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On-site physician home health care

Note: This report represents information on this subject as of December 1996.

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The downsizing of America’s hospitals has moved the provision of acute and subacute medical care into the patient’s own home. As an industry, home care has grown at the rate of 20 percent per year for more than 10 years. In addition to the increasing numbers of professionals and paraprofessionals delivering home care services, there have been revolutionary changes in medical equipment which has been miniaturized for portability to serve the growing home care population. For example, the equipment for many laboratory tests can now be carried in a pocket. A portable Magnetic Resonance Imaging (MRI) machine the size of a small suitcase is being tested and awaiting Food and Drug Administration (FDA) approval.

As this revolution in the delivery of medical care has progressed, the physician’s role has also changed. Increasingly, medical decision-making occurs at a distance via telephone, with physicians relying on the accuracy and comprehensiveness of the clinical reports of on-site home health nurses and other professional staff.

Resolution 511, I-95, introduced by the Resident Physician Section and adopted by the House of Delegates, asks the American Medical Association (AMA) to study the current roles of physicians in providing on-site home health care and to make recommendations for specific programs to 1) educate physicians, physicians-in-training and students about all aspects of home health care, including costs and 2) increase physician involvement in this rapidly growing area of health care.

Background

The AMA Council on Scientific Affairs (CSA) report Home Care in the 1990’s, A-89,1 defined home care as "the provision of equipment and services to the patient in the home for the purpose of restoring and maintaining his or her maximal level of comfort, function and health." Home care was thus defined as including more than the subset of services covered by the "home health care" benefits under Medicare and other insurers. The various domains of medical care delivered in the patient's own home (as distinct from institutional care in nursing homes) include preventive, diagnostic, therapeutic, rehabilitative and long-term maintenance care.

In 1990, the AMA sponsored a national survey of 1161 family physicians and internists to determine their experiences with and attitudes towards home care.2,3 Fifty percent of the physicians surveyed stated that they made house calls. The mean number of visits per year was 21.2 (median, 10) for family physicians and 15.7 (median, 6) for internists. These physicians reported an average caseload of 20 homebound patients. Sixty-nine percent of the physicians who did not make house calls stated that physician house calls were important for selected patients. Fifty-one percent of the family physicians and 62 percent of the internists agreed with the statement: "With readily available visiting registered nurses and nursing aides, most physician home visits are unnecessary." With this strong support of the value of home health nursing visits as a substitute for physician house calls, it was not surprising to find that 88 percent of the physicians surveyed reported at least one referral to a home health agency within the past year (mean 43, range 0-480).

Although those data indicate strong support for home health care, the physicians interviewed were clearly uneasy about their abilities to manage the care of their patients through this modality. Thus 38.8 percent of family physicians and 52.3 percent of internists stated that they cannot provide adequate medical care at home. The survey data clearly defined a need to educate physicians, given the rapid growth and advanced capabilities of home care.

Accordingly, the AMA Council on Scientific Affairs and the Council on Medical Education issued a joint report on Educating Physicians in Home Health Care, A-90,4 which listed ten competencies or goals for the curriculum for physicians-in-training in home care: (1) Physicians should acquire appropriate skills in home health care assessments. (2)  Physicians should be able to assess the adequacy of family caregivers and informal care resources. (3)  Physicians should be able to evaluate the efficacy of home health care efforts and contribute to improved quality assurance in home health care. (4)  Physicians should be able to apply home health care principles and guidelines appropriately. (5)  Physicians should know community resources. (6)  Physicians should be knowledgeable about cost reimbursement policies in home health care. (7)  Physicians should be knowledgeable about home health care technology. (8)  Physicians should be able to integrate home, office and hospital care for patients. (9) Physicians should play an active and major role on the home health care team. (10 ) Physicians should demonstrate that they value home health care as part of their practice.

In 1991, the CSA addressed the mainstay of home care, the family caregivers who provide more than 80 percent of all the care patients receive at home with a report on Physicians and Family Caregivers: A Model for Partnership (1-91).5 The report presents a biopsychosocial model for the physician - caregiver relationship which both considers the caregiver and the patient as a single unit for the physician’s care and also considers the caregiver as a partner with the physician in the care of the patient.

Then, focusing on physician development, the AMA published in 1992 the Guidelines for the Medical Management of the Home Care Patient6 based on the work of an advisory group of physicians expert in the field of home care. The Guidelines cover the following areas: the role of the physician; the physician-patient relationship; medical management in the home including evaluation/assessment process, communication, selecting a Guideline interdisciplinary team, and development of the care plan; patient’s rights and responsibilities; coordination of care/case management; and community resources.

More than 50,000 copies of the Guidelines have been distributed to physicians upon request to the AMA Department of Geriatric Health .

Between 1992 and 1995, the AMA co-sponsored with state and county medical societies and specialty societies a total of 26 workshops in 10 states to further inform physicians about home care, the AMA Guidelines, the local community resources and how to organize a home care practice. Forty-one percent of the workshop attendees reported on a questionnaire sent three months after the workshop that they had made changes in their office practices to facilitate care of their patients at home.7

In 1996, the CSA report on Evidence-Based Principles of Discharge and Discharge Criteria (A-96) defined discharge criteria as Guidelines that protect patients’ interests in the discharge process by following the principle that the needs of patients must be matched to settings with the ability to meet those needs. The principles and process outlined in the report supply guidance for physicians arranging for post-hospital home care.

When does a physician need to make a house call?

The question of when a physician needs to be on-site through making a house call and when sufficient information can be gathered from home health nurses and therapists to make an accurate medical judgment is complex and difficult to answer.

