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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.

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