In the past few weeks, no fewer than three highly respected groups have proposed major health care reforms. They all promise greater use of patient-centered integrated care, but none include supports and services for frail elders or younger people with disabilities.

It took four decades to incorporate a drug benefit into Medicare. Now we seem to be in the same place with supports and services for people with chronic disease. If you were building a health system from scratch, you’d never leave out the non-medical assistance people need to help manage chronic illness—say, help with personal hygiene.

It makes no sense to include physical therapy as part of a plan of care if a patient has no way to get to the therapist. The greatest electronic medical record in the world can’t help someone who is malnourished because she can no longer shop or cook for herself.

Yet, none of these ambitious plans, which otherwise have a lot to offer, integrates such care into a new health system.

Maybe the authors are too focused on traditional medical treatment. Maybe they worry about what they fear will be the added cost—though done right, integrating health and personal care could save money. Maybe they don’t want to open the political can of worms that is long-term care.

But the health challenge for most seniors is chronic disease, and the aim of good care ought to be preventing chronic, manageable conditions from spiraling into acute episodes that result in costly and debilitating hospitalizations.  And a good way to do that may be to provide a modest suite of personal services and supports to these patients.

But none of these plans includes such a design.

All aim to improve care and save money.  All are built on better coordinating care. And all would reward both providers and patients for participating in health plans that provide high-quality care at low cost.

The first proposal comes from Cathy Schoen and Stuart Guterman of the Commonwealth Fund and Karen Davis, the long-time head of Commonwealth who is now at the Johns Hopkins Bloomberg School of Public Health. They propose a program called Medicare Essential which would combine the program’s hospital, physician, and drug coverage (Parts A, B, and D) into a single integrated benefit.

The second plan was designed by the Bipartisan Policy Center, a Washington think-tank, and is aimed at cost containment and quality improvement. It proposes broad system reforms, including a new Medicare design it calls as Medicare Networks. It too focuses largely on medical care. There is a role for nursing facilities and home health agencies, but only as post-acute care providers. These networks would provide some care coordination for those with chronic disease, but not delivery of long-term supports and services.

The third plan was sponsored by the Brookings Institution but designed by a group of health experts from across the policy spectrum including former Medicare and Medicaid administrators Mark McClellan and Mike Leavitt, former OMB directors Peter Orszag and Alice Rivlin and health policy analysts such as Katherine Baicker, Michael Chernew, and David Cutler of Harvard, and Mark Pauly of the Wharton School. Two members, Rivlin and former Senator Tom Daschle, also served on the BPC panel.

This model, like the BPC plan, would make major changes in both Medicare and Medicaid (as well as in the broader health delivery system). It contemplates some limited models of care integration for those who are dually eligible for both Medicare and Medicaid (something many states are already doing). However, its proposal to move Medicare to what it calls Medicare Comprehensive Care is a different story.

It too recognizes the needs of elders with multiple chronic disease, but seems to include only care coordination services, not the added personal care itself within its integrated care model.

Don’t get me wrong. All of these plans are ambitious and all seem to anticipate the political system’s drive towards better integrated care. But they ignore a critical piece of the puzzle for 12 million people now receiving long-term supports and services, a number than will double by 2030. Medical care alone, no matter how good it is, will not improve the quality of life for these people and their caregivers.

The smart people who designed these new reforms need to think a bit more creatively for that to happen.

California has taken the idea of managed care for low-income seniors and people with disabilities to a whole new level. Under an agreement with the Obama Administration announced last week, the state will begin shifting both medical care and long-term supports and services to managed care companies in just seven months.

Watch this closely. You may be looking at the future.

For a fixed, per-patient monthly rate, those firms will be responsible for providing the full spectrum of care to people who have few assets and little income, but who often require extensive levels of care. The program, called Cal MediConnect, will cover people who receive benefits from both Medicare and Medicaid (called Medi-Cal in California)—thus often called dual eligibles.

Over the next 15 months, California expects to enroll 456,000 people in managed care in what will be the biggest program of its kind ever tried. As many as 200,000 will be enrolled in Los Angeles County alone, making the just LA effort bigger than any similar state program in the nation.

Managed care for the frail elderly and younger people with disabilities has tremendous potential, since  people with complex needs are likely to do better with fully-integrated care. For instance, a package of home care services and help with diet and transportation could greatly improve the quality of life for a senior with congestive heart failure and help her avoid the kind of health crisis that would result in a hospitalization.

