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The Future History of Home Care and Physician House Calls in the United States

^a Schools of Medicine, Johns Hopkins University, Baltimore, Maryland
^b Schools of Hygiene and Public Health, Johns Hopkins University, Baltimore, Maryland

Bruce Leff, Associate Professor of Medicine, Johns Hopkins Geriatrics Center, Johns Hopkins University School of Medicine, 5505 Hopkins Bayview Circle, Baltimore, MD 21224 E-mail: bleff{at}jhmi.edu.

Decision Editor: John E. Morley, MB, BCh

	Abstract

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Over the last 20 years, home care has experienced significant change. The home care industry developed into big business and a number of innovative models of home care were developed and evaluated. Although physicians perform many fewer house calls than a half-century ago, there has been a recent revival in house-call training, education, and practice. In addition, telemedicine and other technologies hold great promise for the future of home care. However, the future history of home care will depend mostly on the ability of various stakeholders in the health care system to recognize the value of home care and develop and implement the appropriate incentives to encourage its proper place in the U.S. health care system.

THE image of a physician delivering care to a sick patient at home is one of the essential and enduring images in the collective consciousness of medicine. It is an image that no doubt once inspired, and perhaps still inspires, some to pursue a career in medicine. It is an image from which the medical profession, as a whole, once drew inspiration so as to say "Yes, this is what physicians are about. Physicians take care of patients." However, more recently, when physicians tell colleagues that they make house calls, they may be looked upon as Luddites. More surprising is the reaction from patients in need of a house call when told they can be seen in their home: "I didn't know anyone did that anymore."

It is fascinating how quickly this transition occurred. A mere 50 years ago, house calls accounted for 40% of all physician-patient encounters ⁽¹⁾. By 1980, house calls accounted for only 0.6% of such encounters ⁽²⁾. The shift in site of care delivery from the home to clinics and hospitals was the result of an explosion of biomedical knowledge and technology, increased access of patients to a growing medical system, the growth of third-party payers, and heightened liability concerns ⁽³⁾. In this article, we will discuss recent history and current developments in home care in the United States and then speculate on the future history of home care in America. Semantics in the area of home care have always been a challenge. We will use the term "house calls" to refer specifically to physician house calls and models of home care that include a substantial physician component; otherwise, we will use the term "home care," with the understanding that there is often substantial overlap between the two areas.

	Home Care Today

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Over the last 20 or so years, several important story lines have emerged in home care: the growth of the home care industry into big business; the development and study of a bevy of home care models; the split between nurse and physician home care, with a general decline of involvement by the latter; a recent revival in house call training for physicians and the use of house calls in physician education; and the development of technology for home care with a recent explosion of interest in telemedicine. We will review briefly each of these themes as a prelude to discussing the future history of home care.

	The Business of Home Care

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Beginning in the late 1980s and continuing through much of the 1990s, home care became big business. Through the late 1990s, home care, though a relatively small portion of Medicare's budget overall, was the fastest growing component of that budget, with expenditures increasing at a rate of approximately 20% per year, from $3.5 billion in 1989 to $19 billion by 1997 ⁽⁴⁾.

This increase in expenditures drew the attention of policymakers who were concerned that home care, originally written into Medicare legislation as a supplement to acute hospital care for patients with skilled nursing needs, was fast becoming a de facto long-term care, nursing home-type benefit for frail older persons with chronic illnesses ⁽⁵⁾. In addition, this growth ultimately drew the attention of federal regulators, who were concerned that the rapid increase in home care expenditures, the increase in the number of home health agencies entering the field, and significant geographic discrepancies in the use of the benefit were at least the result of insufficient supervision of the benefit by physicians, if not outright fraud and abuse.

The federal regulators responded with the Balanced Budget Amendment (BBA) of 1997. The BBA established a prospective payment reimbursement system to home health agencies, reduced reimbursement for durable medical equipment and certain therapeutic interventions ⁽⁶⁾, and resulted in a marked decrease in Medicare expenditures for home care that will be detailed later. In addition, the BBA mandated the collection of data about home care patients using the Outcomes and Assessment Information Set (OASIS). Initially developed as a means to provide a picture of the home care patient's situation and improve the quality of home care, OASIS is also being used to determine the prospective payment schedules for home care patients. There have been problems with OASIS related to privacy, costs, and data management, but use of OASIS has been reported to be associated with improved health status outcomes ⁽⁷⁾. However, OASIS may be limited in that it is not a comprehensive assessment tool, such as the Minimum Data Set for Home Care, and it lacks the ability to track patients across various sites of care ^{(8) (9)}.

