House calls

[Saluki]

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I'm thinking about doing general pediatrics, but I've heard that a lot of pediatricians have become somewhat dissatisfied with the increasing patient loads preventing them from practicing medicine the way they want to.

I love the ideas in concierge medicine- the focus on preventive medicine, the smaller number of patients, doing housecalls rather than keeping an office, etc. But it seems like that's just working for a select number of pediatricians who a) feel confident with the financial aspects of running a solo practice and b) live in areas with a wealthy patient base.

Is anyone aware of opportunities for general pediatricians to go back to the golden days of housecalls and extended visits without the pitfalls of concierge medicine?

 

[BigNavyPedsGuy]

I'm thinking about doing general pediatrics, but I've heard that a lot of pediatricians have become somewhat dissatisfied with the increasing patient loads preventing them from practicing medicine the way they want to.

I love the ideas in concierge medicine- the focus on preventive medicine, the smaller number of patients, doing housecalls rather than keeping an office, etc. But it seems like that's just working for a select number of pediatricians who a) feel confident with the financial aspects of running a solo practice and b) live in areas with a wealthy patient base.

Is anyone aware of opportunities for general pediatricians to go back to the golden days of housecalls and extended visits without the pitfalls of concierge medicine?

You'd have to have wealthy clients because insurance isn't going to reimburse extra for it.

There's also a greater-good philosophy. How many sick kids can you treat in a day if you're driving from house to house? How many can you treat in a day if your walking from exam room to exam room? How can you help poor underserved families if they can't pay you any extra for the housecall? Are you going to take rapid streps, flu and RSV swabs as well as all of your standard immunizations with you? I guess you'll have a cooler or portable fridge to store those items?

In theory it's nice, but the only way I see it working in the real world is to turn your back on all but the wealthiest subset of parents.

 

[waldenwoods]

You'd have to have wealthy clients because insurance isn't going to reimburse extra for it.

There's also a greater-good philosophy. How many sick kids can you treat in a day if you're driving from house to house? How many can you treat in a day if your walking from exam room to exam room? How can you help poor underserved families if they can't pay you any extra for the housecall? Are you going to take rapid streps, flu and RSV swabs as well as all of your standard immunizations with you? I guess you'll have a cooler or portable fridge to store those items?

In theory it's nice, but the only way I see it working in the real world is to turn your back on all but the wealthiest subset of parents.

I'm not a fan of using the "greater good" as a rationale for practicing a certain way, because perhaps being satisfied with your career while having a positive impact on pediatric patients is more important than choosing an alternate career path that may cause undue stress to the physician but would have a "greater" positive impact on children. Is part-time work bad, because spending twice as many hours as a full-time employee enables the person to treat double the # of sick kids in a day and contribute more to the "greater good"?

With pediatrics and its many subspecialties, which career path provides for the greatest good to society? Working in private practice general pediatrics, at a community health center where a larger proportion of patients are insured by Medicaid and/or SCHIP, in academics, in a subspecialty private or academic practice, doing research only, working in public policy, doing house calls, or something else? I think for everyone the answer would be different, based on the individual's personality, interests, and values.

I imagine it would be challenging to be adequately compensated for doing house calls.

 

[oldbearprofessor]

http://www.natickpediatrics.com/babyathome.html

Any other links to pedis who do this?

 

[BigNavyPedsGuy]

I'm not a fan of using the "greater good" as a rationale for practicing a certain way, because perhaps being satisfied with your career while having a positive impact on pediatric patients is more important than choosing an alternate career path that may cause undue stress to the physician but would have a "greater" positive impact on children. Is part-time work bad, because spending twice as many hours as a full-time employee enables the person to treat double the # of sick kids in a day and contribute more to the "greater good"?

With pediatrics and its many subspecialties, which career path provides for the greatest good to society? Working in private practice general pediatrics, at a community health center where a larger proportion of patients are insured by Medicaid and/or SCHIP, in academics, in a subspecialty private or academic practice, doing research only, working in public policy, doing house calls, or something else? I think for everyone the answer would be different, based on the individual's personality, interests, and values.

I imagine it would be challenging to be adequately compensated for doing house calls.

You make good points. I have no problem with someone working half time or in a private clinic. It's just frustrating to hear people say things that in essence mean "I'm only going to treat children of very wealthy families" which is what a house-call practice would be.

You're right, everyone can do what they want, but I still won't like that attitude.

 

[billw]

You could always do house calls part time and hold regular office hours part time. Some of the geriatrics people around here do that. Of course, as I understand it, this is possible because medicare reimburses more for house calls with older people if you can establish a medical need to treat them at home (which is probably not a great challenge with older patients).

 

[Saluki]

You make good points. I have no problem with someone working half time or in a private clinic. It's just frustrating to hear people say things that in essence mean "I'm only going to treat children of very wealthy families" which is what a house-call practice would be.

You're right, everyone can do what they want, but I still won't like that attitude.

It does look like that's mainly what it turns out to be, so I guess what I'm asking is if there's a way to do the housecalls without it being that way. It seems like if you don't have the expense of keeping an office building, secretarial staff, etc. that you could maybe have 300 patients who could afford the yearly fee and then take 50 others on some sort of sliding scale..

And since there's supposed to be a surplus of pediatricians by 2020, maybe this is the solution to keep us all from living in cardboard boxes 😛

 

[waldenwoods]

It's just frustrating to hear people say things that in essence mean "I'm only going to treat children of very wealthy families"

I agree. It's incredibly important for pediatricians as a group to figure out how to take care of all kids--regardless of their parents' ability to pay. It would be great to be able to provide house calls to patients who may be unable to leave the home, or whose families are unable to get them to the doctor.

What I do know is that I don't want to feel guilty when the day comes that I decide not to work at a community health center despite that it'll benefit some of the neediest patients, as I currently feel that I'll probably be going into academics. A lot can change during residency and it'll be interesting to look back on how I envisioned my career while I was still a medical student. I'll still devote some of my time and effort toward improving patient access to care (hmm....both for physical and mental health), even if--in the academic center I end up practicing in--the majority of my patients end up having private insurance.

Given your screen name, I'm betting you're in the military, so do all of the kids you see have public insurance? 🙂 Does it pay for house calls, at least in special cases? Just curious.

 

[Stitch]

They still do housecalls in Europe, but the payment system is completely different (and most docs don't have any debt from school, so they're more free to do these types of things). I know some people who have gone the medical boutique route, serving a small number of families, but doing house calls. One person had a $2000 per year buy in. She made close to 200k/year, but each of her patients had her cell number and it was always ringing. Now she had pretty close relationships with her patients and liked going to homes, but it's pretty tiring.

I can't imagine having time or energy to do house calls in addition to office work. It would be hard to make ends meet. But then, general peds isn't something I could ever do, so my hats off to those who can.

 

[BigNavyPedsGuy]

I
Given your screen name, I'm betting you're in the military, so do all of the kids you see have public insurance? 🙂 Does it pay for house calls, at least in special cases? Just curious.

Every active duty member's dependants is covered under Tricare, which is the Military's insurance. Where I work most of them have full coverage at our hospital.

 

[J-Rad]

One model of practice that could include housecalls is fee-for-service (this is not concierge medicine). The FM world has far more experience in this arena, but I would think it can be viable with peds as well. FFS practices will have a set pricelist for services and often have a sliding scale fee system for those with limited income, so the less well off don't just get the boot. Payment is expected at the time of visit and a superbill is provided for the patients (who can turn it into their insurers for reimbursement, thus taking the burden/hassle of dealing w/ insurers off the provider). I think someone with a business sense could make this work and include housecalls.