New Frontier for Medically Complex Homebound at the Last 2 Years of Life

by Dan Osterweil MD, FACP, CMD

In an announcement on April 9, 2018, Health and Human Services Secretary Alex Azar appointed former Landmark Health CEO Adam Boehler as Director of the Centers for Medicare and Medicaid Innovation and as Deputy Administrator of the Centers for Medicare and Medicaid Services.  CMS Administrator Seema Verma made the announcement to staff by email on Friday, CMS confirmed. Boehler is founder and CEO of Landmark Health, a company that provides home-based medical care. Landmark is a medical provider group specialized in caring for complex, chronic patients. Our doctors and providers drive to patients where they live, bringing care through house calls. This home-based medical care is designed to help patients stay well and stay home. We have a multidisciplinary team and collaborate with our patient’s health plan to care for the whole patient, bringing medical care, behavioral health, palliative care and social support services to patients in the comfort of their own home—wherever and whenever they need it. This may be marking a true new direction in how HHS is viewing innovation in health delivery. Away from brick and mortar delivery systems like nursing homes, and other chronic care facilities and back to the home.

This was unheard of 30 years ago, or even 10 years ago, where we all viewed the need to bring the patient to us. That led to conversion of hospital ED as a destination for patients with problems who could not make to the primary care office. Either due to transportation challenge and or access and scheduling issues with the primary care office. This led to escalating costs due to revolving door between hospital home and NH. Physicians practicing in NHs rarely mobilized themselves to see a patient after hours and have rather ordered an ambulance to the ED for evaluation. As we all know, that led more often to an admission rather than return back to the NH. This led to creative coding to justify admissions. UTI became “urosepsis”, dehydration “acute renal failure” and Pneumonia became “respiratory failure”. This has started to change with the advent of CMS declaring certain condition Ambulatory Sensitive Conditions, namely an admission meant that the provider failed to address a problem in the non acute setting and therefore payment for those admissions were curtailed or some other disincentive were put in place.

Landmark and its predecessor CareMore have taken the “old road” going to the patient as opposed to waiting for the patient to come to them. This is a true population health approach with a patient centered focus. For organized medicine in particular managed care systems it becomes cost effective. By going to the patient home we can learn how they live, who is their support system. We can learn what the care preferences are, and we realize to our surprise that they prefer the home visit by an NP to a trip to the ED. They may even elect to forgo curative invasive treatment for easy access and comfort oriented care.