The Council on Scientific Affairs Report on Home Care in the 1990’s1 cited the literature in identifying several indications for diagnostic home visits:(1) Sick patients with multiple medical problems and mobility difficulties who are taking multiple medications; any patient with recurrent falls. (2) Patients with multiple chronic illnesses and suspected interacting psychosocial problems. (3) Sick patients who are responding poorly to medical therapy. (4)Chronically ill patients who are difficult to relate to and seem unsatisfied with their care. (5) Terminally ill patients who wish to die at home. (6) Homebound disabled patients whose caretakers are frustrated or reaching their tolerance limits. (7) Suspected cases of patient abuse. (8) Older persons with known significant medical problems who refuse to be seen in the office.  (9) Recently bereaved homebound persons with coping difficulties.

The AMA 1990 physician survey identified the following reasons for making a house call in decreasing order of importance:2

1. Patient is a long-term patient
2. Pressure from the family
3. Transportation available but inaccessible
4. Provide terminal care
5. Patient could not afford van or ambulance
6. Allow patient to stay home
7. Assess acute problems
8. Manage chronic problems
9. Assess the home situation
10. Improve patient compliance
11. Post-surgical care.

The AMA Guidelines for the Medical Management lists the following circumstances that may require a physician visit:6

Discrepancies in the patient’s reported functioning.

Acute declines in health or function in frail patients.

Unexplained failure to thrive.

Unexplained failure of the care plan.

Request for physician evaluation in the home by another team member.

Need for a patient/family meeting to make an important decision.

New expectations for physician house calls under managed care?

The majority (85 percent) of physicians surveyed in 1990 felt that physicians should use home health agencies more often and that most of the care needed could be provided by the home health nurses and therapists with physician oversight, with only a small selected number of patients requiring a physician house call.

However, cost containment and managed care pressures on hospitals in the last few years have led to an explosive growth of home care for more acutely ill patients of all ages, and that has led to increasing demand and expectations for physician on-site home care.

Thus, the 1995 Milliman and Robertson (M&R) Healthcare Management Guidelines8,

which are a managed care industry standard, list 16 diagnoses in which acutely ill patients who do not meet the M&R criteria for hospital admission are recommended to receive outpatient care or home care via physician house calls. The diagnoses include: angina pectoris; asthma; bronchitis; cellulitis; chest pain; dizziness; gastroenteritis; gastrointestinal bleeding; headaches; meningitis, rule out or viral; phlebitis; pneumonia, community acquired; pyelonephritis, acute; renal colic; chronic renal failure; vomiting. Pediatric diagnoses that might be handled by physician house calls when there is inadequate reason to hospitalize include: abdominal pain, undiagnosed; asthma; bronchiolitis; gastroenteritis.

For an additional 14 diagnoses, the M&R optimal recovery guidelines recommend home care for acutely ill patients who do not meet the criteria for admission to hospital. In these cases, the patient supposedly encounters the physician at the rapid treatment site and will not require a physician house call although home nursing and other care will be needed.

As with all the M&R guidelines, these recommendations are far from current medical practice. However, the intense cost containment pressures of capitated practices may make them reality in the very near future. Two small studies in the managed care arena indicate substantial cost savings from physician house calls for selected patients.

A 1995 study done by Kaiser Permanente in San Diego9 evaluated substitution of a mobile emergency physician van service for patients otherwise cared for at outside emergency rooms (ER) when the Kaiser facilities were overloaded. Approximately $1000 per incident was saved through this physician on-site service, patient outcomes were optimal on clinical review, and the Kaiser Permanente physicians and patients reported high satisfaction with the program.

In 1993, FHP Health Plan in Long Beach/Orange County, California, began a program of physician home visits for homebound/bedbound patients with subacute illness. The patients were identified by the home health or hospice nurses as requiring a physician visit within 24-48 hours to prevent a hospitalization or ER visit. The need for care was urgent but not emergent (as in the Kaiser Permanente study). In this staff model HMO, two physicians were assigned full time to the home visit program. Since they responded only to requests from the home care team and were unable to schedule visits geographically, they averaged 82 visits per month, or only 4-5 visits per day (as compared to seeing perhaps 25 to 30 patients per day in an office setting). In spite of the apparently inefficient use of the physician’s time, at the end of the first year, FHP reported an average savings per case of $1,351.00 and a total savings for the first year of operation of $941,000.00.10

Physician on-site home care has also been found to be cost-effective internationally. A recent study from Israel of a home hospital program offered to 36,500 persons over age 65 in a capitated health plan, found that providing the home hospital instead of traditional hospital for patients who required hospitalization over a 26 month period saved 20,773 general hospital days and 8486 geriatric hospital (equivalent to skilled nursing facility) days for a cost-benefit ratio of 5.7/1. Physicians provided 24-hour coverage and visited patients as often as required, with a minimum of six visits per month.11 Although the Israeli model cannot be easily transposed to the US, it does demonstrate that a home hospital system based on physician on-site care as part of an integrated team can be developed to deliver cost-efficient care to large numbers of people.12

How large is the homebound population in need of medical care?

The US Bipartisan Commission on Comprehensive Health Care (the Pepper Commission) estimated that in 1990 between 9 and 11 million Americans needed home care services.13 The National Medical Expenditure Survey of 1987 found 5.9 million individuals, roughly 2.5 percent of the US population, receiving home care services. Use of home care services increases with increasing age, thus 11.2 percent of the population over age 65 (3 million persons) received home care (see Table)14. Only 16.5 percent of homebound patients receiving other home care services receive physician house calls and these are infrequent. The great majority of homebound patients have to receive assistance in transportation (from family cars to medivans to ambulances) in order to access even routine physician care.