Of course, using well integrated care to avoid acute medical crises also has the potential to save money. That promise of better care at less cost explains why the 2010 Affordable Care Act included new incentives for such a shift to managed care. California estimates only modest savings of about 1 percent in the first year, growing to about 4 percent by the third year.

However, states are anxious to take advantage of managed care because it allows them to share in any cost savings. Under today’s system, if a well-run Medicaid long-term care program reduces medical costs, it is the federal government—which pays 100 percent of Medicare costs—that benefits. The state gets nothing.

Four other states—Illinois, Ohio, Massachusetts, and Washington—have begun similar experiments. Other states, such as Florida, are moving low-income seniors to managed care under separate programs.

However, managed care carries significant risks. For starters, no insurance company has experience in managing fully integrated care for so many people with complex medical and long-term care needs. No one knows quite how to do this. The danger for patients is that managed care companies will find it difficult to provide a high level of care and still make a profit. As a result, they may scale back the care they provide or demand higher state payments.

Can states avoid these pitfalls? Perhaps these firms learned from past mistakes. In addition, California and the care companies will be required to meet tough quality standards that were not required in older models.

While the California program is described as a three-year demonstration, it is hard to imagine an initiative this big ever fading away, unless it proves an utter failure. Interestingly, the Obama Administration scaled back the original proposal from California Governor Jerry Brown, who wanted 800,000 dual eligibles moved to the new system.

Already, three quarters of Medicaid beneficiaries who receive only medical care (mostly low-income mothers and their kids) are in managed care plans. Many other states are looking at shifting their dual eligible populations to either the fully capitated system that California has adopted or managed fee-for-service plans.

Because it is California, and because of the size of its program, this experiment is bound to receive outsized attention overt the next few years. Perhaps it will be the first step towards fully integrating medical and long-term care for all Medicare beneficiaries. Or it may turn out to be a bust. But either way, it deserves close watching.

Broad-based, integrated, community-wide initiatives can help keep seniors out of the hospital, says an important new study from the Journal of the American Medical Association.

The study, done by a team led by Dr. Joanne Lynn of the Altarum Institute’s Center on Elder Care and Advanced Illness is new evidence that by working together, hospitals, physicians, social workers, nursing homes, home health agencies, and community organizations can help seniors reduce both initial hospitalizations and readmissions. This suggests that such teamwork can improve the quality of care for elders with chronic disease.

The researchers looked at 14 initiatives across the country, all involving Medicare Quality Improvement Organizations (QIOs). These are private, Medicare-funded groups that work with medical providers and seniors in each state to improve the quality and efficiency of health care. The study looked at networks in a broad range of communities throughout the country from Miami, FL to Whatcom County, WA. The sites were rich and poor, urban and rural, and those with relatively high hospital usage and those with lower utilization.

Participants used a wage range of methods to reduce hospitalizations. Nearly all used care transition nurses who are specially trained to coach high-risk patients in ways to care for themselves. Most used Project RED (Re-Engineered  Discharge) that standardizes hospital discharges. Nursing homes used software called INTERACT which helps nurses identify and manage residents’ changing health status. What’s striking is these are all readily available off-the-shelf tools that any facility can use.

Some of the programs also used community relationships to help seniors stay out of the hospital. The program in Tuscaloosa, AL, for instance, built on ties with local churches. I have written in the past about a similar model in Memphis TN that aims to accomplish the same goal.  

In other communities, hospitals and nursing homes did a better job sharing data. In others, nursing facilities changed the way they cared for new admissions. My friend Joanne Kenen wrote a nice piece for Politico describing how some of these local projects operate.

The bottom line is that both initial hospitalizations and rehospitalizations were lower in the 14 communities than in 50 similar communities that did not use these interventions.

There are several important caveats to this study. The first is that fewer hospitalizations are not necessarily the same as better care.  It was also hard to find perfect matches between those communities that used the initiatives and those that did not. It also turned out that hospitalizations and readmissions declined in both sets of communities, though they fell more in those that implemented quality programs. Finally, while admissions and readmissions fell, rehospitalizations as a percentage of discharges (a commonly used measure) did not.

Still, this study builds on a growing body of evidence that when doctors, hospitals, nursing homes, community organizations, and patients themselves work together, seniors are more likely to do a better job caring for themselves. And that can keep them out of the hospital, which is usually  a very good thing.

In 2012, about 13 million seniors participated in Medicare Advantage (MA) managed care plans—about 27 percent of the Medicare population and twice as many as were enrolled just seven years ago.

