In his book “Home Game: an Accidental Guide to Fatherhood,” author Michael Lewis tells the story of his infant son’s admission to the hospital for a lung infection with respiratory syncytial virus, commonly known as “RSV.” His son requires oxygen during his stay but gets no other treatment: no antibiotics, no steroids, no ventilator. Michael speculates that the only reason his kid was admitted was so that nurses and doctors could check on him daily in case he got worse and needed to be intubated. And so, feeling the burn of a lost night’s sleep for both himself and his son, Michael stages a minor protest to allow his son to rest. He meets every potential visitor to the room at the door and demands to know their purpose. Nurses are mostly let in. But if the visitor is a resident or medical student “checking in,” for example, he gives them an update on his son’s respiratory rate and oxygen level and shoos them away. After a couple days his son improves and is discharged home.
As of the writing of this blog post roughly 130,000 Americans are hospitalized with COVID-19, up from ~96,000 at the beginning of December, resulting in more than a third of America’s hospitals operating at at least 90 percent capacity. Some of those inpatients are like Michael Lewis’s son: they’ve been admitted because of frailty or a combination of risk factors (age, other diseases, etc.) that put them at higher risk of death, and the primary treatments they are receiving are oxygen and steroid medications that could theoretically be delivered at home.
Like telemedicine, our very idea of the purpose of hospitalization may be morphing under the pressure of a viral pandemic, prompting changes that have been smoldering for decades. CMS is exploring ways to increase hospital capacity during the COVID-19 surge. We can’t solve this problem by building new hospitals. That takes time (at least outside of China), and hospital beds are needed in relatively small numbers in the US (compared to places like Germany) when viral pandemics aren’t raging uncontrollably. CMS is instead encouraging hospitals to be more aggressive in deciding who can be cared for at home in a program they call, unimaginatively, the “Acute Hospital Care At Home” program, a waiver allowing qualifying health systems to provide hospital-level care at patients’ homes for more than 60 conditions, including common reasons for admission like asthma, congestive heart failure, and pneumonia. You can’t be “admitted” to your own bedroom via telemedicine; you have to be transferred from an in-person emergency department or traditional inpatient hospital bed after an in-person evaluation by a physician. And surgical care clearly needs to be done in the traditional setting, at least for now.
Some companies, having anticipated this need, are marketing equipment or even using artificial intelligence-based systems for monitoring “hospitalized” patients at home. And it seems to work. “Hospital at home” may be marginally better than traditional hospitalization: a study in the Annals of Internal Medicine showed that with one home hospital program, only 7% of patients had to be readmitted to the hospital within 30 days of discharge, compared to 23% of inpatients in traditional care, and the average cost of care of home was 38% lower than care in the hospital.
So the next time you’re on your way to the hospital (heaven forbid), be sure to keep your choice in the back of your mind before you hit the door: would you rather be cared for in the hospital, or would you rather convalesce in the comfort of your own bed?
As the Medical Director of the Kansas Business Group on Health I’m sometimes asked to weigh in on hot topics that might affect employers or employees. This is a reprint of a blog post from KBGH.
