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Doctors making house calls

Discussion in 'Topics in Healthcare' started by humuhumu, Dec 19, 2005.

  1. humuhumu

    humuhumu nukunuku apua'a
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    Anyone hear this story on NPR this morning?

    http://www.npr.org/templates/story/story.php?storyId=5059324

    This is a great topic for interviews: a way to provide better quality health care at a lower cost, at least to certain populations.

    Check out this link too for more information: http://www.npr.org/templates/story/story.php?storyId=5059072

    An excerpt:

    According to the Centers for Medicare and Medicaid Services, the average hospital stay for a Medicare beneficiary age 65 and over is nearly six days, at a cost of about $3,500 per day.

    Previous smaller-scale studies have suggested that giving these patients better care earlier can reduce costs down the road. For example, a 2004 study of a house call program in Las Vegas found a 62-percent drop in hospital stays among 91 elderly patients, resulting in a net savings of $261,225 per year.

    Dr. Eric De Jonge, who helps run the house call program at the Washington Hospital Center, says making home visits to his patients, who might otherwise call 9-1-1, has translated into significant cost savings.

    "An urgent house call costs about $100. An ER visit with 9-1-1 calls costs about $2,000," De Jonge says. "On a day-to-day basis, making urgent visits and coordinating the care in the home is clearly going to prevent some of those high-cost events." And when elderly patients in the program are hospitalized, De Jonge says, they are discharged, on average, two-and-a-half days sooner than those not enrolled. In part, that's because staff from the program will check up on them at home.

    In October, Medicare began a three-year pilot program to test the benefits of house calls on a national scale. The program involves 15,000 Medicare patients in Texas, California and Florida, who will receive free, 24-hour access to in-home care. Medicare officials will compare the medical records of those enrolled in the program to those in a control group to see whether house calls translate into cost savings and improved patient health.
     
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  3. Law2Doc

    Law2Doc 5K+ Member
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    Interesting articles - thanks for posting!
    But I'm at a loss for how it could be so much cheaper (by a factor of 20). Unless (1) the doctor is largely eating his costs, and not accounting for the fact that he probably could see a half dozen patients in the office or ER in the time it takes to travel to and see a single patient in the home, and (2) part of the savings is simply foregoing tests that are available in the office/ER but not at the home (in which case it's not exactly better quality health care, just more streamlined and corner cutting medicine). It's fantastic that there are folks who are doing this kind of practice -- definitely helpful for the elderly and disabled. But I'm clueless as to how it is so inexpensive.
     
  4. humuhumu

    humuhumu nukunuku apua'a
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    I think the main savings comes from diagnosing and treating conditions early before they reach the acute stage. Also, doctors making house calls get to know their patients well so they're not ordering unnecessary tests (which is more likely to happen in an ED).
     
  5. Law2Doc

    Law2Doc 5K+ Member
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    I would agree with you except for this quote: "'An urgent house call costs about $100. An ER visit with 9-1-1 calls costs about $2,000,'" De Jonge says". That just makes no sense to me, and seems to involve either significant writing off of the doctor's time, elimination of otherwise standard tests due to infeasibility of transporting them, and ignoring opportunity costs of seeing other patients during the time spent travelling from place to place. So called "fuzzy math", perhaps. But your other points are certainly valid.
     
  6. humuhumu

    humuhumu nukunuku apua'a
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    Not sure. Maybe the $100 doesn't take into account the baseline salary of the physician, and maybe the $2000 is a worst-case scenario involving an ambulance, multiple paramedics, and who knows what else.

    In the LA area there's a company that pays a salary to the house call doctors partly with a cut from insurance companies that are convinced that house calls save money.
     
  7. odrade1

    odrade1 UASOM alum
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    1. The quote may *sound* like hyperbole, but the person quoted was the director of that program at Washington Hospital Center. He probably knows better than we do what the relative costs are.

    2. If 911 is called, the ambulance, a firetruck (or 2) and possibly a police officer will get involved. This adds substantial costs to society and to the individual (or their insurance company).