This rapid shift to managed care by seniors may be just a first step towards a fundamental change in the way Medicare is delivered and financed. And it has the potential to transform the way long-term supports and services are provided as well.

Medicare managed care comes in many forms. Almost two-thirds of MA enrollees participate in HMO-type plans, such as Kaiser Permanente, where treatment is delivered by employed staff. A rapidly growing alternative is offered by preferred provider organizations (PPOs) where community physicians and nurses are under contract with insurers. Among other versions are Special Needs Plans (SNPs) that provide care for people with complex medical requirements, including those who are  very poor and very ill and who are eligible for both Medicare and Medicaid (dual eligibles).    

Typically, Medicare pays these plans a fixed monthly fee per patient. In return, managed care companies provide their patients with all necessary care, including all-important care coordination. These firms are at risk for costs, so if they can manage expenses, they may keep the extra payment as profit but if  their costs of care exceed the Medicare payment, they will lose money.  

Managed care is especially important for seniors with chronic diseases. It holds the potential for far better care than traditional fee-for-service Medicare, which is often chaotic, disorganized, and duplicative. Yet, MA plans carry their own risks for patients. Unless financial incentives are correctly designed, the firms that operate these plans can be rewarded for discriminating against the sickest patients or denying care to high-cost participants.

Do MA patients use less health care than traditional Medicare enrollees? And is that a good thing, or a potential problem?

So far, the experience is mixed. A December, 2012 study  for the journal Health Affairs found that MA patients were one-quarter to one-third less likely to visit hospital emergency departments, likely to spend less time in the hospital, and less likely to receive outpatient surgery. On the other hand, rates of doctor visits were about the same as in fee-for-service Medicare.

MA patients were less likely to have elective knee and hip replacements but more likely to have heart bypass surgery. A separate insurance industry study found MA patients were less likely to be readmitted to the hospital within 30 days of discharge.  

Medicare also measures quality and safety for both MA plans and fee for service providers. By these standards, MA quality is improving. For several key outcome measures, such as controlling high blood pressure and managing diabetes, HMOs scored significantly higher than PPOs. Starting in 2012, Medicare began paying high quality MA plans a bonus.  

Medicare uses a star rating for MA plans (1 is the lowest, 5 is the highest). In October, it reported 127 plans had 4 or 5 star ratings.

For now, MA plans do not necessarily save Medicare money. In fact, for several years MA plans have been getting higher Medicare subsidies than fee for service providers. The 2010 health law will gradually reduce the level of these subsidies and plans will have to find ways to provide high quality care for less money—the challenge that fee for service Medicare providers already face.

MA plan have enormous potential to better coordinate care for seniors and others with chronic disease. Someday, they may also become the basis for a system that integrates medical care with long-term supports and services. For now, MA plans in all their forms remain a work in process. They have some real benefits, including premiums that are substantially lower than for fee-for-service. But consumers need to consider these plans very carefully. And so do policymakers.

Patient-centered care (as it is described by doctors) or person-centered care (the phrase-more frequently used in non-medical settings) is one of those concepts everyone supports–except when it comes to the details. On Nov. 8-9, I’ll be participating in a two-day symposium sponsored by the Samueli Institute aimed at breaking down the barriers between the medical and non-medical world and seeking evidence to show the benefits of patient (or person) centered care.

The conference, which aimed at health care professionals, will be held in Alexandria, VA. I’ll be delivering one of the keynotes, along with Carolyn Clancy, director of the Agency for Healthcare Research and Quality. The Samueli Institute is a non-profit dedicated to integrative medicine, optimal healing environments, the role of the mind in healing, behavioral medicine, health care policy, and military and veterans’ health care.

When I talk to hospital and nursing home administrators, they all say they want to do a better job focusing on the needs of their patients or residents. And many say they are doing it well. But often, they are falling short of true person-centered care. They are improving what hotel marketers would call the “customer experience” by adding amenities. For instance, a hospital recently profiled in The Wall Street Journal now serves wild salmon on its menu and has added ESPN to it cable listings.

Nothing wrong with that. Who wouldn’t want better food in the hospital? But that’s not patient-centered care.

That facility, Grady Memorial in Atlanta, is also teaching doctors to–sit down now–stop interrupting patients while they are talking. Now that is progress.

But letting a patient speak is still not person-centered. That requires another step–actually listening  to what she is saying and making her and her family a real part of the care team. 

In the end, it is all about control. It is about doctors asking patients about their goals–and paying attention to what they say–and sharing decisions with people who have no medical training. 

