Healthcare at Home - the undervalued sector of healthcare

Homecare, Hospice and Tele-Monitoring have been deeply undervalued in our modern medical system. So much so that there isn't even a good name to use when talking about them.  "Post-acute care" is not right - there is so much that can and should be done before (or instead of) a hospital stay. There is some movement lately toward the term "Healthcare at Home".  Seems like an apt description.  The twitter hashtag #healthcareathome shows it as the name of a home care company in India, which may limit its use in the US.  But I'm going to follow the lead of NAHC, as eloquently described in a recent Home Care Technology Report.

Although I have long advocated that home care and hospice need to be part of strategic thinking, health enterprises still not embracing these care delivery systems.  Why is that?

1. Traditional payment for these services has been different than hospitals and physicians are used to.Home care is paid a fixed amount per 60 days of care delivery, regardless of number of visits.
   Hospice is paid a per diem rate, with four different rates based on patient acuity.Essentially, Healthcare at Home has been out of the fee for service business for over a decade!
2. Healthcare at home revenue is small percentage of the system budget
   Just as football and basketball tend to occupy most of an athletic director's energies, Cardiac and Orthopedic surgery departments tend to occupy most of a system CFO's energies.  Time follows money.
3. Clinicians and patients are not in the same building as administration
   Even the most enthusiastic "management by walking around" won't get to the strip mall down the street where the home care agency is, and the patients are spread all over the county.
4. Care delivery is not curative
   Hospice care by definition is not curative (even though there are pilot programs coming up that will allow curative care concurrent with hospice), and home care is mainly teaching patients and caregivers.  The benefits of healthcare at home are in improved quality of life, and allowing patients to remain where they want to be, not in recoveries.  It's not glamorous, but it is good care.

So given all of that, why should Healthcare at Home be part of a health enterprise's strategy?

1. Payment systems are changing
   Healthcare at Home has not been fee for service for a long time.  These services already know how to deliver quality care at the lowest possible cost.
2. Revenue will no longer be attributable to specific functions
   Under value based pricing, entities are paid for quality care delivery and outcomes, not services performed.  Home Care and Hospice can improve care delivery and outcomes, and at less cost than other care delivery mechanisms.
3. Location is less important
   The rise of remote visits, the vast expansion of satellite facilities, and even health kiosks are all signs that the most efficient care delivery does not happen in the largest, nicest building on a health care campus.
4. Outcomes are not always about cures
   The savings from hospice are extremely well documented, as is the amount of money spent in the late stages of care, frequently with no good effect.  Patients consistently say they want to stay at home, even as their health may be fading.

CMS has at least two proposals moving things in this direction:

• CMS is proposing bundling payment for joint replacement care.  My thoughts.
• CMS will let 141 hospice agencies care for patients while they continue to receive curative care.  My thoughts.

Both of these proposals show the largest payer in healthcare is also beginning to recognize this sector as undervalued.