Hi Its your Doctor PDF Print E-mail

From the New York Times September 5, 2013

By EZEKIEL J. EMANUEL

MY father, a pediatrician, kept all his medical equipment in a black leather bag. He used to take it on house calls. My brothers and I would frequently tag along to watch him treat patients. He would remove stitches from over an eye or look into a throat and ears, providing a few pills to start a regimen of antibiotics for an ear infection.

Sometime in the late 1960s, he stopped making house calls. Instead, my father began routinely sending patients to the hospital emergency room.

And he wasn’t alone. In 1930, house calls accounted for 40 percent of physician interactions. By 1980, that number had dropped to 1 percent.

But after a half-century, the house call is making a comeback. The available data on house calls are spotty at best. But one study estimated that in 2010, about 4,000 physicians conducted more than two million house calls. Some do what my father did: attend to urgent but not emergency situations, taking care of people with stomach pain, fever, cuts needing stitches and the like. These kinds of urgent-care problems are best treated by a house call, but account for about 40 percent of the nearly 130 million annual visits to emergency rooms.

Companies like Microsoft and Costco provide similar house calls to their employees in the Seattle area. Carena, a private company under contract for the service, sends out doctors or nurse practitioners to assess the situation with the assistance of computer software. The software uses algorithms to help them differentiate between cases that are safe to handle at home and those that require the emergency room.

Marta Monteiro

In addition to dealing with urgent matters, the house calls let providers teach patients how to deal with chronic problems they might have, like diets for diabetics, care that is always easier in the privacy of a home. The cost is around $500 a visit, which may be covered by their employer’s health plan. Beginning in 2010, Carena began offering “virtual” house calls, allowing people to use a webcam to get medical attention. Those calls are available to both employees of companies and, increasingly, individuals who aren’t employees but who are willing to pay the $85 cost per call, less than the hundreds of dollars it would take to have a rash seen at an emergency room. According to Carena, about 75 percent of those calls are resolved via the webcam, and only 25 percent require an in-person visit with a doctor or a trip to the emergency room.

Other house calls are more like office visits, but done at home, often for frail older patients. Many of those people suffer from multiple diseases — heart conditions, emphysema, diabetes, arthritis, dementia — that make getting to the doctor’s office difficult. And those are the people whose care is often billed to Medicare, so if they don’t see health care professionals regularly, their next stop could easily be the emergency room and a hospitalization. The Department of Veterans Affairs has pioneered this kind of house call.

The Affordable Care Act began financing a project in 2012 to determine in what setting house calls can be most effective. Doctors who make house calls share in savings if they provide quality care and reduce costs.

There are small studies that indicate these primary care visits can decrease hospitalization rates by more than 60 percent and save around 25 percent in total costs — all with extremely high patient satisfaction.

A third kind of house call is really an extension of the hospital. Transitions from hospitals are fraught with problems — patients not taking medications or following doctors’ instructions — and around 20 percent of Medicare patients are readmitted within 30 days of discharge. But hospitals have had little incentive to provide care in the home after treatment because they make money from the readmissions. The Affordable Care Act now imposes penalties on hospitals that have high readmission rates for conditions like heart failure and pneumonia. To avoid the penalties, hospitals are increasingly deploying nurses on these types of house calls.

Finally there is what is called Hospital at Home. Begun at Johns Hopkins in Baltimore, this program takes patients who would otherwise be admitted to a hospital for conditions like urinary and skin infections, pneumonia and heart failure, and instead sets up hospital-type services in the patient’s home. Intravenous antibiotics, oxygen, breathing treatments, even diagnostic tests like EKGs and X-rays are done at home. Physicians visit patients each day. Nurses visit once or twice a day, and monitor the patients remotely.

Studies show that patients treated at home do just as well in terms of recovery as patients admitted to the hospital, and maybe even better when it comes to how quickly they get better and how well they avoid common complications. And they save money. In a study in New Mexico involving more than 500 patients, there was a 19 percent cost savings. In a study at the University of Pennsylvania and at the Veterans Affairs medical center in Philadelphia, there was a 43 percent savings.

So fire up your DeLorean. Health care is headed back to the future. House calls are a sign that we will all see our health care going back to the “old days” when, like my father, the doctor came to our homes, giving us real personalized medicine — and saving money at the same time.