Homebound seniors with chronic conditions are among the most costly for Medicare and Medicare Advantage plans. They usually don't see a primary care physician regularly and end up in emergency departments or are hospitalized due to their conditions going untreated, said Dr. Bruce Leff, the director of the Center for Transformative Geriatric Research at Johns Hopkins University.
Medicare Advantage insurers have been trying to push more care into the home to keep members healthy through partnerships with companies such as WellBe Senior Medical, Homeward Health and HarmonyCares. Those companies provide health assessments, medication management and other supplemental services to members in their homes.
Humana is using its CenterWell Senior Primary Care division to provide home-based care. Last year, the company began piloting in-home care to some homebound members in parts of Georgia and Louisiana. A Humana spokesperson said the company could extend the service to about a dozen other locations where CenterWell Senior Primary Care has locations, but it has no plans to do so yet.
Related: Humana expands CenterWell Senior Primary Care
In an analysis of 2.4 million Humana Medicare Advantage members in 2022, one in five were homebound to some degree, according to a study Leff co-authored and published in the Annals of Internal Medicine last week.
Providers who care for chronically ill and homebound patients often use interdisciplinary teams to treat them to avoid costly hospital stays. Other companies that offer supplemental care to patients where they live generally rely on nurse practitioners or nurses.
Treating complex, homebound patients where they live can save money. The Centers for Medicare and Medicaid Services' Independence at Home demonstration pilot that provided home-based primary care saved Medicare more than $8,200 per beneficiary in 2021. The eight-year program, which ended last year, paid incentives to primary care providers to keep homebound patients out of the hospital.
While providing home-based primary care to homebound older adults with numerous complex conditions can reduce healthcare costs, doing so is a challenge, said Dr. Sachin Jain, CEO of Scan Health Group and Scan Health Plan. The company serves more than 300,000 people in Arizona, California, Nevada, New Mexico and Texas through its Medicare Advantage plans and care delivery divisions.
Scan Health offers home-based primary care and virtual visits to about 1,000 homebound seniors in California through its payer-agnostic Welcome Health unit. Physicians visit patients in their homes at least once a month, or more often if that care is needed. Jain said the 3-year-old program has helped reduce hospitalizations and emergency department visits among beneficiaries, but did not provide additional details.
Jain said some patients can be expensive to treat, even with in-home care.
“What you’ll find is two or three outliers can blow up a whole sample of patients,” Jain said. “It requires really close management of care and it requires a 24/7 continuity of care where they are calling you first, as opposed to going to an emergency room.”
As with other in-home care programs, Jain said scaling home-based primary care programs for homebound patients can be tough if there aren’t enough of them in a region that require more complex care.
Low Medicare reimbursements are another barrier to delivering home-based primary care to chronically ill older adults in their homes.
In 2024, Medicare reimbursed $167.10 for a new patient office visit compared to $138 for a home visit, according to the Home Centered Care Institute. Home visits also don’t qualify for an additional $16 payment for complex patients, while office visits qualify for the enhanced payment, the center reported.
San Francisco-based geriatrician Dr. Carla Perissinotto said low Medicare rates make it challenging to operate her practice, which provides care to about 100 homebound seniors around San Francisco and Atlanta. Perissinotto makes in-home visits to her patients in San Francisco and sees patients virtually in the Atlanta area with help from an onsite nurse practitioner. She said each visit can take anywhere from 45 minutes to two hours depending on the complexity of the patient, while travel to and from the patient’s home can add another one to two hours to the visit.
“What is hard is that you can’t get reimbursed for drive time,” Perissinotto said. “In Atlanta, it took my nurse practitioner 40 minutes to get from her house to a patient’s house and then 40 minutes back.”
Some home-based primary care practices have incentive-based contracts with Medicare Advantage plans that pay more for better outcomes. Northwell Health of New Hyde Park, New York, has three Medicare Advantage contracts and is negotiating a fourth to provide care to about 2,800 homebound older adults in the New York City metropolitan area, said Dr. Konstantinos Deligiannidis, medical director for Northwell House Calls program.
Bloom Healthcare also has incentive-based contracts with some Medicare Advantage plans, while other insurers pay fee-for service rates, said Dr. Danielle Whitacre, chief medical officer for the Lakewood, Colorado-based provider.
Bloom Healthcare provides home-based primary care to about 6,000 older adults, mostly in assisted living and retirement communities around Denver. Treating a number of homebound patients in close proximity to each other makes home-based care more economically viable, but not necessarily lucrative, Whitacre said.
“We feel like we are doing the right thing and these patients need us, but we are not making a margin on certain populations,” Whitacre said.
