UO Magazine - Nov/Dec 2008 > House Calls Return

Do you ever feel overwhelmed struggling with your workload in an office-based practice? Do you wish you had the time to build better and deeper client relationships versus seeing a steady string of patients in a normal workday? Changing from an office-based practice to home care practice by making house calls may be the answer.

Aren’t house calls more or less a thing of the past? Actually, that’s far from the truth. House calls used to be common a generation ago, but traveling made them impractical. However, in the last several years, doctors are finding creative ways to make them viable again.

The American Academy of Home Care Physicians (AAHCP), located in Edgewood, Maryland, has served the needs of thousands of physicians and related professionals and agencies interested in improving patients’ health in the home for more than 20 years. According to AAHCP statistics, for every elderly person in a nursing home, there are three equally infirm seniors living at home. Home health has become the fastest growing segment of Medicare’s budget. According to the Center for Medicare Services (CMS) Medicare National Procedure Summary Data File, the number of house calls paid by Medicare has increased by 100,000 per year since 2001. Although it leveled off in 2004 and 2005, it began to rise again in 2006.

From big cities to small towns

It would appear likely that most physicians who make house calls would be found in large metropolitan areas, however, house calls are being made everyday in suburbia as well, by physicians all over the country. Some home visits are one-doctor operations. Many are affiliated with programs begun in recent years by hospitals. Others belong to house call/primary care programs or by physicians who saw the need to create one.

One such physician is John Horning, MD. Horning has practiced emergency medicine since 1996 in several cities across the country. In 2005, Horning relocated his wife and two daughters to Prague, Czech Republic for a sabbatical. During that year, he commuted to Vail and Aspen, Colorado, where he provided house-call medical services to resorts, hotels, and residences. He enjoyed the opportunity to have the time to connect with patients, who appreciated convenient and professional services. After a year in Prague, his family returned to the United States. His house-call service for the San Francisco Bay Area, Urgent Med Housecalls, was launched in 2007.

What types of patients does Horning see? He says his practice consists primarily of travelers, mostly international. “I recently treated a family of three travelers for food poisoning with meds and IV fluids, all right in their hotel room. It was quite a scene. They were thrilled to have that option. The alternative, of course, would have been to sit in a local ER waiting room for a few hours, strategically positioned near a public restroom.”

Although he is beginning to acquire a local clientele, Horning says growth in this area has been slow due to the heavy HMO presence in the Bay Area. He does get requests from the local well-to-do population, he suspects that the relatively few calls have to do with the excellent attention they receive from their primary physicians.

“Most of my patients have minor urgent medical problems. I do see occasional significant dehydration, usually from gastroenteritis, but more and more I am called for the elderly patient who has stopped eating for whatever reason. A number of local physicians request my services for evaluation of their homebound patients. I have responded to calls to evaluate hospice patients as well, usually by their families.”

Care across the spectrum

Dr. Natan Schleider is the chief medical officer for New York House Call Physicians, a group of health-care professionals who see patients in their homes. They travel throughout New York City including Brooklyn, Queens, Manhattan, Staten Island, the Bronx, Westchester, Long Island, the Hamptons, and New Jersey.

The physicians provide everything from pediatric care to geriatrics, along with allergy and immunology, addiction and pain management, and podiatry. They also provide intravenous therapy, travel vaccinations, audiology and ultrasound services, physical therapy, eye care, hospice, and weight loss treatment.

New York House Call Physicians are a fee-for-service practice specializing in house calls and concierge physician care. Schleider sees about 80 percent of his patients via house calls and prefers to treat his patients like family. They have his cell phone number and can call him at any time.

Concierge medicine is one type of house call. For some physicians, the home visit is centered on their home-bound, most seriously ill patients, not just those who are willing and able to pay for convenience.

Rodney Hornbake, MD, of Essex, Connecticut, is an office-based physician who chooses to make house calls in multiple nearby communities. He says, “Home visits are provided to home-bound patients at the end of the day. Last year, I made 152 home visits. They are scheduled in advance and patients are informed that home visits cannot be provided for emergencies. I see frail elders, quadriplegics, patients with multiple sclerosis, and other chronic neurological disorders. Most patients graduate into home visits when they stop being able to come to the office. The death rates among these patients is greater then 25 percent per year, and they may end up in a hospice program. The focus of care tends to be on palliative issues,” he says. On his website, (www.drhornbake.com), he adds that younger patients with chronic conditions may also benefit from home visits.

Payment particulars

How are physicians in home care reimbursed? What is acceptable to Medicare and private insurers? It varies. Horning says, “I only accept payment up front via cash or major credit card. I use a wireless credit card scanner. I accept payment by invoice billing or check only from fudiciaries for patients who are incapacitated. I do have agreements with certain traveler’s assistance services who refer patients to me. My patients are given a superbill for insurance reimbursement,” he says. House call services are usually reimbursed by PPOs at as much as 80 percent of the regular office visit rate.

As for Medicare, Horning has opted out. Why? “My practice is so unique and innovative that its value is simply not recognized by Medicare. My house-call service is available 24/7. I occasionally drive an hour or more to see patients emergently, after hours. Medicare does not reimburse for prolonged travel, or for after-hours service for house calls—at least not to any significant degree,” he says. “If I were to participate in Medicare as a 24/7 service, I would never rest because I would be inundated by requests from the elderly mobility-challenged, and I don’t believe I could afford to hire quality coverage at current Medicare reimbursement rates. I could not afford to live in San Francisco. It is not financially feasible for me to participate in the Medicare program.”

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