This is not how doctors normally think. But it matters. Does a patient want to live as long as possible, or would she prefer to be pain-free even if it means giving up a few years? Does a patient want to take his chances with a high-risk surgery,even  if the outcome could be death, or a very poor quality of life? 

Does a nursing home resident want a breakfast at 7 :00AM, or 10:00? Who wants spiritual rather than medical care? Who wants both?

The answers, of course, differ from person to person. And that’s the point. This kind of care requires doctors, nurses, and social workers to take the time to get to know their patients and what they want.

That raises the question: Does patient- or person-centered care work? Does it improve outcomes? In the end, are people who participate in their own care decisions healthier? And because there is so much focus on the cost of health care these days, does it save money?   

The Samueli conference will explore many of these questions. I’ll be interested to learn what experts in the field have to say.  

Everybody wants to do a better job coordinating care for the frail elderly and younger adults with disabilities who have extensive medical and personal care needs. But just how to do it is becoming increasingly controversial—especially on Capitol Hill.

The current flashpoint is an aggressive new Obama Administration initiative aimed at improving care and cutting costs for those who are very poor and very sick. There are 9 million of these so-called dual eligibles receiving benefits through both Medicare and Medicaid.

Now, some Democrats are worried that states are moving too fast, some independent analysts fear the initiatives are too big, and some insurers fear the program is too narrow.  But despite all the concerns, Melanie Bella, the Obama Administration official in charge of these programs, told the Senate Aging Committee today that they will move forward.

Their most surprising critic may be Senator Jay Rockefeller (D-W. Va), who authored the initiative in the 2010 Affordable Care Act. Now, fearing it would result in lower quality care for this vulnerable population, he’s asked the Department of Health and Human Services to shut down the program until it can be redesigned. A major concern: a provision that would allow states to automatically enroll duals into managed care plans

Oddly, the managed care program was backed at today’s aging committee hearing by the panel’s ranking Republican, Senator Bob Corker (R-TN). In a rare example of a Republican saying something nice about the ACA, Corker pronounced himself “pleasantly surprised” by the way Bella is handling  the new program for the duals.     

The 2010 health reform law made it possible for the Administration to push several key changes in what has, until now, been a poorly designed care system. Currently, Medicare pays for most medical care for this population while Medicaid pays for personal care, or long-term supports and services.

Because the federal government pays for all of Medicare, while states and the feds share the cost of Medicaid, the system discourages the two from cooperating. For instance, if a Medicaid care manager helps keep a patient healthy and out of the hospital, all the savings go to Medicare while the state pays the care manager’s salary.  

To address this and other problems, the ACA gave the Centers for Medicare and Medicaid Services the authority to set up a new office to coordinate regulations, improve data, and set up demonstration projects to learn how to better manage the care of the dual eligibles.

States, desperate for cost savings, have scrambled to propose demonstrations.  Twenty-six have asked CMS to approve major new managed care programs that would cover as many as 3 milllion–or one-third– of the duals. That would make this the largest Medicare demonstration in history.

My Urban Institute colleague Bob Berenson told the aging panel that these experiments would be far too big, with many aimed at covering all of the duals in a particular state.  This, he fears, would make the programs “too big to fail” even if they did not succeed in improving patient care and saving money.  His other worry: Medicaid managed care companies have little experience in caring for dual eligibles, many of whom have very complicated medical conditions.

Bella said CMS has not approved any demonstrations yet, would probably limit them to about 2 million beneficiaries, and establish national quality standards against which to measure their success. But one thing is clear: the idea of coordinating care for those who need both medical care and long-term care is on its way to becoming an important trend.

Insurance giant Wellpoint is the latest carrier making a big bet on managing care for those seniors and adults with disabilities who are eligible for both Medicare and Medicaid.  About 9 million people, called “dual eligibles” receive benefits from both programs. They are both very poor and very sick and often have significant needs for personal assistance.

Medicaid alone spends $145 billion a year to care for them—most for long-term care services—while Medicare spends $175 billion on medical care for this population. The frail elderly, who have both multiple chronic diseases and personal care needs, are both the most expensive and the most difficult to care for.

To expand its presence in the Medicaid managed care market, Wellpoint this week announced the purchase of another managed care firm, Amerigroup, for nearly $4.5 billion. Earlier this year, Cigna jumped into the Medicare and Medicaid managed care business by purchasing Healthspring for $3.8 billion.

Both firms are betting on a growing trend by states to move their Medicaid patients from fee-for-service Medicaid to managed care. In many of these systems, states pay insurers a fixed fee, or capitated rate, to provide all care for enrollees. If the firm can provide care for lower costs than the state fee, it can keep the difference. If not, it is at-risk for the loss.

