Accountable care arrangements for home-based primary care are still in their early stages, but they have shown promise. During a recent panel discussion, Tom Lally, M.D., founder and CEO of Bloom Healthcare, recently spoke about his Lakewood, Colo.-based organization’s experience as the top-performing High-Needs Population ACO on quality measures in the CMS ACO REACH program.
Bloom provides in-home primary care and hospice services for seniors with complex health needs, serving patients in Colorado and Texas. In addition to the high quality scores, for Performance Year 2023. Bloom achieved a gross savings rate of 24.6%, which means that healthcare costs for Bloom’s ACO patients were nearly 25% below the spending targets set by Medicare.
A dedicated house call physician, Lally spoke recently at the Duke Margolis Institute of Health Policy. First, he described who their patients are.
The typical age of a patient getting home-based primary care is well into their late 80s. They’re generally in their last three years of life and can’t access the care they need. “Even if they can get out to see a primary care physician a few times a year, it’s not a frequency intensity that they need for themselves to be able to age in place,” Lally said. Home-based primary care is for patients who need house calls, not for patients who want a house call, he stressed. The program is designed for those multi-complexity patients who are living in their home and seeking to age in place.
There’s an extremely high incidence of dementia, Lally added. Almost 65% of Bloom’s patients in the home are home-limited, and because of that cognitive issue, they can’t travel safely. They often need one or two others to be able to get them to their appointments, so they become increasingly isolated until an emergency happens. There’s also a high proportion of patients who are dually eligible for Medicare and Medicaid. These are patients who generally are underserved in both rural and urban areas, and need care providers to come to them.
Bloom’s providers have a very high visit frequency and see their patient once or more a month and spend time with them in the home. “That’s one of the key things — that they’re going to be able to build trust in a living room. Having those shared conversations with decision makers right there where the patient is living and aging in place is incredibly important,” Lally said. “And when it comes to that impanelment that we need, it also has to be risk-stratifying. One size does not fit all with this population. High-needs patients still have varied needs and supports, and we really need to take that into account, whether that’s social needs, different economic factors that they have, different social supports that they might have from their family or not. They have to be incorporated into the plan of what matters most to that patient.”
A one-size-fits-all model generally doesn’t have the desired impact Lally said. It’s also got to be very heavy on care management. If a physician sees a home-based primary care patient twice a month, that still leaves 28 days in a month they didn’t see that patient. “We have to be thinking about proactive care management, whether that’s nursing, social work, pharmacy, and others. It is really interdisciplinary. It cannot be done by a single provider or a license type. We need an entire team, which is why it’s not appropriate for patients who just want a house call. Potentially, it’s a very expensive way to care for a patient who doesn’t have high needs, but it’s a very efficient way to care for a patient who does have high needs and is not accessing the care they need.”
Accountable models of care
Turning to how this care is paid for, Lally said that accountable models fit this type of care much better than fee for service.
“What we see in terms of commonalities among top-performing home-based primary care groups is that they are primarily being reimbursed through accountable means, whether it’s a shared savings, accountable care, but some sort of shared risk, where there are really aligned incentives,” he explained. “I think for us, seeing the ACO REACH High Needs being a dedicated track from the Innovation Center was incredible, because it was the first time we ever saw a track that was purpose-built for this type of population. An important ingredient to be able to scale this is to have a program that is really defined for this type of population, because we don’t fit in a normal, healthy bell curve. Our patients are the most expensive. They’re the outliers.”
Noting that home-based primary care is a very fragmented field with a lot of small practices serving urban or rural communities, Lally said, “we need payment methodologies that support all types of practices. It can’t just be for the large ACO-type practices like mine. We need something that is much broader for the field, and has a Medicare Physician Fee Schedule component that allows practices to be successful while they’re still in that world.”
Lally said that developing the workforce is another key issue. “We are taking on a new challenge where these patients are very complex,” he said. The average number of medications may be 10 or 12. They’ve got several chronic health conditions. “We don’t necessarily have the workforce that is trained to be able to manage that population. So a lot of our organizations are building additional training and thinking of ways to be able to work with university and academia to be able to have a workforce that is prepared to be able to take on some of these challenges. As reimbursement changes and this becomes a more sustainable area, I think we can make more progress around training and dedication of the workforce.”
