Evaluation of the Independence at Home Demonstration

Section 3024 of the Patient Protection and Affordable Care Act (Public Law 111-148) enacted the Independence at Home (IAH) demonstration in 2010. The purpose of the IAH demonstration is to test a payment incentive and service delivery model for providing home-based primary care to chronically ill and functionally limited Medicare beneficiaries.

The 18 practices chosen to participate in the Independence at Home (IAH) Demonstration are expected to design and implement coordinated care plans tailored to individual beneficiaries’ chronic conditions and responsive to their preferences, make in-home primary care visits to these patients, and be available 24 hours per day to meet their health needs. The goal of the demonstration is to improve the provision of comprehensive, coordinated, continuous, and accessible care to chronically ill, functionally limited beneficiaries. This evaluation is determining whether—and, if so, how—sites achieve success. The demonstration began with 18 participants in 2012 and was intended to last for three years. Congress has extended the demonstration three times—most recently adding Years 8 to 10 (2021 to 2023). As of Year 8, seven participants remain in the demonstration.

Mathematica is using a mixed-methods design that centers on a set of three key research questions:

What is the effect of the demonstration on processes of care? Our implementation analysis is using qualitative techniques and descriptive methods to assess practices’ actual experience and the factors that helped or hindered their efforts to improve outcomes. Much of the data will be obtained from multiple rounds of site visits to the demonstration practices and telephone interviews with key staff at those practices.
Does receiving home-based primary care result in less expenditures and hospital use for chronically ill and functionally limited Medicare beneficiaries? We use difference-in-differences regression analyses with an appropriate comparison group to control for other simultaneous changes that might be fully or partially responsible for any observed improvement in key outcomes. Using propensity score matching, we are matching Medicare beneficiaries who received home-based primary care with beneficiaries who lived in the same area and met the same eligibility criteria but did not receive home-based primary care. The results provide an estimate of the effect of home-based primary care on the expenditures and hospital use of chronically ill and functionally limited Medicare beneficiaries.
Did the possibility of earning an incentive payment result in less expenditures, less hospital use, better quality of care, and improved health outcomes for chronically ill and functionally limited Medicare beneficiaries? Our mixed methods approach includes difference-in-differences regression analyses with an appropriate comparison group to control for other simultaneous changes that might be fully or partially responsible for any observed improvement in key outcomes. Using propensity score matching, we are matching samples of Medicare beneficiaries to create a comparison group for each of the demonstration practices. The results provide an estimate of the effect of the IAH incentive payment structure on the costs and utilization of IAH practices’ patients. To measure outcomes of interest that are not captured in administrative data, we have developed beneficiary and caregiver surveys. The surveys use a mail with telephone follow-up design.