The 3 million homebound patients who are Medicare beneficiaries are uniquely in need of medical services. This population most resembles the residents of nursing homes and chronic hospitals: all have either physical or mental disabilities, many have both. They are all dependent on the care of others, and suffer a variety of chronic, interrelated medical, psychiatric and social problems. Those patients who require home visits are grouped at the furthest end of the spectrum in frailty and complexity. Homebound patients are always among the highest users of medical services, at the greatest risk for complications and hospitalization, and the most ethically challenging. Their care involves the highest degree of coordination, and the most telephone calls from other health care providers and family members.

In the care of such chronically ill patients, close contact with their physician is vital. Yet, when homebound patients are compared with others who have serious chronic illnesses, they are seen to be seriously deprived of access to physicians. These are the patients who report themselves in fair to poor health, who see their physicians an average of 11 times a year in the office setting,15 or a minimum of 6 times a year, and often more, in a nursing home setting.16 Yet there were only 1.5 million home visits by physicians in 1994 to handle the care of 3 million homebound patients in the Medicare program. Thus, despite the opinion of over 90 percent of primary care physicians in the recent AMA survey2 who agree that housecalls are important, the great majority of homebound patients must be transported, often through specialized and costly transportation services, in order to access routine physician care. Many see physicians only in crisis situations after ambulance rides and admissions to the emergency department of a hospital, with little or no continuing physician involvement between acute episodes.

Physician education

 There is no doubt that physician education about home care is markedly insufficient. A 1994 survey of US medical school deans found that only 66 of 123 schools reported teaching home care.17,18 Of the 66, only 15 required a home care experience in the first two years, and only 27 required a home care experience in the clinical years. Many of these exposures consisted of a single home visit with little or no didactic material. More schools include home care in elective courses, but the number of students taking them is often small.19 Thus, most medical students arrive at a residency with little knowledge of home care.

In residency, the situation is not much better.20,21,22 A 1994 survey of all U.S. internal medicine and family practice residency program directors revealed that most family practice residents receive from 1 to 10 hours of education specifically about home care (41 percent of responses) or from 11 to 25 hours (39 percent).23 This amounts to less than one day of hospital on-call work in the course of three years’ training. For internal medicine residents, 16 percent were considered to receive no formal teaching about home care, with 58 percent having between 1 and 10 hours’ teaching, and 16 percent having between 11 and 25 hours. About one-third of internal medicine residents make one or more housecalls during their residency training, compared with 90 percent of family practice residents. When they do occur, these experiences usually constitute a very small part of residency training, and there is often limited faculty mentorship and guidance. When exploring the root causes of the educational system’s neglect of home care, the main issues prove to be these: 1) lack of available qualified and motivated faculty mentors to teach home care; 2) competing priorities in the curriculum; and 3) insufficient funds. Interestingly, most program directors endorsed home care education as an important element when preparing physicians for future practice.

Thus, the formal exposure to home care in seven years of medical education of most residency-trained physicians entering practice is zero to 35 hours, with a typical experience of about 15 hours. This seems a small amount of time for a dimension of medical care that now constitutes over 3 percent of all health care spending (8 percent of Medicare spending) and involves over $20 billion a year.24 If residency training were comparable to practice demand, 3 percent of residency training should be devoted to home care, or approximately a one month rotation.

When combined with lack of role modeling by practicing physicians, low reimbursement, frustration with hassle factors, and other pressures, the lack of education about home care contributes significantly to the present situation in which physicians make few house calls and where many function poorly as partners to other home care providers. This reality is reflected in national physician surveys, such as the AMA-sponsored survey noted above in which many physicians recognized their limited knowledge in the area of delivering and planning home medical care. It is also reflected by the repeated resolutions before the AMA House of Delegates to increase physician involvement in home care. A specialized area of home care, hospice care at the end of life, has not fared much better in terms of physician education at undergraduate, residency or Continuing Medical Education (CME) levels. The lack of physician knowledge in this specific area is being addressed by an AMA InterCouncil Task Force on Quality Care of the End of Life with a planned major educational outreach from the AMA starting in 1997.

In addition to the AMA workshops mentioned earlier, the American Academy of Home Care Physicians (AAHCP) now offers intensive three-day CME training seminars for medical directors of home health agencies. The first two such seminars have been held; six more are scheduled in the next few months.

Home health agencies, recognizing the need for greater physician involvement in the entire process of the delivery of care in the home, are sending medical directors and advisors to these training programs even though there are no federal regulations requiring a medical director or active physician involvement in the operations of a home health agency. Indeed this is a unique situation: home health agencies are the only health care delivery system that does not have a required physician presence. Medical directors are required for nursing homes and hospices, but although equally complex patients are cared for through home health agencies, there are no federal, state, JCAHO or other accrediting agencies requirements for medical directors.

In addition to the training workshops, the AAHCP offers two or three educational programs nationally each year and has liaison activities with home care sections of medical specialty societies such as the American Academy of Pediatrics, American College of Chest Physicians, American College of Physician Executives, American Geriatrics Society and the Society of General Internal Medicine.

Other offerings in home care education for physicians are occasionally found in programs sponsored by the American Academy of Family Physicians or the American College of Physicians.

Overall, the educational picture in preparing physicians to care for this difficult and growing population is bleak, given the tremendous educational deficit that has been allowed to develop in the past two decades. The development of medical faculties to teach in this area must be a top priority.

