At-home primary care demo hasn’t saved Medicare money, study finds

A demonstration aimed at offering Medicare beneficiaries better primary care services at home and cutting costs hasn’t led to program savings or substantially improved care, an independent analysis found.

The sixth year of the demonstration known as Independence at Home reduced total Medicare expenditures by an estimated 1% per beneficiary per month in 2019, according to research published by the consulting firm Mathematica last week. Earlier Mathematica evaluations of the program through its fourth year found that savings weren’t statistically significant. Though year five in 2018 did result in lower costs, those were driven by a single site that left the program after that year.

The incentive paid to participating providers didn’t impact hospital admissions, emergency department visits, potentially avoidable hospital use, mortality rate or the probability of entering institutional long-term care in 2019, Mathematica found. Many practices also didn’t meet the standards for all six quality measures connected to payment.

“The overall volume of signals in the data is telling us that this payment incentive is really, unfortunately, at this point not appearing to achieve the desired impacts,” said Laura Kimmey, principal researcher at Mathematica and director of the evaluation.

While the Centers for Medicare and Medicaid Services has reported savings in each of the demonstration’s six years, Mathematica uses a different method that focuses on the payment incentive’s effectiveness.

Congress created the Independence at Home demonstration through the Affordable Care Act and extended it in 2015 and 2018. The demonstration currently runs through 2023. In contrast to other demonstration models, Congress has the most say over what happens to the program in the future, Kimmey said.

Mathematica also didn’t find evidence that home-based primary care resulted in lower Medicare or Medicaid costs for dual-eligible beneficiaries. These patients had lower institutional care expenditures but expenditures for home-based services rose.

While Medicare enrollees getting home-based primary care in last three months of life did have lower expenditures, costs were actually higher overall in the last six and 12 months of life. But increases in home-based care costs were balanced by decreases in nursing home expenses.

Patient interest in home care is growing. Medicare enrollees interviewed for the Mathematica study reported they were highly satisfied with home-based primary care, and many preferred it to office visits.

“There’s still a lot to be learned about who might benefit the most from this particular type of care that some some patients and some caregivers do really like,” Kimmey said.

The demonstration applies to a narrow set of beneficiaries, meaning Mathematica couldn’t draw conclusions about how a payment incentive would impact other beneficiaries, or patients served by providers not participating in the demonstration—especially since five of the 12 practices in the demonstration in 2019 were operated by the same corporation.

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The National Association for Home Care and Hospice, which supports Independence at Home, urges policymakers not to abandon the demonstration, Bill Dombi, the organization’s president, wrote in an email.

“We believe that [Independence at Home] warrants further analysis before any hasty actions are undertaken. Even if it may not show Medicare savings, it still provides care management value to patients,” Dombi wrote.

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