Abstract
BackgroundIn the United States, home-based primary care (HBPC) is increasingly proposed as a means of enabling frail elders to remain at home for as long as possible, while still receiving needed medical care. However, there are relatively few studies of either the medical outcome effects or cost benefits of HBPC. In this paper, we examine medical cost and mortality outcomes for enrollees in the HBPC program offered by Spectrum Health/Priority Health (SH/PH), a not-for-profit integrated health care/health insurance system located in Grand Rapids, MI, USA.MethodsWe perform a concurrent matched cohort study. SH/PH HBPC enrollees during 2012–2014 are matched for prior costs, age, sex and comorbidities against controls selected from unenrolled insurance plan members. Twelve and twenty four-month medical costs are compared between HBPC participants and matched controls, overall and conditional on mortality status. Mortality rates of HBPC participants are studied on their own and in comparison to controls.ResultsAt 12 and 24 months, in comparison to matched controls HBPC participants show higher ($2933) and lower ($8620) costs respectively. Relative costs and savings of HBPC participants are a function of short term increased costs upon entry into the program (enrollees who survive the first year cost $5866 more than controls); substantial savings at end-of-life (approximately $37,037 in savings relative to controls are realized); and the overall mortality of HBPC participants (mean residual lifespan is 37.75 months from the time of enrollment). We project the present value of lifetime medical cost savings due to enrollment in the HBPC program to be at least $14,336.ConclusionsThe SH/PC HBPC program reduces healthcare costs while enabling frail elders to remain at home. Reduction in costs is obtained at end-of-life and is offset with a smaller initial increase in costs upon enrollment.
Highlights
In the United States, home-based primary care (HBPC) is increasingly proposed as a means of enabling frail elders to remain at home for as long as possible, while still receiving needed medical care
In one early study of the Veterans Affairs Home-based Primary Care program [7], it was suggested in a comparison of pre- and post-enrollment utilization patterns that enrollment in HBPC reduced the yearly rate of hospital and emergency department (ED) admissions by 84% and 48% respectively, with commensurate medical cost savings of approximately $10,000 per enrollee
We begin our analysis by substantially replicating much of the analysis in De Jonge et al for our population – we match enrollees 1:1 with controls based on a subset of the criteria used by De Jonge et al, and we compare medical costs and mortality rates of HBPC enrollees with matched controls at 24 months as do De Jonge et al And, we show outcomes analogous to those reported by De Jonge et al – a reduction of $8620 in two-year medical costs due to participation in HBPC, with similar mortality rates between enrollees and matched controls
Summary
In the United States, home-based primary care (HBPC) is increasingly proposed as a means of enabling frail elders to remain at home for as long as possible, while still receiving needed medical care. Amongst the most difficult subpopulations are medically and functionally compromised elders, who typically have multiple chronic conditions with commensurately high utilization of emergency department (ED) services and hospitalization; may have difficulty obtaining care through normal channels; and may be approaching end of life but are not yet candidates for palliative care. For such individuals, Home Based Primary Care (HBPC) programs have been proposed as a means of assuring the delivery of ongoing medical care in a cost effective manner [2, 3]. Nowaczynski and Sinha [10] provide an overview of a variety of early (pre-2014) observational studies of HBPC programs, concluding that most identify similar reductions in utilization for enrollees, with mixed results for medical cost savings
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