Home health care is in many ways a fantastic service, especially for those Medicare beneficiaries who are essentially home bound due to frailty or illness.
But it often feels surprisingly hard to synergize with home health care.
The main problem, as I see it, is that home health care agencies have set themselves up to provide only administratively required communication with the ordering doc. (There are rules governing home health care, you know!)
Now, what I need is clinically relevant communication. As in, how is the patient clinically doing, so that you and I can coordinate our efforts together. This has apparently not been built into the home health care workflow.
And things get even more complicated when it’s a patient in assisted living, because then you have the facility nurse who should be kept in the loop as well.
Right now, I am trying to follow up on an elderly woman who lives in assisted living and has paid in-home aides (which are provided by a separate company).
I referred her to home health care a few weeks ago for help managing her skin. On one hand, she was starting to develop a pressure sore from sitting too much in the same position. And on the other hand, she had a fungal rash in her groin, under her incontinence brief.
I prescribed an antifungal cream to be used twice a day for two weeks.
Now it’s been three weeks, and the pharmacy is requesting a refill.
Well…what’s going on with that rash?
What I want to do is send an email to everyone who is involved and might know something.
Three juicy lemons came through my inbox this week. The NY Times published an expose of why hip replacement surgery costs 5-10 times as much in the US as in Belgium even though it’s the same implant. JAMA published research and a superb editorial on the Views of US Physicians About Controlling Health Care Costs and CMS put out a request for public comment on whether physicians’ Medicare pay should be made public. Bear with me while I try to make lemonade, locally, from these three sour economic perspectives.
Here’s a super-concentrated summary of the three articles: The hip surgery is more expensive because, in the US, as many as 10 intermediaries mark-up the price of that same hip prosthesis. Then, Tilburt et al said in JAMA that “physicians report that almost everyone but physicians bears responsibility for controlling health care costs.” The physicians reported that lawyers (60%), insurance companies (59%), drug and device manufacturers (56%), even hospitals (56%) and patients (52%) bear a major responsibility to control health care costs. Finally, CMS is trying to balance the privacy interests of physicians with the market failure that my other two lemons illustrate.
Can we apply local movement principles to health reform? How much of our money can we keep with our neighbors? What policies and technologies would enable the health care locavore? The locavore health system couldn’t possibly be more expensive than what we have now and, as with food and crafts, more of the money we spend would benefit our neighbors and improve our community.
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.
This November, voters weighed in on an array of state ballot initiatives on health issues from medical marijuana to health care reform. Ballot outcomes by state are listed below (more after the jump).
Voters in Alabama, Montana, and Wyoming passed initiatives expressing disapproval of the Affordable Care Act, while a similar initiative in Florida garnered a majority of the vote but failed to pass under the state’s supermajority voting requirement. Missouri voters passed a ballot initiative prohibiting the state executive branch from establishing a health insurance exchange, leaving this task to the federal government or state legislature.
Florida voters defeated a measure that would have prohibited the use of state funds for abortions, while Montana voters passed a parental notification requirement for minors seeking abortions (with a judicial waiver provision).
Perhaps surprisingly, California voters failed to pass a law requiring mandatory labeling of genetically engineered food. Several states legalized medical marijuana, while Arkansas voters struck down a medical marijuana initiative and Montana voters made existing medical marijuana laws more restrictive.
Colorado and Washington legalized all marijuana use, while a similar measure failed in Oregon.
Physician-assisted suicide was barely defeated in Massachusetts (51% to 49%), while North Dakotans banned smoking in indoor workplaces. Michigan voters failed to pass an initiative increasing the regulation of home health workers, while Louisiana voters prohibited the appropriation of state Medicaid trust funds for other purposes.
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.Continue reading…