Medicare’s Hospital-at-Home and Other Reforms

COVID nineteen pandemic. To walk us through this, and we have Mark Braither, a leader at the forefront of change in the healthcare system. Mark is the co founder and executive chairman of Dispatch Health and has a deep background in business and hands on healthcare delivery. Mark, welcome to the podcast.

We've served I think over the last decade, more than a million patients and we do that across thirty states and during that time, the way that we've structured our care is that we do it in a way that's more cost effective than the building. So we've delivered almost a billion and a half dollars of medical cost savings.

so I learned a lot during that run. Ended up managing the West and for us that was about sixty four hospitals, somewhere close to fifteen hundred clinicians. But a few things started to concern me. And again this is probably twenty eleven or so. The first thing I noticed was we were so far off of our healthcare consumer, our patients expectations when it come when it came to pricing. So I was the recipient of a lot of complaints on my desk about the cost of care and the

time with the clinician. And that had changed dramatically since I was a young resident in the nineties, and so I wasn't sure what I was going to do about that, but I wanted to do something that improved that issue. Secondly, was the concept of value based care. So in twenty eleven, we were still debating whether this was a a thing right, whether this was going to happen again. I was there in the early nineties when we tried it, but the second round, to me, looked like it could actually work.

And if it did work, you'd have more and more patients in paneled to these smart primary care docs who would try to navigate patients to the appropriate side of care. And I knew that there was a ton of patients that I treated on a daily basis that could be treated elsewhere. And I think the thing that really moved me forward was that I had some family members and elderly family members that went through hospitalization a post acute

stay that did not go well. They went really poorly, and I just saw the other side of that, and I think I had a little existential moment where I said, have I been doing that? Have I been putting patients in the hospital and maybe to their detriment? And the answer,

if I was honest, was yes. And so I began looking for an alternative, and I wasn't sure what it was, but I reached out to some people who began publicishing this concept of hospital at home in the nineties, a guy like Bruce lef out of Hopkins and al Sioue out of pen These were Maverick geriatricians who were doing something different. I was also being done in other countries, but they were sort of the leaders in publishing in

the States, and it looked really compelling to me. It looked like we could get lower costs and patient satisfaction. But importantly, there was something about it that looked like we could get more efficacy, we could get better clinical outcomes. So, like most naive folks when you're first starting out, I thought, well, too, I've managed ers, I've managed hospitals, I've managed post acute facilities. I could just do this in the home. So it's

been much more of a daunting task than that. But that's the premise of dispatch, is that we would take what we could out of the emergency department, out of the hospital, ward, out of the post acute facility, delivered in the home for lower cost, better outcomes, and better satisfaction.

we not create a mobile er? Could we not do that respond to the nine one one phone call and treat a patient in place? And so that really was the beginning of it. We created a very forward thinking fire chief named Rick Lewis and I and a few other folks built this mobile er and started treating patients in lieu of a transport to the hospital. We did that for two years. In the data it was extremely compelling, and so we took that to our first payer partner

and said would you pay for this? And they said yes, And that was the beginning.

of services are we talking about? And if you look at a hospital at home program in one state or one geography, is it the same as another geography in a different state. Walk us through how the concept has started or how it's evolved, and where we are now.

right that started back in the seventies. And I remember even in the nineties when I was training, lots of us were very concerned about these ambulatory surgery centers where they good quality? Could you safely do it? And you know, very similar situation that we find ourselves in today. But today there's fifty three hundred surgery centers across the country.

