Some physicians say home is where the practice is

When Donald T. Stewart, MD, a family physician in Sammamish, Wash., decided to return to solo practice in 2007 after working for midsize independent and hospital-owned groups, he knew he was going to have to keep a tight rein on costs if he was going to make it work.

He decided to turn the lower-level in-law apartment in his house, which had been used by the billing department of his previous medical office, into his practice space, with one exam room and a waiting area. He provides a wide range of primary care services, including some surgical procedures, lab tests and urgent care, for patients with diabetes and lipid disorders. His practice accepts several commercial insurance plans as well as Medicare. And when he is done for the day, he goes upstairs, locks the door behind him, and he is home, still among the trees and lake views his patients enjoy.

“It greatly reduced my overhead and made life easier,” Dr. Stewart said.

Historically, many physicians worked in a living space with a medical practice area. That slowly fell out of favor in the 1950s, when more and more physicians set up separate offices or worked in hospitals. Many municipalities enacted zoning laws that barred a wide variety of businesses from setting up in residences.

“In many ways, it was a pretty nice life,” said Larry Vernaglia, MPH, a lawyer and chair of the health care practice group with Foley & Lardner in Boston who lives in the home/medical practice that his grandfather, a physician, built in 1941. His father, also a physician, practiced in the house until the late 1970s, although it now functions only as living space. “Things are a little different for a variety of reasons. There are some challenges there, but they can be overcome.”

The home-based medical practice currently is something of an oddity, but some physicians have managed to establish one that meets the standards of a commercial space.

“I think it has a lot of nice advantages,” said Sharlene Kinney, MD, a family physician who opened Berkshire (N.Y.) Family Medicine in her home in October 2008. “You’re not wasting time or gas commuting. I like spending time at home.”

Setting up a home-based practice is like setting up an office, with a few complications.

For example, before Dr. Stewart and Dr. Kinney could move forward with their plans, they had to identify the space for the practice and determine whether local laws would allow it to be used this way. When Dr. Stewart approached the city planning commission with his plans for the Sammamish Diabetes and Lipid Clinic, it said he had to have parking spaces for all employees. This was a fairly straightforward request, because only he and his wife, Eva, were going to work there. A patient with a bulldozing business widened the driveway to accommodate three cars.

Dr. Kinney wanted a house where she could practice as a “country doctor. She identified an old one that had two additions and didn’t need much renovation. Before buying it, she called the city clerk to make sure such a setup would not run afoul of local regulations. She was required to place her sign a certain number of feet from the center of the road but faced no other restrictions.

“I’m not sure we got a great deal, but it was perfect to put a practice in,” Dr. Kinney said. “And we didn’t have to spend a lot of money fixing it up.”

Other jurisdictions may have regulations limiting the number of visitors a home-based business can have, a significant issue for physicians, or in placing other significant constraints.

“I do know other doctors who want to have an office out of their home, but [local governments] wouldn’t let them,” Dr. Kinney said.

Both practices had to conform to other regulations as well. They installed ramps at the main entrance and grab bars in the rest room to comply with the Americans with Disabilities Act.

When the practices opened their doors, Dr. Stewart and Dr. Kinney had to figure out how to get patients into what some may consider an unusual setting. Dr. Stewart contacted the patients at his previous practice, and many followed him to his new one. Dr. Kinney is situated on a two-lane state highway, and a sign directs patients into the driveway. Both practices are full with a waiting list, although they don’t have the volume of many hospital-owned or larger practices. Each physician sees eight to 14 patients a day and works 40 to 50 hours a week.

“I’m certainly as busy as I have ever been, but I’m doing different things,” Dr. Stewart said.

Physicians with in-home medical practices need to determine how to keep work and home separate to comply with the Health Insurance Portability and Accountability Act and to get some true time off. Dr. Stewart’s wife is a nurse practitioner trained in privacy compliance issues. Dr. Kinney trained her husband, Roger Kinney, who helps administer the practice, in the ways of HIPAA. Materials are locked away when guests come over.

To create some separation between the home and practice, both houses have different entrances for patients and residents. But when your home is where you hang your stethoscope, it’s not always easy to maintain firm boundaries where work begins and ends. Sometimes it can be hard to completely turn off.

“I have to force myself to leave it behind when I come upstairs to relax at the end of the day,” Dr. Stewart said.

Both doctors, however, treat patients on evenings and weekends when need be. The short commute between their home and practice makes this less disruptive.

“I don’t have to go anywhere,” Dr. Kinney said. “They just come right to me.”