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Why Health Care Should Bring Back the House Call

Harvard Business Review

Years ago, as a family physician in Louisiana, I made house calls. Certain patients were too sick or too hurt to get to my office. Sometimes a condition or injury had worsened, requiring my evaluation bedside. I would visit patients at home for the simplest of reasons: home was where they needed care.

By the mid-1980s, the pressures of time and money prevented most physicians from making house calls anymore. But I kept seeing patients at home until I retired from my practice after 29 years. Home visits enabled me to better detect, diagnose and treat most health conditions. Many of the patients I saw might otherwise have wound up in an emergency room and eventually been admitted to a hospital.

If we hope to rein in health care costs and improve quality, we need, in effect, to bring back the house call. Americans are living longer than ever before and a higher percentage of the population is elderly, with both trends sure to accelerate drastically in the decades ahead. Baby Boomers are now turning age 65 at the rate of roughly 10,000 per day.

As the older demographic expands, so, too, does the number of people who live with chronic diseases, chiefly diabetes, high blood pressure and heart failure. About three in four of Americans age 65-plus suffer from more than one such chronic condition. The single biggest and fastest-growing contributor to healthcare costs is chronic disease. That's why an estimated, 49% of our health care costs go toward 5% of Medicare beneficiaries.

Yet the U.S. health care system is still based on a massive misconception: that health care for the sickest of the sick, typically the elderly and the chronically ill, should be carried out almost exclusively in institutions, primarily hospitals, but also nursing homes and assisted living facilities. And that health care delivery should consist largely of, say, a trip to the emergency room or a four-day hospital visit for pneumonia. That kind of episodic engagement represents short-term thinking. When it comes to health care, hospitals are essential, but are only a part of the answer.

Rather, health care should be practiced year-round, and even minute-by-minute. Managing chronic disease should involve post-acute care, complete with daily monitoring of vital criteria, including blood pressure, diet and physical activity. Only under such regular oversight can chronically ill patients expect to function well, much less fully. No single approach can do this better than home care. It can shorten hospital length of stay and lower readmissions. And there is mounting evidence that health care delivered at home enables patients to live longer lives and, equally important, better ones.

In the process, home care is doing exactly what's most needed -- increasing quality and driving down costs. An Avalere Health study found in 2011 that health care at home improved outcomes and saved $2.8 billion among patients with diabetes, congestive heart failure and COPD. A 2009 study revealed that home health care reduced hospitalizations and short-term nursing stays, saving Medicare dollars. Indeed, expanding access to home health care for chronic-disease patients could save a projected $30 billion, that same study concluded.

Yet the value of home care remains under recognized. As a result, vast needs are still going unmet. Here's what has to be done:

Define the discipline better. The medical community, including physicians, medical schools, and hospital administrators must better describe what home care does and why it matters in order to bring it to life for policymakers and family caregivers.

Get in sync. Primary care physicians particularly, but also nurses, therapists, social workers and others, must align better with home-care clinicians to coordinate care, especially during and immediately after the transition from hospital to home.

Physician, educate thyself. Physicians should learn about home-care options and discuss them with patients who could benefit.

Adopt new technologies. More companies in the home-care business should use innovative technology to coordinate care in real time, including point-of-care laptops, telemonitoring devices, and Internet portals for physicians that allow all providers to share a patients' information.

Remove policy obstacles. Reimbursements from Medicare and private insurers should reflect the true value of home care. But the payment system now in place sees home care, quite mistakenly, as merely an add-on with little clinical benefit. Policymakers should create a payment model that aligns providers' clinical and economic interests, assigning proper value to good outcomes and recognizing that home care is pivotal to success.

Health care at home is patient-centered, outcomes-driven and truly collaborative, making it a microcosm of how the health care system should function across the board. Only by embracing home care can we truly reform the health care system.

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