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House-Call Pioneers Get Two More Years to Earn Medicare Payments

By Kerry Young, CQ Roll Call

July 16, 2015 -- Congress sent to President Barack Obama a two-year extension of a pilot program that tests whether house calls can save Medicare money by helping preserve the health of very frail elderly people, including those suffering from dementia or those needing help feeding themselves.

Last week, the House cleared by voice vote a bill (S 971) that changes the Medicare Independence at Home demonstration program from a three-year project into a five-year one. Although it was created as part of the Affordable Care Act, there was little controversy about its extension. The Senate Finance Committee moved the bill by unanimous consent before the Senate approved it by voice vote in April. The House Ways and Means Committee then approved it by voice vote in June.

The Centers for Medicare and Medicaid Services (CMS) provides no initial direct investment for the groups participating in the Independence at Home project, said Terri Hobbs, the executive director of Housecall Providers Inc., which was one of the biggest initial winners in the program. Instead, the participating organizations volunteer to be judged on their performance with an intention of later securing incentive payments.

"It was a little tough to not have any influx of support at the beginning," said Hobbs, whose Portland, Oregon-based group has been in operation since the mid-1990s.

Housecall Providers was awarded a payment of $1.23 million from CMS, when it was judged to have met quality measures set by the agency while also saving money. Only about half of the participants, or nine of 17 groups, qualified for the initial set of incentives payments. These ranged from $2.9 million awarded to the Visiting Physicians Association unit in Flint, Michigan, to $275,427 for Durham, North Carolina-based Doctors Making Housecalls, CMS said in a statement last month. The Independence at Home program, which kicked off in 2012, was estimated to save $25 million in its first year.

To qualify for care through the program, a person needs to have at least two chronic conditions, such as dementia and congestive heart failure, and also need a caregiver's help with at least two tasks of daily living, such as eating, walking or bathing. These patients also should have had at least one hospitalization and received rehabilitation services or another form of post-acute care within a year of their enrollment.

CMS said that all of the organizations participating in the program were found to have improved quality of care by at least three of six measurements. On average, results for the more than 8,400 elderly people in the program showed that there were fewer hospital readmissions within a month of an initial stay. CMS also observed a reduction in the use of hospital outpatient and emergency department services for conditions such as diabetes, high blood pressure, asthma, pneumonia, or urinary tract infection.

Among the organizations that didn't qualify for bonus payments was Boston Medical Center, which narrowly missed its financial target. CMS had set a benchmark of $4,781 per person in the Boston Medical Center program, which was judged to have had costs of $4,741. (Housecall Providers, in comparison, had a target of $3,568 and was judged to have costs of $2,434). Boston Medical Center intends to continue with the program, said Melissa Monahan, a spokeswoman.

"We know from our experience that the vast majority of older adults want to remain at home and we will continue to work hard to investigate outcomes to support this model of care for our patients," she said.

Beyond gathering data on the care of these patients, the Independence at Home program may change attitudes broadly about how medical care is delivered, said Bruce Leff, the director of the geriatric health services research program at Johns Hopkins School of Medicine.

There was a shift in the last century away from providing care at home, said Leff, who served on a technical expert panel that advised CMS on the development of quality indicators used in the Independence at Home program. In the past, most care was handled in the community. Leff, who is 54, said he remembers getting house calls from doctors while growing up in the Bronx, he said.

"That all went away," he said.

People began to value more highly the care that could be delivered in hospitals equipped with high-tech equipment, even in cases where the technologies may not provide much health benefit, he said. The money from insurers, including Medicare, incentivized this trend as well.

"There's a tremendous inherent bias toward facility-based care and interventions," said Leff, who also is co-director of the elder house call program at Hopkins.

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