Clinical practice of care in the home

The house call presents an array of professional challenges for which the physician must be prepared, mostly through self-study. There is a natural trepidation in venturing outside the familiar surroundings of the hospital or ambulatory care settings without the immediate support of the nursing staff, availability of diagnostic facilities or easy accessibility of colleagues and consultants. Practicing in the patient’s home tests one’s bedside clinical skills in obtaining a history, performing a physical examination and developing a diagnostic differential upon which to base therapy. Seeing patients in their homes will also uncover situations that require knowledge usually in the province of other health professionals, such as family counseling, financial planning, home safety, assessment for rehabilitative equipment, and linkage with community resources. As advances in miniaturization and technology allow sophisticated medical equipment to be available in the home, practitioners are called upon to deal with devices previously encountered only in the hospital if at all.

Several differences in the physician’s work are associated with visiting patients at home. Advances in medical technology have generally made the delivery of care easier in other settings, but in home care, these advances have intensified the complexity of decision making and the demands on the physician. The fragmented nature of home care services has led to an escalation in the numbers of telephone contacts and the amount of paper work. In addition, there is no learning curve in home care. Each household must be coaxed and coached through every step, and frequent telephone calls with these families are necessary even when the care of the patient is considered custodial and there is no ability to bring in Medicare covered home health nurses for additional support in patient and family education.

Further, additional services are required in the house call that are not part of traditional physician services in the office, hospital or nursing home setting. For example, a physical performance test, or functional assessment, is a part of every house call, since functional impairment resulting in homebound status is a basic underlying problem, and is among the greatest burdens for the patient and the family. Training patients and their families to manage the activities of daily living with particular attention to safety and ergonomic issues for the caregiver is a natural consequence of the assessment, as is checking that the family is capable of providing the support needed.

Counseling as part of disease management is a component of the service provided in all settings; however, unlike the hospital, office or nursing home, care in the home necessitates that both patients and their families be included at every visit. This aspect of the home visit is especially important given the burdens placed on the caregiver and the high prevalence of depression, which may lead to burn-out and the potential for elder abuse and neglect.

Many home care patients suffer from dementia or other severe chronic mental illnesses. These conditions are not usually found in isolation but are more likely one of several other diagnoses that require assessment. Care planning includes family counseling and discussing behavioral strategies for the management of disruptive or dangerous symptoms, or devising environmental interventions.

Finally, the nature of the home care setting thrusts additional responsibilities directly on the physician. In all other settings, ancillary staff assist in gathering information, preparing the patient for and during the examination, procuring laboratory specimens, giving injections and other therapeutic interventions, and completing documentation.

The new electronic black bag

The technological side of the health care revolution continues to outstrip both the government’s capacity to study beneficial changes and the researcher’s ability to evaluate beneficial outcomes. New technologies, especially in home care, are being introduced at a rate that exceeds the ability of regulators to anticipate cost advantages and patient benefits or dangers. The physician is left to assess or utilize this equipment based on information that is difficult to obtain and often inadequate.

Miniaturized diagnostic technology that fits into a pocket or small black bag is now available.25 Portable blood analyzers can produce results from a small amount of blood in a few minutes for the most common laboratory tests: BUN, glucose, hemoglobin, electrolytes, calcium and arterial blood gases.26 These analyzers are electronically calibrated and meet all regulatory requirements under the Clinical Laboratory Improvement Amendments (CLIA). The entire direct operational cost for such testing is under $15. A 12-lead electrocardiogram machine takes up less room than a paperback book. Many of these devices can be connected to telephone lines via modem to send information to other sites.

New portable x-ray machines can be easily transported in a nurse’s or physician’s car. Modified x-ray processors can fit in a small van for on-site processing. The digitized x-ray image can be sent via modem to computers in offices far away. There are portable ultrasound machines that can easily be carried from the car into a patient’s home. While all these devices are currently available, the FDA is reviewing but has not yet approved a portable MRI scanner that is capable of 8 cm body penetration.27

Physicians need no longer send patients to the hospital or to an outpatient laboratory for diagnostic testing; they can just open up their modern electronic black bag instead. These point-of-care technologies enable physicians to complete the diagnostic workup and start definitive treatment all in one encounter and can be predicted to change the way physicians practice in all settings.

Devices for drug delivery and treatment have also been miniaturized and simplified. Intravenous therapy in the home is a rapidly growing area of medical treatment fostered by the ease of use of simple electronic pumps the size of a bar of soap that control the flow of the fluids into the small silaster catheters (some of which can remain in place for years). I.V. poles and glass bottles, stop cocks and steel needles are ancient equipment when it comes to current practice in home care. New devices come to market continuously, each one claiming to be simpler, smaller, cheaper and easier for the patient to use. The therapeutic equipment and drugs in the physician’s black bag have also been streamlined for ease of delivery.

The house call via videotelemedicine

There are many prototypes of long distance medical care and consultation using computers or video. Some are still in the planning stage,28,29 but at least one system is currently in use for home care patients.30,31 This consists of individual monitors in patients' homes with small video cameras that will send images over ordinary telephone wires to the central office where a nurse or physician can receive them and talk to the patient (who sees them over the screen on his or her home monitor). The nurse or physician can see clearly enough to check the patient’s technique in drawing up insulin in a syringe to the proper dose, or in completing a dressing change for a wound that is being cared for at home. The central equipment not only stores the entire video visit, it can be used to recall prior video visits and thus the physician can see on the same computer screen not only the current condition of the wound, but also the image of that wound three days before or a week before. Monitoring of wound healing is now possible with far greater accuracy than ever before (an advance over day-to-day hands-on observation). In addition to the video images, electronic stethoscopes can send accurate renditions of breath sounds and heart tones; vital signs such as blood pressure and pulse are also easy to send over ordinary telephone lines.

