One lesson we’ve learned during the pandemic is that we can no longer rely on hospitals as hubs for helping people who are sick or sick: it’s too expensive, and they don’t have the capacity.
The problem is, we’ve long thought of hospitals as the heart of our healthcare system. American healthcare has always revolved around managing disease — not preventing it — and all the high-tech tools that allow you to manage it are in the hospital.
More recently, hospitals have been pushing for more differentiation in the patients they accept as the cost of hospital care has ballooned, putting a burden on the healthcare system. Hospitals now accept and serve two main types of patients: those with only the most serious problems and those undergoing some kind of surgery.
This has led to more and more people going to the hospital because they are sick only to be sent home to fend for themselves. Net effect: more sick people stuck at home, but no help in recovery.
The healthcare system is catching up.
The solution is to move more care in the healthcare industry from the hospital to the home. We should use some of the country’s more than 10,000 home health care facilities to monitor these patients and help them on the road to recovery. I am the chief medical officer of a hospice and palliative care facility where nurses are trained in a range of home health care services. They mostly work with terminally ill patients, but there is no reason why they can’t work with other home patients.
These so-called “home hospital” schemes are popular in countries with single-payer healthcare systems such as the UK, Canada and Israel. But they are rare in the U.S. at a time when Medicare and other insurers offer limited reimbursement for home care, in part due to intense lobbying by the hospital industry, resistance from some insurers and concerns that the quality of care will be reduced by some who suffer at home .
However, there is some preliminary evidence that home care can be very effective in the United States if well-funded.Johns Hopkins University has been Start a home hospital program Since 1994, it has treated elderly patients who do not want or cannot be hospitalized because they are at risk of infection. Early trials of the program found costs, length of stay and complication rates were significantly lower than in hospitals.
Currently, when a patient leaves the hospital and goes home, this is called “post-acute” care. This framework is all wrong. We need to flip it: we should call hospital care “post-home” care because home care will be the norm. It sounds like semantics, but it’s important.
The logic of moving more patients out of hospitals (or choosing not to admit them in the first place) and sending them home is driven by pure economics—and the trend is only getting more pronounced. For most things, hospitals are much more expensive: X-rays in a hospital, for example, are five times more expensive than out-of-hospital. Taking aspirin is about 20 times more expensive in the hospital.
Patients are no longer admitted to hospitals until this becomes a last resort. If insurers don’t follow strict guidelines about who and what is hospitalized, they actually penalize hospitals. If they make the wrong call, they don’t get paid.
For healthcare managers and insurance companies, everything looks fine on spreadsheets tracking costs. But when we looked at what was actually happening with the patients, it didn’t look good at all.
One example: An elderly patient with shortness of breath, coughing, and spitting came to the emergency room and was told she might have pneumonia. In the past, when I was training as a doctor, my decision was a slam dunk and she would be taken to the hospital and given intravenous antibiotics. After a day or two, when she improved, she was sent home.
The decision is now equally simple, but hospital admission is not an option. It’s “Wait a minute, you’re not seriously ill and borderline sepsis. We can do this at home.”
And, yes, some people can do it at home. They have the support of enough family and friends to do it successfully. But too many people cannot take the necessary steps without outside support and services.
Because they don’t get enough medical attention, many of these patients get progressively sicker, making their outcomes worse and potentially costing the health care system more over time.
In the case of the elderly patient described above, she needs antibiotic infusion services and needs someone to check on her several times a week to help with medication and to treat all other medical issues other than pneumonia.
This is where a new type of home care might emerge.
A well-funded and supportive home health care service is needed to care for these Cat 22 patients: They’re not sick enough to go to the hospital, but too sick to be alone. This care can be provided by a home health agency, hospice or palliative care agency. Skilled nurses can administer IV medications, while different services can check on patients to make sure they are doing well, eating and taking their medications on time.
Some innovative suppliers have backed this up. The resistance comes from hospital groups worried about losing more reimbursement and insurance companies worried about more overall reimbursement. In the short to medium term, costs will rise as insurers are reimbursed for hospital-based care and home care. But over time, the theory goes that the former will decline, and we’ll get a model with a lower cost and more home care component.
We don’t need to create a new way of caring for sick people at home. We can use it now. We just need to fund it.
Photo: Maria Symchych-Navrotska, Getty Images
