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.

“In the beginning, my mother would walk around pacing the floor, taking off her diaper. She would get real angry and try to run away. She’d scratch me when I tried to give her a bath and spit out the food when I fed her. Sometimes I would get so overwhelmed I would scream, but that would only get her more agitated.”

The two women live in a rose-painted apartment in East Harlem, cluttered with family photographs and souvenirs. For a while, Mrs. Morales went to a clinic, but as she got sicker, she refused to go.

“After what my mother did for me, raising me, I thought I could never leave her side,” said Ms. Morales, who scrapped plans to go to college to stay with her mother.

But the constant demands of caring for a deteriorating patient became overwhelming, even for a highly dedicated daughter.

One telephone call changed the lives of both women, and also lifted the morale of the doctors who now treat Mrs. Morales.

About three years ago, Mrs. Morales was selected from a list of clinic no-shows to receive checkups at her bedside.

The doctors cannot cure her disease, but they have treated her bedsores and prescribed medicine to ease her agitation and lower her blood pressure. They have also arranged for nursing aides, paid for by Medicaid. The extra help has enabled Ms. Morales to attend Touro College, earn money as a cleaner in a hospital on weekends, and even resume dating her boyfriend.

And while the Moraleses have benefited, so too have her doctors. Dr. Sonni Mun, her current physician, clearly likes her job.

She enjoys the leisurely time chatting with the family and says it adds a new dimension to practicing medicine in New York City.

The Moraleses are part of a five-year-old program of the Mount Sinai Hospital and Mount Sinai School of Medicine that was started primarily as a teaching strategy. The program, called Visiting Doctors, was founded by Dr. Jeremy Boal, Dr. David Muller and Dr. Laurent Adler, three former residents here, who worried that the grueling demands of residency training were creating a breed of callous, angry physicians.

The three brainstormed for solutions and decided on a month of house calls in the training program to remind residents that their patients are people, not biochemical analyses.

Several residency programs across the country are now incorporating low-tech methods to instill compassion into weary and disheartened trainees. The Mount Sinai course was modeled after a Boston University program, directed by Dr. Sharon Levine. Other strategies include seminars in ethics and role-playing classes to teach bedside manner. But the house-call program is one of the most intensive additions.

“As far as I can see this is a trend that is starting to sweep training programs in our field,” said Dr. William Hall, past president of the American College of Physicians-American Society of Internal Medicine.

“The whole idea of getting away from training primarily in hospitals and seeing where people actually spend their lives opens their eyes to the healthy side of medicine,” Dr. Hall said. “We have spent the past three decades coping with the knowledge explosion, which has been phenomenal in internal medicine, and to some extent might have been done at the expense of spending less time learning communication skills.”

There are no data to prove that a few weeks of home visits will make for happier doctors, but those who teach residents have a hunch the experience, however brief, is rejuvenating.

“You can lecture to death about how important these things are, but you have to be surrounded by it,” said Dr. Margaret Bia, professor of medicine at Yale.

“You have to see that your patients may have kids running around handing pills to their dolls, and that may be why the patient keeps forgetting to take her medicine. In this day and age, when every doctor is burning out and questioning why they went into medicine, you realize the importance of these things.”

Every resident in internal medicine at Mount Sinai is required to spend one month making house calls. In addition, they attend two seminars a week, one on palliative care and the other on literature. At the end of the month, residents complete projects — essays, poems or artworks — reflecting their experiences.

In the house calls, residents learn to take care of all sorts of nonmedical yet crucial components of healthy living. For instance, they help weed through the confusing mass of insurance forms; they check food supplies; they double-check to make sure prescribed medicines are really taken.

“You come to the home visits right after a rotation in the intensive care unit, where you take care of incredibly sick people who you never knew and many of them die,” said Dr. Joanna Sheinfeld, a second-year resident in internal medicine at Mount Sinai.

“The I.C.U. is incredibly hard and there are nights when you think, `What am I doing here? Who am I helping?’ You are too busy to feel like you are helping anyone. And then you start these home visits and it’s like a breath of fresh air.”

