Can Home Be Where the Healthcare Quality Is?

When you think of improving quality, you may think it involves something new—new ways of evaluating data, new methods to pay for care, or new applications of information technology. But it also can mean looking at something old—and seeing if it can have an impact as well—such as encouraging the idea of provider home care visits, especially for the senior population.

While great interest has been emerging over the concept of the patient-centered medical home in both the healthcare and political communities, it may be time to look at care in the patient's home as a way to provide quality care.

Back in 1930, house calls accounted for 40% of the encounters between physicians and patients. However, by 1980, that rate dropped to less than 1%. But that has been changing: in 1995, 1.5 million home visits were paid for by Medicare, and by 2007, those visits increased by nearly 2.2 million. Approximately 4,000 of the nation's physicians, plus nurses and physician assistants, are making home visits part of their practice, according to the American Academy of Home Care Physicians.

And greater changes could be ahead if healthcare reform legislation is approved on Capitol Hill. Incorporated into the House bill (HR 3962) and the Senate Finance Committee bill (S 1796) is a provision called the "Independence at Home Medical Practice Demonstration Program" that would test a "payment incentive and service delivery model" staffed by physicians and nurse practitioners on home based primary care teams.

So why this kind of model? As Peter Boling, MD, the head of general medicine at Virginia Commonwealth University Medical Center in Richmond, tells it, there usually is just enough payment in the current Medicare fee-for-service payment formula to cover short, uncomplicated home-based care visits to patients.

However, "It's not enough to support the really complex case management that actually saves [Medicare] money," said Boling, who speaks from 25 years of experience providing home-based care to Richmond-area residents. "It's hard to grow as a business model."

"We see ourselves saving lots of money for the Medicare program because if the programs are designed the way ours are, we end up keeping people from having to go into the hospital," said Boling, who works with his hospital-supported primary care program that includes several physicians and nurses who make approximately 2,500 to 3,000 home-based calls per year.

Home-based care "ultimately saves the Medicare program money and it makes the patients less sick and more happy—which is also a good thing," he said.

The home-based program described in the bill is a type of "gain-sharing arrangement" in which the main elements of the Medicare program—such as the hospital, physician, and drug coverage—remain the same.

However, for individuals who enroll in a special program called Independence at Home, if the amount of money spent on them was less than what Medicare expected to spend, then the savings would be given to the provider or organization that was providing the healthcare. The Independence at Home amendments, which were actual bills before being incorporated into the reform bills, has attracted strong bipartisan support in both congressional chambers.

Having home-based care available presents many advantages to older and vulnerable patients, Boling said. In particular, patients can receive medical assistance in a few hours rather than a few days, and the care is less disruptive to their day-to-day lives," he said. "We're here to help them manage."

"And the quality of service would be better because we would actually know what was going on with them. We'd see all those pill bottles that they have or we would see the reality of their house . . . Do they have to go up stairs? Do they need some additional equipment?" he said.

There are "all sorts of things that you know right away when you go into somebody's house that you don't always know when somebody's in the artificial environment of the clinic," he said.

And the advantages are there for Medicare, too, such as the reduced hospital readmissions or "incident admissions" to hospitals and emergency rooms. "We've intercepted a certain percentage of hospitalizations before they even happen," Boling said.

And what about the likelihood that home-based programs eventually do expand—posing competition to his group practice? He said that would be a "good problem to have—as opposed to being the only game in town. [We would no longer] have a waiting list of people actually dying before they come into the program, which is what happens now."