Julie Appleby: Whither hospital-at-home services after pandemic?
After seven days as an inpatient for complications related to heart problems, Glenn Shanoski was initially hesitant when doctors suggested in early April that he could cut his hospital stay short and recover at home — with high-tech 24-hour monitoring and daily visits from medical teams.
But Shanoski, a 52-year-old electrician in Salem, Mass., decided to give it a try. He’d felt increasingly lonely in a hospital where the COVID-19 pandemic meant no visitors. Also, Boston’s Tufts Medical Center wanted to free up beds for a possible surge of the coronavirus.
With a push from COVID-19, such “hospital-at-home” programs and other remote technologies — from online visits with doctors to virtual physical therapy to home oxygen monitoring — have been rapidly rolled out and, often, embraced.
As remote visits quickly ramped up, Medicare and many private insurers, which previously had limited telehealth coverage, temporarily relaxed payment rules, allowing what has been an organic experiment to proceed.
“This is a once-in-a-lifetime thing,” said Preeti Raghavan, an associate professor of physical medicine and rehabilitation and neurology at Johns Hopkins University School of Medicine, in Baltimore. “It usually takes a long time — 17 years — for an idea to become accepted and deployed and reimbursed in medical practice.”
Physical therapists traded some hands-on care for video-game-like rehabilitation programs patients can do on home computer screens. And hospitals like Tufts, where Shanoski was a patient, sped up preexisting plans for hospital-at-home initiatives. Doctors and patients were often enthusiastic about the results.
“It’s a great program,” said Shanoski, now fully recovered after 11 days of receiving this care. At home, he could talk with his fiancée “and walk around and be with my dogs.”
But what will remain of these innovations in the post-COVID era is now the million-dollar question. There is a need to assess what is gained — or lost — when a service is delivered remotely. Another variable is whether insurers, which currently reimburse virtual visits at the same rate as if they were in person, will continue to do so. If not, what is a proper amount?
It remains to be seen what types of novel remote care will persist from this born-of-necessity experiment.
Said Glenn Melnick, a health-care economist at the University of Southern California who studies hospital systems: “Pieces of it will, but we have to figure out which ones.”
Hospital At Home
Long established in parts of Australia, England, Italy and Spain, such remote programs for hospital care have not caught on here, in large part because U.S. hospitals make money by filling beds.
Hospital-at-home initiatives are offered to stable patients with common diagnoses — like heart failure, pneumonia and kidney infections — who need hospital services that can now be delivered and managed at a distance.
Patients’ homes are temporarily equipped with the necessities, including monitors and communication equipment as well as backup internet and power sources. Care is overseen by health professionals in remote “command centers.”
Medically Home, the private company providing the service for Tufts, sent its own nurses, paramedics and other employees to handle Shanoski’s daily medical care — such as blood tests or consultations via camera with doctors. They inserted an IV and made sure it was working properly during their visits, which often totaled three a day. Even when Medically Home employees were not there, devices monitored Shanoski’s blood pressure and oxygen levels.
For patients transferred from the hospital, like Shanoski, Tufts pays Medically Home a portion of what the hospital receives in payment. For transfers from an emergency room, Medically Home is paid directly by insurers with which it has contracts.
Before the pandemic, at least 20 U.S. health systems had some form of hospital-at-home setup, said Bruce Leff, a professor at Johns Hopkins University School of Medicine who has studied such programs. He said that, for the right patients, they’re just as safe as in-hospital care and can cost 20% to 30% less.
Tele-Rehab?
Glenn Shanoski, a 52-year-old electrician, spent 11 days with hospital-level care at home —– offered by Tufts Medical Center in Boston. Tufts provides daily visits from medical teams to closely monitor patients in their homes. (Courtesy of Glenn Shanoski)
When the coronavirus shut down elective procedures, many physical-therapy offices had to close, too. But a number of patients who had recently had surgery or injuries were at a crucial point in recovery.
Therapists scrambled to set up video capability, while their trade association called insurers and regulators to convince them that remote physical therapy should be covered.
At the end of April, the Centers for Medicare & Medicaid Services added remote physical, speech and occupational therapy to the list of medical services it would cover during the pandemic. Just as it had done for other services, the agency said payment would be the same as for an in-person visit.
Though some patient care cannot be done virtually, such as hands-on manipulation of tight muscles, the doctors discovered many advantages: “When you see them in their home, you can see exactly their situation. Rugs lying around on the floor. What hazards are in the environment, what support systems they have,” said Raghavan, the rehabilitation physician at Johns Hopkins. “We can understand their context.”
Using video links, therapists can assess how a patient moves or walks, for example, or demonstrate home exercises. There are also specially designed video-game programs — similar to Nintendo Wii — that utilize motion sensors to help rehabilitation patients improve balance or specific skills.
