Starting

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Starting Managing a Home Care Practice
American Academy of Home Care Physicians 2003
Annual Scientific Meeting
JD Gammel, PhD May 15, 2003
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Conventional Wisdom

• House calls are a nice thing to do but
  physicians cannot make a living doing it full
  time

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A Prediction

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Home Care Practice is a Small Business

• Cash flow, cash flow, cash flow!
• Managing cash flow is critical
• Structure overhead appropriately
• Low overhead, invest in practitioners
• Manage very personal relationships
• Patient care givers
• Practitioners staff
• Referral clinicians
• Referral agencies

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Home Care Practice is a Small Business

• Success is in the details
• Scheduling
• Clinical information
• Administrative information
• Billing and collections

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Key Home Care Practice Success Factors

• Define your market
• Differentiated practice staffing
• Information management
• Time management
• Strategic relationships
• Patient care giver life management

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Convergence of Key Factors

• Shifting demographics
• High rate of growth in the over 85 population
• Societal expectations
• Quality of life expectations in aging
• Strong desire to remain and to die at home
• Provider skill sets
• Growth in geriatrics as a clinical specialty
• Integration and acceptance of physician extenders
• Technology
• Advances have made significant clinical
  technology portable

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The Opportunity

• The 3 million homebound patients who are
  Medicare beneficiaries are uniquely in need of
  medical services. This population most resembles
  the residents of nursing homes and chronic
  hospitals all have either physical or mental
  disabilities, many have both. They are all
  dependent on the care of others, and suffer a
  variety of chronic, interrelated medical,
  psychiatric and social problems. Those patients
  who require home visits are grouped at the
  furthest end of the spectrum in frailty and
  complexity. Homebound patients are always among
  the highest users of medical services, at the
  greatest risk for complications and
  hospitalization and the most ethically
  challenging. Their care involves the highest
  degree of coordination and the most telephone
  calls from other health care providers and family
  members.
• - American Medical Association,
• Report 9 of the Council on Scientific Affairs
• On-site Physician Home Health Care

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Long-Term Demographic Trends
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Boomers Affluence and Expectations

• Tomorrow
• Aging, but on their terms
• Accumulated wealth
• Large numbers

• Today
• Well-educated, dual career couples
• Managing careers, children and aging parents
• Significant expectations for service,
  convenience, quality and information
• Managing the care of their parents

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Changing Payor Dynamics

• Cost pressures are increasing
• Forcing payers to explore alternative approaches
  to care of all high-cost patients
• Home visits reimbursed by Medicare at reasonable
  rates
• Medicare managed care changes
• Risk-adjusted premiums for Medicare Plus Choice
  (MC) enrollees effective January 1, 2004

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There is plenty of Money in the System

• Sources of funding
• Medicare
• Medicaid
• Family wealth
• Community agencies foundations
• Must shift funding from facility based to home
  care based reimbursement
• Home care programs will take limited risk in
  the future

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The Potential Impact on Medicare

• Total Medicare spending reached 238 billion in
  fiscal 2001 and is expected to rise to 309
  billion by 2006.
• Of the 40 million people eligible for Medicare
  today, a conservative 5 percent, or 2 million
  people, fit a primary care home visit model.
• - Care Level Management web site

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Attracting Attention of the Market

• Hospital-based models
• Academic / teaching institutions
• Driven by mission
• Building their own and aligning with private
  practices
• Geriatric consults
• Geriatrician as PCP / Care Manager
• Private models
• Driven by the business opportunity and providers
  professional interests
• Range of approaches

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Hospital-Based Models

• Align home visit practice(s) with burgeoning
  geriatric programs and services
• Employed physicians
• Affiliated private practices
• Models
• Geriatric clinics with house calls
• Geriatric consult
• Geriatrician as PCP / Care Manager
• Payment
• Predominantly Medicare FFS supplemented with
  Medicaid, as attainable
• Limited Commercial and private pay

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Hospital-Based Model Examples