Nearly all states have moved young families who receive health care through Medicaid to managed care. But in recent years, at least 11 states have turned some or all of their long-term care supports and services to private insurers though such capitated systems. They range from Blue states such as New York, Washington, and Hawaii to Red states such as Texas, Arizona and Florida. In addition, two dozen states have applied for demonstration grants to provide experimental coordinated care programs for their elderly and disabled populations.

Many consumers fear managed care for seniors will lower quality, as insurers try to save money by skimping on needed care. But insurers insist that by coordinating care, they can both save money by curbing unnecessary hospitalizations and tests and improve quality. One key to good systems will be excellent care managers who can organize complex care from many providers for those with multiple chronic diseases.  

For now, there is little evidence on how well this will work. Because the state programs are so different, we’ll learn a lot in the next few years about which practices succeed and which do not. States will have to keep a close eye on quality since many dual eligibles are too frail to advocate for themselves.

There is little doubt the managed care trend is rapidly gathering speed. Not just insurance companies but providers such as large health systems are increasingly willing to accept the financial risk of caring for patients. And cash strapped-states are increasingly willing to turn over this care to them.

As I have written before, this trend creates another opportunity. If insurers (or big health systems) are able to boost quality and save money by linking long-term care services with medical care for the dual eligibles, there is no reason such a model could not work with Medicare managed care or even the commercial health care market. And if it can, that creates an opportunity to rethink long-term care insurance as a health care product, and not a life product.

People often say that the patients most at risk in the U.S. health system are the elderly who suffer from multiple chronic diseases. But it may be that a subset of these seniors—those with chronic disease who also need personal assistance with routine activities—are in the most jeopardy.

An important 2011 research paper finds they are the most costly to care for.  Only about 15 percent of the total Medicare population suffers from 3 or more chronic diseases and faces functional limitations. But these very frail–mostly elderly–people account for 32 percent all Medicare spending, according to Harriet Komisar and Judy Feder of Georgetown University (Judy is also a colleague of mine at The Urban Institute).

On average, Medicare spent almost $16,000 on these people in 2006, twice as much as the system spent on those who had 3 or more chronic diseases but did not need assistance with daily activities such as bathing, eating, or going to the bathroom.

Medicare spends nearly twice as much for these very frail enrollees on hospital care, almost nine times as much for care in skilled nursing facilities, and almost six times as much for home health care as those with chronic conditions only. Of their average $16,000 in annual Medicare costs, 40 percent was for hospital and skilled nursing facility care—care that might have been unnecessary had they had sufficient help with personal assistance.  

Keep in mind that these costs are for Medicare only. But Judy and Harriet found that about 43 percent of the very frail received both Medicare and Medicaid benefits. Because Medicaid—not Medicare– pays for the personal assistance for these “dual eligibles,” the research excluded those costs. For instance, the study looked at costs in a skilled nursing facility—covered by Medicare—but not long-term stays in a nursing home, which are not (though they may be covered by Medicaid).

Overall Medicaid spends $120 billion on long-term care services for the frail elderly and younger adults with disabilities.

Judy and Harriet conclude that these high costs are a major reason why it is important to coordinate medical and long-term care services for these patients. While they focused on costs only, it is likely that providing better, more coordinated overall care would not save money but improve these patients’ quality of life. After all, preventable events such as falls and infections, or poorly managed diseases such as congestive heart failure or diabetes may be driving these costs.  

People who need help with activities of daily living—many of whom have dementia or some other cognitive impairment—are especially at risk for events such as these.  

Managed care has a bad reputation among many, largely as a result of the HMO experiments of the 1990s. But whether you call it integrated care, coordinated care, organized care, or managed care, well-structured linkages between medical treatment and long-term care services and supports are critically important for the frail elderly.     

The Affordable Care Act includes important experiments aimed at achieving that goal. In many ways, these are the law’s most far-reaching initiatives. Judy and Harriet’s paper is more evidence of why.

By upholding the constitutionality of the Affordable Care Act, the Supreme Court has preserved—at least for now—major changes in the way long-term care supports and services are delivered and financed.

Here are some provisions of the law that directly affect the frail elderly and younger adults with disabilities.

Medicaid: The law is filled with important changes to this state/federal program that currently funds nearly half of all paid long-term care services. While the Supreme Court ruled that most of the 2010 health law is constitutional, it threw out one important provision that would have forced states to cover the health care of millions of currently uninsured working people.

