Metropolitan Jewish Health Care System, Brooklyn, NY October, 2008
Medical Administrators Conference, Washington, DC, June, 2009
Obama Transition Committe Health Care Forum, Roosevelt Island, December, 2008

Nicholas D. Kristof’s column extolling the virtues of the Veterans Affairs health care system (”Health Care That Works,” Sept. 3) is right on target. But he doesn’t mention another way the V.A. system has found to provide more and better care to its patients and save lots of money at the same time — house calls.

All across the United States, thousands of chronically ill veterans have been getting house calls from doctors and nurses through the V.A.’s Home-Based Primary Care program. It is far and away the system’s most popular program. And it saves a bundle of money.

A V.A. analysis in 2002 showed that veterans who got house calls spent 62 percent less time in hospitals and 88 percent less time in nursing homes and cost the system 24 percent less than their colleagues seen in offices.

The sickest 10 percent of Medicare enrollees consume about two-thirds of its budget. Encouraging house calls to that population could cut Medicare costs substantially and provide money to cover the country’s uninsured.

The Independence at Home Act is a provision in the House’s health care reform package that would accomplish just that. The act encourages doctors to take on the care of a home-bound population by allowing them to share in the savings they engender. This is real health care reform — a change in the health care system, not simply in its financing.

Jack Resnick
New York, Sept. 3, 2009

The writer, an internist, provides house calls to 50 homebound elderly and disabled people

The following link takes you to the Times Letters Column of 9/9/2009

To the Editor:

Re ”Napping During Hospital Shifts” (editorial, Dec. 9):

Further shortening hospital doctors’ workweeks will only increase the mistakes patients endure. The all-too-frequent errors my patients encounter when hospitalized are almost always caused by doctors who don’t know them well enough, not by doctors who are too sleepy.

My conversations about patients with hospital staff members almost always begin with, ”I don’t know this patient well — I’m just covering.” This problem began with the decrease in residents’ workweeks in the 1980s. It will only get worse with yet another increase in the number of ”handoffs” to which each patient is subjected.

Every patient should have a doctor who is in charge throughout the entire hospital stay. Internet technology should make that resident available 24 hours a day, 365 days a year, through real-time audiovisual links — even if the doctor is at another hospital, at home or vacationing in the Poconos.

Error rates would drop, the quality of care would improve and doctors in training could experience the emotional rewards of actually shepherding someone through an illness. And the length of the on-site workweek could be reduced.

Jack Resnick
New York, Dec. 9, 2008

The writer is an internist.

Follow this link to the Letters Column in the Times

Visit msnbc.com for breaking news, world news, and news about the economy

Independence at Home was the focus of the meeting I led on Roosevelt Island in New York City on
December 29th, which was attended by over 100 people. I am a board-certified internist and my practice is based on Roosevelt Island, a small community between Queens and Manhattan in the East River.

I treat about 30% percent of my patients through house calls. Many of my patients are elderly or severely disabled, and I have found that what keeps them the healthiest is comprehensive treatment in the home – not the hospital. Five of my patients discuss this in a film that can be accessed at

http://therooseveltdoctor.com.

Hospitals present myriad problems – they put patients at great risk for infection; they are understaffed; and the caregivers are not familiar with their patients. Human error and negligence are commonplace. A stay in the hospital for the frail, sick and elderly frequently results in reversible disorientation, delirium and, then, irreversible dementia.

Caring for these patients in the home provides them with greater independence, more informed and careful treatment, and increased personal attention. They live longer, are healthier and happier. And it’s cheaper.

Good home health care keeps patients out of hospitals, thus reducing the cost of hospital stays and
treatment by 30-60%. Several studies (S Okie and RJ Master in the New England Journal of Medicine, and SD Yaggy in Geritatrics) have proved this point.

Hospitalization accounts for 60% of Medicare’s cost per patient, on average, with an even higher
percentage for most of the patients for whom at-home care would be ideal, such as the elderly or disabled.

Bringing care into the home decreases costs significantly, making our system more efficient and cost effective while providing higher quality care.

Among the causes of the bloated cost of hospital care are:
1. Costly errors and hospital-acquired infections.
2. Culture of using too many super-specialists, invasive procedures, and diagnostic tests. These
resources are often used reflexively because “they are there” and need to be supported financially.
3. Administrative supra structure. Medical centers have become enormous institutions supporting many functions far removed from patient care.

I propose two major changes in how the system functions that would sharply reduce costs, dramatically
improve quality and make patients healthier and happier.

1. Move much of health care out of institutions (hospitals and nursing homes) and into homes. This
requires
• well-trained, well-paid caregivers
• nursing and medical services in the home
• electronic medical records
• early attention to advanced care planning
• continuous exercise and physical therapy
• live audio/video internet connection
2. Create cadre of physicians-in-charge delivering health care at home. This requires MDs who:
• are available 24/7
• know each patient intimately
• have immediate access to electronic medical records
• share in the monetary savings their efforts produce

Below is a table I developed that summarizes the estimated savings from a home-based care method.

Summary – as a percentage of

predicted expenditure                       Low estimate   Medium Estimate   High Estimate

total hospital savings                        21%                32%                       42%

cost of implementation                     15%                 23%                      39%

savings to medicare                          6%                   9%                        12%

In revamping the health care system, we must not only change the financing – we must reform the care
itself.

Jack Resnick, M.D.

The Main Street WIRE, Roosevelt Island’s community newspaper, covered the Obama Forum in an editorial,

It also carried a pre-forum story

and a post-forum story