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Getting cheaper, better healthcare at home?

August 25, 2009|Noam N. Levey

RICHMOND, VA. — Fanning out through this city's old neighborhoods, doctors and nurses from a local medical center have adopted a practice that harks back to a bygone era: They're making house calls.

Surprising as it may seem, this throwback approach may offer a path toward the elusive goal of providing better medical treatment at lower cost.

And although the proposal has generated fewer fireworks than the proposed new government insurance plan, experts say it may help transform the nation's healthcare system.

Lawmakers on Capitol Hill are poised to make house calls a building block of President Obama's promised healthcare overhaul.

"This is one of the most promising ideas I have seen," said Elaine Ryan, a vice president at AARP, the influential seniors group. "It is not only a cost saver . . . it is something that addresses really the most critical issue for Medicare beneficiaries."

The core idea is deceptively simple: By staying in close touch with some of their sickest patients through home visits, doctors and nurse practitioners can avoid admitting them to hospitals, where costs and potential complications multiply.

"These patients are having preventable complications. When they get discharged from the hospital, they are having avoidable readmissions," said Dr. Mark McClellan, who oversaw Medicare in the Bush administration. "Improvements in care could yield big savings."

Like most other ideas for helping the troubled healthcare system, implementing this idea on a national scale probably wouldn't be easy. And the stakes are high.

Medicare, which provides health insurance to about 45 million mostly older Americans, is expected to run out of money in just eight years. Just 10% of Medicare beneficiaries -- most of them suffering from multiple chronic conditions -- account for nearly two-thirds of Medicare spending.

Despite numerous attempts over the last decade, the federal government still hasn't found a formula that both assures top-quality care and reins in spending.

"Our experience hasn't been very good," acknowledged Timothy P. Love, who heads the Office of Research, Development and Information at the Centers for Medicare and Medicaid Services.

But, Love said, Medicare has not yet tried a house call program led by primary care doctors.

On the streets of Richmond, the seemingly anachronistic practice is producing positive results.

Dr. Peter Boling heads a team of four doctors and five nurse practitioners. They see about 275 homebound patients who live within 15 miles of the hospital, visiting each approximately once a month.

Most of the patients suffer from multiple chronic conditions, such as diabetes, heart disease or Alzheimer's. All are so ill that it had become an ordeal to go to the doctor's office for a routine physical or to check on a worrisome symptom.

It's not uncommon for patients like these to experience mild confusion, for instance, which could signal a stroke or a routine urinary tract infection.

Elsewhere, such an episode often prompts a 911 call, an ambulance ride to the emergency room, a battery of tests and a long hospital stay.

"We call it the million-dollar work-up," nurse practitioner Tammy Krukiel said recently.

Krukiel was visiting Barbara Beasley, a 66-year-old retiree with congestive heart failure.

As Beasley rested in her small apartment, propped up with pillows in her bed so she could watch television, Krukiel took her pulse and made sure she was getting enough oxygen.

She checked a plastic bag crammed with Beasley's medications. And over the whir of a hulking window air conditioner and a fan, Krukiel asked Beasley gently about her depression and panic attacks.

This added attention isn't cheap, a barrier that has stood in the way of broader adoption of house call programs.

Medicare doesn't pay enough to cover the Richmond program's $1-million annual budget, but the Virginia Commonwealth University Medical Center picks up about half the tab, Boling said.

What makes the subsidy feasible, said Linda Pearson, the medical center's vice president for finance, is savings generated from fewer Medicare hospitalizations, which are not reimbursed at full cost. "Every day they can keep a patient out of the hospital, it saves us $1,500," she said.

Most promising has been a newer part of the house call program, called transitional care, that seeks to reduce readmission of patients who have been recently discharged from the hospital.

An internal analysis by VCU Medical Center suggested that from 2003 to 2006, the house call program helped cut in half the number of days these patients spent in the hospital, saving the medical center as much as $2 million.

Elsewhere, the U.S. Department of Veterans Affairs, which has operated a house call program since 1972, found in a study of 10,000 veterans that the program cut hospital inpatient admissions by more than one-quarter and slashed the group's total days of hospitalization by more than two-thirds.

It has been more difficult to make house call programs work for doctors who are not affiliated with a medical system that can offset the costs by recouping savings from reduced hospitalizations.

To change that, the proposal on Capitol Hill, known as Independence at Home, would give independent doctors and nurse practitioners a chance to share in the savings that Medicare would see from home visits to patients with multiple chronic conditions.

The proposal has been added to a House version of the healthcare legislation, but its fate is unclear in the Senate.

"We have about 3 million immobile, seriously ill people in our communities whose needs are not being met by the healthcare system," Boling said.

"The promise of this model is that we can do what patients and their families want and need, and at the same time reduce their costs."

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noam.levey@latimes.com

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