The Case for House Calls
By Kate Ledger
Seeing patients in their homes can be a better way to provide care and ultimately save money. So why are so few physicians making house calls?
During 13 years of treating patients of all ages, family physician Nick Schneeman, M.D., came to a grave realization about how the medical world is managing the care of the elderly. “We’re doing a terrible job,” he says. What he noticed was a growing number of frail elderly patients with multiple health problems, often complicated by dementia and the ever-present possibility of suffering a fall, who were unable to get to the clinic to see a doctor. Some of them couldn’t get prescriptions filled or follow the instructions on bottles. Those patients were dropping off their doctors’ radar and fending for themselves. When they wound up being treated at an ER or urgent care, he says, they were getting “fairly impersonal, shoddy care.” What worried him most was that even though physicians are aware of the problem, he says, “It’s gotten worse in my professional lifetime.”
Grappling with what to do about the issue, Schneeman shocked his wife five years ago when he quit his job with physician-owned, multispecialty North Clinic in Robbinsdale and created a new role for himself with the same group as the director of its newly formed geriatric services. Right away, he went out on a limb, establishing plans for what he calls “community-based geriatrics.” In an effort to revamp medical care available to the frail elderly, Schneeman developed two services at North Clinic: a long-term care program that brings primary care doctors to assisted-living sites and a short-term version that brings doctors to rehab centers where patients transition from the hospital to home. But those initiatives didn’t reach the severely underserved elderly—those with multiple health problems who live on their own. “They might be right across the street from a nursing home,” he says, “but they’re not getting care.”
A phone call two years ago from Ed Ratner, M.D., who’d been part of the University of Minnesota’s geriatrics division when it closed in 2000, helped Schneeman address that third group. Ratner had heard about Schneeman’s dedication to bringing care to frail elderly patients and that Schneeman had secured a community health services grant from the state of Minnesota. Ratner had his own expertise to offer: Nationally known for his work as a geriatrician and for his service as past-president of the American Academy of Home Care Physicians, Ratner has devoted his career to mastering the art and science of house calls.
For Ratner, soft-spoken and thoughtful, house calls are something of a calling. He had been making them for several years when he learned firsthand how important a home visit can be. His own daughter, severely disabled, was treated by her pediatrician in their home. “Taking her to the doctor was really a challenge for a variety of reasons, physical and emotional,” he recalls. The pediatrician, who visited severely ill children on Saturday mornings, was able to help Ratner and his family solve some problems with their daughter’s daily care and keep her out of the hospital. “In retrospect,” he says, “I didn’t know [the full worth of] what I was doing until I was on the other side, as a recipient.”
Initially, Schneeman brought Ratner on as a consultant to create a house call program; but shortly after, he recruited him to North Clinic part time. His hope is to make house calls a fully sustainable, long-term practice, with trained physicians bringing health care right to patients’ doorsteps. It may sound like a throwback to a bygone era, but Schneeman and Ratner are convinced that the physician-based home care model they’ve established is the one that can lead to better care of the frail elderly and ultimately save Medicare millions of dollars.
Practicing Below the Radar
Home visits date back to the beginning of medicine; but in recent decades, as physicians have become more pressed for time and their services more expensive, the task of leaving the office to see patients has been relegated to nursing and auxiliary staff. Some doctors still venture to patients’ homes when the need calls for it. Family physician Laura P. Hong, M.D., made home visits in her native Philippines to patients who were unable to afford going to the hospital. Practicing at Lac Qui Parle Clinic in Madison, Minnesota, she went to the bedside, a few years ago, of a hospice patient of hers who had chosen to die at home. Such visits, Schneeman says, usually come from an “occasional kind soul who does this out of the goodness of their heart.” Even so, he says, most physicians willing to see a patient at home are usually so busy they “try to stay below the radar so that nobody else calls them to do house calls.”
Geriatrician Tom Von Sternberg, M.D., concurs that most house calls tend to be arranged privately between the doctor and the patient or the patient’s family. No standardized characteristics or conditions exist, he notes, to qualify patients for a home visit. Practicing 25 years with HealthPartners Riverside Clinic in Minneapolis, he directs HealthPartners’ division of geriatrics, which has a large number of geriatricians and nurse practitioners who routinely offer in-home visits to frail elderly patients who live in assisted living or nursing facilities. They go to 42 different apartment complexes and care for about 750 patients. In addition, a number of other HealthPartners physicians do intermittent home visits to patients they have long-standing relationships with. “Physicians all understand the value of home visits and block out the time, knowing that there’s a reduction in productivity,” he says. No colleague, however, is promoted specifically as a doctor who makes house calls. “It’s still done on a don’t ask, don’t tell basis.”
