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    New financial model may provide future for home visits

    Monica Vandivort, MD, believed she had found her calling as a house call physician practicing in rural southeastern Arizona. She loved being out of the office and developing close bonds with patients. But when one of her Medicaid contractors ended its capitated payment program in late 2011, she found she could no longer make ends meet.

    “By the end of 2013, I was frustrated with the reimbursement structure,” says Vandivort, who previously had received a per-member-per-month stipend from Medicaid in addition to Medicare reimbursement for dually eligible homebound patients. “I was giving great care and keeping patients out of the hospital, but it was very hard under the fee-for-service model.”

    House calls have the potential to reduce healthcare costs among frail, elderly or otherwise homebound patients, according to Medicare data, but most physicians don’t provide them. Although home visits are reimbursable under Medicare, the standard fee-for-service rates usually don’t fully cover physicians’ expenses. 

    Such conditions make it almost impossible for physicians in solo or small practices to make house calls work from a revenue standpoint without extra fees. As a result, house calls are more common in concierge and direct-pay practices that rely on membership fees as their primary income. 

    Ramin Rafie, MD, of Southfield, Michigan, has conducted home visits for nearly a decade through his work with the Visiting Physicians Association, the nation’s largest house call medicine provider. He says it is “possible, but difficult” for smaller practices to conduct home visits, by identifying patients closer to the office to cut travel time and adding a non-physician provider to conduct the visit and share the workload.

    “If doctors in private practice want to do [house calls], they can, under the right circumstances”, Rafie says. “But they could also spin them into a concierge medicine model … as a way to make it more economically feasible.”

    Change may be coming. Medicare has been reporting positive results during the third year of its Independence at Home (IAH) home visits demonstration project, raising hopes that the home care incentive program will be extended to all physicians. First-year performance results showed savings of more than $25 million—$3,070 per beneficiary—with $11.7 million of that paid as shared savings to providers that met cost and quality targets.

    Medicare officials hope the program will make a dent in the high cost of caring for the sickest and frailest patients, who make up 5% of all beneficiaries but account for half of the agency’s spending. To qualify for incentive payments, participating practices must reduce costs while meeting certain quality measures, including fewer hospital readmissions within 30 days and provider follow-up within 48 hours of discharge.

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