On a warm Tuesday morning in October, Dr. Mun, Mrs. Morales’s home physician and an attending physician at Mount Sinai, lugged a canvas backpack filled with medical records, a stethoscope, prescription pads and other medical necessities. In tow were three second-year residents, including Dr. Sheinfeld.

First stop was the Morales home. Next was a woman in Harlem with severe multiple sclerosis, and last was an elderly woman on the Upper West Side of Manhattan. Dr. Sheinfeld said the month solidified her decision to go into geriatric medicine and to continue to make house calls.

“I really think even one house call is powerful,” said Dr. Levine, an associate professor of medicine at Boston University, who helps coordinate house call programs. “You learn to understand your patient in a holistic way; I mean that in the real sense of the word.`

Almost all the residents say the house call segment is their favorite part of their rotation, Dr. Sheinfeld said, adding, “This is the kind of medicine you imagined before you started medical school.”

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.

Bayne, 52, is part of a nascent movement to bring back the house call as a cheaper and better way to care for the nation’s frailest elderly.

The benefits seem obvious. The oldest patients often are too sick or too ornery to make a routine visit to the doctor’s office, so they forgo basic care until a health crisis sends them to the emergency room.

“There are 100 million ER visits each year, but half the time those people don’t need to be there at all,” Bayne says.

Yet these docs–a group of perhaps 1,000 among the nation’s 100,000 primary care physicians–operate on the fringes of a health care system that abandoned house calls long ago. Thirty years ago Medicare slashed fees for home visits by doctors, wiping out any incentive for them to step outside their waiting rooms. In the hour it takes to visit a single patient at home, they can juggle four in the office. Managed care, with its relentless focus on curbing costs, hasn’t embraced the house call because clear-cut data on savings are elusive.

Yet the need for the house call will only increase as the population ages. Of some 35 million senior citizens, perhaps 2 million are so old and frail they can’t leave their homes. They often get even sicker in the hospital–and rack up big bills. The sickest 5% of Medicare patients consume 52% of Medicare’s annual outlays (which totaled $211 billion in 1998).

Caring for the sickest elderly will get even more expensive as their numbers explode in coming years. Some 16 million Americans are age 75 or older; their ranks will grow by an additional 2 million in ten years and could soar past the 30-million mark in three decades.

Once an elemental part of medicine, the Rockwellian house call lost its purpose in the 1950s with the advent of penicillin and the modern hospital. The Medicare system, established in 1966, saw no need for doctors in the home and set reimbursement rates so low that house calls stopped overnight, Bayne says.

As recently as 1997 Medicare paid skilled nurses more than doctors for at-home care–about $100 a visit, compared with just $60 for a doctor. Bayne started his house calls in 1985 but only recently has been able to break even, thanks to changes in Medicare payments.

Technology helps. Bayne can handle all but the most-life-threatening ailments, traveling in his yellow Ford van emblazoned with “1-800-Call-Doc,” and equipped with an X-ray machine (with a 90-second developer), a blood-gas analyzer, an EKG and a cardiac-output machine.

Even low-tech intervention can be immensely useful. Dr. Eric Baron, who heads a house-call practice in Southfield, Mich., tells of a 78-year-old woman with congestive heart failure who was hospitalized six times in the past year. Her primary care doctor was baffled by her worsening condition. Baron visited her at home and discovered she was cooking with seven types of seasoning salt, in defiance of her doctor’s orders.

All house-call doctors have stories like these; what’s missing are large, controlled studies that lay out hard economic and medical benefits. “It’s hard to get respect if you don’t do a randomized study,” says Dr. Bruce Leff, a geriatrician at Johns Hopkins Bayview Medical Center in Baltimore. He ran an experiment that produced interesting, if unrandomized, results: 17 patients who were cared for in a “home hospital” got well at 60% of the cost of a similar group of hospitalized patients.

Absent data to the contrary, some geriatricians and HMOs doubt a house-call strategy would cut down on trips to the hospital for the weakest elderly. “I don’t know that it would be a big enough intervention to prevent the crises,” says Dr. Richard Della Penna of Kaiser Permanente in southern California, with 280,000 elderly members.

