While home-based medical care has been shown to reduce hospitalization rates and lower costs for both homebound and non-homebound populations alike, it continues to be drastically underutilized in the current health care ecosystem.
As a result, there are millions of older Americans — especially those living in rural areas — who are going without the type of life-changing, in-home care they need.
To better understand the use of home-based medical care, a team of researchers from Mount Sinai, Johns Hopkins University, Wake Forest University, Massachusetts General Hospital and the University of Pennsylvania analyzed seven years’ worth of data from the National Health and Aging Trend Study (NHATS). Broadly, the NHATS is an annual comprehensive, population-based survey of late-life disability trends and trajectories.
Researchers looked at 7,552 community-based, fee-for-service Medicare beneficiaries who participated in the NHATS from 2011 to 2017. They then drilled down on that population to see how often home-based medical care was brought into the picture.
“Home-based medical care is serving both clinically and socially complex homebound and non-homebound people, but the number of people who may benefit from this care is much greater than the number who receive it,” the researchers observed.
Generally, the team defined “home-based medical care” as longitudinal services like in-home primary care and palliative care. Any intermittent home-based medical care services — like home health care or physical therapy, for example — were filtered out.
Of the several thousand community-based Medicare beneficiaries surveyed, just 5% received any form of home-based medical care at any point during the study period.
Among the 2,486 homebound individuals in the group, just 11% received home-based medical care. Among the 5,066 non-homebound individuals, less than 2% received home-based medical care at any point during follow-up.
“It is apparent that the current system of community-based primary care does not adequately meet the needs of medically and socially complex homebound people,” researchers noted.
Homebound beneficiaries who received home-based medical care were more likely to live in a metropolitan area or in an assisted living facility compared to those who did not receive such services. They were also more likely to have dementia and to have had a hospitalization in the previous year, researchers found.
Meanwhile, the non-homebound beneficiaries who received home-based medical care typically had more chronic conditions, more functional impairments and a higher overall health care use. Additionally, they also had lower income, a higher use of Medicaid and less education.
“This suggests that home-based medical care may be an important care delivery approach that can address social determinants of health in patients with complex care needs,” the researchers wrote.
Non-homebound individuals that received home-based medical care were also more likely to be nonwhite.
Barriers to home-based medical care
There are 2 million or so older adults who rarely or never leave their homes living in the United States, according to some estimates. There are 5 million more who can only leave with the help of others or after “significant difficulty.”
“The homebound population is understudied and often is invisible to health care delivery systems, payers and quality-reporting programs,” the researchers pointed out.
Moving forward, the homebound population is likely to grow rapidly, particularly with more older adults opting for home- and community-based care instead of moving into a long-term care facilities. The coronavirus has only accelerated that trend.
Several in-home primary care companies and payers have positioned themselves to help meet an increased demand for home-based medical care.
At the end of July, for instance, Humana Inc. (NYSE: HUM) announced a strategic partnership with physician house call company Heal. As part of the partnership, Humana plans to invest $100 million into the Los Angeles-based startup.
Walgreens Boots Alliance (Nasdaq: WBA) and VillageMD also announced a five-year, $1 billion plan last month to expand the retailer’s full-service physician services at hundreds of stores.
On the government side, regulators have been exploring a home-based medical care payment model through the Independence at Home Demonstration. More than two dozen practices participate in the shared savings program, delivering home-based primary care services to high-risk, chronically ill patients across the country.
In its first two years, Independence at Home saved an average of $2,700 per beneficiary per year over expected patient costs. Projections suggest an expansion of home-based primary care could create savings of between $2.6 billion and $27.8 billion over a 10-year period.
Leading with value-based care
There isn’t a clear-cut avenue under fee-for-service Medicare to help pay for home-based primary care.
With that in mind, many home-based medical care providers have sought out value-based contracts to support their work.
“An important driver of the underuse of home-based medical care is the challenge of creating a financially sustainable model of such care within a fee-for-service model in which reimbursement for care of patients with complex chronic illness and functional impairments is limited,” the researchers stated.
But even in value-based contracts, challenges remain.
One big barrier to participation in more value-based care arrangements has been a lack of quality metrics specifically linked to the home setting or the needs of homebound older adults.
“Quality metrics relevant to home-based medical care are necessary to ensure that its providers can participate in the growing number of value-based reimbursement options within both Medicare Advantage and traditional Medicare,” researchers wrote.