Tuesday 24 March 2009
by: Ranit Mishori | Visit article original @ The Washington Post
Pediatrician Natalie Hodge makes a house call to 7-year-old Elizabeth Cupini in Clayton, Missouri. (Photo: AP)
When George Taler meets with a patient, he does all the usual things: He measures blood pressure, listens to the heart and lungs, takes a look in the mouth and ears, and updates the medical chart. But then he does something unusual: He checks out medicine containers in the bathroom, food in the refrigerator and the general condition of the patient's environment.
Taler, a physician at Washington Hospital Center, does house calls.
He is part of a small but growing tribe of doctors, nurses, physician assistants and nurse practitioners who are reviving this once-common practice for keeping Americans healthy and in touch with their doctors. Having virtually disappeared from medical practice by the 1980s, the house call has been making somewhat of a comeback, thanks primarily to Medicare changes that make house calls more easily billable. Advocates say revival of the house call could help reduce health-care costs substantially and enhance quality of care for many elderly and chronically ill patients.
For generations, the home visit was an institution, something a doctor, black bag in hand, just did. In 1930, house calls made up about 40 percent of physician encounters with patients in the United States, according to a recent article in the journal Clinics in Geriatric Medicine.
By 1950, that number had dropped to 10 percent. And by 1980, home visits accounted for a mere 1 percent.
Why did the house call fade away? In part, technology was to blame. As new diagnostic tools and advanced treatments became available in hospitals and clinics, that's where people wanted to go. As the article in Clinics puts it, both doctors and patients came to associate " 'good medicine' with hospitals and clinics. House calls became old fashioned."
Financial incentives also worked against house calls, according to the article. More doctors chose specialized fields that relied on the technology of hospitals, while those who chose primary care could see easily twice as many patients in offices and clinics as they could traveling from home to home.
And then there's the fact that private insurance has rarely fully covered such visits. (A few "concierge" medical practices will perform house calls for those patients willing to pay a substantial annual fee, or a trip fee, that is not covered by insurance.)
Similar constraints and disincentives have not been at work in other countries, including Canada, Denmark, France and the Netherlands, where home visits have continued to be a part of medical practice.
According to the Clinics article, in Britain, which has a strong tradition of primary care medicine and a national system of subsidized health care, doctors make 10 times as many house calls per 1,000 patients each year as do U.S. doctors.
In 1998, Medicare modified its billing procedures, making it easier for practitioners to receive payment for home visits to the elderly and chronically ill and increasing payments by 50 percent. Since then, Medicare statistics show a large bump in physician house calls, from 1.5 million in 2000 to almost 2.2 million in 2007.
Although house calls still account for fewer than 1 percent of all outpatient visits, "there is certainly a growing interest," says Constance Row, executive director of the American Academy of Home Care Physicians. According to the Clinics article, "increasing numbers of physicians have chosen full-time house call practice as their preferred professional role." Row backs efforts to increase the use of house calls as a "win-win situation for everyone. It is one of those things that patients want, that their families and caregivers want and also something that would actually save money."
Ironically, although technology undermined the old practice of house calls, technology has now made the house call a reasonable alternative to office or hospital visits for certain patients. Doctors still rely on the black bag basics (stethoscope, otoscope, blood pressure cuff, blood-drawing equipment), but now they also come equipped with laptops with electronic medical records and wireless capabilities, portable EKG machines, even bedside X-ray and ultrasound devices that were once found only at a hospital, according to Ernest Brown of Unity Health Care, which mainly serves poor people in the District.
Point-of-care testing (where blood, urine and other tests are done at the bedside, with results available in minutes) has become so easy that home-care practitioners can operate very efficiently, with "very little overhead, in some cases working exclusively out of your own car," said Brown, a family physician who does house calls.
For Eleanor Moss, 81, having a doctor who performs house calls has been a blessing. A District native, she suffers from several chronic conditions, including multiple sclerosis, which makes it hard for her to move around, let alone leave her apartment near Howard University to see doctors. She can zip around her small home in a motorized scooter she controls with a joystick, but going much beyond that is onerous and "just wears me out . . . getting my clothes on and whatnot . . . everything," she says.
She seems delighted when Taler, co-director of Washington Hospital Center's medical house call program, shows up on a recent day, black bag in hand. His visits, she says, "save me. . . . I'm telling you . . . it really saves me."
Indeed, it is people like Moss - elderly, with multiple conditions and limited mobility - who represent the biggest clientele for house calls. They are what Row calls the "home-limited elderly," people who don't see a doctor routinely because getting out is so difficult. This "forgotten population," Row says, is "getting much lower-quality care than they should have."
When something goes wrong, they end up in emergency rooms or hospitalized, being treated in a crisis rather than routinely with an eye toward prevention. According to the Clinics article, studies have suggested that house calls may keep people in their homes longer and reduce mortality, particularly in the frail elderly population. That is probably due in part to physicians' being able to identify new or worsening medical problems that, left untreated, could contribute to further disability and even death.
There may also be some significant cost savings. Although homebound patients represent only 5 percent of the Medicare population, they consume more than 43 percent of the budget, according to a congressional analysis. An ER visit can be more than 10 times the cost of a typical house call, which Row pegs at $100 to $150.
But in one of those strange twists of how America pays for health care, the cost-saving benefit of house calls might actually hurt the medical centers that provide them. Institutions such as Washington Hospital Center, which sponsors and financially supports Taler's large house call program, depend on revenue from ER visits and hospital admissions. An analysis by Taler and his colleagues found that seeing patients at home results in a 60 percent savings to the health-care system in general, but the reduction in ER visits and hospital admissions means less money for the hospital and its programs, including Taler's.
"A failure of health-care policy" is what he calls the conundrum.
Still, Taler's service is growing and includes 600 patients - tended to by four doctors, three nurse practitioners, three social workers, one office nurse and four support staffers - in what he fondly calls "the largest nursing home without walls in the District." It is a 24-7 operation, able to take calls and arrange short-notice visits even outside regular business hours. "These are our friends, and we don't want to abandon them to an emergency department," Taler says.
Taler, who acknowledges that he is a "zealot" for house calls, argues for what he calls "slow medicine": an unhurried encounter in the patient's known and non-threatening environment, also known as home. Departing Moss's home the other day, he summed it up emphatically, and a little wistfully: "That's what I went into medicine for."
Or as Ernest Brown puts it, by doing house calls he is not only given the opportunity to be a good doctor, but he also gets to play the part of "psychiatrist, social worker, advocate and, in some cases, 'family.' I give a lot - and get even more in return."
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Ranit Mishori is a family physician and faculty member in the Department of Family Medicine at Georgetown University School of Medicine. Comments: health@washpost.com.
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