Can house calls be revived under health reform?

Beginning in the 1970s, the house call began a slow death. As the medical-industrial complex (MIC) burgeoned, with bigger hospitals and a surfeit of technology, it became incumbent on patients to come see us rather than us going to see you.

Yet there are pockets of house calls still left in the U.S.

For the geriatric age group, there has been growth in the care-at-home sector, especially for homebound elders. They can get not only doctor visits, but nurse visits, wound care, physical therapy, intravenous medications and nutrition, all kinds of medical equipment, and even x-rays at home. To meet the needs of our growing geriatric population, many doctors have chosen to work for agencies that provide in-home care to elderly patients, avoiding the sterility of the office environment.

Many geriatric training programs require their trainees to perform house calls. Whether residents and fellows like the experience or not, no one can deny that seeing a patient in his or her home environment provides a much richer and fuller picture of a patient than seeing them in an office or hospital setting.

Of course the rise of concierge medicine has spurred growth in the house call field. Concierge medicine involves paying an annual fee to put your doctor on ‘retainer,’ so that you can stay in their practice. Paying the fee in theory gives you unfettered access to the doctor, including being able to reach your own doctor 24/7 via direct cell phone access.

A concierge doctor might not only make a house call, but might accompany you to see a specialist and act as your advocate. A concierge doctor has time to do this since usually 90% of their patients opt out of paying the retainer so the doctor has more time to spend with the remaining 10%.

Of course, house calls have never truly gone away at the luxury end of the spectrum. Private physicians have always been willing to deliver customized care to patients in their homes, on tour, or in hotels, for the right price. See Dr. Murray, as in Conrad.

When I was a chief resident, I moonlit for an outfit that provided house call service to hotels in major metropolitan areas. I found out about it by answering an ad in the New England Journal of Medicine. I think it was a spirit of adventure and my latent literary sense that this gig would provide some interesting stories. I did meet some noteworthy characters during my time in the field.

“What kind of medicine can you actually practice in a hotel room?”

I asked the same thing, but as I gained more experience, it became clear: Mostly it was about offering reassurance to weary travelers. Feeling sick in a strange city, people calling our service were grateful and appreciative of a medical presence who could hear their story and offer solace. They paid dearly for the privilege, but the vast majority thought it well worth it.

Now that health care reform has passed, and Medicaid and Medicare will expand to their largest enrollments ever, I wonder if house calls will be included in the ‘experimentation’ phase of the law, or whether they will remain relegated to the fringes of the medical establishment.

As a patient, I’d love to be seen in the convenience of my own home by a doctor who had the confidence to practice without all the whistles and bells of modern medicine.

John Schumann is an internal medicine physician at the University of Chicago who blogs at GlassHospital.

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  • DrB

    As a second note….

    Modern technology gives me plenty of “bells and whistles.” I find there are very few things I cant do in a home. honestly… I do more things in the home than a lot of physicians do in their offices.

    just my opinion.

  • DrB

    Doc99, I beg to differ.

    I started a housecall practice straight out of residency 5yrs ago. no problem getting malpractice. the liability is less , not more. pt’s are a lot less likely to sue when you spend time with them and explain what you are doing.
    check out the American Academy of Homecare Physicians (AAHCP.) the liability “scare” is not a valid concern to not do housecalls.

  • Primary Care Internist

    I still do plenty of housecalls. For the geriatric population it’s not only useful, but I think also relatively low liability. Really, for a 90-yr-old with stable COPD, HTN, BPH, maybe diabetes, on 6-8 meds, seeing them periodically at home for their primary care is useful.

    And if you need the bells and whistles, well that’s what specialty referral is for. But really, why does the patient above need to see urology every 6 months, pulmonary every 4-6 months (with PFTs at least annually), cardiology annually (more testing) etc.? If they develop eg. a COPD exacerbation, the Internist can treat them, and if they would rather see pulmonary then that’s fine, they go out to the office. The vast majority of cases i’ve had like that opt to be treated by the primary, which is how it should be anyway.

    The “bells and whistles” need to be paid for, and are the reason for the subspecialist-heavy system we have today. Perhaps housecalls are a way around that. The demographic is certainly there for that.

