New Directions in the Doctor Patient Relationship
Gaining traction is a new care model that is not really new—that potentially sets the stage for changing the way the home health agencies and hospices could be working with doctors and hospitals in the future.
A past, present and potentially forward look at physician house calls and home health
by Liz Carey

People have been talking about revisions to the home health care industry for years. The basic storyline runs a little like the classic soap opera. You can be away for a while, tune back in, and discover a big chunk of the dialogue has stayed the same: cost, quality, waste, fraud.

When home health diabetes care costs soared in Miami-Dade County, Florida, to an unusual degree compared to the rest of the United States, rules were established to limit suspected, undeserved profiting. Outliers—the term used to signal possible abuse—were said to be just one of the industry’s challenges, along with basing payments on historical averages; understanding the balance of companies with big healthy profit margins and those operating at a loss; and making sure patients truly receive the (appropriate) care being billed.

Points of Interest

2016 Physician Fee Schedule Regarded as economically significant
2017 Physician Fee Schedule Proposes to add codes to list of covered telehealth services, including health risk assessment and care planning for chronic care management (CCM)

2016 Hospice Payment 2.1 percent increase (+$350 million)
2017 Hospice Payment 1.0 percent increase (+$180 million)

2016 Home Health Completion of rebasing effort required by Affordable Care Act, payment rate update –$130 million (–0.7 percent)
2017 Home Health Proposes 0.4 percent decrease (–$80 million) for 2018, 30-day rather than 60-day, reliance on clinical drivers for 2019
Source: CMS

As of July 29, 2017, the Centers for Medicare & Medicaid Services (CMS), HHS extended the temporary moratoria on new enrollment of home health agencies, subunits and branch locations in Florida, Illinois, Michigan, Texas, Pennsylvania and New Jersey, as applicable, to prevent and combat fraud, waste and abuse in these states. Also in July 2017, the new home health proposed payment system rule rang some alarm bells too.

Throughout Industry Upheaval, People Still Need Care

Gaining traction is a new care model that is not really new—that potentially sets the stage for changing the way the home health agencies and hospices could be working with doctors and hospitals in the future. Policy and payment incentives appear to be giving homebased primary care (HBPC) a lift.

Meet Dr. Thomas Cornwell in Chicago, one of the thought leaders behind the HBPC movement. Cornwell has made more than 32,000 house calls over the past 24 years. Today, he is one of the practicing leaders in the shift to more medical care at home.

Cornwell directs the Home Centered Care Institute (HCCI) based in Schaumburg, Illinois, and, with the partnership of eight medical institutions around the United States, launched a new comprehensive home-based primary care training and curriculum program in August 2017. The program is largely supported by organizations including the John A. Hartford Foundation, a private national organization dedicated to improving the care of older adults.

Cornwell envisions a shift toward more primary care at home as part of Medicare’s value-based payment design.

The Power of Partnership

Home-based primary care presents a new kind of partnership between the doctor and other in-home providers, such as the home health agency, HME providers and hospice, to better align with the needs of patients. It also factors in the need for specialists and potentially other home-based clinical services such as X-rays and ultrasounds, Cornwell said.

“There is so much we can do in the home now. Home-based primary care can improve the quality of life for homebound patients and caregivers, and decrease health care costs by enabling patients to remain at home and avoiding expensive emergency department visits, hospitalizations and nursing home care.”

CMS, by way of the new home health prospective payment system, is looking to change the home health payment structure to a more clinically based system. The changes are set to start in 2019, and are meant to align the highest payments with the highest-cost, sickest patients.

Does This Model Make Sense?

“Home-based primary care providers are great partners for home health agencies, because they fully understand and utilize the skills of the home health personnel to safely care for patients at home,” says Cornwell, who discussed a recent patient where the home health nurse called to report that a heart failure patient had increased shortness of breath, leg swelling and had gained four pounds over two days. Rather than calling 911, he had the nurse adjust the medication and offer guidance to call if symptoms worsened, with follow-up the next day. The following day the shortness of breath was gone, the patient was down two pounds, and a hospitalization was averted.