There is an important caveat. While home health nurses find they can see 25-30 patients a day over videotelemedicine as opposed to five or six in person, this technique must be considered complementary to hands-on home visiting and not a complete substitution for direct care.32 The equipment is currently being used in homes in which the nurse visits in person once or twice each week and checks the patient over videotelemedicine daily.

In the near future, physicians may conduct video house calls on 20 patients in an afternoon, sometimes including three way dialogue with the patient and the home health nurse.

The communication revolution in home care

The greatest frustration for physicians in caring for patients at home is poor and delayed communication of information from home health staff. The frustration is shared equally by home health nurses who cannot get the information they need from hospitals or physicians. The bulk of communication is still sent back and forth through ordinary mail service on complicated forms, but times are changing. Faxes, cellular phones, e-mail and computerized patient records are already reality in some home health care agencies and programs. As of May 1996, the revised Home Health Agency Coverage Manual (HIM-11) gives home health agencies approval to use faxed physician signatures on plans of care and verbal orders; there are instructions on how to authenticate computer generated plans of care.33

Barriers to physician involvement in home care

Multiple resolutions passed by the AMA House of Delegates have called for greater physician involvement in home health care (Policies 210.986, 210.988, 210.991, 210.994, 210.998, AMA Policy Compendium).34 Such exhortations have had little effect due to three major barriers to physician involvement: 1) financial loss associated with providing this care, 2) conflicting regulatory and legal requirements and 3) lack of physician education in home care.

Financial loss

If the three million seniors who receive care at home instead of going into a nursing home were to have the same access to physicians at home as they would have in a nursing home, more than 18 million house calls would be charged to Medicare each year instead of 1.5 million.

Physician refusal to provide this service is the principle cause for this deficiency. Inadequate remuneration is the most frequently cited reason for eschewing home visits among physicians:

  • A 1990 AMA telephone survey of a nationally representative sample of 1,161 family physicians and internists found that 88 percent felt that reimbursement was inadequate for physician services in the home.2
  • The Physician Payment Review Commission, in its 1994 report to Congress, stated: First, the homebound represent perhaps one of the most vulnerable Medicare populations. Declines in primary care services to this population might therefore merit more attention than would changes in services to other Medicare beneficiaries. Second, home visit services take a considerable amount of physician time but are relatively poorly paid.... Advisors to the Commission have suggested that the combination of time and low hourly remuneration along with financial pressures on providers’ practices might make home visits a service that is curtailed by providers.35 
  • A 1995 report from Office of the Inspector General, entitled The Physician’s Role in Home Health Care, found that physicians say these visits are infrequent and only when absolutely necessary. They add that since Medicare pays so little for a home visit it is not affordable for them to see patients in their homes.36

There are many reasons why physician house calls have been so poorly reimbursed (even with small increases granted by the Health Care Financing Administration (HCFA) every year for the last four years, physicians still receive only half to three-fourths of the reimbursement rate provided to home health personnel such as nurses, physical therapists and social workers). With the HCFA five year review of the Resource-Based Relative Value Scale (RBRVS) starting in 1995, a serious effort to re-examine and re-value house calls has been spearheaded by the American Academy of Home Care Physicians (AAHCP) under the auspices of the American Geriatrics Society and in cooperation with the American Academy of Family Physicians, the American Academy of Pediatrics, the American Society of Internal Medicine, the American Podiatric Association and the American Nurses Association. The issue of reevaluation of house call codes was brought to the AMA/Specialty Society Relative Value Update Committee (RUC).

In a separate initiative mandated by Congress, HCFA will be developing new resource based practice expenses relative values. There may be adjustments to account for the extra expenses in house calls including excessive time spent in traveling between patient’s homes, basically down time which the physician cannot productively utilize.

The background of the RUC and the update process

In 1991, the American Medical Association and the national medical specialty societies formed a process through which the health care professionals could review the implementation of the RBRVS developed by HCFA. This process culminates in an AMA/Specialty Society Relative Value Scale Update Committee (RUC) which is charged with the responsibility for recommending relative work values for all medical services that have been codified in the Physician’s Current Procedural Terminology (CPT) manual. The relative work values are used by HCFA and nearly all commercial health insurance carriers to help determine the remuneration for each service. As new approaches are developed for patient care or as the demands on physician’s services change with technological advances, the RUC recommends reevaluations to HCFA so that payments might remain current with clinical practice.37

The RUC is broadly representative of the medical profession community and has input from many other health care providers. Twenty-one members are appointed by major national specialty societies and two seats rotate every two years, with one for an internal medicine subspecialty and the other open to any other specialty. The RUC Chair and representatives for the AMA, the CPT Editorial Board and the American Osteopathic Association hold the remaining seats. One member of the RUC co-chairs a Health Care Professionals Advisory Committee which represents the interests of selected licensed practitioners and allied health professionals. The primary function of the RUC is to adjudicate recommendations for changes in the assigned relative values brought forward by one or more of the 82 members of an Advisory Committee representing the interests of the specialty societies. These recommendations are usually based on a survey process that uses vignettes of typical cases related to services described in the CPT manual to help physicians and related health care practitioners ascribe values to the time, complexity and stress of providing the services, and comparing these to the relative values given to other services. The surveys are intended to represent the range of generalists and specialists, geographic diversity, and difference in practice settings. The RUC reviews the findings of these surveys in relation to the whole of medical practice in developing its own recommendations to HCFA.

