Home care medicine: It’s back and better than ever, DOs say
San Diego-based home care physician Paulo V. Zizzo, DO, treats 98-year-old Gladys Sweet. (Photo courtesy of Dr. Zizzo)
Speak with a physician who does house calls, and you’ll likely hear the word “save” many times. House calls save money, physicians say, by providing homebound patients with preventive care. They save time by yielding fewer emergency room and hospital visits from these patients. And they save patients from a host of inconveniences such as ambulance transportation, waiting rooms and exposure to other patients’ illnesses.
Once a mainstay of medical care, house calls all but disappeared by the 1980s. But changes in Medicare reimbursement rates, realization of cost savings and advances in portable technology mean physician home visits are making a comeback.
Paulo V. Zizzo, DO, transitioned from an office-based practice to solely performing house calls in private practice in 2000. The San Diego-based physician primarily sees geriatric and disabled homebound patients who have coverage through Medicare. This method of health care—house calls for the homebound—is a financially responsible model, he says.
“For people who can’t get out to see the doctor, if they have even a minor problem, what are their avenues?” he says. “They’re going to call an ambulance, they’re going to go to the urgent care or the emergency room, and there are a lot of costs associated with that.”
Home visits vs. ER, hospitalization
House calls can save money in myriad ways, says Constance Row, the executive director of the American Academy of Home Care Physicians. For homebound patients with chronic conditions, routine visits from a physician can help prevent flare-ups that require emergency or hospital care. And when patients do need immediate help, a physician’s home visit is less costly than ambulance transport and hospitalization.
For instance, Dr. Zizzo received a call one morning from a patient’s son. The patient had amyotrophic lateral sclerosis; his son called because the feeding tube in his father’s stomach was leaking. Shortly after Dr. Zizzo arrived, the tube ruptured and came out of his stomach.
Dr. Zizzo reassured the patient’s wife and son that the three of them could handle the problem. Dr. Zizzo put gauze over his patient’s abdomen and headed to the hospital to pick up a new feeding tube. After returning to the patient’s home and installing the tube, Dr. Zizzo had a radiologist come by to take an X-ray to make sure it was in the right place. After that, they were done.
Performing all these services took one or two hours, Dr. Zizzo says, and could have taken a whole day in the ER or longer. As the patient’s ruptured feeding tube wasn’t technically an emergency, the staff may not have been able to take him until the next day. However, receiving same-day care made a huge difference for the patient and his family.
“It wasn’t an emergency, but to the family it was a massive emergency,” Dr. Zizzo says. “Because how else were they going to feed their father? He has a hole in his stomach with some stuff leaking out of it—how are they going to deal with that?”
Dr. Zizzo estimates ER care for this patient would have cost at least $5,000. Although he says Medicare refused payment for this particular service, his charge for the home visit was $700.
Short history of house calls
Although some modern physicians such as Dr. Zizzo built their practice around house calls, home visits are rare among family physicians today. This wasn’t always the case. Physician home visits were the original form of medical practice, says Norman E. Vinn, DO, the AOA’s president-elect and the chief medical officer of Housecall Doctors Medical Group in San Clemente, Calif.
Adding house calls to an office-based practice
Office-based physicians interested in taking on house calls may want to keep the following tips, provided by house call physicians and the AAHCP, in mind:
- Consider the geographic locations of potential house call patients. Selecting patients who live close to the office or the physician’s home can cut travel time.
- Designate a house call coordinator, or hire one. This person will serve as a liaison between the physician, the patient, and other care providers and services.
- Brainstorm ways to reduce office overhead. Cutting costs can enable a physician to perform more house calls.
- The billing system for house calls is different; take some time to learn how to bill for home visits.
- Strive to make house call visits as efficient as possible.
- Consider performing house calls in partnership with an accountable care organization; this can reduce costs.
- Regularly monitor quality indicators to ensure patients are receiving high-quality care.
- Maintain a list of service providers and community resources, such as ambulance, portable X-ray, laboratory, mental health, meal and legal services.
- When preparing a house call bag, obtain portable versions of equipment to avoid taking tools out of the office.
