By James Miley
While paging through the newspaper last week, I noticed an article with the above stated headline: Want better health Care? Have doctors make house calls! The piece was written by Dr. Mindy Fain. Up to this point in time, I had not heard of, or had seen any other articles by Dr. Fain.
The article opened with a hint of nostalgia; <em>“I make house calls. Remember those? When a doctor came to your door with a little black bag?
As I read through her article, it brought back memories of my youth. When one of my two uncles, both physicians, would stop by our home on their way from work to dispense treatment for whatever ailment myself, or one or more of my eight brothers and sisters needed at the time. That’s right, nine of us, within a twelve year span. Thinking back, I have no idea how my parents were able to handle just the scheduling duties brought on by a brood of this size, let alone coordinating the entire process needed to parent our lively crew.
The story started by describing an elderly couple. “He’s 86, she’s 82. He’s got several health issues: obstructive lung disease, heart failure, diabetes, hypertension, arthritis, and early Alzheimer’s. She takes care of him, organizes his 14 medications, and prepares low-salt meals. They’re managing.
But then on Tuesday they noticed he’s getting more short of breath and his legs are a bit swollen. They cross their fingers and hope this is temporary. They’re not stupid; it’s kind of denial. Neither of them drives. They’d have to get a ride from a nearby daughter, but she’s got two kids and they don’t want to bother her if they don’t have to. So the wait a day. Or two. By Thursday, it real. His symptoms are worsening. They call their doctor’s office and are told to go straight to the emergency room – it’s too complicated for a quick office visit. They grow used to these intermittent hospitalizations. Like a lot of people, he jokes that he’s going in for a “tune-up”.
This is how millions of people with chronic conditions get into the cycle where all their care is emergency care.” Dr. Fain then points to a recent Brookings Institute report, citing “older people with chronic conditions suffer ‘repeated cycles of crisis, hospitalization and expensive but ineffective or even counterproductive treatment – leading to more of the same.” Dr. Fain then points out ‘that patients like this who constitute the top 10 percent of Medicare beneficiaries account for 57 percent of Medicare spending. In-home medicine makes so much sense for these patients, and could cut those costs significantly. She goes on, citing “multiple studies finding that even among the ill and elderly, at least 30 percent of hospitalizations are potentially avoidable. Dr. Fain then points to a VA study on in-home care for VA patients that found a nearly 14 percent reduction in total health care costs, and a forthcoming study on a Medicare program in Washington suggests savings around 17 percent”.
She then analyzes the situation concerning the couple above. Suggesting that ‘if they had called my program on Tuesday rather than waiting, we would have visited them that day. We have the technology to take x-rays and analyze blood on-site. Within an hour we could have diagnosed his problem, set him up on oxygen and started any necessary medications before returning to check on him the next day.’
Dr. Fain states, ‘this is not only cheaper, but also better and safer than a hospital stay. Older patients are particularly susceptible to infections and medication errors. Away from familiar settings, they also get confused, tired and weak. They might fall.
Patients lose slightly more than 1 percent of their muscle mass for every day they are in the hospital. So after a week, an older person has lost 10 percent of his or her strength. She called this; “death by bed rest” – patients are cured of a disease but can no longer step into a bathtub, stand to cook, or climb stairs. Often they can’t even go home. According to a major study, 75 percent of patients over 75 years old who were living independently before admission to the hospital were no longer independent on discharge, and 15 percent require nursing home placement.
The article went on to identify some of the obstacles plaguing this method of medical care. “Office visits are more convenient for physicians, and much more lucrative. Medicare’s fee-for-service model, for example, doesn’t account for time and expense for travel, care coordination and paying for nonmedical members of the in-home care medical team including the social worker and nurse.” “Medicare, Medicaid, private insurance companies, integrated health systems and health plans have to dismantle the reimbursement barriers to in-home medicine. This bureaucratic hurdle is keeping tens of thousands of chronic patients from getting better treatment right where they live.
As I continued to read through Dr. Fain’s piece, I was reminded of the time when all my mother had to do was call one of her brothers to have them stop by on their way home for us to be treated professionally, conveniently, and have it all fit into her hectic schedule.
It seems that as I progress through the ‘circle of life’, I may again be able to receive high quality health care at an affordable cost, in the comfort of my own home! Three cheers for Dr. Fain!
Dr. Mindy Fain is a professor of medicine at the University of Arizona Center on Aging and a fellow with the OpEd Project. She wrote this column for the Los Angeles Times