Once seen as luxury available only to the wealthy and privileged, house calls are getting a second look by legislators interested in exploring their potential to keep emergency department visit and hospitalization costs under control.
Rolled into health reform bills is the Independence at Home Act (H.R. 2560/S. 1131), which would create a 3-year pilot program to offer home care to Medicare beneficiaries who have high-cost chronic health conditions and also need help with such activities of daily living as bathing and dressing. The program would operate in 26 states and the District of Columbia.
In return, physicians and other health care providers who help save Medicare a minimum of 5% in hospitalization costs and who meet certain patient satisfaction and performance standards would be eligible for a percentage of the savings above the 5% threshold.
If enacted, the pilot program could help draw attention to the benefits of home care and spread the model, said Constance F. Row, executive director of the American Academy of Home Care Physicians.
The IAH “is a very good step and it should provide incentives for practitioners, but you have to be careful and document very conservatively,” noted Dr. Jeffrey Katz who spent a decade working as an emergency physician before leaving the hospital to start Physicians' House Calls, which provides primary care to patients in their homes. His goal: to reach people before they get sick enough to need emergency care.
House calls have the potential to provide better and lower-cost care for homebound or noncompliant patients who typically come to the emergency department only when their conditions have significantly worsened, said Dr. Katz.
When Dr. Katz started Physicians' House Calls to provide care to residents in central Maryland in 1999, he was building a practice from scratch. But he was able to make the practice financially sustainable in only a few months. “The need was profound,” Dr. Katz said. “There were so many people who really wanted this service.”
He originally offered the service to Medicare patients, but with the federal government cutting payments to Medicare physicians, it quickly became difficult to sustain the model, he said. More recently, Dr. Katz teamed up with Amerigroup Corp., a managed care company that coordinates care for Medicare and Medicaid beneficiaries in several states. He treats a group of Medicaid beneficiaries in Maryland who are heavy users of emergency department services. Dr. Katz said that the primary care he provides these patients helps avoid costly hospitalizations and trips to the ED.
In a cost analysis conducted by his firm in 2001, spending $109,013 on 485 home visits for 57 patients (at $225 per visit), helped avoid spending an estimated $138,000 on emergency department visits (at $1,200 per visit). In addition 132 hospitalizations were avoided, saving an estimated $1,188,000, at $9,000 per admission.
Kent Jenkins Jr., a spokesman for Amerigroup, said the work that Dr. Katz does is part of a larger push within the organization to bring primary care to patients with chronic illnesses. Within Amerigroup, case managers try to identify people who would benefit from home visits or other interventions. One of the typical red flags, Dr. Jenkins said, is someone who has been repeatedly hospitalized for the same underlying condition. “That's just a clear marker that something is wrong here,” he said.
The managed care company might recommend a range of options depending on the patient's needs, such as providing transportation to appointments, receiving prescription drugs through the mail, or having home visits from a physician. The overall program, including the house calls, has been a success in terms of care improved care and reduced cost, Mr. Jenkins said. While Amerigroup hasn't done a study on the effect of these interventions, he said that generally they have seen reductions in visits to the ED and inpatient admissions.
While Amerigroup views home visits by physicians as good business, other insurers have been slow to embrace the concept, said Constance F. Row, executive director of the American Academy of Home Care Physicians. Currently, most home visits are made by a small group of physicians who work with physician assistants and nurse practitioners to see Medicare fee for service patients. The Department of Veterans Affairs also has a home-based primary care program for its patients.
Payment is one of the major barriers to providing more home care, Ms. Row said. The current Medicare reimbursement for home visits in most parts of the country does not cover full costs, she said.
For example, travel time isn't a covered expense. To make a home care practice viable, physicians have to become extremely efficient or get a hospital system to provide a subsidy for the work, she said.
Aside from the cost issues, there's a general lack of training in home care. Another challenge is that physicians providing home care have to become mobile medical providers, which means having an electronic medical record and carrying miniaturized diagnostic equipment, Ms. Row said.
But challenges aside, home care isn't for all physicians. Unlike in the office, the physician isn't fully in charge when they are working in someone's home. To be successful, they have to learn to adapt, she said.
“The physicians who do this—and there are many family physicians who do—are people who are not just technicians, but people,” Ms. Row said. “They have to have both sets of skills to be successful.”
But Ms. Row said she is hopeful that at least some of these issues can be addressed by Congress through the IAH legislation.
In the meantime, Dr. Katz is continuing to refine his practice model. On a typical day, he works about 10-11 hours each day, which gives him time to see 7-8 patients, travel between visits, and do some administrative work. He visits each patient at least twice a month. He also gives his cell phone number to all 150 patients in his practice.
Setting aside time for longer visits is essential, he said, because these patients need comprehensive care. The average patient in his practice has 5-10 diagnoses and in some cases has other issues that complicate care, from a history of drug abuse to having been victims of violence. But this patient profile is familiar to him from his time in the ED.
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