Another means by which specialty societies can seek changes in remuneration for services is to redefine the work through the CPT Editorial Panel. Requests for a review of the description of a specific code is evaluated by staff and, if considered a new issue or significant new information is received, it is sent to a committee of specialty advisors, who recommend changes to the Editorial Panel. If these recommendations are accepted, the CPT manual is updated and the new information is forwarded to the RUC for assignment of a relative work value.

The American Academy of Home Care Physicians, under the auspices of the American Geriatrics Society, presented to the RUC the results of physician surveys by five specialty societies, which indicated greater work values for house calls than were previously considered. Discussion before the RUC noted that the complexity of care in the home has increased as technology promoting independent living has escalated and the acuity of illnesses treated at home has increased under pressure to reduce acute care hospital usage from the Medicare Prospective Payment System and managed care organizations. In April, 1996, the RUC unanimously recommended increases that are among the highest granted over the past several years. The RUC recognized the significant differences between home care visits and the other evaluation and management services, including the severe and multiple disabilities of the patients, the need to assess patients’ functional and mental status, to train both patients and their families, and the need to manage problems related to dementia, other psychiatric problems and caregiver pathologies. These recommendations have been forwarded to HCFA.38 In addition, the RUC recommended the CPT Editorial Panel review the description of house call services to better reflect the services provided, particularly: 1) the need for higher level codes for the most complex services; 2) incorporating an annual visit code similar to that in the nursing home setting; and 3) the need for either the home visit codes or the care plan oversight codes to address the comprehensive case management involving the patient’s family.

Conflicting regulatory and legal requirements

A tangle of well-intentioned but illogical regulations unnecessarily complicates the delivery of coordinated care in the home by preventing physician activities that are normal in other settings, such as the hospital or nursing home.

Physician referrals of their ill patients to hospitals or nursing homes in which they may have a financial interest (through ownership, investment, employment, participation in a network, PHO, etc.) are accepted easily, but if the referral is to a home health agency in which the physician has a financial interest it is illegal.

Under the original Medicare regulations, (42C.F.R. 424.22(d)) while physician financial involvement in home health agencies was suspect, it was allowed as long as the financial interest was less than 5 percent of the total assets, stock or profit or less than $25,000 per year in total reimbursement for salary and other benefits. If the financial interest was greater, then the physician could not refer patients to the home health agency in which he or she was working.

One of the bizarre consequences of this regulation was that a medical director of a home health agency had to restrict his or her time available to the agency and refuse to provide care through house calls for agency patients even when their own doctors were unable to see them. No such restrictions are placed on the medical directors of nursing homes, who often become the primary doctor for a majority of the patients. No such restrictions are placed on the medical directors of hospice programs who are expected to provide both administrative and clinical services.

Under the Medicare/Medicaid Anti Kickback laws (42 U.S.C. 1320c-7b(b) and Stark II self-referral legislative provisions, (42 U.S.C. 1395nn) the situation has become even murkier. Recent letters signed by Thomas E. Hoyer, Director of HCFA’s Office of Chronic Care and Insurance Policy,39 indicate that if a hospital owns a home health agency and employs physicians who provide direct patient care at various hospital clinics and outpatient settings, the hospital-employed physician cannot refer patients to the hospital owned home health agency if the total physician compensation for work anywhere in the hospital departments is in excess of $25,000. It now appears that if a patient is cared for by a physician who has financially invested in a physician-hospital organization (PHO) that owns or has a significant financial relationship with the home health agency, that patient may not be referred to the PHO’s home health agency but must be sent outside the network. Clinical concepts of coordination and continuity of care are ignored in the face of the all-pervasive fear of fraud and abuse. Again, there are no problems for the physicians to refer these same patients to the hospitals or nursing homes that are part of the network.

Unexpected consequences of Medicare regulations based on traditional office and hospital practice make point-of-service care in the home extremely difficult. There are many situations in which immediate test results can lead to prompt treatment without delay. For instance, cardiac iso-enzymes are now available in portable laboratory instruments that need only monthly calibrations and that can be easily used for early identification of myocardial infarction in the home. CLIA regulations, based on high volume independent laboratories and their traditional equipment, require every eight hours wet controls calibrations that are not necessary for the newer equipment and prevent its cost effective use by physicians. So far, only the few tests mentioned earlier can be done with electronically calibrated equipment, which are then the only cost-effective (under current CLIA regulations) tests that can be performed in the home.40

The lack of understanding of the needs of point-of-service medical care on the part of government regulators leads to inconsistent and illogical regulatory and reimbursement policies that prevent physicians from providing the most effective on-site home health care.

When it comes to collaborative practices, where physicians employ and work closely with physician assistants or nurse practitioners, these are acceptable in hospitals or nursing homes, but not in home care. The home care team must be, by law, controlled by two different entities, which makes for confusion and loss of continuity of care.

At the same time that physicians are under suspicion for possible kickbacks in their relations with home health agencies, they are also being asked to carefully scrutinize41,42 (from outside the agency) the work of the home heath agency to be able to certify that all services provided were necessary and that the agency was not fraudulently padding their claims to Medicare.43

The Health Insurance Portability and Accountability Act of 1996 has more explicit fraud and abuse provisions, threatening the physician with heavy fines if he or she knowingly approves care that does not meet Medicare guidelines. The civil monetary penalty for physicians who falsely certify that a beneficiary meets all of Medicare’s requirements to receive home care is set at three times the amount of payments for the provided home care services or $5,000, whichever is greater.44 Under the legislation signed August 21, 1996, prosecutors would have to prove the physician acted with deliberate ignorance and reckless disregard for the truth.

