K. Eric De Jonge, M.D.Medstar Washington Hospital Center

May 14, 2014

No Financial Conflicts of Interest

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Title: Effects of Home-Based Primary Care on Medicare Costs in High-Risk Elders

K. Eric De Jonge M.D. 1, Namirah Jamshed M.B.B.S.1, Daniel Gilden, MS 2, Joanna Kubisiak, MPH 2, Stephanie R. Bruce M.D. 1, George Taler M.D. 1

1 MedStar Washington Hospital Center (MWHC), Section of Geriatrics, Washington D.C.

2 JEN Associates, Cambridge, MA

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Hypothesis: ◦ Home-Based Primary Care (HBPC) reduces total

Medicare FFS costs

Problems:◦ Major selection bias for those who enter HBPC

Low function, severity of illness, terminal stage, SES◦ Control group challenges◦ Ethical barriers to RCT◦ Lack of full CMS cost and survival data

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2009◦ Define question What are Medicare FFS costs

and survival for similar HBPC and control populations?

◦ Found JEN Associates (Dan Gilden and team, www.jen.com)

◦ Funding to hire JEN, then buy CMS data ($75K)

◦ Case-control concurrent study (full CMS data)

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Apply for CMS Data- Many hoops, IRB, privacy 2004-2008 CMS Database

◦ 909 New HBPC Cases 722 Eligible Cases◦ 1,765,972 Medicare pts. 2161 Controls

Longitudinal picture -- Cases and Controls◦ Define major selection biases, incident dates◦ Match 3:1 by gender, age bands, race, SES, LTC status,

frailty, major chronic illnesses, cognitive impairment◦ Check Baseline utilization (prior 4 months)

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Home-Based PC team at MWHC

◦ 4 Geriatricians, 4 NPs, 4 SWs, 4 Coordinators, 1 LPN

◦ Intensive home-based 24/7 care, over time/setting

◦ Directly manage all primary and urgent care, specialists, social services, and hospital care

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Main Outcomes◦ Medicare costs, pattern of utilization, mortality

CMS Data- All Medicare files except Part D

Death events - SSA benefit records

Multivariate regression model with covariates◦ Major chronic diseases, baseline utilization◦ Premodel matching of patient characteristics

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Variable Cases (722) Controls (2161)

Female 76.7% 76.7%

Mean Age 83.7 years 82.0 years

African-American 90.2 90.3

Low SES (Medicare buy-in) 36.3 % 36.3%

Dementia 57.5% 57.4%

High JFI Frailty Index 37.0% 36.9%

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Outcome Cases- 722 Controls- 2161

P-value

Mean F/U period

23.3 months 24.2 months p=.18

Total Medicare Costs (FFS)

$44,455 $50,978 p= .01

Hospital Care $17,805 $22,096 p=.003

SNF Care $4,812 $6,098 p= .001

Home Health $6,579 $4,169 p= .001

Hospice $3,144 $1,505 P= .005

Other $7,962 $11,392 P= .001

Mortality 40% 36% HR=1.06, p=.44©AAHCM

Cases◦ 105% more generalist visits (p=.001)◦ 23% less specialist visits (p=.001)

Multivariate Regression Model

Cases Average $8,477 less per patient (2 years)

17% Lower total Medicare Costs (p=.003)

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A Home-Based Primary Care model reduced total Medicare costs by 17% for ill elders, with similar survival outcomes.

Such results argue for payment reform (e.g. IAH) to scale such teams across the U.S.

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Patients and Families in MWHC program

MWHC Geriatrics team, Bruce Leff

JEN Associates- Dan Gilden, Joanna Kubisiak

Deerbrook Charitable Trust

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