Signs for Optimism as Health Care Transitions to the Future

Amidst the doom and gloom that pervades discussions about health care finances and the bleak reimbursement environment in which many practitioners operate, one New Jersey physician entrepreneur is using technology to build a home care practice that produces improved outcomes for patients and a better quality of life for physicians. Alan Faustino, MD, of NJR Healthcare talks about the importance of high-quality transitional care, the need for physicians to be proactive in confronting the challenges facing their profession, and why home health care may hold the key to designing more innovative approaches to health care delivery.

How has home health care changed since the days of the country doctor making house calls? What are some of the services you offer currently?

Thanks to advances in medicine and technology, life expectancy has increased and more older people are living at home nowadays. The Medicare population has grown immensely. A large percentage of patients in that age group have difficulty getting out of their homes, or for some reason or another have difficulty getting to the doctor. Our practice model is based on taking care of patients in the comforts of their home. Studies have shown that patients who receive care at home do better overall. Many years ago, back when it was more common for physicians to make house calls, the problem was that the technology and equipment then was big and cumbersome, and you pretty much had to take the patient to the technology. Now, the technology has gotten smaller and portable. Now, we can do just about everything in the comfort of the patient’s home that could be done in a primary care office. We can do EKGs, ultrasounds of any part of the body, transtelephonic monitoring, Holter monitoring of the heart, two-dimensional echocardiography, x-rays, etc. The portable technology that is available is really incredible. We use a portable radiology unit that only weighs about 25 pounds. In addition to new technology making it easier to treat people in the home, there’s a new trend in labs that focus mainly on doing blood work on people who are homebound or who would rather receive medical services at home.

All of these services are covered under Medicare. Our main practice is focused on patients age 65 and older who are homebound and can’t get out to see the doctor. Medicare reimburses pretty well for that. There are also all kinds of incentives for physicians who have a high percentage of Medicare patients to adopt this practice model because studies are showing that taking care of patients at home increases patient satisfaction and can save a lot of health care dollars.

Does private insurance reimburse for this also?

Most patients don’t realize that their insurance will actually pay for house visits. I have a number of patients who are under age 65 who have private insurance that will pay for home visits.

Aside from the fact that studies show that home delivery of health care can improve satisfaction and outcomes, what made you pursue this practice model?

I got into it because I did a favor for somebody who couldn’t get out to the doctor and needed some health services at their house, and I found it incredibly rewarding. Because I did this as a favor and not for financial reasons, I got to spend quite a bit of time with the patient in their home and really got to know them. That was very satisfying. Plus, my accountant said, “Look, you know, you got paid pretty well for that visit.” I didn’t know that you could bill for these services. It made me change my whole way of thinking about the delivery of health care.

At first, I didn’t do this to contain costs; I did it because I wanted a better lifestyle for myself, and I wanted to spend more quality time with my patients. One of the reasons I went to medical school was because I wanted to really get to know patients and learn about their social conditions that greatly affect their medical conditions. Home health care allowed me to do that. It gave me greater professional satisfaction at the end of the day. My hours didn’t change; I worked the same hours, but I came home feeling more invigorated and more useful. I realized I didn’t have to be the typical assembly line physician who had to see 35 patients a day just to meet overhead.

As the years went on and health care expenditures started going through the roof, many experts and government agencies saw that if we can provide quality services, including preventative health services, and do something to control the escalating cost of Medicare, it would be of great benefit to everybody. The Independence at Home Act that has been approved by Congress incentivizes physicians to go out and do this. In affiliation with home health care nursing, palliative and hospice nurses that visit the home, other visiting labs and visiting home health agencies that provide eldercare services, it’s beneficial and cost-containing.

I also found that home health care offers a great opportunity to produce something and be proactive. Physicians unfortunately complain a lot but do nothing about their current situation. I felt a great need to not only provide these services but also to do something to change how we’re practicing medicine. We need to think outside of the box. The way we deliver care is very sophisticated, yet there are other countries that are much better at delivering health care services than we are because their care philosophy is different. They have a different mode of thinking.

