Home Care Medicine s Mission

Transcription

1 First-Time Attendees: Logistics Thomas Cornwell, MD Information in the slides is from HomeCarePhysicians, Wheaton IL. It is to show health systems the value of supporting a house call program. There is also information and resources for making house calls. Copyright 2015 by Home Centered Care Institute Copies Permitted Educational Purposes Home Care Medicine s Mission 1. Improve the quality of life of homebound patients 2. Improve the quality of life of caregivers 3. Decrease health care costs by enabling patients to remain at home and avoid expensive emergency departments, hospitals and nursing homes. 1

2 1997 NEJM: House Calls to the Elderly A Vanishing Practice Among Physicians 1930: 40% of medical care in the home 1950: 10% 1980: 0.6% 1993: 1.1 million house calls down 31% from 1.6 million in : further 12.3 % decline to 984,000 house calls Meyer GS, Gibbons RV. N Engl J Med 1997; 337(25): Three Reasons for the Decline of the House Call 1. Increased office/hospital based technology 2. Fear of increased liability 3. Financial disincentives 2

3 Technology allows quality of care in the home Software: Electronic Medical Records; Medical Apps Diagnostic: Ultrasound; X-rays; EKGs Therapeutic: IVs; Wound care; Therapy; Ventilators Chest X-ray in the home Ultrasound Machine fits in your pocket iphonecase turns phone into EKG Home Care Medicine s Perfect Storm Demographics: Aging of Society Health Care Reform: The Affordable Care Act 1. Readmission Reduction 2.Medicare Shared Savings Programs (MSSPs): Accountable Care Organizations 3. Independence at Home Quality end-of-life care that also reduces costs and decreases hospital mortality rates Medicare and Medicaid Fiscal Crisis Federal rebalancing legislation: Money Follows the Person (MFP) Recent evidence of the value of house calls 3

4 Home Care Medicine s Value to Health Systems Readmission Reduction Increased Volume (Medicare) Health System Adherence Cost-Reduction (Medicaid/Uninsured) Shared Savings (At-Risk Contracts, Managed Care, ACO) Public Relations/Community Good-Will The Right Thing to do (Wonderful Care) The Return of the House Call House Calls to the Elderly a vanishing practice among physicians. NEJM 12/18/97: ,000 house calls Trends in House Calls to Medicare Beneficiaries JAMA 11/16/05: % increase to 2,060,039 (0.9 of EM Services) 83% in domiciliary visits (Assisted Living Facilities) from 1,579,197 in 2006 to 2,883,201 in 2013 (overtook house calls) 4

5 Downstream Revenue: HomeCare Physicians Referrals to CNS Home Health & Hospice Home Health Hospice Private Duty HCP Referrals 3,235 1, CNS Total 41,793 8,238 2,051 Percent 7.80% 13% 9.50% CNS Home Health and Hospice is owned and operated by Cadence Health which also owns and operates HomeCare Physicians % of 4,633 Dr. Cornwell s certifications and recertifications for home health were with CNS. 53% were with 60 other home health agencies. In many of these cases the outside home health agency referred the patient to HCP. HomeCare Physicians Payor Mix 2013 Source Referrals % Medicare Only % Medicare + Supplemental % Medicare + Medicaid 98 9% Medicare Advantage 29 3% Medicaid Only 24 2% Medicaid Manage Care 31 3% Insurance 57 5% Uninsured 9 1% HMO Only 6 1% TOTAL 1, % 5

6 Marketing: HomeCare Physicians Referral Sources Source Referrals % Doctor % HHA % Hospital/Rehab % Assisted Living Facility % Group Homes % Word of Mouth % Other 57 8% Total % 1 HHA are asked to talk to primary physician prior to referral Note: These numbers are representative of a mature program. New program referrals largely come from home health agencies (80%). Carbonless, duplicate instruction sheet. Copy is left with patients and caregivers, and original is faxed to home health agency as orders. 6

