K. Eric De Jonge, M.D. Medstar Washington Hospital Center May 14, 2014 No Financial Conflicts of Interest ©AAHCM 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 1 ©AAHCM 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 ©AAHCM 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) ©AAHCM Apply for CMS Data- Many hoops, IRB, privacy 2004-2008 CMS Database ◦ 909 New HBPC Cases 722 Eligible Cases ◦ 1,765,972 Medicare pts. 2161 Controls 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) ©AAHCM 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 ©AAHCM Main Outcomes ◦ Medicare costs, pattern of utilization, mortality CMS Data- All Medicare files except Part D Death events - SSA benefit records Multivariate regression model with covariates ◦ Major chronic diseases, baseline utilization ◦ Premodel matching of patient characteristics ©AAHCM 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% ©AAHCM 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 ©AAHCM 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) ©AAHCM 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. ©AAHCM Patients and Families in MWHC program MWHC Geriatrics team, Bruce Leff JEN Associates- Dan Gilden, Joanna Kubisiak Deerbrook Charitable Trust ©AAHCM ©AAHCM