They're performing twenty million procedures annually, and it's estimated that they are saving you know, call it forty billion dollars annually. I often use another really tangible example from my history. So over the time that I practice, the standard of care changed, right, And if we talked about let's say a blood clot in your leg, you came and saw me in the emergency room, we made that diagnosis. Call

it fifteen years ago. The treatment at that time would have been to admit you to the hospital on bed rest on an ivy medication called hepron. Now let's fast forward to today, and if you went to the emergency room had that diagnosis, what would happen. You'd go home in an hour on a medication, you know, a shot that you gave yourself for a pill. It's pretty interesting how we've evolved. And that's exactly what this whole hospital

at home concept really is. So when people hear it today, they often equate it to the concept of the waiver, which is really a payment mechanism. It's not this delivery of the service. But during the pandemic, there was an initiative called the Acute Hospital Care at Home Initiative, And I remember getting a call from the administration one night

and thinking, whoa good am? I in trouble. But I showed up the next morning and it was all of us in the community who were delivering this type of care, and they were very worried that the hospital beds were going to fill up and that they weren't going to

be able to service all of the sick patients. And so I think very thoughtfully they said, well, can we take the reimbursement mechanism that we use for the hospital and just transferred to the home right and we'll use you experts to tell us what a good program looks like,

and then that'll be the standard. And that really was a nice catalyst to get hospitals thinking that way, although you know, there were obviously hospitals doing it at that time, and so that was really the beginning of, you know, I think the popularization of the concept of hospital at home. So when you mentioned, you know, is it the same everywhere?

So there are some standards that we put in place, you know, our program essentially, when you're admitted into the dispatch program, you are monitored continuously, you have access to our nurses and doctors twenty four to seven. You have you know, on demand rescue therapy, which would be either our mobile er units or ems UH, and then we provide all of the services that you would receive typically

in your hospital stay. That could be physical therapy, that could be you know, oxygen, that could be help with activities of daily living. We bring all of that into the home and then I think importantly, our model continues for thirty days. So as you know, we have a problem in this country where we'll treat you in the hospital for call it three and a half days, discharge you, and one in four one in five times you'll come

back to the hospital. So we continue to keep you on our service for thirty days, all the while integrating you back with your primary care doctor and ensuring that that care plan is continued throughout the thirty days. And so at the end about our readmit rates about half of what you get inside the hospital. And then you know, can you do this throughout the country anywhere? Well, I would tell you that it's being done in a lot

of geographies today. We do this, you know, like I mentioned, I think we're in thirty states, but forty markets where we provide that on demand er substitute of care imaging. And then we have fourteen markets where we provide that ability to you know, quote unquote hospitalize in the home or recover in the home. And those are very disparate markets throughout the country, and so far we haven't encountered a situation where we couldn't provide that care.

make that successful. So, you know, when we think about what happened during the pandemic, this was also a time when the digital aspects of healthcare kind of blew up as well. So can you walk me through what the infrastructure is like or is needed to make it successful?

be done without it. So we use remote monitoring, we use telehealth. We've had to build a lot of our own capabilities because you know, every EMR in the world is built around the concept of a building where everybody is in the building. And for us, you know, the patients in a building, but everybody else is driving around, right the physical therapist, the pharmacists, the everything, And so

we've had to become logistics experts. We literally had the team that built early Uber come in and build our logistics model. And that's a logistics model that's clinically informed, meaning you know, is to something need to be happened faster because of the clinical acuity of that patient. So those are things that we've had to build over the

decade that I think, are you know different. And then to me, you know, I'm an old hospital doc that manage lots of other docs and clinical quality is super important. So the foundation here really is built on what we used to do back inside the hospital. So a patient center to focus that is you know, highly focused on clinical quality and consistency.

this scaled? Why hadn't we done more of it? And I would ask some of the folks who were doing this, and they mentioned things like, well, it's hard to get oxygen to the bedside, or it's hard to get reimbursed, and you know, in my head, those are all things that we could solve. I thought that the fundamental problem that we had in scaling this was the site of origination, meaning we were starting the care after the patient had

already arrived in the emergency department. And as an old er doc, I can tell you there's so many people that once the patient gets there, they really don't want them to leave, right. It's a hassle for the er doc to keep that patient longer than is needed and work on getting them back home. That's a lot of work. If you think of then about the hospitalist. You know, is it easier to arrange all this stuff in the home or is it easier just to admit them upstairs?