States can still insure those people through Medicaid—and the federal government has agreed to pay nearly all of the costs of that expansion for the next decade—but now states can refuse to provide that new coverage if they choose. Whatever choice states make, it will not only effect health benefits for poor families, but also Medicaid benefits for long-term care services.

Home and Community-based Care: The ACA includes important new incentives for states to expand Medicaid long-term care services for people living at home. Today, nursing homes still get the lion’s share of Medicaid long-term care dollars. Yet seniors and adults with disabilities overwhelmingly want to receive assistance at home. The ACA includes a number of new programs to expand those home and community-based programs.  

Medicare: The ACA slowly closes the “donut hole” for seniors who participate in the Part D drug benefit. That extra assistance would go away. It also includes a small increase in the payroll tax that is aimed at increasing revenues for Medicare, which is under great financial pressure. 

Integrated Care: In the long-run, perhaps the most important provisions for seniors are a far-reaching package of experiments aimed at improving the way care is delivered to people suffering from chronic disease, as nearly all seniors do.

For example, the law creates a new office to coordinate the health and long-term care of people who receive both Medicare and Medicaid. These “dual eligibles” are often the poorest and sickest seniors. It also includes important incentives to encourage hospitals, nursing homes, doctors, and other providers to work together to improve care for people with chronic disease.

The CLASS Act: CLASS has already been abandoned by the Obama Administration, but it does remain on the books.

Of course, while the legal battle over the Affordable Care Act is now ended, the political fight is just beginning. Mitt Romney and congressional Republicans vow to repeal the entire law. President Obama and most Democrats would preserve it. While health and long-term care reform will remain a secondary issue to the economy in the coming election, the fate of the 2010 health law will be a very big deal to seniors and those with disabilities.

 What if you could be admitted to the hospital—in your own bedroom?

That’s the idea of a health care model called Hospital at Home, which is aimed at elderly patients with diseases such as congestive heart failure, emphysema, urinary tract infections, or pneumonia.

According to a new study published in the journal Health Affairs, people receiving this care through the New Mexico-based Presbyterian Healthcare Services had equal or better outcomes than those getting  traditional hospital treatment, and were more satisfied with their care. In addition, care at home cost nearly 20 percent less than a hospital stay.

Hospital at Home (HaH) was created by Dr. Bruce Leff and colleagues at the Johns Hopkins schools of medicine and public health. The idea is pretty simple, though a little hard to grasp at first.

Like anyone else, an HaH patient is admitted to the hospital, usually through the emergency department. But some carefully selected patients—if they choose–can be cared for at home instead of receiving treatment in a room at the hospital. All the necessary equipment, such as a bed, oxygen, or medications, as well as monitoring devices, is provided at home. Physicians and nurses visit regularly and the patient’s vital signs are constantly monitored remotely. As with any hospital stay, the patient is discharged at an appropriate time, after which she may receive separate post-acute care if she needs it.  

While patients in the Presbyterian model may live alone, HaH patients often have the assistance of family caregivers who may supplement the care provided medical professionals. That can save money and potentially improve care, but also increase the burden on those family members.

Unfortunately, traditional fee-for-service Medicare won’t pay for AaH. Under Medicare rules, a patient must receive hospital care only in a hospital, and nowhere else. But integrated care programs such as Medicare Advantage and Medicaid managed care, as well as a few commercial health plans, do pay for HaH. A nice story in Kaiser Health News describes how Presbyterian and a few other health systems are planning to expand the model. In addition, the program is available on a limited basis through the Veterans Administration and is also being offered in Europe.

The Presbyterian results are striking. The HaH patients’ average length of stay was shorter (3.3 days v. 4.5 days), quality and patient satisfaction were higher. HaH patients were less likely to die during their admission. However, they were also slightly more likely to be readmitted to the hospital with 30 days, and about 2.5 percent of them had to be transferred from home to the hospital during their HaH admission.

The program also saved money. Why? Presbyterian concluded it was because those lengths of stay were shorter and, interestingly, because it reduced the number of diagnostic tests these patients received.  After all, a doctor can’t just send a patient down to imaging for yet another MRI when she is at home.

One other fascinating result: Once Presbyterian realized how well care at home works, it decided to take a step back to the future and has now deployed physicians to do medical house calls.

Implementing Hospital at Home is not easy. As the researchers at Presbyterian note, it requires careful care coordination and significant changes in payment structures. But it is a model that has great promise—both for patients and health systems.