Aging population with multiple comorbidities increased not only the need for HHC but also the economic burden on health expenditure. The NHI in Taiwan is on an unsustainable growth path in terms of health care expenditure and must get costs under control.27 Economic aspects should be an integral part of HHC in order to provide comprehensive, cost effective care and create sustainability.16 We thus conducted this retrospective cohort study to identify factors associated with health expenditure among HHC patients. The majority (85%) of patients in our study had multiple chronic conditions with CCI of 4 or greater, and totally functionally dependent (BI scores of 0–20). The study population was vulnerable and dependent, which was similar to other home care studies in Taiwan and worldwide.5, 8, 28 Our study demonstrated that higher health expenditure was associated with the diagnosis of neoplasm, registry of catastrophic illness, indwelling tracheostomy tube, and requirement of higher need for skilled nursing services. On the other hand, regular HHC visits had the potential to reduce expenditure for ED, OPD, and hospitalization, as well as total health expenditure of home care patients.
In our study, we observed that the majority of health expenditure among home care patients is attributed to hospitalization. Regular HHC visits may contribute to the improvement of preventive intervention and the early response to initial phases of exacerbation, which minimize unnecessary hospitalizations and thereby reduce health expenditure.28, 29 Previous studies have shown that HHC could reduce hospital admissions and health expenditure in individuals with heart failure30, chronic obstructive pulmonary disease31, or any acute infection32, 33. One study regarding disabled people who received HHC in Taiwan indicated that higher intensity of nursing visit (more than 12 times per year) was associated with a significant reduction in the risk of hospitalization and emergency services use; while higher intensity of physician visit (more than 6 times per year) was associated with fewer emergency services use.5 Worthy of note is that our study disclosed further information that regular home care visits have a potential role to reduce expenditure in these highly dependent population.
On the other hand, health expenditure was higher among patients with the diagnosis of neoplasm or registry of catastrophic illness certificate. For patients with high-cost serious illnesses, detailed care coordination by an interprofessional team, creation of a long-term relationship with patients and their family caregivers, and elicitation of patients’ preferences are key elements in providing high quality of care.34 Since HHC providers not only understand the patients’ diseases but also know their life directives, caregiver resources, and family situation, they can help them make the decisions that best align with the patients’ preferences. For frail patients with serious illnesses, before disease entering terminal stage, goal of care should be discussed and early intervention of palliative management should be provided.35, 36 When patients’ condition worsen, HHC providers can deliver treatment plans that are concordant with patients’ priorities, and avoid costly but futile treatments.37 A concurrent match cohort study published in 2018 had reported that savings of home-based primary care were mostly in end-of-life stage.17 Recognition of patient preferences should be enhanced in HHC providers, especially in patients’ with underlying neoplasm or catastrophic illnesses.
Furthermore, long-term indwelling tubes may increase the risk of infection, patient morbidity, and mortality resulting in increased healthcare use and expenditure.38–40 The tube placement rate among HHC patients was high in our study. 96.8% of participants had at least one indwelling tubes. Previous studies disclosed that the prevalence of indwelling urinary catheters or nasogastric tube insertion among long-term care patients in Taiwan is higher than that in the United States or European countries.39, 41, 42 We found that indwelling tracheostomy tubes, as well as RUG-2 and RUG-3, were associated with higher health expenditure. Because the NHI in Taiwan reimburses home nursing visits at a fixed rate based on RUG classifications of patients, which is dependent on the number of skilled nursing services, this fee-for-service payment might result in the high rate of tube placement and the potentially inappropriate intubation of HHC patients.43, 44 However, we believe that government should provide incentives for HHC providers to remove unnecessary indwelling tubes and proposes care provisions to prevent catheter-associated infection, in order to reduce health expenditure.45
Our study has several limitations. First of all, this is a single-center, retrospective cohort study. Although the size of study population included 1285 participants, the generalizability of these results to the nationwide or worldwide population may not be fully applicable. In addition, for those countries with social health insurance coverage of HHC, the number of HHC visits should be taken into account when making reimbursement policy. Secondly, our data did not provide detailed socio-economic information such as family composition, caregiver status, polypharmacy and nutrition status, which precluded analysis of possible contributing factors. Furthermore, much development of new home care model including adoption of telemedicine has occurred in the past years, so further analysis with more recent data would be informative. Despite these limitations, our study findings still provide a better understanding of factors affecting health expenditure among home care patients.