Is There A Doctor In The House?

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.

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."