Planning and Preparation
As we enter the new year, many of us focus on planning: resolutions, goals, vacations, etc. When we don’t plan, we simply react to what happens to and around us. This inefficient way of interacting with the world can drain our financial and emotional resources, while often yielding results below the standard set when planning occurs.
The same can be said for value-based care (VBC). Planning and preparation are essential to success in VBC. This month’s newsletter highlights some areas of planning for our new year.
As a foundational piece, we will look at Advanced Care Planning. This valuable tool often gets overlooked as simply something to do when a person has cancer or end-stage heart failure. We’ll see how planning, and even the regular discussion around planning can have a huge impact on patient well-being and VBC revenue.
Our innovator this month continues the theme from last with care at home as we look at Hospital at Home. The types of services available in the home today are light-years beyond what we used to do in the home. As we’ll see, though, planning and preparation are keys to the success in Hospital at Home. This topic gains even more importance as sites of service payment will likely be further debated in Congress in 2024. Additionally, we’ve seen in the news lately about the increased investment payers like CVS-Aetna and Humana are making in care at home with WellBe and CenterWell, respectively.
Thanks for joining the new year with us at The Business of Primary Care, and let’s get on with planning!
Tried & True
Successful performance in value-based care (VBC) requires planning and preparation to perform on that planning. Innovations, like care at home, don’t just happen organically (as you will read in this month’s innovation article). Planning is required so all are aligned on expectations, processes, and needs.
Another area of VBC that follows this path of planning and preparation is our foundational topic this month, the oft-forgotten cousin of the Annual Wellness Visit - Advanced Care Planning (ACP).
ACP is a face-to-face service (including telemedicine) where a patient and their physician discuss the patient’s health care wishes should they become unable to make decisions about their care. Things like advance directives (AD) and Health Care Proxies are discussed. [You can generally find ADs on your State attorney generals’ office website.]
Medicare pays for ACP as either an add-on element of a patient’s AWV (with no added copay for the patient) or as a separate Medicare Part B medically necessary service when there’s been a change in patient status (patient copays apply).
From a fee-for-service (FFS) perspective, the activity adds reimbursement revenue for the physician. When documented properly as part of the AWV and more than 15 minutes is spent on the task by the physician and/or office staff, ACP adds $85 to the reimbursement of the AWV service with no added copay by the patient.
Because patients also benefit greatly from advance care planning with better experiences and improved outcomes and lower medical expenses, the intentional addition of ACP to a practice is a great starting point when transitioning a practice from FFS to VBC. While physician compensation is gradually moved from production to value incentives (more to come on this topic in future newsletters), the ACP offers an avenue of greater production while setting the practice up for VBC success.
The palliative care literature has long touted the improvements to both patient experience as well as improved quality of life outcomes when ACP is utilized. Let’s look at the medical expense benefit.
A 2018 study by William Bond MD MS, et al looked at the impact of ACP on medical expense.1 They found that ACP both increases documentation of advanced directives and was associated with a reduction in overall costs of $9,500 per patient per annum when ACP was performed in the last 12 years of life. The cost reduction was driven primarily by a decrease in inpatient utilization.
So, if you knew who was going to die in the next 12 months, you could do ACP only on those people, and have potential substantial savings for your Medicare patients in a risk contract.
If it were only that easy. Well, in a way, it is.
In an article on ACP last year, I did the math to determine an expected annual death rate for a typical Medicare ACO population based on CDC statistics. About 5% of a typical Medicare cohort will die in the next 12 months.
Given this information, especially given my propensity toward risk stratification, the temptation is to identify patients more at risk of death in the next 12 months and focus solely on them. However, many people die unexpectedly over a 12-month period, leading to missed opportunities.
The good news is that the low cost added by doing an annual ACP on every patient is far eclipsed by the savings generated associated with appropriately doing an ACP. Your ROI would be higher if you could accurately predict mortality in the next 12 months through fine-tuned risk stratification parameters based on things other than age, like presence of certain chronic conditions like diabetes or heart failure, or new conditions like cancers with short overall survival rates. However, it would decrease overall savings revenue potential, and, more importantly, miss the opportunity to engage patients in their care in a way proven to improve their experience and quality of life.
