More than half of the providers participating in CMS's Independence at Home demonstration project received bonus payments for improving cost and quality of the frailest, sickest Medicare patients by keeping them out of the hospital.
In 2012, the Centers for Medicare & Medicaid Services announced an ambitious project, Independence At Home, to tame the rising costs of caring for one of the costliest patient populations: the frail elderly. Now, three years later, results from 17 providers are in, and they are positive. More than half (53%) have been given bonuses ranging from $275,000 to $2.9 million for shrinking Medicare costs and improving patient care.
MedStar Washington (D.C.) Hospital Center, a 926-bed hospital that is one of ten within the $4.6 billion nonprofit MedStar Health system, will share a $1.8 million bonus payment from CMS with two other providers, Penn Medicine and Virginia Commonwealth University Medical Center. The three providers form the Mid-Atlantic Consortium (MAC), which received the second-highest bonus awarded. The payment will be split three ways, based on the proportion of patients each provider had, says K. Eric De Jonge, MD, co-founder of the Medical House Call program at MedStar Washington.
K. Eric De Jonge, MD |
"The consortium was formed to apply to be an Independence At Home site. We accepted the results as a team," says De Jonge, who estimates that his site saw 60% of the 400 patients studied.
The MAC was able to reduce Medicare costs by 20% for frail elderly by providing all the care the patients needed at home instead of at the hospital. Instead of spending the projected $5,076 per beneficiary per month, the MAC providers spent $4,060.
Preventing Anxiety and Readmissions
For Arnold Goldberger, an 88-year-old retired physicist, the MedStar program has given him peace of mind. He helps take care of his wife, 87-year-old Avriel Goldberger, who has two chronic medical conditions, which is a requirement of the Independence at Home program.
"Prior to the House Call program, I was calling and making routine appointments in northern Virginia, going to a waiting room full of people," he says. "Now, a nurse comes once a month, takes our vital signs, checks in with the doctor, and you see the same nurse every time."
The nurse who visits the Goldbergers is part of a 10-person team that includes physicians, NPs, social workers, and an LPN and business manager. At each house call, which the Goldbergers try to schedule around lunch so they can visit with the nurse or doctor, vital signs are taken and medications are reconciled.
"They don't take our word for it," says Goldberger. "They say, 'Take out the bottles.' They are very thorough and they never rush you, like they do at the hospital."
Last year, MedStar published results from the House Call program showing that it cost less to provide care at home than at hospitals or physicians' offices. MedStar's study focused on the total population of its House Call program while the CMS demonstration project studied the sickest subgroup.
"Independence At Home examined the more expensive subgroup … in our study, we showed a 17% reduction overall, but it was averaged out," says De Jonge. "You can save a lot more money in the high-cost subgroup because before, patients were getting subpar care. They had to use 911 because they didn't have good access to urgent care, and they ended up in the ED, and because they are so sick and medically needy, they ended up in the hospital."
Arnold Goldberger's experience backs up De Jonge's claim. Earlier this year, his wife slipped and sprained her ankle. Within an hour, Goldberger talked to two nurses, his wife's ankle was x-rayed, and the diagnosis was "nothing serious."
"Compare that to going through 911, an ambulance ride, and an ER visit where other patients would have priority and we'd sit around for God knows long," says Goldberger. "Instead, it was one phone call and the whole process was set in motion."
Keeping patients out of the ED was one of six quality measures each Independence at Home site had to meet in order to receive a portion of Medicare's shared savings. The bonus depends on how many measures were met. MedStar says each provider in the MAC met all six:
- Reduce 30-day readmissions
- Provider follow-up within 48 hours of hospital admission
- Medication reconciliation within 48 hours of hospital discharge
- Advance care directives documented
- Reduce ED admissions for treatable chronic conditions
- Reduce hospital admissions for treatable chronic conditions
Who Gets Shared Savings?
After divvying up the $1.8 million among the MAC participants, De Jonge says he isn't sure what will fall to the individuals on the care team.
"If I have anything to say about it, I'd like to have compensation significantly enhanced for all providers on the team to attract more people to this work," says De Jonge.
Pay for providers who treat the frail elderly is a significant challenge.
"PCPs and geriatricians are some of the lowest-paid doctors and have a rigorous work schedule," says De Jonge. "It's not that everyone has to be paid the same, but the savings payments allow us to compensate PCPs, NPs, and social workers for the value of their work. You create a level playing field."
With concrete results and cash in hand from providing care at home, MedStar is now looking to scale the model across the MAC region. De Jonge says they will focus on the population that they know best—the frail elderly—but the demonstration project shows that it could also be applied to Medicare Advantage plans.
Jacqueline Fellows is a contributing writer at HealthLeaders Media.