7 Medicare House Call Codes/Payment 1997 New New (Min) AHCCS 3 IDPA $ (20) $57.53 $57.82 $58.99 $43.91 $ $ (30) $77.58 $84.49 $85.34 $63.29 $ $ (45) $ $ $ $ $ (60) $ $ $ $ $ (75) $ $ $ $ $ Estab Est. (Min) AHCCS 3 IDPA $ (15) $45.43 $58.59 $59.39 $44.18 $ $ (25) $65.54 $88.75 $89.64 $66.84 $ $ (40) $94.92 $ $ $ (60) $ $ $ $ $ Additional 1998 higher level Medicare house call codes 2 IDPA: Illinois Department of Public Aide 3 Arizona Health Care Cost Containment System (Arizona Medicaid) Shaded payments are most frequently used house call codes Note: Medicare Payments vary by locality. These are for Locality 15. Place of Service Code for Home = 12 Domiciliary (Assisted Living) CPT Codes/Payments 2005 New New (Min) AHCCS 3 IDPA $ (20) $62.80 $58.20 $59.37 $44.18 $ $ (30) $91.76 $85.04 $86.27 $63.83 $ $ (45) $ $ $ $ $ (60) $ $ $ $ $ (75) $ $ $ $ $ Estab Estab. (Min) AHCCS 3 IDPA $ (20) $48.73 $63.39 $64.61 $48.03 $ $ (30) $76.88 $ $ $75.09 $ $ (40) $ $ $ $ $ (60) $ $ $ $ $ Additional 2006 higher level Medicare house call codes 2 IDPA: Illinois Department of Public Aide 3 Arizona Health Care Cost Containment System (Arizona Medicaid) Shaded payments are most frequently used house call codes Note: Medicare Payments vary by locality. These are for Locality 15. Place of service code = 13 7

8 Care Plan Oversight (CPO) and Home Health Certification / Re-Certification Payments Medicare Reimbursement IDPA 3 Total # Total # Total # Total # CPO HH G $78.73 $ $ $ CPO Hospice G $78.73 $ $ $ HH Cert G $77.50 $57.02 $ HH Re-cert G $65.35 $43.74 $ In 2001 CPT codes and changed to G0181 and G0182 respectively 2 Medicare began paying for certification and re-certification of home health in IDPA: Illinois Department of Public Aide Note: Medicare payments vary by locality. These payments are for locality 15. House Call Program Logistics: Billing Other Commonly Billed Procedures CPT PROCEDURE MEDICARE $ Debride: Subcutaneous $ Debride: Muscle $ Toenail Debridement $ Dest. Granulation tissue(agno3) $ Unna Boot $ Change G-tube $ Cerumen Removal $ EKG $ Rhythm Strip $ Medicare Payments vary by locality. These are for Locality 15 for

9 HCP Patient Satisfaction FY13 N=200 Question Level of support provided your family and/or caregiver 82% Provider spending adequate time and not seeming rushed 84% Provider s level of courtesy and friendliness 91% Provider s explanation of medical condition and treatment 83% Providers level of compassion 85% Ability to obtain a timely house call for an urgent problem 82% Staffs level of courtesy and caring when the office is called 89% % Excellent Ratings Overall quality of care provided by HomeCare Physicians 88%* Likert Scale: Poor, Fair, Good, Very Good, Excellent * Other responses: Very good 9%; Good 3%; Fair 0%; Poor 0% HCP Patient Satisfaction FY13 N=152, FY12 N=152 Respondentswere asked in the past 12 months: 1.HCP s serviceshave reduced my trips to the Emergency Room. 2.HCP s services have helped me avoid hospitalizations. 3.HCP s serviceshave helped me avoid being placed into a nursing home. YES FY13 FY12 NO FY13 FY12 Uncertain FY13 FY12 82% 85% 13% 9% 5% 6% 80% 87% 15% 10% 5% 3% 80% 84% 10% 11% 10% 5% 9

10 5/14/09 2/18/11 (1 year, 9 months (645 days)) 44 Emergency Department Visits (avg 16 days between visits) 27 Hospitalizations over half required ICU days (avg. 25 days between stays) HCP First Visit 3/2/11 (365 Days) 1ED visit + 1 Hospitalization (May 2011) Expected: 25 ED visits, 15 Hospitalizations Following Year: 0 ED, 0 Hospitalizations 1/1/12-12/5/12 17 Emergency Department (ED) Visits 13 Hospitalizations (69 Days) Multiple rehab stays HCP First Visit 12/5/12 1 ED Visit/1 Hospitalization 12/18/12 (4 days) 0 ED Visits/0 Hospitalizations in 2013 Passed away at home 7/22/13 on hospice 10

