By Amy Tsao
Doctors aren't afraid to say it: Practicing medicine has never been more difficult. General practitioners are under intense pressure to see dozens of patients daily. Because of an overburdened health-care system, many say a once-personal business has shifted to a hand-on-the-doorknob, quantity-over-quality model.
"The medical system has evolved around the financial demands of medical technology rather than focusing on the best ways to serve the needs of the patient," says Eric Baron, a physician based in Southfield, Mich.
As a result, a growing number of disenchanted doctors are finding a respite in a vestige of decades past: house calls. For each of the past three years, the total number of house calls has grown by 100,000 a year, according to Constance Row, executive director of the American Academy of Home Care Physicians. Some 1.8 million were made in 2003.
Why the continued increase? The health-care system, built around hospitals and physicians' offices, isn't set up to take care of frail, homebound elderly -- as many as 1.5 million patients over the age of 65. So the people who need doctors most aren't seeing them regularly. And when they do get medical attention, it's often to treat a high-cost event like a stroke or heart attack. "This is a neglected population," Row says.
The economic impact is significant: The sickest 5% of the elderly population accounts for more than half of Medicare's budget. While a house call costs Medicare at most $200, an emergency-room trip runs at least $1,000.
House calls were common a generation ago, but the impracticality of traveling long distances from patient to patient drove them to near extinction. Lately, however, doctors have found ways to make the business viable again. Medicare payments, though creeping lower, are sufficient to turn a profit on the practice, if the patient meets their strict definition of homebound.
BEYOND THE BLACK BAG.
Some home-visit practices are one-doctor operations, others are aligned with academic hospitals that have large teaching components. While most are based in densely populated cities, some are finding success in suburbia. (A directory of home-care physicians, physician assistants, and nurse practitioners by state is available on the American Academy of Home Care Physicians Web site.)
Modern technology has also helped the resurgence. Eric DeJonge, Washington Hospital Center's director of geriatrics, says he and his colleagues bring along a computer, portable devices that can measure blood oxygen, a device to administer electrocardiograms (EKGs), and wound-treatment equipment -- a far cry from the doctor's little black back of yesteryear. "Our cars are our offices," says DeJonge, who plans to add electronic medical records sometime next year.
Among the most successful ventures are hospital-supported projects like Mount Sinai Hospital's visiting doctors program in New York. A dozen physicians take care of some 800 patients in their homes all over the city. The program was formed in 1996 by a group of young, frustrated physicians. "We sat down and were wondering what we could do to feel better about being doctors," says David Muller, co-director and one of the program's founders. Performing house calls "was one of the crazy ideas we had."
Not too crazy, it turns out. Hospitals have found the services pay for themselves and can reduce costs down the road because patients get better care earlier. Both Muller and DeJonge say their hospitals' respective programs are profitable. In part, that's because the demand is consistent -- about 20 new patients sign up for DeJonge's program each month. "There's an endless supply of patients who need the service," says DeJonge, noting that one of the fastest growing populations in the country is those over age 85.
At Washington Hospital, the average length of stay for normally homebound patients used to be 8 days. That figure declined to 5.6 days after the house-call program started. "Because we take such close care of the patients, they don't get stuck in the hospital" for longer than necessary, says DeJonge. He has already duplicated the program in five other hospitals, and he plans to expand nationwide.
Others have found success in building physician groups. Founded in 1995, Baron's practice, House Call Physicians, comprises five full-time physicians, with supporting staff, computer specialists, and a small fleet of cars. The company coordinates with various health agencies, covering patients across three counties in suburban Detroit. "It's a powerful answer to the needs of certain elderly patients with chronic illness," Baron says.
Some physicians are going the distance alone. Andrew Lyons, who has been doing house calls in Manhattan for the past four years, says getting out in the field has been far more fulfilling than the typical office-based practice. "My relationships with patients are a lot more intimate," he says. "To me it's more of a vocation than a business."
Making 1,000 to 1,200 visits a year, Lyons earns about $160,000 in house-call revenues and an additional $40,000 or so in referral revenue to a community hospital. After deducting student-loan payments, malpractice insurance, and equipment costs, he's left with about $120,000 before taxes. "Your income is limited to what you can do yourself," says Lyons. With travel time, he sees five patients a day, on average.
Despite their increasing popularity, house calls aren't immune to the ongoing pullback of coverage. Private insurers seldom cover home visits. And reimbursements by Medicare -- the main payer for house calls -- are declining, Lyons says. A house call for which he would be reimbursed $139.12 this year will be worth $129.38 in 2005.
Lifestyle issues also have to be considered. Ann Scheetz, a geriatrician based outside Chicago says her three-year-old house-call business is viable only with help from her retired husband, who handles the finances and office administration. She brings in $145,000 annually, but spends about $36,000 on overhead.
"We take all of our own calls, we don't take vacations, we don't leave town," Scheetz says. She currently has 80 patients, making an average of six visits daily. Traveling as far as 35 miles, Scheetz spends about two or three hours a day driving.
House calls are still knocking at the door of mainstream medicine, but it may be the doctors themselves who change that: Despite a myriad of challenges, a growing number of physicians are finding the rewards well worth the sacrifices.
Tsao is a reporter for BusinessWeek Online in New York
Edited by Rod Kurtz