People who use home health care in New Jersey following their hospital stays are less likely to be readmitted, saving the state�s health care system millions of dollars, according to a new study released by the Home Care and Hospice Association of New Jersey.
In fact, patients who receive in-home services are 30% less likely to return to the hospital , according to the findings�a figure that further decreases when the patient in question has multiple chronic conditions.
The study, conducted by the Quality Insights Quality Innovation Network as contracted by the Centers for Medicare & Medicaid Services (CMS), sought to determine the effectiveness of home health care services in preventing a 30-day hospital readmission after an inpatient hospital discharge. It included Medicare fee-for-service claims among New Jersey beneficiaries who had been discharged from a New Jersey hospital in 2014.
Among those referred for care, 71.76% ended up receiving the services, while 28.23% chose not to utilize home health. The 30-day hospital readmission rate among beneficiaries who opted into home health care were lower than those who didn�t, according to the study, at 17.2% as compared to 24.5%.
�Considering that the 30-day readmission rate among individuals who were referred for home health services but did not receive them was 7.3% greater than the rate among those who were referred for home health services and did receive them, it is possible that at least [$6.9 million] could have been saved if this population would have utilized the home health services for which they were referred,� the report states.
The study comes after New Jersey learned last year that it had the highest percentage of hospitals penalized by CMS for not reducing high readmission rates of Medicare fee-for-service patients within 30 days of their initial discharge, New Jersey radio station 101.5 reported.
Are house calls really dead, as we suggested in a blog post Monday? Dr. Michael Oppenheim begs to differ.
Oppenheim, 76, has spent virtually his entire career making house calls in Los Angeles. The core of his practice is serving as an on-call doctor for hotels and for travel insurance companies whose foreign subscribers fall ill while visiting here. But he also does shifts for Heal, a new Uber-like service that dispatches doctors to homes at a charge of $99 per visit to patients without insurance to cover the house call. (Heal is an in-network provider for some insurers, whose patients are charged merely a standard co-pay.)
"I enjoy what I do," Oppenheim told me. "I don't mind long drives, or getting up at night. I don't have to go to an office in the morning."
Oppenheim reached out to us in response to our post Monday expressing skepticism about the idea of an "Uber for healthcare." The post observed that physician house calls, which are the stock in trade of new Uber-like services such as Heal and Pager, are poorly suited to the modern healthcare market.
Because they're massively inefficient uses of doctors' training and time, the argument went, they're unlikely to be priced affordably for most patients or to attract a sizable cadre of doctors.
Oppenheim's experience illustrates both the virtues and the limitations of the house call. He chronicles many of these aspects of his practice on his very entertaining blog, thehoteldoctor. Let's hear him out.
After receiving his undergraduate degree from UCLA and his medical training at New York University, Oppenheim came back west to do his residency in Santa Barbara, then worked at the Veterans Affairs hospital in North Hills. (The hospital was torn down after sustaining damage in the 1994 Northridge earthquake.) In 1979 he answered an ad placed by a Malibu doctor with a house-call practice, and took over the practice entirely in 1983.
At the time, only luxury Beverly Hills hotels kept doctors on call. But over time, Oppenheim managed to persuade even mid-level hotels that "having a hotel doctor was a good idea." Eventually he made it onto the on-call rosters of travel insurance companies and airlines that needed coverage for their traveling crews. By 2003, when he retired to Kentucky, his annual earnings had peaked at about $140,000 and he had maxed out at about 1,200 calls a year.
He didn't care for retirement, so he moved back to L.A. in 2007 and rebuilt his practice from scratch. Now he makes 350-400 calls a year, charging $300-$350 (slightly more for distant or off-hour runs) and grosses an average of up to about $120,000.
Most of his calls involve minor health complaints; when he gets a call from a hotel, he always insists on speaking with the guest, and roughly half the time he concludes that a visit isn't necessary. Anything serious, and he refers the patient to an office visit or sends him or her to the ER. Normally, he spends 15 minutes or so with a patient, or at most, an hour for a more complicated case.
