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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