[See Editorial Comments by Peter A. Boling and Bruce Leff, pp 1974Leff, pp -1976 OBJECTIVES: To determine the effect of home-based primary care (HBPC) on Medicare costs and mortality in frail elders. DESIGN: Case-control concurrent study using Medicare administrative data. SETTING: HBPC practice in Washington, District of Columbia. PARTICIPANTS: HBPC cases (n = 722) and controls (n = 2,161) matched for sex, age bands, race, Medicare buy-in status (whether Medicaid covers Part B premiums), long-term nursing home status, cognitive impairment, and frailty. Cases were eligible if enrolled in MedStar Washington Hospital Center's HBPC program during 2004 to 2008. Controls were selected from Washington, District of Columbia, and urban counties in Virginia, Maryland, and Pennsylvania. INTERVENTION: HBPC clinical service. MEASUREMENTS: Medicare costs, utilization events, mortality. RESULTS: Mean age was 83.7 for cases and 82.0 for controls (P < .001). A majority of both groups was female (77%) and African American (90%). During a mean 2-year follow-up, in univariate analysis, cases had lower Medicare ($44,455 vs $50,977, P = .01), hospital ($17,805 vs $22,096, P = .003), and skilled nursing facility care ($4,821 vs $6,098, P = .001) costs, and higher home health ($6,579 vs $4,169; P < .001) and hospice ($3,144 vs. $1,505; P = .005) costs. Cases had 23% fewer subspecialist visits (P = .001) and 105% more generalist visits (P < .001). In a multivariate model, cases had 17% lower Medicare costs, averaging $8,477 less per beneficiary (P = .003) over 2 years of follow-up. There was no difference between cases and controls in mortality (40% vs 36%, hazard ratio = 1.06, P = .44) or in average time to death (16.2 vs 16.8 months, P = .30). CONCLUSION: HBPC reduces Medicare costs for ill elders, with similar survival outcomes in cases and controls.

OBJECTIVES To determine the effect of home‐based primary care (HBPC) for frail older adults, operating under Independence at Home (IAH) incentive alignment on long‐term institutionalization (LTI). DESIGN Case‐cohort study using HBPC site, Medicare administrative data, and National Health and Aging Trends Study (NHATS) benchmarks. SETTING Three IAH‐participating HBPC sites in Philadelphia, PA, Richmond, VA, and Washington, DC. PARTICIPANTS HBPC integrated with long‐term services and supports (LTSS) cases (n = 721) and concurrent comparison groups (HBPC not integrated with LTSS: n = 82; no HBPC: n = 573). Cases were eligible if enrolled at one of the three HBPC sites from 2012 to 2015. Independence at Home‐qualified (IAH‐Q) concurrent comparison groups were selected from Philadelphia, PA; Richmond, VA; and Washington, DC. INTERVENTION HBPC integrated with LTSS under IAH demonstration incentives. MEASUREMENTS Measurements include LTI rate and mortality rates, community survival, and LTSS costs. RESULTS The LTI rate in the three HBPC programs (8%) was less than that of both concurrent comparison groups (IAH‐Q beneficiaries not receiving HBPC, 16%; patients receiving HBPC but not in the IAH demonstration practices, 18%). LTI for patients at each HBPC site declined over the three study years (9.9%, 9.4%, and 4.9%, respectively). Costs of home‐ and community‐based services (HCBS) were nonsignificantly lower among integrated care patients ($2151/mo; observed‐to‐expected ratio = .88 [.68‐1.09]). LTI‐free survival in the IAH HBPC group was 85% at 36 months, extending average community residence by 12.8 months compared with IAH‐q participants in NHATS. CONCLUSION HBPC integrated with long‐term support services delays LTI in frail, medically complex Medicare beneficiaries without increasing HCBS costs.

The relation between the timing of do-not-resuscitate (DNR) orders and the cost of medical care is not well understood. This prospective observational study compares hospital costs and length of stay of 265 terminally ill patients with admission DNR orders, delayed DNR orders (occurring after 24 hours), or no DNR orders (full code). Patients whose orders remained full code throughout a hospital stay had similar lengths of stay, total hospital costs, and daily costs as patients with admission DNR orders. Patients with delayed DNR orders, by contrast, had a greater mortality, longer length of stay, and higher total costs than full code or admission DNR patients, but similar daily costs. The causes of delay in DNR orders and the associated higher costs are a matter for future research. C urrent knowledge about the influence of do-notresuscitate (DNR) orders on health care costs is inconclusive. 1-4 Although 27% to 30% of all Medicare expenses occur in the last year of life, 5 we do not know how much of this care, if any, is unnecessary. 6,7 One review cast doubt on whether we could reduce costs by limiting end-of-life care, arguing that most such expenses are unavoidable. 8 Others argue, however, that setting explicit limits on high-tech care of the dying is a good first step toward containing costs of marginally beneficial care. 9 Most studies of the resource implications of DNR orders have been retrospective, identifying patients by a known outcome of death or DNR orders, and therefore subject to selection bias. 3,4,10 This study prospectively compares the hospital costs of terminally ill patients who have admission DNR orders, delayed DNR orders (those occurring after 24 hours), and full code status. METHODS Settings and SubjectsThis study identified patients with four diagnoses that have a high expected 1-year mortality (30%-60%) [11][12][13][14] : AIDS patients with a T4 cell count of less than 50 cells/ mm 3 ; patients with unresectable lung cancer; patients with severe chronic congestive heart failure (CHF); and nursing home patients with dementia and malnutrition (malnutrition defined as serum albumin Ͻ 3.5 mg/dL). Study Design and MeasurementsThe study protocol was approved by institutional review boards at each hospital. A DNR order was defined as a written order that a patient not receive cardiopulmonary resuscitation or intubation. Data included diagnosis, DNR status during the hospital stay, age, gender, race, type of attending physician (generalist or specialist), hospital site, insurance type, APACHE III score on admission, 15 and hospital survival. Economic variables included length of stay, total physician and hospital costs, and daily costs. For each physician fee, a resource-based relative value scale value was multiplied by a Medicare conversion factor to arrive at actual costs. 16 At the university hospital, a cost-accounting office provided a summary of daily hospital costs. At the community hospital, each charge was multiplied by a charge-to-cost ratio. Addition of physician and hospital cost...