Author: Jim Nonneman

Slowly Getting Serious: The New CMS Primary Care Models And Implications For Serious Illness Care

Post author By Jim Nonneman
Post date July 31, 2019

Doctor making a house call discussing serious illness

July 31, 2019 | Health Affairs | Mark Japinga, Mathew Alexander, David Casarett, William K. Bleser, Mark B. McClellan, Robert S. Saunders

In April, the Centers for Medicare and Medicaid Services (CMS) introduced five new payment models as part of its Primary Care First (PCF) and Direct Contracting (DC) programs. The models represent CMS’s latest push to move primary care providers away from fee-for-service payments and into care models that focus on total cost of care, using varying levels of capitated payments that can help facilitate investment in critical services not sufficiently reimbursed under fee-for-service, such as care coordination, 24-hour call centers, and home visiting.

Care for high-risk, high-need patients earns significant attention, especially in the Serious Illness Populations (SIP) track within PCF. This model specifically builds on proposals from the American Association for Hospice and Palliative Medicine (AAHPM) and the Coalition to Transform Advanced Care (C-TAC) and offers the clearest glimpse yet into how CMS is incorporating new delivery models targeting this population.

The implementation challenges for practices will be similar to those found by our recent work on serious illness care in accountable care organizations (ACOs). This includes a national survey and case studies on diverse ACOs with mature serious illness care programs and sustained success in ACO models, which chronicled how some ACOs are going beyond simply identifying a serious illness population and working to transform their care. This research is especially relevant given that PCF and SIP, as currently described, focus more on improving whole-person care for high-risk patients with multiple chronic conditions, centralized in primary care settings. This is a key distinction from the AAHPM and C-TAC models, which focus on advanced illness, pre-hospice, or end-of-life care with a strong role for palliative care teams. In other words, these models may serve as a bridge to more comprehensive, person-focused serious illness care approaches in the coming years.

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Benefits of HBPC HCCIntel Training Training & Education

House Calls Are Reaching the Tipping Point — Now We Need the Workforce

Post author By Jim Nonneman
Post date July 30, 2019

home-based primary care training and education

7-29-2019
Written by: Thomas Cornwell, Home Centered Care Institute; Northwestern Medicine Regional Medical Group
Journal of Patient-Centered Research and Reviews

Abstract

Home-based primary care (HBPC) improves the lives of high-cost, frail, homebound patients and their caregivers while reducing costs by keeping patients at home and reducing the use of hospitals and nursing homes. Several forces are behind the resurgence of HBPC, including the rapidly aging population, advancements in portable medical technology, evidence showing the value of HBPC, and improved payments for HBPC. There are 2 million to 4 million patients who could benefit from HBPC, but only 12% are receiving it. The number of these patients is expected to double over the next two decades. This requires a larger and better prepared HBPC workforce, making St. Clair and colleagues’ article published within this same issue very timely. They showed residents exposed to HBPC had increased interests in providing HBPC in the future. They also found HBPC training fulfilled all 6 Accreditation Council of Graduate Medical Education core competencies and at least 16 of the 22 Family Medicine Milestone Project subcompetencies. Such medical education curricula are necessary to sufficiently develop a future workforce capable of appropriately providing HBPC to an increasing number of patients.

Recommended Citation

Cornwell T. House calls are reaching the tipping point — now we need the workforce. J Patient Cent Res Rev. 2019;6:188-91.

Benefits of HBPC Event Events HBPC in the News HCCIntel Legislative News Uncategorized

AAHCM and HCCI present a webinar on new CMS Primary Cares Payment Models

Post author By Jim Nonneman
Post date July 23, 2019

The American Academy of Home Care Medicine (AAHCM) in collaboration with the Home Centered Care Institute (HCCI) will host a webinar Tues. July 30 at 4 pm (ET) on the new CMS Primary Cares Initiative payment models relevant to home care medicine. The three different payment models will be discussed in detail; Primary Care First (PCF), Seriously Ill Population (SIP), and Direct Contracting (DC).

CMS Primary Cares Initiative

In April, the Center for Medicare and Medicaid Innovation (CMMI) announced a CMS Primary Cares Initiative which includes new payment demonstrations meant to promote value-based care, with a shift of up to 25 percent of primary care Medicare fee-for-service patients to these new models. Primary Care First (PCF), Seriously Ill Population (SIP), and Direct Contracting (DC) will offer enhanced payment for home care medicine and other providers to provide primary care for people with advanced illness.

