Illustration by Keith Pfeiffer
It may seem counterintuitive, but it may well be cheaper — and better for you — for the doctor to come to you when you’re sick than for you to travel to your physician’s office.
Peter Boling has been an advocate of the physician house call since the 1980s. He’s the chair of geriatric medicine at Virginia Commonwealth University’s School of Medicine, and he started VCU’s house call program at the behest of a former administrator.
What he learned firsthand was that home visits can come with big benefits to patient health and subsequently save money in treatments. Chronically ill, elderly patients typically seen in a home visit may otherwise not seek treatment until they’re in a full-blown medical crisis. So home visits can help head off expensive and unnecessary hospital stays and treatments, while offering a better level of care, too. “I started and realized that it was a better way to do health care for people,” Boling says.
House calls were a regular part of medical practice well into the 20th century, but they fell from favor. The problem, as with most things in life, was finding funding. Medicare and Medicaid, which set the pace for paying for treatments, provided scant reimbursements for home visits.
Boling and other advocates successfully worked to have reimbursement rates nearly doubled, which in turn resulted in an increase in home treatments from about 1 million to 4 million. Boling’s team at VCU has also played a leading role in creating and working with the Independence at Home Demonstration, which seeks to provide cost-efficient, premium care for some of the oldest and sickest among us. It’s a federal program based on a team of providers making home visits, with a goal of keeping the patients in their residences and out of the hospitals. The programs that meet care standards and save money in the process get a payment bonus. The three-year program began in 2012 as part of the Affordable Care Act, and was extended through fall 2017. Advocates are seeking another two-year extension this year from Congress, says Boling.
VCU is in a consortium with Pennsylvania University and Medstar Washington Hospital Center for the program. Their work shows a 20 to 30 percent reduction in costs and significant reductions in hospitalizations.
Home care is a godsend for someone who lacks mobility. Boling says about 2 to 4 million people across the nation could potentially benefit from such a program. “We need to go take care of the people wherever they may be,” he says.
But that will take doctors, and that is a concern. Medical students tend to like the idea of home-delivered health care, but Boling notes that med students may graduate with $250,000 in financial obligations to repay, and a practice focused on house calls has to be financially viable.
“We need to solve the problems of the economics,” he says. “We’re trying to figure [out] how to make this work well for everybody.”
Caring for Kids at Home
While Boling cares for some of the oldest and sickest among us, Edward Wiley makes home visits to some of the youngest. He’s a pediatrician who in May 2017 started working from home and took his practice on the road with At Your Door Pediatrics. He contends that home visits are a great way to take time with his patients and their family members, to see what’s going on in the home, and to sit, listen and really get into it. “I’m not doing anything special, but I think I’m doing what every doctor would love to do,” Wiley says.
Wiley, who had previously had a traditional pediatric practice, says he turned to the home-visit model out of frustration with the time constraints and red tape that come with the current health delivery model.
Wiley has a fee-based service, with families paying monthly, and he does not take health insurance. Amounts vary by age and circumstance. The fee covers home visits and general pediatric services such as wellness checks, treatment for strep or ear infections, and vaccinations. Some limited lab services such as strep tests are included, and Wiley drops off any specimens at the laboratory. He does not provide emergency care, but he does coordinate care with specialists.
It’s been a gratifying switch, but one that has required some mental adjustments. He likes having a degree of control over his schedule and his practice, but there are drawbacks to no longer having an office manager. “Instead of following a list, I have to make up a list of what I’m going to do today,” he says.
It’s Urgent
Sometimes it’s more convenient to have the doctor come to you instead of making the trip into your regular physician’s office. That’s where a service such as DispatchHealth comes into play.
The Denver-based business partnered in November with Bon Secours Richmond Health System to provide at-home urgent health-care visits. You access the service via a call (804-495-0053) or an app through the website. The service is appropriate for urgent-care such as flu, urinary tract infections, minor fractures or gastrointestinal distress, but it’s not meant for medical emergencies, such as chest pain or symptoms of a stroke.
House calls are made by teams, generally a nurse practitioner or physician's assistant with an EMT, with an emergency doctor on call. Teams arrive within 90 minutes, and each spends about 45 minutes on the call. Kevin Riddleberger, chief strategy officer for DispatchHealth, describes it as a “house call on steroids.”
In its first two months, the service received approximately 130 to 140 calls in metro Richmond. A basic visit costs about $150 to $300. Services are generally covered by insurance. Riddleberger says the service helps reduce the number of emergency room visits, aids in the transition from hospital to home and reduces the chances that a patient will be readmitted.
Bon Secours says the partnership will help transform health care. “We see the future of health care moving beyond the walls of our hospitals and into the community,” says Toni R. Ardabell, CEO for Bon Secours Virginia Health System.
