My grandmother had lived just outside of Boston since 1944 in the same house where she raised her five sons. As he got older, it became harder and harder to stay. While it might have eased everyone else’s mind for her to go to a nursing home, that wasn’t what she wanted at all.
She was eventually able to die at home a few years ago. What it included was not extraordinary: the level of support from a social worker to coordinate care and transportation to her doctor’s offices. Remarkably, these cost-effective interventions are still not prioritized over the status quo of systems and care delivery in Massachusetts facilities, even after years have shown the dire need for alternatives.
Ranked as one of the top three states by the Commonwealth Fund and the second healthiest state by the United Health Foundation, Massachusetts established itself as one of the nation’s top performing health care systems in 2017.
But cost and health disparities remain a major obstacle. About 1 in 4 residents reported missing out on needed medical or dental care because of costs. Emergency department, hospital ambulatory and urgent care, and hospital utilization were above national averages, contributing to high costs and ranking the state 37th in preventable hospitalizations. The Massachusetts Health Policy Commission adopted a statewide target for sustainable growth in health care spending: 3.6% for the first five years, then 3.1% in 2018. Unfortunately, since this benchmark was established, health care spending are an average of 3.59% per annum.
It was in this environment that our stories — Landmark’s, Massachusetts’, and mine — collided when I was asked to launch the integrated home care model in the state where I have lived all my life. Already established in New York, California, Washington, and Oregon, Landmark has brought an interdisciplinary care team of social workers, behavioral health providers, clinical pharmacists, and nurse managers into the home to provide true preventive care and manage with the social determinants of health. We started in Boston by negotiating risk-based, value-based contracts with local health plans.
Our patients have an average of six to eight visits per year with their Landmark physician or pre-practice provider. And when urgent care issues arise, we’re on call 24/7 to triage and avoid unnecessary hospital visits. This alternative model intrigued me as my grandmother’s struggles were paramount. What surprised me the most, though, was that no one else did.
From 2018 to 2019, health care spending growth in Massachusetts was 4.3%. The Massachusetts Health Policy Commission’s efforts to control costs include limiting sites that can bill as hospital outpatient departments and implementing site-neutral payments in an effort to counter the ripple effects of health systems buying physician practices . Landmark is growing throughout Greater Boston in the ultimate neutral location: a patient’s home. By adapting care to the daily habits of the individual patient, we have improved outcomes at lower costs.
In 2020, as many as 17% of Medicare beneficiaries have five or more chronic conditions, and at least two million Medicare beneficiaries are entirely housebound, with little access to home care. And as a result, over the course of the pandemic, the perception of where and how people age has changed dramatically – for good reason. Home is where the day-to-day care happens for our patients, who have an average age of 77 with more than eight chronic conditions and more than 12 medications. Landmark’s results speak for themselves: a 26% reduction in mortality and a 20% reduction in medical costs over the past 12 months. Sending clinicians home is not cheap, but a 25% reduction in hospital admissions shows that our model pays for itself in one year.
It took a public health emergency to show that orienting a system toward emergency care was putting too much pressure on one end of the system. And for all their reputations for health reform and innovation, Massachusetts’ major health systems are swimming downstream. We can change the trajectory of what it means to grow old in the United States. We had a solution all along. Right here at home.
Chris Johnson is CEO of Landmark Health.