Therefore, there is a case to be made for having an advanced care planning discussion with every patient, every year.
Consider these benefits of annual ACP:
Routine, annual discussion about end-of-life issues will make physicians and providers more comfortable with the topic.
Routine, annual discussion about end-of-life issues will make patients and families more comfortable with the topic, and, therefore, make these discussions more fruitful.
It can easily become a part of the AWV, which has multiple other benefits.
Everyone has some risk of death in the next 12 months, so setting the foundation for planning is important for all.
A potential ROI of around 5 to 1 makes the financial case for universal ACP for patients over age 65 from a cost and savings perspective.2
The rate-limiting steps to reaching these results is the comfort and intentionality to have ACP discussions, and an easy way to document and save the data in the medical records. All of these can be overcome with the added reimbursement of ACP to cover the added work to staff, and the planning and preparation to make it happen.
Bond, MD, MS, William F., et al (2018) “Advance Care Planning in an Accountable Care Organization Is Associated with Increased Advanced Directive Documentation and Decreased Costs.” JOURNAL OF PALLIATIVE MEDICINE, Volume 21, Number 4, 2018
In a full-risk model, where revenue from services offsets the savings revenue in medical expense ratio, if ACP is properly performed:
1000 patients at $85 per documented ACP = $85,000 spend and revenue
Fifty of those patients would be in their last 12 months of life
At $9,500 potentially saved for those 50 patients, the exercise of discussing and documenting end of life plans would potentially save $475,000
ROI = 5.6 to 1 with a projected net savings of $390,000 per 1,000 patients (excluding the E&M revenue from ACP reimbursement).
With an average ACO size of 23,000 members (based on CMS ACO performance data), that’s $8.97 million in projected savings per ACO per year.
Innovation
We will carry on from last month’s newsletter the theme of care in the home as an innovative tool in value-based care (VBC). By no stretch of the imagination is care at home a new thing, but it seems that only a cutting edge few have leveraged this activity to benefit their work in VBC. This month we will look at Hospital at Home.
Hospital care at home is usually thought of as something only big health systems have been testing out since the COVID pandemic. Certainly, they are the ones in the news, but others are engaging patients at home, as well. The good news is that these large health systems are recognizing the benefits of hospital care at home for appropriate patients.
Becker’s Hospital Review had a recent article entitled “Inside the Top 8 hospital at home programs (https://www.beckershospitalreview.com/innovation/inside-the-top-8-hospital-at-home-programs.html, 12/7/2023). Systems like Atrium Health (North Carolina), Mass General Brigham, Mayo Clinic, and Kaiser Permanente all noted decreased readmissions, improved patient and family satisfaction (experience), decreased rehab and nursing home utilization, and decreased patient deconditioning / immobility. They all also noted a decrease in cost, with Mass General citing costs for care at home as one third less than in their hospital.
While many of these home-based programs saw their boom or birth caring for COVID during the pandemic, they are now mostly treating infections such as cellulitis and pyelonephritis, and patients with exacerbated chronic conditions, such as heart failure, COPD and diabetes.
The more savvy reader may note that many of the health system names in that article were not from health systems known for their work in VBC. Colleen Hole, BSN, administrator of Atrium's hospital-at-home program is quoted as saying the primary motivation for the program was a capacity issue – a sentiment echoed by other facilities on the list. However, she goes on to say, "But as a clinician, I believe the highest value is to our patients who experience healthcare differently and better in their own environment."
These subjective statements by hospital at home providers amplify the positive objective findings of the initial outcomes of the Acute Hospital Care at Home Waiver program recently published by JAMA (JAMA Health Forum. 2023;4(11):e233667. doi:10.1001/jamahealthforum.2023.3667).
Interestingly, Mayo Clinic’s physician leading the care at home program states the most limiting factor in hospital care at home programs is logistics. That’s where this month’s featured innovator steps in.