House-call compensation has gotten a boost in the last two years, thanks to the efforts of the American Academy of Home Care Physicians, a 700-member group. Rates for treating the sickest patients have doubled, to $180 for a new patient, $145 for an established one, about on par with office payments. But travel time still isn’t reimbursed, and equipment coverage is meager.

“It’s still very difficult to break even,” laments Dr. Thomas Cornwell. His practice in Carol Stream, Ill. makes 300 house calls a month but will run losses of $80,000 this year, despite subsidies from the local Central DuPage Health system.

But in San Diego, Dr. Bayne thinks his business has turned the corner. Last year he garnered $5 million in venture capital, enough to pay eight doctors and four nurse practitioners. He has hired a new chief executive, Hank P. Fanelli, and marketing and development pros. For the first time, the practice is turning a small profit on $1.5 million in billings. “The market forces are there,”Bayne says hopefully. “It’s just a question of when they’re going to bubble to the surface and break out.”

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.”

The technology allows the company, 1-800-Call Doc, to compete with other medical offices. In just one year, business has doubled to about 1,200 house calls a month.

On the day we tag along, Bayne is visiting 99-year-old Robert Mahaffey’s, who was complaining of weakness in his heart. The patient learns right away what’s causing the problem and so does his regular doctor. The results of the cardiac output test are sent by wireless phone straight to the doctor’s office.

The doctors at 1-800-Call Doc are available between 9 a.m. and 9 p.m. Patients are assessed at a central phone center and prioritized based on urgency. Emergency calls are redirected to 911. All other calls are assigned to a board certified doctor.

Average response time is about three hours, but doctors can be there as quickly as an hour.

So far, a CAT scan is not available at home, but a portable MRI is in development.

The costs are reasonable and many insurance plans – including Medicare – will pay. If you are in a PPO and pay 20 percent, it is actually cheaper than the emergency room.

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.

Qualcomm, Cardiodynamics, and Call Doctor are all San Diego companies backed by original institutional investors.

To our knowledge, this is the first time in history a human’s cardiac output has been transmitted through wireless means in an encrypted medical record from the home. The cost of services under Medicare assignment for the 47 minute housecall was:

Physician Level 2 home visit: $71
Cardiac Impedance study: $40
Pulse Oximetry: $8
Total cost: $119

The Call Doctor Company
www.1800calldoc.com

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.

CALL DOC physicians can provide diagnosis and treatment, from setting broken bones to providing care for chronic conditions. New technology allows CALL DOC physicians, nurses and technicians to offer:

• In home X-Rays, EKG
• Lab tests: Blood Chemistry, Urinalysis
• Medications in your home
• From broken bones to treatment of chronic conditions
• About 1/3 the cost of an emergency room visit

With many criticizing health care today for becoming increasingly impersonal, CALL DOC is a welcome change. Already CALL DOC is handling over 750 housecalls each month and expects to see that number double by the end of 1999. CALL DOC has plans to open offices throughout the country over the next five years.

CALL DOC has provided services for several famous San Diegans, most notably Dr. Benjamin Spock and, Dr. Bayne, the company’s President and founder, personally assisted on Air Force One while George Bush was in office, which led to additional CALL DOC recommended medical equipment to be installed on the Presidential aircraft.

For more information on 1-800-CALL DOC contact our customer service division at 1-800-CALL DOC. That’s 1-800-225-5362.

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.”

Welcome to pocket-size medicine. The revolution in micro-electronics that gave us cellular phones and palmtop computers now allows doctors like Bayne to take their healing arts out of the hospital and onto the road. The result: fully functional EKG machines no bigger than a box of chocolates; blood-sample analyzers no larger than a princess phone; portable ultrasound machines that fit in the truck of a car. There is even a hand-held MRI scanner in the works that is about the size and shape of a catcher’s mitt. And last week the U.S. Food and Drug Administration approved a paperback-size automatic defibrillator that can shock a stopped heart back into a normal rhythm.

