The case for house calls: Patient satisfaction and practice profitability

About five years ago, family physician Samantha Pozner, MD, received an urgent request from the daughter of one of her chronically ill patients. Her mother was experiencing breathing problems, but the daughter didn't think she could bring her mother into the office. The daughter was hoping Dr. Pozner could recommend a home care nurse who could come over quickly.

Instead of referring the daughter to a nursing service, Dr. Pozner did something that was at once quaintly old-fashioned and radically forward: She made a house call.

At the time she didn't think much of it. "The family lived near my office. I was leaving within an hour or so. So I offered to come by," she remembers.

But the process didn't end with that visit. The house calls continued every few weeks over the year as the patient's health deteriorated. The patient stayed out of the hospital and died in her own home. "I had a great sense of satisfaction," Dr. Pozner says. "I really feel I made a big difference in that woman's and the family members' lives."

Dr. Pozner, who is part of four-doctor Springfield (N.J.) Family Practice. now regularly does house calls every other Wednesday and occasionally at other times if patients need to be seen quickly. She limits this service to a handful of patients: only those who absolutely cannot come to the office, and who live relatively near the office or on the route Dr. Pozner follows when she picks up her children after work.

She says she has been able to keep many patients out of the hospital and finds she gets to know people better when she can examine their home situations. "I see their environment, their quality of life, the effectiveness of their caregivers. Those all helps me make better medical decisions," she says. She also has a much better relationship with patient and family than she can achieve in brief office visits.

From a business standpoint, Dr. Pozner says, Medicare reimbursement is fair enough. "At least I'm breaking even."

But more important, her house call service has increased her reputation as a caring and committed physician. Each family she serves spreads the word to friends, and because the service is relatively unusual, her reputation increases at each telling. In fact, she attributes 100 new in-office patients to the recommendations of the family of one house call patient.

House calls on the upswing

While still rare, house calls, once referred to as a disappearing practice, are enjoying a modest uptick. For example, a research letter in the Nov. 16, 2005, Journal of the American Medical Association reported a 43% increase in Medicare-paid house calls from 1998 to 2004. The overall numbers are still low, accounting for only 0.78% of Medicare outpatient evaluation and management services in 1998 and 0.90% in 2004.

The report ties the increase to the aging population, advances in portable medical devices, information technologies, point-of-service laboratory tests, handheld computers and the 1998 Medicare increase of nearly 50% in allowable reimbursement for home visits.

But doctors looking into house calls aren't using Medicare rates alone to make the business case. "Medicare reimbursement for home visits does not take into consideration potential revenues lost while a physician is away from the office, travel expenses to and from patients' homes, or the amount of money that Medicare, through its postpayment audit process, will try to recoup from physicians who make frequent home visits," wrote Bernard Leo Remakus, MD, a Hallstead, Pa., family physician, in a letter to JAMA on March 15, 2006.

However, making a house call can be less expensive for everybody than a visit to an office or emergency department.

C. Gresham Bayne, MD, who launched a full-time house call practice 22 years ago, says house calls can provide more efficient and better care than the emergency department, the only alternative for many. In fact, Dr. Bayne, who is now part of San-Diego-based four-doctor Call Doctor Medical Group, got the idea for a house call business in the 1980s when he ran an emergency department in San Diego. "I realized that the vast majority of the patients did not belong there. They just had a hard time getting to a more traditional facility. So their only alternative was to call 911."

There are basically two distinctly different types of house call practices. So-called concierge practices provide house calls for virtually anyone willing to pay for it. Because most insurance companies won't pay extra for house calls for patients who are physically able to come to the office, concierge practices normally require their patients to pay out of pocket.

On the other side of the business model are doctors who see patients who are too sick to come to an office. These visits typically are paid by Medicare or Medicaid, or both.

Building a practice

If you plan, like Dr. Pozner, to do house calls for only a handful of patients, you don't have to worry about marketing that side of your business, experts say. Patients who need house calls will be obvious.

On the other hand, doctors who want to launch a full-time house call business often find starting up somewhat challenging. Doctors report that referrals from other primary care groups that do not provide house calls are extremely rare. Other traditional means of growing a practice -- newspaper ads, talks and lectures, mailings -- also don't work well, many doctors say.

