Briefly describe a specific question, or set of related questions, about a health care test or treatment that this program should consider.

For the disabled and elderly with multiple comorbidities, what is the comparative effectiveness of physician housecalls on outcomes and total cost?

Does your question include a comparison of different health care approaches? (If no, your topic will still be considered.)

yes

If yes, explain the specific technologies, devices, drugs, or interventions you would like to see compared:

Physician and NPP housecalls are rapidly expanding and have increased access using different levels of point-of-care technologies.

What patients or group(s) of patients does your question apply to? (Please include specific details such as age range, gender, coexisting diagnoses, and indications for therapy.)

Patients over 75 and homebound disabled with complex or multi-morbid conditions have reduced access to transportation beyond the 911 option. As Bob Berensen has published, patients with five or more chronic conditions see 14 physicians in 36 encounters annually leading to polypharmacy and lack of primary care controls. Housecall physicians attempt to correct the clinical chaos and early literature suggests dramatic savings.

Are there subgroups of patients that your question might apply to? (For example, an ethnic group, stage or severity of a disease.)

The multi-morbid, homebound population is dramatically more female, frailer with multiple dysfunctional ADLs, more likely to be poor and a minority, and more likely to have three or more chronic conditions. Specific diseases such as Alzheimer's, diabetes, CHF, CAD, COPD and chronic renal failure are highly prevalent.

Describe the health-related benefits you are interested in. (For example, improvements in patient symptoms or problems from treatment or diagnosis.)

I am interested in patient satisfaction outcomes, objective data for improved mood, and particularly improvement in depression scores. I am interested in mortality rates, since homebound patients are usually more interested in comfort care than aggressive hospital-based care.

Describe any health-related risks, side effects, or harms that you are concerned about.

There is little known about comparative mortality rates in this high-cost, complex, multi-morbid patients receiving physician housecalls on a regular basis. Patients exhibit a high degree of therapeutic nihilism which may translate to higher mortality rates or lack of treatment for treatable conditions with physician housecalls. I am concerned about the lack of access to housecalls these patients have in managed care organizations.

Appropriateness for EHC Program

Does your question include a health care drug, intervention, device, or technology available (or likely to be available) in the U.S.?

yes

Which priority area(s) and population(s) does this topic apply to? (check all that apply)

EHC Priority Conditions (updated in 2008)

• Arthritis and nontraumatic joint disorders
• Cardiovascular disease, including stroke and hypertension
• Dementia, including Alzheimer's disease
• Depression and other mental health disorders
• Diabetes mellitus
• Functional limitations and disability
• Pulmonary disease/asthma

AHRQ Priority Populations

• Low income groups
• Minority groups
• Women
• Elderly
• Individuals with special health care needs, including individuals with disabilities or who need chronic care or end-of-life health care

Federal Health Care Program

• Medicaid
• Medicare
• Other

Importance

Describe why this topic is important.

The Independence at Home demonstration now underway will most likely confirm dramatic cost savings with physician housecalls as the center of care delivery, which will accelerate an already dramatic increase in physician housecall services, both concierge and insured. Since housecalls aggregate the patients representing the top 10% most costly tranche of patients, understanding the comparative effectiveness of housecalls is key.

What specifically motivated you to ask this question? (For example, you are developing a clinical guideline, working with a policy with large uncertainty about the appropriate approach, costly intervention, new research you have read, items in the media you may have seen, a clinical practice dilemma you know of, etc.)

Our clinical practice has made over 350,000 physician housecalls in thepast 29 years. We have strong opinions and a bias as to the patient advantages, but know very little about comparative effectiveness. Newer studies confirm major cost savings, but my concern is that this might be related to the strong patient bias for less care at the end of life.

Does your question represent uncertainty for clinicians and/or policy-makers? (For example, variations in clinical care, controversy in what constitutes appropriate clinical care, or a policy decision.)

yes

If yes, please explain:

We have debated this topic for years on the Board at AAHCP. Very little is known about housecalls beyond the cost savings. Is the physician key, or do NPPs do as well? What is the role of technology at the point-of-care. We have doctors putting chest tubes in patients in the home and routinely doing blood gases during in-home visits, but is this appropriate?

Potential Impact

How will an answer to your research question be used or help inform decisions for you or your group?

The Independence at Home Act (Section 3024 of PPACA) gives CMS the authority to expand the gainsharing bonus program nationwide after the first year and has already removed the 10,000 patient cap in the demonstration. The AAHCP is the lead organization for policy guidance in the housecall arena and will use this research to inform its members.

Describe the timeframe in which an answer to your question is needed.

12-18 months will allow timely input to CMS for their decision about expanding IAH nationwide.

Describe any health disparities, inequities, or impact on vulnerable populations your question applies to.

Physician housecalls are currently perceived to benefit those with limited access to office visits, particularly women, medicaid recipients, and those in lower socio-economic strata. Housecall practices aggregate the high-cost patients with multiple co-morbidities and vastly disproportionate problems with polypharmacy, dementia, CHF, and chronic wasting diseases.

Nominator Information

Other Information About You: (optional)

Please choose a description that best describes your role or perspective: (you may select more than one category if appropriate)

The Independence at Home Act (Section 3024 of PPACA) gives CMS the authority to expand the gainsharing bonus program nationwide after the first year and has already removed the 10,000 patient cap in the demonstration. The AAHCP is the lead organization for policy guidance in the housecall arena and will use this research to inform its members.

Are you making a suggestion as an individual or on behalf of an organization?

Individual

Please tell us how you heard about the Effective Health Care Program