Academic journal article The Hastings Center Report

The Economic Impact of High-Technology Home Care

Academic journal article The Hastings Center Report

The Economic Impact of High-Technology Home Care

Article excerpt

The resurgence of home medical care as an alternative to hospitalization is in a sense a return to the past. Prior to World War 11, the dearth of institutional facilities meant that treatment and care had to be delivered at home. When the war ended, technologically advanced hospitals were built on a large scale and quickly became the "modern" and preferred way to deliver care.

Over the past twenty years, the pendulum has swung dramatically in the opposite direction and an increasing share of the nation's health care dollar has been apportioned to home care. In 1970 expenditures for hospital care exceeded those for home care by a margin of 279 to 1; by 1991 this margin had shrunk to 29 to 1.[1] Another recent shift came as high-technology home care began to play a more prominent role in the home care market beginning in the early 1980s. It has increasingly become an alternative to hospitalized care rather than just a means to recover from it.

What Is High-Tech Home Care?

While traditional home care focuses on the provision of personal care and housekeeping assistance, high-tech home care involves the use of more sophisticated apparatus, such as infusion therapy to provide nutrition or medication; medical devices for patient monitoring; and ventilator systems that provide breathing assistance. We concentrate here on infusion therapies, which have expanded rapidly, are extremely costly, and are increasingly used in HIV and cancer treatment.

Under some circumstances infusion therapy must be administered by skilled nurses, but technological refinements have made it easier for family members or other caregivers to provide most necessary patient care and the therapy can even be administered by patients themselves in some circumstances. Infusion therapy delivers nutrients or medications, requires specialized equipment and infusion solutions, and can be administered by two different routes. Enteral feeding, sometimes referred to as tube feeding, is used to infuse nutrients and water into the stomach or intestine when the gastrointestinal tract is unable to digest and absorb food normally. Parenteral feeding (also known as total parenteral nutrition or TPN) infuses nutrients and water into the veins through a catheter, bypassing the gastrointestinal tract.

There are many nutritional applications of home infusion therapy for persons with HIV. For example, it is used to provide fluids to counter the severe dehydration that accompanies opportunistic infections and to treat the weight loss that characterizes generalized wasting syndrome.[2]

Home antibiotic therapy to treat infections has historically been administered intravenously through drip flow systems. However, more sophisticated infusion devices allow greater control over the flow of drugs and, as a result, permit the use of more complex medications. For example, HIV-infected patients now receive bactrim or pentamidine for the treatment and prevention of Pneumocystis carinii pneumonia and ganciclovir and foscarnet to treat cytomegalovirus and herpes infections.[3]

The direct costs of high-technology home care are primarily for medications, equipment, supplies, and personnel. Indirect costs include program administration, training, and marketing.

Drugs. A direct cost of high-tech home care is the medication or nutritional supplement. In theory, the unit cost per dose should be the same in inpatient and outpatient settings. However, home care agencies often include a preparation or admixing fee in the cost of solutions, partly to cover personnel and administrative costs. If patients are permitted to mix their own solutions, costs may be reduced.[4] In general, these drug costs are rising because the newer antibiotic infusion therapies, such as ganciclovir or foscarnet, tend to be considerably more expensive than standard antibiotics such as penicillin.

Medical Supplies and Equipment. Equipment costs depend upon the administration route. …

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