Continued
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Hornbake, who has an office-based practice but makes approximately 150 to 200
home visits per year, sees things somewhat differently. “Medicare and commercial payers in my area pay for home visits. The reimbursement
is reasonable, even when you consider travel time. Many physicians do
not make home visits but spend a lot of time on the telephone managing patients
who cannot get to the office. So when I do the math, I figure I come out way
ahead of them in terms of return on expended effort,” Hornbake says. “I make sure I see patients discharged from the hospital or skilled rehab within
one week, so some patients are only seen at home once then return to the
office.”
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According to Schleider, most insurance companies will reimburse for house calls,
however, the enormous amount of paperwork and bureaucracy involved makes it
difficult for physicians to manage, regardless of the nature of their medical
practice. “We offer old-fashioned high-quality, personal, modern service and eliminate the
middle man, the insurance company,” he says. Patients with PPO insurance plans may be reimbursed part or all of our
fees, depending on their plan. Medicare and Medicaid also reimburse for
physician house calls but at low rates; approximately $100 to $150. “Sometimes we spend $50 to $100 in gas, tolls, and medical supplies in providing
health care,” Schleider says.
How can doctors afford to do house calls in the age of declining reimbursements
requiring increased productivity? Constance Row, the executive director of
AAHCP admits, “Declining reimbursement is a major challenge. The Medicare fee schedule does not
cover all operating costs for most practices. However, house calls pay somewhat
more than office visits; efficiency is required choosing the travel schedule;
some use ancillary revenue [as additional income]. Others are subsidized by
their universities or health systems,” she says.
Douglass Harroun, MD, is a house-call physician located in Federal Way,
Washington, who does geriatric internal medicine. He says, “I do only home visits, mostly to adult family homes, in several cities. Medicare
and medical supplemental policies pay me. I don’t know about other doctors, but I can afford to do it because I have low
overhead: a home office, my wife doing the administrative office tasks, EMR, and grouped
visits.”
Jay Parkinson, MD, is based in Williamsburg/Brooklyn and makes house calls to
the Brooklyn and Manhattan areas. He specializes in children and adults ages 18
to 40 years old. He has nearly no overhead and says “I work out of my apartment and see patients in their homes. I used a hodge podge
of free technology to streamline the overhead out of my practice. I have no
office and no staff. I started my practice with less than $1500. I also don’t accept insurance. I give patients an invoice and they can submit it to their
insurance company. The insurance companies haven’t had a problem paying [patients] for my services because I don’t charge that much,” he says. “It’s funny to think that since doctors are told to bill the insurance companies
upward of 200 percent of what they know they’ll get reimbursed, it causes a lot of inefficiencies in the system. I didn’t enjoy that mayhem and I’ve found people within my own neighborhood who respect me as a professional and
want to pay me.”
Office on wheels
How do house call physicians handle billing, visit documentation, and other
administrative tasks? According to the AAHCP’s Row, billing and documentation are the same as any other set of codes on the
Part B fee schedule, using the CPT manual for code descriptions.
Horning says he handles all administrative tasks himself by using a superbill he
created with updated codes. Most medical documentation is done on the superbill
with the exception of cases that are referred by other physicians. He types or
dictates these separately and copies are always sent to the referring
physicians. All records hard copies are scanned and digitally backed up.
When it comes to stocking an office on wheels, it may be surprising how much
technology is portable, though it’s impossible to take an entire office on the road.
Horning, an emergency physician by training and experience, and prefers to treat
acutely ill patients normally seen in the emergency department or urgent care
center that “many primary-care house-call doctors would not be comfortable treating. I carry
comprehensive airway and resuscitation equipment and always keep these nearby
when injecting medications or when the
patient is potentially very ill. This, I believe, is the only way to safely
provide these types of house-call services. I even carry a palm-sized
ventilator just in case,” Horning says.
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Other typical “black-bag” equipment includes on-site lab equipment, 12-lead EKG machines, laceration
trays, splints, spirometers, bandage equipments, medications, and routine
office bandaging and testing equipment, as well as laptop computers for medical
records
Getting the word out
How do house-call physicians build clientele? Advertisements, web sites, and
word of mouth are all effective. Horning says, in his experience, local
newspaper ads have been “practically worthless.”
Yellow page ads have been of some benefit, but “joining organizations such as the American Academy of Homecare Physicians and
San Francisco Visitors and Convention Bureau has been worthwhile,” he says.
“I have personally introduced my practice to most of the hotels in San Francisco
and derive a substantial portion of my clientele from this. Travelers,
especially international travelers, tend to be enthusiastic about the
house-call concept, probably because house calls are commonplace elsewhere,” Horning says. “Domestic travelers are more hesitant and sometimes require reassurance on my
part but always seem converted once I have completed the visit. I have great
rapport with certain concierge and hotel staff,” he says.
Horning has also sent practice announcement letters to local physicians and
received referrals from them, perhaps in part because he doesn not provide
continued care, so patients are always sent back to their referring doctor. “I can offer their patients a convenient after-hours alternative to the ER,” Horning says.
There are many advantages to making house calls, both for patients and
physicians. Through home-care treatment, physicians are better able to interact
with the patient and caregivers. Physician often find home visits gratifying.
In addition, the cost of home care versus hospital visits, ER admissions, and
ambulance transportation is significantly lower. One ER visit is typically
$1,500—equivalent to 10 house calls.
Steven Landers, MD, who does house calls as part of his work for the Cleveland
Clinic, says house calls should become the trend. “People want to ‘age in place,’ and house calls are a service that support this when people are less mobile,” he says. “Technology is also driving this. The diagnostic tools and electronic information
systems are becoming more and more portable.”
Row agrees house calls should become the trend. She says, “Aging in place is preferred and is so much less expensive than our current
institutional emphasis. However, if reimbursement continues not to cover costs,
only private pay is likely to be available, where available at all,” she says. “There are not enough primary-care physicians, let alone geriatricians, and the
problem is expected to get worse.”
House calls result in excellent, convenient care for the patient with easier
access. For physicians, house calls can be financially rewarding, but more
importantly, they allow doctors to practice medicine the way they intended, and
this may be the ultimate attraction.
END
Marcia Travelstead is a regular contributor to UO.
Steven Landers, MD, does house calls as part of his work for the Cleveland
Clinic.