NEW YORK TIMES
June 4, 2002
By RANDI HUTTER EPSTEIN
What a difference a few house calls can make. Sometimes even the doctors feel better.
There was a time, before physicians started seeing Rosalia Morales at her home, when this very ill 66-year-old widow was not getting any medical care at all. Mrs. Morales suffers from Alzheimer’s disease and has had several strokes. She is bedridden and cannot feed herself.
“It was only me,” said Milagros Morales, her 30-year-old daughter.
The house call needs a comeback. It’s the best–and cheapest–way to care for the frailest elderly, but the medical system isn’t listening.
By Alexandra Alger – Forbes
WHEN 99-YEAR-OLD Elvira Mozqueda wouldn’t eat for two days, her family called Dr. C. Gresham Bayne. Within hours he was at her bedside. Suspecting heart failure, he gently hooked her up to a machine that measures blood-pumping strength. False alarm. “Her heart is fine. She needs to drink more liquids,” Bayne told a granddaughter.
Bayne runs Call Doctor Medical Group, a house-call service in San Diego that makes 900 visits a month to the homebound elderly. He had treated Mozqueda at home for a year, saving her from having to spend any time in a hospital. Cost to the system: about $150 a visit, compared with $2,000 for a trip to the emergency room. In August his frail patient died quietly in her own bed, surrounded by family. “Most Americans want to die at home like she did, but 95% of them are in hospitals or nursing homes,” Bayne says.
SAN DIEGO, Jan. 19 – Dr. Gresham Bayne used to run one of the busiest emergency rooms in San Diego. Now the sick don’t come to him. He runs door to door, taking medicines and his skills to them.
Yes, he’s making house calls. Thanks to a local company, the practice is actually making a comeback of sorts. And you’d be amazed at what goes into the little black bag these days.
“Everything’s become lighter, cheaper, faster,” Bayne says. “You know, digitalization has allowed us not only to improve our communications, but allowed us to carry portable lab instruments that will fit in your purse and measure the seven most common emergency room blood tests in two minutes in the privacy of your bedroom.”
October 28, 1999
Another history-making housecall for Call Doctor Medical Group, Inc.
History: The patient is an 85 year old lady who signed out of the hospital against medical advice to go home and be with her 96 year old husband for their 64th anniversary. Upon arrival at home the nurse practitioner from Call Doctor performed a non-invasive cardiac impedance test showing her cardiac output, stroke volume and ejection fraction had decreased by 30% probably due to the multiple new medications she was on, including Lopressor, a beta-blocker that impedes the force of contraction of the heart. The Lopressor was stopped but the home health nurse called two days later requesting an emergent physician visit, as she thought the patient was in heart failure, coughing all night and extremely weak.
The Housecall: The Call Doctor arrived after re-triage indicated no life-threatening immediacy. The patient did have some signs of failure, but was unable to give a history due to Alzheimer’s disease. Using the BioZ machine from Cardiodynamics, connected through the Vectis electronic medical record of Call Doctor by the CDMA technology of a Qualcomm phone, the doctor created the medical record on line with the server ten miles away, printed the chart in the office for electronic billing and emailed an encrypted version of the data to a related physician. The test confirmed that the patient was not in failure and the cough was probably due to medication.
When San Diego residents can’t get to the doctor or hospital, 1-800-CALL DOC sends a physician and mobile hospital to their front door.
Gresham Bayne, MD, and his CALL DOCTOR Medical Group have brought the housecall back to San Diego residents who find it difficult or even impossible to get to the doctor’s office or hospital. CALL DOC is not an ambulance or substitute for 911, but with their ultra high-tech, brightly colored vans, CALL DOC physicians practically bring a hospital emergency room right into the patient’s living room.
Miniaturized devices let doctors take the ER with then – and may even bring back the house call.
By Christine Gorman
Dr. Greshan Bayne practices medicine in some pretty unusual places. Just last month the San Diego physician was worshipping at the Point Loma community Presbyterian Church when a fellow parishioner collapsed in her pew. Rather than call 911 to rush the 96-year-old woman to the hospital, Bayne asked the ushers to take her to the church parlor. The doctor, who is something of a gadget freak, was equipped for any contingency. Stashed in his black bag – actually, a blue-and-gray fishing-tackle box – was a miniaturized version of every diagnostic tool he needed to assess her symptoms as well as a full supply of standard emergency-care drugs to treat them. “You’ve got to stop thinking about bricks and mortar.” Bayne says. “today, I am the emergency room.”
By Gresham Bayne, MD
For some four thousand years, the practice of medicine was delivered in the patient’s home. It made sense: sick people can’t or don’t want to go anywhere; physicians were valuable mainly for their cognitive skills, and had little or no testing instruments to be used in evaluation of patient’s’ treatments were limited to simple blood-letting or herbs delivered orally, if at all. Thus, the entire doctor-patient relationship was confined to the privacy of the home and relatively few treatment options, supported by the trusting nature of the doctor-patient relationship.
Over this period the Hippocratic Oath became the mainstay for Medical School Graduations, and we blindly swore an oath that we had no possibility of keeping. Born of a time when the sanctity of the doctor-patient relationship was everything, initiated in the privacy of the patient’s home, where both physician and patient were attending voluntarily, this Oath in managed care-modern times has become, perhaps the most abused sworn statement in modern culture.
What happened to the housecall, and the magnificent traditions it entailed?
American Academy of Home Care Physicians
By Mark McDonnell, MD
The home care industry as been besieged from all sides in the past two years.. The explosive growth of home health care has brought a greater amount of regulatory scrutiny to the industry. Much of this scrutiny is justified by fraudulent practices of some home care companies who take advantage of government reimbursement systems. However, the marketplace has also been buffeted by declining reimbursement from managed care payers, conversion to a prospective payment system by Medicate, and massive consolidation within the industry.
Understanding the forces of influencing the marketplace will help physicians make better-informed decisions regarding home care providers they choose for their patients.
American Academy of Home Care Physicians
Promoting the art, science and practice of medicine in the home.
1999 Vol. 11 No. 4
Issn# 1049-0028
Questions… and Answers – How Many MD Home Visits Are Required?
Dear Academy: I need some advice as to how I can measure the number of visits that a visiting physician needs to see his patient. My mother, age 82, will not leave the house, is physically very healthy (except for blood pressure and dementia). I found an agency which supplies a doctor who makes house calls and wants to come by at least once a month. At the last minute, there are phone calls as to when he is coming wants to do lots of tests. I don’t want to dissuade him from coming for fear my Mother will end up with no doctor. Would like to have some advice as to the manner in which I need to be gracious and yet be able to somehow discern what is necessary for the ongoing medical needs of my Mother. Perhaps someone can help. My thanks, Ed Gembka
Reply: The answer to your question is both simple and profound. The number of visits and tests necessary for your homebound mother, whom I presume to be of Medicare age, is defined by Medicare regulations as what is “medically reasonable and necessary.” Of course, the physician’s role in determining what is “medically reasonable and necessary” must be based on professionalism and your trust.
