June 25, 2018
Dive
Brief:
- A bundled payment of acute
hospital-level care in the home plus 30 days of postacute transitional
care shows better clinical outcomes and increased patient satisfaction
versus inpatient hospital care, according to a new study in JAMA Internal
Medicine.
- Researchers evaluated 507 adult
patients in New York City with fee-for-service Medicare and an acute
illness requiring inpatient-level care between November 2014 and August
2017. All qualified for hospital-at-home care, and 295 chose that route.
The rest comprised the controls.
- Despite the at-home group being
older and more functionally impaired, patients had shorter lengths of
stay, lower re-admission rates, fewer emergency room visits and skilled
nursing home admissions, and greater overall satisfaction.
Dive
Insight:
The
idea of hospital at home care is simple: Patients tend to prioritize care from
home and for hospitals, costs are lower.
In
2014, the Center for Medicare and Medicaid Innovation (CMMI), of the
Centers awarded a grant to the Icahn School of Medicine at Mount Sinai to
demonstrate the clinical effectiveness of HaH care bundled with a 30-day
postacute period of home-based transitional care.
In
the study, among the benefits was fewer adverse events.
“We
were able to reduce the incidence of delirium, as well as falls and pressure
ulcers,” Albert Siu, a doctor at the Icahn School of Medicine at Mount Sinai
and one of the study’s authors, told Healthcare Dive. “We believe that we were
also able to reduce the incidence of secondary infections.”
While
the cost analysis is not done, Siu expects to see savings as well. “If you’ve
looked at the total Medicare cost within 30 days for these payments, you know
that most of those costs are driven by re-admissions. So we suspect that when
all the numbers are in, there will be substantial savings for the 30-day
period.”
The
program was funded through a CMS grant that ended in September 2017. Mount
Sinai has continued it with support from a number of health plans, Siu said.
The
researchers also submitted a bundled payment model to CMS dubbed HaH-Plus that
would combine discounted DRG base payment for acute and 30-day postacute care
and fee-for-service billing for other services. The proposal calls for
“reconciliation and shared savings on total 30-day spending,” according to the
study.
The
CMS Physician Technical Advisory Committee unanimously recommended the proposal
for full implementation. Just days ago, HHS Secretary Alex Azar directed CMS to
work with stakeholders to develop a home-based, hospital-level care services
payment model, Liu said. The issue of post-acute services was not addressed.
The
nod is another sign that the Trump administration plans to continue the move to
value-based reimbursement, including bundling episodes of care, even if not on
a mandatory basis.
CMS
Administrator Seema Verma has repeatedly said she supports value-based care,
but feels mandatory bundled payments are too constraining on providers. In
January, the agency announced a new voluntary bundled payment model that covers
32 clinical episodes —29 that are inpatient and three that are outpatient.
Called Bundled Payments for Care
Improvement Advanced (BPCIA), it qualifies as an advanced APM for
MACRA reporting purposes.
The
Mount Sinai study highlights the potential benefits of thinking outside the box
when it comes to care delivery, but also possible risks, according to an
accompanying commentary.
“In
conjunction with technological advancements to deliver high-acuity care outside
of the hospital, such a model could have far-reaching implications for care
delivery," Joshua Liao, University School of Medicine and others wrote.
At
the same time, such models raise important clinical and policy concerns. Since
they encourage providers to shift care from the hospital to home, quality and
safety “are paramount,” and standards similar to those used in hospitals would
need to be developed to guarantee a minimum level of care, they note.
Bundled
payments for HaH also need policies to guard against “unintended consequences,”
such as converting outpatient visits to HaH episodes, which could drive up the
intensity of care and reduce cost savings, the authors add.
https://www.healthcaredive.com/news/better-outcomes-satisfaction-with-hospital-at-home-care-programs-jama-stu/526458/
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