I had a conversation with Anthony Wehbe, DO, the founder of SENA Health, a company specializing in the coordination of care at home, in particular, hospital at home. When asked why now, Dr. Wehbe said, “The rapid advancement of technology, coupled with its increasing affordability for healthcare entities, is propelling the evolution of patient care delivery. The evolving landscape of healthcare, a transformative blend of technology and a paradigm shift in our approach to healthcare consumption has empowered us to offer a myriad of services within the comfort of patients' homes.”
Anthony Wehbe
Founder of
SENA Health
Healing at home, hospital at home, and acute care in the home consulting services.
The services now available at home, enabled by technology, stretch far beyond what we used to be able to do in the home. Dr. Wehbe explains that these extend beyond routine medical care, encompassing a comprehensive spectrum of services akin to those typically provided on a general medical floor, including phlebotomy, imaging, durable medical equipment, nursing, physician consultations, vital signs monitoring, physical/occupational/respiratory/speech therapy, infusions, oxygen administration, and more.
What about the issue of logistics noted above? Dr. Wehbe says that nut can be cracked using the communication tools currently available with an emphasis on collaboration with a network of experts across various fields, ensuring streamlined communication, the delivery of high-quality care, and operational efficiency, including redundancy and feedback loops in communication plans. “Integrating user-friendly technology into workflow processes is paramount,” per Dr. Wehbe.
This attention to the detail of communication extends beyond the home and the hospital at home care team. The patient will eventually improve and need to transition back to their PCP for care. Regardless of the complexity of the care received, “Engaging, informing, and communicating with the PCP are crucial elements,” according to Dr. Wehbe, “with a planned and confirmed handoff of patient care upon completion of the home-based care episode.”
As is typical in VBC, handoffs and seamless transitions are part of the workflow to ensure success.
When coordinating the work of a diverse team of professionals into a home, both physically and virtually, ensuring expectations and education are essential. SENA Health serves as the convener and coordinator of services using a network of providers. This network must be vetted, and service level agreements (SLAs) encompassing infection control, communication, and reporting, are imperative. Dr. Wehbe adds, “Provider network education is equally critical, given the novelty of this care setting, necessitating the seamless incorporation of technology into individual workflows.”
Education doesn’t stop with the providers, though. According to Dr. Wehbe, ensuring patients and their families can proficiently use these tools and have adequate internet network availability at home is of utmost importance. As for communication with patients and families, it spans various modalities, including standard audio or video tools, texting, telemedicine services, or personal emergency response systems.
Like other hospital at home providers, SENA Health tracks the metrics discussed above, and is showing improved outcomes compared to in-hospital results for patient types appropriate to care in the home. Additionally, and perhaps more importantly, Dr. Wehbe notes that the home setting allows enhanced tracking of social determinants of health variables and social risks, enabling the care team to address root causes of diseases.
There are few things more effective in improving a patient’s health and well-being than eyes, ears, hands, and feet in the home, seeing and experiencing the circumstances impacting the patient’s ability to heal or stay healthy – food adequacy and appropriateness, fall risks, adequate housing, transportation, connectivity (both social and interpersonal), etc.
Big question: how does this get paid for? There have been challenges, but Dr. Wehbe notes it’s improving. The CMS hospital at home waiver, reimbursing health systems for hospital-level care in the home, has been a pivotal driver, with commercial payers following suit. Dr. Wehbe says, “some commercial payers adopt a fee schedule format to reimburse medical groups for non-hospital setting of acute care, marking a transformative shift in reducing overall care costs and enhancing patient-physician experiences.”
From a VBC perspective, forward-thinking providers in value-based contracts and ACOs should recognize the value of establishing acute care at home programs to curtail overall care costs. Collaboration with a health system or a convener of services (like SENA Health) can positively impact acute care spend as well as post-acute spend. These areas are some of the major drivers of medical expenses, so limiting their impact on cost increases at-risk dollars available at the end of the year.
Oh, and (most importantly) patients do better and feel better with care at home. Win-Win.