    3. Doing the same thing in the ER costs a hospital several times what it would in a primary care outpatient clinic or home visit. Only a fraction of visits to ERs are actually emergent cases. The rest could be handled by a nurse, PA, family doc, or internist. Actually, some of the emergent cases could be handled by a family doc or internist. Once someone gets admitted to a hospital, costs go up. Once someone checks into an ER, costs go up. I had a visit to the ER where all I got was an ambulance ride, some X-rays, "observation" and a shot of demerol. I never even got a hospital bed! 3 hours, >$3500 bill. OUCH!

    4. Hospitals often practice "defensive medicine" in cases that a government-paid doctor working for medicaid would not. This is especially true of tests, scans, and prophylactic consults from other disciplines, all of which add costs.

    5. The $100 cost of the home doctor visit seems low, and it makes me wonder: how much are they paying their docs!? Maybe they have found a way for the travel docs to treat lots of patients in a given day.
    Assuming 40 hrs/wk for 47 weeks a year, a doc only needs to make $80 an hour to gross 150K. Maybe they average a patient and a half per hour? So maybe the numbers are real.
     
  8. sscooterguy

    sscooterguy Senior Member
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    Yes, this sounds like fuzzy math to me. $100 may be how much it costs for a house call. But what exactly can one do at a house call? You can rule out minor conditions, tweak medications, assess for fall prevention, check patient compliance, and probably some other things too. House visits are more common for some of the family practioners in my area, but they all tell me they can only afford to do it once a month, and only for those that are truely house bound.

    If you had a porbable ekg, then maybe it could help you rule IN a heart attack, in which case you would need to call a squad any way. The thing about the ekg is, you can't rule OUT a heart attack, which would be much more money saving. Admittedly, one can make diagnosis 70% of the time with history and physical exam, but what about treatment? There are only so many drugs one can take with you, and many will need initial or follow up labs/studies. Without labs, xray, and other tools, what about that other 30% that you don't have a diagnosis?

    The average cost of the house visit may indeed be $100 for raw material with a huge cut to the physician's salary, but the biggest problem of the story is the "average hospital stay", as most people going to the ER aren't even admitted. Yes, if they are sick enough to be admitted, then it may cost that much. However, if they were sick enough to be admitted, then they would probably be sick enough for the house visiting physican to admit the patient any way.

    The way that some hospitals are trying to save money are having triage nurses stationed OUTSIDE the ER (once the patient steps in, its too late). If they deem it an urgency, they send them to the urgent care/physician's office right accross the street, if not, they go into the ER. House visits should be for those that are indeed house bound or otherwise need house visits. I think this may be a better solution to the problem.

    peace outside,
    sscooterguy
     
  9. Law2Doc

    Law2Doc 5K+ Member
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    This is the real problem I have with that figure. Grossing 150K in the manner you suggest means a doctor's salary must be substantially lower than that -- assuming equipment costs, transportation costs, licensing, insurance, legal, general and administrative, the physician's salary would end up but a small fraction of any such "gross" figure. (perhaps doable if you send med students or junior residents, I suppose.). And that's assuming very brief time with each patient, and assuming all your patients live close to each other, and not far from the doctor's home base, to limit travel time. And as sscooterguy indicated, you probably still have to send blood, stool, etc. to labs for follow-up tests, so there are costs to that, and if the $100 covers that as well, then you are operating at a loss. While I don't doubt that a simple ER visit can be expensive, I question whether a housecall can actually be that cheap if you are going to provide equivalent value.
     
  10. odrade1

    odrade1 UASOM alum
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    I think the main savings is in preventing unneccessary trips to ERs. Think of the old man/lady at home who catches a cold & needs to see a doctor. If you can't drive yourself (and many medicaid/medicare people can't), and you think you need to see a doctor, you call 911 & get a "free" ambulance ride. Really this person may need just a decongestant and some assurance that what they have is uncomfortable, but not life threatening. If the doc is unsure, but knows that the case is not emergent, a patient escort van could be called to transport the patient to the outpatient/ambulatory care clinic or to the local Public Health clinic run by the state. This is instead of using 911 to get the patient to the ER. Our hospital has such a patient escort service. If it could be paired with traveling docs or PAs, it seems that we could save (the hospital, the patient, and society) a ton of money. The travel docs help triage potential ER patients before they arrive at the ER, thus driving down costs.

