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Am Fam Physician. 1999;60(5):1337-1340

See article on page 1481.

Home care has enjoyed a resurgence over the past 10 years. The growth in home care has been fueled by several factors: the growth of managed care and Medicare's Prospective Payment System, which have reduced the length of hospital stays; liberalization of Medicare coverage policies for community-based care; increasing patient preferences to avoid nursing home placement; and demographic shifts resulting in a burgeoning population of patients with chronic illnesses and disabilities. Although home care remains a relatively small part of total health care expenditures, it has been the fastest growing sector of health care throughout the 1990s.

Change brings with it both good and bad. Let us look at the down side first.

The failure of the Health Care Finance Administration (HCFA) to anticipate these expenditures contributed substantially to the recent cost overruns for Medicare. Much of the blame can be attributed to a critical gap in the range of services provided in this setting. Despite being legally accountable for ordering and monitoring the services and equipment used in the home, the vast majority of physicians have little experience or interest in home care and have little knowledge of the regulations governing eligibility, indications for continued services or the effectiveness of the medical care plan. The consequence has been a government perception of insufficient supervision and unbridled excess, if not flagrant fraud and abuse.

The federal response to these developments has been jolting. The Balanced Budget Amendment of 1997 authorized HCFA to extend prospective payment to home care agencies and curtailed reimbursement for a wide range of equipment, supplies and therapeutic interventions. According to the National Association for Home Care, approximately 2,000 home care agencies have either disappeared through mergers or closed their doors since July 1998 when prospective payment was implemented. Similar to hospitals' length-of-stay, the average number of visits per episode of care has plummeted among home care providers. In addition, the Office of the Inspector General recently released a fraud alert for physicians that stipulates the conditions under which services in the home can be initiated, delineates responsibilities for documentation and assigns substantial fines for noncompliance with federal regulations.

These are the early “growing pains” of a blossoming health care delivery system—not unlike that of the nursing home industry nearly 30 years ago, but the potential for expansion is far greater. According to the 1992 National Home and Hospice Care Survey conducted by the National Center for Health Statistics, for every one resident in a nursing facility, up to three to four patients of equal debility reside in the community with the assistance of family, friends and the intermittent services of home health care agencies.

Advances in technology and smaller equipment allows diagnostic capabilities equivalent to those available in the office and therapeutic interventions similar to those available on a hospital ward. Life-support technologies, such as ventilators, intravenous infusion devices, dialysis and enteral feedings pumps are no longer rarely encountered on a house call.

Disease management programs have extended the use of acute care protocols into the home, including the use of investigational drugs. Reimbursement for house calls by physicians has increased, and these billing codes are now applicable to home visits by nurse practitioners and physician assistants. Telemedicine is an emerging technology that facilitates frequent monitoring of patients with especially unstable conditions. Therefore, it is conceivable that within the near future, primary care physicians will spend as much as one half of their time overseeing the care of chronically ill and severely disabled patients in their homes—as is the current practice of medicine throughout the rest of the Western world.

In light of these changes, the specialty of family medicine can no longer ignore the education of physicians in the important differences and challenges of providing care in the patient's home. To assume that clinic-based experience is adequate training for home care is as fallacious as was the conceit that hospital care prepares one for the ambulatory setting. More recently, several focused efforts are emerging, slowly and tenuously.

The Hartford Foundation has funded the development of undergraduate curricula on home care in 10 medical schools, but the good news is that 70 of the nation's 123 medical schools submitted applications. Although most of the primary care specialties have defined curricular guidelines for residency training, no practical means exists for recouping the clinical charges for the services provided. Unfortunately, there has been little support for continuing medical education for practicing physicians.

In this issue of American Family Physician, Unwin and Jerant1 offer a framework for approaching the comprehensive assessment of patients and their supportive environment. The article is a welcome addition to the article by Montauk in a previous issue.2 I am heartened to see greater attention paid to this aspect of medicine. Perhaps, in time, we can all look forward to the return of house calls to the mainstream of medicine. After all, it is what I would want for myself and my family.

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