If Home Healthcare Is Often Better Than Hospitalization (and It Is), Why Is It So Uncommon in the U.S.?

Greggory Moore | Moore Lowdown
If Home Healthcare Is Often Better Than Hospitalization (and It Is), Why Is It So Uncommon in the U.S.?

image by: Myfuture.com

Healthcare hasn’t left the news for years. The fact that the talk is almost always about the $$$ may explain why home health care hasn’t caught on even though it often provides better patient outcomes and saves cash.

Small medical studies do not typically make national news. But in early February the CBS Evening News did a piece on a randomized study of just 20 people. Why? Perhaps because the subject concerns healthcare costs, a consistent topic of debate since Donald Trump took office. And the researchers feel they have identified a sector in which costs can be cut by 50 percent.

Over the last year a team of researchers led by Harvard University’s Dr. David Levine ran a pilot randomized control trial of “[a]dults admitted via the emergency department with any infection or exacerbation of heart failure, chronic obstructive pulmonary disease, or asthma” to “[d]etermine if home hospital care reduces cost while maintaining quality, safety, and patient experience.” Eleven patients received standard hospital care, while nine received “home hospital care, including nurse and physician home visits, intravenous medications, continuous monitoring, video communication, and point-of-care testing.” Want they found was that on average the homecare costs were over 50 percent lower than the hospital costs, with home patients having fewer laboratory orders, less frequent consultations, better sleep, and more physical activity. Otherwise, there were no significant differences in quality, safety, and patient experience.

What CBS didn’t report was that these findings are not especially new. For example, Dr. Bruce Leff has long believed that in many cases home-care patients can receive better outcomes than hospital patients at significantly less cost. For the last two decades Leff and his colleagues at Johns Hopkins have been refining a home-care model they call Hospital at Home, which was put to a real-world trial by Presbyterian Healthcare Services (PHS), New Mexico’s largest healthcare provider, between 2010 and 2012. The results? On average Hospital at Home patients experienced better outcomes at 19 percent less cost.

Shortly after his team released their report, Leff told Managed Care that their work was originally inspired by a pair of observations. One is the reluctance of some patients who needed hospital care to seek it out, a reluctance such people attribute to a variety of factors, including poor treatment of hospital patients and the fear of developing complications.

The latter fear is well founded enough to be the basis of Leff and company’s second observation: “[W]e saw many patients who had been admitted to a hospital and should have been easily treated but came out much worse for the wear. They’d develop delirium, they’d fall, they’d experience adverse drug reactions, they’d acquire nosocomial [meaning “originating in a hospital”] infections.”

The dangers inherent to hospitalization don’t stop at infections. In 2014, Dr. Robert Pearl wrote in Forbes of three types of risk hospitals impose:

  1. psychological harm due to such factors as “beaming florescent lights, beeping machines and loud hallway conversations [that] disrupt natural sleep patterns. Patients are routinely awakened at night for status checks,” etc.;
  2. physical harm, including an increased risk of falling (often due to the administration of sedatives partly to help patients deal with the psychological stresses hospitalization), a lack of physical activity, and increased exposure to germs;
  3. iatrogenic harm, i.e., harm directly caused by medical intervention. Pearl quotes an Institute of Medicine estimate that 98,000 people die annually in hospitals due to medical error.

(Pearl adds a fourth risk related to problems some patients have resuming their home routines once they have been hospitalized.)

While Leff notes that only patients meeting certain criteria are candidates for Hospital at Home, the reason why such a small percentage of eligible patients have this option may come down to profit motive. “Presbyterian [Healthcare Services] offers a nurturing fiscal environment for Hospital at Home,” he said. “That is, in an integrated system [such as PHS], hospital administrators have an incentive to keep patients out of their beds. Elsewhere, however, most hospital administrators in the fee-for-service world remain eager to fill their beds. One person’s savings is another person’s lost revenue.”

That is the same conclusion drawn by Drs. Luis Tacona and Kevin Schulman in a 2016 paper published in the New England Journal of Medicine. “In health care systems that bear full risk for costs and full responsibility for outcomes, the ability to substitute such services for hospitalization makes sense, given the differences in cost between inpatient care and home care,” they write, noting that programs like Hospital at Home are more common in countries such as the United Kingdom, France, and Australia. “[…] But in general, the lack of financial alignment in our [U.S.] system is an important concern. Fee-for-service systems have little incentive to develop these programs: hospitals stand to lose revenue, outpatient care providers have no incentive to work collaboratively with home care providers, and payers do not want to be burdened with ensuring appropriate utilization of these services.”

However novel the concept of providing hospital-level care for patients in their own homes, the reason the United States has yet to normalize such practices may be as old as capitalism. In short, follow the money.

About the Author:

Except for a four-month sojourn in Comoros (a small island nation near the northwest of Madagascar), Greggory Moore has lived his entire life in Southern California. Currently he resides in Long Beach, CA, where he engages in a variety of activities, including playing in the band MOVE, performing as a member of RIOTstage, and, of course, writing.

His work has appeared in the Los Angeles Times, OC Weekly, Daily Kos, the Long Beach Post, Random Lengths News, The District Weekly, GreaterLongBeach.com, and a variety of academic and literary journals. HIs first novel, The Use of Regret, was published in 2011, and he is currently at work on his follow-up. For more information: greggorymoore.com

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