Bayne took full advantage of the new technology that Sunday morning in Point Loma. Although he could not feel a pulse at this patient’s wrist, he was able to determine that is had fallen from a normal 80 beats a minute to 38 by placing a digital pulse monitor the size of a lemon on the woman’s finger. He then touched her chest with a portable EKG machine and analyzed her cardiac rhythms. Had there been any indication that she was suffering a heart attack, Bayne would immediately have called 911. When he determined that wasn’t the case, he decided to perform a battery of blood tests.

No sooner said then done, from the woman’s wrist the doctor drew a sample, injected it into a tiny sassette and snapped it into a hand-held blood analyzer. Within two minutes, all readings came up normal. There was no sign of dehydration, anemia, insulin shock or dikney failure. “in a standard emergency room, it would have taken me 30 minutes to an hour to get those test results,” Bayne says.

Questioning his patient, Bayne finally deduced that a prescription drug she was taking had caused her heart to slow, decreasing the flow of oxygen to her brain and sending her into a faint. That settled, he administered a stimulant called atrophine to strengthen her heartbeat. Total elapsed time from pew to recovery: eight minutes, just about as long as it would have taken to get her to the emergency room in an ambulance.

It would be impractical, of course, to put a doctor in every church – or even on every street corner. Buy Bayne has an answer for that. He is one of the founds of the Call Doc Medical Group, five well-equipped physicians and three technicians who work through a central dispatcher to bring their high-tech tools to elderly, homebound and disabled patients. San diegoans can just pick up the phone and dial 1-800-call-doc to patch through to one of the group’s physicians. If the symptoms are not so dire that they require a call to 911, one of Call Doc’s physicians can be on the scene within a few hours. Average cost per call is $150, which compares quite favorable to a typical $350 charge for an ambulance and anywhere from $1,000 to $3,000 for a visit to the emergency room.

Call Doc is not the only doctors’ group taking advantage of the new flexibility the miniature equipment affords them. Similar associations are forming in Tampa, Florida, and Palm Springs, California. Patients appreciate the service, and the physicians seem to enjoy providing it. “Now that I can make house calls,” says Bayne, “I feel like a doctor again.”

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?

Following the World Wars, surgeons came home with new techniques and procedures which saved lives and preserved limbs, which had simply been loped off in years past. But such techniques required rapid treatment and complex machinery delivered by teams of health professionals. Ambulances and helicopter evacuation systems were invented to transport trauma patients in the civilian world to major hospitals growing up in the 1950s around the concept of high-tech care. It simply wasn’t possible to do blood testing, transfusions, Xrays, and procedures requiring anesthesia outside of the “Medical Centers.”

In 1963, President Johnson signed the Medicare legislation changing the course of history forever. With this single act, the government because the insurance company for the elderly, the disabled, and the destitute. Thus, payment no longer was controlled by the patient and the perception of value in physician services. Physicians, who originally fought hard to prevent the Medicare legislation, quickly found out that office visits could be performed much more lucratively than housecalls, which lad never received payment attention in the Medicare system.

From 1963 to 1998, the performance of housecalls disappeared from the lexicon of physician services. Why would a physician take an house to run out and make a housecall for $44 (the payment in 1985), when they could receive $40 each for 6-10 patients coming to their office in that same hour under the Medicare out of the $40B budget for physician services, totaled a mere $57M (a little over one tenth of one-percent).

Physician cited two reasons for the decline, in addition to the obvious economic one. First, the quality of care required by modern standards used a high degree of objective testing (lab and Xray) to corroborate their clinical opinion. Secondly, the massive increase in litigation spawned a “defensive medicine” mentality further requiring testing as a protective function for the physician, as well as the patient.

Then, massive change came, again through government intervention. In 1973, President Nixon signed legislation which began the NMO phenomenon, forcing seniors into managed care plans to avoid a monthly co-payment and 20% of the fee-for-service charges by physicians. Healthy seniors found economic benefit from the lack of additional premium payments to their Medicare benefit. More importantly, managed care organization began a massive education campaign for physicians going back to the prior philosophies that 85% of the diagnosis is in the taking of a history. Translated: you don’t need to do so much testing, especially if the ERISA statute can be used to prevent you from being sued most of the time.

