“I didn’t choose it because I wanted to be involved in national politics and national health care activities. I saw it was the only way to solve the problem.” – Peter Boling
Medicare is a large, complex, and sometimes unyielding system that covers nearly 50 million Americans. It takes a special kind of person to see a better way to do things, prove that it’s better, and then take on that vast system to improve it for everybody.
Meet Peter Boling, MD.
He is interested in a lot of things. He majored in English. Then came science, anthropology at one point. “There wasn’t room on my shelves,” he says. He’s an energetic guy.
Boling is chair of geriatric medicine at Virginia Commonwealth University (VCU) Medical Center, an essential hospital and Richmond’s only academic medical center. It is the teaching hospital for VCU medical students. Boling is also a professor of internal medicine at VCU. Since 1984, he has been focused on building – and validating – the VCU House Calls program.
To understand Boling’s passion for this program and in-home care, imagine a common experience for geriatric patients.
An elderly female patient lives with her children and grandchildren. She has numerous health issues: diabetes, dementia, hearing and vision problems, heart disease. Her family “was starting to come apart at the seams,” Boling says. “She was having some behavioral issues and some other things that were making it difficult to care for her. They were ready to put her in a nursing home.” It was a costly, devastating solution that likely would not have improved the quality of her life.
By going into her home and gaining a better understanding of all of the issues involved in her care, Boling was able to change her care plan to meet her needs – including her medical and social services needs. And now, a year later, “she’s sitting there in her living room, happy as could be. They’re [all] happy … because here’s a three-generational family that’s committed to taking care of their grandma and now they’re able to,” he says.
So what if a doctor could show up at her door, administer her primary care, on a regular basis? And if she gets sick, provide intensive care at her home? Could her future be changed? Could she and her family have better options? These are the questions that started Boling’s quest – now more than 30 years in the making.
Focused on Primary Care
Boling attended medical school at the University of Rochester, which followed a unique curriculum called the biopsychosocial model of clinical care. “We were trained much more extensively in interviewing techniques and understanding the whole person,” he says, “as opposed to a series of organs and diseases.”
He went on to do his residency at VCU Medical Center, specializing in primary care – a less common choice among medical students at the time, he remembers. Just as he finished up in 1984, VCU leadership decided to invest in its primary care medical school curriculum and at the same time, focus on patients who were being left behind in primary care.
Boling landed a job that was part of this effort, spending half of his time teaching med students and the other half making house calls.
A strong primary care workforce is critical for an effective health care system. These doctors keep people healthier, saving the entire system money.
Patients Respond to House Calls
Traveling up and down the East Coast, Boling began his work by researching what few house calls programs already existed. He liked those that focused on continuity and comprehensive care – where patients saw the same nurses in their homes, in the clinic, wherever they needed care. With a base idea in mind, Boling set out to find his patients.
I looked at the [outpatient] clinic … at the people who were there on stretchers, and I would ask them if they would want to have somebody come see them at their home rather than coming to the clinic. Pretty much everybody said yes. After a little while, the waiting room was empty of stretchers. Then I started on wheelchairs, and the people using walkers and oxygen, and so on. Soon I had 75 charts… going around every afternoon making about five or six house calls.
Helen is a house calls patient. She’s 93 and lives alone in a retirement community. She’s in decent health but struggles with mobility – a tremendous challenge and a pain for most people her age. What happens when she comes down with pneumonia?
Boling describes the typical scenario when someone like Helen gets sick:
It’d take days to get organized to get somebody to help, arrange for transportation. Somebody would have to take time off from work to go with them. Then there was the matter of getting an appointment, [which is] usually brief, and the people seeing them knew nothing about their cases, and made silly recommendations for their home-based care. Because they really didn’t know their story, what they needed.
A person in Helen’s condition will often land in the hospital’s intensive care unit (ICU) – “She got really sick. I mean, she got really sick,” Boling says. Once in the hospital, geriatric patients are likely to stay for much longer, and they’re susceptible to complications like infections, delirium, and falling. It can be scary for the patient – especially one like Helen, who can’t hear or see well. It is also hard on the family and extremely costly for the hospital and health care system.
Instead, with help from the house calls team, Helen rode out pneumonia at home. The team administered IV antibiotics and collected specimens for lab work. Staying home was a calculated risk that she took, but it led ultimately to better care. She recovered completely, in her own environment, with her own food, and without all the jarring realities that come with a hospital stay. And then there’s the price tag. “She didn’t have the $20,000 hospital stay. She had about $1,500 worth of care in the home, and she’s all better.”
The Value Proposition
Medicare provides health insurance for the vast majority of elderly Americans, and it would have footed most, though not all, of Helen’s hospital bill. There are a couple of things to know about Medicare. First, it pays providers lower rates than private health insurance, and payments are often less than a provider’s costs. This means a hospital can lose money caring for Medicare patients. Second, traditional Medicare payments tend to reward volume of patients seen over quality of care delivered.
Medicare is the main insurer for patients of VCU House Calls, which was up and running by the end of 1984. Boling could see pretty quickly the value in caring for patients this way. “Once you go into a home, you know what the real story is right away,” he says. “We just need to find a way to pay for it. I would spend a lot of time on that.” One of the issues with house calls was that it was hard to make a living at it.
Boling found that Medicare was reimbursing physicians for house calls at a far lower rate than it paid for those same services provided in the hospital or a clinic. He knew that the services he provided in a patient’s home were at least as complex as those he would deliver in a hospital with more assistance – why was he paid less for them?
He did some digging and found others in the house call field coming up against the same barriers. Together, they discovered that Medicare didn’t really understand house calls. The payment system didn’t reflect how sick these patients were. They couldn’t account for a patient being anything more than mildly sick. There was just no billing code for it.
