Return of the House Call
A Breakfast Forum
Housecall Providers
June 4, 2014
The Mission of House Calls
1.
2.
3.
Improve the quality of life of homebound patients
Improve the quality of life of caregivers
Decrease health care costs by enabling patients to remain at
home and avoid expensive emergency departments,
hospitals and nursing homes
Three Reasons for the Decline of the House Call
1.
2.
3.
Increased office/hospital based technology
Fear of increased liability
Financial disincentives
Technology is Not a Barrier
Liability is Not a Barrier
Medicare House Call Codes/Payments
1997 New
99341
99342
99343
1997 Estab.
99351
99352
99353
1997
$62.51
$77.71
$101.62
1998 New (Min)
1997
$46.66
$59.37
$74.80
1998 Est. (Min)
99341 (20)
99342 (30)
99343 (45)
993441 (60)
993451 (75)
99347 (15)
99348 (25)
99349 (40)
993501 (60)
1998
$57.53
$77.58
$110.19
$140.50
$166.24
2014
$58.99
$85.34
$139.16
$193.94
$233.70
IDPA2
$27.95
$37.40
$54.90
$70.55
$85.55
1998
$45.43
$65.54
$94.92
$136.00
2014
$59.39
$89.64
$135.18
$189.15
IDPA2
$24.25
$31.30
$47.50
$68.85
1 Additional 1998 higher level Medicare house call codes
2 IDPA: Illinois Department of Public Aide
Shaded payments are most frequently used house call codes
Note: Medicare Payments vary by locality. These are for Locality 15.
Place of Service Code for Home = 12
The Return of the House Call
Why?
• Demographics: Aging of Society
• Health Care Reform: The Affordable Care Act
1. Readmission Reduction
2. Accountable Care Organizations
3. Independence at Home
• Medicare and Medicaid Fiscal Crisis
• Recent evidence of the value of house calls
Demographics: Aging Society
Exploding
Homebound
Population!
For half of the patients readmitted within 30 days, there
was no bill for a physician visit during that time.
Resource Use Among Elderly Congestive Heart Failure:
Patients Who Received a Transitional Care Intervention or
Usual Care, Six Philadelphia Hospitals, 1997–2001
$600,000
Intervention
Control
$489,420
$500,000
$400,000
$358,472
$300,000
$236,144
$205,528
$218,035
$200,000
$145,581
$100,000
$0
0-3 Months
3-6 Months
6-12 months
Transitional Care of Older Adults Hospitalized with Heart Failure: A
Randomized, Controlled Trial (Naylor, M.D. et al. 2004. JAGS 52:675–84.)
5/14/09 – 2/18/11
(1 year, 9 months (645 days))
 44 Emergency Department Visits (avg 16
days between visits)
 27 Hospitalizations—over half required
ICU days (avg 25 days between stays)
HCP First Visit 3/2/11 (365 Days)
 1 ED visit + 1 Hospitalization (May 2011)
 Expected: 25 ED visits, 15 Hospitalizations

Following Year: 0 ED, 0 Hospitalizations
1/1/12-12/5/12
 17 Emergency Department (ED) Visits
 13 Hospitalizations (69 Days)
 Multiple rehab stays
HCP First Visit 12/5/12
 1 ED Visit/1 Hospitalization 12/18/12 (4 days)


0 ED Visits/0 Hospitalizations in 2013
Passed away at home 7/22/13 on hospice
End-of-Life Care
HomeCare Physicians Patient Deaths 2003-2013
Number
Percentage
Total
2049
100%
Home
1,521
74%
Hospital
389
19%
Nursing Home
102
5%
Unknown
37
2%
HomeCare Physicians and End-of-Life Care
• 9/1/12-8/31/13 215 deaths
–
–
–
–
–
79% died at home
71% where on hospice
Average length of stay 2.1 years
Median length of stay 0.56 years
25 died in first 30 days
• 23 (92%) died at home
• 25.1% of the $556 billion Medicare dollars goes to care in last
year of life
Riley, Lubitz; Health Services Research 4/2010
Average Traditional Medicare per capita Spending, 2009
$60,000
$55,763
$50,000
$40,000
$30,000
$20,000
$10,000
$9,702
$4,584
$Bottom 90%
Top 10%
Source: The Kaiser Foundation
Average
Independence at Home Demonstration
1.
Focuses on the highest cost Medicare beneficiaries (10% of
Medicare beneficiaries with ≥ 5 chronic conditions account for
2/3rds of Medicare spending)
1.
2.
3.
2.
≥ 2 chronic conditions
Emergent hospitalization in past year + post acute care services
Functional dependence (≥ 2 ADL deficiencies) and frailty
Holds IAH provider organizations strictly accountable for three
performance standards
1.
2.
3.
Minimum savings of 5%
Good outcomes commensurate with the beneficiary’s condition
Patient/caregiver satisfaction
Independence at Home Demonstration
• Savings beyond 5% are split 80% / 20% with Medicare thereby
creating an incentive for greater savings and generating
revenue that can be invested in new mobile technologies that
generate further savings such as decisional support, point-ofservice diagnostic testing and portable therapeutic devices.
Medicare/Medicaid Crisis
• Medicare facing insolvency
• Medicaid increased from 8% of state spending in FY1985 to
22% in FY2004 overtaking K-12 education as the largest
component of state budgets
• Most rapidly increasing Medicaid cost is for long term care
Costs of Care Before vs During HBPC for 2002
(per patient per year) *includes HBPC cost
N=11,334
$103,048,728
Total Cost
of VA Care
Hospital
Before
During
HBPC
HBPC
$38,228 $29,136*
$18,868
$7026
$11,842 (- 63%)
Nursing home
$10,382
$1382
$9000 (- 87%)
Outpatient
$6490
$7140
$650 (+ 10%)
All home care
$2488
Change
-$9,092 (- 24%)
P < 0.0001
$13,588* $11,100 (+ 460%)