Wednesday, September 22, 2010

Home-care project could improve delivery, cut costs

A few blocks from the nation's Capitol, a project is under way that may actually have a significant chance of improving the delivery of health care.
In health reform vernacular, the project is called Independence at Home. To patients there, it is known as the Medical House Call Program, an outreach of the Washington Hospital Center. The idea is to have doctors and nurses provide as much care as possible for Medicare patients at home to avoid unnecessary hospitalizations.

This gives rise to a clinical question: Would home visits from a physician provide better care and be more cost justified by the elimination of hospitalizations?

From the perspective of manpower, it will take significantly more time for physicians to make house visits than to see patients in a clinic. In clinics the average physician can see 30 or more patients a day. When a doctor is making house calls, even in a narrow geographic area, the metric drops to 10 to 11 patients a day.

So much for professional efficiency, but what about other costs?

The Medical House Call Program at Washington Hospital Center serves roughly 600 patients and was started more than a decade ago. Its participating patients have found their expected hospitalizations for the sickest patients to be reduced by two-thirds.

Accordingly, the program has a track record of success, but now Medicare must determine if it will succeed on a larger scale, and whether it is a model for the rest of the country.

Project finances are cloudy

The Independence at Home Program, funded by the CMS Center for Innovation, is Medicare's three-year demonstration project slated to begin in January 2012.

It takes 10,000 of Medicare's sickliest and most expensive patients — those chronically ill patients who would be likely to visit an emergency room several times a year and be hospitalized repeatedly. The program would reward providers who cut treatment costs by 5 percent, receive positive patient reviews and improve health outcomes.

As with most medical innovations, the project finances are cloudy. The Medical House Call Program does not receive any upfront money. Physicians are not paid to travel from home to home or for coordinating an individual patient's care. The project requires a shared savings approach in order to make it financially feasible.

Only a few years ago, hospitalists were considered to be innovative. Since that time, Nashville startups like CareHere have placed physicians in employer settings and achieved significant savings.

Tennessee's largest nursing home provider is now modeling a program in which physicians are based full time in skilled nursing facilities. Whether in the hospital, in the nursing home or at home, dedicated care by a doctor can result in significant savings.

Let's hope these innovative projects are properly funded and fairly analyzed. Stay tuned for the results.

Dick Cowart is chairman of the Health Law and Public Policy departments of the Baker Donelson law firm and a past president of the American Health Lawyers Association. Reach him at

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