After Carolyn, a patient in her late 60s who suffered from liver and heart failure, depression, and frequent falls, was admitted to the hospital six times in 2011, her daughter sought a way to secure more comprehensive care for her mother.
Margaret O'Kane, M.H.A., president of the National Committee for Quality Assurance, discusses the growth of the medical home model during a recent forum. Shawn Martin, AAFP senior vice president of advocacy, practice advancement and policy, also spoke at the forum.
She found it in MedStar Washington Hospital Center's Medical House Call Program in Washington, D.C., an Independence at Home(innovation.cms.gov) demonstration project supported by CMS. After entering the program, Carolyn was admitted to the hospital only twice from 2011 to 2015, and she received urgent care and screenings via 150 house calls.
Eric De Jonge, M.D., director of geriatrics at MedStar Washington Hospital Center, told Carolyn's story during a recent National Coalition on Health Care forum focused on scaling up successful medical home programs. The house call program, he said, allowed an interdisciplinary team to monitor Carolyn more closely and visit her regardless of the time of day. According to Carolyn's daughter, the change saved both her mother's life and her own. De Jong said it also saved money, which funded higher salaries for physicians.
The house call program is designed to both keep patients out of the hospital and substantially reduce costs, De Jonge explained. To achieve these goals, teams of physicians, nurse practitioners, social workers and care coordinators provide care for patients who generally are too ill to visit a clinic. Initially approved as a three-year pilot program, it was extended for another two years in July.
- The medical home model can improve care and save money if given proper support, said panelists at a recent forum on scaling up successful practice models.
- Success will require competitive compensation for physicians and a care team that is committed to treating patients with multiple chronic conditions.
- Savings have the potential to fund such transformation, a panelist said.
Nationally, the Independence at Home initiative reported $25 million in savings for 8,500 high-cost patients in 15 programs during its first year and has drawn attention from physicians and policymakers alike. Family physician Thomas Cornwell, M.D., of Wheaton, Ill., who specializes in caring for homebound patients, spoke about the initiative during a panel discussion at the 2015 National Conference of Family Medicine Residents and Medical Students that focused on the Health is Primary campaign.(www.healthisprimary.org)
For its part, however, MedStar Washington Hospital Center was so skeptical that the house call program would generate sufficient revenue that it did not even market it to patients at first. No upfront payment was provided to participants, but a shared savings payment in 2015 allowed De Jonge to increase pay for primary care physicians who make house calls by about 15 percent. The program now cares for 3,200 patients.
De Jonge estimated that if the house call program expanded across the nation -- where 2 million Medicare beneficiaries with severe chronic illnesses consume 43 percent of the Medicare budget -- it could save between $21 billion and $34 billion over 10 years.
But to be successful, De Jonge said, such programs will need to pay physicians competitively, and the care team has to be committed to treating the frail elderly with multiple chronic conditions.
Margaret O'Kane, M.H.A., president of the National Committee on Quality Assurance (NCQA), echoed De Jonge's call for greater financial and staffing support.
There are now 169 medical home incentive programs in 48 states, compared with just 26 programs in 18 states six years ago, O'Kane said. Further growth will require payments that adequately reflect operating costs, she added. Although it costs about $4 to $5 per member, per month to operate a medical home, payments are typically no more than $3 per member, per month.
"It's a big lift when you think about what you are asking primary care physicians to do," O'Kane said. "When you visit a physician's office, you notice there is not a lot of downtime. Now we're asking them to do something transformational. You can't expect people to do a lot more without additional resources."
Successful expansion of the medical home model will require participation from all insurers, said forum speaker Shawn Martin, AAFP senior vice president of advocacy, practice advancement and policy, because family physicians care for patients with all forms of insurance. It also will require electronic health records to support, rather than hinder, coordinated care, a goal the AAFP is pushing hard for in Washington.
After the medical home model achieves significant savings, De Jonge said performance targets will be lowered and monthly payments will need to increase. Eliminating waste would free up funds to pay for such a move, he added.
"I think there is plenty of money in Medicare," De Jonge said. "So much money is being wasted on poor care."