Qual­ity gains, cost re­duc­tions make strong case for the mod­ern house call

Modern Healthcare - - COMMENT - By Dr. Glen Stream

Nearly ev­ery day a claim is made that some­thing will make our lives bet­ter, health­ier, eas­ier. And while many of th­ese claims are in­ter­est­ing, and some be­come game chang­ers, most are hype.

Nowhere is this phe­nom­e­non more prom­i­nent than in medicine. Sci­ence has pro­duced what only a few decades ago were con­sid­ered mir­a­cles—treat­ments, pharmaceuticals, di­ag­nos­tics and surg­eries, that have made, for ex­am­ple, many can­cers cur­able or treat­able as chronic dis­eases. Hav­ing a stroke or a heart at­tack is no longer a death sen­tence. The list goes on.

How­ever, as medicine con­tin­ues to make huge strides with tech­nol­ogy as its part­ner, we of­ten for­get that physi­cians re­main at the cen­ter of medicine, and pa­tients are at the cen­ter of physi­cian prac­tices. This brings us to an old prac­tice that is be­com­ing new again: the house call.

While tra­di­tional house calls never dis­ap­peared, their fre­quency dwin­dled be­cause they didn’t fit into the mod­ern fee-for-ser­vice model. How­ever, our in­ter­est never dis­ap­peared. We have al­ways known their ben­e­fit, which, com­bined with the cur­rent fo­cus on value over vol­ume, has caused pol­i­cy­mak­ers to look again at an old but good idea.

In June, the CMS an­nounced that af­ter just one year of its three-year In­de­pen­dence at Home Demon­stra­tion (IHD), par­tic­i­pat­ing physi­cian prac­tices saved an av­er­age of $3,070 per ben­e­fi­ciary—while de­liv­er­ing high-qual­ity pa­tient care in the home.

U.S. Med­i­cal Man­age­ment and its af­fil­i­ate, Vis­it­ing Physi­cians As­so­ci­a­tion (an IHD par­tic­i­pant), rep­re­sented 25% of the pa­tient care in the demon­stra­tion. Par­tic­i­pat­ing prac­tices showed high per­for­mance on many qual­ity and cost mea­sures, in­clud­ing a 16.4% re­duc­tion in ex­pected costs, and re­duc­tions in all-cause 30-day read­mis­sions, in-hospi­tal ad­mis­sions and emer­gency depart­ment vis­its for am­bu­la­tory care-sen­si­tive con­di­tions.

For fam­ily physi­cians like Dr. Thomas Corn­well, this is great but not un­ex­pected news. As the leader of the Home Cen­tered Care In­sti­tute in Wheaton, Ill., he has made 32,000 house calls to more than 4,000 pa­tients through his house-call prac­tice. Corn­well calls this Af­ford­able Care Act ini­tia­tive a part of the per­fect storm that is driv­ing an in­creased de­mand for mod­ern house calls. Un­like tra­di­tional home care, this new ver­sion of the house call is based on a med­i­cal home; house calls are not a sup­ple­ment.

Also driv­ing this per­fect storm is a quickly aging baby-boomer pop­u­la­tion, the Medi­care and Med­i­caid fis­cal cri­sis, health­care re­forms, in­clud­ing the CMS’ goal to re­duce hospi­tal read­mis­sions, and the shift from vol­ume­based to value-based pay­ment.

As a re­sult, house-call physi­cians are part of an ef­fort to get Congress to pass leg­is­la­tion to move this home­care demon­stra­tion into a new house­call ben­e­fit sim­i­lar to how the Pro­gram of All-In­clu­sive Care for the El­derly, or PACE, pro­gram be­came a new ben­e­fit. PACE is de­signed to keep peo­ple age 55 and older out of nurs­ing homes by pro­vid­ing com­mu­ni­ty­based care and ser­vices.

This would mean more shared cost-sav­ings op­por­tu­ni­ties. There­fore, more providers would be in­cen­tivized to of­fer home care. And be­cause only about 15% of the peo­ple in the U.S. who need home care are re­ceiv­ing it, there is plenty of po­ten­tial for growth.

An Oc­to­ber 2014 study in the Jour­nal of the Amer­i­can Geri­atrics So­ci­ety an­a­lyzed the Vet­er­ans Health Ad­min­is­tra­tion’s Home-Based Pri­mary Care Pro­gram, which started over 20 years ago and serves more than 30,000 vet­er­ans. The study found:

A 24% re­duc­tion in to­tal health­care costs un­der the pro­gram (2002 data), which amounted to an an­nual sav­ings of more than $10 mil­lion.

The HBPC pro­vided four times more pri­mary home care ver­sus tra­di­tional home health, but still pro­duced a 63% re­duc­tion in hospi­tal costs, and an 87% drop in nurs­ing home costs.

2007 data found a 59% re­duc­tion in hospi­tal days, an 89% re­duc­tion in nurs­ing-home days and a 21% re­duc­tion in 30-day read­mis­sions.

All of th­ese re­sults have piqued the in­ter­est of ma­jor med­i­cal net­works look­ing to bet­ter serve their pa­tients while re­duc­ing read­mis­sions and costs. And this has fam­ily physi­cians ex­cited about the fu­ture of the house call. “Those who have been the pioneers of house calls have known about its value for years,” Corn­well said.

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View guide­lines at mod­ern­health­care.com/op-ed.

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Dr. Glen Stream is pres­i­dent and board chair­man of the not-for-profit Fam­ily Medicine for Amer­ica’s Health and past pres­i­dent of the Amer­i­can Academy of Fam­ily Physi­cians.

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