Care management programs of all stripes have struggled to demonstrate improved cost and health outcomes. A study covered in Health Affairs examined whether doing home visits for Medicare patients can reduce overall utilization and costs. (HA Article) The program being studied is run by United HealthGroup for its Medicare Advantage members. Physicians or nurse practitioners make an annual in-home visit to each plan member to make a full evaluation of health problems, including a physical exam, a medication review, identification of health risks and member education. At the end of the visit recommendations are made for the member and his or her primary care physician regarding follow-up. About 46% of visited members get at least one referral stemming from the visit, with 26% being for medication management. Primary endpoints for the study were number of primary care visits, specialty care visits, hospital admissions and ER visits in the year following the home assessment. Comparisons were made between all patients who got the visit, complex care patients who did, a FFS group, an MA group that did not get the intervention and a pre and post comparison for a group that was evaluated in the home. 93% of the complex patients and 46% of the other MA members agreed to receive an in-home assessment. Patients who got the intervention had fewer hospitalizations in the following year, with the complex care patients showing the largest reduction. They also had fewer nursing home admissions. The effect on ER visits was somewhat mixed, with a lowering in some subgroups. Outpatient visits, particularly to specialists, increased.
Unfortunately, one of the primary motivators of home visit programs such as the one which was the subject of this study is that they can generate extensive lists of diagnoses which then raise the patient’s risk score for purposes of reimbursement to the Medicare Advantage plan. CMS has continually adjusted reimbursement downward to counteract the effect of “excessive” diagnosis identification in the Medicare Advantage arm of the program compared to the FFS arm. Last year it suggested it might not accept diagnoses which came from some or all home assessments. And it might decide that the current method of risk adjustment is just too subject to being gamed and needs to be fundamentally changed. So while home visits, particularly by actual clinicians, could well be a worthy method of keeping patients in better health, it would be nice if the health plans would do it for that reason rather than just being motivated by getting paid more.