As published in HFMA, August 22nd, 2018
By Lola Butcher
After two years of experience with their home-hospitalization initiative, leaders at Marshfield Clinic Health System and its affiliate, Security Health Plan, are enthusiastic about the concept.
Marshfield Clinic Health System is composed of a large multispecialty medical group and three hospitals located in 34 Wisconsin communities. In 2016, it partnered with a private company to start a program that provides hospital-level care to patients in their homes.
Since then, Security Health Plan members who require hospital care and who meet certain criteria are given the option of being treated at home. The program has evolved as the partners have gained experience, but they like what they have seen so far, says Marshfield Clinic CFO Gordon Edwards.
In its first year, the program reduced overall treatment costs by 30 percent for commercially insured patients—and 17 percent for patients in a Medicare Advantage plan—compared to similar patients treated in an inpatient setting.
“The partnership is profitable, the health plan is saving money, and the members are saving money,” Edwards says.
Equally important, patient-satisfaction scores are high and clinical outcomes compare favorably to those of similar inpatients, says Swetha Gudibanda, MD, a Marshfield Clinic hospitalist who treats home-hospitalization patients. “I'm thinking this is going to be the future of hospital medicine,” she says.
Hospital-at-home programs will work only if payers are willing to support the innovation, Edwards says. Even though pioneering programs have demonstrated good outcomes in quality, cost, and patient satisfaction, most health plans are still on the sidelines.
That may change, however, if the Centers for Medicare & Medicaid Services creates an alternative payment model (APM) that supports hospital-at-home care. The Physician-Focused Payment Model Technical Advisory Committee (PTAC) has recommended that the Center for Medicare & Medicaid Innovation consider two bundled payment models—one proposed by the Marshfield Clinic partnership, the other by the Icahn School of Medicine at Mount Sinai—for home hospitalization. PTAC was established through legislation for the purpose of recommending physician-oriented APMs.
In June, Health & Human Services (HHS) Secretary Alex Azar responded to the PTAC recommendations by stating that HHS would explore “a model that allows [Medicare] beneficiaries with certain acute illnesses or exacerbated chronic diseases to receive hospital-level services in their homes.”
How It Works
Marshfield Clinic’s Home Recovery Program each month serves about 14 to 20 Security Health Plan members, most of whom are referred into the program from the Marshfield Medical Center emergency department. The program recently expanded to the health system’s new hospital in Eau Claire, Wis.
“Home Recovery Care is all about bringing essential elements of inpatient care to the comfort and convenience of the patient's home,” Gudibanda says. “We see this as an opportunity to advance our existing value-based care by extending it into the home.”
The program is staffed by:
- Marshfield Clinic hospitalists and acute care registered nurses
- Physical therapists, respiratory therapists, and other clinicians employed by Marshfield Clinic
- Home Recovery Care coordinators, all of whom are registered nurses employed by the Clinic’s vendor partner
The program accepts patients with almost any diagnosis, with the following exceptions: surgery patients, pregnant women, and patients who need intensive care or telemetry. If an ED physician and Home Recovery Care coordinator agree that a patient is appropriate for home care and the patient is amenable, a hospitalist is assigned to examine the patient, discuss the care plan with the patient’s nurse, and place orders for medication, medical equipment, and tests.
“Once all this is done, then we are set to send the patients home,” Gudibanda says.
As the patient heads home—transported by a family member or hospital-arranged driver, depending on the need—IV poles, a tablet used for video visits between patient and clinicians, and other equipment are heading there as well. The patient’s vital signs are monitored remotely. A registered nurse visits the patient at home, and all clinicians—hospitalist, nurses, and therapists—interact with the patient at home or via video technology as needed. Coordinators monitor vital signs, order medical equipment, communicate with physicians, help with medication, provide patient education, and help schedule follow-up appointments. A coordinator is available to patients around the clock during their hospital-at-home stay.
The Home Recovery Care partnership receives a bundled payment that covers the home stay plus all necessary medical visits, lab testing, and medical equipment for a 30-day period. Patients are admitted to and discharged from the hospital-at-home program, but their stays are not categorized as hospital admissions and they do not incur inpatient copays, Edwards says.
Quality and Cost Outcomes
Marshfield Clinic is among a group of hospital-at-home pioneers that also includes Presbyterian Healthcare Services in New Mexico, which launched its program in 2008. An analysis of its early results—patients served by the program between Jan. 1, 2009, and Dec. 31, 2010—found comparable or better clinical outcomes compared with similar inpatients, higher patient-satisfaction scores, and 19 percent lower costs. The lower costs were attributed to a shorter average length-of-stay and the use of fewer lab and diagnostic tests.
More recently, researchers reviewed the performance of the hospital-at-home program at New York City’s Icahn School of Medicine at Mount Sinai, the recipient of a federal Health Care Innovation Award to demonstrate the clinical effectiveness of hospital-at-home care bundled with a 30-day post-acute period of home-based transitional care. The study—295 patients enrolled in the hospital-at-home program—is believed to be the biggest of its kind.
The research team compared the experience of hospital-at-home patients with a control group of patients who qualified for the program but either refused at-home care or were evaluated in the emergency department during weekends and weeknight hours, when hospital-at-home clinicians were unavailable to enroll them.
The study documented that more than half of patients with hospital-at-home qualifying conditions were served by the novel program. (Of 406 patients who were approached by the hospital-at-home team, 19 were ineligible because of clinical instability or home factors and 146 refused.) The four most frequent admission diagnoses were urinary tract infections, community-acquired pneumonia, cellulitis, and congestive heart failure.
Patients treated in their homes with 30 days of post-acute transitional care had shorter acute-care length of stay, lower odds of hospital and emergency department readmissions and skilled nursing facility admissions, and higher patient ratings of care compared with the control group of inpatients. Total costs of care were not analyzed.
The Health Plan Perspective
Security Health Plan sees hospital-at-home care as a high-value proposition because it lowers the patient’s out-of-pocket costs and the total cost of care, while delivering high patient satisfaction and good clinical outcomes, says Eric S. Quivers, MD (pictured at right), chief medical officer.
For example, in the first year of the Marshfield Clinic program—from September 2016 to September 2017—11 Security Health Plan members were treated for cellulitis in the hospital-at-home program, and the health plan’s cost per episode was roughly $11,000, which included physician fees, readmissions, and all other related costs. Inpatient treatment of that diagnosis would have cost nearly $13,000, not including the additional costs related to the 30-day episode.
Comparing Home Recovery Care costs to historical inpatient costs, the insurer saved about $1,600 per episode, or nearly $18,000 on those 11 patients, Quivers says.
In total, the health plan saved $101,732 in the first year of the program, which got off to a slow start because it was limited to a handful of DRGs: congestive heart failure, chronic obstructive pulmonary disease, deep vein thrombosis/pulmonary embolism, urinary tract infection, cellulitis, and pneumonia.
In the second year, the list of conditions was expanded—to 151 DRGs —and the health plan saved $129,122 in the first 3.5 months.
The cost savings are partially attributable to improved outcomes. In the first year, patients enrolled in the home-hospitalization program had a 57 percent lower 30-day readmission rate, and the mean length-of-stay was 34 percent shorter than for comparable inpatients.
Meanwhile, patient satisfaction scores for the Home Recovery Care program are around 93 percent since its inception. Patient satisfaction with the program is consistently higher than that of traditional inpatients, Edwards says. “That makes sense because you don't wear funny gowns, you've got your own bed, you've got your family support around you,” he says. “Receiving care at home rather than a hospital setting can be a more comforting environment.”