• University of Cincinnati
• Department of Family Medicine
• Washington Hospital Center
• WHC Medical House Call Program
• University of Arkansas for Medical Services
• Donald W. Reynolds Center Home Medical Visit
  Program

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Private Models

• Various types of organizations are in the market
• Practice within a group practice
• Independent new practice
• Corporation contracting with physicians/group
  practices/IPAs
• Models
• Range from Geriatric-only to luxury
• Payment
• Medicare fee for service
• Medicare risk (managed care)
• Commercial fee for service (considering risk)
• Private pay

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Private Model Examples

• Retail boutique
• Travel MD
• OnSiteDocs
• AM/PM House Calls
• Geriatric only
• Visiting Physician Association
• Mobile Medical Industries
• Payer focused
• Care Level Management

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House Call Program Case Examples

• Care Level Management
• Working with payers to manage care for the
  sickest and frailest of the elderly
• OnSiteDocs
• Retail/boutique practice providing on-site care
  for families, the elderly and corporations
• The Washington Hospital Center Medical House Call
  Program
• Hospital-based program that provides in-home
  primary care and coordinates specialty and
  facility-based services for the frail elderly

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Care Level Management

• Overview
• Primary focus on the frail, complex elderly of
  Southern California in MC products
• Awarded a Medicare demonstration project with
  PacifiCare MC
• Model Payer focused
• Geriatrician as PCP/Care Manager
• Profit from managing the risk for the 3 to 5 a
  MC patient base that accounts for 50 of costs

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Care Level Management

• Team approach
• Physicians
• NPs
• Allied health professionals
• Contracts, arranges coordinates continuum of
  care
• Home care
• Outpatient
• Inpatient
• SNF / Nursing home

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OnSiteDocs Bringing Care to the Patient

• Overview
• Puget Sound (Seattle-based) service area
• Contracts with regional medical groups to provide
  medical care on-site for families, employers and
  the elderly
• Traditional insurance remains in place
• Model Retail / boutique medicine
• Families and individuals pay an annual membership
  fee based on number of persons
• Employers pay for on-site medical services

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WHC Medical House Call Program

• Overview
• Concentrate on core geriatric, primary care
  medical services
• Focus on the sickest of the frail elderly
• Serve a well-defined, target-rich service area
• Limit building costs and infrastructure
• Embrace and invest in technology

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WHC Medical House Call Program

• Model
• Team approach collegial relationships
• Provide house calls and inpatient services
• One team provides care for up to 250 to 350
  active patients
• Generates approximately one inpatient admission
  per patient
• Leverages advancements in technology
• Creates awareness through marketing and community
  outreach

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WHC Medical House Call Program

• Team structure
• Two physicians (1.0 FTE total)
• Each physician performs in-home patient visits
  half-time
• Balance of work is inpatient and outpatient care,
  teaching and research
• Two Nurse Practitioners full time in-home
  patient visits
• Social Worker Support staff

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WHC Medical House Call Program

• Facility requirements
• No office-based exam rooms, waiting rooms or
  ancillary services
• Often, can function with less than 2,000 square
  feet of administrative office space
• Leverage available high-technology
• Use a house calls focused Electronic Medical
  Record (EMR)
• Carry the physicians modern black bag

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House Call Program Keys to Success
Do
Dont

• Secure physician leadership
• Invest in education and careful planning
• Establish provider roles
• Define the services and service area
• Invest in and embrace technology

• Expand beyond the core patient population
• Create large, ill-defined service areas
• Neglect to build a team environment
• Focus on quantity of staff, but rather quality
• Create unnecessary infrastructure

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Summary

• Market opportunity exists for house calls
• Demographics, economics, technology and societal
  expectations have converged to create the
  opportunity
• Responses to the opportunity are diverse
• And there is also great promise
• Patient-centered, site-based care models suggests
  an immense potential to reduce costs, improve
  quality of care / life and generate desirable
  margins which will fuel house call program growth
  over the next 5 -10 years

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904-261-2605 jdgammel_at_bellsouth.net 1875 Ocean
Village Drive Amelia Island, FL 32034