Medicine is coming full circle, Aaron Yao likes to say. Once, doctors would gallop on horseback to care for the infirm in their own homes. In modern times, patients generally have had to transport themselves to hospitals and doctors' offices. Now, the prolonged aging of the population bulge known as the baby boomers is necessitating an upgraded return to the ways of yore, with cars instead of horses.
There's just one major problem: The U.S. lacks the doctors, nurses and others to make house calls to the estimated two to four million people who need them.
“We don't have enough home-based medical care,” said Yao, an assistant professor at the University of Virginia School of Medicine. The lead author of a study published Monday in Health Affairs, Yao and fellow researchers combed through two years' worth of data from traditional Medicare, combined it with the Census Tract, and concluded that more than half of Americans live more than 30 miles away from full-time providers of home-based medical care.
The cutoff radius varies, but because these centers limit how far they send doctors, nurses, physician assistants or other primary care providers, the healthcare system needs to expand the ways it gets care to these homebound patients, many of whom suffer from chronic diseases.
“These are the high-cost, high-need people.” Yao said. “We live longer, but we also suffer for longer years,” he added, noting that if doctors can get to patients' homes and manage their symptoms, they could help stave off or prevent emergency room visits and hospitalizations.
For Medicare, a program whose growth rates are projected at 7.1% over the coming decade, to become a $1.075 trillion program by 2026, the savings from improved home-based care could be significant. Of the $632 billion Medicare spent in 2015, 23% went to hospital inpatient services and a slim 3% went to home health.
Already, treating older Americans with chronic conditions accounts for two thirds of the country's healthcare budget, according to the Centers for Disease Control and Prevention. Medicare insures 57 million people, most of whom are 65 years of age or above. Over the next quarter century, the number of elderly is expected to reach roughly 72 million.
“The current model doesn't work,” Yao said.
The study defined high-volume and full-time providers of care as those who made more than 1,000 visits per year. But 53% of Americans, especially those in rural areas, do not live within 30 miles of one of these centers, the study found. And a minority of places offering such care also do most of the heavy lifting, Yao and his colleagues found.
In 2013, 5,000 primary care physicians made 1.7 million home visits to traditional Medicare beneficiaries. It was 9% of those providers that did 44% of the work, carrying out at least 1,000 visits a year. Meanwhile, nearly half of those providers carried out a sliver — 6.2% — of all visits.
The study also found that what Medicare pays for home-based care varies widely with a patient's address. In the District of Columbia or Kentucky, the CMS spent more than $10 per beneficiary. For those living in Montana or the Dakotas, however, the cost plummeted to less than 10 cents.
The study drew on data from fee-for-service Medicare from 2012 and 2013 and population data from the 2010 Census Tract. It geolocated providers of home-based medical care, then overlaid populations of those 65 and older. Then, the researchers applied a frailty index — “we assume it's evenly distributed,” Yao said — to gauge how many homebound patients were far from home-based care providers.
In other words, the study did not calculate geographic disparities specifically using homebound patients.
“If we had better data, we could do that,” Yao acknowledged. And although using Census Tract information was not a “very, very accurate calculation,” he said, “it's good enough to tell the story.”
The researchers also used data only from traditional Medicare beneficiaries, which “may not be representative of a physician's entire practice,” the study acknowledged. But, it said, services provided to Medicare beneficiaries were generally “highly correlated to the services provided to a physician's entire practice.”
Despite the study's limitations,Yao said his findings drove home crucial points about the need for more, and more widely available, home-based medical care providers in the U.S. He said he hoped more medical students would consider home-care as an occupation and that more existing primary care providers would start to offer it as a service.
"It's not a high-paying job," said Yao. In some cases, in order to see patients in their homes, providers would have to invest in portable medical equipment, such as mobile EKGs. Still others have concerns like personal safety, he added.
In 2012, the CMS launched a five-year demonstration project, Independence at Home, to test whether home-based primary care could improve costs and cut spending for Medicare patients with multiple chronic conditions. The project involves 14 different practices and is scheduled to end at the end of September 2017.
