I make house calls. Remember those? When a doctor came to your door with a black bag? You might think of this as a quaint vestige of prewar life, or a luxury for the exceptionally wealthy with their concierge doctors. But home care medicine, as it's now called, is extremely efficient and effective in modern America. Indeed, it often makes more medical and financial sense than a trip to the doctor's office.
Picture an older couple: He's 86, she's 82. He's got several health issues: obstructive lung disease, heart failure, diabetes, hypertension, arthritis and early Alzheimer's. She takes care of him, organizes his 14 medications, prepares low-salt meals. They're managing.
But then one Tuesday they notice he's getting more short of breath and his legs are a bit swollen. They cross their fingers and hope this is temporary. They're not stupid; it's a kind of denial. Neither of them drives. They'd have to get a ride from a nearby daughter, but she's got two kids and they don't want to bother her if they don't have to. So they wait a day. Or two.
By Thursday, it's real. His symptoms are worsening. They call their doctor's office and are told to go straight to the emergency room — it's too complicated for a quick office visit. They grow used to these intermittent hospitalizations. Like a lot of people, he jokes that he's going in for "a tuneup."
This is how millions of people with chronic conditions get into a cycle where all of their care is emergency care.
According to a recent Brookings Institution report, older people with chronic conditions suffer "repeated cycles of crisis, hospitalization and expensive but ineffective or even counterproductive treatment — leading to still more of the same." This is one reason our healthcare system is so expensive. Patients like this who constitute the top 10% of Medicare beneficiaries account for 57% of Medicare spending.
Home care medicine makes so much sense for these patients, and could cut those costs significantly. Multiple studies have found that even among the ill and elderly, at least 30% of hospitalizations are potentially avoidable. Research on home-based care for VA patients found a nearly 14% reduction in total healthcare costs, and a forthcoming study on a Medicare program in Washington suggests savings around 17%.
Take the couple above. If they had called my program on Tuesday rather than waiting, we would have visited them that day. We have the technology to take X-rays and analyze blood work on-site. Within an hour we could have diagnosed his problem, set him up on oxygen and started any necessary medications before returning to check on him the next day.
This is cheaper. But it's also better and safer than a hospital stay. Older patients are particularly susceptible to infections and medication errors. Away from familiar settings, they also get confused, tired and weak. They might fall.
Or they might not leave bed. Bed rest is devastating, especially for older people. Patients lose slightly more than 1% of their muscle mass every day they are in the hospital. So after a week, an older person has lost 10% of his strength. And it's hard to get it back. I call it "death by bed rest" — patients are cured of a disease but can no longer step into a bathtub, stand to cook or climb stairs. Often they can't even go home. According to a major study, 75% of patients over 75 years old who were living independently before admission to the hospital were no longer independent on discharge, and 15% required nursing home placement.
A home care team provides more than an alternative to hospitalization. Our team — which includes physicians, nurses, nurse practitioners, social workers, pharmacists and others — teaches families how to manage chronic conditions, discusses the goals of treatments, helps adapt the home to prevent dangerous falls and provides support to spouses, children or other caregivers.
There are obstacles to this becoming the new norm. Office visits are more convenient for physicians, and much more lucrative. Medicare's fee-for-service model, for example, doesn't account for time and expenses related to travel, care coordination and paying for the nonphysician members of the home care medicine team, including the social worker or nurse.
Despite that, more home care medicine practices are popping up. Some have arrangements with larger, integrated medical systems that see an opportunity to both improve the quality of care and save money. Accountable care organizations — groups of hospitals, doctors and other healthcare providers that are reimbursed by Medicare based on the quality of care and cost savings — also have incentive to roll out home care medicine programs.
But the change is not happening quickly enough. Medicare, Medicaid, private insurance companies, integrated health systems and health plans have to dismantle the reimbursement barriers to home care medicine. This bureaucratic hurdle is keeping tens of thousands of chronic patients from getting better treatment right where they live.
Home care medicine makes sense. It's what we want for our loved ones, and what we want for ourselves: the comforting knock on our door when we are in need. We are building the healthcare system that we're all going to grow old in. Let's do it right.