Physician Housecalls: It is Time for the Public to Act!
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?

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.