While Congress is debating health reform and struggling to accomplish the apparently competing goals of reducing costs while improving quality, I am part of a program that does both. As co-director of the Washington Hospital Center’s Medical House Call Program, I visit the sickest, frailest Medicare patients who consume a wildly disproportionate amount of Medicare dollars. Not only am I providing better care for my patients, I’m doing it where they want it — at home. House calls allow me to better manage their chronic conditions by seeing their medications, diet and home life and enabling me to better support their caregivers and coordinate their medical care. The math is simple: the better I do, the happier they are and the fewer times they need to visit an expensive hospital or nursing home. Shockingly, this proven approach that reduces unnecessary spending is being overlooked in the current reform debate.
Take one of our patients, Mrs. C, who has heart failure and pulmonary disease. She is chair- and bed-bound. She relies on her daughter for all her basic needs and cannot easily get to the office. Through our program, a team of doctors, nurse practitioners and social workers can visit Mrs. C at home and provide care on-site. We can manage her heart and lung problems on the spot, rather than having to wait until her symptoms are so severe that she has to go to an emergency department by ambulance. Additionally, avoiding the hospital means Mrs. C is less likely to face medical complications from a hospital visit. The accrued savings pay for a year’s worth of house calls for eight patients. Our program has shortened the hospital stays of 600 patients by a quarter, and reduced hospitalizations at end of life by 75 percent.
Mrs. C represents a population of patients who are virtually invisible to the office-based primary care physician and to most specialists until they land in a hospital. If we want to reduce health costs, we need to provide better medical care to these patients at home. People with multiple chronic diseases consume 60 percent of Medicare expenditures, despite the fact that they comprise only 10 percent of all Medicare beneficiaries. By targeting these high-cost patients and providing them with higher quality, more convenient care, the American Academy of Home Care Physicians estimates that we could save $14 billion a year and perhaps much more.
The Veterans’ Administration’s Home-Based Primary Care program has been operating a similar program for over 30 years in nearly every state and has seen reductions in hospital days by nearly two-thirds, nursing home days by 88 percent and costs associated with these patients by nearly a quarter. Further, this program enjoys the highest satisfaction rate of any program within the VA system.
But the benefits are not just financial. By going into someone’s home, we can help patients and their families practice what we preach. It is one thing to tell a patient to reduce his sodium intake, and it’s another to walk in and do what we call a “kitchen biopsy,” to uncover all the sodium-rich foods in the pantry and teach them healthier habits. Home visits help prevent complications; they don’t just treat them.
Successful programs like these are only able to do so with private funding to supplement what Medicare pays. You cannot build a system of care solely on altruism. If we want this kind of care for our loved ones, or for ourselves, we need to find a way to make house calls sustainable.
There is a solution. The pending Independence at Home Act (S. 1131, H.R. 2560), establishes the framework and incentives to make home-based primary care a reality. These savings could actually be used to help fund health reform.
At best, this legislation saves Medicare money, and at worst, it costs Medicare nothing. Under the proposed legislation, Independence At Home (IAH) programs must achieve 5 percent savings — which is more than enough to “bend the curve” of unbridled growth. These programs promote the best patient outcomes by sharing in any savings over 5 percent. This legislation is a win-win-win—for patients, Medicare and physicians.
This legislation creates pilot programs in 26 states and the District of Columbia; half of those states have the highest-cost patients. Because there are so many of these programs already in place, the IAH Act could be implemented tomorrow. It is the medical version of a “shovel-ready” program and the savings will start immediately.
How can Congress and the Administration ignore a proven cost-saving plan that addresses our most expensive patients? By 2020, the number of Americans over the age of 80 will double. We need to act now to improve quality and reduce costs for these patients or Medicare will struggle even more to cover them. If Congress is serious about reforming our health system, they should join with the bill’s sponsors, Representative Markey and Senator Wyden, to support a model that reduces costs, and improves both care quality and outcomes from these patients’ homes.
It is going to take smart use of nimble, ready-made, cost-saving programs like this one to begin to attack health spending and turn our system around. By taking better care of patients like Mrs. C, we can achieve those goals and provide coverage and better quality care to all Americans.
Dr. George Taler, MD, is the Director of Long Term Care at the Washington Hospital Center, and Co-Director of WHC’s Medical House Call Program. He previously served as the President of the American Academy of Home Care Physicians (AAHCP) and is currently the Chair of Public Policy. Dr. Taler is also a Professor of Clinical Medicine at Georgetown University School of Medicine.