6 DYNAMICS CREATING MOMENTUM TOWARD HOME-BASED CARE DELIVERY
From the 1940s norm of house calls to the 2020s transition to telehealth, health care delivered at home has been an option—even preferred—for those searching for care from the comfort and safety of home. However, over the past decades, as populations aged, institutional care became the benchmark for its infrastructure and technology to safeguard elderly as family caregivers disappeared into the workforce.
February 8, 2021
Today, there is yet again a trajectory toward home-based delivery of care for reasons beyond comfort and safety. The Centers for Medicare and Medicaid Services (CMS) are shouldering a transition from fee-to-value payment models, putting the risk on providers to achieve better patient outcomes while reducing costs. In concurrence, the world finally faced its underbelly—a global pandemic that has both rocked healthcare to its core and inspired it to adapt and innovate.
The result has been a groundswell of patient need for at-home services to which policymakers responded. There have been new disruptors and solutions—from SNF-at-Home to Hospital-at-Home (and everything in between)—that is creating momentum toward a future of increased access to and options in home-based delivery of care.
“Pre-COVID, if you had a long, debilitating type of illness, we were not set up from an infrastructure perspective, funding perspective, or a workforce perspective to age in place,” says Anne Tumlinson, Founder and CEO of ATI Advisory. As COVID infiltrated skilled nursing facilities, it was like we all woke up, and said ‘whoa, that is not what I want for myself or my family.’ And that has driven some of the policy response toward more home-based care.”
As leaders in healthcare policy and coordinating community-based care at home, ATI and Integrated Care Solutions (ICS) collaborated to discuss six dynamics creating momentum toward home-based delivery.
COVID-19 / Market Behavior
As the beginning stages of the pandemic were unfolding, the No. 1 priority was to free up capacity across the hospital/post-hospital care continuum by moving patients into home treatment to prevent exposure to the virus. CMS issued waivers to alter requirements for post-acute care settings. Many states expanded who could render services (both in terms of family caregivers and scope of services offered) and allowed more virtual care for Home & Community Based Services (HCBS).
“Policymakers are willing to do things that they’ve never been willing to do before. For example, introducing new ways of paying for telehealth and loosening the rules around how you can access home health services. It’s just been an unprecedented response from policymakers, from the perspective of what can be done to make this as easy as possible for the beneficiary.” —Anne
As hospitals vacated beds, there was also a fundamental avoidance of institutional care settings. At the onset of the pandemic (April 2020), ICS data at the clinical level found that patient volumes were down about 40 percent from pre-pandemic levels. Initially, the assumption was that people were avoiding elective, non-urgent surgeries. Instead, the Centers for Disease Control and Prevention (CDC) indicates—and ICS data supported—that the American public avoided a significant amount of medical care including routine, urgent, and emergency care.
Additionally, there was a drastic change in behavior upon discharge when hospitalization was unavoidable. According to ICS data, 20 percent of those who had tested COVID-positive went home, yet 55 percent of those who tested COVID-negative went home. This behavior was influenced by the influx of family members—prospective caregivers—being at home.
“Some of this behavior was just what I call the ‘fear factor.’ People were scared of SNFs because of the bad press they were receiving and what we heard about outbreaks. Also, caregivers were home—working remotely, home with children, or laid off from their jobs. And so the caregiver unit in a family expanded during the height of the pandemic, and there was a place for those patients to go that allowed them to avoid institutional care.” —Brian Fuller, ICS CEO
Fiscal Realities of Medicare Trust Fund
It’s no secret that the Medicare Trust Fund is in trouble. The Congressional Budget Office (CBO) recently projected that the fund would be exhausted by 2024, the closest to bankruptcy it’s been in 55 years. Once again, the United States finds itself at a moment when the funding coming into the trust fund doesn’t match the money going out.
Also, the fund’s depletion makes it easier for policymakers to cut programs to fund other special interest projects. Necessary cuts are likely to shed light on the benefits of value-based models.
