By Christopher Guadagnino, Ph.D..
Louis C. DeMaria Jr., M.D., is a medical director at Independence Blue Cross in Philadelphia.
PND: Can you give a brief description of your physician home visiting program?
LCD: The Care Level Management pilot program, which we call the Physician In-Home Visiting Program, has been initiated to improve quality and access to care for frail patients enrolled in our Medicare Advantage program, Keystone 65. Independence Blue Cross identified the need to provide these very frail members care for relatively urgent problems that could be delivered and managed in the home. The patients are all Keystone 65 members who have been in the hospital two or more times in the previous 12 months and have two or more co-morbidities that are chronic in nature. Many of these patients have mobility problems and most of them are home-bound. Letters are sent to individuals who are pre-selected for enrollment, and to the member’s physician. A phone call is made to the member’s home in order to secure permission for a home visit assessment, at which the personal visiting physician evaluates the member’s medical, psycho/social and functional problems to develop a care plan that will be shared with, and a complement to, the primary care physician’s plan.
PND: How are the home visiting physicians selected?
LCD: IBC developed a collaboration with Care Level Management (CLM), a provider company out of California that recruits, trains and pays physicians exclusively to provide home care to frail elderly patients. These physicians live in and around the Philadelphia market and have been approved by our credentialing processes. They are all full-time employees of CLM and have no other office or hospital practice.
PND: How large is the program?
LCD: This is a pilot program that started in Oct. 2006 and will run for 18 months, with five physicians who are managing 500 enrollees. That ratio was developed based on experience that CLM has had in six other markets over the last six years. A physician does about seven or eight visits per day, and with five doctors that works out to a caseload of about 80 to 100 patients per doctor. Visits are made, on average, about once a month. Patients can be seen off-hours during evenings, early in the morning, on weekends. CLM has been in existence for six years and has at least six other plans around the country with whom they have contracts that are beyond the pilot stage. They also have 15,000 patients from traditional Medicare enrolled in a CMS demonstration project. I’m not aware of this type of project being in place in any other part of Pennsylvania.
PND: What is the relationship between CLM’s visiting physician and the patient’s primary care physician?
LCD: That relationship is really crucial. While the visiting physician is still in the patient’s home, a call is made to the primary care physician or the office manager to establish in what way the primary care physician wants CLM to contact them, e.g., by fax, direct phone call, e-mail. They all carry PDAs and are connected electronically to their base computer. The key component to the whole program is to have direct communication with the patient’s primary care physician so that the two care plans can be integrated and consistent with the primary care physician’s overall goals.
PND: Have you consulted with area physicians about their attitudes and concerns about this program?
LCD: Absolutely. We held a number of orientation sessions with physicians whose patients had been pre-selected, and we’ve had several one-on-one discussions with primary care physicians. Initially, you might imagine there would be some skepticism and concern over whether the visiting doctor was going to take over the care, and about whether the patient would be “lost” to CLM. The primary care physicians, after they understand the program, have contact with the visiting physician, and have experience with these urgent housecalls that occur in the evening and on weekends, have said things like, “The visiting physician is my eyes and ears in the home so that I can provide the best care possible to my patients.”
Take, for example, an individual living at home who has a number of chronic diseases. It’s 3:00 on a Friday afternoon and the primary caregiver is a daughter who is at work. When a problem develops, such as a fever or cellulitis, and this individual may be a diabetic, there is a cascade of events that has to occur in order for that individual to get seen. The daughter has to leave work, pick up her mother, probably shower her first, call the physician’s office. By the time all of that is arranged, office hours have probably ended, so the doctor says to the daughter, “Take your mother to the emergency department.” What this program does is short-circuit all of that. It allows the patient to remain at home. The database is available to the visiting physician. The primary care physician knows and has had contact with the visiting physician in the past. There is a call between the two of them late Friday afternoon and the primary care physician is told, “There is a fever and a red swollen leg. I’d like to start some oral antibiotics, see the patient again tomorrow, and check back with you on Monday – is that okay?”
PND: What would the reimbursement impacts of this program be for the primary care physician?
LCD: Patients are members of our Medicare HMO, and the capitation payments to the primary care physicians do not change. CLM’s visiting physicians have been educated as to our Practice Quality Assessment Scores (PQAS) – which are used to assess individual primary care practices based on utilization, office review of records and preventive health issues. The visiting physician makes sure the patient gets a flu shot, and other preventive health measures – in effect, helping the primary care physician with his or her PQAS, which for higher scores offers a bonus on top of the capitation payments.
PND: What are the relative advantages of having a visiting physician, rather than a visiting nurse, which is the traditional home visit model?
LCD: If a visiting nurse goes to see the patient and a problem is identified, there is always a delay built in to service at the point of care. A call has to be made to the primary care physician, and the usual response is to send the patient to the ER or to the office. Here, with a physician in place, you’ve got direct, doctor-to-doctor communication about the assessment, the physical exam, any laboratory data that may be needed – such as a glucose check, and the therapy is started immediately. It could be oxygen therapy. It could be intravenous medicines, some of which the visiting physicians carry around in their doctor’s bag. It could be bringing in an infusion service to provide IV antibiotics. For all of those, quality and access to care is improved and care occurs outside of settings such as the emergency department or the hospital. CLM says they can cut costs and increase quality and access to care for very frail members, including decreasing emergency room and hospital visits by half, sometimes more. We’re piloting the program to see how they function in our market.
PND: What is the patient participation level?
LCD: About 15 to 20 percent of pre-selected patients elect to participate. There are many reasons for this. Some people who we identify as being potential enrollees have died, some are living in nursing homes, some are in hospice care, some have changed health plans, some have chronic dialysis for which there is another program. If the member or their caregiver says they are not interested, we leave it right there.
PND: How are you monitoring the success of the program?
LCD: The study has been carefully structured by our actuary staff and, at the end of the program, the analysis will tell us whether it has been meeting the goals that we’ve set, including access to care, quality of care, patient satisfaction and cost. Results of our analysis won’t be available until about a year from now. The big question would be whether the program could be part of the normal benefit package for the Medicare Advantage program, and then perhaps expand to commercial lines, as well.