Article in The Atlantic Highlights Benefits of Home-based Care Over Hospitalization
December 6, 2013 01:43 PM
In this month’s edition of The Atlantic Monthly, author and Brookings Institute Senior Fellow Jonathan Rauch examines the benefits of home-based care for the chronically ill over hospital-based care. Mr. Rauch has written previously about end-of-life care in May of 2013.
In his most recent article, Mr. Rauch analyzes several new home-based care programs – either through health system collaborations or independently – and states that, “a more humane, effective, and affordable health-care system is closer than we think.”
“This article clearly illustrates the benefits of home-based care over the traditional care approach of putting sick people in hospitals and having them return time and time again,” said Val J. Halamandaris, President of the National Association for Home Care & Hospice (NAHC). “I hope that Americans read this article and become allies of the home care and hospice community. The article makes clear what we have been saying for decades: home care is the most preferred and cost-effective method of care. Despite growing support, the industry is battling a recent CMS rule that will decimate access to and availability of care through their recent rebasing rule. Buy their own analysis, 43% of home care providers will be in the red under their new scheme, which we will continue to oppose. This article makes clear why we need allies, why our fight is worthy and why millions of Americans prefer – and should - be treated in their own home.”
Below are excerpts from the article:
“Brad Stuart is one of those changes. He is a leader in a growing movement advocating home-based primary care, which represents a fundamental change in the way we care for people who are chronically very ill. The idea is simple: rather than wait until people get sick and need hospitalization, you build a multidisciplinary team that visits them at home, coordinates health-related services, and tries to nip problems in the bud. For the past 15 years, at Sutter Health, a giant network of hospitals and doctors in Northern California, Stuart has devoted himself to developing home-based care for frail, elderly patients.
For years, many people in medicine have understood that late-life care for the chronically sick is not only expensive but also, much too often, ineffective and inhumane. For years, the system seemed impervious to change. Recently, however, health-care providers have begun to realize that the status quo is what Stuart calls a “burning platform”: a system that is too expensive and inefficient to hold. As a result, new home-based programs are finally reaching the market, such as one launched about five years ago at Sutter, called Advanced Illness Management. “It’s much more feasible now to make a program like this work than it was a few years ago,” Stuart told me. “There are a lot of new payment schemes in the pipeline that are going to make this kind of program much easier to support.”
The problem that home-based primary care addresses has been well understood for years. Thanks to modern treatment, people commonly live into their 70s and 80s and even 90s, many of them with multiple chronic ailments. A single person might be diagnosed with, say, heart failure, arthritis, edema, obesity, diabetes, hearing or vision loss, dementia, and more. These people aren’t on death’s doorstep, but neither will they recover. Physically (and sometimes cognitively), they are frail. Joanne Lynn, the director of the Altarum Institute’s Center for Elder Care and Advanced Illness, says that this “frailty course,” a gradual and medically complicated downslide, was once exceptional but is now the likely path for half of today’s elders.
Seniors with five or more chronic conditions account for less than a fourth of Medicare’s beneficiaries but more than two-thirds of its spending—and they are the fastest-growing segment of the Medicare population. What to do with this burgeoning population of the frail elderly? Right now, when something goes wrong, the standard response is to call 911 or go to the emergency room. That leads to a revolving door of hospitalizations, each of them alarmingly expensive. More than a quarter of Medicare’s budget is spent on people in their last year of life, and much of that spending is attributable to hospitalization. “The dramatic increase in costs in the last month of life is largely driven by inpatient hospital stays,” Helen Adamopoulos recently reported on MedicareNewsGroup.com. “On average, Medicare spends $20,870 per beneficiary who dies while in the hospital.” …
Sutter figures that…by keeping patients out of the hospital whenever possible, saves Medicare upwards of $2,000 a month on each patient, maybe more. The VA, for its part, says its program reduces hospital days for its patients by more than a third and reduces combined costs to the VA and Medicare by about 13 percent.
But now we come to the business model, which has been problematic. For doctors, nurses, health systems, and insurers, providing in-home service costs money. Medicare pays for hospitalization, but it does not pay for much by way of in-home care, or for social workers, or for time spent coordinating complex cases and traveling to homes and talking with caregivers. Where in-home primary care has existed, it has tended to be a foundation-funded experiment, or a charitable project, or part of a vertically integrated system like the VA, which can capture any savings. The home-care program at Washington Hospital Center runs at a 30 percent loss. Meanwhile, hospitals lose “heads in beds,” and therefore revenue. Medicare—which is to say, taxpayers—may save money, but it has no mechanism either to track savings or to pay providers and insurers for hospitalizations that do not happen.
This is why Brad Stuart was frustrated for so many years. He could see the path forward, and others could see it, but it was blocked. Today, though, he’s feeling optimistic. The path is clearing.”