This wouldn’t have been possible without some of these technological advances? What else do you see happening in the next few years?

Before, it was impossible for me to carry hundreds of charts with me when I would see patients. Now, I can access it all through Web-based technology. About five years ago, I developed an EMR that was specifically suited for the home care industry and physicians who make house calls. Eventually, I got some investors involved, and then a venture capital company. We were the ninth government-certified Web-based EMR. With it, physicians can practice in the office setting or go mobile and visit patients in their homes.

EMRs and related technologies will allow us to better predict which patients are at higher risk for illness and complications, enabling us to intervene before they end up in the hospital. We’re developing protocols that will help us to recognize certain key factors and indicators and enable us to intervene at home before these situations get out of control and patients have to go to the hospital. That’s where I see this going.

Telemedicine is evolving. Skype and other technologies let senior citizens use their TVs as a portal to connect with their providers, who can ask questions and monitor their day-to-day health. The decrease in cost it takes to deliver that information and care is going to revolutionize how we take care of patients in general. Telemedicine is already an accepted mode of practicing medicine used by a lot of hospitals. Now, we’re moving that model away from the hospital and into the home environment. I believe that the future will involve more and more of that kind of care being delivered.

Does your approach enhance the continuity of care for patients? Are there communication barriers that make it difficult to coordinate with other physicians?

Those communication barriers are becoming obsolete. With technology, now it’s easier for us to communicate with physicians when we transition patients from the hospital to sub-acute rehab to the home environment. For example, our certified EMR lets us communicate with the hospital and pharmacies through sophisticated and secure feeds. Now I know which physicians saw my patients in the hospital, and I know which medicines they were discharged on. The visiting nurses also have access to the same system. Until recently, communication during transitional care from the hospital to the primary care doctor to the home environment was a real challenge. But now with the technology that we have today, it’s less of a challenge.

I actually think that transitional care will be a specialty in the future. Physicians will specialize in providing care to patients who have been discharged from the hospital, making sure they’re on the right medication regimen, making sure that they stay out of the hospital. We know with most of these patients that communication is the key‑‑they don’t understand the medicines; the physician in the hospital doesn’t understand that the medicine they’re prescribing is not preferred, so there’s a $100 copay and there’s no way the patient is going to get it. A transitional care physician will be able to step in and identify those patients and make sure the transition from one setting to another is run efficiently, with a decrease in complications.

This improves outcomes and patient satisfaction, as well as improves your professional satisfaction?

I truly believe that the physicians who are truly happy in the practice of medicine don’t measure success based on dollars‑‑they measure it based on outcomes. At the end of the day, I’m not thinking about how much money I made; I’m more satisfied when I know that I’ve prevented a hospitalization, or treated an illness early enough to prevent further pain and suffering. I think most physicians are that way. Those who are really satisfied in their practice value that as the main target for their professional satisfaction.

Does that make this practice model a more attractive career track for young physicians who are concerned about their quality of life and don’t want to practice assembly line medicine?

Yes, and I’ll tell you why. The younger physicians — I call them Facebook physicians – they’re very communication savvy. They’re very media savvy and very social networking savvy. They understand that using these tools will help improve overall health care of patients. And they’re beginning to see that they can use cutting-edge technology to make a good living. We’re using wireless Bluetooth, EKGs, pulmonary function tests, and other technology in real time to make decisions about patients, whether you’re in front of them or using TV or Web cams. It’s very sophisticated, rewarding, and modern. It can pay for a physician to go into this type of medicine. You’re not going to be a millionaire, but the satisfaction is there and you’ll make a good income compared to your other primary care colleagues. It’s got all of the ingredients for a successful and happy lifestyle for a physician who just got out of medical school and residency.

This is also a low-overhead model of practice?

Absolutely. The overhead is quite low because there’s so much competition out there now in the marketplace for new technology, so it’s not all that expensive. Most of the Web-based technologies are simple applications that you can download and use via wireless technology. A lot of cities are going wireless now. Philadelphia is completely wireless, for example. The technology makes it very inexpensive to start this type of practice. You could start this in a room of your home, like I did. It’s a very cost-effective, low-overhead, high-satisfaction life.

