Rubicon’s Adam Boehler: Home Health, Hospice Are ‘Underappreciated’ Tools for Slashing Health Care Spending

One of the nation’s former CMS Innovation Center leaders is getting back to his entrepreneurial roots to reimagine how health care is delivered in the U.S.

Former Center for Medicare and Medicaid Innovation (CMMI) Director Adam Boehler announced earlier this month the launch of Rubicon Founders, a Nashville, Tennessee-based investment firm focused on “building and growing transformational health care companies.”

In months to come, Rubicon will hone in on a variety of value-based care investments, from early-stage startups hoping to grow to more established players looking to pivot, Boehler told Home Health Care News.


“For the rest of the year, we’ll continue building out our team, then probably start a couple companies and make a couple purchases,” he said. “We’re a pretty focused portfolio. We get really operationally involved. I don’t want to do too many deals at once.”

Nashville is one of the country’s largest health care innovation hubs, in addition to Louisville, Kentucky, which is commonly referred to as “America’s Aging Capital” due to the high numbers of aging care businesses that have opened up shop there.

As the city’s newest investment firm, Rubicon will have an overarching focus on value-based care and risk-sharing models moving forward.


Boehler and his team are interested in several spaces, including the red-hot senior care market.

“I think there are some real opportunities,” Boehler said. “There continues to be a lot of home-based care opportunities, in particular, but there continues to be opportunities in facilities, too. Today, I don’t know if there are facilities out there that I’d recommend my parents go to. To me, that represents a place where we can improve.”

Rubicon is also “taking a hard look” at women’s health and kidney care, the latter of which grew into a major focus for Boehler during his time at CMMI from the spring of 2018 to the summer of 2019. Specifically, Boehler helped design and roll out five new CMS Innovation Center models aimed at transforming kidney care, partly by encouraging greater use of home dialysis.

Across the U.S., about 37 million patients suffer from chronic kidney disease, with more than 726,000 having end-stage renal disease. Currently, about 11% of all dialysis in the U.S. is conducted in the home, a far lower rate compared to other nations like Hong Kong, which does about 75% of its dialysis in the home.

“I think we can do a little better,” Boehler said.

The beginning of Landmark

It’s too soon to say what kind of move Rubicon will pull off first, but there’s a good chance home-based care will be in the picture.

Prior to CMMI, Boehler was the founder and CEO of Landmark Health, one of the companies responsible for orchestrating the return of the physician house call. Founded in 2014, the Huntington Beach, California-based Landmark provides comprehensive in-home medical care to tens of thousands of patients in 17 states, working alongside individuals’ existing health care providers.

The genesis of Landmark was a desire to care for the sickest, frailest populations under a risk-based model. That naturally led to an in-home care approach.

“When we started Landmark, we didn’t start out necessarily to build a home-based care company,” Boehler said. “What we did was look at a certain group of patients — the really sick patients. In fact, our code name for the project was ‘Sickest of the Sick,’ or SOS. We wanted to figure out what works, what really makes a difference. Caring for the sickest of the sick is a major issue in our system. Something’s not working out there, so how can we improve it?”

The blueprints of Landmark were drawn up after carefully canvassing the market and spending time talking to multiple risk-based groups, including ChenMed and Kaiser Permanente.

The U.S. Department of Veteran Affairs also served as inspiration.

“That’s when we started to realize that it’s time to kind of go back to the future and bring house calls back, but we wanted to do it in a way where we’re taking risk,” Boehler said. “We didn’t want our incentive to be doing more visits, but rather just taking care of the patient.”

The VA has long been known as the “Tesla of home care” for its ability to innovate.

“We’re working in this environment of challenging budget constraints, and at the same time, we’re a very mission-driven organization,” Thomas Edes, director of comprehensive geriatrics and palliative care programs for the Department of Veterans Affairs, told HHCN in 2019. “Put those together and what happens? That really pushes us to innovate.”

At the time of its launch, Rubicon also announced a partnership with investment firms Oak HC/FT and Welsh, Carson, Anderson & Stowe (WCAS), both of which have been very active in the home-based care arena.

‘A better place’

Boehler describes himself as “a big fan” of home health and hospice care. Even before his Landmark days, he learned about those two spaces by going on visits with providers.

Both home health and hospice have played bigger roles in the continuum of care in recent years, but there’s still ground to be gained, he noted.

“I find that those modalities are traditionally underappreciated as ways to reduce spend,” Boehler said. “Sometimes, health plans think more about home health and hospice as costs that they need to push down, instead of thinking about those as tools to reduce overall costs.”

Several studies have backed up that idea.

In one case study, a partnership between the Minnesota-based Lifesprk and North Memorial Health was found to lower hospitalizations and ER visits by 47% and 51%, respectively. In a separate study, the use of home health care directly after an ER visit was found to save $7,313 per patient.

If there have been any silver linings of the COVID-19 pandemic, they have been the cutting of red tape around telemedicine and the acceleration of health care into the home, Boehler explained.

The hospital-at-home waiver program from the U.S. Centers for Medicare & Medicaid Services (CMS) is a good example of that.

“When you look at acute services, why is it that ‘acute care delivery’ is defined as whether you’re in the four walls of a facility versus the services themselves,” Boehler said. “People want to receive care at home. It’s convenient. It’s a better place for most things, right? Different [settings] have their purpose, but for a group of patients, receiving care at home is a better modality.”

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