The Future of Home and Community Care

Author(s): Patrick H. Conway, MD, MSc; Alex Rosenblit, MBA; and Scott Theisen
Source: catalyst.nejm.org/doi/full/10.1056/CAT.22.0141

Nathan Walcker's Thoughts

This article provides a sweeping historical and modern day perspective on the care delivery ecosystem beyond the four walls of a hospital. While site of care (hospital, community, home, remote, etc.), and its appropriateness / value remains a hot topic of debate, there is no questioning that ultimately the best interests of the patient should govern where care is received / delivered. For oncology/hematology patients, safe, convenient and high quality / low cost care is best received in community settings, like here at Florida Cancer Specialists & Research Institute. Whenever site of care enters a patient discussion, there must be an acknowledgment of the underlying incentives / motivation for suggesting care in the hospital (340B), and/or in the home (white bagging). Until this is made clear and transparent to patients, families and stakeholders, community oncology providers across the country will continue to face challenges and ultimately be forced to assess the inherent tradeoffs of remaining in private practice, which over the medium / long-term is likely worse for the entire healthcare ecosystem.

It is hard to believe that medical house calls used to make up 40% of all U.S doctors’ visits.1 Home visits used to be the norm, but somewhere in the mid-20th century something changed, and by 1980 house calls accounted for fewer than 1% of patient encounters.2 As a result, people have largely forgotten about the once-famous black medical bag that physicians used to carry from door to door.

Numerous developments were responsible for the shift of care delivery from the home to clinics and hospitals, but perhaps none more than the rise of third-party payers and fee-for-service medicine. In 1960, patients personally paid for 67% of the aggregate bills for medical consultations. By 2014, that number fell to 11% as private insurers and government programs began paying for a larger share of care.3 With clinicians having less control over the money flow, convenience for the patient became less important and acknowledgement of their preferences for house calls dwindled. Instead, volume-based medicine and fee-for-service reimbursement makes it hard to justify the amount of time required to do house calls. Home visits were deemed inconvenient for the provider and an inefficient use of medical resources.

Author Affiliations

Patrick H. Conway, MD, MSc – Chief Executive Officer of Care Solutions, Optum, Boston, Massachusetts, USA; Alex Rosenblit, MBA – Director of Capabilities, Optum Health, Boston, Massachusetts, USA; Scott Theisen – Chief Executive Officer of Home and Community, Optum Health, Minneapolis, Minnesota, USA

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