Accountable care arrangements for home-based primary care are still in their early stages, but have shown promise. During a recent panel discussion, Tom Lally, MD, founder and CEO of Bloom Healthcare, recently spoke about his Lakewood, Colorado-based organization’s experience as the highest-needs population ACO with the best performance on quality measures in the CMS ACO REACH program.
Bloom provides home-based primary care and palliative care services for seniors with complex health needs and serves patients in Colorado and Texas. In addition to high quality scores, for the 2023 performance year, Bloom achieved a gross savings rate of 24.6%, meaning healthcare costs for Bloom’s ACO patients were nearly 25% lower. below spending targets set by Medicare.
Lally, a dedicated home physician, recently spoke at the Duke Margolis Health Policy Institute. First, he described who his patients are.
The typical age of a patient receiving primary care at home is around 80 years old. They are generally in their last three years of life and cannot access the care they need. “Even if they can get out to see a primary care doctor several times a year, that’s not an intensity of frequency that they need to be able to age in place,” Lally said. Primary home care is for patients who need home visits, not for patients who want a home visit, he emphasized. The program is designed for those patients with multiple complexities who live at home and seek to age in place.
There is an extremely high incidence of dementia, Lally added. Nearly 65% of Bloom’s home patients have limitations in their home and, because of that cognitive issue, are unable to travel safely. They often need one or two more to be able to take them to their appointments, so they become increasingly isolated until an emergency occurs. There is also a high proportion of patients who are dual eligible for Medicare and Medicaid. These are patients who are typically underserved in both rural and urban areas, and need care providers to come to them.
Bloom’s providers have a very high frequency of visits, seeing their patients one or more times a month and spending time with them at home. “That’s one of the key things: that they’ll be able to build trust in a living room. Having those shared conversations with decision makers right there, where the patient lives and ages, is incredibly important,” Lally said. “And when it comes to that consolidation that we need, you also have to stratify risk. One size does not fit all in this population. High-needs patients still have varying needs and supports, and we really need to take that into account, whether it’s social needs, different economic factors that they have, different social supports that they may or may not have from their family. They have to be incorporated into the plan of what matters most to that patient.”
A one-size-fits-all model typically doesn’t have the desired impact, Lally said. It also has to be very important in attention management. If a doctor sees a primary care patient in their home twice a month, there are still 28 days in a month when they did not see that patient. “We have to think about proactive care management, whether it’s nursing, social work, pharmacy and others. It’s really interdisciplinary. It cannot be done by a single provider or type of license. We need a full team, so it is not appropriate for patients who only want a home visit. “It’s potentially 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 isn’t getting the care they need.”
Responsible care models
As for how this care is paid for, Lally said accountable models are much better suited to this type of care than fee-for-service.
“What we see in terms of commonalities among the top-performing home primary care groups is that they are primarily reimbursed through responsible means, whether it’s shared savings, accountable care, but some type of risk sharing, where there really is matches. incentives,” he explained. “I think it was incredible for us to see that ACO REACH High Needs was a dedicated track from the Innovation Center, because it was the first time we saw a track built specifically for this type of population. To be able to scale this is to have a program that is really defined for this type of population, because we do not fit into a normal and healthy bell curve. Our patients are the most expensive. They are the outliers.
Noting that home primary care is a very fragmented field with many 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 large ACO type clinics 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 are still in that world.”
Lally said workforce development is another key issue. “We are taking on a new challenge where these patients are very complex,” he stated. The average number of medications may be 10 or 12. They have several chronic health conditions. “We don’t necessarily have the trained workforce to be able to handle that population. So many of our organizations are creating additional training and thinking about ways to be able to work with universities and academia to be able to have a workforce that is prepared to be able to take on some of these challenges. As reimbursements change and this becomes a more sustainable area, I think we can make more progress on workforce training and dedication.”