And frankly, there are some incentives and their pay that would you know, make them maybe want to admit the patient. And then you know, if I'm the CFO of a hospital, it's very hard for me to send the patient out if I could have kept them in. And there's the whole idea of like, let's keep the lower acuity stuff out and just do you know the higher acuity stuff in the building. But in the moment, I think that's hard. And so with dispatch, what we said was, let's create

a system in the home. Let's be able to bring an er to the bedside and diagnose and treat somebody just like I would have in the er. Now, short of a cat skin. But everything else I can do, and that's really important because you have to risk stratify

the patient in terms of their clinical condition. So you have to have a moderate complexity lab, you have to have EKG, you have to have X ray, ULTRASOUM, all those things, but we do, and then we can do that work up at the home and admit directly to home. Patient never leaves their h never leaves the bedside, So

that's really the difference. And we're one of a handful of programs that can actually do that in the country because of all the infrastructure that's required to do that now hospital systems and we partner with many of them across the country. We're better together than a part and they understand that we built infrastructure that other people haven't, we have technology that other people haven't, and so we

can integrate with them help them deliver this care. They may want to use some of their own staff, they may want to use some of our staff, but we can work together to decide how to do that as long as the clinical quality meets our standards.

Let's say she has emphysema and let's say she's on the phone with her doctors saying, I'm really struggling breathing and I think I've had a fever and a cough. Well, that's a pretty sick patient potential, especially if she's you know, eighty years old. And the work up. You know, doing all of that inside a primary care office is almost impossible,

so typically that patient we get sent to the er. Instead, that doc could say, oh, you know what, I have a partner, and we do function as an extension of a primary care doc. We don't impanel our own patients, and so they can say, I have a partner that'll come and evaluate you that you know, emphysema, COPD, congestive heart failure, pneumonia, complex UTI. The classic medical admission diagnoses are our bread and butter and right.

We'll talk about that. But there's a lot of conversations about whether the data is showing that this is successful and there's concern or maybe making sure we focus on how this is equitable for everybody in terms of you know, people this program works for people in certain geographies versus it doesn't work well in others making sure that everybody has access regardless of where they live, regardless of demographics.

And so I want to get into kind of the data and the health equity and racial disparities discussion that it's going to be probably a conversation when Congress looks into whether they should be extended or not. And so, you know, you said, you know this can work in various geographies, but how do kin of some of the demographic factors play in to how this can work and whether it works? And you know, for example, somebody living with a couple of different generations in the same household.

I guess where I'm trying to go is how do we ensure that as many diverse patients as possible benefit from the program?

this again, like the waiver. We like the idea. We'll talk about that later, but when we get reimbursed, we're partnering with managed care plans and some of our earliest partners were in Denver and they were managed Medicaid plans, and they were pace programs, so dual eligible folks who were who were Medicare age but then met criteria for Medicaid. And so we've been in you know, homes that aren't

you know, the fancy suburban home since we started. And when we think about is a patient safe for admission? We have obviously our clinical checklist, but we also have you know, a social checklist. But you'd be surprised how short that is. Is the electricity on, is the water running right? And if those basic things are there for the most part, we can generally deliver care. So I would agree with you. I think that's very important that we keep this as equitable as possible. I also understand

the concerns. When I first read about hospital at home. You know, I was a bit of a snobby doctor who trained in the nineties at UCLA and thought, well, only you know, real medical care can happen inside that building. I've come to change my tune quite a bit over time, but I understand the reticence. I do think it's important that as we broaden this, that we are measuring safety

and quality, and you know, frankly, we're inviting regulation. We're in the process of sort of being regulated, and we're okay with that.

