Once it was simple: You went to the hospital, you got better, and then you went home. But it's not that simple any more.
Pressed by Medicare and insurance companies to cut costs, hospitals are discharging patients faster and forcing them to spend their convalescent time at home, rather than in the hospital.
It's a problem, yes, but also an opportunity -- one that bigger hospitals are rushing to fill by jumping into the home health business themselves.
Most bigger local hospital companies set up home health care subsidiaries by 1984, many of them racing to beat a state deadline that allowed hospitals to start home health operations without winning a certificate of need from the state.
But now, changes in Medicare policy, the continuing high cost of hospital care, and the demographics of an aging population are combining to set the stage for explosive growth in home health care in years to come.
"We'll have more patients than we could ever imagine," said Maryann Timon, chief administrator at Mercy Ventures Inc., which runs home health programs affiliated with Mercy Medical Center in Baltimore.
"People need pretty complex care when they get home," said Gill Chamblin, a spokeswoman for Howard County General Hospital in Columbia. "You used to recuperate in the hospital. Now you're being released days after surgery."
Hospital companies have been making new or expanded moves into home care even as recently as this year. The parent company of Howard County General Hospital entered a joint home care venture with Bon Secours Hospital in West Baltimore six months ago, a spokeswoman said, and the Johns Hopkins Health System's for-profit Dome Corp. affiliate set up a new subsidiary in July, in part to manage home health operations serving Hopkins hospitals.
"I think home care is going to absolutely mushroom," Irwin P. Bloom, president of newly formed Dome Management Services Inc., said in a July interview. "If I didn't think so, I probably would have run another hospital somewhere," said Mr. Bloom, who headed North Charles Hospital before it affiliated with Hopkins and changed its name to Homewood Hospital.
Hospital officials say that home health care hasn't grown as quickly in Maryland as in some states because Maryland hospitals operate under different regulations than hospitals outside the state.
Maryland's hospitals are not subject to Medicare's strictest rules governing length of hospital stays because the state has relatively low hospital costs, officials said. Those rules, often criticized for forcing hospitals to discharge patients "quicker and sicker," have been an important force in the growth of home care.
The growth of home care in Maryland could also be retarded by state budget cuts, which have slashed Medicaid coverage of home care. The budget bill pending before Congress is another wild card.
"God knows what they're going to do to Medicare," said Cate Albright, vice president of marketing for the Upper Chesapeake Health System, parent organization of Fallston General and Harford Memorial hospitals, as well as a home health agency based at Fallston General.
But Ms. Timon said the rules won't keep the lid on home care forever. She expects that Maryland eventually will lose its exemption from the Medicare discharge rules. And the built-in economics of hospital care and home care dictate a steadily growing shift toward moving as much care as possible into the home.
"Hopefully people will realize it's better to keep people in their homes," said Ms. Albright. "It's better for the payer [insurer] too."
"In the future, the economics will be the engine that matters most," Ms. Timon said. Money will matter more than the aging of baby-boomers who will need more health care as they age and more than changes in public policy.
Ms. Timon said one often-overlooked economic issue is that hospitals can use their home health operations to cement their customers' loyalty. If a patient uses Mercy-based home health services after being discharged from the hospital, it's no trick to guess who's likely to get the business if the patient has to return to the hospital, she said.
"It keeps you in the network," said Robert W. Adams, vice president for operations at the University of Maryland Medical System, the parent organization of University Hospital in Baltimore.
Mr. Adams said University doesn't have a home care subsidiary, and potential loss of patients is a concern. "If we discharge a patient to Bon Secours home health agency, we might never get that patient back. The patient might like Bon Secours," he said.
Hospitals likewise are a source of business for the home health agencies, Ms. Albright said. "A great percentage of any home health agency's business are discharges from a hospital -- well over 50 percent," she said.