2014 Jewish Home Lifecare Palliative Care Conference: It's Not the Place, It's the Practice

1. Home Based Primary Care
Bridging the gap for chronic palliation between
restorative care and end of life care
JHLC – Geriatric Palliative Care conference
November 12, 2013
Andrew Lyons, MD
Medical Director

2. Home Based Primary Care

3. The American Academy of Home Care Physicians (aahcp.org)
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For the period of year 2000-2030 the number of Americans with
chronic conditions will increase by 37%
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125 million to 171 million individuals
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Costs associated with Care of Chronic Illness will rise
exponentially
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High cost, chronically ill beneficiaries
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Fill an average of 20 different prescriptions per year
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Account for 76% of all Hospital Admissions
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See an average of seven different Physicians per year
Are 100 times more likely to have a preventable hospitalization
compared with a non chronically ill population
A small percentage of Medicare Fee for Service Beneficiaries
consume the majority of costs
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Top 7% - 53%, Next 5% - 16%, Next 12% - 17%
In aggregate, the top 24% consume 84% of costs
80% of Medicare Spending is for people with 4+ Chronic
Illnesses
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4. What Patients Value
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Personalized Care
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Access to their Physicians
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Autonomy to make Decisions
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Continuity of Care
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ER and Hospital Avoidance
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Advanced Directives for Medical Care
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Relief from worry
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Protection from catastrophic costs
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Chronically ill patients are not price sensitive consumers
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5. The Merry Go Round
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Acute Exacerbation of Chronic Illness
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ER evaluation and Hospital Admission
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3 Day Length of Stay qualifies patient for “post acute” care
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Sub Acute Rehabilitation Stay (restorative?)
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Non Physician Home Care Services
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Primary Care Provider awaits patient back in office
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Chronic Illness Persists
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Acute Exacerbation of Chronic Illness
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“Sicker and quicker” discharges
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Hospital directive to reduce LOS, adhere to DRG period
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Care Transitions between Hospitalist and PCP
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Treatment initiated as Inpatient not complete
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Need for restorative rehab services arises
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Need for supportive care is identified
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6. Factors Affecting Re-Hospitalization Rates
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NEJM 2009 – Medicare Beneficiaries
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90% of rehospitalizations within 30days are unplanned
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Targeted interventions at time of discharge are superior to relying upon
community resources
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Hospital and MD collaboration is essential
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Post surgical patients benefit from Medical coordination prior to
procedure
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Wide State to State variability
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Lack of follow up with PCP in majority of cases
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Medication reconciliation requires a prescriber engaged in the
care of the patient
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Home Care services work best with PCP cooperation and
support
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Post Acute Care period is great opportunity to establish
Advanced Directives
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NYS has earned distinction for readmissions
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7. Policy Initiatives for Primary Care
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PPACA – Expanded coverage, expanded costs
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Primary care focused on symptom management
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Primary care focused on Prevention
Evidence based treatment and outcomes
HIT incentives
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EMR subsidies for MU certified systems
ePrescribing incentives and penalties
Accountable Care Organizations
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Lump sum payment and incentives tied to outcomes
Adherence to “quality” measures
Medical Home Model
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Primary Care Development Corporation
National Committee on Quality Assurance (NCQA)
Primary Care Incentives
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10% bonus for primary care E&M codes and HPSA bonuses
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Loan forgiveness – serving at FQHC sites
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G code/CPT Codes for Transitional Care Coordination
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8. The House Calls Model
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Focused upon the sickest, most frail high cost beneficiaries
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Superior access to Primary Medical Care
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Proper engagement with necessary Home Care entities
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Preferred care for the patients, consistent with their values
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Low cost compared with the Merry go Round
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Delivers appropriate care without imposing tone of austerity
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Only effective way to deliver appropriate Transitional Care
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Prescriber becomes the care coordinator
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Lab, xray, ultrasound diagnostic services in the home
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Point of care lab services in the home
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The Primary Care of the Future because it retains what was good
about the past.
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Data from VA program over 40 yrs has been used to influence
recent CMS pilot studies: 24% reduction in overall costs, 62%
reduction in inpatient days
http://www.iahnow.com/IAHcostsavings.htm
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9. Payer Models for House Call Programs
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Medicare
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Primary Care Bonus
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Fee for service rates above office visits
Home Care Certification and Care Plan Oversight
Independence at Home – “Medical Home at Home”
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Care Coordination Fee and Gain Sharing
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2012 Demonstration Project (PPACA)
Separate and apart from ACO concept
Medicaid
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Primary Care fees scheduled to rise under PPACA to Medicare rates
Managed Care
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Medicare Advantage
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Dual Eligible Special Needs Plans (ISNP’s, IESNP’s)
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HCC Scores, HEDIS Measures, STAR ratings
Capitation
Concierge Private Pay
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Retainer based + Out of Network Insurance
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10. Outlook for Growth
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Huge unmet need (10,000 Americans age in to Medicare daily)
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Patients value this model
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Payers are beginning to value this model
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Central planning and care management can be enhanced
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Only for high cost beneficiaries or initial HCC risk scores
Complexity of conditions requires longitudinal intervention
Hospitals may value this model
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Part of strategy to avoid readmission and for ER decompression
Home Care companies do value this model
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An engaged PCP is frequently missing from their care model
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The House Call PCP helps their model work better
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No comparable program for Primary Care access and cost
containment exists
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Government payers are supporting this model
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House Call E&M codes qualify as Primary Care
Will require infrastructure support to maintain standards for
quality and outcomes measures (safe harbor partnerships?)
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