Home Is Where the Physician Is

Patients with multiple chronic disorders often spend the majority of their time going from one doctor to another. With different providers and hospital visits, it is difficult to provide clinical care coordination and communication between providers. The lack of communication and coordination usually leads to disjointed care, duplicate tests and ultimately adds to the expense of a healthcare delivery system.

Now, chronic disease patients can merely open the door to their home to receive primary care services. Pursuant to the Patient Protection and Affordable Care Act (“Healthcare Reform Act”), the Federal Government has directed the Centers for Medicare and Medicaid Innovation (“CMI”) to engage in a demonstration project to test a model of providing care in the patient home instead of in a physician office. The concept is to engage primary care physicians and physician extenders to provide care in each patient’s home. Ultimately, the intent is to reduce the costs to the Medicare program by bringing the care to the patient and coordinate the care in a familial setting to ensure the patient’s support program is readily available. In fact a primary goal of at-home care is to improve patient satisfaction by reducing hospitalizations and emergency department visits and promoting care consistent with beneficiary preferences.

Although at home care sounds convenient for all, this program is limited to patients that have multiple chronic illnesses. In addition, the patient must require someone’s assistance with two or more activities of daily living such as bathing, dressing, eating or walking. The patient must also have had a medically-necessary hospital admission and received rehabilitation services in the last 12 months. Thus, the eligible population is limited.

The provider participants are also limited. Specifically, this program is focused upon group practices of primary care physicians or a consortium of multiple different primary care providers. The primary care provider or consortium must also have a patient population and mix of at least 200 patients with chronic disorders. Under this program, instead of seeing patients all day in the office, the physician, physician assistant or nurse practitioner will travel to the patients home and it is anticipated that the provider will spend more time with the patient to address all of the patient’s comprehensive needs. These providers can change the model of how healthcare is delivered for this high risk population.

If a primary care provider can spend time with a patient in the patient’s home, the Federal Government intends to share the savings in the Medicare program with the providers. Similar to the Accountable Care Organization (ACO) model, primary care providers that provide at home care will report on specific quality measures. In fact, the primary care physicians will be charged to reduce the costs associated with the providing the care and to the extent the costs are reduced, the primary care physician will be eligible to share in the savings. This is just another model to incentivize the providers to actively manage the patient to reduce costs by permitting the physician to share in the savings.

The other side of this coin is that if a provider participates in this demonstration program, he or she will not be eligible to participate in a Medicare ACO program. The healthcare industry is already trying to adjust to a shrinking population of providers. Under this program, it would appear to require more time and focused attention by the providers on the high risk population. Thus, this may have an adverse impact on the actual accessibility of primary care services available for low risk Medicare beneficiaries. Further, because the providers that participate in this program will not be permitted to participate in other ACOs it may also adversely impact the regional ACOs that are searching for primary care physicians to serve as the medical home for the assigned Medicare beneficiaries.

Balancing at-home care for the high risk with the shortage of physicians is a challenge the will impact accessibility to services. However, the potential upside of improving healthcare outcomes and reducing costs may counter these concerns. For providers, participation in this program should be based upon their current patient population and payer mix. Ultimately, depending upon the outcomes of this program, this model may drive providers to change how and where they deliver care to all patients.

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