    Equivalent care is obtained after all, since the doc triages the patient. Equivalent care should not be based on defensive medical practices or extravagant uses of tests/technology, but on sound medical care based off of the evidence presented by the patient. (Interestingly, a doctor may have better insight into the patient's life and lifestyle if they actually visit the patient at their home. This could also lead to better care.)
    Truly emergent cases: First, the doctor back-hands the patient for not calling 911, despite the obvious difficulty breathing and constant, copious bleeding. Then the doc is on-site to minister to the patient until the ambulance arrives.
    Serious, but not emergent: the doc calls public health or the hospital to arrange for non-ambulance transport to admitting.
    nonserious: the doc takes blood samples and puts them in a refrigerator or cooler in her car, then submits them to the lab at the end of the day. Arrangements can be made to schedule an appointment with a specialist, as necessary. Prescriptions can be given when with the patient, or faxed to a pharmacy of the patient's choice after the labs come back.
    Trivial: the doctor back-hands the patient and tells them to get real.

    If you visit 1.5 patients a day in an 8 hour day, you see 12 patients. At 100 per patient, that equates to a cost of 1200 per doc per day. IF the doctor works all but 5 weeks out of the year, then the payroll costs are 150K. But the total cost of treating the patients seen by the doctor are 282K. This (crude) estimate allows for 132K in overhead, administrative expenses, etc (per doc) that go beyond the doctor's pay & incentive package. This maintains the 100 per visit cost. If 8 patients are seen per day, instead of 12, the cost of treating the patient is 188K. This alllows for 38K beyond the 150K salary costs. (Frankly, it 150K for a state employee is a little high, and I'm not sure how much you would need in administrative costs per doctor). Given the typical inefficiency of governments, 38K per doc in admin costs is possibly a bit low. Who knows.

    I'm just excited by anything that curbs the abuses of ERs and the overuse of intensive care units. This system could really improve care while reducing the overall costs (even if not by a factor of 20, even a factor of 2 is TREMENDOUS).
     
  11. tigress

    tigress queen of the jungle
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    I just caught the end of the story this morning. But from what I heard it seemed like many of the housecalls were for routine bloodwork checks (done by MSNs it seemed like?), hospice-type visits, and follow-up care. One reason it was profitable to the hospital was because their patients (all geriatric) enrolled in the program always come to this hospital's geriatric unit rather than to other hospitals. At least that's what they said. I was really touched by the doctor at the very end who said he enjoyed making housecalls because it made medicine personal, like how he had wanted it to be in the first place.

    Anyway like I said I just caught the end of the story, and I didn't read the link :oops:
     
  12. Law2Doc

    Law2Doc 5K+ Member
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    I agree that its a good program, and if done correctly and on a shoe string budget (perhaps even with non physican health professionals most heavilly involved in the home visits) could be a bit cheaper to national healthcare in the long run, and so is something insurance companies ought to get behind. However saying it is going to be 20 times cheaper still sounds to me like puffery with a capital P.
     
  13. humuhumu

    humuhumu nukunuku apua'a
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    I'm excited by the idea too, and so were my interviewers. I've ended up weaving it into just about every interview I've had. I first learned about it earlier this year from a very nice LA Times article. Here's the full text (this will take a couple posts):

    ---------------------------------------------------
    There's a Doctor in the House

    By Lisa Girion
    Times Staff Writer
    29 July 2005

    Dr. Tamika Henry carries a stethoscope in her bag. But that's about all she has in common with doctors who visited patients in the heyday of the house call.

    Her woven tote from El Salvador is a virtual office, carrying diagnostic tools and a pocket computer that gives her instant access to patient charts. "Dr. Tamika" — as doting patients call her — is a thoroughly modern physician helping to revive a bygone style of medicine.

