House Calls Make a Comeback

Think the only place physicians make house calls is in the "classic TV" shows of the 1950s and '60s? That may be changing. With the graying of America comes a growing population who find mobility increasingly difficult. They may not be truly housebound, but getting to a physician appointment could be problematic. One solution? Companies that employ house-calling physicians to provide a much-needed service to frail, elderly, or disabled patients who can't get to the doctor's office.

When Chicago- and Detroit-based Mobile Doctors started up in 1993, reimbursement for house calls was "so low that it was done most often as something from the goodness of your heart," says the company's chief operating officer, Dike Ajiri. But the picture is becoming brighter: In 1998, physician reimbursement from Medicare for house calls increased from $40 to $60 per visit to $60 to $140 per visit, depending on the complexity of the case. That increase fueled the growth of Ajiri's company, which now has seven physicians and six podiatrists seeing 1,600 patients, about 95 percent of whom are geriatric.

This year, Medicare reimbursement rates range from $58 to $209, depending on the complexity of the patient and the geographic region where the physician works, says Constance Row, executive director of the American Academy of Home Care Physicians (AAHCP), an organization that worked hard to win the reimbursement increases.

Reimbursement still dominates the agenda for the AAHCP, says Row. "There are reimbursement glitches, issues about reimbursement for travel time, and reimbursement for residents who make house calls," she adds, as well as issues surrounding care that takes place in assisted living facilities. Right now, calls made to such facilities only get one-third to half of regular house call rates.

Despite the AAHCP's feeling that there is still far to go, house calls have proved to be a lucrative business for Mobile Doctors, says Ajiri, with revenues last year between $750,000 and over $1 million at the two locations. He notes that while the patient doesn't have to be homebound for a visit to be covered by Medicare, the physician must still document that a home visit is necessary and why.

Different approaches

Each of the Mobile Doctors physicians, who are independent contractors, makes about 12 calls per day and is paid a per-visit fee. None of them work call; instead, night and weekend calls are routed through a staff nurse.

For the physicians, the lack of call is a definite bonus. Russell Miller, MD, spent 16 years in private practice before landing at Mobile Doctors a year ago. He loves what he calls the "middle class" aspect of going to work, getting the job done, and then not worrying about it when evening rolls around. But, he admits, "My training is to provide continuous healthcare. I'm still trying to work out if I can do this for [the rest of my] life."

HouseCallsUSA of South Florida takes a slightly different tack to the house calls business, catering to the traveling public and relying on a "staff" of more than 2,000 physicians around the country who agree to see patients any time, any day, any place, as needed. The fees usually run $225 per visit -- cash, check, or credit card only. There is no insurance billing, and physicians collect about $125 per patient.

Although about 95 percent of the patients the company serves are traveling at the time, that may change, says company president Harris Mones, DO. He has been in talks with managed-care organizations in New York and Florida about setting up an after-hours care operation. In theory, his physicians would make house calls as a way of cutting down on emergency room visits.

Row sees pediatrics as another leading edge for house calls. "We have pediatricians who jump up and down about this issue," she says. "Taking kids to the emergency room is expensive, and the chances of a typical emergency room having a pediatric specialist are low." She knows of one physician in New York City who makes house calls to his pediatric patients, but it is subsidized by a hospital, and Row says without that subsidy, it wouldn't happen. "There has to be an impetus for managed-care plans to pay for this."

For the physicians who work for HouseCallsUSA, extra cash is a prime motivator. Robert E. Goubeaux, DO, a primary-care physician in a Miami group practice, uses the money he collects from the 10 to 20 monthly house calls he makes to help pay off his student loans. "It's a good way of putting aside some extra money," he says.

Building better doctors?

Not only does the house call business present financial opportunities and a change from the usual routine, there are physicians who think making house calls improves the quality of the care they give - in effect, they become better doctors. Jeremy Boal, MD, an assistant professor at Mt. Sinai Medical School in New York City created a visiting doctors program as a way of "rehumanizing" residents. He believes that making house calls is "a privilege. It's hard to get satisfaction in our work when things are so rushed. To sit with someone for an hour and find out what they need and who they are is really why we went into medicine."

Boal says that a typical 30 to 60 minute visit (or two hours for a first-time house call) allows him to make better use of diagnostic skills and hone his bedside manner. "For the patient, it's obvious why this is good. It may be the only way they can get care. I don't think it's the most efficient way to practice, but for end-stage conditions, or for patients with specific mental or physical issues, I think there is a big role for home care."

Miller says it's a shame that house calls aren't more highly valued. One of his peers said he wasn't interested in home-based medicine because "it doesn't improve your resume." But, Miller adds, "then you talk to the patients and you find it is valued. There is a whole world out here that most physicians don't know about, and this is a way to get them access to the system." He adds that, for variety, making house calls can't be beat. "I see a population that most physicians just don't see -- from MS and quadriplegic patients, to the morbidly obese and some severely demented patients."

It's not all roses

While spending more time with patients and seeing fewer of them may sound appealing, making house calls all day isn't necessarily a dream job. "I think it takes three things to be a good house call physician," Ajiri says. "First, you have to be a physician who, clinically, can take very good care of patients. Mostly, these are older patients with multiple problems, and being an internist or geriatrician is probably beneficial."

Second, he says, it helps to have a down-to-earth attitude. "You are a guest in their home, no matter how humble it is," Ajiri says. Lastly, house call doctors must practice great documentation. "You have to be legible and thorough, because even if you are clinically great and the patients love you, if you don't get the right thing down in your notes, you'll get in trouble."

Row says that while audits can occur in extreme cases, for most physicians, the danger of having sloppy or incomplete documentation lies in payment denials. Many Medicare intermediaries are unfamiliar with house calls as an element of modern medicine. "They may not know what they are looking at and reject claims. I've talked with many physicians who have had to explain it all to some medical director in order to get paid. Because this is new, it is going to be questioned more often."

Boal says that some physicians have trouble with the "uncertainty" of this kind of medicine. "You don't always have technology with you," he explains. In his own black bag, Boal carries an otoscope, blood draw equipment, an ophthalmoscope, debridement gear, equipment for joint injections, a blood pressure cuff, a stethoscope, and some common medications like steroids and vaccines.

One thing is certain, though. Boal, like any physician who makes home visits, can tell the story of some frail elderly patient who has had an effect him. Of all his house calls, Boal's first sticks most clearly in his mind: an older, slightly demented woman in East Harlem, essentially trapped in her second floor apartment. "She would sometimes stand up and wouldn't be able to sit down," recalls Boal. "This was 10 blocks from the hospital, but she might as well have been on an island. I just wasn't prepared for what I saw. This -- and every subsequent visit -- has sensitized me to the way people live. When they come into the office having missed appointments or without their meds, you assume it's because they aren't interested. But people have very complicated lives, and you don't really realize that until you see them in their own environment."

Lisa Jaffe Hubbell can be reached via editor@physicianspractice.com.  

This article originally appeared in the September/October 2002 issue of Physicians Practice.