House calls making a limited comeback

Once a mainstay of Americana, doctors who make house calls are now a rarity.

But the need for them seems to be coming back to a certain degree for a particular portion of the population.

Patients who depend on home care are typically elderly, and that number is growing, said Constance F. Row, executive director of the American Academy of Home Care Physicians.

The current health debate, and the pending Independent at Home bill, is that if there were house call programs across the country serving the highest-risk person, unnecessary emergency room visits and hospitalizations would be significantly lower, creating a savings of $14 billion a year, she said.

"A typical house call is maybe a $100 and a typical emergency room (visit) for an elderly patient is (usually) 10 times that," Row said, depending on where you are in the country.

One problem that AAHCP readily points out that the number of physicians who make house calls is alarmingly low.

"There are not enough primary physicians and geriatricians across the country," Row said. "There are between 1,000 to 1,500 doctors doing this across the country and we need much more. There aren't many in Las Vegas, there aren't any most places and there aren't any in lots of places."

The journal Clinics of Geriatric Medicine notes that home visits by doctors dropped from 40 percent in 1930 to 10 percent by 1950. By the 1980s, house calls had almost disappeared. Much of that decline is due to the advanced technology available at a doctor's office and insurance coverage, liability factors. Medicare increased reimbursement for house call services in 1998, opening the door for doctors to return to the practice. The health and longevity of homebound patients improved, as did the doctor's enjoyment of medicine.

Dr. Gregory Bryan started the local Advanced House Calls in 1998 working out of his home. He was a hospitalist at a local institution but was slowly seeing the health care system cut off those in need at home. An article about the need for doctors to make house calls for geriatric patients caught his attention. After layoffs at his hospital, he began the business with fellow doctors and a nurse. One perk? Getting out in the field has been far more fulfilling.

"It's a different experience than in the office," Bryan said. "I feel confined by that now. I don't feel chained down by the office now."

His black bag includes the usual, stethoscope, medication samples and suture supplies, but medications, IVs, labs, and even X-Ray services can easily be brought to his patients. Advanced House Calls provides geriatric and internal medicine specialists, health care professional exams, diagnostic testing referrals, mobile laboratory referrals, home health referrals, general physicals and medical supply and equipment orders.

Many procedures can be safely performed in the home-and are often covered. By seeing clients in their homes, most of whom are elderly with chronic diseases that make it difficult for them to get to a doctor's office, Bryan says he can offer more thorough treatment. "You really get more of a sense of the person, what their life is like when you go into their house," he said. "You see what they eat, what the financial state of the household is, get a sense of the other factors that they have to deal with and you can do a more comprehensive job in how you care for them."

For instance, he recently treated a morbidly obese woman who was not doing well on her diabetic medication. At her home he saw her in her natural habitat, surrounded by junk food and mostly immobile.

"If I'd seen her in an office, I would have increased her medication maybe," Bryan said.

"Seeing her in bed with crackers and cookies covering the bed with her, I knew exercise and diet was (a better) plan."

He acquires new patients mostly through word of mouth. Patients on Medicare, which cover his services, make up about 75 percent of his client base with 20 percent from Medicaid and a sprinkling of younger patients.

In home nurses mainly refer patients to Bryan if they are missing doctor appointments or seem to be neglecting their health due to their illness.

"There are a lot of disenfranchised older people here who don't have family in town, they are basically alone and depending on friends and neighbors to take them to the doctor or to pick up their medication," Bryan said.

Bryan offers primary care that when caught early can prevent major health issues.

"I see all the kinds of things that people would go to an internist or their family doctor for, like heart disease, COPD, diabetes, the bread and butter problems," he said.

His personal care also saves the patient money and time.

"A lot of these people do better outside of the hospital, where they are subject to the bacteria in hospitals," Bryan said. "If we can keep them out of the hospital, it's a lot easier on the patient and the families."