Because current interpretations of the Stark legislation and other regulations keep physicians from day-by-day involvement with home health agencies, they are not in a good position to oversee the actual care provided. Physicians rarely, if ever, see the patient’s charts or the written observations of the home health professionals providing the care the physician has authorized. Very inadequate information is provided in the obligatory summaries mailed to the attending physicians.

One solution for many physicians has been to refer their patients to agencies affiliated with their hospitals or health care networks, but that may not be possible in the future, as discussed above.

Another solution has been to encourage physicians to spend more time conferring with the home health nurses to become more fully aware of what services are being provided and to offer more timely medical advice and direction. This solution has been strongly supported by HCFA in the decision to reimburse physicians for their time spent in care plan oversight (CPO), conferencing or communicating with the home health (or hospice) staff.45

In the first year following the new policy, although HCFA assumed some $310 million in claims would be submitted, only $45 million in claims were reimbursed and 14 percent of the claims were denied.46 HCFA has increased the relative value units (RVUs) for CPO from 1.61 units to 1.73 units in 1996, so that reimbursement has increased from an average of $60 for 30 minutes of time per month to $80. Reasons given for the scarcity of physician claims range from physicians who say they spend only 15-20 minutes per patient per month and therefore cannot bill to those who say they cannot take the time to document all the telephone calls.

Nevertheless, it is to be hoped that more physicians will expand their practices to include greater communication and coordination with the home health staff so that they can be more certain of the appropriateness of the care being provided.

The third solution, of course, would be for an increase in physician on-site observation through house calls.

Education

The inadequate state of home care education has already been described. In addition to the ten domains for the curriculum in home health care outlined in the AMA Joint Council report on Educating Physicians in Home Health Care, there are other areas of home care education that must be addressed: (1) Regulatory and legal issues that constrain some physician activities in regard to their home care patients. (2)  Identification of fraudulent or abusive activities on the part of home health agencies, durable medical equipment (DME) vendors or others, and methods to report such activities. (3)  Greater familiarity with the practices of the allied health professionals so that their services can be better utilized and evaluated. (4)  Greater awareness of the myriad of devices and equipment being utilized in the home by the patient, family, home health staff and physicians. (5) Training in methods to evaluate new devices and technology in this era of rapid change. (6) Training in the ethics of medicine in the home, including: (a) The goals of care range from cure, as in the acute care setting, to coping as in the nursing home setting, to caring as in hospice. The physician needs to help the patient and family reach concordance in goals setting. (b) Invasive and specialty diagnostics are more difficult to obtain and this may influence the aggressiveness of the medical care plan, underscoring the importance of goals. (c) The home is the patient’s domain and the physician’s authoritarian role in the hospital becomes more of an advisory role in the home. The doctor-patient relationship has more parity. Negotiation and educational skill are paramount.

Recommendations

The following statements, recommended by the Council on Scientific Affairs, were adopted by the AMA House of Delegates as AMA policy at the 1996 AMA Interim Meeting. The AMA:

  1. Recognizes that timely access to physician care for the frail, chronically ill, or disabled patient is a goal that can only be met by an increase in physician house calls to this vulnerable, underserved population.

  2. Supports the role of interdisciplinary teams in providing direct care in the patient's own home, but recognizes that physician oversight of that care from a distance must sometimes be supplemented by on-site physician care through house calls.

  3. Recognizes the value of the house call in establishing and enhancing the physician-patient and physician-family relationship and rapport, in assessing the effects of the social, functional and physical environment on the patient's illness, and in incorporating the knowledge gained into subsequent health care decisions.

  4. Believes that physician on-site care through house calls is important when there is a change in condition that cannot be diagnosed over the telephone with the assistance of allied health personnel in the home and assisted transportation to the physician's office is costly, difficult to arrange, or excessively tiring and painful for the patient.

  5. Recognizes the importance of improving communication systems to integrate the activities of the disparate health professionals delivering home care to the same patient. Frequent and comprehensive communication between all team members is crucial to quality care, must be part of every care plan, and can occur via telephone, FAX, e-mail, videotelemedicine and in person.

  6. Recognizes the importance of removing economic, institutional, and regulatory barriers to physician house calls.

  7. Supports the requirement for a medical director for all home health agencies, comparable to the statutory requirements for medical directors for nursing homes and hospice.

  8. Recommends that all specialty societies address the effect of dehospitalization on the patients that they care for and examine how their specialty is preparing its residents in-training to provide quality care in the home.

  9. Encourages appropriate specialty societies to continue to develop educational programs for practicing physicians interested in expanding their involvement in home care.