You might imagine that if an ailment can be treated with a house call, it isn’t “serious.” But the house calls team cares for patients with needs as serious and urgent as those seen by specialists in the ICU. This was the case Boling made as he went to bat for more of the Medicare pie.
We were arguing with radiologists and dermatologists and heart surgeons and ophthalmologists and other people and saying, “We’re taking care of very complicated, sick patients.” It's really almost just like the ICU sometimes except you don't have a nurse for every two patients and you don't have an arterial line and a monitor beeping and an oximetry device and X-ray at your shoulder and labs in the morning every day when you come to make rounds. You're just going there by yourself with your brain and your backpack. Whatever happens, happens.
They got the message across to the Medicare coding organization and “We ended up more than doubling the values associated with those codes, which was almost enough to get you to a viable model,” Boling says. What he means by “almost” is that you’d have to practice what Boling calls “rip and run”: working without a team and keeping appointments as brief and patients as numerous as possible, since payments are made per service – the volume-based system.
But this went against Boling’s core beliefs and his understanding that caring for the whole person, especially a very sick, complex person, takes time. Doing anything less, he says, “you leave the value proposition behind.”
Boling’s problem with the system wasn’t new. In fact, less than 10 years into Medicare’s existence, policymakers could see it needed flexibility and adaptability. As the main provider of health insurance for America’s elderly – a population that would eventually explode with aging baby boomers – Medicare had to be responsive to change.
“There are certain parts of patient care that don’t make any money,” Boling says. “But when targeted and done well, these things ultimately improve the care [patients] get and make them healthier – and ultimately, it does save everyone money. But it only works if the payment system and the clinical system have the same values.”
In 1972, Congress gave the agency that runs Medicare, the Centers for Medicare & Medicaid Services (CMS), the authority to conduct demonstration programs and experiment with alternative forms of payment and service delivery. This became an avenue for quality-based change.
In 1999, the Institute of Medicine issued To Err Is Human, which estimated that preventable medical errors claim 44,000 to 98,000 lives each year. This news generated a flood of responses, including creation of the National Quality Forum to help develop nationwide patient safety standards. CMS also began to conduct pilot programs to help hospitals evaluate and improve patient safety practices.
So, theoretically, the system can evolve. But the Medicare payment system is based in law, so to change it, you have to change the law. It can be done, but it often requires painstaking, incremental progress. It requires timing. It requires knowing how to open doors in Washington and finding a lawmaker willing to listen to your ideas while also thinking about every other issue in America.
Boling and his peers knew they had a good clinical model. “There was no doubt in any of our minds that this was a better way to deliver health care for this group of patients. It was so unequivocally clear,” he says. Since the move toward quality improvement, “patient-centered care” has become a buzzword in the health care industry. But as Boling says, “It’s not patient-centered to take a sick, frail, miserable, painful older person, drag him out of bed, put him in an ambulance, haul him down to the doctor’s office for 20 minutes, and haul him back home. Sometimes, it takes two or three days to get over [that]. It’s an upside down world for these patients.”
Plus, when patients with multiple chronic conditions have to go to the hospital, it costs a lot of money. They generally have to stay longer and use more of the hospital’s resources. The hospital never will recoup the full cost of their care from Medicare. By demonstrating that regular house calls could help keep these complicated, costly patients out of the hospital – or, at least, shorten their stays once there – Boling and his group knew they could save money for everyone and take better care of these people. Better care, lower costs – the ultimate goal.
The Moving Vehicle
So, with a model in hand and lobbying help in Washington to build congressional support, they wrote a draft amendment. Now they needed a legislative vehicle: a bill actively moving through Congress that could carry their amendment. But this can be a challenge, as bills often stall and remain untouched for long periods.
In 2008, 14 years after VCU House Calls began, Boling and his group found their vehicle: the Affordable Care Act (ACA). Most active bills attract amendments. Lawmakers can use amendments as bargaining chips to move a bill through Congress, and the ACA is notable for the considerable number of amendments attached to it.
The amendments Boling helped write – one for the House, one for the Senate – moved fairly smoothly through with bipartisan support. The Senate amendment was actually voted in unanimously. The amendments were also supported by a broad coalition of stakeholders, including America’s Essential Hospitals, which may have helped push them along. “We made our way through to the ACA, Section 3024. That’s how Independence at Home came to be,” Boling says.
Independence at Home
The Independence at Home demonstration project was passed in the ACA as part of a larger effort to propel the idea of pay-for-performance in health care forward. The ACA mandated that CMS create an innovation center to foster demonstration programs and other initiatives as a part of health reform. Independence at Home was included as part of the CMS Innovation Center’s work.
The three-year pilot, which began June 2012, includes 17 physician practices that can serve up to 10,000 people enrolled in Medicare. The practices provide personalized, home-based care to people who have complex, chronic conditions and limited function or mobility. Practices that succeed in meeting quality measures while generating Medicare savings will have an opportunity to share in those savings.
VCU House Calls is part of the project. It’s in a group of practices called the Mid-Atlantic Consortium.
In June 2015, CMS released the results from the first year of Independence at Home. The practices saved more than $25 million while delivering quality care. The Mid-Atlantic Consortium reduced the cost of health care for their patients by 20 to 30 percent. “We met all the quality measures, we had very high patient satisfaction, and we substantially reduced total health care costs in a group of people with very serious health problems,” Boling said in response. “These results are externally validated evidence that delivering the right care – in the right place, at the right time, and with the right team – makes a difference.”
As of now, it seems that Independence at Home is on the right track. In July of 2015, Congress voted to extend the demonstration from three to five years. And maybe one day it will be more than a demonstration. But that’s not where the story ends. House calls is destined for more, as it is just part of a whole.GO TO NEXT STORY