“Tele-rehab was very much in the research phase and wasn’t deployed on a wide scale,” Raghavan said. Her department now does 9 out of 10 visits remotely, up from zero before March.
Pneumonia Monitoring
Even before the coronavirus emergency, some patients with mild pneumonia were treated as outpatients.
Now, with hospitals busy with COVID-19 cases and patients eager to minimize unneeded exposure, more physicians are considering this option and for sicker patients. The key is using a small device called a pulse oximeter, which clips onto the end of a finger and measures heart rate, while also estimating the proportion of oxygen in the blood. Costing at most a few hundred dollars, and long common in doctors’ offices, clinics and emergency rooms, the tiny machine can be sent home with patients or purchased online.
“We do it on a case-by-case basis,” said Dr. Gary LeRoy, president of the American Academy of Family Physicians. It’s a good option for relatively healthy patients but is not appropriate for those with underlying conditions that could lead them to deteriorate rapidly, such as heart or lung disease or diabetes, he said.
A pulse oximeter reading of 95% to 100% is considered normal. Generally, LeRoy tells patients to call his office if their readings fall below 90%, or if they have symptoms like fever, chills, confusion, increasing cough or fatigue and their levels are in the 91-to-94 range. That could signal a deterioration that requires further assessment and possibly hospitalization.
“Having a personal physician involved in the process is critically important because you need to know the nuances” of the patient’s history, he said.
What It All Looks Like In The Future
Virtual therapy requires patients or their caregivers to accept more responsibility for maintaining the treatment regimen, and also for activities like bathing and taking medicines. In return, patients get the convenience of being at home.
But the biggest wild card in whether current innovations persist may be how generously insurers decide to cover them. If insurers decide to reimburse telehealth at far less than an in-person visit, that “will have a huge impact on continued use,” said Mike Seel, vice president of the consulting firm Freed Associates in California. A related issue is whether insurers will allow patients’ primary caregivers to deliver treatment remotely or require outsourcing to a distant telehealth service, which might leave patients feeling less satisfied.
The industry’s lobbying group, America’s Health Insurance Plans, said the ongoing crisis has shown that telehealth works. But it offered no specifics on future reimbursement, other than encouraging insurers to “closely collaborate” with local care providers.
Whether virtual therapy is cost-effective “remains to be seen,” said USC’s Melnick. And it depends on perspective: It may be cheaper for a hospital to do a virtual physical therapy session, but the patient might not see any savings if insurance doesn’t reduce the out-of-pocket cost.
Julie Appleby is a Kaiser Health News reporter.jappleby@kff.org, @Julie_Appleby
Melissa Bailey: Even in New England, global warming putting physicians in hot seat
Person being cooled with water spray, one of the treatments of heat stroke in Iraq in 1943
BOSTON
A 4-year-old girl was rushed to the emergency room three times in one week for asthma attacks.
An elderly man, who’d been holed up in a top-floor apartment with no air conditioning during a heat wave, showed up at a hospital with a temperature of 106 degrees.
A 27-year-old man arrived in the ER with trouble breathing ― and learned he had end-stage kidney disease, linked to his time as a sugar cane farmer in the sweltering fields of El Salvador.
These patients, whose cases were recounted by doctors, all arrived at Boston-area hospitals in recent years. While the coronavirus pandemic is at the forefront of doctor-patient conversations these days, there’s another factor continuing to shape patients’ health: climate change.
Global warming is often associated with dramatic effects such as hurricanes, fires and floods, but patients’ health issues represent the subtler ways that climate change is showing up in the exam room, according to the physicians who treated them.
Dr. Renee Salas, an emergency physician at Massachusetts General Hospital, said she was working a night shift when the 4-year-old arrived the third time, struggling to breathe. The girl’s mother felt helpless that she couldn’t protect her daughter, whose condition was so severe that she had to be admitted to the hospital, Salas recalled.
She found time to talk with the patient’s mother about the larger factors at play: The girl’s asthma appeared to be triggered by a high pollen count that week. And pollen levels are rising in general because of higher levels of carbon dioxide, which she explained is linked to human-caused climate change.
Salas, a national expert on climate change and health, is a driving force behind an initiative to spur clinicians and hospitals to take a more active role in responding to climate change. The effort launched in Boston in February, and organizers aim to spread it to seven U.S. cities and Australia over the next year and a half.
Although there is scientific consensus on a mounting climate crisis, some people reject the idea that rising temperatures are linked to human activity. The controversy can make doctors hesitant to bring it up.
