Sunday, July 26, 2009
Practice making a recovery
Washington Post
WASHINGTON — When George Taler meets with a patient, he does all the usual things: He measures blood pressure, listens to the heart and lungs, takes a look in the mouth and ears, and updates the medical chart.
Then he does something unusual: He checks out medicine containers in the bathroom, food in the refrigerator and the general condition of the patient’s environment.
Taler, a physician at Washington Hospital Center, does house calls.
He is part of a small but growing tribe of doctors, nurses, physician assistants and nurse practitioners who are reviving this once-common practice for keeping Americans healthy and in touch with their doctors. Having virtually disappeared from medical practice by the 1980s, the house call has been making somewhat of a comeback, thanks primarily to Medicare changes that make house calls more easily billable. Advocates say revival of the house call could help reduce health-care costs substantially and enhance quality of care for many elderly and chronically ill patients.
For generations, the home visit was an institution, something a doctor, black bag in hand, just did. In 1930, house calls made up about 40 percent of physician encounters with patients in the United States, according to a recent article in the journal Clinics in Geriatric Medicine.
By 1950, that number had dropped to 10 percent. And by 1980, home visits accounted for a mere 1 percent.
Why did the house call fade away? In part, technology was to blame. As new diagnostic tools and advanced treatments became available in hospitals and clinics, that’s where people wanted to go. As the article in Clinics puts it, both doctors and patients came to associate “‘good medicine’ with hospitals and clinics. House calls became old fashioned.”
Financial incentives also worked against house calls, according to the article. More doctors chose specialized fields that relied on the technology of hospitals, while those who chose primary care could see easily twice as many patients in offices and clinics as they could traveling from home to home.
And then there’s the fact that private insurance has rarely fully covered such visits. (A few “concierge” medical practices will perform house calls for those patients willing to pay a substantial annual fee, or a trip fee, that is not covered by insurance.)
Similar constraints and disincentives have not been at work in other countries, including Canada, Denmark, France and the Netherlands, where home visits have continued to be a part of medical practice.
According to the Clinics article, in Britain, which has a strong tradition of primary-care medicine and a national system of subsidized health care, doctors make 10 times as many house calls per 1,000 patients each year as do U.S. doctors.
In 1998, Medicare modified its billing procedures, making it easier for practitioners to receive payment for home visits to the elderly and chronically ill and increasing payments by 50 percent. Since then, Medicare statistics show a large bump in physician house calls, from 1.5 million in 2000 to almost 2.2 million in 2007.
Although house calls still account for fewer than 1 percent of all outpatient visits, “there is certainly a growing interest,” says Constance Row, executive director of the American Academy of Home Care Physicians. According to the Clinics article, “increasing numbers of physicians have chosen full-time house call practice as their preferred professional role.” Row backs efforts to increase the use of house calls as a “win-win situation for everyone. It is one of those things that patients want, that their families and caregivers want and also something that would actually save money.”