While home-based primary care interest and availability has steadily increased over the past few years, the model has yet to reach a true tipping point.
As a result of the COVID-19 public health emergency, however, the U.S. health care system is becoming more decentralized. That shift, in turn, is opening up the door for a true return of the physician house call — and all of the health outcomes and cost savings that come with it.
As that happens, home health providers may see an uptick in business as well, in-home primary care experts believe.
Broadly, home-based primary care programs send primary care physicians and other medical professionals into the home setting to provide care for high-risk, medically complex patients. Compared to the traditional office or facility-based model, house calls give doctors a chance to observe social aspects of health while often spending more time with patients.
As the nation continues to see a rise in the number of individuals who are 65 and older, there will be an increase in those more likely to be homebound. Currently, about 2 million people are homebound due to frailty and illness, according to the American Academy of Home Care Medicine (AAHCM).
Of those homebound individuals, only 15% are being served using home-based primary care models, according to Dr. Thomas Cornwell, executive chairman of the Home Centered Care Institute, a nonprofit organization that advocates for the expansion of home-based primary care.
“Sometimes, I say, ‘What if we were only servicing 15% of oncology patients or heart patients?’” Cornwell told Home Health Care News. “We would think that’s terrible. Not only is this care remarkable for this highest-cost population, but nothing has been shown to save more health care costs.”
Indeed, the home-based primary care model has gained a reputation for cost-effectiveness. One specific program in Washington, D.C., for example, saved $4,000 per patient annually, according to AAHCM.
The Independence at Home (IAH) Medicare house call demonstration program — a Center for Medicare & Medicaid Innovation (CMMI) project that tests the delivery of primary care services at home — started in 2012. Overall, IAH saved $100 million — or $2,000 per patient — in its first five years.
Today, the Veterans Administration (VA) has the largest home-based primary care program in the U.S. Previously, the VA found that its program’s annual Medicare costs were 10.8% lower than predicted costs, according to AAHCM.
Aside from the cost benefits, the home-based primary care model has been shown to improve overall outcomes, too.
“Most studies have shown about 15% to 20% reduction in hospitalization and oftentimes a 15% reduction in emergency department use,” Cornwell said.
Even with a solid track record of cost savings and improved patient outcomes, the home-based primary care model hasn’t really taken off. One of the major reasons for this is the fee-for-service payment system, according to Cornwell.
“House calls do pay about $10 to $30 more than an office visit, but you can do at least double the number of office visits in time it takes to do a house call,” he said. “House calls have been shown to be a high-value [model] — and yet it’s a low-volume business. Fee-for-service has been the drawback, because you just could not financially make it on the Medicare payments.”
Home-based primary care services are typically reimbursed through Medicare, Medicaid, dual Medicare-Medicaid plans, Medicare Advantage and other commercial health plans.
Heal, a Los Angeles-based home-based primary care provider, found success with its doctors-on-demand model that allows patients to book physician house calls through its technology platform.
The company has about 100 doctors in its network. Currently, Heal operates in California, Northern Virginia, D.C., Atlanta and New York.
Amid the COVID-19 public health emergency, home-based primary care is especially crucial when it comes to avoiding hospital settings that are susceptible to becoming sources of cross-contamination, Nick Desai, CEO of Heal, told HHCN.
“The value is enormous,” Desai said. “You’re not exposing yourself to the germs. You can get extremely high-quality care in the comfort and safety of your own home. A lot of seniors have trouble getting to the doctor’s office, now they can get care without risking exposure. COVID-19 is just bringing that to the forefront.”
In-home primary care doesn’t always have to be in-person, though. Since the start of the public health emergency, Heal has doubled down on its use of telehealth, including phone, video conferencing and remote monitoring.
Unlike home health care, the Centers for Medicare & Medicaid Services (CMS) has created reimbursement mechanisms for doctor visits delivered via telehealth.
“In light of COVID-19, we’ve changed our entire model to initiate the doctor-patient relationship by telemedicine first,” Dr. Renee Dua, chief medical officer at Heal, told HHCN. “We are finding that patients are able to get what they need out of us from a telemedicine call.”
Telemedicine has also enabled the company to provide “peace of mind” while upholding social distancing, according to Dua.
Due to increased demand and support from updated CMS policies, the company’s telemedicine business has grown 614% in the past five weeks, according to Desai.
While the company has been able to provide part of its care using telehealth during the COVID-19 emergency, Dua still stresses the importance of comprehensive home-based care.
“One is not enough without the other,” she said. “You can provide care with telemedicine calls, but being able to sit with your patient, hold their hand, give them comfort and examine them is critical.”
The home health opportunity
One misconception that persists about home-based primary care that it is identical to home health care.
Though this isn’t the case, there is ample room for collaborations and partnerships between home health and home-based primary care, according to Cornwell. In fact, it’s something that Cornwell has seen firsthand.
“My house call program has generally been two doctors and two to three nurse practitioners,” he said. “Despite being only two out of 1,000 doctors at my health system, we made up 7.3% of all home health referrals … between 2003 and 2017. Home-based primary care and home health work great together, because we have common goals to try and safely keep the patient home.”
For Heal, for example, this has meant collaborations with Kindred at Home, 24 Hour Home Care and other providers.
“It’s that collaboration that makes Heal so powerful,” Desai said. “A home health worker is there to help someone live their life, and when that person’s role is coordinated with a primary care doctor who is monitoring health issues and creating care plans, both functions work better.”