Even at the climate change discussion in Boston, one panelist suggested the topic may be too political for the exam room. Dr. Nicholas Hill, head of the Pulmonary, Critical Care and Sleep Division at Tufts Medical Center of Medicine, recalled treating a “cute little old lady” in her 80s who likes Fox News, a favorite of climate change doubters. With someone like her, talking about climate change may hurt the doctor-patient relationship, he suggested. “How far do you go in advocating with patients?”
Doctors and nurses are well suited to influence public opinion because the public considers them “trusted messengers,” said Dr. Aaron Bernstein, who co-organized the Boston event and co-directs the Center for Climate, Health, and the Global Environment at Harvard’s school of public health. People have confidence they will provide reliable information when they make highly personal and even life-or-death decisions.
Bernstein and others are urging clinicians to exert their influence by contacting elected officials, serving as expert witnesses, attending public protests and reducing their hospital’s carbon emissions. They’re also encouraging them to raise the topic with patients.
Dr. Mary Rice, a pulmonologist who researches air quality at Beth-Israel Deaconess Medical Center here, recognized that in a 20-minute clinic visit, doctors don’t have much time to spare.
But “I think we should be talking to our patients about this,” she said. “Just inserting that sentence, that one of the reasons your allergies are getting worse is that the allergy season is worse than it used to be, and that’s because of climate change.”
Salas, who has been a doctor for seven years, said she had little awareness of the topic until she heard climate change described as the “greatest public health emergency of our time” during a 2013 conference.
“I was dumbfounded about why I hadn’t heard of this, climate change harming health,” she said. “I clearly saw this is going to make my job harder” in emergency medicine.
Now, Salas said, she sees ample evidence of climate change in the exam room. After Hurricane Maria devastated Puerto Rico, for instance, a woman seeking refuge in Boston showed up with a bag of empty pill bottles and thrust it at Salas, asking for refills, she recalled. The patient hadn’t had her medications replenished for weeks because of the storm, whose destructive power was likely intensified by climate change, according to scientists.
Climate change presents many threats across the country, Salas noted: Heat stress can exacerbate mental illness, prompt more aggression and violence, and hurt pregnancy outcomes. Air pollution worsens respiratory problems. High temperatures can weaken the effectiveness of medications such as albuterol inhalers and EpiPens.
The delivery of health care is also being disrupted. Disasters like Hurricane Maria have caused shortages in basic medical supplies. Last November, nearly 250 California hospitals lost power in planned outages to prevent wildfires. Natural disasters can interrupt the treatment of cancer, leading to earlier death.
Even a short heat wave can upend routine care: On a hot day last summer, for instance, power failed at Mount Auburn Hospital in Cambridge, Massachusetts, and firefighters had to move patients down from the top floor because it was too hot, Salas said.
Other effects of climate change vary by region. Salas and others urged clinicians to look out for unexpected conditions, such as Lyme disease and West Nile virus, that are spreading to new territory as temperatures rise.
In California, where wildfires have become a fact of life, researchers are scrambling to document the ways smoke inhalation is affecting patients’ health, including higher rates of acute bronchitis, pneumonia, heart attacks, strokes, irregular heartbeats and premature births.
Researchers have shown that heavy exposure to wildfire smoke can change the DNA of immune cells, but they’re uncertain whether that will have a long-term impact, said Dr. Mary Prunicki, director of air pollution and health research at Stanford University’s center for allergy and asthma research.
“It causes a lot of anxiety,” Prunicki said. “Everyone feels helpless because we simply don’t know — we’re not able to give concrete facts back to the patient.”
In Denver, Dr. Jay Lemery, a professor of emergency medicine at the University of Colorado School of Medicine, said he’s seeing how people with chronic illnesses like diabetes and chronic obstructive pulmonary disease suffer more with extreme heat.
There’s no medical code for “hottest day of the year,” Lemery said, “but we see it; it’s real. Those people are struggling in a way that they wouldn’t” because of climbing temperatures, he said. “Climate change right now is a threat multiplier — it makes bad things worse.”
Lemery and Prunicki are among the doctors planning to organize events in their respective regions to educate peers about climate-related threats to patients’ health, through the Climate Crisis and Clinical Practice Initiative, the effort launched in Boston in February.
“There are so many really brilliant, smart clinicians who have no clue” about the link between climate change and human health, said Lemery, who has also written a textbook and started a fellowship on the topic.
Salas said she sometimes hears pushback that climate change is too political for the exam room. But despite misleading information from the fossil fuel industry, she said, the science is clear. Based on the evidence, 97% of climate scientists agree that humans are causing global warming.
Salas said that, as she sat with the distraught mother of the 4-year-old girl with asthma in Boston, her decision to broach the topic was easy.
“Of course I have to talk to her about climate change,” Salas said, “because it’s impairing her ability to care for her daughter.”
Melissa Bailey is a Kaiser Health News journalist.
Melissa Bailey: @mmbaily
