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Doctor in the House

Now that the fastest-growing segment of the U.S. population is 85 and older, and the number of adults age 65 and up is expected to double by 2030, Americans are starting to look outside hospitals and nursing homes for their long-term health care.

"Most people would choose to be home getting medical care rather than in a nursing home," said Dr. Theresa Soriano, director of New York's Mount Sinai Visiting-Doctors Program, "and with the population aging as it is, [home-based health care] is going to become more and more of an issue for the medical community and policymakers to consider."

But for many older patients who are too weak or sick to visit a doctor's office, home-based health care is not just an issue. It's one of the only options.

The doctors at Mount Sinai serve about a thousand homebound older patients, a fraction of the more than 100,000 people age 65 and older living in New York City who require, or would benefit from, this type of care. Although Mount Sinai doesn't advertise its program, there is a two-month waiting list of about 150 potential patients. Nationwide there are at least 1 million older Americans who are permanently homebound, and 2 to 3 million more who are so disabled they can't go to a doctor's office, according to the American Academy of Home Care Physicians.

But despite the increased need for this type of service, there are challenges facing those who would like to specialize in home-based health care. First, it isn't as profitable as other areas of medicine, reported Dr. Peter Boling, professor of internal medicine at Virginia Commonwealth University.

"If we had a good incentive structure and a good care-delivery system, there would be no trouble building up a workforce in a decade," he estimated. "I'm convinced. In fact, I'm certain of it." According to Boling, there are two sources of payment for doctors under the current structure: fees for individual visits and fees for oversight of home nursing care—and this fee schedule does not consider some of the inherent costs physicians incur, such as travel time.

Boling also stated that the best take-home salary that a typical physician can earn in a full-time home care practice, without having some type of institutional subsidy, is below what one would earn in most other types of medical work.

"Done right, the work is hard," said Boling, "so we have a hard work, low-pay scenario, making it difficult to attract large numbers of qualified physicians to the field." Regardless of obstacles, Boling believes it's time to make home-based health care "attractive for physicians to do what's right for patients."

Enter the Independence at Home Act, which Boling expects to be introduced in Congress by the end of its session in early January. If enacted, the legislation would offer incentives for visiting-doctors programs by allowing them to receive usual payments from Medicare and monthly stipends to cover costs associated with managing the practices, provided they help Medicare save at least 5 percent of its annual costs.

Also under the act, these programs would receive the majority of Medicare savings gained from prevented hospital visits. Such savings are measured by comparing the cost to Medicare of patients enrolled in visiting-doctors programs to the expected cost for similar individuals who aren't. In short, the major goals of the act are to decrease Medicare's costs, to provide incentives for talented professionals to enter the home-health care field, and to offer patients the best medical care possible.

Dr. Ana Blohm, one of the doctors at Mount Sinai, treats many patients in their mid-80s, most of whom have serious medical conditions. She said that she and her colleagues try "to prevent that catastrophic hospital visit that can occur at the end of someone's life." The people this happens to are the ones who get lost in the health-care system at times when they need it the most. According to Blohm, they "disappear for two or three years, in which they coast without medical care and then reappear into the system" after a 911 call. The service Mount Sinai provides is catching people in the window of time during which this can be prevented.

There is a lot of overlap in what visiting doctors can offer at home and in the office. Blohm, for example, recently treated two pneumonia patients in their own homes. If these patients had visited a doctor's office, they would have been admitted to the hospital, she adds. But this way, they are able to recover where they're comfortable.

Sometimes, Blohm says, visiting doctors can even offer better quality of care to patients at home. During home visits, she is able to focus on things that might not be apparent during an office visit, such as whether a patient is still smoking or isn't eating properly. She even notices simple things like whether a patient needs grab bars or whether their furniture needs to be rearranged to make it easier to get around.

"When we do a home visit, we notice a lot of things a patient may not admit to when they're in the doctor's office," Blohm related. "Red flags come up you can't see when they're in an office."

Physicians sometimes feel as if they aren't providing the care they should because of the pace of typical office visits, Blohm said. But home visits allow her to connect with patients on a more human level.

"When you see someone in their environment— surrounded by objects that reflect their personal history and trying to be a gracious host despite their physical or mental impediments—there is sort of a moment," Blohm said. "You can pause, stop, and appreciate the human being you're dealing with [as] opposed to the blood pressure, blood sugar, or whatever medical issues may be going on."

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