It is 1976. Brad Stuart is in his third year of medical school at Stanford, doing his first clinical rotation. He is told to look at an elderly man with advanced lymphoma. The patient is feeble and near death, his bone marrow eviscerated by cancer. The supervising oncologist has ordered a course of chemotherapy using a very toxic investigational drug. Stuart knows enough to feel certain that the treatment will kill the patient, and he does not believe the patient understands this. Like a buck private challenging a colonel, he appeals the decision, but a panel of doctors declines to intervene. Well, Stuart thinks, if it must be done, I will do it myself. He mixes the drug and administers it. The patient says, “That hurts!” A few days later, the man’s bed is empty. What happened? He bled into his brain and died last night. Stuart leaves the room with his fists clenched.
To this day, he believes he killed the patient. “I walked out of that room and said, ‘There has got to be a better way than this,’ ” he told me recently. “I was appalled by how we care for—or, more accurately, fail to care about—people who are near the end of life. We literally treat them to death.”
Here is a puzzling fact: From 1970 until 2009, spending on health care in this country rose by more than 9 percent annually, creating fiscal havoc. But in 2009, 2010, and 2011, health-care spending increased by less than 4 percent a year. What explains the change? The recession surely had something to do with it. But several recent studies have found that the recession is not the whole story. One such study, by the Harvard University economists David Cutler and Nikhil Sahni, estimates that “structural changes” in our health-care system account for more than half of the slowdown.
In a sense, Brad Stuart is one of those changes. He is a leader in a growing movement advocating home-based primary care, which represents a fundamental change in the way we care for people who are chronically very ill. The idea is simple: rather than wait until people get sick and need hospitalization, you build a multidisciplinary team that visits them at home, coordinates health-related services, and tries to nip problems in the bud. For the past 15 years, at Sutter Health, a giant network of hospitals and doctors in Northern California, Stuart has devoted himself to developing home-based care for frail, elderly patients.
For years, many people in medicine have understood that late-life care for the chronically sick is not only expensive but also, much too often, ineffective and inhumane. For years, the system seemed impervious to change. Recently, however, health-care providers have begun to realize that the status quo is what Stuart calls a “burning platform”: a system that is too expensive and inefficient to hold. As a result, new home-based programs are finally reaching the market, such as one launched about five years ago at Sutter, called Advanced Illness Management. “It’s much more feasible now to make a program like this work than it was a few years ago,” Stuart told me. “There are a lot of new payment schemes in the pipeline that are going to make this kind of program much easier to support.”
This is good news. Generalizing from a small sample is always perilous, but if what is happening at Sutter is any indication, a more humane, effective, and affordable health-care system is closer than we think.
The problem that home-based primary care addresses has been well understood for years. Thanks to modern treatment, people commonly live into their 70s and 80s and even 90s, many of them with multiple chronic ailments. A single person might be diagnosed with, say, heart failure, arthritis, edema, obesity, diabetes, hearing or vision loss, dementia, and more. These people aren’t on death’s doorstep, but neither will they recover. Physically (and sometimes cognitively), they are frail. Joanne Lynn, the director of the Altarum Institute’s Center for Elder Care and Advanced Illness, says that this “frailty course,” a gradual and medically complicated downslide, was once exceptional but is now the likely path for half of today’s elders.
Seniors with five or more chronic conditions account for less than a fourth of Medicare’s beneficiaries but more than two-thirds of its spending—and they are the fastest-growing segment of the Medicare population. What to do with this burgeoning population of the frail elderly? Right now, when something goes wrong, the standard response is to call 911 or go to the emergency room. That leads to a revolving door of hospitalizations, each of them alarmingly expensive. More than a quarter of Medicare’s budget is spent on people in their last year of life, and much of that spending is attributable to hospitalization. “The dramatic increase in costs in the last month of life is largely driven by inpatient hospital stays,” Helen Adamopoulos recently reported on MedicareNewsGroup.com. “On average, Medicare spends $20,870 per beneficiary who dies while in the hospital.”
Hospitals are fine for people who need acute treatments like heart surgery. But they are very often a terrible place for the frail elderly. “Hospitals are hugely dangerous and inappropriately used,” says George Taler, a professor of geriatric medicine at Georgetown University and the director of long-term care at MedStar Washington Hospital Center. “They are a great place to be if you have no choice but to risk your life to get better.” For many, the worst place of all is the intensive-care unit, that alien planet where, according to a recent study in the Journal of the American Medical Association, 29 percent of Medicare beneficiaries wind up in their last month of life. “The focus appears to be on providing curative care in the acute hospital,” an accompanying editorial said, “regardless of the likelihood of benefit or preferences of patients.”
Taler can attest to one of the more peculiar elements of this situation, which is that a better model—namely, providing care and support at home—has been known and used for decades. Taler himself pioneered an interdisciplinary house-call model in Baltimore in 1980, and in 1999 he co-founded a home-based primary-care program at Washington Hospital Center that has served almost 3,000 people. In the 1970s, the Veterans Administration (now the Department of Veterans Affairs) began building a home-based primary-care program, which now operates out of nearly every VA medical center and serves more than 31,000 patients a day. This is not newfangled, untested stuff.
Home-based primary care comes in many varieties, but they share a treatment model and a business model. The treatment model begins from the counterintuitive premise that health care should not always be medical care. “It’s not medical treatment, it’s helping meet personal goals,” Brad Stuart said. “It’s about ‘Who is this person, and what do they want in their life?’ ”
In Sutter’s Advanced Illness Management program, known as AIM, each patient is assigned to a team of nurses, social workers, physical and occupational therapists, and others. The group works under the direction of a primary-care physician, and meets weekly to discuss patient and family problems—anything from a stroke or depression to an unexplained turn for the worse or an unsafe home.