    Now if only medicare would pay a reasonable fee for it (although none of the commercial insurers pay it at all, in my experience).

  • Dr Synonymous

    As a family physician, I still make house calls and have for over thirty years. I made one yesterday and got to I&D an abscess among other things. Nothing like pus and blood in the patient’s natural habitat. For more on the richness of making house calls, see my blog post for 4/10/2010 House Calls: Paid in Full Plus Tips at DrSynonymous.blogspot.com. Peace.

  • Gene Cone MSI

    I obviously haven’t practiced or even been exposed to the practice of medicine enough to debate the relative medical merits of housecalls. In the era of cost-savings and reform, however, it seems as though any service in which it is mostly “about offering reassurances to weary travelers” but that you need to “pay dearly for the privilege” is doomed to be phased out or to be under-reimbursed to the point that it is not worth it for a doctor to provide it.

  • Doc99

    Check with your malpractice carrier before you attempt to practice medicine without all those “bells and whistles.”

  • http://wellescent.com/health_blog Wellescent Health Blog

    Especially for the elderly and the frail for whom a visit to the doctor or clinic can be a significant effort and potential health risk in of itself, house calls make a lot of sense. I would much rather have my 90 year old grandparents visited at home than worry about them driving or getting sick from a cold that they contracted while sitting in the doctor’s office. This is despite them being very healthy for that age.

  • Manalive

    My elderly housecall patients chastize me for not raising my rates. They tell me that the visiting podiatrist who spends 10 minutes trimming their toenails is paid far more than me, even though I manage their diabetes, venous insufficiency, etc.
    Of course, it does not matter what I charge….

  • Dorothy Knapp-Hollingsworth, PA-C

    Here’s my list of bells and whistles: an ISTAT machine that gives me a BMP, Hgb/Hct, troponin, BNP, PT/INR and blood gases within a few minutes. An EKG machine, though after 4 years of doing exclusively housecalls, I’ve found that I letting our x-ray tech do the EKG’s along with the x-rays and cardiac impedance studies makes more sense – studies usually get done the next day, but can get done the same day in urgent situations with results then being sent immediately to my and & my supervising physician’s computer via an air-card (HIPAA compliant). We used to only be able address homebound patients with sleep apnea with overnight oximetry studies but we just got one of the first in-home sleep study devices (Res-Med I think is the name of the company). Our statistics apparently show that we’re REALLY good at managing heart failure patients and keeping them out of the hospital (I managed a lady w/an EF of 14% w/the help of my supervising physician for 2 years before she passed away peacefully at home). I can get oxygen out to patients within a couple of hours and at any given time I’m working with several different home health agencies who’s resources include (invariably) nursing, PT/OT and social work, as well as (perhaps less immediate) access to speech therapists, dieticians, and I’m probably forgetting something. Home health pscyh nurses can sometimes be helpful, though one local HH agency now has a team totally devoted to psych issues w/a prominent psychiatrists at its head and I’ve come to appreciate their multi-pronged approach to psych issues. Our care coordinators/dispatchers are trained in the 911 dispatcher protocol. With an average patient age of 82 each with an average of 11 diagnoses, patients do on occasion need to go the hospital. Our system allows us to quickly create for the ER doc (or hospitalist in the case of direct admissions) a customized document including the current chart note which then can be ‘faxed’ directly from my computer in a HIPAA compliant manner to the hospital while sitting the patient’s couch waiting for the EMT’s or paramedics to arrive (that scenario played out two nights ago with 29 DMD pt on a vent who turned out to have a kidney stone). Speaking of which, we can also get renal u/s, echocardiograms, etc. done in the home. All our bells & whistles have been carefully selected for their dispositive value by my supervising physician who’s board certification is in emergency medicine. These tools are invaluable in allowing us to walk out of the patient’s home (which my doc equates with sending the patient home from the ER) with some ‘back-up’ of our clinical assessment of the patient as ‘stable’. However, as much of what we do ends up being on-going management of chronic conditions in their advanced stages, I think the important details and insights we get from visiting the patient in their home allows us to act with precision, identifying little problems which have the potential to morph into big problems, thus keeping them stable and out of the hospital (where they typicially dread going anyway).

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