Primary Care First (PCF) & Seriously Ill Population (SIP)

The Primary Care First (PCF) and Seriously Ill Population (SIP) models will be offered in 22 states and 4 regions for a January 2020 start date: STATEWIDE in Alaska, Arkansas, California, Colorado, Delaware, Florida, Hawaii, Louisiana, Maine, Massachusetts, Michigan, Montana, Nebraska, New Hampshire, New Jersey, North Dakota, Ohio, Oklahoma, Oregon, Rhode Island, Tennessee, and Virginia. In Local Regions of Greater Buffalo, NY, Kansas City (Kansas and Missouri), Greater Philadelphia (Pennsylvania), North Hudson-Capital Area, NY, and Northern Kentucky.

PCF/SIP Timeline: A letter of intent (LOI) is not required for PCF or SIP. A request for application (RFA) will be released in the coming weeks and is required for participation. Both models are scheduled to begin January 2020.

Direct Contracting

The Direct Contracting (DC) path will engage practices or groups of providers who can reach 5,000 beneficiaries by Year 3 (with potential exceptions for smaller practices), as well as Health systems, Accountable Care Organizations, Medicare Advantage plans, and Medicaid Managed Care Organizations. DC builds upon the Next Generation ACO model and has no geographic limitations on who may apply. The DC path will include three models: Professional PBP, Global PBP, Geographic PBP (Proposed).

Timeline: A Letter of Intent (LOI) is required to apply for participation in the DC Models and is due on Friday, August 2. The LOI is non-binding. CMS will then release the request for application (RFA), which will be required for participation. All models are scheduled to begin January 2020 except the DC Geographic Option, which will begin at a later date.

HCCIntel Practice Management Tip of the Month Training & Education

Why is HCC Coding so Important for Home Care Medicine?

Post author By Jim Nonneman
Post date July 11, 2019

A hot topic in health care today is Hierarchical Condition Categories (HCCs), and there is no better time to consider the value of HCC coding to your home-based primary care program! HCC coding is the risk adjustment method used by Centers for Medicare and Medicaid Services (CMS) to determine the annual payments for patients in Medicare Advantage plans. HCC risk adjustment uses predictive modeling to determine the severity of patients’ conditions, health risk, and status to project the cost of health care coverage for that population. This is how CMS determines cost savings for patients enrolled in Accountable Care Organizations and the Independence at Home Medicare Demonstration, and HCC risk adjustment will also determine into which Practice Risk Group patients will be placed for the new Primary Care First Model.

Correct diagnosis coding is always important, but it is critical for accurate risk adjustment because it drives appropriate reimbursement for provider services in value-based payments. An easy “best practice” to initiate is to always code to the highest specificity. Unfortunately, Electronic Health Records (EHRs) complicate this because the search list populated for diagnosis codes frequently brings the unspecified codes to the top of the list. To overcome this challenge, we recommend creating a list of HCC diagnosis “favorites” that will more easily display for selection. Check if your EMR can highlight diagnoses that map to HCC scores. Partnering with a certified medical coder can assist in ensuring accuracy in the common conditions included as “favorites,” especially for disease combinations such as diabetes with chronic kidney disease. In addition, you can also consider running a diagnosis utilization report to identify your most frequently treated HCC diagnoses and then review and update your problem lists so you can be as specific as possible for patients with those conditions.

Correct coding is essential for accurately predicting future health care costs for patients and ensuring the appropriate reimbursement for providers.

To enhance your understanding of which conditions carry a risk adjustment factor, download our HCC Resource Sheet for Home-Based Primary Care (HBPC) which provides a list of common HBPC diagnoses for HCC scoring.

Benefits of HBPC HCCIntel

The Doctor Will See You Now, In Your Home

Post author By Jim Nonneman
Post date June 17, 2019

doctor house call medicine visit — senior woman gets a home visit from gpsame shoot

The old-fashioned house call is back in a big way. Here’s how it works.

June, 2019 | Harvard Health Newsletter |

It’s hard to get to the doctor when you don’t drive anymore or you’re struggling with several chronic medical conditions. The result may be missed appointments and a lack of needed care.

