UO > Feature > The House Call of the 21st Century

Love is a strange thing. Neither poets nor scientists can explain the attraction of one soul to another. Physicians can be similarly drawn to a specialty, and that is what seems to be the case for those who practice geriatric medicine in long-term care settings, including the 2,100 continuing care retirement communities (CCRCs) in the United States. Some doctors enjoy exploring the complexity of a frail older person’s medical, emotional, social, and spiritual needs. Others like a history that lasts for decades and echoes of a patient’s bygone world. Flexible hours, professional autonomy, and steady paychecks without the burden of an office practice appeal to others. Whatever draws them, there’s a cadre of physicians who practice in retirement communities and other long-term care settings, ‘mini-cities’ for affluent seniors that provide housing, health care, and support services. (See sidebar “The CCRC Practice Environment,”)

Two common forces shape the careers of physicians practicing in long-term care settings: their fondness for geriatric patients and their desire to avoid the bother and expense of office-base practices. But the career path for a doctor interested in facility-based geriatric medicine isn’t as clear as the more traditional route—an internist or family physician establishing an office practice, then becoming the attending physician and/or medical director at one or more nursing homes. Because physician services at most retirement communities are limited to patients in the skilled nursing part of the campus, with perhaps medication management and a handful of patients in the assisted living section, a physician has to dig to find the right opportunity, both professionally and financially.

There are three main routes to a physician’s CCRC practice. One, the facility builds in the cost of on-site medical services by subsidizing them through residents’ fees, a model engineered by Baltimore-based Erickson Health Systems. Two, the CCRC offers de facto support by building medical offices on the campus and then leasing it to a medical group. Woburn Medical Group of Massachusetts and Presbyterian SeniorCare of Oakmont, Pennsylvania, both offer that option. Three, a practice management group employs physicians, handles all administrative tasks, and contracts with retirement communities for physician services. Extended Care Physicians of Asheville, North Carolina, uses that model.

Andrew Carle, the director of the assisted living/senior housing administration program at Fairfax, Virginia-based George Mason University, sees a CCRC practice as a path for physicians who like the venerable house call. “They can’t do it economically in today’s world because it would involve driving to 50 or 100 individual homes. With congregate senior housing, patients are gathered into one large home. I’ve had physicians proudly show me the black bags they purchased so they could go unit to unit in a retirement community to see their patients,” says Carle.

The retirement community physician caters mostly to affluent elderly consumers who can exercise choice about their post-retirement living arrangements. According to the MetLife Market Survey of Assisted Living Costs, the average monthly base price rose 15 percent, from $2,524 in 2004 to $2,905 last year. “As the population ages, assisted living is fast becoming a viable and often preferred option for those who are relatively independent but need supportive services,” says Sandra Timmermann, the director of the MetLife Mature Market Institute in Westport, Connecticut. “But the cost of care in an ALF is rising rapidly and in many areas, is outpacing inflation.”

Although CCRCs market their lifestyle amenities more than medical care, an important part of their package is access to health care. Not surprisingly, retirement community physicians do play a powerful role in keeping residents healthy. A 2002 Johns Hopkins’ University study comparing the disease burden and functional impairments of CCRC vs. community dwellers found that while CCRC residents had significantly higher prevalence of angina, heart attack, stroke, osteoporosis, blood clots, and aneurysms, and twice the functional impairment as community dwellers, their life expectancy was 20 percent greater than community dwellers.

For some retirement communities and their prospective residents, swimming pools and gourmet meals loom larger than medical services. For Erickson Retirement Communities, a network of 14 communities housing 3,000 residents in nine states, however, its medical group is its cornerstone. Caring for Erickson residents only, the closed practice group, America’s largest geriatric practice, employs 61 professionals: 40 physicians, 15 nurse practitioners, and six advanced practice nurses who specialize in mental health. Matthew Narrett, MD, who has been at Erickson for 12 years and was recently promoted to chief medical officer, cites a long list of services the group provides both at on-site medical offices and in the assisted living and skilled nursing facility (SNF) units: emergency medical services, urgent care, prevention and wellness, home support, physical therapy, speech, mental health, everything short of hospitalization. On a typical day, physicians see two scheduled patients an hour, leaving space for one urgent care visit.

