CMMI Independence at Home Program Falling Short After 8 Years
By Tiffany Ferguson, LMSW, CMAC, ACM
In late April the Center for Medicare & Medicaid Innovation Center (CMMI) released the evaluation of their Year 8 Independence at Home (IAH) demonstration. IAH is a Congressionally mandated initiative that seeks to evaluate the efficacy of incentivizing home-based primary care, reducing healthcare spending, and enhancing the quality of care for high-cost, high-need Medicare beneficiaries. This evaluation has provided valuable insights into the impact of such interventions, particularly in the context of the COVID-19 pandemic.
The IAH initiative commenced in 2012 with 18 participating practices, aimed at testing whether payment incentives could drive improvements in healthcare outcomes. Over subsequent years, the number of participating practices decreased, with only seven practices remaining by Year 8, amid the challenges posed by the pandemic for in-home services.
Some of the decline in participating primary care clinics is attributed to the program’s strict requirements, such as being available for primary care home visits at all hours, pending patient need, and the requirement to achieve success in cost reduction at least once in three consecutive years. The beneficiary requirements include that Medicare Fee-for-Service (FFS) patients have at least two chronic conditions, require assistance with at least two activities of daily living, and have been hospitalized and received acute or subacute rehabilitation services in the 12 months prior to program enrollment. Beneficiaries must also not be in any long-term care or hospice program at the time of enrollment in the demonstration.
The evaluation focused on assessing the effects of IAH on total Medicare spending per beneficiary per month (PBPM) and other relevant outcomes, such as the number of ambulatory visits compared to acute-care services the members received during the demonstration period. In Year 8, although there was a potential reduction in total Medicare spending, it was not statistically significant. Notably, the incentive payments made to IAH practices exceeded the estimated spending reduction, raising questions about the cost-effectiveness of the program.
The report noted that while IAH beneficiaries experienced 16 percent more ambulatory visits compared to their counterparts, primary care remained the central service to their healthcare delivery needs. The breakdown of results was mixed: although inpatient spending was down, hospital admissions increased in Year 8, as did readmissions.
The findings suggest that while the IAH initiative may seem theoretically appropriate to enhance the patient-PCP relationship, the sole mechanism of home-based services did not yield significant results (and likely was near-impossible during the pandemic). In addition, this is likely difficult to scale, given the already known shortage of primary care physicians and the efficiencies that telemedicine can provide, which are outside model expectations.
Additionally, the role of extenders to support home-based services such as chronic care management and community health workers may be better-suited to address in-home care for patients with chronic conditions and in need of home assistance than pulling primary care providers out of the clinic for home-based services.
In conclusion, this model makes splitting the value-based and FFS payment structures difficult, as program design was incentivizing services on top of a FFS reimbursement structure, rather than a replacement via other capitation or value-based payment methodologies.