But a growing trend makes it far easier for older adults to get medical attention, bringing routine exams and diagnostic tests to the patient’s doorstep. It’s called home-based medical care — when doctors, nurse practitioners, physician assistants, or other providers visit and treat older adults right in their homes.

Different from home health care

Home-based medical care isn’t the same as home health care, which sends skilled nurses and therapists to your home specifically to help you recover from illness, injury, or surgery, with the goal of helping you get better and regain your independence.

Instead, home-based medical care is more like a beefed-up house call. “These are their regular visits. The only difference is that we bring the equipment to them,” says Dr. Diane McMullin, a geriatrician with the House Calls program at Harvard-affiliated Mount Auburn Hospital.

In some cases, the house call provider can visit when you develop a sudden illness, like an infection. Some providers can bring mobile x-ray or ultrasound machines and equipment to draw blood and collect urine.

Is it covered?

“Medicare began recognizing home visits about 20 years ago,” says Brent Feorene, executive director of the American Academy of Home Care Medicine. And the number of Medicare-funded house calls has been increasing. For example, Medicare paid for 1.6 million home care visits in 2001. By 2015, the number was 2.6 million.

But Medicare won’t pay for a house call as a simple matter of convenience. “The expert must certify that the visit was medically necessary,” Feorene says.

What’s considered medically necessary? Coverage generally applies when an older adult has a condition that restricts the ability to leave home, making a visit to the doctor’s office considerably taxing. For example, the person might need the help of an assistive walking device or wheelchair, the assistance of another person, or medical transportation; or the person may have a cognitive, psychiatric, or emotional issue that makes it hard to get to an appointment.

Whether your private insurance will pay for a house call is a different story. That depends on your insurer.

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Benefits of HBPC HCCIntel

‘Eyes In The Home’: ACOs Use Home Visits To Improve Care Management, Identify Needs, And Reduce Hospital Use

Post author By Jim Nonneman
Post date June 17, 2019

June, 2019 | HealthAffairs.org

Authors: Taressa K. Fraze, Laura B. Beidler, Adam D. M. Briggs, Carrie H. Colla

Abstract

Home visits are used for a variety of services and patient populations. We used national survey data from physician practices and accountable care organizations (ACOs), paired with qualitative interviews, to learn about home visiting programs. ACO practices were more likely to report using care transitions home visits than non-ACO practices were. Eighty percent of ACOs reported using home visits for some of their patients, with larger ACOs more commonly using home visits. Interviewed ACOs reported using home visits as part of care management and care transitions programs as well as to evaluate patients’ home environments and identify needs. ACOs most often used nonphysician staff to conduct home visits. Home visit implementation for some types of patients can be challenging because of barriers related to reimbursement, staffing, and resources.

More than a half-century ago, it was not unusual for physicians to make house calls. Modern medicine, however, transitioned care from the patient’s home to the provider’s office in an effort to improve efficiency.¹^,² Still, there are advantages to house calls: to offer the patient convenience and safety, help providers build more personal relationships with patients, comprehensively assess patients’ needs, and identify issues related to the home environment.³ Moreover, many patients benefit from more intensive, home-based care,⁴^,⁵ and evidence suggests that care provided in patients’ homes can both reduce costs and improve quality.⁴ ^–⁷ Medicare has created new reimbursement models to support home visits for patients who are functionally unable to attend office-based visits.⁸

Home visits can improve the quality of care by easing transitions between care settings, enhancing care management, and helping older patients successfully age at home.³^,⁹ Home visits can be used for a variety of services and patient populations, such as care management for patients with chronic disease, home-based primary or acute care, postdischarge care transitions, and support for frail patients. Home visits have the potential to reduce spending by preventing readmissions or by helping people with complex needs manage their conditions in lower-acuity (and lower-cost) settings.⁷^,¹⁰ Home visits are particularly useful for addressing unforeseen challenges after discharge, such as those related to obtaining support from caregivers, understanding a care plan, understanding the full spectrum of medications a patient has at home, and making necessary adjustments to the home environment.⁴^,¹⁰

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Benefits of HBPC HCCIntel

Blue Shield of California targets patients with complex needs in house call program

Post author By Jim Nonneman
Post date June 17, 2019

May 22, 2019 | by: Paige Minemyer | FierceHealthcare.com

Blue Shield of California has teamed up with Landmark Health to offer more house calls to members with chronic conditions—at no additional cost.

