K. Eric De Jonge, M.D.
Medstar Washington Hospital Center
May 14, 2014
No Financial Conflicts of Interest
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Title: Effects of Home-Based Primary Care on
Medicare Costs in High-Risk Elders
K. Eric De Jonge M.D. 1, Namirah Jamshed M.B.B.S.1,
Daniel Gilden, MS 2, Joanna Kubisiak, MPH 2,
Stephanie R. Bruce M.D. 1, George Taler M.D. 1
MedStar Washington Hospital Center (MWHC),
Section of Geriatrics, Washington D.C.
2 JEN Associates, Cambridge, MA
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Hypothesis:
◦ Home-Based Primary Care (HBPC) reduces total
Medicare FFS costs
Problems:
◦ Major selection bias for those who enter HBPC
 Low function, severity of illness, terminal stage, SES
◦ Control group challenges
◦ Ethical barriers to RCT
◦ Lack of full CMS cost and survival data
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2009
◦ Define question  What are Medicare FFS costs and
survival for similar HBPC and control populations?
◦ Found JEN Associates
 (Dan Gilden and team, www.jen.com)
◦ Funding to hire JEN, then buy CMS data ($75K)
◦ Case-control concurrent study (full CMS data)
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Apply for CMS Data- Many hoops, IRB, privacy
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2004-2008 CMS Database
◦ 909 New HBPC Cases  722 Eligible Cases
◦ 1,765,972 Medicare pts.  2161 Controls
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Longitudinal picture -- Cases and Controls
◦ Define major selection biases, incident dates
◦ Match 3:1 by gender, age bands, race, SES, LTC status,
frailty, major chronic illnesses, cognitive impairment
◦ Check Baseline utilization (prior 4 months)
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Home-Based PC team at MWHC
◦ 4 Geriatricians, 4 NPs, 4 SWs, 4 Coordinators, 1 LPN
◦ Intensive home-based 24/7 care, over time/setting
◦ Directly manage all primary and urgent care,
specialists, social services, and hospital care
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Main Outcomes
◦ Medicare costs, pattern of utilization, mortality
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CMS Data- All Medicare files except Part D
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Death events - SSA benefit records
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Multivariate regression model with covariates
◦ Major chronic diseases, baseline utilization
◦ Premodel matching of patient characteristics
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Variable
Cases (722)
Controls (2161)
Female
76.7%
76.7%
Mean Age
83.7 years
82.0 years
African-American
90.2
90.3
Low SES (Medicare buy-in)
36.3 %
36.3%
Dementia
57.5%
57.4%
High JFI Frailty Index
37.0%
36.9%
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Outcome
Cases- 722
Controls- 2161
P-value
Mean F/U
period
23.3 months
24.2 months
p=.18
Total Medicare $44,455
Costs (FFS)
$50,978
p= .01
Hospital Care
$17,805
$22,096
p=.003
SNF Care
$4,812
$6,098
p= .001
Home Health
$6,579
$4,169
p= .001
Hospice
$3,144
$1,505
P= .005
Other
$7,962
$11,392
P= .001
Mortality
40%
36%
HR=1.06,
p=.44
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Cases
◦ 105% more generalist visits (p=.001)
◦ 23% less specialist visits (p=.001)
Multivariate Regression Model
 Cases  Average $8,477 less per patient (2 years)
 17% Lower total Medicare Costs (p=.003)
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A Home-Based Primary Care model reduced
total Medicare costs by 17% for ill elders,
with similar survival outcomes.
Such results argue for payment reform (e.g.
IAH) to scale such teams across the U.S.
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Patients and Families in MWHC program
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MWHC Geriatrics team, Bruce Leff
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JEN Associates- Dan Gilden, Joanna Kubisiak
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Deerbrook Charitable Trust
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In Medicare FFS - American Academy of Home Care Medicine