“What this means is that there will be more pressure to push the risk on a per-person basis for spending, not just to the insurance, but all the way to the provider level. We won’t be slow-walking value-based care quite as much as we have in the past.” —Anne
Value-based care and alternative payment models were precipitated by the passage of the Affordable Care Act (ACA) in 2010 to respond to the Medicare Trust Fund. While efforts like the recent Direct Contracting program and others have been a positive step forward, the innovation and implementation of these programs has been slow. Solutions to keeping the Medicare Trust Fund intact will require faster and more efficient development of programs that are directly tied to financial outcomes.
“At some point, we’re going to have to narrow the universe of models that are out there, figure out how to align them better, figure out what the overall strategy is going to be around payment delivery and reform, and make sure it all works in concert rather than what we’ve been doing—throwing a bunch of balls against the wall trying to figure out what sticks.” —Brian
Biden’s Healthcare Agenda and Home Care
Over the summer, Biden stood in recognition of better job creation in healthcare and made it clear that alternatives to institutional settings need more consideration. In response, he proposed $450B in funding for better jobs for direct care and extended funding to Medicaid to improve patients’ options at home before seeking institutional long-term care. The healthcare system is at a tipping point where the benefit of value-based care and preventative measures cannot be ignored. COVID made it impossible for policymakers and the public to turn a blind eye to how the long-term care system operates today, which is still very heavily biased towards senior citizens ending up in nursing homes.
“One of the critical policy components of all of this is around the workforce. Biden has proposed not only a federal minimum wage of $15 an hour, but he’s also proposing comprehensive health care benefits, better overall compensation, childcare—all of the things that will support the workforce needed to build an infrastructure for home-based care. I think you’ll see more and more of the policymakers, CMS, and CMMI connecting the dots in ways that haven’t been connected before.” —Anne
With a new administration, there have already been a slew of announcements regarding regulatory actions, and we should continue to expect many more. From a boots on the ground perspective, Medicare payment models will continue to evolve. Both voluntary and mandatory models are expected to continue. Models like Direct Contracting—that put 50-100 percent risk on the provider and consider holistic, preventative measures for patients—will grow. Additionally, there could be a push for more supplemental services that support care at home such as improving transitions where patients are most at risk and leveraging Medicare Advantage plans to coordinate benefits to stay home and focus on preventative care.
“I think we’re going to see more funding available for building infrastructure that isn’t just about the actual provision of home care itself, but all of the things that have to wrap around someone in order to make sure they have access to and use services in a way that really keeps them out of hospitals and nursing homes.” —Dana Strauss, ICS VP of Partner Engagement
Growth of Medicare Advantage
The Medicare Advantage program, and value-based purchasing in general, were set up to give more flexibility, push down risk to providers, and incentivize investments in improvement. In the last few years, CMS and Congress introduced an unprecedented level of flexibility to Medicare Advantage to expand the definition of traditional supplemental benefits—like dental, vision, hearing, or fitness benefits—to encompass non-medical supplemental benefits. These benefits can include support for caregivers, in-home delivery services, and even pest control—all in an effort to prevent hospitalization.
“This is still a highly regulated part of the Medicare program. However, we’re at a turning point—paying for services that have never been covered benefits before. There’s a growing recognition that under these risk-based models, the federal government said, ‘here’s the sum total of healthcare expenditures for which you are responsible. If you can figure out a way to do this more efficiently and effectively, great.’” —Anne
Medicare Advantage has been very successful because it aligns incentives with providers. Due to the program’s success, new models are imitating it like Direct Contracting. Unfortunately, elsewhere in healthcare, the incentives are not aligned. Physicians don’t get paid for pushing care into the home. Hospitals don’t get paid for pushing care into the home. But Medicare Advantage does get paid for lowering overall cost of care, utilizing home wherever possible. With Medicare Advantage, providers don’t have to sift through conflicting messages.
Also, Medicare Advantage along with Medicaid managed care organizations (MCOs) are encouraged to coordinate long-term support services for patients at home who are at risk for hospitalization or institutional placement. Direct Contracting offers this as an option for Direct Contracting Entities (DCEs) as well. It will be interesting to learn how that plays out as the program officially begins April 1.
