My grandmother had lived near Boston since 1944, in the same house where she raised her five sons. As she got older it became harder to stay. While going to a nursing home may have reassured everyone else, it wasn’t what she wanted at all.
After all, she was able to die at home a few years ago. What that entailed wasn’t extraordinary: assisting a social worker in coordinating care and transportation to her doctors’ offices. It is noteworthy that these low-cost interventions are still not placed above the status quo of systems and facility-based care in Massachusetts, even after the years have pointed to the urgent need for alternatives.
Ranked one of the top three states by the Commonwealth Fund and the second healthiest state by the United Health Foundation, Massachusetts has established itself as one of the top-performing healthcare systems in the country in 2017.
However, cost and health disparities remained a major stumbling block. Up to 1 in 4 residents said they forgo the necessary medical or dental care because of cost. Emergency departments, outpatient and acute hospital care, and hospital utilization were above the national average, contributing to high costs and ranking the state 37th for avoidable hospitalizations. The Massachusetts Health Policy Commission adopted a statewide target for sustainable health care spending growth: 3.6% for the first five years, then 3.1% for 2018. Unfortunately, since that benchmark was established, health care spending has averaged 3.59% per year .
In this setting, our stories—Landmark, Massachusetts’s and mine—collided when I was asked to spearhead the entry of the integrated care-at-home model into the state where I’ve lived my entire life. Landmark, already based in New York, California, Washington and Oregon, brought a multidisciplinary care team consisting of social workers, behavioral physicians, clinical pharmacists and care managers to the home to provide true preventive care and address social determinants of health. We began negotiating high-risk, value-based contracts with local health plans in Boston.
Our patients attend an average of six to eight visits per year to their Landmark Physician or advanced practice provider. And when urgent care issues arise, we’re on call 24/7 to make choices and avoid unnecessary hospital visits. I was fascinated by this alternative model because it focused on my grandmother’s struggles. However, what surprised me the most was that no one else did.
From 2018 to 2019, healthcare spending growth in Massachusetts was 4.3%. Efforts by the Massachusetts Health Policy Commission to control spending have included limiting locations that can be billed as hospital outpatient clinics and introducing location-neutral payments to counter the impact of healthcare systems buying doctors’ offices. Throughout the greater Boston area, Landmark grew in an absolutely location-neutral place: a patient’s home. By tailoring care to the daily habits of the individual patient, we improved outcomes at a lower cost.
As of 2020, up to 17% of Medicare beneficiaries have five or more chronic conditions, and at least two million Medicare beneficiaries are completely homebound with little access to home care. And as a result, over the course of the pandemic, perceptions of where and how people age have shifted dramatically — and for good reason. Daily health care takes place at home for our patients, who have an average age of 77 years, are treated with more than eight chronic diseases and more than 12 medications. Landmark’s results speak for themselves: a 26% reduction in mortality rates and a 20% reduction in medical costs over the last 12 months. Sending doctors to homes doesn’t come cheap, but a 25% reduction in hospital admissions shows that our model pays for itself over the course of a year.
It took a public health emergency to show that gearing a system toward acute care puts far too much pressure on one end of the system. And with all its reputation for healthcare reform and innovation, Massachusetts’ major healthcare systems are swimming downstream. We can change the course of what it means to age in the United States. We had the solution all along. Right here, at home.
Chris Johnson is CEO of Landmark Health.