Narrett says he hires career-minded doctors who commit to Erickson because they love geriatrics. “It’s a great opportunity for a young physician. Instead of investing in establishing an office, he or she can be a medical director at a new community.” A generous compensation package reflects the medical group’s subsidy from resident fees. “It’s a hugely important component of why seniors choose Erickson. They value what we do so much and that makes the medical group financially whole,” explains Narrett. In addition to base salary, Erickson physicians can earn company shares and bonuses. There’s also an annual $2,500 CME stipend, with license and malpractice costs covered. If a physician arrives at Erickson with a large malpractice “tail,” a low-interest loan is available to pay off the tail.

Erickson’s reputation was no doubt boosted by the results of a three-year demonstration project called Erickson Evercare Medicare Advantage HMO. Medicare awarded Erickson the grant (to form the HMO) because Erickson’s costs and acute care utilization were 30 percent lower than what Medicare typically was paying for a CCRC population, Narret says: “This isn’t your typical HMO. If Mrs. Smith has a compression fracture and can’t return to her apartment, we can put her in our SNF without the three-day hospitalization required by Medicare.” Paperwork hassles are gone, and Erickson’s care coordinators ensure that Mrs. Smith is treated as the doctor ordered.

Erickson doesn’t lack job candidates. Narrett says that he looks for “a spark, someone who is friendly and excited and gets what we’re about. We want people who convey to us that they love geriatrics and seniors, have good communication skills, and will fit in that extra patient on a busy day.”

In the heartland, doctors like Roger Weise, MD, who want a career in a retirement community environment have just the right place. In 1991, after 10 years in private practice, Weise returned to the Chicago health system where he completed his residency. Starting part-time on grant funding, he eventually became a full-time salaried employee of the Bonaventure Medical Group, part of the Alexian Brothers’ Health System. The practice grew steadily as it won accolades for its care quality from U.S. News & World Report and others. Today, the group includes five other doctors, all fellowship trained in geriatrics, three nurse practitioners and a physician’s assistant. Together, they cover 14 nursing and assisted living facilities.

Weise’s practice combines the old-fashioned virtues of Marcus Welby with high-tech medicine. He and his partners see patients in any of their three offices, two in CCRCs and one hospital-based, and make house calls throughout the CCRC—to a patient’s apartment, assisted living residence, or nursing home. Weise practices “the holistic side of medicine, which is very rewarding and hands on.”

Grounded in the Germany-based Alexian Brothers’ mission since 1860 to serve the elderly in the United States, Bonaventure physicians like Weise minister to patients who are, on average, 83 years old in the CCRCs, and 91 years old in the skilled nursing facilities. “We see from eight to 15 patients a day, not 30 or 40, and we earn a decent living,” says Weise. In addition to salary, physicians receive additional stipends as medical directors and can earn productivity bonuses.

Key to Weise’s success is a comprehensive initial assessment that sets a baseline for the patient’s physical, social, emotional, and spiritual functioning. Once that’s done, the physician-patient relationship deepens over time. Because they know their patients, the doctors work toward helping patients achieve their functional goals and make sure end-of-life issues get addressed, so they don’t have residents in the ICU who don’t want to be there. “If a patient with CHF wants to walk with his grandchildren and is also demented, we’ll focus on reducing the swelling in his legs so that he can walk better,” Weise says.

As for call, one physician covers each week, with three on the weekends for 24/7 coverage. Currently, Bonaventure keeps paper records but will move to electronic medical records by spring, when the group moves to larger offices. Overall, Weise calls his CCRC practice “much more rewarding than private practice had been. We’re part of a developing movement of treating the whole person over a long period of time.”