Also see the AMA Geriatric health Web site

References

1. AMA Council on Scientific Affairs Report, Home Care in the 1990’s. JAMA. 1990;263:1241-1244.
2. Keenan JM, Boling PA, Schwartzberg JG, Olsen L, Schneiderman M, McCaffrey DJ, Repsin CM. A national survey of the home visiting practice and attitudes of family physicians and internists. Arch Intern Med. 1992;152:2025-2032.
3. Boling PA, Keenan JM, Schwartzberg JG, Retchin SM, Olson L, Schneiderman M. Reported home health agency referrals by internists and family physicians. JAGS. 1992;40:1241-1249.
4. AMA Council on Scientific Affairs and Council on Medical Education Report. Educating physicians in home health care. JAMA. 1991;265:769-771.
5. AMA Council on Scientific Affairs Report Physicians and family caregivers: A model for partnership. JAMA. 1993;269:1282-1284.
6. AMA Home Care Advisory Panel. Guidelines for Medical Management of the Home Care Patient. Arch Fam Med. 1993;2:194-206.
7. Guttman R, Schwartzberg JG. Impact of training on physician attitudes and practices in home and community care of the elderly. (in revision)
8. Doyle RL. Healthcare Management Guidelines, Volume 1: Impatient and Surgical Care. Milliman and Robertson, Inc. 1995.
9. Armstrong T. Can a mobile emergency service be a cost-effective addition to emergency rooms? American Academy of Home Care Physicians Newsletter 1995;7(2):5-8.
10. Aliotta S, Director, Patient Case Management, Quality Continuum, a division of FHP Health Care. Personal Communication. January 24, 1995.
11. Stessman J, Ginsberg G, Hammerman-Rozenberg R, Friedman R, Ronen D, Israeli A, and Cohen A. Decreased hospital utilization by older adults attributable to a home hospitalization program. JAGS. 1996;44:591-598.
12. Leff B and Burton JR. Acute medical care in the home. JAGS. 1996;44:603-605.
13. US Bipartisan Commission on Comprehensive Health Care. The Pepper Commission Fiscal Report: A Call For Action. Washington, DC; US Government Printing Office; 1990. S. Prt. 101-114.
14. Altman BM and Walden DC. Home health care: use, expenditures, and sources of payment. (AHCPR Pub. No.93-0040). National Medical Expenditure Survey Research Findings 15, Agency for Health Care Policy and Research. Rockville, MD: Public Health Source; 1993.
15. Braden J and Beauregard K. Health status and access to care of rural and urban populations (AHCPR Pub No. 94-0031). National Medical Expenditure Survey Research Findings 18, Agency for Health Care Policy and Research. Rockville MD Public Health Service, 1994.
16. Physician visits at least every 60 days to their patients in nursing homes are necessary to be in compliance with 42 CFR 483.40(c)(1).
17. Steel RK, Musliner MC, Boling PA. Home care experience in medical schools. (letter) N Engl J Med. 1994;331:1098-1099.
18. Steel RK, Musliner MC, Boling PA. Home care experience in the urban setting-- A challenge to Medical Education. Bull NY Acad of Med. 1995;72:87-94.
19. Schwartzberg JG. Home care education for physicians. Caring. 1992;11:18-24.
20. Boling PA and Miller RN. Teaching home care to physicians during residency. National Home Care Month. 1995, Washington, DC. p.60-62.
21. Boling PA, Buchsbaum DG, Pancoast SA, Buchanan RG. Primary care internal medicine residents’ responses to a continuity-- oriented longitudinal home visit experience. Teaching and Learning in Medicine 2, No 1 (1990):34-7.
22. Sullivan GM, Boling PA, Ritchie C, Levine S. Curriculum Recommendations for Resident Training/Society of General Internal Medicine Task Force on Geriatric Medicine. Presented at the American Geriatrics Society Annual Meeting, Washington DC, May 21, 1995.
23. Boling PA. Personal communication, as yet unpublished data.
24. National Association for Home Care Basic statistics about home care 1996 National Home Care Month. 1996, Washington, DC.p. 62-71.
25. Gorman C. Pocket-Size Medicine. Time. September 23, 1996 p. 56.
26. Erickson KA, Wilding P. Evaluation of a novel point-of-care system, the i-STAT portable clinical analyzer. Clin Chem. 1993;39:283-287.
27. C. Gresham Bayne, MD, personal communication, October 11, 1996.
28. Linder A. The telemedicine revolution hits home, Healthcare Informatics October 1995:72-76.
29. Home Care Goes High Tech. Home Health Business Report April 1996 p.3.
30. Davis JE. Telemedicine begins to make its case FORTUNE Webmaster, November 27, 1995, copyright 1995 Time, Inc.
31. Kent C. House calls return-- high tech style. AMNews October 7, 1996 p.3.
32. Gilbert S. New needs of society bring back a medical dinosaur: House calls. NY Times September 18, 1996,. 137.
33. Samen J. Home Health Agency Coverage Manual (HIM-11) 1996. Health Care Financing Administration.
34. AMA Policy Compendium 1996.
35. Prospective Payment Review Committee Report to Congress, 1994.
36. Brown JG. The physician’s role in home health care. Office of Inspector General, Department of Health and Human Services. 1995 [OEI-02-94-00170].
37. AMA/Specialty Society RVS Update Process 1994 American Medical Association.
38. AMA Comment letter of June 27, 1996 from Grant D. Rodkey, MD to Bruce Vladek, PhD.
39. Hoyer TE. Letters of December 15, 1995 and February 29, 1996 Policy Interpretation of 42 CFR 424.22 as reported in Home Care News June 1996 p. 1-2.
40. Bayne CG,Home care, clinical laboratory improvement amendments(CLIA) and the portable lab. American Academy of Home Care Physicians Newsletter,1996,8:4-6.
41. Welch HG, Wennberg DE, Welch WP. The use of Medicare Home Health Services. N Engl J Med 1996;335:324-329.
42. Medicare: Home Health Utilization Expands While Program Controls Deteriorate, U.S. General Accounting Office Report to the Chairman, Special Committee on Aging, U.S. Senate, March 1996 [GAO/HEHS-96-16].
43. Office of the Inspector General, Home Health Fraud, June, 1995 (OIG-95-08).
44. National Association for Home Care. NAHC Report, Number 673, August 9, 1996.
45. Federal Register 63410 (December 8, 1994) and corrections published at 60 Federal Register 46 (January 3, 1995).
46. Boling, PA. A physician's view of care plan oversight. Caring 1996;15:38-42.

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