    In 2004, doctors rang more than 2 million doorbells — up nearly 9% from the previous year. The movement has been propelled by advances in medical technology, an increase in Medicare reimbursements and a growing recognition that house calls make economic sense for certain patients.

    While most primary-care doctors are tethered to offices and tight schedules, Henry drives a gray Acura through neighborhoods south of downtown Los Angeles. She sees half a dozen patients on a typical day, often spending an hour or more with each.

    "If I'm sick and need her, she will come," said Mary Conner, who lives near Henry's alma mater, USC. "When I tell my friends about it, they can't believe it. They say this happened back in the '30s."

    House calls, which accounted for almost half of physician visits in 1930, all but disappeared decades ago. Their decline left a gap in medical care, particularly for older people with chronic illnesses.

    Whether they get sick in the middle of the night, are bed-bound or just can't get a ride to the office, these patients — known in hospitals as "frequent fliers" — often are unable to see a doctor who knows them well. As a result, they get sick more often and more severely, and end up cycling in and out of emergency rooms, hospital wards and nursing homes.

    These episodes are hard on patients and their families — and expensive for taxpayers. A recent Congressional Budget Office study found that these patients make up only 5% of Medicare enrollees but their care consumes 43% of the Medicare budget.

    Some physicians and other advocates are championing house calls as part of the answer.

    "If we don't have a better chronic-care management system — with house calls — for the frail elderly who are the most expensive, we're going to bankrupt the Medicare program," said Constance Rowe, executive director of the American Academy of Home Care Physicians. "It's not only cheaper, it's what people want. They don't want to be hospitalized."

    Mary Conner smiles when she sees her doctor bounding up the wheelchair ramp to the front door of her blue-and-white bungalow. The 75-year-old great-grandmother has hypertension and takes nitroglycerin for angina. She was hospitalized three times for congestive heart failure before Henry started making house calls more than a year ago. She hasn't been hospitalized since.

    As Mary lets Henry in, her husband, James, waits in a motorized wheelchair in the couple's sunny dining room. The 78-year-old man, also a patient of Henry's, has diabetes and undergoes dialysis three days a week for advanced renal disease.

    The couple's great-granddaughter toddles into the dining room to watch as Henry puts her stethoscope on James' chest.

    Her visit turns the room — filled with anniversary portraits, school pictures and other family photos — into an impromptu examination room. Henry turns to Mary to ask about a recent appointment with a specialist.

    "What did your cardiologist say?"

    "He didn't get back to me," Mary replies.

    "I need to talk to him for you," Henry says.

    Serving as a coordinator is an important role for Henry and doctors like her. They make sure that care prescribed by specialists is carried out — and is working.

    Henry's broad smile and charm help her elicit clues to her patients' health. If she can catch a problem early enough, she often can treat it on the spot. Sometimes just a medication adjustment can mean the difference between a patient's sleeping through the night and making a midnight run to the emergency room.

    Henry's first job out of residency, at a Long Beach community clinic, didn't allow her the time to get to know her patients. "There was so much paperwork, and then the hustle and bustle of trying to see so many patients every 10 or 15 minutes," the Lynwood native said.

    Then Henry heard about Care Level Management, a start-up company in Calabasas that was looking for doctors to make house calls full time. She leaped at the chance.

    "I like to spend time with people. I like to talk."

    Although a few practices catering to the wealthy still make house calls for a heavy fee, most doctors can't charge enough to pay for the extra time involved. The typical office-bound general practitioner sees 15 to 20 patients a day. Patients with urgent problems who can't get into the office are told to dial 911.

    Such calls trigger a cascade of expensive interventions — including tests that duplicate results on file elsewhere and hospital stays. These episodes also expose fragile patients to the risk of new problems, such as infection.

    Seeing an opportunity to head off these problems in some patients, San Diego physician C. Gresham Bayne launched a full-time home-care practice in 1987 and mounted a campaign that in 1998 won the first substantial increase in Medicare fees for house calls in two decades.

