Abstract
Objectives
As the shift from volume to value in healthcare expands, efforts to develop alternatives to hospitalization are gaining momentum. This study explores home health care initiated directly from the emergency department (ED) using the Medicare-reimbursed home health benefit as a potential alternative to hospitalization. We address barriers to home-based care by comparing costs and utilization of care for older adults dispositioned to home health care versus hospital admission.
Study Design
We conducted a retrospective institutional and carrier claims analysis of 5% of total Medicare fee-for-service beneficiaries from January 2012 through December 2013 using 2 cohorts: patients treated in the hospital following an ED visit (inpatient) and patients treated at home following an ED visit (home health). Patients had 1 of the following: congestive heart failure, chronic obstructive pulmonary disease, urinary tract infection, pneumonia, or cellulitis.
Methods
Propensity score—weighted regression was used to measure the total cost of care for 90 days post index visit, hospital admissions/readmissions, and ED revisits.
Results
Total 90-day costs were lower for the home health cohort than for the inpatient cohort ($13,012 vs $20,325; P <.0001). The home health cohort also had lower hospital admissions/readmissions (23.7% vs 33.0%; odds ratio, 1.535; P <.0001) compared with the inpatient cohort. Although the home health cohort had fewer ED revisits, the difference was not statistically significant.
Conclusions
The findings suggest that risk-bearing healthcare organizations could use home-based alternatives to hospital admission as a means of providing high-quality care at a lower cost.
Healthcare spending in the United States exceeded $3.3 trillion in 2016, which translates into an average of $10,348 per capita annually.1 Despite some slowing in growth in 2016, experts still predict an unsustainable spending trajectory.2 Of total healthcare spending, hospital-based care accounts for the largest percentage at 32%, or $1.056 trillion. In 2016, hospital costs increased by 4.6%, which, although 1% slower than the growth in 2015,3 is still unsustainable. Because of this unsustainable growth in healthcare costs and poor value for the amount we spend, major efforts are underway nationally to shift Medicare from a volume-based system to a value-based system. Due to the high cost of hospitalization, alternatives to hospital admission have become a focal point of that shift.
Providing hospital-level care at home as an alternative to hospitalization is showing promising results in value-based care and may become a significant asset to a chronic care model in a senior service line portfolio.4 A growing body of evidence suggests that providing higher-intensity acute care in the home achieves the quadruple aim of improving population health, lowering costs, and improving patient and provider experience.5-15 This particular type of hospital-level care at home has demonstrated significantly better outcomes for selected patients compared with standard inpatient hospitalization, including comparable mortality,5,6 improved mortality,6,7 similar readmissions,7 decreased readmissions,8 decreased length of stay (LOS),7,9,10 significant cost reduction,6-11 improved functional recovery,12,13 overall positive provider evaluations,12 lower levels of family member stress,14 and increased patient satisfaction.6,7,15 In late 2017, the Physician-Focused Payment Technical Advisory Committee recommended that the secretary of HHS implement the hospital-at-home model as an advanced payment model.16
Despite evidence that home-based acute care models are cost-effective and safe, the scaling and sustainability of these models has been limited by the historical lack of payment reimbursements by Medicare parts A and B.17 The objective of this paper is to address this issue by investigating the potential for Medicare cost savings and reductions in utilization when providing home-based acute care. This study is unique in that it explores the implications of using the Medicare home health benefit to pay for the delivery of needed care after an emergency department (ED) visit, as opposed to the typical stand-alone hospital substitute model described in the literature. We compare the costs and utilization for seniors transitioned from the ED to home health care versus admission to the hospital from the ED. Data were analyzed to explore (1) whether care delivered in the home following an ED visit has lower costs than that delivered in a hospital and (2) whether ED and hospital utilization are reduced in the 90 days following an episode of care for similar patients. Answers to these 2 questions have important implications for policy makers and the medical community, as adoption of acute home-based care innovations is currently limited in the United States.