Time for payment models to stop discriminating against in-home care

American healthcare delivery is seriously dysfunctional. It takes patients about three weeks to get a doctor’s appointment, they sit in the waiting room for a long time,  get 10 to 12 minutes with the doctor and then have a hefty deductible and/or copay despite paying handsomely for insurance.

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American medicine costs about three times per capita more than most other developed countries, yet outcomes are no better, patient satisfaction is low and burnout among physicians is high.

As to hospitalization, it is very expensive, the risk of a medical error is real, hospital-acquired infections are all too common and the patient frequently leaves feeling unsatisfied.

But do all those individuals admitted necessarily need hospitalization? Today the answer is generally yes. But tomorrow, that could, and probably will change, for the better. What if many of the attributes of the hospital could be brought to the home? Attributes like nursing care, electronic monitoring of vital signs and intravenous therapy, to name just a few.

There is really no reason why the home cannot serve this purpose for some selected patients today. When it does, the patient remains in familiar, comforting surroundings; the chance for errors and infections can go down and the costs of care can decline substantially. The critical question, of course, is whether the clinical outcomes are just as good, or possibly even better.

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Enter an innovative and exceptionally transformational approach. Think of it perhaps as a virtual hospital that maximizes the capacity to use today's digital technology.

Embryonic at best in the United States, there are multiple examples worldwide as recently reviewed in the New England Journal of Medicine.[1] The basic idea is to follow emergency room evaluation (or even doctor’s office evaluation) with the decision to admit to the hospital or to use hospital at home care.

Not all patient conditions are appropriate for home care of course, but among those that are often appropriate: exacerbation of heart failure and chronic obstructive pulmonary disease, community-acquired pneumonia, asthmatic attacks, deep vein thrombosis and possibly pulmonary embolus and deep-seated skin or soft tissue infections.

One study compared 50 patients treated at home for a 34-day period to a similar group treated in the hospital after initial evaluation in the emergency room or observation unit. At the conclusion of the study period, the at-home patients had greater satisfaction with multiple query categories and met standard quality measures for their specific diagnoses. Those patients were less likely to need readmission over the ensuing ninety days.[2]

Some keys to success include effective two-way digital communication systems that allow for virtual physician and nurse visits in a HIPAA secure setting along with remote virtual biometric monitoring. Proper patient selection is important, as those who might need more intensive diagnostics (e.g., MRI) or therapeutics (e.g., surgery) are inappropriate candidates.

Next: The time is right for implementation

It is also important that the work traditionally done by hospital personnel not be offloaded to the family members; this will defeat the purpose and lead to ill-will. Maintaining contact virtually and with home visits for a prolonged period after the immediate acute episode will likely improve the care transition and lead to fewer readmissions.

With positive results nationally and internationally, why hasn't the hospital-at-home model become commonplace? I suspect it has multiple causes not least of which is physician concern.

Medical professionals are loath to make dramatic changes when the current system works, or at least works reasonably well for most episodes. Add in, of course, that the fee-for-service reimbursement model for physicians and hospitals discourages interest. Only when the physician can be paid for virtual/digital care approaches and the hospital benefits financially from fewer admissions will real interest develop.

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Innovative? Certainly. Transformative? Definitely. Makes sense from a quality of care perspective? Yes. Leads to greater patient satisfaction? Yes. Means fewer safety lapses and care associated infections? Perhaps. Reduces unplanned remission rates? Probably. Costs less? Yes.

In sum, the time is right for implementation in those settings where payment models do not discriminate against in-home care models. Logical places to start would be Medicare Advantage plans, military or veterans plans and other entities that hold total fiscal and care risk.

Home hospitalization could be one step in improving the American dysfunctional healthcare delivery system with improved care, greater satisfaction and reduced costs-the Triple Aim.

 

Stephen C. Schimpff, MD, is a quasi-retired internist, professor of medicine and public policy, former CEO of the University of Maryland Medical Center, scientific advisor to Sanovas, senior advisor to Sage Growth Partners and is the author of Fixing the Primary Care Crisis: Reclaiming Relationship Medicine and Returning Healthcare Decisions To You And Your Doctor

November 18, 2016

Tags: Home hospitalization, virtual physician visits, biometrics, unplanned readmissions, remote monitoring, biometric monitoring,

[1] Ticona, L and Schulman, K,  Extreme Home makeover – the role of intensive home health care, NEJM, 2016; 375: 1707-1709

[2] Summerfelt, w, etal, Scalable hospital at home with virtual physician visits: pilot study, Amer J Managed Care, 2015; 21: 675-684