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Out of Sight, Out of Mind: Home-Bound Patients Get Less Care Than Nursing Home Residents

Home-bound patients in large cities, as well as nursing home residents, benefited the most from house calls from doctors and nurses. But are rural patients being left behind due to their geography?

A new study published in Health Affairs by public health professors found that health care providers were far more likely to visit large-city nursing home residents than non-urban home bound patients.

The skewed visitation patterns expose the challenge of shifting care outside of expensive nursing homes to less expensive home-based care. Seems like the driving time is far less lucrative for doctors than simply checking in on a handful of patents in the same hallway.

Numbers from the study:

Using recent data from the Medicare fee-for service program, we found that the majority of Americans live more than thirty miles from any of the 475 primary care providers who made 1,000 or more home visits in 2012 (Exhibit 1). Collectively, about 5,000 primary care providers made 1.7 million home visits to Medicare fee-for service beneficiaries annually in 2012–13 (Exhibit 2), accounting for 70 percent of all home-based medical visits. Approximately 9–10 percent of these providers performed almost half of these home visits, making them the highest-volume providers of home-based medical care in the country.

Ironically, though the home-based patients outnumber the nursing home residents, those in nursing homes get more attention:

There are at least two million homebound frail people and fewer than two million nursing home patients in the United States. However, about seven times more primary care providers (34,000 of them) visited nursing facilities than visited patients at home (data not shown). The volume of nursing facility visits also greatly exceeds that of home visits. For example, internal medicine physicians made about eight million nursing facility visits but only about half a million home visits in 2012, and Medicare paid those providers $500 million for nursing facility visits but only $50 million for home visits.

The authors also note the irony that in-home treatments often cost less than the nursing home bound residents:

The Independence at Home Demonstration project of the Centers for Medicare and Medicaid Services (CMS) tests home-based medical care in the context of a shared savings payment model. The project saved CMS an average of $3,070 for each participant in the first performance year (June 2012–May 2013), compared to the calculated target expenditure—which is expected.

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