The Covid-19 epidemic has had a massive effect on the way the health care industry provides care, with a particular spotlight on the potential of at-home care. In this episode of Radio Advisory, host Rachel Woods sits down with Travis Messina, co-founder and CEO of Contessa, to discuss why he believes at-home care can be beneficial not only to patients, but to hospitals as well—and how Contessa has helped hospitals in the wake of the Covid-19 epidemic.

How three providers expanded hospital-at-home amid Covid-19

Read a lightly edited excerpt from the conversation below, and download the episode for the full interview.

How Markham Stouffville Hospital developed their hospital-to-home program

Rachel Woods: I do want to be careful about buzzwords, I think that semantics actually really matter here, especially with the words, "hospital at home." What does that actually mean?

Travis Messina: I can't thank you enough for asking that question, Rae, because there are so many companies and health systems and people out there who are talking about hospital level care at home, and it means a thousand different things to a thousand different people.

When Contessa talks about hospital at home, we are talking about those patients who have failed ambulatory treatment and need to be admitted to a facility for several nights of care, typically for medical conditions.

Woods: So give me an example about how that would work. What's a medical condition that can't be taken care of in the ambulatory space, but which needs hospital-level care—tell me how that actually works in the patient's home.

Messina: So, if you think about the admissions to health systems, about 40-ish percent of them are for medical conditions, general medical complications. So, let's take congestive heart failure, or COPD, or pneumonia, those are very frequent cases that we treat in our hospital-at-home programs. Many times those patients can be treated with ambulatory treatment plans, however, those plans often fail, and that's when those patients require to be admitted to a facility for several nights.

And so if we have, for instance, a pneumonia patient, they've probably had oral antibiotics for a number of days and it's just not taking care of that pneumonia, and so they're going to need more continuous monitoring, oxygen treatments, infusion antibiotics, much higher acuity services, and we are able to replicate all the care they'd get in the hospital in their home.

Woods: How? I mean, when I think of hospital-level care, I think that is care that requires specialized equipment, specialized technology, specialized training and staff. How do you actually make that happen in someone's home?

Messina: So the number one misperception is that people think that you can do hospital at home without hospitals. And we partner with health systems and hospitals because when patients need that level of care, 80 to 85% of the time, they actually show up in the ED.

So we have team members who are based within the EDs of our partner health systems, they identify those patients as needing that level of care, we use admitting hospitalists, no differently than a hospitalist would admit to the floor, they admitted to our program, and we send that patient home.

If you think about a traditional general medical admission, they're getting rounding by a nurse every few hours, but they're not continuously monitored. If you need continuous monitoring, you're going to the ICU, send nurses to the home twice a day, and they render labs, plan film imaging, infusion services, and once a day, while they're there, a hospitalist rounds on that patient virtually using a remote patient monitoring kit.

Woods: And this, I think is top of mind for the entire health care industry right now because, as we know, Covid-19 has just put a spotlight on site of care shifts in general. I want to take a moment and talk about the role that Contessa has played when it comes to the Covid-19 crisis specifically, the direct impacts of battling this pandemic. What did you see as Contessa's role in the fight against this crisis?

Messina: There's been several instances in which Contessa has been leveraged throughout the pandemic. The one that immediately comes to mind is the work that we did in New York. So we are partnered with the Mount Sinai health system, and as everyone knows, New York was hit hardest and first by the surge. And so, I think it's okay to say this, but at one point in the spring, Mount Sinai had every single bed in their system filled by a Covid positive patient, and there were just simply not enough beds. They had tents and everybody knows that they were using the Javits Center, and all these things.

And so we began using our model to free up capacity so they could use that bed for higher acuity patients first and foremost. And while we first were not planning to treat Covid-positive patients, it became a necessity.

4 steps to develop a successful hospital-at-home program

The physicians came to us and said, "Look, I know that this is something that we haven't done, but we have to come up with a care plan. We have to come up with it quickly and make sure that we're not jeopardizing patient safety." And so that was probably the second use case where we stepped in and started treating Covid-positive patients at home.

Woods: To protect capacity, to stave off outbreaks, and ultimately to just treat more patients, obviously there are use cases beyond the surges, especially as surges seem to finally be getting under control here in the United States.

So beyond the kind of direct impacts of the pandemic, what are the other strategic reasons that an organization might want to partner with Contessa to invest in home-based care?

Messina: So, having come from a big integrated health system and being more of a finance and accounting guy by training, rather than a clinician, when we created the company, we were trying to think of the ways that we could satisfy strategic reasons why health system should offer this as part of their toolkit, for lack of a better description. Because if you're not at capacity, and you don't own the premium dollar risk, why on earth would you willingly take a patient you could send to the floor and get reimbursed for it and send them home.

And so those were the questions that we were really trying to solve when we started the company. And ultimately, I think before the pandemic, we came up with a couple of reasons. One, medical admissions typically have a very poor margin profile, from an economic perspective for health systems. And so we thought that if we could come up with the appropriate reimbursement structure, a system would be financially incentivized to do so, to admit to a hospital at home program, as opposed to admit to their floor.

Woods: Because it also means that opens up capacity for more profitable services for that hospital.

Messina: That's not exactly the argument that I would use because I would never say that you could guarantee you're going to backfill that bed. And more importantly, how do you know that you're not going to backfill that bed with a Medicaid patient or an OPA patient?

And so we look at it, when we do the financial analysis, we always assume that you are not going to backfill that debt, and what would the financial impact be under our risk arrangement versus the traditional health care or hospital delivery system.

Woods: I do want to go deeper into the financial. So I think what I just heard you say is that you create the right reimbursement structure to make it make sense financially for this kind of medical care to exist in the home. How does that work? What is the reimbursement structure?

Messina: So we use a bundled payment approach for our hospital at home programs. All of our health plan contracts are risk-based arrangements for 30- or 60-day episodes of care. And so we're not just looking at what health plans reimburse the hospital, but we're looking at all the related spend over that 30 to 60 days.

And that is what enables the health system to participate in economics that are outside of what is in their control, and that's where you make the financial benefit to a health system that's not at capacity.