Sources: Norman E. Vinn, DO, Benneth Ann Husted, DO, Paulo V. Zizzo, DO, and the AAHCP’s booklet Making House Calls a Part of Your Practice (available for purchase from the AAHCP).
“There was no doctor’s office until the early- to mid-18th century,” Dr. Vinn says. “House calls persisted throughout the interim period until the late 1970s, when medicine became increasingly specialized.”
As medicine became more specialized, says the AAHCP’s Row, primary care physicians were less likely to receive training to perform some procedures, and the evolution of malpractice insurance meant they couldn’t do certain things such as deliveries. The proliferation of emergency medicine also meant that it became easier for physicians to refer patients to the ER rather than make a late-night house call.
Patients would have to see specialists for more procedures, and specialists were less likely to perform house calls. In addition, there were advances in medical technology in the ’60s and ’70s, Dr. Vinn says, that physicians could not bring with them into homes. The new standard was for patients to come to the office, where the latest tests and technology were available. To see a patient without access to these things was viewed by some as a lawsuit risk.
Concurrently, changes in the insurance reimbursement system eventually led physicians to see more and more patients each day, which rendered house calls impractical and unsustainable, says the AAHCP’s Row. Reimbursement rates did not keep up with the increasing costs of maintaining a practice, says Benneth Ann Husted, DO, the medical director of Portland, Ore.-based Housecall Providers.
“It became necessary for physicians to see 20 or 25 patients a day to make an adequate living and to cover their infrastructure costs,” Row says. “House calls nearly vanished in all of that.”
Technology, rates fuel comeback
The percentage of physician encounters taking place in homes dropped from 40% in 1930 to 10% in 1950 and 1% in 1980, according to American Family Physician.
But over the last 15 years, changes in technology and the Medicare reimbursement rate mean house calls are more feasible for a growing number of physicians and patients. For instance, the increasing portability of technology means today’s house call physicians can, in some cases, access even more resources than they could in a traditional office setting, Row says. Some physicians trained in emergency medicine bring ER devices, such as cardiac impedance measurement tools, to patients’ homes, she says.
At the same time, Medicare began to greatly alter its reimbursement structure for residential visits in the late ’90s and early 2000s, which opened the doors for a resurgence in house calls. Medicare paid for 2.6 million house calls in 2011, up from 1.5 million in 1996, according to the AAHCP. Medicare reimbursement for a home visit is now higher than reimbursement for office visits to account for travel time, transport costs and fewer patients being seen, Dr. Zizzo says.
Industry-wide information on house call coverage from private insurers is not readily available, according to Susan Pisano of America’s Health Insurance Plans.
And house calls may become even more common in the future. The Centers for Medicare and Medicaid Services announced the Independence at Home Demonstration (IAH) in April. Part of the Patient Protection and Affordable Care Act, IAH is an effort to assess whether residential physician visits for homebound patients with multiple chronic conditions can cut Medicare expenditures, according to the CMS website.
CMS is working with 18 organizations and tracking the health costs of patients from each organization for three years starting in 2012. Sites whose patient care costs show significant savings over what Medicare estimates their care would cost outside the home will be eligible to receive incentive payments, according to the CMS website.
Portland, Ore.-based Housecall Providers is one of these test sites. Dr. Husted, the Housecall Providers medical director, says house calls are in her blood.
“I’m the daughter of a DO,” she says. “On Sunday afternoons after church when I was about 8 or 9, we would get in the car, and Daddy would go visit the patients of his who could no longer come to his office. My father did this on a pretty regular basis for his frail, elderly patients.”
Shortly after she became a physician herself in 1981, Dr. Husted worked in an office-based practice for 9 years, but she occasionally did house calls. At that time, she had no idea she would one day run a house-call-based practice with 1,300 patients.
Dr. Husted’s path from office-based physician to house call crusader was circuitous. She took a break from medicine in 1990 and went to a seminary. At the end of her time there, she prayed for inspiration, and the idea of home care medicine came to her.
“At first I thought, what in the world?” Dr. Husted says. “But I really began to look at house calls as a distinct possibility.”
Dr. Husted moved to Portland in 1992, packed a “black bag” and started looking for patients. At first, she worked alone. The money wasn’t great. In those early years, the most she earned was $28,000 annually, she says. But she didn’t mind.