It seems like you have some experience on both ends of this, So how do you respond to some of the criticism.

think the concerns. Yes, let's make sure that we are touching the patient as much as possible, but let's continue to measure. Let's understand what's gone so well in these other countries and try to replicate that, because it looks to me, and you know, I'm not the only one, that we are getting better clinical outcomes at a lower cost with higher satisfaction. You know, there's also a point, and I'm not sure if you were going to get there. People have brought up the fact that caregivers might be

burdened in this model. I think that's a legitimate question, right, And so what we did, and again it's it's not massive numbers, but what we did was we looked at the experience of forty four caregivers, right, and these were caregivers who's loved one had been both admitted to a hospital recently and then admitted to our program in the home.

And ninety five percent of those caregivers voiced a clear preference for our in home model, and overwhelming ninety six percent of them cited, you know, a significant decrease in their stress levels when managing their loved ones care. So I think you got to keep an eye on that. But to me, and maybe it's our program or something, but it looks like, at least in our experience, that the caregivers are pleased with the program.

You could imagine that a lot of program, a lot of patients in our program are end of life and so our providers are highly skilled at this and they have thirty days, right, it's not just one day, it's not one hour. We develop a relationship by the nature of our program that allows us to address that. And you know, the goals of care are changing almost twenty percent of the time a patient's understanding of their disease at the beginning versus the end. Do I really want

to be resuscitated? You know, having those tough discussions, even enrollment in hospice and palliative care, I think that's like seven or eight percent of time when we admit our patients. So I think that's some of it. You know. It's not that other programs don't do that as well, but that's been a focus of ours.

twenty twenty four. It doesn't seem like maybe I should just ask the question of rgin your mouth, but does your business model rely on Congress extending the waiver again? And you know, regardless of the answer, you know, are you confident that that Congress will extend the waiver?

we just need more time and data right this. You know, if we had an extension for five years, that gives us more time, data and you know these every time you admit a patient. The way the work waiver works today, you're you're sending in your case, right, You're letting CMS know how you did. So this isn't a black hole. This is very transparent what's going on. And I think if we can get you know, ten twenty thirty thousand of these admissions, were really going to know how safe

this is. So that's why I would completely encourage extension of the waiver.

And one of the things that I've heard Metpack Medicares Payment Advisory Committee took up this topic in one of their sessions, may have in March of this year, but at this point, at some point this year, it was discussed, and one of the things that were topics that came up was, well, hospital at home or this care at home should we be thinking about whether the reimbursement model changes, because you know, it's my understanding that the payment rates,

the reimbursement rates are all the same for care that's in a theoretically lower cost setting. Is that a concern for you or the industry that Congress could come in and say, or maybe the administration say, you know, we're going to make this a two tiered approach. If we're talking about care at the home, for these hospital level services, we should have a different reimbursement level. What goes through your mind when you hear.

and mortar like all of that. Right, So, I think, you know, we've been able to demonstrate on average five to seven thousand dollars of savings per admission in our model. And that has to do with some of those readmission reductions. It has to do with a few other things the way we've you know, set the reimbursement. But I think, you know, a bottom's up, look, that's fair because you want to incentivize this, right, I think that's perfectly reasonable.

what it is now. You know, one of the things I like to ask our guests about some of these policy questions. Is well, look in your crystal ball and not just tell us what's going to happen in five years. But you'll be disappointed in five years if something happens or something doesn't happen. So let me ask you this fast forward five years. You'll be disappointed if.

a bunch of stiffs with spreadsheets. Right. You're you're the future, and we need you to enact your dreams and vision. So have the guts to go do what you believe.

this moves forward. So I think that has been very helpful for me that help me understand what it is we're talking about, and I think that's a good place to wrap up this episode of Boots and Verdicts. Mark, thank you for joining us today and you have a lot on your plate and I appreciate you taking the time to talk with us, and thank you all for listening and for joining us. As a reminder, you can read all of our BI research on the Bloomberg terminal

at BI go. Once again, thanks for listening, and you have a great day.