Health Services Research & Development

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2017 HSR&D/QUERI National Conference Abstract

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1037 — A Case for VA Home Based Primary Care Expansion: HBPC Reduces Costs and Improves Community Survival

Lead/Presenter: Ciaran Phibbs
All Authors: Kinosian B (GEC-DAC, CMC VAMC, Philadelphia, PA) Makineni R (GECDAC, Providence VAMC, Providence, RI) Dally S (GECDAC Palo Alto VAMC, Menlo Park, CA) Phibbs CS (GECDAC Palo Alto VAMC, Menlo Park, CA) Edes T (Department of Veterans Affairs, Washington, DC) Davis D (Department of Veterans Affairs, Washington, DC) Intrator O (GECDAC, Canandaigua VAMC, Rochester, NY)

Objectives:
VA Home Based Primary Care (HBPC) provides longitudinal primary care to medically complex veterans, using a broad interdisciplinary team (IDT). The scope and cost of the IDT have raised questions about VA net savings. We sought to clarify if HBPC produces net savings to VHA.

Methods:
Three-year cohort study using calibrated projected costs for veterans enrolled in HBPC, compared to actual costs of veterans enrolled in VA-HBPC. VA utilization, cost and fee files, linked with Medicare claims; Residential History File for community survival. We identified 202,775 Independence at Home Qualified (IAH-Q) veterans in VA at the start of FY2013. IAH-Q veterans were those who had a hospitalization and post acute care in the past 12 months, 2+ chronic conditions, and 2+ functional deficits, using a JEN frailty index > = 6. We used the concurrent Nosos, augmented with calibration factors for each Nosos decile among the IAH-Q population, to project costs for the 12,131 IAH-Q HBPC patients and standard Nosos for 18,151 non-IAH-Q HBPC patients. We used a Residential History File to compute the share of days each veteran was in the community.

Results:
In 2013 the 12,131 IAH-Q Veterans had per-capita annual costs of $52,515 with expected costs of $64,457, while the 18,150 non-IAH-Q had costs of $33,955 with expected costs of $33,962. From 2013-2015, the prevalent HBPC population grew from 30,281 to 34,422; the mean observed costs grew from $41,390 to $44,243 while the mean expected costs grew from $45,716 to $52,450, resulting in savings of $4,326 to $8,207, with savings of 9.5% (2013 $135M), 12.2% (2014 $192M), and 15.6% (2015 $281M). Compared to a stratified sample of IAH-Q patients in PACT (N = 9,992) 85% of HBPC days were non-institutional (vs 81% for PACT), with 25% of HBPC patients, vs 5% of PACT patients, having 99% of days in community. Of 127 HBPC programs, 104 produced savings > 5%.

Implications:
VA HBPC produced substantial savings of 10-15% among high need, high cost Veterans.

Impacts:
Expansion of HBPC targeted to high need, high cost Veterans can produce substantial savings for VA.