Health Reform Testing Home-Based Care

Medicare users with chronic health problems are the focus of effort to improve care and lower costs.


The health reform spotlight usually focuses on the 2014 requirement that most people buy health insurance, the creation of new state health insurance exchanges, and whether states will participate in the law's big increase in Medicaid services. But under the radar, the law has also triggered a flurry of new programs searching for better and cheaper ways to provide healthcare.

One of them, the Independence at Home (IAH) demonstration project, could have a huge impact on seniors with chronic illnesses. With growing numbers of older Americans, many of whom will post impressive longevity gains, rising healthcare costs are a national and personal problem. If the IAH test is successful, it would point the way toward lowering costs and also boost the broader provision of home-based healthcare services, thus helping seniors age in place in their homes and avoid institutionalized care.

The project, overseen by the government's Center for Medicare and Medicaid Innovation (CMMI), has recently finished enrolling 19 medical practice groups throughout the country. Over the next three years, these groups expect to provide in-home care to about 10,000 people with multiple chronic health conditions. A detailed study by Medicare of 2008 treatments and expenses found that more than 90 percent of its expenses were to treat people with multiple chronic conditions.

Treating seriously ill Medicare beneficiaries is enormously expensive, in part due to the high expenses of repeated hospital stays and related care and drug expenses. According to Medicare records, the five most common chronic conditions in 2008 were hypertension (affecting 56 percent of all beneficiaries), high cholesterol (43 percent), heart disease (32 percent), diabetes (27 percent), and arthritis (21 percent).

These figures include disabled beneficiaries, many of whom are younger than 65. The percentages of people age 65 and older with these chronic conditions is even higher. About a third of all beneficiaries have two or three chronic conditions, and another third have more than three. While only about 12 percent of Medicare recipients had six or more chronic conditions, they accounted for 40 percent of Medicare's expenses.

The 19 practices chosen for the IAH demonstration already have experience providing home care to chronically ill Medicare patients. They were also selected to reflect different parts of the country, including rural and urban practices. To qualify for the program, patients must:

• Have two or more chronic conditions

• Have coverage from original, fee-for-service (FFS) Medicare

• Need assistance with two or more functional dependencies (walking, feeding, dressing and other activities of daily living)

• Have had a non-elective hospital admission within the last 12 months

• Have received acute or subacute rehabilitation services in the last 12 months

Even with these restrictions, an estimated 1.4 million Medicare beneficiaries would qualify if the program was offered in all markets in the country.

"Many of these people have difficulty getting out of their home and getting to their doctor's office," says Rick Gilfillan, CMMI director. The goals of the IAH test are to see if in-home care can improve the health of participants, provide a more satisfactory care experience, and save money, he explains. Over time, practices that achieve all of these goals would be able to keep some of the money saved through reduced care expenses.

As an example of how at-home care would work, care professionals would go into the patient's home and look at the medications they are taking. Often, people are prescribed additional medication when they are discharged from a hospital but either don't fill these new prescriptions or even understand them. At-home care providers would check to see that prescriptions have been filled and that patients are taking the right drugs in the proper doses.

The demonstration period is three years. But Gilfillan says the CMMI doesn't need to wait that long to set up additional tests. It has the authority, for example, to create additional demonstrations of approaches by some IAH practices that have produced very positive early results.

Twitter: @PhilMoeller