“Often when a home health nurse calls a busy office practice, they are told to call 911. This is why there is such a high rate of readmissions associated with home health.” 

Cornwell adds that home-based primary care providers are also good home health partners because they know the importance of good documentation to enable home health agencies to bill and to help DME companies get paid for the equipment that patients need.

He works alongside others envisioning the expansion of medical care at home. Icahn School of Medicine at Mount Sinai, which appears on the list of HCCI’s Centers of Excellence, pursues the Hospital at Home Plus (HaH-Plus) physician-focused payment model for the provision of acute hospital hospital-level care and 30 days of transition services in the homes of carefully selected Medicare beneficiaries.

Not Possible Through Traditional FFS Medicare

Dr. Dennis S. Charney leads the way for HaH-Plus at Mount Sinai. “Although the acute hospital is the standard venue for providing acute medical care for serious illness, it may be hazardous for vulnerable older persons, who commonly experience functional decline, iatrogenic illness, and other adverse events during care, and it is expensive,” Charney stated in a February 2017 letter to the Physician-Focused Payment Model Technical Advisory Committee (PTAC) and the U.S. Department of Health and Human Services (HHS).

Mount Sinai’s mobile acute care team hospital at home services are for beneficiaries with qualifying diagnoses and an acuity level that would otherwise require hospitalization. It involves an integrated team of mobile providers. Services such as these cannot be billed with traditional fee-for-service (FFS) Medicare, the letter states.

What Are the Challenges?

“We’re in a period of innovation and experimentation” says healthcare markets and regulation expert Michael Chernew, professor of Health Care Policy at Harvard Medical School. “The challenge is to find an efficient way to get the physicians to the patients. It’s execution: getting the right resources to the right patients at the right time. A lot depends on the condition of the patient.” And he adds, “Throughout the health care system, the portion of care that’s paid by Medicare is subject to all the pressures that Medicare faces.”

Cornwell is hopeful. “The new Medicare program for this decade could be house calls, and this could be an incredible benefit to the population, but they need both house calls and home health and hospice.”

CMS, which directed a hospice pay increase of 2.1 percent ($350 million) in 2016 for 2017, delivered another hospice pay increase of 1.0 percent ($180 million) in 2017 for 2018, as of an August 1, 2017 statement—and new quality measures with both.

Policy Developments Are Moving Targets

Policy developments help to scale such operations. Of direct impact, for examples, have been the Independence at Home Act and MACRA, known as the Medicare Access and CHIP Reauthorization Act of 2015.

MACRA, regarded by some as “quietly transforming health care” behind the scenes, is in its first year of implementation in 2017. Under MACRA is the Quality Payment Program, which for those opting into the Advanced Alternative Payment Models (APMs) offers incentives for participating and for those opting into the Merit-based Incentive Payment System (MIPS) offers a performance-based payment adjustment. The first payment adjustments based on performance go into effect January 1, 2019.

For the 2018 performance year, CMS estimates that more than 125,000 clinicians will participate in Advanced APMs and qualify for the 5 percent incentive payment. Working with such clinicians is Dr. William Mills, a home-based primary care physician at Kindred Healthcare, where he was also chief medical officer of Kindred At Home, sits on the board for the American Academy of Home Care Medicine and leads his own company, Chronic Care Management, LLC.

Mills has practiced home-based primary care for about 10 years. Primary care in the home, which includes physician house calls and visits by physician assistants and nurse practitioners, can be practiced in traditional Medicare fee-for-service, as well as advanced alternate payment models, like Accountable Care Organizations or CPC+ (Comprehensive Primary Care Plus), a five-year model that started January 1, 2017.

Kindred House Calls is a CPC+ participant, one of more than 2,900 primary care practices nationwide participating in a partnership between payer partners from CMS, state Medicaid agencies, commercial health plans, self-insured businesses and primary care providers. The physician house call arm of Kindred fledged in 2013 when Kindred At Home launched.