“Medicare Advantage is dynamic, unique, and has all of the incentives aligned—clinical and financial—to ultimately drive as much care as can reasonably be delivered into the home with significant flexibilities. That reality doesn’t exist to that degree anywhere else in healthcare, except for Medicare Advantage.” —Brian
Driving Technology Solutions
The inundation of more innovative and accessible technology in home-based care has shifted the consumer reality. Unexpectedly, consumers, and older adults, in particular, have rapidly adapted to a digital-driven delivery system. Many gaps still need to be addressed to ensure equitable access, such as internet connectivity, flexibility for different modalities, and payment methods.
“Technology is enabling a rapid transformation of the delivery system and we’re not going back.” —Anne
The COVID pandemic caused our society to rely on technology as a means to connect when in-person visitation was out of the question. Prior to COVID, hospitals were the go-to site of technology and infrastructure. As demand grew for in-home care as a means to evade exposure, so did technology. Seniors have been forced to use technology, and in turn, the barrier of fear has been removed. Technology has made it easier and more accessible to reach physicians remotely. Now, we’re looking to push technology in new ways to reduce care costs—incorporating wearable devices like smart watches into real-time and preventative care.
“Technology solutions, in conjunction with the flexibility of value-based care programs, broaden ways to support a population, avoid hospital transfers, and other inpatient settings. It also gives patients and families—fearful of transitioning home after a hospital stay—peace of mind. Telemonitoring, telehealth, remote patient monitoring, and many other solutions, in conjunction with the permissions under at-risk and other capitated models of care, make living at home longer a reality.” —Dana
Desire of Consumers
“There’s been a large public desire to avoid institutions, though COVID escalated this demand. We’ve seen a boom of consumer awareness of what’s possible to do at home and a much greater acceptance of home health care.” —Anne
In many ways, the pandemic was a wake-up call regarding aging in America. As society was forced to see the reality of how a virus could infiltrate institutional care, the desire of consumers grew to keep their loved ones safely at home. Paired with new policy and a movement toward value-based care that serves the patient and provider, care is transitioning home—again.
“Consumers’ desire to age-in-place at home is growing, but that’s always been the desire of healthcare consumers in our nation’s history. The challenge has been that healthcare infrastructure and payment systems have not supported large-scale, aging-in-place at home. Currently, this requires significant caregiver support (with all its inherent challenges and burnout) or the system moves people into institutional settings, such as nursing homes. To support the growing demand of the American healthcare consumer to age-in-place at home will require supporting the policy and reimbursement changes needed to make that possible.” —Brian
But will the United States transition too fast without an infrastructure? Without a sufficiently paid workforce or caregiver support, it’s like a “Field of Dreams” scenario where the nation finds itself with a field but no team. What if there is a shift to highly medicalized models where the providers’ burden is to deliver everything from the hospital to home? But if the hospital moves home, does the patient lose the benefit of “home”?
The success of home-based delivery will rely on increased adoption by federal entities, relaxed policy and flexibility, more value-based payment programs, and long-term infrastructure. If there isn’t a workforce to care for individuals at home, this more innovative, cost-effective, and patient-centered healthcare delivery could be short-lived. Let’s continue to push for policies and ask the hard questions to make sure seniors have the care they deserve.
About the Authors:
Brian Fuller is the CEO of Integrated Care Solutions, a care management and care coordination company focused on improving performance under a variety of value-based care payment programs for hospital systems and physician partners. He is a recognized thought leader on the impact and importance of post-acute care in new healthcare reform environments and a leading expert on care integration and partnership development across the continuum, including evaluating and implementing new payment initiatives such as bundled payments and ACOs.
Dana Strauss is ICS’ Vice President of Partner Engagement and a Doctor of Physical Therapy. She is a subject matter expert in care transitions, care coordination, all sites of post-acute care and utilization, case management, and alternative payment models. She has worked directly with hospitals and physician partners successfully implementing BPCI, CJR, BPCI-A, ACOs, and other alternative payment models.
Anne Tumlinson leads the nation in setting the direction on aging and disability policy. She founded ATI Advisory to reform health and long-term care delivery and financing for the nation’s frail and vulnerable older adults. Anne also founded and runs Daughterhood, an online and in-person community that connects family caregivers with each other for support and information.
ICS helps organizations improve community care coordination and drive the transformation to value-based care. Learn more about how ICS delivers results for organizations by putting patients first. Call us today: 860-622-7645.