House calls becoming a viable practice model

The potential of health care reform to improve patients' access to physicians by increasing insurance coverage has been much discussed. Fewer people know, however, about the plans to improve access more literally, by bringing physicians into patients' homes.

The reform bill passed earlier this year includes a pilot of house call care for chronically ill Medicare beneficiaries. Called Independence at Home, the program would involve interdisciplinary teams of physicians, nurses and other clinicians caring for patients who have multiple chronic conditions, difficulties with activities of daily living, and a history of hospital utilization.

But some physicians have been practicing this way for years, or even decades. They're pleased by the growing attention being paid to the field and full of advice for physicians considering the leap out of the office.

“There are certainly things to learn about how to take care of patients in the home, but I think it could be easily taught and learned by any internist who has some interest and some aptitude for it,” said Bruce Leff, FACP, associate director of the Elder House Call Program at Johns Hopkins Bayview Medical Center in Baltimore.

There's also potential benefit to patients. “It's the right thing to do because it's very hard for [these] patients and families to get to the doctor,” said Peter Boling, FACP, director of long-term care and geriatrics at Virginia Commonwealth University in Richmond. “We have the capability to take the patient's health care to them.”

A select group

The capability may be available for all patients (see sidebar), but house calls are most valuable to a small but growing group, according to the experts.

“I take care of quite a few very old, very debilitated people who it's just enormously difficult for them to get into my office. Logistically, it's an all-day affair and sometimes darn near impossible,” said Wayne McCormick, FACP, section chief of the division of gerontology and geriatrics at the University of Washington in Seattle. “More and more we're getting call-ins from patients and their children, who are my age, that they would like a house call.”

If not for house calls, some of these patients would have only one means of accessing care: calling an ambulance. “They stay at home until they're really sick, then they go to the emergency room, then they get admitted to the hospital,” said Dr. Boling.

It makes intuitive sense then that, if house calls could prevent these hospitalizations, overall health costs for the patients would be reduced. The Department of Veterans Affairs' (VA) Home Based Primary Care program has provided the evidence to support this assumption.

The VA's first analysis of its program, which included 11,000 patients in 2002, found that enrollment in a house call program was associated with a 62% reduction in VA hospital bed days and a 24% reduction in the total cost of care for the VA. A later study also included Medicare payments to make sure that costs weren't being shifted, and it found reductions in cost and utilization for both the VA and Medicare, with a 25% reduction in overall hospital admissions and 13.4% lower costs with house calls.

“That is after adding in the cost of the intervention of home care, so we think that this is a very solid model,” said Thomas Edes, FACP, director of home and community-based care for the VA.

Sharing the gains

The goal of the Independence at Home pilot is to expand the savings accrued by the VA to similar patients in the Medicare population. Health care costs for patients in the pilot will be compared to the patients' expected costs based on previous utilization, and the savings will benefit both Medicare and participating physicians.

“Everybody gets paid the way they do now, but in addition there would be gainsharing opportunities,” said Dr. Boling, who was active in the development of the pilot legislation. “The savings would be shared between Medicare and the provider group after Medicare first took off 5% from the top in mandatory savings.”

The program—the administrative details of which are still being worked out by CMS—could offer a significant improvement over the current reimbursement for house calls. In the mid-1990s, lobbying by house call advocates resulted in an increase in Medicare payments, so that the relative value unit for a physician house call is substantially more than that for an office visit. “It's occasionally [financially] beneficial to set aside some time to make house calls,” said Dr. McCormick.

However, with the time and complications involved, the field has continued to be economically tenuous. “You can about make a decent living doing house calls if you're really careful about your time and your business,” said Dr. Boling.

Current performance measure systems also put house call physicians at a disadvantage, Dr. Edes noted. “With very few exceptions, most of our health care system measures, for productivity and for quality, actually punish providers for taking on this population,” he said.

Because they're so sick, house call patients require less routine screening, more medication, longer visits, and therefore a smaller panel size, all factors that would score badly on some measure sets. An Independence at Home clinical practice would have one physician and one or two nurse practitioners for every 200 patients, Dr. Boling estimated.

More than money

Given the reimbursement hurdles, house call physicians have had to find other rewards in this kind of practice. “You're welcomed in, you are an important person in that person's life and in their health care, and you have a grateful patient from the moment you start,” said Dr. Boling.

Some information is also easier to gather in the home than the office. “I could have been seeing them in the office for a few years and literally within two minutes of walking into their house I will almost always learn something that really influences the way I take care of them. It wasn't for lack of asking, but sometimes we don't ask quite the right question or patients don't give quite the correct or honest response,” said Dr. Leff.

For example, medication adherence, or its absence, may become apparent. “You'll come in and there's a basket or a bowl on the kitchen table and they just have all their different pills mixed up in a bowl,” said Dr. Leff. “They'll say, ‘Some days I take two blues and some days …’ It's like a big bowl of M&Ms.”

