k. eric de jonge, m.d. medstar washington hospital center may 14, 2014 no financial conflicts of...
TRANSCRIPT
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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