"You can't really deliver sophisticated medical care in a house call," he acknowledges. And he's understanding with hotel guests who might call with a complaint that turns out to be routine. "You can't blame people for calling the doctor for something that's not that serious," he says. "People call the doctor when they feel sick."
Oppenheim knows his professional lifestyle isn't for anyone. "My record was eight to 10 visits a day, and that was exhausting," he says. "If you're on the freeway, five visits is exhausting. Doing it in Los Angeles, unless a doctor limits himself to the Westside, he really couldn't do more than eight or nine house calls in 10 hours."
As he wrote on his blog in 2012, "I never considered myself unique until I tried to find a helper. My ideal would be competent, likable, available 24 hours a day, and willing to travel anywhere. That describes me." Many of those who answered the ad he placed in a local medical journal had day jobs, or lacked malpractice insurance that would cover them outside a clinic. "A surprising number of doctors announced they were free during the day and eager to make visits no matter how distant. All made me uncomfortable. Why didn't they have a job?"
Oppenheim also wonders about the business model of services such as Heal, which keeps doctors on eight-hour shifts at $75 an hour. (He occasionally takes two-hour sub-shifts to help out busy Heal doctors.) "They must be hemorrhaging money," he says, "because they can't make money charging $99."
Heal's co-founder and chief medical officer, Renee Dua, says that the service is profitable in Los Angeles and has 150 doctors on its roster -- and a waiting list to join in. From the physician's standpoint, she says, "an in-office doctor who sees 40 patients/day [has] to see about 30 just to pay for the office, staff, bureaucracy, collections, etc. We eliminate all those costs."
Oppenheim doubts that healthcare will be moving back to the old paradigm of a family doctor making neighborhood rounds with thermometer, stethoscope and black satchel. But that doesn't mean there's no place for the relationship. "If this country ever gets organized with some sort of national health policy, house calls won't be a terribly important part of it," he says, "but they will be some part of it."
The federal government should make it easier for states to fund home- and community-based services (HCBS) through their Medicaid programs, as part of a series of reforms to how senior care is financed.
The Initiative was formed in 2013, under the leadership of former Republican Wisconsin Governor and U.S. Health and Human Services Secretary Tommy Thompson, former Senate Majority Leaders Tom Daschle (D) and Bill Frist (R), and Dr. Alice Rivlin, who was Congressional Budget Office Director in the Clinton administration. The Initial Recommendations to Improve the Financing of Long-Term Care report, released Monday, includes a section on expanding HCBS by streamlining the waiver process.
Currently, states receive waivers of federal Medicaid requirements in order to include home health and other services, and approximately 3 million individuals receive HCBS each year thanks to these waivers. Still, the amount of HCBS varies dramatically among states, in part because the process of getting waivers through state plan amendments (SPAs) is too complicated, the report states.
�Streamlining and consolidating existing waiver authority into a single SPA would assist states seeking to expand the availabilityof HCBS,� the authors write. �Combining features of existing SPAs would permit states to offer HCBS in a way that moves toward eliminating Medicaid�s bias for institutional or facility-based care, give states the flexibility and predictability they need to expand services to best address the needs of varying populations, and maintain essential provisions of federal law that allow individuals to direct their own care.�
Permitting states to cover any item or service that the Health and Human Services Secretary has approved for coverage under an HCBS waiver, including certain rehabilitative and respite care
In addition to the streamlined waiver process, HCBS services could be better supported by more affordable private insurance, the report proposes.
Three potential �retirement long-term care insurance� plans are outlined in the report, ranging from $100 daily maximum benefits for a two-year period to a $200 daily maximum for three years. The plans would have various deductibles and elimination periods, and all would include 20% coinsurance. The beneficiary would have discretion over how to apply his or her benefits�they could go toward assisted living, home health or other services deemed eligible.
