When Simon Jacobsen’s aging mother needed to see a doctor, she first had to descend the stairs — a journey that once left her with a broken neck. After that, Jacobsen and his father carried her down themselves, but their method was hardly graceful.
“We were just a couple of gorillas doing the best we could,” says Jacobsen, a 49-year-old who lives in the District of Columbia. Meanwhile, the care his mom received was fragmented, time-consuming and physically and emotionally exhausting for the entire family.
“It just got to a point where we realized we couldn’t move this person, but we also believed that she didn’t belong in a nursing home,” Jacobsen says.
So Jacobsen’s father called Dr. Ernest Brown, a 47-year-old family physician in the District of Columbia who runs a house call-only independent practice. Until Jacobsen’s mom’s death about five years later, Brown served as her primary provider, coordinating with other doctors for more specialized care, driving her to the hospital himself and eventually setting up a type of in-house hospice care. Some weeks, he visited every day.
“I think this is care that everybody deserves,” Jacobsen says.
For Brown — who’s tough to miss in blue scrubs with “House Call Doctor” embroidered on the back and a classic black medical bag in his hand — one of the most rewarding aspects of his job is being a part of the community. “I feel like I belong,” he says between calls last week, while sipping a cappuccino at a local Turkish restaurant — whose staff he treats.
Brown cares for many hotel guests, including visiting heads of state and tourists, as well as low-income, elderly people whom he sees pro bono. He also treats airline employees, hotel concierges and a wide circle of friends — nearly all within a few mile radius of his apartment. “I really don’t have to go but a few blocks to do what I do — provide care,” he says.
Brown is a rarity among an already small cohort of doctors. Only 13 percent of family physicians surveyed made regular house calls in 2013, and only 3 percent made more than two per week, according to the American Academy of Family Physicians. Even fewer run practices like Brown’s that are exclusively house calls, says AAFP’s president, Dr. Robert Wergin, a family physician in Milford, Nebraska, who goes on a couple house calls each month.
Still, the historic practice of seeing patients in their homes may be making a comeback, says Dr. Justin Davis, a primary and urgent care doctor in San Francisco who typically sees a few house call patients every day in addition to treating people in his private practice.
“When I first started [making house calls] 10 years ago, it was even more unheard of,” he says. “Now, there’s a paucity of it in actual practice, but there’s a lot of talk about it. It’s becoming more in people’s consciousness.”
A Personalized Experience
The concept of a doctor coming to a patient rather than a patient going to a doctor is hardly revolutionary. In 1930, about 40 percent of doctor-patient interactions were through house calls, but by 1980, the rate was down to 1 percent, according to a Clinics in Geriatric Medicine article. “It used to be the norm, and the norm was decency,” Jacobsen says. “[Dr. Brown’s care] is an act of incredible decency that seems so foreign to so many people now because they’re just not used to it.”
From a patient’s perspective, summoning a doctor to your house has plenty of appeal: No waiting rooms, traffic or skipped work. No dragging a sick and tired body out of bed to see a doctor whose prescription is to go back to bed. No feeling like a number.
Patients are looking for “a personalized experience,” Davis says. “They want to feel like they’re with somebody who knows about them, or at least cares about them, and can give them time and really listen to them.”
For doctors, aspects of the practice are attractive too: more satisfying patient interaction and the ability to see how patients live. “There’s nothing like going into the home saying, ‘This is what their environment looks like,” Wergin says. “If there’s food that’s old on the counters, if it’s just in disarray, that tells me … that maybe they’re going to need more help.”
The health care system also seems to benefit. A study last year in the Journal of the American Geriatrics Society found that Medicare costs among 722 elderly patients in a house call program were $8,477 less on average per person than costs among a group that didn’t receive house calls over two years. The house call group also had 9 percent fewer hospitalizations, 10 percent fewer emergency department visits and saw specialists 23 percent less.
While house call patients in the study saw generalists more than twice as often as the other group, those visits still saved the health care system money since specialists’ care is usually more costly. For Brown, the chance to prevent illness is key. He can track the origin of a restaurant worker’s sickness, for instance, because he knows the employee’s lifestyle and colleagues. He can also predict who else may get infected — and then try to prevent it. “I can do more here than I ever could in a clinic,” Brown says.
What’s the Hold Up?
Despite the benefits, there are logistical barriers to making house calls more widespread among physicians. And of course, not all medical issues should be handled at home. “Sometimes the office setting is good because then you have your whole team there,” not to mention more equipment, Wergin says.
When house calls are appropriate, physicians who make them can take the hit in their paycheck, since they’re predominantly paid for the number of patients they see and the number of procedures they perform. Doctors who travel to patients’ homes simply can’t pack in nearly as many visits as doctors who have patients come to them. And, while most insurance companies do reimburse for house calls, they’ll only do so if there’s a medical reason why the patient can’t or shouldn’t visit an office instead.
For some house call doctors, it’s easier to deal outside of insurance networks altogether. Davis, for one,charges new patients a minimum of $250 for an office visit and $450 for a house call, which they can pay out of pocket or submit to their insurance company for reimbursement. With this model, he sees anywhere from four to 18 patients a day. A primary care doctor in an office-based practice, on the other hand, might be expected to see up to 40, he says.
Brown also eschews insurance. “Anytime an insurance company comes in, I get hives,” he says. He charges patients on a sliding scale based on the care provided, length of the visit and the patient’s financial situation. And no patients are charged until they’re healthy. As Brown told an inquiring German hotel guest whose wife was bedridden with either food poisoning or gallstones, “I charge [patients] when they get better.”
Brown’s setup pays his bills and satisfies him, but it wouldn’t work for all doctors interested in making home visits. “While it can certainly be financially rewarding for physicians to give up their current way of doing things or go out of their practice and sort of strike out on their own, doing this can be very daunting,” Davis says.
But as the Affordable Care Act is implemented, that prospect may be a little less so. The law penalizes hospitals for high readmission rates — something house calls can help avoid — and shifts Medicare from a volume-based, fee-for service system to one that also depends on quality of care, Wergin says.
“That’s where telemedicine — and maybe even home visits on occasion — come in,” he says. Wergin predicts an increase in virtual house calls through technologies like Skype, while Davis expects to see more nurse practitioners and physician assistants offering house calls at a lower price point than physicians.
“It’s difficult to say how that will pan out, but I do think there’s a definite trend toward expanding health care,” he says. “Physicians and patients alike are both looking for a better health care experience, and I think this is definitely one of the avenues you’ll see more of.”
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Is the House Call Doctor Coming Back? originally appeared on usnews.com