Can this work with non-Medicare populations?

Approximately 5% of my patients are not Medicare, they’re privately insured. Many private payers pay for home care. Some plans pay for home care whether you’re homebound or not.

You have a pretty positive view of the current prospects for enterprising physicians who want to practice home health care, and your optimistic vision for the future of this area of medicine is a refreshing contrast to the gloomier pronouncements one often comes across. Can this business model offer a way forward for other areas of practice?

We definitely have a health care crisis on many fronts in this country. We reward physicians for performing procedures, not for being proactive and preventing disease. We should do a combination of both. We need to put more emphasis on preventative care and preventing accidents. When it comes to health care, a penny saved is truly a penny earned. The government has realized that we have the technology and the ability to intervene early, so what can we do to motivate physicians to participate in that model?

I’m excited because every day I’m contacted by people who introduce me to new health care technologies. It’s just mindboggling the things that we can do now. Sometimes, I feel a bit like a pioneer, working with these technologies and putting together certain tools and assessments and working closely with forward-thinking ancillary services like the visiting nurses and others who are excited by this.

If you look at what is happening at the federal level, the government is telling us, “Look, you have the technology; you tell us how this is supposed to work. If you can prove that this works, we’ll fund it.” I feel like I’m on the cutting edge, which is incredibly motivating. This can be applied to many sectors of medicine. For example, look at the use of telemedicine by hospitals and clinics that don’t have access to a neurologist on staff. A neurologist in one location will use a webcam to assess patients and make decisions on treatment in real time. We’re applying these technologies in various sectors already in the US. I’m currently involved in a program to prevent rehospitalizations among patients with congestive heart failure. It’s difficult clinically to tell if a patient has had a heart attack or if they have low blood pressure because they’re dehydrated, or if they’re having an emphysema flare versus being in heart failure. But, technology such as iStats, which are portable chemistry analyzers that fit in the palm of your hand, we can now at the bedside at the patient’s home, do a simple tests that tell if the patient has had an a heart attack or MI and needs to go to the hospital. It allows us to differentiate between other patients who may have the exact same appearance, symptoms, and vital signs and are in heart failure and need different treatment (IV diuretics at home, nitroglycerin, electrolytes, etc). We’re developing the protocols for this. The smart application of technology is helping us change the setting in which the patient receives care, which saves money and time, and improves morbidity, mortality, and satisfaction. I guarantee that we’ll be able to use this in other settings in the future.

How will the Patient Protection and Affordable Care Act, as currently configured, affect all of this? Barring major changes to the law, what implications will it have for home health care as you practice it?

If we can’t prove that we’re containing costs, the government is going to do what it did in the 1970s and 1980s. Back then, the government looked at house calls and decided that it wasn’t beneficial to see Medicare recipients at home. So they paid next to nothing for it, and physicians stopped doing house calls. Back then, all of the new technology was in the hospitals. But it was big and bulky, so you had to bring the patient to it. Now, that’s changed. But if we don’t prove in the next few years that we’re containing costs, the government may take another approach that may not be in the best interests of patients and physicians.

I’m talking about the specter of socialized medicine looming over us. If physicians don’t take a greater leadership role and become more vocal advocates for our patients and ourselves, then that’s what’s going to happen to this country. The government will ration care to a greater degree, and socialize health care. That’s a direction we don’t want to go in. We have the technology, now we need a leader to say, “It is my goal within the next five years to contain the costs of Medicare while ensuring that everybody can get quality health care in the home environment.” It’s not an impossible goal; we just need physician entrepreneurs to step up and become part of the process and take a greater role in fixing the problems in health care instead of complaining about it and doing nothing. That’s what we’ve been doing for too long, and that needs to change. I’m very encouraged because I’m starting to see more physicians standing up and doing this.

To learn more about innovative home health care, contact Alan Faustino, MD, at afaustino@njrhealthcare.com or visit the NJR Healthcare website at www.njrhealthcare.com.