Better outcomes, satisfaction with hospital-at-home care programs: JAMA study
- 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.
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.