Outlook for Home-Based Primary Care Positive

HealthLeaders recently had a conversation with Sacks about the present status of home-based primary care and prospects for the future. The following is a lightly edited transcript of that conversation.

HealthLeaders: What are the main elements of home-based primary care?

Julie Sacks: The most basic definition of home-based primary care is that it is a way of providing primary care to the most at-risk and vulnerable people in our society. Generally, home-based primary care is provided to homebound and frail people who oftentimes are not getting primary care because it is too difficult for them to leave home.

The services you get through home-based primary care include annual wellness visits, vaccinations for patients and their caregivers, remote patient monitoring, telehealth, and care coordination. The home-based primary care doctor is often the quarterback of a patient’s care team. They provide primary care, but they also know when to bring in palliative care, hospice, and home health services.

HL: How does a house call add value to a patient’s healthcare?

Sacks: There is a strong relationship that gets developed between the clinicians and the patients. I went on house calls when I first started working at HCCI, and there was a gentleman who told the physician that he would not be alive without his care. This patient was homebound. He was depressed. He was really struggling. Having a physician come into his home to check on him was like a life preserver.

HL: How is home-based primary care financed?

Sacks: Generally, home-based primary care is financed in the same way that office visits to primary care practices are financed. Medicare reimburses the practice based on the coding that is submitted—so it is a fee-for-service model.

Initially, home-based primary care tends to be more expensive than office-based care largely because clinicians’ transportation time is not reimbursed by Medicare. And because of clinician transportation, healthcare providers cannot see as many patients as an office-based clinician can see. In the long run, though, research shows that a practice or health system will benefit significantly from creating a house call program. That is because this model of care has been shown to reduce costly emergency department visits and hospital readmissions. It also improves the quality of patient care and offers people an alternative to expensive nursing home placements.

In addition, there are ways to manage the transportation challenge. For example, assisted living facilities are considered homes because they are a residential setting. When a clinician sees multiple patients in an assisted living facility, there is obviously less travel time involved. So, by including a mix of assisted living facilities, skilled nursing facilities, and individual homes, you can address the transportation challenge.

Beyond the fee-for-service model, there are also new payment models being launched by the Centers for Medicare & Medicaid Services and the Center for Medicare & Medicaid Innovation. These models are either capitated models where clinicians get a per-member-per-month fee to take care of patients or total-cost-of-care models where a practice takes on the risk of care.

HL: Are commercial payers financing home-based primary care?

Sacks: The commercial payers are definitely contracting with home-based primary care practices. They see the value of home-based primary care for their members—particularly for members who are the most seriously ill.

Some commercial payers are contracting with practices directly to provide services, but some of them such as Humana are creating their own home-based primary care programs because they see the value of this model of care.

HL: How are home-based primary care services offered at the practice level?

Sacks: Historically, there have been more practices that only provide home-based primary care, but we are seeing it move to office-based primary care practices.

During the pandemic, one of the last places you want a frail senior is in a hospital. So, we are seeing more of the office-based practices realizing the value of treating people in the home. We see this as a big area of growth.

Historically, there have been more small- to mid-sized home-based primary care practices. But now, we are seeing both models. An office-based practice can start small by hiring a nurse practitioner and sending that clinician to patients’ homes.

Another trend we have seen over the past year and half is venture capital and private equity coming into the home-based primary care space. Venture capital is seeing the value of this care model, and they can invest significant capital in home-based primary care and participate in the new payment models that often require an upfront investment. There are venture capital-backed companies that are doing strictly home-based primary care.

HL: How can health systems launch home-based primary care services?

Sacks: One thing we have found is that home-based primary care at health systems must have C-suite support. There must be buy-in from the top levels of the organization.

Health systems also must understand which patients are appropriate for home-based primary care. Not every health system patient is appropriate for this model of care—it is too expensive. You want to use home-based primary care for the right patients, so you must train your whole health system on how to identify those patients. You want to have your emergency department physicians, discharge managers, and social workers aware of a home-based primary care program. You want your office-based primary care doctors aware, so they can identify high-risk patients who have not been in for a visit in a year or two.

It takes a system-wide effort to make home-based primary care successful at a health system.

HL: After the coronavirus pandemic has passed, what is your forecast for home-based primary care?

Sacks: Not every visit has to be in-person, so telemedicine will continue to benefit home-based primary care practices. It is unlikely that we will go back to seeing as little telemedicine as we saw before the pandemic.

The increased recognition by the public that home-based primary care is needed will have an impact on the market for these services after the pandemic. What I hope will happen is that patients and caregivers will start to demand this type of care now that they know that it exists. We plan to help mobilize that grassroots pressure, so that more and more health systems will adopt home-based primary care.