Who will drive the (slow) introduction of more hospital-at-home services?
Insurance companies (payers) are great candidates for supporting hospital at home because they have an incentive to keep patients out of care and reduce their costs. In pure economic terms, hospitals, doctors, & clinics make more revenue the longer their patients are in care. In the US private insurers pay about 80% of their revenues to providers and in 2018 the total direct written premiums by private insurers reached over $870 billion. This post by Yoav Fischer of HealthIL gives a great overview of private and public insurance/health systems.
By working with providers and pushing for more value-based care payment plans, insurers have the potential to become advocates for more hospital-at-home services. Some articles related to the topic below:
Hospital at Home Waiting for Payer Endorsement (The Commonwealth Fund): Although studies have shown that total cost of at-home care is 32 percent less than traditional hospital care (coupled with better outcomes) CMS and most private payers do not yet pay for hospital care delivered at home and restrict payments for telemedicine. In Victoria (Australia), for example, where hospital at home is more widely implemented, the state government offers the same reimbursement for at-home care and inpatient care. Although there are many challenges, it is clear that the payers are currently a gatekeeper and slowing the move to more digitally-centered care (including hospital from home).
Hospital from Home Fits "Value-Based Care" Model (Medium): Marki Flannery, President and CEO of the Visiting Nurse Service of New York, discusses why we have started to see payers and providers working together. The move towards "value-based" purchasing arrangements (providers are paid based on their ability to provide quality care within a pre-set budget) encourages both payers and providers to reduce healthcare costs by improving patient's health and providing quality care. Flannery explains why this is great for care from home, as care from home is an excellent way to provide better quality of life for patients while reducing health care costs.
CMS Announces New Value-Based Payment Model (Hea!thcare Innovation): In April of this year the US Department of Health & Human Services announced a new set of voluntary value-based payment models for primary care physicians. Through the opt-in Primary Care First Initiative, CMS (Centers for Medicare & Medicaid Services) will make monthly population-based payments along with a simple, flat rate each time a provider sees a patient. There will be significant payments if patients stay healthy and at home. The model is set to be released in January 2020. The Direct Contracting Initiative has three different payment options (Professional, Global, & Geographic), but all provide predictable monthly payments in return for moving all or some of the total cost of care to the providers. Both of these initiatives support home-based models because they revolve around value-for-care and moving the incentive of lowering health costs to providers. You can read more about the policies here.
Why The CMS' Primary Care Initiative Isn't Good Enough (Med Page Today): Although the above sounds rosy, this article discusses the inadequacies of these payment models. Some major issues are: 1) PCPs will still have about 40% of their revenue tied to face-to-face office visits, but receive half of what they are paid today per visit. Consequently, clinics might not be able to cover their costs. 2) There would not be any differentiation between sicker and healthier patients so it might reduce the availability doctors have for healthier patients. 3) Performance metrics are mostly correlated with reducing hospitalization rates, but do not measure the quality of care patients are receiving. The Center for Healthcare Quality and Payment Reform (CHQPR) has more information regarding the problems with the Initiatives here.