The Other Medical Home

At the signing of the Medicare bill in 1965, president Lyndon B. Johnson remarked that the American tradition of helping those in despair was at the core of the law. He said, “It directs us never to ignore or to spurn those who suffer untended in a land that is bursting with abundance.”¹ Today, Medicare's potential for mitigating untended morbidity and mortality remains unmet. The prevailing public policy discussion is that Medicare is too costly and the anticipated increase in spending is unsustainable.² Despite high Medicare expenses, older adults with serious chronic illness are at high risk for mortality, functional limitations, poor quality of life, high out-of-pocket costs, and often report dissatisfaction with their care and barriers to adequate care.^{3 - 5} For the most ill and costly beneficiaries, physical illness and mental health problems are frequently compounded by the burden placed on a family caregiver, a “hidden patient” whose physical and emotional needs often remain unnoticed.⁶

The Medicare Payment Advisory Commission (MedPAC) recently provided a set of recommendations for Medicare payment reforms.⁷ A key piece of this reform agenda is pilot testing a payment for a “Medical Home,” a concept that creates a way for primary care clinicians to receive payment for added care coordination, care integration, quality improvement, and education activities for patients with chronic diseases. The extra payments would be accompanied by added requirements and accountability for outcomes.

However, the Medical Home initiative, as currently articulated, ironically fails to emphasize the complex chronically ill patient's actual home. This represents a failure to recognize the profile of the highest-risk beneficiaries driving much of the high Medicare costs—that is those with 4 or more chronic conditions and activity limitations⁵ whose homes and bodies are filled with the latest equipment, devices, and drugs, but often without the accessible, personal, holistic, and integrated care they need to take advantage of these interventions in ways that improve their overall well-being. These highly vulnerable Medicare beneficiaries often cannot access office-based medical practices because of their functional limitations. Even if these patients could readily get there, many physician practices are high volume and not well positioned to deliver or coordinate the type of time-intensive multidisciplinary care that can improve outcomes for these patients. This shortcoming more reflects a financing system that undervalues generalist physicians and other primary care clinicians than a failure of the physicians and practices themselves. The proposed pilot program does not go far enough to change this.

The Medical Home initiative and projects under way seem designed to meet the needs of mobile patients earlier in the course of chronic illness who need appropriate chronic disease care and self-management support to prevent debilitating sequelae. There is no clear emphasis on asking these practices to find the highly vulnerable, functionally limited patients who are driving most of the Medicare expenses. These patients are more likely to be found transitioning between hospitals, nursing facilities, and home. Another limitation of MedPAC's proposal for meeting the needs of older adults with complex chronic illness is that there is no attempt to reform the narrow, disease-based evaluation and management visit to ensure that patients have an assessment of their comorbidities, “geriatric syndromes,” functional status, prognosis, psychological condition, and social circumstances.

Although the Medical Home initiative as described could potentially improve the overall primary care infrastructure, and over several years may delay death and disability from advanced chronic illness, it is not clear that it can affect the care trajectories, cost, and quality of care for low-mobility/high-cost Medicare beneficiaries who are already experiencing the consequences of long-standing chronic disease. Any optimism for early secondary prevention to reduce Medicare costs in the coming decades should be tempered by the realities of a baby boom generation already reaching its 60s with high prevalence of chronic illness and obesity.⁸ This is not to construe that there is not a humanistic or societal benefit to strengthening primary care office practices or to reducing the long-term complications of chronic illness, but only that this strategy may not lead to the Medicare cost reductions the MedPAC reforms propose to address. At the same time, the strategy does not address the untended disability and hardship of the most vulnerable beneficiaries who are driving these costs.

A promising way to strengthen and broaden the Medical Home initiative for high-risk Medicare beneficiaries may be to make their actual homes the central venue of primary health care. This could be accomplished through another reform agenda that specifically empowers family caregivers, home health and hospice nurses, social workers, therapists, and personal care aides. This agenda places primary care physicians, advanced practice nurses, and physician assistants as partners and advisors to ongoing multidisciplinary care teams in the patient's home.

Broadening and strengthening the Medicare home health and hospice benefits and their integration with primary medical care would be ideal ways to meet the needs of the high-cost beneficiaries in a compassionate and cost-effective way. A hidden reason behind many of Medicare's high facility and physician chronic illness costs is the lack of basic nursing services, social support for caregivers, and unmet personal care needs.⁹ Many seriously ill elders have Medicare coverage for physician care, medications, devices, and technological advances of biomedical research, but have unmet basic needs such as feeding, personal hygiene, safe home, and caring human touch. Additional Medical Home reforms to consider for pilot testing include:

Pilot testing and Medicare demonstration projects in these areas would empower home care clinicians to assume a more pivotal role in the primary care of the high-cost, low-mobility Medicare beneficiaries in the community who are often receiving inadequate care.¹² More care would occur in the patients' homes, which is a win-win venue because it can be less costly for payers without sacrificing quality,¹³ and it is where patients want to be. Many older adults fear nursing homes more than death.¹⁴ The strategy outlined is also promising because it promotes primary care as a mix of physician, nurse, and personal care. Another advantage is that there is currently an established risk-adjusted prospective payment system for home health services and an established outcomes-based quality reporting system that can be used to promote good care. Why spend time and millions of dollars reinventing the payment and quality measurement wheel?

Expanding the eligibility criteria, reimbursement, and breadth of services under the home health and hospice benefits could lead to inappropriate overutilization of these services. The pilot/demonstration projects would have to be evaluated on their cost-effectiveness with the ideal result being improved quality with a decrease in the overall cost of care. One creative approach to improving the care of high-cost Medicare beneficiaries in their home is a reform being promoted by the American Academy of Home Care Physicians called the “Independence at Home Act.” This approach could potentially lead to higher reimbursement for home medical care practices that provide aggressive care coordination if their patients' cost to Medicare is reduced by 5% or more while maintaining quality and satisfaction.¹⁵ The opportunities listed above could complement the Independence at Home Act by invigorating the grass roots home health and hospice clinicians who would be partners with the physician home care practices.

It is unlikely that there will be a large enough physician, advanced practice nurse, and physician assistant workforce to address all the needs of the growing population of vulnerable elders, so it will be essential that a large degree of in-home primary care be performed by family and personal caregivers who have an ongoing relationship with a nurse who is working under the holistic care plan of an engaged physician. Advances in telehealth monitoring, home modification, medication management equipment, and other technology breakthroughs may also play a role in mitigating the human workforce challenges.

The main offsets for increasing home health and hospice expenditures would be substitution of these home health and hospice services for other, more expensive services. Furthermore, payment systems for these newly empowered home health entities could be partially “risk-based,” accounting for their success at lowering other costs. Indirect cost reduction due to improved health and productivity of family caregivers could be another potential outcome. State-level Medicaid costs for institutionalization also may decrease if there is a greater shift to long-term care in the community rather than in institutional settings. In the home environment, no matter what reimbursable care is provided, there is almost always a prominent role taken on by family, friends, and others.

The shared responsibility between the family, community, and government payers should be considered an attractive alternative to facility-based care where virtually all meaningful care is provided by government funding. Ultimately, better care across all health care settings for an expanding population of older adults will likely cost more, and compassionate health care for sick older patients should be one of the highest priorities of this “ . . . land bursting with abundance.”¹