    Physicians, who had been collecting an average of $60 per call, now get more than $100 for visiting patients with standard Medicare plans. Private insurers who cover house calls pay about the same.

    Patients in San Diego, Riverside and San Bernardino counties who call Bayne's Call Doctor Medical Group's toll-free number are promised same-day visits and urgent care within an hour. With five physicians and two physicians' assistants backed up by an office staff of four, the group makes about 800 house calls a month.

    They perform procedures once possible only in offices and hospitals, including electrocardiograms and X-rays. Advances in portable technology, telemetry and instrument design allow much of modern medicine to fit into a bag — and even more in the trunk of a car.

    "It's really a great way to practice medicine," said Bayne, president of the American Academy of Home Care Physicians. "You are not in a windowless building with an army of people telling you what to do. You are a master of your own destiny. And there is no waiting room."

    But even with the Medicare fee increase, a house call practice is tough to pull off, Bayne said. Among the biggest challenges is getting fully paid by Medicare. Although the insurance program for the elderly has covered house calls for decades, the claims still are so rare that they often get audited.

    House-call physicians could go broke fighting for reimbursements, Bayne said. Such battles would have shuttered his practice if not for more than $12 million in venture funding he had obtained over the years, he said.
     
  14. humuhumu

    humuhumu nukunuku apua'a
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    Making house calls could become a more robust business if an idea pioneered by Care Level Management succeeds. The company contracts with insurance companies to provide house calls for selected patients in exchange for a cut of the resulting savings on hospital visits. An entrepreneur and a physician launched Care Level in 2001, and they say it has been profitable since 2003.

    Care Level physicians are paid fixed salaries starting at about $165,000 a year. They care for no more than 120 patients each and control how and when they pay visits. The patients all live in urban areas and are grouped by proximity to limit doctors' drive times.

    "It's a dream for them," said Care Level's co-founder and chief executive, Raouf Khalil. "We offer them the best package out there."

    There is one catch: Physicians must be available around the clock, seven days a week. They get out of bed at 3 a.m. if a patient calls.

    "Chronic disease is a 24/7 business," Khalil said. "You have to have access. Otherwise, they are going to go to the E.R. The more barriers you put between these patients and the doctor, the more costly it's going to be."

    Khalil's pitch to insurance companies is this: Allow our physicians to take care of your sickest patients, and we will save you money. Care Level is so confident that its ounce-of-prevention approach will save a pound of cure that it promises to rebate fees if it does not deliver a savings.

    In the company's first four years, "that has never happened," Khalil said. "And it never will."

    Timely care makes all the difference, Khalil said. For example, if a patient with a heart condition develops symptoms of pneumonia after office hours, she may resort to going to the emergency room, where she may wait for hours before being seen.

    Hospital physicians unfamiliar with her history would probably order a battery of tests. Then they might recommend a course of intravenous antibiotics administered in the hospital, where, according to a recent study, the average cost for treating pneumonia is at least $6,900.

    With Care Level, that same patient could call a physician familiar with her health who would examine her in her home. The physician could order an in-home intravenous antibiotic treatment and make a follow-up visit — all at a cost of $750, according to Care Level.

    Better yet, said Care Level co-founder Dr. Henri Becker, a house-call doctor could catch the symptoms early, avoiding the need for an IV.

    Some of the care by these doctors could not be provided in an office or hospital. They weed out expired drugs from the medicine cabinet, for example, and get rid of throw rugs that could trip elderly patients.

    "We can spend sometimes hundreds of thousands of dollars on a patient in the hospital and discharge them, and the house has no food or is poorly lit," said Sheldon Zinberg, a physician and founder of CareMore Medical Group in Downey, which also sends doctors to the homes of "frequent fliers."

    "Hello, Sunshine!" Dr. Henry shouts as she walks into Bonnie Jones' garden apartment in Garden Grove. Striding into a bedroom in back, she finds her patient sitting in a blue recliner in a bright spot in front of a sliding glass door. Jones, 79, is struggling to sort pills from a dozen bottles into a plastic tray with compartments for each day of the week.

