Accountable Care Organizations Are Diving Head First Into Home-Based Care

Accountable care organizations (ACOs) have considerably increased their home-based care arsenals over recent years.

They’ve also diversified the types of home-based care they offer, and are finally finding ways for it to make economic sense in capitated models. That’s according to the Institute for Accountable Care (IAC), which conducted a wide-ranging study on ACOs and home-based care that was released Thursday.

Of all the home-based care programs started among ACOs, 50% were created from 2017-2019, compared to the only 26% created between 2014-2016 and 24% created in 2013 or earlier.

Furthermore, two-thirds of ACOs reported some sort of home-visit activity. A quarter of all ACOs had formal home-visit programs, another quarter provided occasional home visits and 17% were actively developing programs at the time of the study.

Source: Institute for Accountable Care

The study was conducted prior the public health emergency. Some ACOs had to scale back home-visit programs during over the last two years, but that was generally temporary.

“I think ACOs are growing more and more interested in home-based care and delivering it to their beneficiaries,” Rob Mechanic, the executive director for IAC and the study’s lead author, told Home Health Care News. “There’s been a lot of growth in the past three or four years. A lot of the programs are new. And they’re being implemented at a time when the Medicare program is shifting much quicker to mandatory risk models, so ACOs have more pressure to generate savings, not generate losses. That’s pushing them to look for more innovative care models.”

The IAC provides research, analytics, health policy analysis and performance improvement collaboratives for the ACO industry.

This is obviously not traditional home health care that ACOs are providing. Instead, it’s usually home-based primary care, home-based care coordination, transition to home, social needs care and hospital-level home care.

It’s generally provided by physicians, nurse practitioners, paramedics and community health workers, usually to people that “are medically and socially complex, who typically fall through the cracks of the health care system,” Mechanic said.

Source: Institute for Accountable Care

“When clinicians come into the home, they see things that they just don’t see in the office,” he said. “They see how the patient lives, they get a better sense of what other factors – beyond just the medical – are influencing their life and their health. It’s super patient-centric care. My take-home point would be that ACOs have gotten really interested in, and are continuing to or beginning to, deploy home-based care in a whole variety of contexts.”

The flip side to this is that the economics of home-based care for ACOs have always been hard.

Conducting home visits versus office visits for primary care, for instance, naturally take more time. It’s impossible to deliver the same volume of visits, and the corresponding reimbursement doesn’t account for that.

“They do get a higher rate for providing care in the home,” Mechanic said. “But it’s not enough to make up for all the travel time. And so the economics of it are tricky.”

To some extent, most providers still find the trade-off worth it – especially when these home-based care visits are generating savings.

In order to keep up the home-based momentum for ACOs, the IAC and Mechanic make a few policy recommendations:

– Expand home-visit waivers to the Medicare Shared Savings Program (MSSP) ACOs taking downside risk

– Expand the hospital-at-home waiver to independent medical groups

– Allow for payment for telehealth in conjunction with home-based primary care services on a permanent basis

“The research that we have shows that these programs are really effective in reducing unnecessary care, reducing hospitalizations and emergency visits and saving money for complex patients,” Mechanic said. “The problem is the economic model of shared savings programs. If your ACO doesn’t hit the thresholds to earn share savings, the program can save money, but the ACO doesn’t get rewarded for it.”

If Mechanic could choose only one recommendation to come to fruition, it would be the creation of a payment mechanism for ACO home visits when there’s downside risk involved.

“I would create a payment mechanism for home visits,” he said. “And the government’s protected if the provider is bearing significant downside risk. And so I think that they should move that back into the Medicare Shared Savings Program.”

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