Parallel to the dramatic reduction in testing and increase in ambulatory visits, ostensibly for “preventive health” check-ups, another revolution was brewing: the technology revolution. During the late 80s and 90s, new instruments were designed that replaced the big, hospital-based machines required for testing most critical lab values. Portable Xray and EKG machines became lighter, cheaper, and simpler to use. Modern versions were so simple a physician can act as doctor, lab tech, and nurse all at the same time, saving personnel costs and redundancy of visits to recheck the patient’s lab tests.

Using lab instruments the size of a telephone, results are known at the “point of care.” Treatment decisions can be more timely and perhaps of better clinical benefit. It seemed intuitively obvious that starting antibiotics for pneumonia a day earlier would yield better outcomes. Taking the Xray to confirm or rule out the pneumonia at the time of an initial housecall might, presumably, save the life of the patient to fearful to go to the emergency room.

But there was a problem in taking these concepts to their logical conclusion: delivery of care in the home for those patients too sick to get to the office: Medicare still paid less than the cost of the service as recently as 1997. As a backlash from the abusive billing practices under the fee-for-service system, Medicare officials were hardened to the concept that anything new could save money or be better. Various proof standards, never before required for clinical services, became de riguer for Medicare consideration of payment: outcomes studies, reasonableness tests, cost-effectiveness studies, all must be used to prove a new concept. And, since physicians didn’t make housecalls, how could one generate the data?

Fortunately, there was a small group of evangelical physicians under the non-profit organization of the American Academy of Homecare Physicians, who believed care in the home had real applications in modern times, as well as ancient. Although few made housecalls in any number, they made enough, and dealt with home health nurses enough, to remain convinced that home-based treatments were both cost-effective and safe.

From 1995-1997, the ASHCP because highly visible as the lead organization of a consortium of professional medical societies asked by the health Care Finance Administration and the American Medical Association to redefine the housecall, and adjudicate a new valuation based upon the 1989 OBRA standards mandating Physician Payment Reform.

As a result of this massive undertaking, both political and administrative, HCFA dramatically increase the payments for housecalls in both 1998 and 1999. The highest payment for a new patient housecall in an emergency went from around $67 to over $170 with these changes. This change reflected a national physician approval of the expense of delivering a housecall, as well as that of the HCVFA. However, HCFA chose to delete the time of travel to and from a patient’s home from the reimbursement equation, so physicians are still delivering uncompensated services when making a housecall. In addition, the payments for housecalls to rest homes was not changed at all, so the most physically-challenged seniors, required 24-hour care support, are still being seen at fees less than $60, on average. In sum, however, the economic rationale for physicians NOT making housecalls has been removed.

Numerous other changes in law and regulation have been passed, which, presumably, should support the public” intense desire to have housecalls when they are really sick. HCFA now required payment without debate for emergency services when, in the eyes of a “prudent layperson,” they patient feels they need immediate physician attention. This payment is not restricted by statute to the emergency room.

New instrumentation now allows non-invasive measurement of critical heart function identical to techniques formally requiring intensive care nursing. Patients who “bounce back” to the hospital after a “quicker and sicker” discharge must be treated without further payment to the hospital by Medicare, and housecalls have been shown to reduce the number of bounce-backs. Later this year, Medicare will begin bundling the payments of post-hospital home health for the first three days into the original hospital payment, but not physician housecalls. Clearly, there is increasing reason for the public to take notice of the rationale for physician housecalls.

So, the obvious question is why did the number of physician housecalls remain unchanged in 1997 and 1998? The answer is: physicians have no awareness of the technology, the new payments, the public demand, and the intrinsic value of restoring the sanctity of the doctor-patient relationship in the home.

The majority of younger American physicians are salaried, and expect integrated healthcare employers to make their delivery systems’ decisions for them. These managed care companies are slow to act for obvious reasons: housecalls attract and retain the sickest and most infirm patients in the population; those which cost the HMO the most. Few, if any, systems exist that demonstrate the cost-effectiveness of home care in general and physician housecalls in particular. Finally, the ten-year-old attack on home health for abusive practices “taints” homecare services delivered by physicians with the same, questionable brush of overutilization of services. If physicians make housecalls and the seniors what them to, won’t they be incentized to make too many? The public should be aware of and plan to control all of these factors.

