Michael Millie , 2025-04-08 13:55:00
It is well documented that access to primary care in the U.S. is decreasing. The cause is multi-factorial. Some of the problems are a result of patient-related factors, such as mobility and location, but a large part is due to physician shortages. In fact, a new report from the Human Resources and Services Administration (HRSA) predicts a shortage of 87,150 by 2037. The net result is that some of our most vulnerable patients are left without primary care access, ultimately leading to disease progression, poor outcomes and increased costs. To solve access issues, we need to find ways to bring care more reliably to our patients and to scale the skills of our hard-working primary care physicians.
In response to rising costs, healthcare organizations are trying to move patients away from higher-acuity settings, such as the ER or skilled nursing facilities, to lower-acuity settings, such as an outpatient office or even the four walls of the patient’s home. However, none of this solves primary care physician shortages, meaning care delivery organizations will need to scale by leveraging technology such as remote patient monitoring and telehealth and a team-based approach to care.
First, as we move complex care out of hospitals and brick-and-mortor clinics and into the home to help those who struggle to make it to doctor visits, I suspect we will also see the rise of a new specialty: the “Housepitalist.” Similar to a hospitalist who provides complete care for patients while they are in the hospital, the “Housepitalist” will deliver complex, high-quality care for patients at home. Just as the hospitalist has slightly different skill sets than ambulatory primary care physicians, so does the “housepitalist.” In-home care requires new capabilities that go beyond the usual scope of primary care, often requiring physicians to focus on social determinants of health (SDoH), such as mobility, frailty, and other issues related to the home-bound and home-limited population – all of which are delivered in complex and ambiguous settings.
To do this well, physicians will need to truly perfect notetaking and physical exam skills and rely less on things like complex imaging. They will need to become comfortable with care delivery in sometimes precarious situations filled with distractions. They will need to become experts at observing and learning from their patient’s surroundings and how these affect outcomes.
Second, primary care providers will need to find ways to scale their skills. They will need to rely on asynchronous care in the form of remote monitoring and telephonic “touchpoints.” A “Housepitalist” will need to become comfortable depending on multi-disciplinary teams that include the patient’s unskilled caregivers. A Housepitalist will need to function as a team leader as much as an individual contributor to serve patients in the home at scale.
While I expect these shifts to help close the gap for patients who struggle with traditional access in the age of physician shortages, we still have a long way to go before in-home primary care is a mainstream, scalable alternative to traditional care models. Here are a few of the key barriers to in-home primary care that will be on healthcare executives’ minds in 2025 – especially as we look to scale in-home primary care.
Adding tools to the doctor’s bag
For more than a decade, the healthcare industry has acknowledged the role of SDoH in a person’s health and wellbeing. In-home care presents an unprecedented opportunity to bridge this gap. Yet, as an industry, we still have no standard way of collecting and integrating SDoH data – let alone the technology to support it.
It takes significant time and effort for care teams to identify and address social and environmental factors that influence health outcomes for each patient we serve. In 2025, we will see providers working to implement more systematic processes to address these gaps. For example, a mobile-friendly EHR can be customized to support in-home workflows like coordinating community referrals and tracking individual social determinants.
Solving the last mile of in-home healthcare delivery
So many factors go into a healthcare provider’s arrival at a patient’s doorstep: staffing, transportation, drive time, and more. Having a highly trained primary care provider stuck in traffic or on a long drive to a rural area is expensive and inefficient. This will be a key area for technology to address. In-home primary care providers and organizations of all types need the same advanced scheduling software with dynamic routing algorithms as Amazon or Uber to ensure highly-trained physicians spend less time on the road and more time providing care. Providers will also need to get comfortable with remote monitoring and low-technology touchpoints such as telephonic check-ins.
Once the provider arrives, they may find other logistical barriers, such as a lack of WIFI or available durable medical equipment and services, including mobile lab and radiology services, in the nearby region. While basic in-person care can still be provided without the Internet, there is a lot of logistical infrastructure that needs to be coordinated to deliver the same level of care that you would receive in a doctor’s office or emergency room.
Advocating for value-based care
In-home primary care will remain niche for as long as the healthcare industry uses a fee-for-service financial model. Fee-for-service reimbursement simply doesn’t reward preventative, team-based care that is focused on keeping the sickest patients healthy, at home and out of the hospital.
Instead, we must advocate for accelerating the shift to value-based care. Value-based models prioritize holistic patient-centered care, preventative care, chronic disease management, and cost efficiency – all strengths of in-home healthcare. Value-based care provides agency to the primary care physician who has the deepest insight into what will keep their patient healthy and at home – and this may not be something easily covered with a CPT code.
There is important work being done through voluntary programs, like ACO REACH and the Medicare Shared Savings Program (MSSP), to improve health equity through coordinated value-based care. CMS and the healthcare industry need to continue to remove barriers to entry into these programs for both patients and providers.
Paving the path forward
We are at a tipping point. The in-home primary care service model is poised for rapid growth and transformation. However, there is more work to be done before the “Housepitalist” becomes a household word.
Now is the time for payment models, training programs, trainees and service vendors to begin thinking of in-home healthcare as a medical specialty and a career pathway. A hundred years ago, most care was delivered in the home. Now, the old is new again. Let’s come together and find ways to scale access to complex primary care for our patients who need it most.
Photo:boonchai wedmakawand, Getty Images
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