The insurer has enrolled 3,500 people in the program over the last year and has provided 15,000 in-home visits in that opening window, Blue Shield announced Wednesday. The key, the team told FierceHealthcare, is making sure both members and physicians understand that this is not meant to replace primary care providers (PCPs).

Instead, Landmark’s providers work alongside a patient’s existing PCP to provide care, particularly in the case of an urgent emergency to avoid a pricey, unneeded hospital admission.

“We see this as a real strategy—comprehensive, coordinated care for a physically vulnerable population,” said Malaika Stoll, M.D., senior medical director at Blue Shield of California. Read the full article

Benefits of HBPC HCCIntel

A Large-Scale Advanced Illness Intervention Informs Medicare’s New Serious Illness Payment Model

Post author By Jim Nonneman
Post date June 10, 2019

June 2019
Written by: Brad Stuart, Elizabeth Mahler and Praba Koomson
Publication: HealthAffairs.org

Abstract

Patients with advanced illness receive fragmented, hospital-based care that is unaligned with their preferences near the end of life. We describe a team-based intervention that provides home-based, coordinated care to more than 2,000 seriously ill patients daily in nineteen urban, suburban, or rural counties in California. In the last month of life, compared to matched Medicare beneficiaries in similar counties, this program reduced hospital days by 1,361 per 1,000 beneficiaries, hospital deaths by 8.2 percent, inpatient payments by $6,127, and the total cost of care by $5,657 per beneficiary. The Centers for Medicare and Medicaid Services (CMS) has announced a new Medicare payment model for serious illness care, based in part on this program. To inform model development and implementation, we describe lessons learned about changing the focus of care for advanced illness from hospital to home, broadening care coordination to achieve system integration, and developing methods for payment and quality accountability that transform care delivery.

Beneficiaries with advanced illness (also called “serious illness”) account for 4 percent of the Medicare population but 25 percent of its costs. Advanced illness refers to late-stage chronic illness, when one or more conditions become serious enough that general health and function decline and treatments begin to lose their impact—a state that progresses to the end of life.¹ Patients with advanced illness often undergo unwanted, avoidable, and costly hospitalizations near the end of life.

Neither current Medicare reimbursement nor the present portfolio of the alternative payment models of the Centers for Medicare and Medicaid Services (CMS) adequately finances home-based care to remedy this, and available services are underused and overstressed. Medicare pays for home hospice care, but many enrollees don’t benefit from its services because they are not admitted until days before death, often following intensive hospitalizations.² Lacking a major expansion initiative, palliative care fellowship training programs will not meet the burgeoning demand as the US population ages.³

New clinical and payment models are needed, particularly for the two-thirds of beneficiaries enrolled in fee-for-service Medicare, to integrate fragmented delivery systems and incentivize providers to create team-based care at home for patients and their families and caregivers. The Coalition to Transform Advanced Care (C-TAC), a not-for-profit organization representing over 150 US health systems, health plans, hospices, community-based organizations, and leading consumer and patient advocacy organizations,⁴ has proposed such a delivery and payment model for patients with advanced illness⁵ to the Center for Medicare and Medicaid Innovation (CMMI). The model, called Advanced Illness Management (AIM), was developed at Sutter Health, a large integrated health system in California. CMMI has announced a new serious illness payment model based on C-TAC’s proposal and another from the American Academy of Hospice and Palliative Medicine.⁶

In this article we describe the piloting, scaling, and testing that formed the backbone of C-TAC’s model. Based on that experience, we share lessons learned that could inform CMMI’s efforts to improve care for Medicare beneficiaries with advanced illness.

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Benefits of HBPC HCCIntel

CMO Dr. William Shrank on Humana’s physician strategy, ‘Medicare for All’ and home care as the Netflix of healthcare

Post author By Jim Nonneman
Post date June 6, 2019

Morgan Haefner | June 4, 2019 | Beckers Hospital Review

Humana wants to do for healthcare what Netflix did for home entertainment.