�Many features, such as the premium design and inflation protection, would be standard among all retirement LTCI,� the report states. �Product features would include cash deductibles, coinsurance, inflation protection, a non-forfeiture benefit, and an innovative non-level premium design that would bemore sustainable for carriers and offer consumers the opportunity to benefit from lower-than-expected claims experience.�
Certain regulatory and legal barriers would have to be lifted in order for these plans to be offered. In particular, current law should be altered so that younger employees can tap into 401(k) and other retirement accounts to purchase long-term care insurance, the report proposes. Employers who offer these plans should be extended safe harbor protections to limit fiduciary liability, and the plans also should be available on state and federal exchanges. This report and the additional work forthcoming this year reflect an emerging consensus among senior care advocates about the best approaches for financing reforms, according to Long-Term Quality Alliance Executive Director Larry Atkins, Ph.D. He moderated a panel discussion about the BPC report on Monday.
�I think there�s been a concerted effort in [Washington, D.C.] to try to bring these different pieces in place together � because the only way we�re going to advance this is start to build a large base of support on the business side, the consumer side and the practitioner side,� Atkins told SHN. �I think it�ll help getting sponsors on the Hill, for them to feel like we�re not having a big argument about how to do this, we�re all thinking about this in a similar way. Some of us may decide to tweak it one way or a different way, but hopefully we�ll have enough common ground to have a well-informed and rational policy discussion and make progress [on this issue], even though the political situation on the Hill may get in the way in other areas.�
The bipartisan nature of the new report is notable given that the Congressional Long-Term Care Commission split largely along partisan lines in 2014. Tasked with providing recommendations on long-term care financing reform, the Commission provided two separate reports on the topic, with one emphasizing private sector involvement and the other focused on the government�s role.
But the LTC Commission lacked important data on the services and supports people are receiving and the associated lifetime costs, said Atkins, who was executive director of the group. That data subsequently was compiled and released and by The Urban Institute and actuarial/consulting firm Milliman, and enabled greater consensus in this BPC report. This report is �taking it to the level,� Atkins said, but he was quick to emphasize that more data and research still is needed to support additional recommendations and refine these.
Barbara Melgar, 92, sits on the edge of the couch in her Moreno Valley home with her walker nearby, waiting for visitors.
Her face brightens when Dr. Wael Hamade and Dr. Marcus Uribe arrive in their white coats, toting a medical bag.
Melgar fell recently, which makes it difficult for her to travel to the geriatric clinic at Riverside University Health System, the county hospital. So the doctors came to her.
�When you have a complex patient, 15 minutes in and out at a clinic visit doesn�t work for them,� Hamade said. �It�s important to assess the living situation, the environment. You can see things you�re not able to assess in clinic.�
On a house call, doctors can more easily evaluate a patient�s mobility, safety and nutrition, and assess them for signs of dementia, he said.
Riverside University Health System in Moreno Valley is expanding its house call program for geriatric patients with a $2.5 million grant from the U.S. Health Resources and Services Administration.
As part of the three-year grant, the hospital is partnering with UCLA�s geriatrics program, UC Riverside�s medical school, county social workers and nursing students from Cal Baptist University and Riverside City College to provide patient-centered care, which includes home visits.
The project�s multi-discplinary team is expected to track the frequency and severity of falls and dementia-related behavioral problems in patients, along with stress and depression in caregivers.
With an aging population and changes in reimbursement under the Affordable Care Act, hospital-based house call programs are on the rise.
Kaiser Permanente in Riverside began offering home care almost two years ago for patients diagnosed with pneumonia, congestive heart failure, skin and kidney infections, diverticulitis, and chronic obstructive pulmonary disease.
Visiting doctors and nurses treat patients with intravenous blood thinners and antibiotics and take blood samples for lab tests, said Dr. David Wong, assistant area medical director for Kaiser Riverside.
More than 125 patients have been treated since the program began. Their 30-day hospital readmission rate after treatment is as good as or better than patients who were only cared for in the hospital, he said.
�Home is a place where patients are familiar,� Wong said. �They�re less likely to get confused, less likely to fall and are more mobile then when they are in the hospital.�
Hamade, the only geriatrician on staff at Riverside University Health System, cares for about 30 patients in their homes.
He has been Melgar�s doctor for five years. After her fall, he wanted to visit her at home and evaluate her environment.
Melgar lives with her three adult daughters, who share in preparing her food and medicines and coordinating her medical care.