“Once I started doing it, I loved it,” Dr. Husted says. “And what I didn’t get in reimbursement, I was getting in appreciation from patients and their families.”
Dr. Husted discovered a great need for house call physicians in the Portland area. She became swamped with referrals and recruited a few friends to help. She filled out the paperwork to incorporate Housecall Providers as a nonprofit and subsequently brought on more staff. The late-’90s changes in Medicare reimbursement helped the practice grow further; last year, Housecall Providers made more than 12,000 house calls. The practice currently employs roughly 25 clinicians.
When Housecall Providers was selected as a demonstration site for IAH, Dr. Husted was elated not just for her practice but for the potential changes to reimbursement rates.
“I have great hopes,” she says. “Under this mandate, Medicare is seriously looking at how they might provide better care while controlling costs.”
Dr. Husted says one reason public programs such as Medicare are experimenting with different methods of care is that the sickest patients use a substantially greater proportion of health care dollars. For instance, 5% of the U.S. population accounted for nearly half of all health care expenditures in 2009, according to the federal Agency for Healthcare Research and Quality. In-home care could bring those costs down and help these patients at the same time, Dr. Husted says.
Drawbacks of house calls
If IAH is successful, Medicare may further change its reimbursement structure for house calls, Dr. Husted says. Currently, Medicare reimburses house call physicians on a fee-for-service basis. Although the reimbursement rates account for travel time and transportation, house calls are typically less lucrative for physicians than office visits. This is one of the reasons Housecall Providers incorporated as a nonprofit, though the organization also serves low-income patients. Dr. Husted says 80% of the organization’s budget comes from fees for medical services, while grants and fundraising fill the gap.
“Over the last 12 years, we’ve received $1 million from various foundations, which has helped us sustain our practice,” Dr. Husted says. “What we do doesn’t pay for itself. We had to become a nonprofit organization just to survive.”
In addition to the lower pay, physicians who do house calls also must brave the elements to get to patients, Dr. Zizzo says, though he notes that this isn’t too hard to do in San Diego. Also, not all physicians will be comfortable practicing in an unfamiliar setting such as a home. People live and keep their homes in different ways. Dr. Zizzo has a patient who resides in a 8-by-15-foot trailer with her pets.
“You go in there and sweat and sit amongst the dog hair and still try to treat this person with the dignity that she deserves,” he says. “If you’re not used to it, it can be a little shocking to really see how our fellow people live. But a little bit of patience and empathy go a long way.”
House call physicians often work in tandem with social services in coordinating patient care. Some physicians prefer to stay in the office, where their practice is focused on medical concerns, the AAHCP’s Row says.
“You have to be willing to deal with more than the medical needs of the patient,” she says.
Benefits of home care
But these pitfalls don’t deter those who primarily do house calls, such as Dr. Zizzo. For all the downsides, he says he wouldn’t go back to an office-based practice—the pros of home care medicine far outweigh the cons.
“It builds a very unique doctor-patient relationship, which I wasn’t able to find in the office,” Dr. Zizzo says. “And I’m not sure too many doctors are able to find that in the office anymore. I’m probably one of the lower-paid doctors in San Diego, but I’m probably one of the most satisfied and happy. And for me and my partner both, that’s been our goal in medicine.”
Glimpsing a patient’s home life can give a physician clues about the patient’s condition that he or she would be reluctant to share in the office, Dr. Zizzo says. A patient says he’s eating? His physician can look in the fridge. A patient says she’s taking her medication? Her physician can check her prescription bottle.
House call physicians can more easily work with their patients’ caregivers and home health aides, Dr. Husted says. In the office, patients visiting by themselves might not remember instructions or information the physician provided.
Gladys Sweet, a patient of Dr. Zizzo’s in Carlsbad, Calif., says Dr. Zizzo talks with her caregivers during his visits, and then they answer any questions she has later on. The 98-year-old former food service manager says it would be hard for her to visit a physician’s office because her relatives would have to drive her. Another perk? Dr. Zizzo’s visits always brighten her day, she says.
“He never seems to rush me or be in a rush,” she says. “He just sits down and visits a little bit, and he is very thorough. He’s very concerned if there’s anything wrong, and it’s been a very good relationship.”