11 Quality End-of-Life Care HomeCare Physicians Patient Deaths Number Percentage Total 2, % Home 1,663 74% Hospital % Nursing Home 113 5% Unknown 37 2% Cost of End-of-Life Care 25.1% of the $556 billion Medicare dollars goes to care in last year of life Riley, Lubitz; Health Services Research 4/2010 From 2000 to 2009 deaths increased at home 30.7% to 33.5% and decreased at hospitals from 32.6% to 24.6%, use of hospice increased from 21.6% to 42.2% BUT: ICU stays in last month increased from 24.3% to 29.2% Hospitalizations in last 3 months of life increased from 62.8% in 2005 to 69.3% in 2009 Short hospice stays (<3 days) increased 22.2% to 28.4% (40.3% were preceded by hospitalization with ICU stay) Teno; Change in End of Life Care for Medcare Beneficiaries JAMA 2/

12 HomeCare Physicians and Quality End-of-Life Care 2013: 222 deaths 80% (178) died at home (compared to 33.5% nationally) 74% (165) where on hospice (compared to 42% nationally) Average length of stay 2.2 years (the highest cost years) Median length of stay 1.1 years 25 died in first 30 days with 22 (88%) dying at home Decreased hospital mortality 2013: 222 deaths 178 (80% at home); Expected = 33.5% = 74; Thus 104 additional deaths at home than expected decreasing hospital mortality rate Central DuPage Hospital had 247 deaths in 2013 Top 1% Median Cost $97,859 Top 5% Median Cost $43,038 Lowest 50% consume 2.7% of spending Median Cost $234 12

13 The intervention below involved nurse practitioners doing the hospital discharge then providing house calls for three months. There were substantial cost savings during the three month intervention period that continued for an additional three months. $600,000 $500,000 $400,000 $300,000 $200,000 $100,000 $0 $236,144 $489,420 Intervention $145,581 $358,472 Control $205,528 $218, Months 3-6 Months 6-12 months Transitional Care of Older Adults Hospitalized with Heart Failure: A Randomized, Controlled Trial. (Naylor, PhD, et al JAGS 52: ) Resource Use Among Elderly Congestive Heart Failure Patients Who Received a Nurse Practitioner Transitional Care Intervention or Usual Care, Six Philadelphia Hospitals, Costs of Care Before vs. During HBPC for 2002 (Per patient per year) *Includes HBPC cost N= 11,334 $103,048,728 Total Cost of VA Care Before HBPC During HBPC $38,228 $29,136* Change -$9,092 (-24%) P< Hospital $18,868 $7,026 $11,842 (-63%) Nursing Home $10,382 $1,382 $9,000 (-87%) Outpatient $6,490 $7,140 $650 (+10%) All Home Care $2,488 $13,588 $11,100 (+460%) 2007: Hospital days 59%; NH days 89%; 30-day readmission 21% 13

14 More Evidence: Better Care at Lower Costs Better Access, Quality and Cost for Clinically Complex Veterans with Home-Based Primary Care; Edes, et al JAGS 10/ ,425 newly enrolled HBPC comparing VA + Medicare costs 6,951 dually enrolled MC + VA: costs 13.4% VA costs 16.7%; Medicare costs 10.8%; Hospitalizations 25.5% Patient and caregiver satisfaction (highest in VA) Effects of Home-Based Primary Care on Medicare Costs in High-Risk Elders; DeJonge, et al JAGS 10/14 Washington DC 722 HBPC cases vs. 2,161 controls over two years 17% lower Medicare Costs ($8,477 savings per beneficiary; $6.1 million total savings) Hospitalizations 9% ; ED 10% ; SNF 27% Primary care visits; Home health; Hospice 14

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16 Patient Assistance : Central DuPage Auxiliary donates $30,000 to patient assistance 4/00: HCP receives a $15,000 grant from DuPage County for the Patient Assistance Fund 2001 HCP receives a $300,000 estate gift to permanently endow the patient assistance fund 16

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18 HomeCare Physicians Public Relations Sun Times Front Page Tribune (6) Daily Herald (13) Local Newspapers (35) Medical Publications (21) TIME Magazine, UIC Magazine (Cover) Television: PBS Healthweek, WGN News, Local CBS, NBC and ABC News 18