	Home Care Research—Development of Home Care Models

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As home care activity expanded in the nonacademic world, home care established a modest academic research base in the creation, evaluation, and limited dissemination of various models of home care. Hundreds of studies have been reported and have been summarized in the literature ^{(10) (11) (12) (13)}. This research has been difficult and criticized for a number of reasons. Many studies lacked methodological sophistication. Studies described and often grouped together under the rubric of "home care" or "community-based long term-care" were, in fact, describing many different types of interventions, some social, others medical, and still others combining medical and social approaches. In addition, the studies targeted disparate populations of patients and examined a variety of outcome measures ^{(14) (15)}.

Despite such difficulties, recent home care research has demonstrated clearly the effectiveness of several types of home care models. We will highlight meta-analytic data as well as data related to specific home care models, such as interdisciplinary home care, home geriatric assessment, postacute hospital home-based case management strategies, including discharge planning, and home hospital.

Meta-analysis of the effects of home care on mortality and nursing home placement demonstrated a small, beneficial effect of home care on mortality that fell short of statistical significance and stronger evidence of the ability of home care to reduce nursing home placement ⁽¹⁶⁾. Another meta-analysis found a small to moderate positive impact of home care in reducing hospital days, ranging from 2.5 to 6 days per 180 days of follow-up ⁽¹⁷⁾.

Interdisciplinary home care programs integrate medical and social supportive services focusing on the care of chronically disabled older persons. These programs involve physician visits and an interdisciplinary team approach, which often includes regular team meetings to discuss patients and develop mutually conceived management strategies. Randomized controlled trials of these programs suggest that they can be cost effective and associated with greater caregiver satisfaction, fewer acute hospital readmissions, and, in some cases, fewer nursing home days ^{(18) (19) (20) (21)}. Home geriatric assessment in a relatively unselected population has been demonstrated to delay the development of disability and reduce permanent nursing home stays among elderly people living in the community ⁽²²⁾. In patients with risk factors for functional decline, home geriatric assessment has been demonstrated to identify important new or worsening medical problems ⁽²³⁾. Postacute hospital case management schemes, especially those that focus on illnesses such as congestive heart failure, which are associated with a high rate of acute hospital readmission, have been well studied and widely replicated throughout the United States. The intervention in such studies is nurse-directed with physician back-up and focuses on patient education about the illness, dietary counseling, medication management, and social services consultation. These interventions result in a reduced rate of acute hospital readmissions, fewer hospital days, and improved quality of life ^{(24) (25)}. In randomized controlled studies, comprehensive discharge planning, begun in hospital by advanced practice nurses, and home follow-up of hospitalized older persons with a variety of illness have demonstrated fewer readmissions and fewer hospital days for those patients for whom such planning was undertaken ⁽²⁶⁾. In addition, home hospital programs have been developed. These programs are designed to provide acute care in the home as a substitute for hospitalization by bringing critical elements of the acute hospital to the home: physician visits; nursing visits; intravenous infusions; durable medical equipment; basic laboratory testing; and diagnostics, such as echocardiogram and basic radiograph. Early studies suggest that such programs are feasible, clinically sound, cost effective, satisfactory to patients and caregivers, and associated with lower rates of hospital-associated complications, such as confusion ^{(27) (28) (29)}.

On the whole, this body of research suggests the following: home care can be effective when properly structured; targeting home care interventions to the appropriate patient population is critical; innovative models require a flexible approach; there is value in physician involvement in home care; and, in a health care system that is becoming increasingly fragmented, home care can help bridge gaps in the continuum of care.

	Who Does Home Care?

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Although physicians romanticize the house call, it has been nurses, therapists, and home health aides who have been doing the work of home care. At national meetings of home care professionals, audiences have been reported to break into uproarious laughter at the mention of physician involvement in home care, and the available data suggest that their sense of humor is well placed. Physicians, by and large, have stopped making house calls. In an analysis of Medicare claims data in 1997, Meyer ⁽³⁰⁾ estimated that approximately 727,000 physician house calls were made to Medicare beneficiaries nationwide in 1993. This corresponded to less than 1% of Medicare beneficiaries receiving a house call. Patients who received the house calls were very sick and near death. The reasons cited for the lack of physician involvement and leadership in house call medical practice have been reviewed previously ^{(31) (32)} and include lack of faculty skilled in house call medicine, inadequate reimbursement for physician visits, the inconvenience and time inefficiency of a house call, concerns about quality of care delivered in the home, and liability concerns. To a large extent, liability concerns have been debunked ⁽³³⁾. The Center for Medicare and Medicaid Services (CMS; Health Care Financing Administration) has made extensive revisions to rules for home visits, including significant changes in reimbursement to reflect better, although not perfectly, the nature of home care medicine ⁽³⁴⁾. In addition, recently published federal regulations will allow physicians to make referrals to home health agencies with which they have a financial relationship and removed a $25,000 cap for compensation for physician medical direction of a home health agency. This cap had often precluded full- or even half-time medical direction for a home health agency ⁽³⁵⁾.