I believe we are at the crest of a dramatic new public, grass-roots movement whose direction can only be predicted by the public’s demand for a value-added proposition from the physician community. When the public finds out that physicians can safely and profitably see them in the home, performing immediate lab tests and Xrays as necessary for final diagnosis and treatment, they will ask one more question: how much does it cost? Under today’s Medicare assigned charges they costs typically average under $200 for moderate emergencies, and under $400 for complex emergencies. That is less than the cost of an ambulance ride to the emergency room.

When the public demands the housecall service by paying up front, in order to save money from their deductible or co-pay to a hospital emergency room, or to attain better service than their HMO is providing, they physician community will respond. And when the physicians make that first housecall, they will see the immediate value of a mutually volitional interaction in the privacy of one’s home: our patients will trust us again, as they did for four thousand years.

The technology industry has built us the new machines; a small group of physicians has demonstrated their value in housecalls; even the government has recognized the value of more than doubling the payment for physicians in the home.

The rest is up to the public.

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.

The problems in the home care market are reflected in the performance of publicly traded home care stocks. The Home health business Report Stock Index dropped 14% from its close in June, 1998, and the HHBR Home Health Services Index was down 19.8% during the same time period. Losers led gainers 6-to-1 in the publicly traded index. The biggest surprise came from on large national pediatric home care company whose stock dropped 78.8% (from 512.22 to $3.28) in one day of trading after publishing an unexpected poor earnings report. As a whole, revenue is ip at most home health care companies but earnings are down reflecting difficulty in integrating previous mergers, increasing business at lower margins, and a decrease in government reimbursement for home health services.

Much of the nervousness in the public markets is centered on the Health Care Financing Administration’s (HCFA( implementation of the Prospective Payment System (PPS). HCFA was charged by Congress to develop a more cost-efficient means to reimburse for home care services in order to curb the growth in home health expenditures. The current cost-plus system of reimbursement did not promote cost-efficiency in the delivery of home care services. The PPS will provide a capitated-type of reimbursement to home care companies based on historic utilization rates and regional cost difference. The PPS will certainly reduce reimbursement to medicare home care agencies and potentially discourage new home care companies from entering this market. The effect for physicians and their patients would be fewer home health agencies to choose from and higher rates charged to private payer insurance plans leading to higher deductible payments for patients and their families.

The implementation of PPS has been delayed until after HCFA finishes its Year 2000 computer problems. In the meantime HCFA has implemented an Interim payment System (IPS) which will be a transitional payment formula until PPS is in full effect. The IPS has been met with significant criticism by the hone care industry because of consequential reductions in home health reimbursement. The IPS capped payment at the lesser of a percentage of an agency’s historical annual reimbursement or a historical national median level in addition to capping per beneficiary payments.

Home care agencies who cared for the sickest patients or who historically provided more efficient care were the most adversely affected by this change in reimbursement. The IPS has been blamed for the closure of 763 (according to the GAO0 or approximately 1,000 (according to NAHC) home care agencies nationally. Congress is currently investigating ways in which to alter the IPS formula in order to relieve the critical reimbursement burden to many home care agencies.

In addition to the reimbursement issues, the federal government has also undertaken an investigative project to eliminate fraud and abuse in the home care industry. Operation Restore Trust (ORT) was launched last year with the intent of saving the federal government billions of dollars in fraudulent home care billing practices. The ORT has been successful in meeting its goals but many upright home care companies have been caught in its crosshairs.

Similar to HCFA’s investigation into university faculty hospital billing practices, some home care agencies have been accused of fraud for honest filling mistakes or for misunderstanding complicated Medicare billing rules. Additionally, the Office of Inspector General (OIG) has launched a compliance program for home care agencies, similar to its billing compliance program for hospitals, which seeks to institute elaborate safeguards to prevent fraudulent billing practices. Some estimate that it will cost a home care agency over $50,000 to comply with all of the OIG guidelines. This expensive compliance program has been viewed as economically detrimental to many small community-based home care agencies.

