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K. Eric De Jonge, M.D.Medstar Washington Hospital Center
May 14, 2014
No Financial Conflicts of Interest
©AAHCM
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
©AAHCM
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)
©AAHCM
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%
©AAHCM
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
©AAHCM
©AAHCM