    Henry drops her bag and helps Jones figure out which pills go where.

    "How's your appetite?" Henry asks.

    "I never really feel hungry, but I know I have to eat," Jones says.

    Jones had a cancerous piece of her jaw removed and replaced with bone from her leg. House calls help her return to the comfort of her home — and stay there — each time she finishes a round of chemotherapy in the hospital.

    "What do you eat besides mashed potatoes, pudding and soup?" Henry asks. "How about a sweet-potato pie?"

    "Oh yeah," Jones says, her eyes lighting up.

    "Are you drinking enough?"

    Jones grabs a water bottle from the floor next to her recliner and shows Henry how much she's had this morning. Then, for good measure, she takes a gulp.

    Henry listens to her heart and lungs and then puts the stethoscope to her stomach.

    "You've been through so much," Henry says, telling her how much she admires her spirit.

    "I'm not going to let this get me down," Jones replies. "I think I'm more fortunate than most people — I have plenty, including you."

    Standing to leave, Henry says, "OK, Sunshine — let me give you a hug."

    Care Level sends physicians to the homes of patients covered by about 10 insurers in parts of Southern California, the Bay Area, Arizona, Texas and Florida. Because of the expense, insurers offer the service only to the sickest 1% to 5% of their elderly HMO patients — at no extra charge.

    "We just can't offer it to our total membership — it's just too costly," said Mark Kiffer, a medical officer with health insurer Humana Inc.

    But for about 700 Humana Medicare members in Phoenix and San Antonio, where the insurer has contracts with Care Level, the house calls have "made a remarkable difference," Kiffer said.

    "Hospital inpatient care is the costliest portion of our healthcare delivery system today," he said, "so by avoiding unnecessary hospital admissions we're able to reduce the overall cost of care."

    Care Level's round-the-clock house call coverage has reduced hospital admissions among frequent fliers by 60%, the company says. A study commissioned by Care Level found that one insurer saved $7 million in six months last year after it enrolled 318 of its 15,000 members in the house-call program.

    Such results have caught the attention of the nation's biggest health plan — Medicare. The agency recently awarded Care Level a three-year demonstration project to serve as many as 15,000 patients in California, Texas and Florida. Like private insurers who work with Care Level, Medicare will share some of its savings with the company during the trial, said Jeff Flick, Medicare's administrator for the Western region.

    "If this works, we can structure other things like this in other parts of the country," he said.

    As far as Mary and James Conner are concerned, the benefits of house calls already are proven.

    "How are you feeling?" Henry asks James during her recent visit to the couple's South L.A. bungalow.

    "Oh, I'm all right," he says.

    "You don't complain about anything, though," she says, turning toward Mary. "How's he been doing?"

    "He's tired, real tired on dialysis days," Mary says. "And I'm concerned about his foot after they took the nail off."

    Henry moves in to have a look. Diabetics are prone to infections and often feel no symptoms. Henry values Mary's insights into her husband's condition and takes care to draw them out.

    "In an office, you may forget something," Mary said. "But at home, you think of everything because you are more comfortable."

    James' toe is healing fine, Henry says, grabbing her pocket computer and pulling up his chart. She notes that he has brought his blood sugar level into the range she had targeted.

    "That's great — I'll take 140 and run with it," Henry says. "What did you have for breakfast?"

    "Bacon, ham and oatmeal."

    "I wish I could get that," Henry quips, glancing at Mary.

    Like many of Henry's patients, Mary tries to feed her almost every time she comes by. She has promised to make the 32-year-old doctor a cake for her bridal shower in the fall.

    "She acts like she's my daughter," Mary says. "I'm real comfortable with her."
     
  15. mackie

    mackie Senior Member
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    I can see how housecalls would help save the patient and the hospital money. And, I guess if you're a salaried physician being paid in a way that is not necessarily based on productivity, then I can see the benefit for all. However, there is no way a doctor can see as many patients in a day doing housecalls and they could see in their office or in the hospital.
     

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