Nobody questions that poor reimbursement is a factor in keeping physicians from incorporating home visits into their regular routine. Doctors who do house calls exclusively might see six patients a day, while an office-based physician might see as many as 25. Physicians are typically reimbursed for house calls, and the Medicare fee schedule for a house call is 25 to 30 percent more than for an office visit; but that still doesn’t cover travel time or make up for the reduction in the number of visits a physician can do in a day.
Doctors committed to making house calls sometimes have other means to supplement their income, says Constance Row, executive director of the American Academy of Home Care Physicians. For example, some work part time as medical directors of home care agencies or have academic appointments, or they provide and bill for ancillaries such as at-home labs or X-rays in order to augment their income. “We really think the answer in the long run is to have more adequate funding from Medicare for this kind of service,” she says. In fact, a bill to be introduced in Congress by Sen. Ron Wyden (D-Oregon) and Rep. Edward Markey (D-Massachusetts), called Independence at Home, aims to improve reimbursement for home visits.
Despite the financial hurdles, home visits have begun reappearing in certain pockets of the country. The trend is strongest in cities such as New York and Boston, Row points out, where there are large populations of elderly people as well as medical schools with programs focusing on geriatric medicine. “All the major teaching hospitals have invested in house call programs,” she says, and these programs bring energy for home care and continue to advance the specialized training required. Thanks to Ratner, who teaches about geriatric care, the University of Minnesota Twin Cities offers second-year medical students the chance to learn about house calls. In regions where geriatric programs don’t exist, Row adds, “the primary care physicians aren’t getting any training [in how to care for the frail elderly] and neither is anybody else. The idea that geriatric patients need to be cared for by people who have that skill set is just not present in many [medical] programs.”
What Keeps the Doctor Away
What has long baffled Ed Ratner is why house calls are not utilized more widely in Minnesota. There seems to be little question that when the frail elderly get adequate attention, the cost of their care is minimized. (The Independence at Home bill heading for Congress even proposes a savings-sharing plan: Physicians would get a 20 percent cut of whatever they save Medicare over a 5 percent margin by helping patients avoid ER visits and in-patient hospitalizations.) The dollar comparisons for costs of care are staggering, says Neil Johnson, director of the Minnesota Home Care Association, the trade organization for home care providers. According to insurance company Genworth Financial, which compiled data about care for the elderly, to maintain a patient in a Minnesota nursing home can cost more than $60,000 a year, while assisted living can cost about $30,000 to $40,000. Keeping a patient living at home costs less than $20,000. There’s some indication that people are beginning to take note, finding ways to help patients stay out of the hospital and out of nursing homes. “The state has been generous helping us get started,” Ratner says, speaking of the grant that initiated the house calls program. North Clinic recently entered into a contract with UCare and Medica, which are offering new insurance products for seniors with chronic conditions that will cover care management, including physician home visits.
Even so, North Clinic’s house call program has been slow to get off the ground. Currently, Ratner is the practice’s sole house call physician, seeing about 40 patients in the north metro. In some states, he says, house call programs have taken root as part of an entrepreneurial model of medicine (one practice in New York that takes no form of health insurance charges $400 for a home visit). Physicians who are excited about home visits are trying to find ways to make money offering them or they’re finding enterprising ways to incorporate them into their practices. “Minnesota lags far behind the rest of the country,” he says.
A physician based in Stillwater, Todd Stivland, M.D., established Bluestone Physician Services, a traveling private practice that focuses on patients in group homes and assisted-living facilities in and around the Twin Cities and Duluth. Stivland and a recently hired associate, Matthew Logan, M.D., visit elderly, brain-injured, and mentally handicapped patients at sites where nursing care, medical equipment, and computers are already in place. Stivland is interested in doing house calls; but he acknowledges that it’s easier and more efficient for him to work with clusters of patients in one location and make use of the existing infrastructure.
As for whether other models of home care can be fully developed here, Ratner is uncertain. Growth in house calls has been greatest where nonphysician investors are permitted to innovate with medical practice models. “Minnesota doesn’t allow anyone but physicians or a nonprofit to have ownership in a medical practice,” he points out. “We will either need grant support or better insurance payment methods to sustain house calls here.”
