train a workforce at a high level of skill to serve those most complex patients.”

According to the Home Centered Care Institute, one in four Americans has multiple chronic conditions — many of those age 65 and older — and more than 4 million people have conditions that leave them homebound. The institute estimates there are about 1,000 providers in the U.S. making the majority of home-based primary care visits today. It wants to grow that workforce by training 5,000 clinicians and practice managers over the next five years.

These are the eight new Centers of Excellence:

  • Cleveland Clinic
  • Icahn School of Medicine at Mount Sinai
  • MedStar Health — Medical House Call Program
  • Northwestern University Feinberg School of Medicine
  • Perelman School of Medicine at the University of Pennsylvania
  • University of Arizona Center on Aging
  • University of Arkansas for Medical Sciences
  • University of California, San Francisco

Source: https://www.bizjournals.com/baltimore/news/2017/08/01/medstar-joins-seven-institutions-in-new-home-based.html


August 4, 2017
Eight academic centers join effort to address home-care shortage
  • Posted By : Leif Brierley/
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By Maria Castellucci  | August 1, 2017
About 5% of the Medicare population—or 2 million beneficiaries—would benefit from home-based primary care. These patients are too sick to leave their home and have serious chronic conditions that require frequent visits from a physician, nurse practitioner or physician assistant.

Despite the demand for home care, only about 100,000 Medicare beneficiaries actually receive it because of a severe shortage of providers trained and willing to give such services, experts say.

“There just aren’t enough providers right now,” said Dr. Eric De Jonge, director of geriatrics at MedStar Washington (D.C.) Hospital Center.

There are several reasons why doctors and other providers aren’t flocking to home-based care. The current fee-for-service reimbursement model is so low for home-care services, it isn’t appealing for providers saddled with debt who can work in higher-paying specialties. Another problem is that most providers simply aren’t exposed to home-based care during their residency and training. Education for providers, especially doctors, is still largely focused on the inpatient setting, so most graduates aren’t comfortable with giving care in the home or even aware that such services are so valuable.

“There is a great familiarity for providers to take care of patients in the hospital .?.?. to suddenly do it in a completely new space is just completely different than what they are used to,” said Dr. Thomas Cornwell, a long-time home-care provider and CEO of the Home Centered Care Institute, a not-for-profit organization that works to advance home-care services.

To help address the shortage, the Home Centered Care Institute along with MedStar Health and seven other academic medicine institutions launched an initiative Tuesday to train home-care providers. They estimate about 1,000 providers currently offer home-based primary care, and their goal is to increase that number to 5,000 within five years.

As part of the initiative, the eight academic institutions will teach recently graduated providers a comprehensive home-based care curriculum to expose them to the unique skills needed to give home care. The curriculum was developed by trained professionals at the Home Centered Care Institute with help from the American Academy of Home Care Medicine. Training will be open to physicians, nurse practitioners and physician assistants.

The courses will be taught by leaders who are part of each institution’s respective home-care program. Each center hopes to enroll 40 students for the first classes, which will begin in early 2018.

The curriculum will focus on skills not usually provided in medical school, like how to change a feeding tube in the home and use certain mobile technologies not needed in a hospital setting, Cornwell said.

The curriculum will also expose providers to a variety of scenarios that can occur in a home and how best to handle it. Home health providers can witness issues in the patient’s environment that can sometimes be unsafe. Because of that, offering care in the home requires some “street smarts,” MedStar’s De Jonge said.

The efforts that have been made so far to move home-based care from fee-for-service to value-based care will also be part of the curriculum.

The CMS Innovation Center in 2012 launched the Independence at Home Demonstration, which rewarded 17 physician practices across the U.S. if they provided high quality home care while reducing costs.

A study from the Commonwealth Fund found that participating practices saved on average $3,070 per beneficiary in the first year, primarily by reducing hospital use. The CMS saved $25 million in total.

The demonstration was so successful, the Senate is currently considering a bill that would establish a permanent independence at home medical practice program under Medicare.

If the bill passes, the need for home-care providers will only grow, Cornwell said. The push to value-based care will also likely draw more providers to home health since they’ll be financially rewarded for savings. Home-based primary care is frequently touted by advocates for its cost effectiveness because it keeps patients out of nursing homes and can prevent costly hospital readmissions. “Under value-based payments those who save the most will be rewarded the most, and nothing saves as much as home-based primary care,” Cornwell said.

In order to get providers to enroll in classes, the Home Centered Care Institute will begin a public awareness and marketing effort to notify doctors, nurse practitioners and physician assistants of the opportunity. It will also let home health providers know of the curriculum so they can pass it on to others.

The students targeted for the curriculum are recently graduated providers who already have the core medical skills and only require some additional training. “We are going to show them the best practices to really create a robust workforce and a new career path,” De Jonge said. “We have the potential to make a big difference.”

The eight academic institutions involved in the effort are:

  • Cleveland Clinic
  • MedStar Health—Medical House Call Program
  • Icahn School of Medicine at Mount Sinai
  • Northwestern University Feinberg School of Medicine
  • Perelman School of Medicine at the University of Pennsylvania
  • University of Arizona Center on Aging
  • University of Arkansas for Medical Sciences
  • University of California at San Francisco

Source: http://www.modernhealthcare.com/article/20170801/NEWS/170809999


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