Home-based medical care offers older homebound adults with multiple chronic conditions and functional limitations access to care — while enabling them to avoid living in an institution. As the U.S. health care system moves away from paying for individual services toward more value-based care under the Medicare Access and CHIP Reauthorization Act (MACRA), we in the field have developed quality measures appropriate to the needs of the homebound, and are working to address shortcomings in the new payment system.

Current State of Home-Based Medical Care

The value and effectiveness of home-based medical care are being increasingly recognized, as shown in a recent Commonwealth Fund report. The Centers for Medicare and Medicaid Services’ (CMS) Independence at Home Demonstration, for example, achieved robust savings for the Medicare program and underscored the impact that even relatively small medical practices can have on the health of homebound older adults.

Yet national data suggest that making home-based medical care available to all who could benefit from it will require a better-prepared workforce and better financial incentives to encourage more clinicians to enter the field. Currently, the community of home-based medical care providers is small relative to the number of people who would benefit from the services, and most homebound people live more than 30 miles from a high-volume provider. In one study, we found that about 7,000 primary care providers made over 1,000 nursing home visits each year, while only 470 providers made more than 1,000 home visits, even though there are more frail homebound people than nursing home residents in the United States.

Home-Based Medical Care and MACRA

MACRA, a law that passed with bipartisan support in 2015, creates a new framework for rewarding physicians for providing higher-quality care by establishing two tracks for payment, including the Merit-based Incentive Payment System (MIPS). Under MIPS, quality measures captured in the CMS-approved qualified clinical data registry are eligible for performance payment under MACRA. Therefore MACRA also creates an opportunity for the home-based medical care provider community to realize its potential by creating quality measures appropriate to the home setting and to the needs and characteristics of home-based medical care patients, and by developing a culture of quality and quality improvement.

However, this opportunity is hampered by a shortcoming in the design and implementation of its incentives. Because the MIPS program was conceived with only the traditional office-based practice in mind, the quality indicators are not optimally geared toward a home-based medical care practice’s population. Further, important risk-adjustment data, such as functional status, are often not available or easily integrated into the measures reporting. Finally, MIPS is generally more challenging for small practices to implement because it requires a quality measurement collection and reporting mechanism unavailable to a majority of home-based medical care practices.

The Rub

Perhaps most critically, the method by which CMS will award quality points under MIPS creates a zero-sum game for providers reporting on a particular quality measure in which a gain for one provider always means a loss for another. Points are awarded based on performance of all providers reporting on a quality measure, rather than a threshold or benchmark consistent with high quality.

Because a measure developed that is specific to the homebound population or any other special population will likely have relatively few providers reporting on the quality measure, there will be winners and losers in the awarding of quality points, even if all providers are clinically performing well, i.e., above an acknowledged threshold or benchmark. Unfortunately, this approach has the potential to penalize providers using more appropriate quality measures for specific patient populations.

The Path Forward

Despite these new obstacles posed by MACRA, the National Home-Based Primary Care and Palliative Care Network has continued to push ahead by developing and testing quality measures appropriate to a homebound and often seriously ill population. The network is currently engaged in a learning collaborative of several home-based medical care practices that will use the quality measures and capabilities of a CMS-approved data registry.

The network also has sought to mitigate the potential liabilities posed by MACRA by including established and more broadly relevant measures in its data registry, as well as the custom measures, and by offering opportunities for MIPS-eligible quality improvement initiatives. In addition, addressing these liabilities will require ongoing advocacy on behalf of a rational regulatory approach to measuring clinical performance for special populations such as the homebound. It is only through these approaches that home-based medical care providers will survive in the context of CMS’s current method of calculating quality performance points under MIPS.