Home-based care: A blast from the past might be health care’s future

Back in the 20th century, many physicians conducted home visits. Whether it was for a serious illness or a minor problem like a common cold, patients had access to doctors without leaving their homes.

Today, many patients don’t have proper access to physicians at a health care facility, let alone at home. In fact, lack of access is an especially serious problem for people that are homebound. About 2 million older Americans are homebound and another 5 million have trouble leaving home without getting some assistance. Of those that are completely homebound, less than 12% report receiving any primary care services at home. Poor access to physicians leads to unmet health needs and, in the long run, increased health care spending.

But house calls may be making a 21st century comeback. To combat increasing costs and provide more comprehensive care, government organizations have created programs that pay for home-based care. These programs have interdisciplinary teams that include physicians, nurse practitioners, physician assistants, behavioral health professionals, care managers, pharmacists, and rehabilitation specialists.

Two government programs have provided some early evidence that home-based care helps patients—and with managing health care budget.  CMS’ Independence at Home Demonstration, is a pilot project that provides primary care services for Medicare beneficiaries with multiple comorbidities. During its first performance year, the program saved more than $25 million and awarded $11.7 million in incentive payments to nine participating practices. CMS also found that beneficiaries participating in the pilot program had, on average, fewer hospital readmissions and used fewer inpatient hospital and emergency department services for chronic conditions such as diabetes, hypertension, and asthma. Utilization of health care services for acute conditions, such as pneumonia and urinary tract infections, also decreased. During the second year of the program, 15 participating practices served more than 10,000 beneficiaries and were able to save approximately $7.8 million in aggregate. In addition to the savings, seven practices earned a total of $5.09 million in incentives.

The Department of Veterans Affairs also has a home-based primary care program for patients with complex health care needs. The program, which got started in the ’70s, now serves more than 31,000 patients a day across the nation. In 2002, the VA found that the program resulted in a 62% reduction in hospital days, 24% reduction in cost to the VA, and 25% reduction in hospital admissions. Although this research was done quite some time ago, it shows the potential home-based care has for saving health care dollars.

Still, several obstacles stand in the way of large-scale adoption of home-based care. Fee for service is still the dominant form of compensation, and the reimbursement for home-based care is inadequate, if it exists at all. Many providers are not set up to provide home-based care, which, ideally, involves many different types of providers. Travel time is issue. It is difficult to make the economics of home-based care work if a practice is serving relatively few patients scattered over a wide geographic area.

But none of these issues are insurmountable. With the advent of novel technology and increasing ability to connect with people remotely, clinicians are developing more ways to provide accessible health care. By following the examples set by CMS and the VA, other stakeholders could—and should—develop their own home-based care programs as one of the innovative new ways to deliver health care.