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.
House calls: Not just a thing of the past
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.
Payments for home care
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.”
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 aome patients are only seen at home once then return to the office.”
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 reimbursments 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 $1,500. 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.
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.
Marcia Travelstead is a regular contributor to UO.