My grandmother has lived outside Boston since 1944, in the same house where she raised her five children. As she got older it became difficult to survive. Although her going to a nursing home might have eased anyone else’s mind, it wasn’t at all what she wanted.
In the end, I managed to die at home a few years ago. What it involved was not unusual: the social worker’s level of support to coordinate care and transportation to her doctor’s offices. Remarkably, these cost-effective interventions still do not take priority over the current state of systems and facility delivery in Massachusetts, even after years have indicated a critical need for alternatives.
Ranked as one of the top three states by the Commonwealth Fund and the second healthiest by the United Health Corporation, Massachusetts established itself as one of the best performing healthcare systems in the country in 2017.
But disparities in cost and health remained a major obstacle. Up to 1 in 4 residents report not needing medical or dental care because of the cost. Emergency department, hospital outpatient and acute care, and hospital utilization were above national averages, contributing to higher costs and ranking 37th in preventable hospitalizations. The Massachusetts Health Policy Committee has passed a statewide target for sustainable growth in health care spending: 3.6% for the first five years, then 3.1% for 2018. Unfortunately, since this standard was set, health care spending has averaged 3.59% annually.
It was in this environment that our stories collided—the stories of Landmark and Massachusetts, my own—as I was asked to launch a home-based integrated care model into the state, where I have lived my whole life. Already established in New York, California, Washington and Oregon, Landmark has brought a multidisciplinary care team consisting of social workers, behavioral health providers, clinical pharmacists, and nurse care managers into the home to provide truly preventative care and address the social determinants of health. In Boston we began negotiating value- and risk-based contracts with local health plans.
Our patients average six to eight visits per year from a Landmark physician or advanced practice provider. And when urgent care issues arise, we’re on standby 24/7 to triage and avoid unnecessary hospital visits. This alternative paradigm intrigued me, with my grandmother’s struggles being paramount. What surprised me most is that no one does that.
From 2018 to 2019, health care spending growth in Massachusetts was 4.3%. The Massachusetts Health Policy Commission’s efforts to control spending included limiting sites that could bill as hospital outpatient departments and implementing on-site neutral payments, in an effort to counter the ripple effects of health systems buying physician practices. Landmark has grown all over Greater Boston in a final neutral location: the patient’s home. By adapting care to the patient’s daily habits, 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 completely residing at home, with little access to care at home. As a result, over the course of the pandemic, the perception of where and how people age has changed dramatically — and for good reason. Home is where the daily work of health care happens for our patients, who have an average age of 77 with more than eight chronic conditions and more than a dozen medications. Landmark’s results speak for themselves: a 26% reduction in death rates and a 20% reduction in medical costs in the last 12 months. Sending doctors home isn’t cheap, but a 25% drop in hospital admissions shows our model pays for it over the course of a year.
It took a public health emergency to demonstrate that steering a system around acute care puts too much pressure on one end of the system. And with all its reputation for health reform and innovation, Massachusetts’ large health systems are swimming downstream. We can change the course of what it means to age in the United States. We’ve had the solution the whole time. Here, at home.
Chris Johnson is the CEO of Landmark Health.