The Patient Will See You Now, Doctor: A Sea Change In the Hospital–Patient Relationship
July 1, 2021
A serial blog by Charles J. Shanley, M.D. and David Ellis, MS
Health care leaders participating in a recent American Hospital Association panel discussion opined that secular changes in the locations of care delivery will influence hospital design. “With lower-acuity care increasingly moving to outpatient settings and surgery centers and the rise in retail clinics and virtual care services, there will be significant ramifications for acute care and specialty hospitals,” including “even greater space flexibility.” They stressed the need to evaluate new technologies and solutions on the entire health care ecosystem.
Is there a hint of uncertainty, if not panic, in these bland pronouncements? Surely, “space flexibility” isn’t the half of the “significant ramifications” to come. All interests- providers, payers, policymakers, device makers, suppliers, patients … everyone vested in the annual $3.8 trillion U.S. health enterprise-urgently need to note that “outpatient settings” no longer means just tens of thousands of physician offices, ambulatory surgical centers, urgent care centers and retail clinics. It means tens of millions of homes. To an accelerating extent, the traditional outpatient setting is beginning to double as the inpatient setting with profound implications for traditional bricks and mortar-based care delivery paradigms.
Alert to this trend, about two dozen hospital and health systems already offer so-called “hospital-at-home” service. They include Adventist, ProMedica, Cardinal, UNC, Johns Hopkins, Presbyterian, Mass General and,most recently,Mayo Clinic and Kaiser Permanente. The latter two have invested $100 million in a hospital-at-home provider offering patients treatment for routine infections, chronic diseases, emergency care, cancer, acute COVID-19 , infusions, lab and imaging tests, rehab, behavioral health and transfusions. The nurses, physician assistants and paramedics who deliver the hospital-at-home care are controlled and coordinated from 24/7 command centers at the hospital, staffed by integrated care teams.
In pilot programs, Mayo and Kaiser saw lower readmission and improved patient satisfaction compared to their traditional care model, while delivering “the same quality, the same safety and the same outcomes” according to an official quoted in the cited article.
The hospital-at-home movement has been catalyzed by the COVID-19 pandemic, telehealth waivers from CMS, and higher reimbursement. The model installs tablet computers, two-way radios, remote monitoring tools, emergency response systems and durable medical equipment in patient homes, enabling around-the-clock monitoring and consultations with participating hospitals.
Julie Appleby of Kaiser Health News points out that investors will have a hard time recouping bets on costly new hospital beds if the beds go unfilled.And a growing number of beds is likely to go unfilled if a coalition of industry groups, including Amazon, succeeds in lobbying for changes in federal and state rules to allow broader access to a wide range of in-home medical services.
It is claimed (and the Mayo and Kaiser pilots seem to confirm, at least in part) that compared to in-patient hospital care, in-home care is just as safe, may produce better outcomes, and may be up to 30 percent cheaper. Put that in the context of the $3.8 trillion annual hospital spend and disruption is inevitable. Admittedly, it’s early and the current initiatives barely dent this gargantuan budget, but as we have pointed out in our previous posts, we live in exponentially accelerating times. The finger has been pulled from the dike and pressure from vested interests will continue to grow and widen the hole until it bursts and swamps the hospital industry as we know it today.
Of course there will be challenges, such as broadband access forthe poor and in rural areas, staffing, social issues and other challenges. In Detroit, Wayne Health has been addressing these challenges by leading innovation in the rapidly evolving “care where they are” delivery paradigm and facilitating care access through our mobile health initiatives. What began as a mobile COVID-19 testing program has evolved into a mobile vaccine administration, health screening and treatment program that also includes critical linkages to resources addressing social determinants. The bricks and mortar “hospitals” of the future will largely transition to ICUs and operating rooms for high-risk procedures. What are the implications of this megatrend for clinical practice, biomedical innovation, health care reimbursement and training in an ecosystem centered around patients rather than providers?
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 That was the cost in 2019 (seemingly the latest available data), according to CMS. See https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/NationalHealthAccountsHistorical
 Kacik, Alex (2021). “Mayo Clinic, Kaiser Permanente invest $100 million in hospital-at-home model.” Modern Healthcare, May 13. Available (subscription required) at https://www.modernhealthcare.com/patient-care/mayo-clinic-kaiser-permanente-invest-100-million-hospital-home-model
 Appleby, Julie (2021). “Is Your Living Room the Future of Hospital Care?” Kaiser Health News, May 24. Available at https://khn.org/news/article/is-your-living-room-the-future-of-hospital-care/