Doing More and Saving More with Primary in Home Care

In this week’s episode of Tuning In to the C-Suite podcast, MHE Associate Editor Briana Contreras interviewed VillageMD’s Senior Medical Director of Village Medical at Home, Dr. Tom Cornwell. Dr. Cornwell discussed the main benefits of primary care at home, which includes the benefit of cost savings for patients, maintaining control of hospital readmissions and others. Dr. Cornwell also noted what has changed in the industry of at-home care and if there has been interest from payers like insurance companies and medicare in the service.

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Below is a brief Q&A of the interview with Cornwell which has been edited for length and clarity.

Q: What are some of the benefits of primary care at home? Whether that be financial benefits just as much as others.

A: Just in terms of home based primary care, what is the modern day house call, I say that most of it is high-touch quality, high-touch primary care. But there is an amazing high-tech capability now where I can literally on the same day, get x rays, ultrasounds on my patients in the home. I can draw any blood test I need in the home, and you have to spin down the blood within a certain amount of time. We have centrifuges in the car that plug into the lighter that we can spin blood down between patients. While while it is largely high-touch, just quality primary care, I can actually do more in the home than most primary care doctors can do in their office.

This quality care has been shown because there's this concentration of healthcare costs in the population where 5% of the Medicare population consumes 50% of all the costs. But even more amazing is the costliest 1%, consumes 22.5% of all the costs and an average cost of about $112,000 per patient. A lot of these patients, not all, but a lot of them are because they're homebound with multiple chronic diseases. Their only recourse, because they're homebound is when they get sick - whether it be severe or something little - their only recourse is to go to an expensive hospital, which for the frail elders is not only costly, but it's not the best primary care. So instead of having them go to a hospital for their primary care, we bring primary care to them.

Q: How can at-home care keep hospital readmissions down and can it keep admissions down now that more COVID-19 cases are rising in the country?

A: There was already a dramatic increase going on in home-based primary care before COVID. But COVID has really accelerated it. For a couple of reasons, hospitals were full. We wanted to keep patients at home as much as possible, but patients weren't excited about going to hospitals that had all these COVID patients in them. Medicare really quickly answered the call in terms of supporting telehealth. However, they also allow things like starting oxygen right away on COVID patients in the home to try to help them get over the virus without having to go to the hospital.

The most effective treatment is called monoclonal antibodies for COVID-19, which we're actually starting to give that treatment, it's a one time infusion. We're starting to give that treatment in the home, currently, just in our Houston market. But again, it just shows the innovation and the value of home care.

So your listeners are not confused, VillageMD is one of the largest primary care networks in the country. It started with only 14 family doctors or primary care doctors in Houston in 2013. We're now up to 3,000. Currently, only about 30 of those 3,000 are at home providers. So we are definitely in the expansion mode. We're mostly a typical office-based primary care program. We also do significant telehealth, but then we also have this home-based primary care component. So we can really have the entire continuum of primary care to do the right care in the right place at the right time.

Q: What are some other things changing in the industry of at-home care? For example, can you explain the John Hopkins capable program?

A: I have been doing this for 28 years, and most of those years under fee for service, this was really a struggle, because it made no economic sense. You just couldn't do the same number of patients in a day as you're traveling. Well, now, because there's these new Value-Based Payment Models where you want to reduce cost, we've actually seen this in this home-based primary care field. Over the past three years, about $3 billion of investment, venture capital investment, private equity coming into this space to support organizations that are either exclusively home-based primary care, or have a significant component of home-based primary care. That investment coming in that has just markedly increased health costs in this country has been a big change.

The technology that I talked about, even in in some of our markets, we have these scales that people stand on and there's actually cellular technology in them that their weight is automatically sent into our electronic medical record. Then there's parameters. This is for mostly heart failure patients, that if they gain a certain amount of weight in a day or certain on in a week, we get alerted. And again, this is that whole thing about trying to prevent hospitalization. The information you need to keep them out of the hospital when you need to increase their diuretics. That's another big thing changing is technology that's in the home, both diagnostic technology like I talked about, but also this remote patient monitoring of patients in the home.

As far as the capable program goes, there's just so much innovation. It's a program that sends an occupational therapist into the home for four to six visits over four months. The patients need a criteria, they need to be low-income, they need to have multiple chronic problems, and they need to have functional impairments. The Occupational Therapist makes their home safer. The nurse helps them engage with their multiple chronic problems and help with their weight, help them with their sodium intake for the heart failure, help them to control their diabetes. What is magical about the program, after the second occupational therapy visit, we bring in a handy worker and the patient and the Occupational Therapist put together a work order.

We pay up to $1,600 for the handy worker to put in, grab bars, raise toilet seats, ramps, smoke detectors, air conditioners, if they don't have one in our Georgia, Houston and Arizona market. You can imagine what a $300 air conditioner might do for an 85 year old patient's health. How amazing is that? That healthcare is giving someone an air conditioner so they don't get dehydrated in their home. It really is just transformative healthcare, where again, we are given a certain amount of money to care for them. We can be so innovative in that care, and where the revenue comes from is keeping them out of the hospital, which no one wants to be.

Q: Have you seen interest from payers such as insurance companies or Medicare in the service?

A: Absolutely. Because insurers have to pay for care, they desire care to be better and less costly so they don't have to pay for it. Even Humana just recently announced a desire to get more into this area. United Health has a home based primary care program called Prospero, there's actually new plans that have been created like devoted, which is exclusively like home based primary care, and they really support home based primary care. And it's even amazing the people that are involved like for devoted former Senator Bill Frist is on their board, former Health and Human Secretary Kathleen Sebelius is on their board. It really is amazing, the caliber of people that are getting involved in this as well as the financial support from both payers, and investors in terms of spreading this in the country.

Q: Anything else you'd like to share?

A: Our mission is to improve the quality of homebound patients and their caregivers while reducing healthcare costs by enabling them to remain at home and avoid hospitals and nursing homes. The one thing we haven't talked about is quality end of life care, which is a huge part of what we do. In my previous practice, about 20% to 25% of my patients pass away a year. Seventy-five percent over 4,000 patients who have passed away, 75% have passed away at home when that is what they wanted, compared to only 30% nationally.

And again, this is not just fulfilling their wishes to be at home surrounded by loved ones. There are enormous cost savings 25% of all medical costs occur in people's last year of life. And it's because 29% of patients are in the ICU within 30 days of death, which you know, you know, when are we know our time is coming? How many of us would truly want to be you know, on breathing machines hooked up to tubes. And so it's just another amazing part of home based primary care. As the as the incredible palliative care and end of life care. It gives, you know, these patients that you know are at the you know, closer to the end of life.