Abstract
Objectives
To describe the use of home-based services in accountable care organizations (ACOs).
Study Design
Cross-sectional analysis of 2019 ACO survey.
Methods
We analyzed surveys completed by 151 ACOs describing the characteristics of home-based care programs serving high-need, high-cost patients. We linked survey results to publicly available information about ACO characteristics, governance, and risk model participation.
Results
Twenty-five percent of respondent ACOs had formal home-based care programs, 25% offered occasional home visits, and 17% were actively developing new programs. Home-based primary care was the most common program type. Half of programs were established within the past 3 years. The programs utilized multidisciplinary care teams, but two-thirds had fewer than 500 visits annually. Funding sources included direct billing for services, health system subsidies, and ACO shared savings. A majority of respondents expressed interest in expanding services but were concerned about their ability to demonstrate a return on investment (ROI), which was reported as a major or moderate challenge by three-quarters of respondents.
Conclusions
ACOs deliver a diverse array of home-visit services including primary care, acute medical care, palliative care, care transitions, and interventions to address social determinants of health. Many services provided are not billable, and therefore ACO leaders are hesitant to fund expansions without strong evidence of ROI. Expanding Medicare ACO home-visit waivers to all risk-bearing ACOs and covering integrated telehealth services would improve the financial viability of these programs.
Takeaway Points
Many accountable care organizations (ACOs) provide home-based care to high-need patients, including primary care, acute care, support for care transitions, and interventions to address social determinants of health. However, many services are not well reimbursed, limiting program growth.
There is no prior research describing the full range of home-based care programs in ACOs.
With Medicare’s expansion of mandatory downside risk, more ACOs are considering home-based programs.
ACO managers are hesitant to expand these programs unless they can demonstrate a return on investment.
Expanding home-visit waivers to all risk-bearing Medicare ACOs and covering telehealth for patients receiving home-based primary care would improve these programs’ financial viability.
Improving care for high-need, high-cost (HNHC) individuals with multiple chronic conditions, functional limitations, and complex social needs is an issue of growing interest for policy makers, health systems, and payers.1 These individuals account for a large proportion of Medicare spending generally and a disproportionate amount of potentially preventable spending.2 The needs of HNHC individuals are frequently not well addressed by a health care system and culture that are focused on specialized and facility-based care.3 Home-based care is increasingly recognized as an approach with potential to improve outcomes and patient experience for HNHC individuals.4
There are many different home-based care models: home-based primary care (HBPC), hospital at home (HAH), community paramedicine, postdischarge transitional care, and care coordination services that employ both clinical and lay personnel. These models are distinct from certified home health agency services, which are not covered in this paper.
HBPC is well established but regularly practiced by relatively few providers. In 2013, approximately 5000 primary care providers made 1.7 million home visits to Medicare fee-for-service (FFS) beneficiaries, but almost half of the visits were delivered by just 470 providers.5 More than half of Americans live more than 30 miles from any of these high-volume providers, limiting Medicare beneficiary access to HBPC services.5
Medicare reimbursement affects the availability of home-based care. Medicare pays for HBPC delivered by physicians or advanced practice clinicians (APCs), but HBPC providers see far fewer patients than office-based providers because of travel time, which limits revenue. Medicare has not historically paid for HAH, but in late 2020, CMS established a waiver covering certain HAH services during the COVID-19 pandemic.6 Transitional care management services are covered by Medicare when provided by a clinician but are typically offered in a provider’s office or telephonically.
Home-based programs rely on multidisciplinary teams, and patients may be visited by nurses, social workers, paramedics, and community health workers—none of whom can bill for home visits in most circumstances. As a result, many programs rely on financial support from a hospital, medical school, or philanthropic organization.7
Although not historically well reimbursed, studies have shown that HBPC,8,9 HAH,10 home-based care transition support,11,12 and home-based programs led by registered nurses or lay health workers13,14 can lower spending for complex patients. These savings do not accrue to providers under traditional FFS reimbursement but generate financial benefits under models like capitation that pay a fixed per-member per-month amount for covered beneficiaries.
Accountable care organizations (ACOs) are well positioned to improve care for HNHC populations. ACOs are provider groups that take responsibility for caring for a specified set of beneficiaries. They are eligible to share in savings if they manage spending below a prospective budget target. Many ACOs have data systems and processes to identify high-risk beneficiaries and establish care plans to coordinate services for complex patients.15 Prior research suggests that a majority of ACOs make home-based care transition visits, primarily conducted by nonphysician staff.16 This paper offers a more comprehensive assessment of home-based care in ACOs.