So, says Michael Smothers, MD, of Housecalls LLC in Elkhart, Ind., "most of our patients find us through word of mouth."

In Dr. Smothers' case, that process was helped by the fact that he had been a longstanding and well-known member of his community. A family physician, he had been employed by a hospital-owned practice where part of his responsibilities was seeing patients at home.

In 1999, Dr. Smothers started a practice in which 95% of his patients are homebound. His initial marketing strategy was chatting up social workers, home nursing agency officials, staffs of local aging councils, and even members of his church.

One advantage doctors have in building a house call practice is that they do not have to find as many patients as do physicians in traditional primary care settings. A house call panel likely will tend to be elderly patients you see regularly who require multiple services with each visit.

Family physician Tom Cornwell, MD, part of two-doctor HomeCare Physicians in Wheaton, Ill., says he has a financially sound business seeing only eight to 12 patients a day. His panel size varies from about 200 to 300 patients, compared with panels of 2,000 to 3,000 in many primary care practices.

But on the other side of the ledger, deaths among such a patient panel come at a much higher rate than from in-office patients. Dr. Cornwell says that 28% of his patients die each year. That can take an emotional toll, on top of the need to find new patients frequently.

When building up a house call practice, many physicians find it helpful to supplement their incomes with positions that also may yield patients for the house call side of the business. For example, Dr. Smothers maintained a nursing home practice for a few facilities.

Phoenix-based, five-doctor Geriatric Solutions, a full-time house call practice, owns a hospice. "That's a good way to supplement our profits while remaining in the general field of house call medicine," says Kevin Jackson, MD, a family physician and geriatrician who founded the group.

Scheduling and equipment

For many house call physicians, whether full- or part-time, efficient scheduling is key to profitability. "What we all try to do is spend as little time behind the wheel and as much time in front of patients as possible," Dr. Jackson says.

Geriatric Solutions has divided the densely populated sections of Phoenix into four quadrants. Doctors work in a different quadrant each day, a protocol that aids in scheduling. Most physicians in the group use an online mapping program that helps them plan routes.

Dr. Cornwell uses a separate photocopied map image for each working day. He places the names of the patients he plans to see along the map's route. Equally important, he has made a deal with a local school to use physician assistant interns to do the driving. "That gives them an opportunity to view comprehensive exams, and it gives me time to do paperwork in the car."

For efficiency as well as safety, patient location is often one of the criteria physicians use when deciding whether to accept patients. For example, most house call doctors either severely limit or completely reject patients who live in areas where house calls may be 20 minutes or more apart.

While many house call doctors rely on standard "black bag" equipment -- blood pressure cuff, otoscope, stethoscope -- a few bring more sophisticated devices. For example, Dr. Cornwell has an ECG machine that works with his laptop computer. He also has a heart monitor that can transmit information to his cell phone within 60 seconds. Dr. Cornwell has considered purchasing portable lab equipment, but so far, he says, he doesn't do enough lab tests to justify the cost.

Whatever medical equipment house call doctors decide to use, the vast majority have remote electronic medical record systems. The use of EMRs reduces after-hours work because data entry can be accomplished at the bedside, They also eliminate the need to pull patient records before the physician leaves the office. "If I get a call on my cell phone that I have to see a patient who wasn't on my schedule, I never have to worry about picking up the chart," Dr. Bayne says.

The most important factor in creating a profitable house call practice is reimbursements. Medicare pays a premium fee for house calls. And while doctors complain about a slight decrease in Medicare pay in the last two years, many hope that won't become a trend and eventually will be reversed.

Many house call patients are dual-eligibles, having both Medicaid and Medicare. But Dr. Bayne says that when he sees such patients, he has to write off Medicare's 20% co-payment, because his state's Medicaid system won't cover it.

Doctors with full-time house call practices are well aware of the challenges of making their businesses viable. Says Dr. Cornwell: "If this were an easy to way to make money it wouldn't be so uncommon. But if you're careful, it is workable."