Andrew Lyons-Home Based Primary Care: Bridging the Gap for Chronic Palliation Between Restoritive Care and End Of Life Care
1. Home Based Primary Care
Bridging the gap for chronic palliation between
restorative care and end of life care
JHLC – Geriatric Palliative Care conference
November 12, 2013
Andrew Lyons, MD
Medical Director
3. The American Academy of Home Care Physicians (aahcp.org)
For the period of year 2000-2030 the number of Americans with
chronic conditions will increase by 37%
125 million to 171 million individuals
Costs associated with Care of Chronic Illness will rise
exponentially
High cost, chronically ill beneficiaries
Fill an average of 20 different prescriptions per year
Account for 76% of all Hospital Admissions
See an average of seven different Physicians per year
Are 100 times more likely to have a preventable hospitalization
compared with a non chronically ill population
A small percentage of Medicare Fee for Service Beneficiaries
consume the majority of costs
Top 7% - 53%, Next 5% - 16%, Next 12% - 17%
In aggregate, the top 24% consume 84% of costs
80% of Medicare Spending is for people with 4+ Chronic
Illnesses
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4. What Patients Value
Personalized Care
Access to their Physicians
Autonomy to make Decisions
Continuity of Care
ER and Hospital Avoidance
Advanced Directives for Medical Care
Relief from worry
Protection from catastrophic costs
Chronically ill patients are not price sensitive consumers
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5. The Merry Go Round
Acute Exacerbation of Chronic Illness
ER evaluation and Hospital Admission
3 Day Length of Stay qualifies patient for “post acute” care
Sub Acute Rehabilitation Stay (restorative?)
Non Physician Home Care Services
Primary Care Provider awaits patient back in office
Chronic Illness Persists
Acute Exacerbation of Chronic Illness
“Sicker and quicker” discharges
Hospital directive to reduce LOS, adhere to DRG period
Care Transitions between Hospitalist and PCP
Treatment initiated as Inpatient not complete
Need for restorative rehab services arises
Need for supportive care is identified
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6. Factors Affecting Re-Hospitalization Rates
NEJM 2009 – Medicare Beneficiaries
90% of rehospitalizations within 30days are unplanned
Targeted interventions at time of discharge are superior to relying upon
community resources
Hospital and MD collaboration is essential
Post surgical patients benefit from Medical coordination prior to
procedure
Wide State to State variability
Lack of follow up with PCP in majority of cases
Medication reconciliation requires a prescriber engaged in the
care of the patient
Home Care services work best with PCP cooperation and
support
Post Acute Care period is great opportunity to establish
Advanced Directives
NYS has earned distinction for readmissions
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7. Policy Initiatives for Primary Care
PPACA – Expanded coverage, expanded costs
Primary care focused on symptom management
Primary care focused on Prevention
Evidence based treatment and outcomes
HIT incentives
EMR subsidies for MU certified systems
ePrescribing incentives and penalties
Accountable Care Organizations
Lump sum payment and incentives tied to outcomes
Adherence to “quality” measures
Medical Home Model
Primary Care Development Corporation
National Committee on Quality Assurance (NCQA)
Primary Care Incentives
10% bonus for primary care E&M codes and HPSA bonuses
Loan forgiveness – serving at FQHC sites
G code/CPT Codes for Transitional Care Coordination
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8. The House Calls Model
Focused upon the sickest, most frail high cost beneficiaries
Superior access to Primary Medical Care
Proper engagement with necessary Home Care entities
Preferred care for the patients, consistent with their values
Low cost compared with the Merry go Round
Delivers appropriate care without imposing tone of austerity
Only effective way to deliver appropriate Transitional Care
Prescriber becomes the care coordinator
Lab, xray, ultrasound diagnostic services in the home
Point of care lab services in the home
The Primary Care of the Future because it retains what was good
about the past.
Data from VA program over 40 yrs has been used to influence
recent CMS pilot studies: 24% reduction in overall costs, 62%
reduction in inpatient days
http://www.iahnow.com/IAHcostsavings.htm
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9. Payer Models for House Call Programs
Medicare
Primary Care Bonus
Fee for service rates above office visits
Home Care Certification and Care Plan Oversight
Independence at Home – “Medical Home at Home”
Care Coordination Fee and Gain Sharing
2012 Demonstration Project (PPACA)
Separate and apart from ACO concept
Medicaid
Primary Care fees scheduled to rise under PPACA to Medicare rates
Managed Care
Medicare Advantage
Dual Eligible Special Needs Plans (ISNP’s, IESNP’s)
HCC Scores, HEDIS Measures, STAR ratings
Capitation
Concierge Private Pay
Retainer based + Out of Network Insurance
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10. Outlook for Growth
Huge unmet need (10,000 Americans age in to Medicare daily)
Patients value this model
Payers are beginning to value this model
Central planning and care management can be enhanced
Only for high cost beneficiaries or initial HCC risk scores
Complexity of conditions requires longitudinal intervention
Hospitals may value this model
Part of strategy to avoid readmission and for ER decompression
Home Care companies do value this model
An engaged PCP is frequently missing from their care model
The House Call PCP helps their model work better
No comparable program for Primary Care access and cost
containment exists
Government payers are supporting this model
House Call E&M codes qualify as Primary Care
Will require infrastructure support to maintain standards for
quality and outcomes measures (safe harbor partnerships?)
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