No place like home. The first question patients ask when they are in the hospital: ‘when can I go home?’

Five years ago, we showed that 46% of the activities taking place in the hospital could be provided at home. Our study postulated that the healthcare system would develop according to the following metaphor: doctors as air traffic controllers, patients as pilots of their own diseases.

This study examines the developments of the past five years. How many patients now receive their care at home, and what strategies did providers and countries follow? The good news is that 12% of patients now have the option to receive their care at home. 66% of hospitals have embraced home care as a key strategy. Many of the barriers have been removed: patients and doctors have been able to experience that care at home works, reimbursements have been adjusted and cost of the required technology has lowered.

The not so good news: it makes a big difference where you live as a patient. The difference between countries is large, and within countries the differences are at least as large.

The success of hospital care at home raises some tough questions for healthcare systems. Volume disappears from hospitals, data needs to flow between the various electronic patient records of different care providers, and care processes need to be redesigned.

In the short term, volume that disappears from the hospital may appear like a blessing: after all, hospitals are still clogged with care that has been postponed due to the corona crisis. In the long term, this reduction of care volume in hospitals may threaten the accessibility of the hospital care that cannot be provided at home. Since healthcare providers have high fixed costs, a decrease in volume can lead to inefficiencies of scale, which may cause financial problems.

In the Netherlands, large hospitals are leading the way in transforming care. This is not surprising: they have the scale to innovate. Increasingly, the availability of new technology will enable smaller providers to deliver advanced care. In fact, as they are no longer limited to their own hinterland they can actually expand their reach. Just like the rise of the internet blurred geographic boundaries. This creates new opportunities for regional hospitals. That is good news for the patient and the payer.

Because our Western societies are getting older, the number of patients with more than a single condition will increase. It is the multimorbid patient who benefits most from a hospital that is well connected to the local web of healthcare providers, such as GP’s, and elderly care. This leads to lower costs in two ways: better coordination (so more “first time right”), and more care in a more cost-effective setting. In the Netherlands, this could lead to annual savings of up to EUR 1,6 billion .

Whether this becomes reality depends on the choices each country makes. While suppliers work worldwide, how care is delivered is mostly locally determined. As with the development of the internet, a winner takes it all situation can easily arise. Investors seem to know where it is headed. A bet of over EUR 40 billion is already made (almost two years of national Dutch hospital budget). It is difficult to guess what the effect of these investments will be. Will these investments make health care more efficient? Will they disrupt health care systems? Chances are, it will be at the expense of current providers.

As the pandemic progressed, the value of surplus hospital capacity became very visible. Treatment at home is a flexible, scalable, safe, and more cost-effective alternative for most nursing days. If other countries followed the same course as Denmark and the Netherlands, one hospital per million people can be saved.

The interaction between people and technology in the treatment of care at home creates an enormous opportunity to increase effectiveness in the delivery of care. Processes will become scalable for the first time. But to reap these benefits, government and health care insurers need to act. If they adopt a laissez-faire attitude, quality and efficiency risks arise. The scale on which digital care and care at home can be efficiently designed exceeds individual hospitals. Sub-optimal and therefore cost-inefficient care concepts are likely. That is, unless a disruptive (new) care provider suddenly gains a major market share.

On the other hand: a rigid top-down approach will harm progress. To return to our metaphor of the airport: safety is only possible through cooperation with market parties. An (inter)national body must establish and maintain the standards on which people and technology can safely provide care together and create an open environment where everyone can learn from failures and near misses.

No place like home is an independent study conducted by and for Gupta Strategists. This is a sequel to the initial study on the topic of transition of care from hospitals to the home setting published in 2017. Although written in English, most chapters of this study have been aimed at the Dutch situation.

(1) In the Netherlands, this number increases from 5.4 million to 6.6 million. Source: https://www.volksgezondheidtoekomstverkenning.nl/c-vtv/trendscenario-update-2020/ziekten-aandoeningen, last consulted on May 13th 2022.
(2) Analysis by Gupta Strategists that 20% percentile of hospitals have 5% lower integral healthcare cost than average in their care region. The total healthcare insurance cost (zvw) in the Netherlands is around EUR 40 billion. EUR 40 billion * 5% * 80% is EUR 1,6 billion.