“Kindred is currently utilizing this innovative program to provide additional longitudinal care management support for some of its sickest primary care patients. The level of engagement and resources that are now made possible with CPC+ and other programs, such as chronic care management, can provide patients “in-between visit” resources that were often impossible to provide in traditional fee-for-service,” Mills said.

“I have long viewed my clinical practice and the practice of home-based primary care as being the quarterback of the care team, a coordinator of the types of care and services that homebound patients need. Those services include home health care, therapy, DME, private duty and hospice.”

Mills spent several years in hospice practice through the company he founded, HopeBridge Hospice in Cleveland, that is now part of Kindred and operates under the Kindred Hospice name. He adds that hospice continues to be underutilized in the United States. By activating hospice sooner for patients with terminal illness, many patients have a better chance of staying out of the hospital or a nursing home in their last month of life, a point Cornwell makes too.

The difference between CPC+ and the home-based primary care that Cornwell speaks of is that the CPC+ model is applicable to a variety of different practice sites including traditional office settings, whereas Independence at Home is focused on patients who receive primary care at home.

The Independence at Home Act, through the at-times maligned Affordable Care Act, propelled a demonstration project that tested if and how primary-based care in the home helped to reduce hospitalizations, save health care dollars and improve outcomes for frail elderly patients with multiple chronic conditions and chronic care management (CCM) needs. Obamacare earmarked millions of dollars to help test new care models, including home-based primary care.

Both the Independence at Home and the CPC+ programs help to support and strengthen Medicare providers who care for chronically ill patients. Additionally, Medicare’s Chronic Care Management (CCM) program is currently helping practices across the country transition to value-based care models. The CCM program—which is referenced in the recent Physician Fee Schedule proposal, specifically to add codes to covered telehealth services—is helping practices of various degrees of sophistication utilize it to perform comprehensive care planning for patients, while providing new revenue to participating practices. Taken together, CMS views CCM as a bridge to value-based care.

New Directions in the Doctor Patient Relationship

“What used to be a 7-minute visit every six months is moving toward the physician being better connected with the patient,” Mills says. “The areas that CMS continues to invest in are largely those efforts that provide more holistic, goal-directed care—and person-centered care planning is a pivotal part of chronic care management. All of these developments are moving us in the right direction.”

As a stakeholder in the coordination and service of care, how will a more formal adoption of home-based primary care and/or hospital care at home work for you?

We welcome your predictions, thoughts, concerns, questions and comments: Send an eLetter to HomeCare Editor Liz Carey at, or comment via Facebook.

More Information
Home-Based Primary Care Education Program

Medical institutions in Ohio, New York, Illinois, Pennsylvania, Arizona, Arkansas, California, Maryland and Washington, District of Columbia joined the HCCI Centers of Excellence rollout. The program focuses on four core components of home-based primary care—foundational principles, economics, operations and clinical care.

CY 2018 Physician Fee Schedule Proposed Rule, Comment Deadline
This proposed rule updates payment policies, payment rates, and other provisions for services furnished under the Medicare Physician Fee Schedule (PFS) on or after January 1, 2018. In addition to policies affecting the calculation of payment rates, this proposed rule proposes potentially misvalued codes, adding procedures to the telehealth list, and a number of new policies. CMS will accept comments on the proposed rule until September 11, 2017, and will respond to comments in a final rule.

Hospice Center Spotlights
See short snippets of major developments.

Extension Moratoria, Home Health Agencies
Document support for the rationale for the moratoria extension, indicators of fraud, waste and abuse, outliers; Provider Enrollment Moratoria Access Waiver Demonstration; (81 FR 51116); (82 FR 35122).

Quality Payment Program - Fall 2016 Developments, CMS
This document also references APMs, Medical Home Model, Transforming Clinical Practice Initiative (TCPI), Quality Innovation Network (QIN)-Quality Improvement Organizations (QIO).