One of the lessons that has been hammered home during the pandemic is that we can no longer rely on hospitals to be the hub for helping people who are sick or suffering from illness: It’s too expensive and they don’t have the capacity.
Problem is, we’ve long considered the hospital to be the nucleus of our healthcare system. Healthcare in the U.S. has revolved around managing illness — rather than preventing it — and all the high-tech tools that allow you to manage illness have been in hospitals.
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More recently, as the cost of hospital care have ballooned, burdening the healthcare system, there has been a push by hospitals to be more discriminating about which patients they take. Hospitals now mainly admit and serve just two types of patients: those with only the direst problems and those who are getting surgeries of some kind.
That has created a growing population of people who travel to the hospital because they are sick only to be sent back home to fend for themselves. The net effect: More sick people are stuck at home but without any help with the recovery.
And the healthcare system is playing catch up.
The solution is to shift more of the care in the healthcare industry from the hospital to the home. We should use some of the country’s 10,000-plus home-healthcare agencies to monitor these patients and help them on a path to recovery. I’m the chief medical officer at a hospice and palliative-care agency, where the nurses are trained in a broad array of home healthcare services. Mostly they deal with end-of-life patients, but there is no reason why they can’t work with other home-based patients, too.
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These so-called Hospital at Home programs are popular in some countries that have single-payer health systems like England, Canada and Israel. But they’re rare in the U.S. because Medicare and other insurers at this point offer limited reimbursement for home-based care in part because of furious lobbying from the hospital industry, resistance from some insurers, and fears among some that the quality of care would suffer in the home.
There is, however, some preliminary evidence that home-based care could be highly effective in the U.S. if funded properly. Johns Hopkins has been running a Hospital at Home program since 1994 that treats elderly patients who either don’t want to be in a hospital or can’t because they’re in danger of infection. Early trials of that program found that costs, length of stay and the incidence of complications were all significantly lower than in the hospital.
Currently, when a patient leaves the hospital for their home, it is referred to as “post-acute” care. This framing is all wrong. We need to flip it: We should refer to hospital care as “post-home” care because home care will be the norm. It may sound like semantics, but it’s important.
The logic of removing more patients from hospitals (or choosing not to admit them in the first place) and sending them home is being driven by pure economics—and that trend is only going to get more pronounced. Hospitals are drastically more expensive for most things: For example, an X-ray in a hospital costs five times more than what it costs outside the hospital. For administering an aspirin, it’s about 20 times more expensive in the hospital.
Patients are no longer being admitted to a hospital until that becomes the option of last resort. Insurers actually punish hospitals if they don’t follow rigorous guidelines for who and what gets hospitalized. If they make the wrong call, they don’t get paid.
For healthcare administrators and insurers, it all looks good on a spreadsheet that tracks costs. But when we look at what’s actually happening to patients, it doesn’t look so good at all.
An example: an elderly patient who is feeling short of breath, coughing, and spitting up gets to the emergency room and is told she likely has pneumonia. In the past, when I was training as a physician, the decision was a slam dunk that she would be admitted to the hospital and given intravenous antibiotics. One or two days later, after she had made progress, she would be sent home.
Now the decision is just as straightforward, but admission to the hospital is not one of the options. It’s “wait a second, you’re not severely ill and borderline septic. We can do this at home.”
And, yes, some people can do this at home. They have enough support from family and friends to successfully pull it off. But way too many can’t take the needed steps without outside support and services.
Because they’re not given enough medical attention, many of these patients get progressively sicker, leading to worse outcomes for them and potentially costing the healthcare system even more over time.
In the case of the elderly patient above, she’ll need infusion services for antibiotics and someone checking in on her several times a week to help with medications and treatment for all the rest of their medical issues beyond the pneumonia.
That’s where a new kind of home care could come in.
What’s needed is a fully funded and supported home healthcare service to care for these patients who are stuck in a Catch 22: they are not sick enough for the hospital, but too sick to be left on their own. This care could be provided by home healthcare agencies, hospice agencies, or palliative agencies. A skilled nurse could administer IV medications, while a different service could just check in on the patient to make sure they’re doing ok, eating, and taking their medications on time.
There is a groundswell of support for this among some innovative providers. The resistance has come from hospital groups that are worried about losing more of the reimbursement and insurers that are worried about more overall reimbursement. In the short-midterm, there would be a rise in costs, as insurers are reimbursing both for hospital-based care and home-based care. But over time, the theory is the former would come down, and we’d be left with a lower cost model that has a greater home-care component.
We don’t need to create a new way to care for sick patients at home. That’s available to us right now. We just need to fund it.
Photo: Maria Symchych-Navrotska, Getty Images
Michael Lalor, MD, MBA, CPE, FACHE, HMDC, FAAHPM, FAAPL is the Chief Medical Officer of Trellis Supportive Care in Winston-Salem, NC., and is an Assistant Professor of Medicine at Wake Forest University. Dr. Lalor earned his medical degree from the University of Medicine and Dentistry of New Jersey, and his MBA with an emphasis in Healthcare Management from West Texas A&M University. He has an extensive background in hospice and palliative medicine, and lectures widely on regulatory topics affecting physicians. He serves on the Board of Directors for the Association of Home and Hospice Care of North Carolina, and is a Fellow of the American Academy of Hospice and Palliative Medicine. An alumnus of the Leadership College of the North Carolina Medical Society, Dr. Lalor is a Certified Physician Executive and Fellow of both the American College of Healthcare Executives and the American Association for Physician Leadership.
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