Often, I think of the bumpy road health care has traveled over the past eight years. The discussions of national health reform in the early 1990s gave way to programs for incremental change to improve the efficiency of the health care industry. Managed care has changed how many of us think about health care services, and certainly how we pay for much of them. Medicare and Medicaid continue to introduce changes that put health care providers at increasing financial risk for the services they provide.

Early concerns centered around hospitals and physicians, but now the spotlight is on long-term care. Recent articles in The Washington Post and elsewhere lament about the financial instability in the nursing home industry and the decline in quality of care. Others point to changes in Medicare's payment policies for home care and predict massive reductions in the number of home care agencies.

Despite these changes, this nation continues to spend more of its domestic national income on health care - estimated to grow to over $2.1 trillion in 2007 - than any other industrialized nation. Moreover, the reforms of the 1990s have not addressed the challenges of providing insurance coverage to this nation's uninsured, the ranks of which have grown from approximately 37 million in 1994 to over 43 million in 1998.

All of this comes at a time when leading demographers are predicting a 50% to 100% increase in the elderly (age 65 and older) by 2020. How are we going to ensure that our elderly citizens are going to have the health care they need in 2020 when we can't even adequately provide for those who need it now?

We believe the answer may lie in using telehome care technologies to bring these services into the home. Over the past 10 years, I have had the privilege of helping to develop telehealth policies in the Federal government and sponsoring programs in over 450 communities that provide and receive health services at a distance through the use of modern telecommunications technologies. And for the last couple of years, we have seen these technologies make a difference in the home care setting. For example:

A terminally ill hospice patient in Arizona is able to stay comfortably and securely alone in her home through daily conversations with her physician, nurse case manager and son via a simple desktop unit that also measures her vital signs.

A recent victim of a heart attack is sent home with the support of his nurse case manager, who helps him adjust to a rigorous lifestyle modification program through phone calls and simple, unobtrusive monitoring devices (e.g., a scale that daily records his weight and sends it via the computer to the nurse). The family of an elderly woman can see and talk to her daily over a videophone. Not only have these programs improved the quality of patient care, but they also have been shown to save health care costs.

So, you might well ask, why aren't more folks doing telehome care? For one, these programs are quite new and it takes time for any new use of technology to catch on. For another, home health agencies find it difficult to invest in new approaches to care when they are already strapped for cash. And when they look at the world of telemedicine, they often see high-tech, high-cost systems that are in no way appropriate or affordable in the home care setting.

But we believe this picture is going to change quickly. The very ratcheting down in Medicare and Medicaid payments noted above and the move to capitation is going to force home health agencies that want to survive to look at new ways of doing business. And the cost of telehome care technologies is increasingly affordable. The revolution in desktop computing has put much of the technology at the bedside for less than $3,000 a unit and a simple telephone connection.

Moreover, many of this nation's elderly and their families would welcome a low-cost desktop video system that would enable closer contact among health care providers and their loved ones, provide closer monitoring, and identify early on any acute exacerbation of chronic disease. Such systems could be financed through development of a tele-home care service that charges a monthly payment for equipment rental and patient monitoring.

As we move into the 21st century, the demand for high-quality home care services will only increase. But what we most want to avoid is a two-class system, whereby only those with means will be able to stay at home. As health care providers, you are in a unique position to help develop the affordable technologies to ensure that this doesn't happen. But to do so, you must act now. You can help by working with your agency to identify and partner with programs that are working in telehome care within your state. A good place to start in finding out about these programs is to look on our Web site: http://telehealth.hrsa.gov.

We look forward to hearing from you.