Slightly more than half of the doctors who responded to a physician survey in Massachusetts last fall said they kept patients in the hospital longer than necessary because of a lack of access to home health services, according to a new report.
But most of the doctors said they were aware that use of such agencies can safely reduce days of hospitalization and their cost as well as emergency room utilization, an increasing priority in the health reform agenda.
"As physicians see it, greater use of home services can ease costs without compromising quality of care. In today's healthcare environment, that's a winning formula," said Mario Motta, MD, president of the Massachusetts Medical Society.
The society collaborated with the Home Care Alliance of Massachusetts, a nonprofit trade group, to produce the report.
Patricia Kelleher, executive director of the alliance, said there are enough home health agencies around, but "certain kinds of specialized services are in short supply."
"The biggest delay is in getting physical therapists, who in general have been in short supply," she said. "When the patient is ready to be discharged on Monday, but the agency can't get someone to the home until Thursday or Friday, doctors must face a choice between sending patients home with no therapy for two or three days until the service can be found, or keeping them for an extra two or three days in the hospital."
The survey was launched because, according to the society, there is "a dearth of research on physicians' utilization of, and satisfaction with" home health services. Nevertheless, home healthcare can provide an increasing amount of skilled nursing, physical, occupational, and speech-language therapy, and medical social services to people in their homes.
Kelleher added that the survey has implications for the creation of accountable care organizations, in which the silos of hospital care, physician care, and home healthcare are torn apart and the three entities work together to reduce costs and produce better outcomes for patients.
"This report says that at least for Massachusetts, there are very good relationships between physicians and home health agencies that can form a building block for any sort of accountable care organization that we may be envisioning in the future," she said.
The survey found four other significant trends in the use of home healthcare for patients discharged from the hospital, a resource that promises to become much more important as the population ages and new federal limits on paying hospitals for readmissions take effect:
- Although reimbursement issues are a barrier to the use of home health agency services, 71% of physicians said they do not submit "care plan oversight" charges to Medicare for reimbursement, which they are entitled to receive for managing patients' home care programs. Thirty-five percent of primary care physicians and only 19% of specialists said they had submitted this charge to Medicare.
- 45% of physicians selected the home health agency based in part on a patient's request or patient's reference while 79% said they took into consideration the agency's affiliation with a hospital or network.
- Specialists were far less likely than primary care physicians to recommend their patients for home healthcare, either for terminal care or for chronic disease management, the survey found.
- More than half of physicians called out paperwork as the biggest barrier to their use of home healthcare services for their patients, while 40% said it was reimbursement issues.
The survey found that 64% of the doctors said they were unaware they could be reimbursed, which amounts to about one office visit charge. Other reasons for failure to submit include the perception among physicians that the rules for documenting how much time was spent are too cumbersome or some physicians may think it's not worth the effort for what they would be paid, Kelleher said.
"One of the impediments is that while a physician may feel that a patient may benefit from home health services, they sometimes are not covered by insurance because their needs don't meet the level of acuity of care deemed necessary for the insurance company to pay for it," said Dennis Dimitri, MD, a Worcester physician, who is president of the Massachusetts Academy of Family Physicians.
He added that another obstacle is the "bureaucratic paperwork, which can be a nightmare of filling out forms and signing requests," not to mention the amount of time it takes to set up referrals, communicate with nurses, and maintain oversight of the medical status reports that come back.
The survey has an important limitation, however. It sent the surveys to 3,000 of the 22,000 physician and medical student members for a sampling of 12 specialty areas of practice, but received responses from only 8.3% or 248.
The survey report concluded that "educating physicians on reimbursable home healthcare services and providing them with less burdensome administrative processes" could improve access for physicians and their patients.
According to a May report funded by the Alliance for Home Health Quality and Innovation, early use of home health services following discharge from a hospital saved Medicare $1.71 billion between 2005 and 2006, and another $1.77 billion would be saved if all Medicare beneficiaries with similar chronic diseases had access to such programs.
Dimitri said that one important finding from the survey is that "physicians utilize home health services a lot, and find them helpful in transitioning patients from hospital to home when they aren't quite able to take care of themselves at home.
He said that home health services are especially important for terminal patients, who would rather be at home during their last days.
"This is not only good thing from a fiscal point of view, but also it's much better for patients," said Dimitri.