Humana’s CMO William Shrank, MD, said the insurer’s strategy for its 16 million members, most of whom are Medicare Advantage enrollees, is to meet patients where they are — at home.

“If you look at the movie industry, you see there was a time when people used to go to the retail outlet to buy or rent their DVDs, and now there’s a better service that’s more convenient. It’s more personalized in the home,” Dr. Shrank told Becker’s Hospital Review during an in-person interview June 4. “That’s our goal. Our goal is to be that more progressive solution that is patient-focused, convenient, integrated and meets patients where they are. It’s more of a Netflix kind of thing.”

For Humana, this means better leveraging data, technology and analytics to be proactive, and reaching out to patients before medical issues arise to provide appropriate services in their bedrooms, kitchens and living rooms.

It’s a different tactic than competitors like CVS Health/Aetna and UnitedHealth Group have used, but Dr. Shrank said that to Humana, home-based care is the future of healthcare. The insurer’s investments are evidence: Humana and two private equity firms bought Louisville, Ky.-based post-acute care provider Kindred Healthcare in a $4.1 billion deal, with the trio also buying hospice operator Curo Health Services for $1.4 billion.

Here, Dr. Shrank further discusses Humana’s at-home strategy and answers questions on the payer’s primary care moves, its partnerships with hospitals and the possibility of “Medicare for All.”

Editor’s note: Responses have been lightly edited for clarity and length.

Question: CVS/Aetna just announced plans to open 1,500 “HealthHubs.” UnitedHealth’s Optum is acquiring physicians. Amid these moves from competitors, what’s your physician strategy?

Dr. William Shrank: The large payers — at least the three of us focused heavily on Medicare Advantage — are blurring the lines between payer and provider. We’re thinking more holistically about how we manage a population rather than figuring out how to pay claims. We are all taking a little bit of a different tactic. Ours is focused on the home, on meeting patients where they are. United is going to buy more and more primary care docs, and CVS is doing more in the retail space. We think the future of healthcare is going to be in the home. Read the full article

Benefits of HBPC HCCIntel

ACOs Commonly Use Home Visits for Complex Patients During Care Transitions

Post author By Jim Nonneman
Post date June 6, 2019

June 4, 2019
Authors: Taressa K. Fraze, Laura B. Beidler, Adam Briggs, and Carrie H. Colla
commonwealthfund.org

The Issue

Years ago, it was not uncommon for physicians to make house calls. But in the past 50 years, care has largely transitioned to physicians’ offices. Office-based visits are more efficient, and reimbursement for home visits can be challenging under fee-for-service payment. However, there are advantages to home visits: they can improve health outcomes, and they can decrease spending on patients with complex needs, including patients with chronic conditions and those recently discharged from the hospital. With support in part by a six-foundation collaborative that includes the Commonwealth Fund, Peterson Center on Healthcare, Robert Wood Johnson Foundation, SCAN Foundation, John A. Hartford Foundation, and Milbank Memorial Fund, researchers looked at whether health care providers contracted with accountable care organizations (ACOs) were more likely than non-ACO practices to employ home visits. The study, published in Health Affairs, used 2017–2018 survey results as well as data obtained from interviews with 18 ACO leaders.

What the Study Found

ACO physician practices were more likely than non-ACO practices to conduct home visits for complex patients within 72 hours of hospital discharge (25.7% vs. 18.8%).
ACOs using home visits tended to be larger (include a hospital or contract with more physicians) and more likely to be part of an integrated delivery system than ACOs that did not use home visits.
More than 50 percent of ACOs that participated in risk-bearing payment arrangements, such as episode-based bundled payment, employed home visits. In comparison, only 30.2 percent of ACOs that did not have risk-bearing contracts used home visits.
In addition to using home visits as part of a care management or care transitions program for complex patients, ACOs used home visits for patients who were noncompliant or nonresponsive with office-based care.
Postdischarge visits were common, but some ACOs also used home visits on an as-needed basis, such as when care teams sense something is not right with a patient or a patient cannot be reached by phone or other means.
Care team members who conducted home visits included care management staff, nurses, social workers, health coaches, and pharmacists.
Looking at only Medicare ACOs, the researchers saw no significant differences in quality scores or likelihood of achieving shared savings between ACOs that used care transition home visits and those that did not.

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