The final regulatory blow for many small home care providers has been the requirement to purchase a surety bond which would be used to guarantee repayment of overpayments to medicate. Unfortunately the bonds were difficult to obtain, and when they could be obtained they were very expensive and required personal guarantees on the part of agency principals. This regulation was net with an outcry equal or greater than that leveled against the IPS, and has since been suspended until HCFA can change the regulations so that more home care companies can obtain these bonds.

Although most pediatric home care agencies do no receive Medicare reimbursement, they are still expected to meet the same HCFA requirements as adult home care agencies. Pediatric agencies have been somewhat protected from the decrease in reimbursement experienced by Medicare agencies because the federal and state governments have been working to increase reimbursement for health care for children through the Medicaid program in accordance with the Child 200 projects.

These agencies that have focused more on private insurance payers have found themselves dealing with other important reimbursement issues. The greatest problem has been assuring timely reimbursement from managed care payers. The healthcare industry traditionally has been very slow to pay providers compared to other types of industries. In home healthcare, however, the time to collect receivables has been greatly prolonged so that having an average days of receivables outstandings past 100 days is considered normal. Even some large national home care companies with information system resources has struggled to decrease their outstanding receivables to less than 110 days. This delay in payment has a tremendous impact on an agency’s available cash flow and increased the costs of providing services.

As is typical in a service industry, home care survives on a small profit margin. Typically, the home care industry has achieved profit margins of 5 to 10%. These margins are quickly eroded, especially in smaller agencies, when resources are directed to meet additional regulatory requirements or to fund accounts receivables. The turmoil in the home healthcare industry has put many financially marginal providers out of business and has made it more difficult for the remaining providers to meet their financial and clinical goals. As companies struggle to survive, less emphasis will be placed on developing clinical programs to meet the needs of a growing home care population.

I believe it is important that physicians are aware of the type of agency that they are referring patients to. If the agency is experiencing serious financial problems then the quality of care may also suffer. Recently, a large regional pediatric and adult home are provider on the West Coast closed its doors after struggling for over a year to meet regulatory and financial obligations. The patients were left without home care services once it closed its doors and many families had to scramble to find alternative arrangements.

Physicians should work to build an alliance with their home care providers in order to assure that the needs of their patients are being met. Physicians play an important role in helping a home care provider keep in compliance with statutory regulations. Physicians should talk with their home care agency staff to determine how they can help keep them in compliance with all regulations. Physicians may also be able to assist by appealing claims that have been denied by government and private payers. Physicians who use a significant amount of home care services may want to participate on an agency’s Professional Advisory Board or Governing Body. These boards, established by Medicare regulations, have the ultimate responsibility for assuring effective, efficient, appropriate, and adequate services to meet the needs of the patient population served by the agency.

Home Health Agency Closings in 1998

Total 1,032

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.

The periodicity of house-calls has never been studied, but some recommendations and observations can provide guidance. The American Geriatric Society has published statements that the care of geriatric patients in the office, which presumes a mobility and mental status that may be quite a lot better than your mother’s, requires 10-12 visits per year, or roughly once monthly. A unique frail elderly practice in Orange County, California supported by For Health corporation, assumes complete financial risk for their patients, paying all costs of care, whether in the hospital or not. They have told me that over the past five years, they have found the most dramatic reduction in overall cost of care is not achieved until they average NINE visits monthly to this population. Their patients may be sicker and more infirm than your mother, as all of their patients qualify for placement in a skilled nursing facility.

In summary, it is reasonable to expect monthly visits for treatment of dementia-related problems, monitor the many chronic conditions of the elderly, and to prevent untoward medical events; however, the intimacy and power of the physician house-call comes from the mutual trust that must be the foundation of all quality care. If you feel your physician is not providing services based upon what is “medically reasonable and necessary,” you are encouraged to discuss your issues with the doctor and expect frank and understandable explanations.

- Gresham Bayne, MD