A lack of physician education has also been cited as a barrier to physician participation in home care medicine. A survey of U.S. medical schools in the early 1990s found that only half devoted even a single hour to home care in the course of a 4-year curriculum and only 3 of 123 schools required five or more home visits during the clinical years ⁽³⁶⁾. More recently, however, this too has begun to change. When the John A. Hartford Foundation issued a request for proposals to develop curricula in home care for medical students, over half of U.S. medical schools applied and ten schools received funding. In addition, a certification examination in home care medicine has been created to respond to the growth in home care and the need for physician knowledge and involvement in this area ⁽³⁷⁾. Such an examination should legitimize further physician involvement in house call medicine.

	Technology

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Technological advances have also facilitated the expansion of home care. Intravenous infusion technology, radiography, ultrasound, feeding pumps, ventilators, pulse oximeters, hand-held blood analysis devices, and other technologically advanced devices, once found only in the hospital, are now relatively commonplace in the home and expand the capabilities of home care and the ability of the house call physician to provide quality care in the home.

In addition to technology in the form of devices such as infusion therapy, the greatest technological advances that may influence the future of home care are just beginning to be seen in the area of telemedicine ⁽³⁸⁾. The definition of telemedicine is fairly broad but includes programmed telecommunication; interactive videos; programmed computer guides to diagnosis, treatment, and prevention; e-mail access to the physician; virtual offices at home with videophones for the interview; examination and testing of the patient; and others ⁽³⁹⁾. Such telemedical services have been evaluated and more are being developed and tested. Studies suggest that telemedicine in various forms can improve diabetic management ⁽⁴⁰⁾, provide access to specialists for nursing home patients with dementia ⁽⁴¹⁾, assist in the evaluation and treatment of pressure sores ⁽⁴²⁾, and improve blood pressure control ⁽⁴³⁾. The Kaiser Permanente telemedicine home health research project evaluated the use of remote video technology in home health care for patients with chronic medical illnesses. The technology was effective, well received by patients, and demonstrated a potential for cost savings ⁽⁴⁴⁾. Data suggest that a substantial proportion of home nursing visits would be suitable for telemedicine ^{(45) (46)}. And, although some suggest that telemedicine may change the physician-patient relationship because of a lack of touch and privacy, others suggest that the "advent of telemedicine has provided the opportunity to develop a hybrid home care delivery system that incorporates the best aspects of the old and new home health care models" ⁽⁴⁷⁾. Aside from the glitzy technology side of telemedicine, one of the most interesting potential uses of it may be to coordinate, through Internet-based information portals, the variety of social and medical services required to properly care for frail homebound older persons. Such models are being developed (L.C. Burton, personal communication, January 9, 2001).

	Home Care—Future History

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What will be the future history of home care? The home care industry has grown and developed ⁽⁴⁸⁾, as have several effective models of home care. Reimbursement for physician home visits has increased, and some restrictive regulations concerning physician relationships with home health agencies are easing. The education of medical students and residents in house calls and the development of faculty to develop further the academic base of home care and teach it are on the rise. Technology to facilitate delivery of quality home care medicine has improved and telemedicine, though not a panacea for home care (or geriatrics) ⁽⁴⁹⁾, seems ready to explode ⁽⁵⁰⁾.

That these factors augur well for home care is clear. However, a utopian future for home care is by no means assured. In fact, it may not even be an even money bet. The field is full of romantics ^{(51) (52)}. However, sentiment alone will change little. As a keen observer of the home care field recently told an audience of the home care faithful "it's the incentives, stupid. That is what produces change" ⁽⁵³⁾. That is, getting the health care system to simply do the right thing because in the opinion of patients and certain physicians it is the right thing to do is insufficient incentive for the health care system to change. Home care will succeed, as will any other element of the health care system, when appropriate incentives exist so that it makes sense to provide it (see Table 1 ).

