Independence at Home Demonstration
Performance Year 2 Results

Independence at Home Demonstration
Performance Year 2 Results

Home-based primary care allows health care providers to spend more time with their patients, perform assessments in a patient’s home environment, and assume greater accountability for all aspects of the patient’s care. This focus on timely and appropriate care is designed to improve the overall quality of care and quality of life for patients served, while lowering health care costs by forestalling the need for care in institutional settings.

The Independence at Home Demonstration provides chronically ill patients with a complete range of primary care services in the home setting. Medical practices led by physicians or nurse practitioners provide primary care home visits tailored to the needs of beneficiaries with multiple chronic conditions and functional limitations. The Demonstration also tests whether home-based care can reduce the need for hospitalization, improve patient and caregiver satisfaction, and lead to better health for beneficiaries and lower costs to Medicare.

The Independence at Home Demonstration is authorized by Section 3024 of the Affordable Care Act. The demonstration began in 2012 and was originally authorized for three years. It was subsequently extended for two additional years through September 30, 2017 by the Medicare Independence at Home Medical Practice Demonstration Improvement Act of 2015. 

Summary of Results from Performance Year 2

The analysis conducted by the Centers for Medicare & Medicaid Services (CMS) and the independent evaluation contractor found that in Performance Year 2 of the demonstration, Independence at Home practices saved over $10 million, an average of $1,010 per beneficiary. CMS will provide incentive payments in the amount of $5,719,526 to seven participating practices (See Table 1). In the second performance year of the demonstration, 10,484 beneficiaries were enrolled in the 15 participating practices. For the second performance year, all 15 of the Independence at Home practices improved quality from the first performance year in at least two of the six quality measures for the Demonstration. Four practices met the performance measures for all six quality measures.

Table 1.  Performance Year 2 Results for Participating Practices

* The Year 2 Spending Target and Year 2 Expenditures are on a per beneficiary per month (PBPM) basis.

Quality Measures

Under the Independence at Home Demonstration, participating practices must meet the performance measures for at least three of the six quality measures in order to qualify for the incentive payment. The six measures are:

• Follow up contact within 48 hours of a hospital admissions, hospital discharge, and emergency department visit;
• Medication Reconciliation in the home within 48 hours of a hospital discharge and emergency department visit;
• Annual documentation of patient preferences;
• All-cause hospital readmissions within 30 days;
• Hospital admissions for Ambulatory Care Sensitive Conditions; and
• Emergency department visits for Ambulatory Care Sensitive Conditions.

Shared Savings Methodology Modifications

For the first performance year of the Independence at Home Demonstration, a regression-based methodology was predominantly used to determine demonstration savings. Under the regression-based methodology, CMS derives the savings estimates by making comparisons between the treatment group, or demonstration beneficiaries, and the group of comparison beneficiaries, a matched group of beneficiaries identified in CMS’ administrative data who meet the demonstration eligibility criteria and do not receive home-based primary care. For the second performance year of the demonstration, CMS identified potential issues under the regression-based methodology with the comparability between the treatment group and the comparison group used in the analysis of the demonstration savings. CMS conducted many analyses concerning the comparability issues. Revisions for the second performance year were made to the variables describing beneficiaries that are used for matching and the selection of beneficiaries treated by Independence at Home practices for analysis.

Another methodological change to enhance comparability concerned technical matching criteria.  To construct the comparison group, beneficiaries who met the demonstration eligibility criteria and were statistically similar to the demonstration beneficiaries in their health conditions, activities of daily living (ADL) limitations, and demographic characteristics, such as age and sex, were matched to demonstration beneficiaries. For the second performance year, revisions were made to the detailed health characteristics and other variables used for matching. CMS also revised the approach to measuring characteristics of beneficiaries who continued in the demonstration from its first year into its second year without meeting all of the eligibility criteria again. Collectively, these changes helped to improve comparability between Independence at Home beneficiaries and their matched comparison group beneficiaries. Participants using the regression methodology in the first performance year had the choice between the original regression methodology and this revised regression methodology for the second performance year.

Beneficiary Participant Limit

The statute limits participation in the demonstration to no more than 10,000 beneficiaries. With Performance Year 2 enrollment slightly exceeding the 10,000 beneficiary limit, the demonstration design used a method to reduce the number of beneficiaries proportionately across all practices so that the beneficiary limit was not exceeded in the calculation of the incentive payments. This proportionate reduction occurred only for the purposes of the incentive payment calculations. No limits were imposed on the number of beneficiaries that practices could enroll in the demonstration.

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