At Home Primary Care and Medicare Costs in High-Risk Elders
At Home Primary Care and Medicare Costs in High-Risk Elders
Objectives To determine the effect of home-based primary care (HBPC) on Medicare costs and mortality in frail elders.
Design Case–control concurrent study using Medicare administrative data.
Setting HBPC practice in Washington, District of Columbia.
Participants HBPC cases (n = 722) and controls (n = 2,161) matched for sex, age bands, race, Medicare buy-in status (whether Medicaid covers Part B premiums), long-term nursing home status, cognitive impairment, and frailty. Cases were eligible if enrolled in MedStar Washington Hospital Center's HBPC program during 2004 to 2008. Controls were selected from Washington, District of Columbia, and urban counties in Virginia, Maryland, and Pennsylvania.
Intervention HBPC clinical service.
Measurements Medicare costs, utilization events, mortality.
Results Mean age was 83.7 for cases and 82.0 for controls (P < .001). A majority of both groups was female (77%) and African American (90%). During a mean 2-year follow-up, in univariate analysis, cases had lower Medicare ($44,455 vs $50,977, P = .01), hospital ($17,805 vs $22,096, P = .003), and skilled nursing facility care ($4,821 vs $6,098, P = .001) costs, and higher home health ($6,579 vs $4,169; P < .001) and hospice ($3,144 vs. $1,505; P = .005) costs. Cases had 23% fewer subspecialist visits (P = .001) and 105% more generalist visits (P < .001). In a multivariate model, cases had 17% lower Medicare costs, averaging $8,477 less per beneficiary (P = .003) over 2 years of follow-up. There was no difference between cases and controls in mortality (40% vs 36%, hazard ratio = 1.06,P = .44) or in average time to death (16.2 vs 16.8 months, P = .30).
Conclusion HBPC reduces Medicare costs for ill elders, with similar survival outcomes in cases and controls.
The most costly 5% of Medicare beneficiaries account for approximately half of Medicare expenditures. These high-cost beneficiaries tend to be older and disabled and are more likely to have multiple chronic conditions and to enter a hospital or a skilled nursing facility (SNF). They have serious illnesses such as dementia, congestive heart failure (CHF), atherosclerotic disease, stroke, psychiatric disease, and cancer and have high symptom burden and functional impairment. These traits predict greater mortality and higher medical costs. Individuals with two or more chronic conditions are at greater risk of emergency department (ED) visits, hospitalization, and use of postacute care services. Since 2000, such elders have experienced greater rates of hospitalizations in the last 90 days of life. Much current care for these elders is fragmented, ineffective, and expensive. Given the implementation of the 2010 Affordable Care Act, which emphasizes value-based care, health providers need to create care models that produce good clinical results and prevent high-cost events.
Home-based primary care (HBPC) is a mobile care innovation that focuses on the most-ill subset of elders. Interprofessional HBPC teams deliver medical and social services to elders with severe and disabling chronic illnesses who find it difficult to get to a doctor's office. The Department of Veterans Affairs (VA) operates more than 150 HBPC sites, which are associated with a reduction in hospital and nursing home usage. Observational VA studies demonstrate that their HBPC model is associated with 24% lower total VA costs and 11% lower Medicare costs. A current Medicare demonstration program, Independence at Home, is examining the effects of such HBPC on quality and costs.
To the knowledge of the authors of the current study, no well-controlled studies have tested the effect of an HBPC model on costs and survival in the Medicare fee-for-service (FFS) arena. This study examined the effects of a HBPC program on costs and survival in a population of high-risk elders in Washington, District of Columbia, using a robust case–control methodology and comprehensive Medicare claims data.
Abstract and Introduction
Abstract
Objectives To determine the effect of home-based primary care (HBPC) on Medicare costs and mortality in frail elders.
Design Case–control concurrent study using Medicare administrative data.
Setting HBPC practice in Washington, District of Columbia.
Participants HBPC cases (n = 722) and controls (n = 2,161) matched for sex, age bands, race, Medicare buy-in status (whether Medicaid covers Part B premiums), long-term nursing home status, cognitive impairment, and frailty. Cases were eligible if enrolled in MedStar Washington Hospital Center's HBPC program during 2004 to 2008. Controls were selected from Washington, District of Columbia, and urban counties in Virginia, Maryland, and Pennsylvania.
Intervention HBPC clinical service.
Measurements Medicare costs, utilization events, mortality.
Results Mean age was 83.7 for cases and 82.0 for controls (P < .001). A majority of both groups was female (77%) and African American (90%). During a mean 2-year follow-up, in univariate analysis, cases had lower Medicare ($44,455 vs $50,977, P = .01), hospital ($17,805 vs $22,096, P = .003), and skilled nursing facility care ($4,821 vs $6,098, P = .001) costs, and higher home health ($6,579 vs $4,169; P < .001) and hospice ($3,144 vs. $1,505; P = .005) costs. Cases had 23% fewer subspecialist visits (P = .001) and 105% more generalist visits (P < .001). In a multivariate model, cases had 17% lower Medicare costs, averaging $8,477 less per beneficiary (P = .003) over 2 years of follow-up. There was no difference between cases and controls in mortality (40% vs 36%, hazard ratio = 1.06,P = .44) or in average time to death (16.2 vs 16.8 months, P = .30).
Conclusion HBPC reduces Medicare costs for ill elders, with similar survival outcomes in cases and controls.
Introduction
The most costly 5% of Medicare beneficiaries account for approximately half of Medicare expenditures. These high-cost beneficiaries tend to be older and disabled and are more likely to have multiple chronic conditions and to enter a hospital or a skilled nursing facility (SNF). They have serious illnesses such as dementia, congestive heart failure (CHF), atherosclerotic disease, stroke, psychiatric disease, and cancer and have high symptom burden and functional impairment. These traits predict greater mortality and higher medical costs. Individuals with two or more chronic conditions are at greater risk of emergency department (ED) visits, hospitalization, and use of postacute care services. Since 2000, such elders have experienced greater rates of hospitalizations in the last 90 days of life. Much current care for these elders is fragmented, ineffective, and expensive. Given the implementation of the 2010 Affordable Care Act, which emphasizes value-based care, health providers need to create care models that produce good clinical results and prevent high-cost events.
Home-based primary care (HBPC) is a mobile care innovation that focuses on the most-ill subset of elders. Interprofessional HBPC teams deliver medical and social services to elders with severe and disabling chronic illnesses who find it difficult to get to a doctor's office. The Department of Veterans Affairs (VA) operates more than 150 HBPC sites, which are associated with a reduction in hospital and nursing home usage. Observational VA studies demonstrate that their HBPC model is associated with 24% lower total VA costs and 11% lower Medicare costs. A current Medicare demonstration program, Independence at Home, is examining the effects of such HBPC on quality and costs.
To the knowledge of the authors of the current study, no well-controlled studies have tested the effect of an HBPC model on costs and survival in the Medicare fee-for-service (FFS) arena. This study examined the effects of a HBPC program on costs and survival in a population of high-risk elders in Washington, District of Columbia, using a robust case–control methodology and comprehensive Medicare claims data.
