Looking Forward To A Past Practice

December 20, 2007
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There may be a doctor ringing your doorbell in the near future, because a remnant of medicinal care from a bygone era is beginning to make a comeback.

And according to one group, that medical relic could improve the quality of care, unclog the aisles in many emergency rooms across the country and bring primary care to patients who are otherwise deprived of such treatment.

Few HQ readers are likely to remember a time when something that once was widely practiced was also widely popular — the house call. Decades ago, doctors actually took their little black bags to their patients’ homes to deliver care, often staying a few minutes to chat and have a cup of coffee, a la Marcus Welby, M.D.

The American Academy of Home Care Physicians recently surveyed 7,000 primary care physicians in the New York, Chicago, Los Angeles and San Francisco metro areas and found that 70 percent of those doctors said making house calls would improve care, result in fewer trips to the ER and, in turn, reduce medical bills.

“Without question, these physicians on the frontlines believe that a return to house calls will improve patient care. As such, they have a strong interest in finding solutions to time management and reimbursement issues that presently limit the number of doctors making house calls,” said C. Gresham Bayne, M.D., immediate past AAHCP president, in a release.

But the survey also found that only 1 percent of primary physicians — in such specialties as family practice, geriatrics and pediatrics — currently make regular house calls, defined as seeing at least 25 patients in their homes each week.

Nearly eight of 10 said they don’t make those calls every week, but 41 percent reported they do make home visits from time to time. A quarter of those doctors, though, said they would be buying new PDAs, cell phones and pocket PCs in the next few years so they could get out on the road more often.

“What is increasingly clear is that three factors — an aging population, advances in portable medical technology, and dissatisfaction by many physicians with the cost and effectiveness of contemporary medical care — are driving the increased interest in physician house calls,” said Bayne.

AAHCP Executive Director Constance Row told HQ that many of the patients now being seen in their homes are sick and frail seniors, as the trips are covered by Medicare. She said most have multiple chronic conditions and are essentially homebound. Being unable to get to a physician’s office means they get little or no primary care and often end up in the ER, a place that Row described as their main source of management for acute events.

“So the impact of having this population having access to care is they reduce and, in many cases, prevent unnecessary ER visits and in-patient hospitalization, which is a huge cost saver to the Medicare program,” she said.

Row, though, said very few private insurers cover home visits.

“Increasingly, the wiser insurers understand that the high-risk, high-cost patients need a different kind of care than the routine, office-based care, which is usually the only one made available. But generally, it’s not covered by other insurances.”

Row said the AAHCP and its 700 members believe covering house calls would help lower the overall health care cost in the country. She said, however, she didn’t think insurers would add this coverage as a convenience item in a plan, as opposed to a medical need, because doing so would increase the cost of a plan to the insurance firm. Row said home visits could also raise operational costs for some physicians who have made big investments in their offices and equipment.

Still, she said, covering house calls as a medical need would be best for everyone involved.

“Even if they only covered it for people where there is a need, and it certainly is not just the elderly,” said Row. “There are lots of people who are home-limited: younger people, people with a serious mental illness who cannot or will not leave their houses, and other patients with chronic diseases and disabilities who once would have died earlier and are now living longer.

“Once again, it is in some cases impossible to get these people to a physician often or at all, or to get these people to a physician’s office on a timely basis, especially if they have a chronic condition that requires episodic and very intense treatment.” 

The survey also shows that 89 percent of the doctors said house calls would increase patient comfort, and 80 percent said the visits would lead to more direct patient care. Fifty-eight percent of the physicians surveyed are in private practice, while 57 percent have been practicing for more than 10 years.

HouseMD Today, a forum for physicians, physician assistants, nurse practitioners, hospital and health system administrators and other professionals, conducted the survey with AAHCP. The survey was paid for by a grant from Takeda Pharmaceuticals of North America. For more information, visit www.aahcp.org

“We certainly can point to the medical-need categories lacking access to primary care as a growing problem,” said Row, “and one we hope insurers will, in fact, address.”    HQX

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