The Hospital Is No Place for the Elderly (3rd of 3 installments)

https://www.theatlantic.com/magazine/archive/2013/12/the-home-remedy-for-old-age/354680/

The elderly flock to Phoenix, Arizona. Not surprisingly, the city is home to one of the country’s biggest nonprofit hospice organizations, Hospice of the Valley. Better than most people in the medical system, hospice providers understand the trouble with hospitals. In the early 2000s, Hospice of the Valley began experimenting with an in-home program designed to bridge the frailty gap—that is, the gap between hospital and hospice. That experiment led to the development of a team-based approach in which nurses, nurse-practitioners, social workers, and sometimes physicians visit clients’ homes, provide and coordinate care, and observe people outside the context of the medical system. “That face time is what makes the program work,” David Butler, Hospice of the Valley’s executive medical director, told me. Butler says that for the 900 people it serves, the program decreases hospitalizations by more than 40 percent, and ER visits by 25 to 30 percent.

Though the program collects whatever payment it can from Medicare and private insurance, it operates at a loss, and is run as a community service and a form of R&D. But things have changed recently. Insurance companies and other providers have begun asking Hospice of the Valley to contract with them to pick up their caseloads of high-cost, chronically ill patients. At the beginning of this year, the program was earning enough in reimbursements to cover one out of seven patients; today the rate is more like one in three. That is still not enough, but when a few more big contracts come through, Butler says, perhaps in a year or 18 months, enough of the patient base will be covered to tip the program into the black.

This would have been impossible a few years ago. Most people saw in-home care as too expensive and logistically complicated even to think about—and in any case, no one would pay for it. So what’s happened?

A few things, not least among them the Affordable Care Act. Under the new health-care law, Medicare has begun using its financial clout to penalize hospitals that frequently readmit patients. Suddenly, hospitals are not so eager to see Grandma return for the third, fourth, or fifth time. Obamacare has also earmarked money specifically to test new care models, including home-based primary care. Thanks to a $13 million Medicare innovation grant, for example, Sutter is rolling out Advanced Illness Management to its entire health network, to test whether the program can be scaled up. If the results of such tests are good, that would provide impetus—and of course, the very fact that Medicare is investing in the experiment signals its interest. Perhaps most important, Obamacare is changing the business calculus by creating alternatives to fee-for-service payment. It is beginning to set up new provider networks and payment schemes that let health systems and insurers share in what they can save by preventing unneeded treatment (while also requiring them to shoulder some of the risk of cost overruns).

Those reforms are still fledgling, and too technical to garner public attention amid the ballyhoo over insurance mandates and the like, but they have already begun to reinforce what people in the geriatrics world tell me is a change in the culture of health care. “The idea of cost avoidance is no longer categorically rejected,” Butler says.

Stuart speaks of a new receptiveness among health systems’ financial executives, at Sutter and elsewhere. “A few years ago, you couldn’t get a new idea across the desk of a CFO unless it generated revenues. If all you could do was save money, it was like, forget it.” Now, he says, CFOs want to hear about savings, because they expect the old sources of revenue—more treatments with more gadgets at higher costs—to dry up. Jeff Burnich, a vice president at Sutter, told me that the business case for aim is only getting stronger. “Most health providers, if not all of us, lose money on Medicare, so how we make up for that is, we cost-shift to the commercial payers,” he said. But the space for cost-shifting is shrinking. “The way you bend the cost curve now is by focusing on where there’s waste and inefficiency, and that’s the end of life in the Medicare population.” He expects to see a wave of hospitals fail in coming years if they don’t provide better value. “The music has stopped,” he said, “and there are five people standing, and one chair.”

Switching to a home-based model of primary care will be a challenge. Medicare, a bureaucratic behemoth designed in the 1960s, moves slowly and will need a lot of time to adjust. Physicians, a notoriously self-important lot, will need to see themselves as part of a team in which a nurse or a social worker often takes the lead. Nurses will need to see hospitalization as a last rather than a first resort. Patients will need to learn that home care can be as good as hospital care, often better. None of this will happen fast.

Still, the mood among people I’ve talked with in the home-based movement is upbeat. I think of them as mammals skittering beneath the feet of dinosaurs, fragile and vulnerable in a newly established niche but better adapted to the changing ecology. The very fact that change agents like Brad Stuart at Sutter, George Taler at Washington Hospital Center, and David Butler at Hospice of the Valley have found success and built constituencies within big corporate health-care systems speaks volumes. At Sutter, aim has acquired institutional and financial momentum of its own; executives there say they expect to expand their annual patient load from about 2,000 today to between 5,000 and 7,000, which would make it the Sutter network’s standard method of care for the frail. “We can’t staff up fast enough to meet the demand,” Sutter’s Jeff Burnich said. “It would be easier to close a hospital than to close this program.”

Believing that aim’s future is secure, Brad Stuart recently left Sutter and, with a colleague, formed a consulting company called Advanced Care Innovation Strategies, to advise health systems and insurance companies around the country on better ways to cope with frail patients and advanced illness. With his 65th birthday coming up, Stuart will soon qualify for Medicare himself. His wife wishes he would slow down, before his own frailty course sets in. He refuses. “That would be like spiritual suicide right now,” he told me, “because there is so much going on. I’m more hopeful all the time. We’ve rolled the rock all the way to the top of the hill, and now we have to run to keep up as it rolls down the other side.”