Dr. McCormick also conducts what he calls a “refrigerator biopsy.” “After I've talked to the patient, got a little bit of history and a brief exam, I'll ask them if I can look in their refrigerator and/or in their medicine cabinet. I've never had anybody turn me down,” he said.

Whether it's a totally empty fridge or shut-off water or a three-story walk-up, the incidental findings of these home visits can be revealing. “I made the mistake for a long time of envisioning that each of my clinic patients was going back to a home not too much unlike mine,” said Dr. Edes. “Now I understand why you can't put on a clean dressing three times a day; it's difficult to get food for yourself.”

Some of these problems are beyond house call physicians' ability to fix, but in many cases, they can help by prescribing adaptive equipment, suggesting home modifications and referring patients to social support services.

Technology travels

Medically, the physicians can do almost anything (with obvious exceptions like surgery) during a house call. “I actually think I can do more in a home visit than most doctors are able to do in an office visit these days, in terms of the ability to use portable electronic medical records and portable technology,” said Dr. Leff. He has experimented with Hospital at Home, a model in which seriously ill patients are cared for at home instead of in the hospital, often resulting in better outcomes.

Much of the technology available in the office or hospital is relatively simple to get into the home, according to Dr. McCormick. “You can do X-rays at home,” he said. “You can get a lot of lab-type information in people's homes, if you know how to do it, if you know how to connect with companies that offer those services. Some doctors carry around a device for doing bloodwork and some doctors carry around an EKG that plugs into their laptop.”

Still, house call physicians tend to rely more on their diagnostic skills than they would in the office. “I really like that it always forced me to be a better doctor, to really be better at communication, to be good at taking a history. It definitely forced me to push my physical exam skills up several notches,” said Dr. Leff.

The environment may also push physicians to interact differently with patients. “It's not uncommon for doctors in the hospital to be with the patient and walk out of the room saying, ‘I'll be back in a minute’ without any intention of coming back in a minute. That's a pretty impossible thing to do when you're in someone's home,” Dr. Leff said.

Not all physicians enjoy the change. “There are those doctors who want control, need structure, need schedules, need support staff around them, need the authority of their office,” said Dr. Boling. “They are not necessarily enamored of the home medical practice.” There are also traffic jams, weather problems, dogs and bugs to contend with, he noted.

Other physicians enjoy the freedom and fresh air. “For people who like that nomadic day or half-day out of the office, it can be kind of fun,” said Dr. McCormick.

In some cases, house call scheduling offers more flexibility. “If you're in an office practice ... patients are on a schedule with expectations. If their appointment's at 10, they want to be seen at 10. If you are on house calls, you don't have that. The people are usually at home; they usually don't have a schedule,” said Dr. Boling. If one patient needs urgent attention, others can usually be rescheduled without much trouble, he explained.

Giving it a try

Many physicians haven't had the chance to determine whether they'd like making house calls or not. “Just like a physician is unlikely to do a thoracentesis if they've never seen one, a physician is unlikely to do a house call if they've never seen one,” said Dr. McCormick.

Some medical schools and residency programs, including the University of Washington, are increasing future physicians' exposure, requiring house calls in the fourth year of medical school as part of the chronic care clerkship, said Dr. McCormick. “We know empirically that if medical students or residents make even one house call, they're far more likely to do that in practice.”

At Johns Hopkins, Dr. Leff has also seen positive effects from bringing trainees on house calls. “The system tends to deflate their idealism to a degree. I always see that idealism reignited when I take them out to see patients in the home.”

Even the most idealistic house call physician will have to deal with some financial barriers, however. “You do need to make sure you're being efficient in your use of time,” said Dr. McCormick. He, like most of the other house call experts, practices in a relatively urban area, where it doesn't take long to get from patient to patient. “I actually don't drive much to house calls—maybe once a month—and I make quite a few house calls in the course of a month. I often will walk to them,” he said.

There's also the issue of wasted overhead. “If you're in solo practice, having your office staff in the office while you're out making house calls probably doesn't make great economic sense. If you're in a multi-member practice, it may make sense for you to make house calls,” said Dr. Leff. Solo practitioners may be able to make the model work by closing the office for a day or half-day and conducting all house calls then.

Another option is to make your practice house-call-only, a model that can reduce overhead by about two-thirds, according to Dr. McCormick. “That's been gaining traction rather substantially,” said Dr. Leff. “You still need staff to make that fly, but you need less staff.”

These are the sorts of practices that Dr. Leff and other advocates of house calls hope will be involved in the upcoming pilot. “Independence at Home really provides a framework to incentivize the development of these types of practices,” he said.

If all goes well, it could be just the beginning. “We hope that the people selected for the pilot will be the best and the brightest around the country, that they will hit home runs, that there will be 25% savings relative to base costs, which we think is easily obtainable,” said Dr. Boling. “We would like to move through a highly successful demonstration phase into a national benefit in short order.”

Then patients who have difficulty getting to the doctor could look forward to quality care in the most convenient location. “It is a truly patient-centered medical home, in their home,” said Dr. Boling.