Shelby Livingston November
13, 2019
When a patient
turns up in the emergency department at one of Allegheny Health Network's
hospitals with uncomplicated pneumonia, a bacterial skin infection or another
lower-risk ailment, that patient may now get the choice to skip the hospital
bed and go home to receive care.
Highmark Health,
the parent company of Pittsburgh-based Blues insurer Highmark and integrated
system Allegheny Health Network, is introducing a program to deliver inpatient
hospital care to patients in their homes, where it says certain healthcare
services can be provided in a safer, lower cost way through a combination of
in-person home visits and telehealth.
"We firmly
believe that a certain percentage of patients do not to need to be hospitalized
if you have the capability to (care for them) at home in a safe
environment," said Dr. Tony Farah, chief medical and clinical
transformation officer at Highmark Health.
Highmark Health
is now rolling its program out to certain commercial plan members in Western
Pennsylvania and will expand it to Medicare Advantage members on Jan. 1. It has
plans to push the program out to all of its members in central and Western
Pennsylvania in the next year.
Highmark is
following in the footsteps of a small number of health systems embracing
hospital-at-home programs. It launched the program with the help of
Nashville-based company Contessa, which has worked with Mount Sinai Health
system, Dignity Health and the Marshfield Clinic on similar programs. The two
created a joint venture company called Home Recovery Care.
When patients
come to the ED, Home Recovery Care's coordinators will screen them to see if
their conditions can be treated at home and if they are Highmark's health plan
member. Eligible patents may get the option to be transported home to receive
inpatient care, so long as their homes are generally safe for the patient and
caregiver, meaning they have central air or heat and water, for instance.
Once at home, the
patients begin 30-day episodes of care. During the first few days, nurses visit
the home twice a day to check vital signs, conduct basic lab tests and give
infusion services, and once a day the nurse and patient check in virtually with
an Allegheny Health Network hospitalist. For the rest of the period, the
patient will be monitored via a telehealth kit left in the home
Contessa CEO
Travis Messina said the company meets with the patient an average 27 times over
the 30-day episode, either in-person, virtually or by telephone. It contracts
with the health plan for 44 different conditions, including pneumonia, chronic
obstructive pulmonary disease, congestive heart failure, cellulitis and
diverticulitis. The medical conditions included in the program account for
about 40% of hospitalizations, Messina said.
Contessa's
contracts with Highmark and others are bundled-payment arrangements, in which
it pockets the savings if it can deliver care below an agreed-upon amount.
Messina said its program typically provides about a 15% discount on the
historical cost of a 30-day episode of care for Medicare Advantage patients,
and a 20% discount for commercial members.
But the cost
savings are a "byproduct" of higher quality care, Messina said.
"While
hospitals have a lot of great things to offer, you are susceptible to bad
outcomes (there.) You are around other people who have other illnesses. You can
catch infections. You avoid that when you are in the confines of your own
home," he said.
Providing acute
inpatient care at home aligns with the broader shift in the U.S. healthcare
system toward providing more care in lower cost settings and away from
expensive hospitals. Though some hospitals, such as Baltimore-based Johns
Hopkins Medicine, have been delivering acute care at home for years, it's still
an emerging model for most.
Some research
shows that delivering care at home can produce better outcomes and save money
compared to caring for a patient in a hospital.
According to a 2018 study in JAMA Internal
Medicine, patients who received care from Mount Sinai Health
System's hospital-at-home program had fewer readmissions and emergency
department visits and reported a better patient experience than patients who
stayed at the hospital. Mount Sinai tested its program as part of a
demonstration under the Center for Medicare and Medicaid Innovation.
Danville,
Pa.-based Geisinger executives wrote in the Harvard Business Review last
week that with the hospital's Geisinger at Home program they've seen a 35%
decrease in ED visits, 40% decrease in hospital admissions, and an average
annual reduction in spending per patient of almost $8,000 for more than 5,000
patients enrolled in the program. The program involves delivering acute care,
wound care, regular home assessments and specialty care to medically complex
patients where they live.
There are clues
the CMS is supportive of home-based
care. Beyond its Medicare demonstration pilots, the agency this year
loosened restrictions in Medicare Advantage that made it easier for plans to
provide in-home supports to help with activities like bathing, dressing and
cooking. It also allowed plans to pay for palliative care in the home.
Farah said his
conversations with CMS Administrator Seema Verma and HHS Secretary Alex Azar in
the last several months have led him to believe that the CMS will continue to
provide more protections and incentives for programs like Highmark Health's.
"This type
of program will expand across the country as time goes on," Farah said.
"Just like anything else that's brand new it requires many things to be in
place. One is to have all the required elements that are well-coordinated, and
two, an incentive to make this work, and we believe that the federal government
is very much supportive of such types of programs because of improved quality
and lower total cost of care."
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