- 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.
“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.”
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.
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.
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.”