Can house calls cut costs?
Dr. Daniel Oates knew what time it was. His patient, 92-year-old Roberta Baskerville, prefers that he not visit when “The Price Is Right” is on. But there he was, arriving at the Dorchester home that Baskerville has lived in for half a century and rarely leaves, just as the TV show was airing.
Baskerville’s son, Elliott, had called Oates this spring, concerned about his mother’s cough. Oates sent a technician to administer a chest X-ray in the home and found pneumonia. Baskerville improved with antibiotics, and Oates visited recently to check on her progress, taking notes on his laptop in the kitchen while the television flashed silently nearby.
Oates is a Boston Medical Center geriatrician who makes house calls, part of a cadre of physicians nationwide who serve a growing need for homebound seniors. He believes home visits provide more personalized, consistent care to people who might not otherwise see a doctor and can prevent hospitalizations or delay a move to a nursing home.
Now the Centers for Medicare & Medicaid Services, in a program created under the newly-affirmed Affordable Care Act, is looking at the Boston program and 15 others to see whether they also can save money. Advocates hope the results will persuade more doctors to begin seeing patients at home.
Elliott Baskerville said he is certain his mother, who has severe arthritis, would have ended up in an emergency room without intervention by Oates. For decades, she avoided doctors and would have put off seeking care for her cough, he said.
“She let Dr. Oates in,” said Baskerville, who lives in New Jersey and speaks with Oates by phone during each visit. “It’s like talking to a friend instead of going to some clinical type of situation.”
Programs like the one at Boston Medical Center are not common. Home care accounts for about 1 percent of all Medicare billing for “evaluation and management services,” essentially time spent talking with doctors, versus tests or procedures, said Gary Swartz, associate executive director of the American Academy of Home Care Physicians.
One reason: the cost. David Kornetsky, administrative director of geriatric services at Boston Medical Center, said it costs about $3,000 per year to cover each person enrolled in the home care program, now about 575 people. Medicare and other insurance coverage pays for only about half, he said. The hospital, which has been sending doctors to patient homes since 1875 with a focus on the elderly in the past three decades, subsidizes the rest.
But Kornetsky said he sees long-term value in the program. “The model has finally arrived,” Kornetsky said.
Hospitals increasingly are under pressure to do more to manage the care of their sickest patients. Starting this fall, as required by the federal health law, they will be penalized for high rates of patients returning to the hospital within 30 days of discharge from a stay for pneumonia, heart attack, or heart failure. Increasingly, doctors are being paid in ways meant to reward them for preventing costly acute care, particularly for patients with chronic illnesses.
But studies of the cost of home care are mixed. One, published in 2000 in the Journal of the American Medical Association, followed 1,966 patients with restricted mobility connected to 16 Veterans Affairs medical centers. Researchers found that the half who received home care had a better quality of life, as did their caregivers. But care for those patients cost about 12 percent more over the one-year study period.
More recently, however, Veterans Affairs has reported cost savings and reduced hospitalizations among people in the home care program. Smaller, site-specific studies also have shown progress in preventing more expensive care.
The national pilot program, called Independence at Home, is designed as a large-scale test of costs and quality, with up to 10,000 patients.
Boston Medical Center is in the process of enrolling about 100 patients who qualify and must maintain an average enrollment of 200 over the three-year trial, Kornetsky said. Participants must have traditional Medicare coverage, a recent hospitalization, chronic illnesses, and functional limitations. The Centers for Medicare & Medicaid Services will compare the overall cost of caring for those patients with the cost for similar patients not enrolled in the program.
If the Boston program saves more than 11 percent, the agency will share savings with the hospital. The pilot also will track various quality measures, including patient satisfaction and how often people visit an emergency room or are hospitalized with preventable conditions. And it will measure how providers feel about their work, in a field in which recruitment of doctors is difficult.
“For me, these patients are all like my grandparents,” said Oates, who was close with his own.
Working with a group of social workers and nurse case managers to help people with issues that go beyond medical conditions is rewarding, he said.
Home visit teams might look for loose rugs or poor lighting that could cause a fall, and do what Swartz called the “refrigerator biopsy” to see if people are getting enough food.
Oates said he and colleagues also detect whether patients are safe in custody of their caregivers — he had several open protective services cases in mid-June — or if their drugs are taken by relatives or others in the home. And, he said, going over a patient’s drug regimen in the home, where they have their medications on hand, can help dispel confusion.
Oates sat recently in the second-floor bedroom of the Dorchester home where 88-year-old Ella Mitchell spends nearly all of her time. He told her she could stop one of the many medications she takes to treat a complicated list of conditions, including emphysema, history of pulmonary embolism, and a degenerative joint disease. But Mitchell wasn’t sure which one he meant.
She pulled her pill bottles from a desk drawer, and Oates went through them with her, identifying the blue pill she no longer needed.
“Medical care has been sort of provider-centric,” said Al Norman, executive director of Mass Home Care, a network of organizations that provide support for elderly people living at home. “The patient is at home. Where the provider lives is at the office. Historically, the provider has won out.”
Norman said he would welcome the expansion of services such as those Boston Medical Center provides, though he noted that physician assistants, nurses, or caseworkers, who are paid less, can play a big role in addressing medical needs in the home.
With home care, “you’re getting a window into the person’s life that you can’t possibly get in the office,” said Len Fishman, chief executive of Hebrew SeniorLife, a large senior care and housing provider in the Boston area. The group does not provide home-based primary care, though one of its Brookline housing facilities has a clinic on site. Fishman said he is encouraged by the Independence at Home pilot. But, he said, “if it works, then what?”
Swartz, whose organization is assisting with the pilot, said expanding the shared savings program beyond 10,000 patients nationally would require action by Congress. But if the federal agency shows that home care saves money over time, he said, more doctors may be inspired to get out of the office.