But Ratner believes poor reimbursement is only part of what keeps physicians from making house calls. “It’s not easy finding doctors who want to do this,” he says, “even if you pay them enough.” The reason, he believes, is that medical training produces doctors who are comfortable in hospitals and clinics and not in patients’ homes. For the last eight years, Ratner, who is also an associate professor of internal medicine and on the faculty of the Center of Bioethics at the University of Minnesota, has had every second-year medical student complete a Web-based tutorial on house calls (www.geriatrics.umn.edu) and then do a practice visit with a volunteer senior. The students, he’s found, tend to be good at meeting patients in home settings and respond enthusiastically to the experience. Few, however, end up choosing careers where they travel to meet patients at home and solve difficult life problems on site.
In fact, he’s found being able to make house calls takes a certain kind of personality. “For a physician to go into a patient’s home, you have to give up a certain amount of control over the encounter,” he explains. The traditional rules of doctor-patient etiquette don’t necessarily apply in a patient’s living room. A physician might be used to accepting a call or answering a page in the middle of a clinic appointment. “The reverse happens when you’re seeing a patient in their own home,” he says. “The phone rings, and they pick it up and start talking. If that drives you nuts, you can’t do this kind of work.”
Moreover, doctors who do home visits, particularly for frail and demented patients, are constantly confronted with (and must be willing to accept) the truth about patients’ compliance. An office-based doctor who writes a prescription that fails to lower a patient’s blood pressure might believe the drug didn’t work or that the dosage was wrong and write out an entirely new prescription. “You don’t really face the fact that they didn’t get the prescription filled or that they didn’t take it. When you go into a patient’s home, you are faced with the fact that patients don’t do what you tell them,” Ratner explains.
The Big Picture
Ratner hopes the students who accompany him on house calls learn to respect and appreciate the patient’s lifestyle and environment. That respect can be communicated in subtle ways, even in the way they enter a patient’s house. Ratner always takes care to allow the patient to sit down first. “You don’t want to sit in the chair that they always sit in.” The patient’s cleanliness or eating habits may not be what the physician would choose, but if it does not impinge on the patient’s health, he doesn’t talk about it. “When you visit people at home,” he says, “you really see the differences between how other people live and how you live, or how you want your patients to live.”
Ratner has no doubt, however, that visiting a patient’s home makes it possible for him to offer better care. “Just looking around,” he says, “you know a lot of things that the office-based doctor can’t know.” On a monthly house call to a patient, he checks out such details as the patient’s personal hygiene and whether there’s food in the refrigerator. He also can look at their medications and streamline their prescriptions (he says elderly patients can wind up on 20 different medications from specialists whose care is not coordinated), observe how care-giving family members are handling their loved one’s needs, and locate services to help the patient such as home health agencies, hospice, or Meals On Wheels and check to see whether they’re being utilized.
Doing house calls has also broadened Ratner’s understanding of medical systems. Instead of receiving relayed information from a nurse or therapist, he becomes the primary author of the health care assessment. He works with an office-based, geriatrics nurse at North Clinic, who “deals with the phone calls and the paperwork and the scheduling,” he says. It’s a delegation of work that he believes “makes more sense.” He’s also able to order IV antibiotics that can be administered at home or to arrange quickly and easily for blood work and other labs. And if the patient gets admitted to the hospital, Ratner stays in contact with the admitting physician, providing much-needed continuity throughout the patient’s care. “There’s a systems understanding and a regulatory understanding that a home-care physician needs,” he says, “beyond being a geriatrician.”
The fact of the matter remains, though, that changes in reimbursement will be necessary for house call programs to succeed. “Fee-for-service is not an adequate system to serve the frail elderly,” Ratner states. He and Schneeman hope to see changes in which services are covered (physicians’ travel time is currently not reimbursed by Medicare) and in which populations can easily receive house calls (the state fee schedule for patients receiving Medical Assistance reimburses physicians less for a house call than for an office visit). Right now, patients who sign on with the recently created UCare Secure or Medica Complete Solution and pay a modest premium can take advantage of North Clinic’s program. A glitch in the process, Schneeman acknowledges, is that for a patient to switch from their current coverage is cumbersome and can take months, which has made it hard to recruit families right off the bat. But for the program that Schneeman and Ratner are creating, the premium and enhanced coverage make up for some of Medicare’s shortcomings, helping to compensate physicians for travel time and the length of a house call. Ultimately, Schneeman hopes to show highly qualified, exceptionally talented physicians that it’s possible to make a good living doing home visits. “You have to get the best and brightest involved, reward them to do it, and we’ll save Medicare zillions of dollars,” he says. “And the patients will get better care.” MM
Kate Ledger is a freelance writer and regular contributor to Minnesota Medicine.