However, there is at least one example in the health care system today where home care flourishes because economic, political, and social incentives are well aligned. It is the Program of All Inclusive Care for the Elderly (PACE), in which community-dwelling, nursing home–eligible patients who qualify for both Medicare and Medicaid may be cared for in a fully capitated model. A PACE site, which operates using a day health center model, receives the Medicare and Medicaid capitation and is at full financial risk for all patient care, including long-term care. Being at financial risk for long-term care is a critical bit of incentive because as these frail patients become increasingly frail, the economic incentive for PACE and the desire of the patient to stay at home, in lieu of acute hospital care or a long-term care facility, are perfectly matched. PACE programs are heavy users of home care services. PACE programs can be proactive and don't need to wait for a skilled need to appear before implementing home care. PACE has been successful at helping patients avoid hospital admission and nursing homes ⁽⁵⁶⁾. Unfortunately, PACE programs care for relatively few persons across the country and there are substantial obstacles to expanding the model to the millions who could benefit from it ⁽⁵⁷⁾.

Medicare managed care is another setting where incentives, at least in theory, are reasonably well aligned toward home care. A Medicare managed care plan receives a capitation from the CMS based on a person's age, sex, income, type of residence (nursing home or independent dwelling), and geographic location. In such a capitated system, it might be reasonable to predict that the Medicare managed care plan would utilize home care services to help prevent hospitalizations among their frail and often high-cost beneficiaries. Unfortunately, research suggests poorer outcomes for home care in managed care compared with fee-for-service care ⁽⁵⁸⁾. Some of the home care models highlighted previously, such as interdisciplinary home care and home hospital, would be advantageous for a Medicare managed care plan. However, the plans haven't adopted these models on a large scale. The reasons for this are complex; however, Boult and colleagues ⁽⁵⁹⁾ suggest that economic and organizational forces mitigate against their adoption. Such forces include the inability of Medicare to appropriately risk-adjust capitation payments for the frail elderly population. Thus, implementing systems that attract chronically ill older persons may be ill advised from an economic viewpoint; many plans rely instead on "favorable selection" of enrollees. In addition, the models of home care themselves are insufficient; they cannot be pulled off a shelf. To implement such models and realize their full potential, Medicare managed care plans will need to integrate such programs into coordinated systems of care, develop comprehensive data management systems, train personnel in geriatrics, and develop teams of providers who can work across the continuum to provide care to frail older persons.

In the absence of widespread dissemination of a PACE model, the ability or inclination of Medicare managed care plans to implement home care programs on a large scale, or the adoption of a new national heath care policy that values home care, the future of home care may depend mostly on the ability of local health care entities in the fee-for-service sector, such as physician groups, hospitals, and academic centers, to recognize and adapt to the incentives that exist presently in the system. Physician practices devoted to home care that eliminate the office-based component of practice are increasing in number because they recognize that in doing so they can reduce substantially office overhead expenses (G. Taler and K. E. DeJonge, personal communication, June 2000). Hospitals and academic centers may expand their home care systems because they recognize that in order to capture the necessary market share to stay solvent they need a home care service as much as they need a cardiac catheterization lab; that they need to develop house call physicians and faculty as much as they need an interventional cardiologist. This brand of hospital-based home care can assure a hospital of a substantial admission stream of patients as it fills gaps in the continuum of care. In addition, the ability of such programs to extend home care to the growing assisted-living environment may, regulations permitting, provide economies favorable to such programs. Last, these centers may recognize that home care programs are excellent sources of favorable press and philanthropy.

	Conclusions

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That home care will survive into the future is a certainty. What is less certain is the nature of the home care system that will evolve. It will depend on the ability of Americans to recognize and fight for a health care system that reflects their purported values. If Americans truly value widespread access to high-quality humane care that meets their needs, delivered on a personal and humane basis, in whatever venue is most appropriate, then the correct incentives can be built into the system to ensure the proper development of home care and other areas of the medical system. If such values are not widely held or cannot be translated into favorable policy, then the outcome for home care and house calls is bleak. In such a scenario, home care will become increasingly fragmented, medicalized, available only to those with the means to pay, and informal; that is, the responsibility for providing home care will fall increasingly on family caregivers.

One additional item deserves mention. A bit of dissonance that has always been troubling is that unlike other forms of primary care, home care has always had to prove its "worth." Ambulatory or nursing home visits (required at least every 60 days by law) have never had to prove their value in quite the same way. Home care can provide access to care for those whose access to care would otherwise come only by an ambulance ride to the emergency room or not at all. People die for lack of such access to care ⁽⁶⁰⁾. If nothing else, home care can provide that ⁽⁶¹⁾. As we contemplate incentives to build the home care systems of the future, we should try not to forget that.

	Acknowledgments

 
The authors thank Dr. Knight Steel for his thoughtful comments and suggestions.

Received April 9, 2001

Accepted April 30, 2001

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