There’s a Doctor in the House

Dr. Tamika Henry carries a stethoscope in her bag. But that’s about all she has in common with doctors who visited patients in the heyday of the house call.

Her woven tote from El Salvador is a virtual office, carrying diagnostic tools and a pocket computer that gives her instant access to patient charts. “Dr. Tamika” -- as doting patients call her -- is a thoroughly modern physician helping to revive a bygone style of medicine.

In 2004, doctors rang more than 2 million doorbells -- up nearly 9% from the previous year. The movement has been propelled by advances in medical technology, an increase in Medicare reimbursements and a growing recognition that house calls make economic sense for certain patients.

While most primary-care doctors are tethered to offices and tight schedules, Henry drives a gray Acura through neighborhoods south of downtown Los Angeles. She sees half a dozen patients on a typical day, often spending an hour or more with each.

“If I’m sick and need her, she will come,” said Mary Conner, who lives near Henry’s alma mater, USC. “When I tell my friends about it, they can’t believe it. They say this happened back in the ‘30s.”

House calls, which accounted for almost half of physician visits in 1930, all but disappeared decades ago. Their decline left a gap in medical care, particularly for older people with chronic illnesses.

Whether they get sick in the middle of the night, are bed-bound or just can’t get a ride to the office, these patients -- known in hospitals as “frequent fliers” -- often are unable to see a doctor who knows them well. As a result, they get sick more often and more severely, and end up cycling in and out of emergency rooms, hospital wards and nursing homes.

These episodes are hard on patients and their families -- and expensive for taxpayers. A recent Congressional Budget Office study found that these patients make up only 5% of Medicare enrollees but their care consumes 43% of the Medicare budget.

Some physicians and other advocates are championing house calls as part of the answer.

“If we don’t have a better chronic-care management system -- with house calls -- for the frail elderly who are the most expensive, we’re going to bankrupt the Medicare program,” said Constance Rowe, executive director of the American Academy of Home Care Physicians. “It’s not only cheaper, it’s what people want. They don’t want to be hospitalized.”

*

Mary Conner smiles when she sees her doctor bounding up the wheelchair ramp to the front door of her blue-and-white bungalow. The 75-year-old great-grandmother has hypertension and takes nitroglycerin for angina. She was hospitalized three times for congestive heart failure before Henry started making house calls more than a year ago. She hasn’t been hospitalized since.

As Mary lets Henry in, her husband, James, waits in a motorized wheelchair in the couple’s sunny dining room. The 78-year-old man, also a patient of Henry’s, has diabetes and undergoes dialysis three days a week for advanced renal disease.

The couple’s great-granddaughter toddles into the dining room to watch as Henry puts her stethoscope on James’ chest.

Her visit turns the room -- filled with anniversary portraits, school pictures and other family photos -- into an impromptu examination room. Henry turns to Mary to ask about a recent appointment with a specialist.

“What did your cardiologist say?”

“He didn’t get back to me,” Mary replies.

“I need to talk to him for you,” Henry says.

Serving as a coordinator is an important role for Henry and doctors like her. They make sure that care prescribed by specialists is carried out -- and is working.

Henry’s broad smile and charm help her elicit clues to her patients’ health. If she can catch a problem early enough, she often can treat it on the spot. Sometimes just a medication adjustment can mean the difference between a patient’s sleeping through the night and making a midnight run to the emergency room.

Henry’s first job out of residency, at a Long Beach community clinic, didn’t allow her the time to get to know her patients. “There was so much paperwork, and then the hustle and bustle of trying to see so many patients every 10 or 15 minutes,” the Lynwood native said.

Then Henry heard about Care Level Management, a start-up company in Calabasas that was looking for doctors to make house calls full time. She leaped at the chance.

“I like to spend time with people. I like to talk.”

*

Although a few practices catering to the wealthy still make house calls for a heavy fee, most doctors can’t charge enough to pay for the extra time involved. The typical office-bound general practitioner sees 15 to 20 patients a day. Patients with urgent problems who can’t get into the office are told to dial 911.

Such calls trigger a cascade of expensive interventions -- including tests that duplicate results on file elsewhere and hospital stays. These episodes also expose fragile patients to the risk of new problems, such as infection.

Seeing an opportunity to head off these problems in some patients, San Diego physician C. Gresham Bayne launched a full-time home-care practice in 1987 and mounted a campaign that in 1998 won the first substantial increase in Medicare fees for house calls in two decades.

Physicians, who had been collecting an average of $60 per call, now get more than $100 for visiting patients with standard Medicare plans. Private insurers who cover house calls pay about the same.

Patients in San Diego, Riverside and San Bernardino counties who call Bayne’s Call Doctor Medical Group’s toll-free number are promised same-day visits and urgent care within an hour. With five physicians and two physicians’ assistants backed up by an office staff of four, the group makes about 800 house calls a month.

They perform procedures once possible only in offices and hospitals, including electrocardiograms and X-rays. Advances in portable technology, telemetry and instrument design allow much of modern medicine to fit into a bag -- and even more in the trunk of a car.

“It’s really a great way to practice medicine,” said Bayne, president of the American Academy of Home Care Physicians. “You are not in a windowless building with an army of people telling you what to do. You are a master of your own destiny. And there is no waiting room.”

But even with the Medicare fee increase, a house call practice is tough to pull off, Bayne said. Among the biggest challenges is getting fully paid by Medicare. Although the insurance program for the elderly has covered house calls for decades, the claims still are so rare that they often get audited.

House-call physicians could go broke fighting for reimbursements, Bayne said. Such battles would have shuttered his practice if not for more than $12 million in venture funding he had obtained over the years, he said.

Making house calls could become a more robust business if an idea pioneered by Care Level Management succeeds. The company contracts with insurance companies to provide house calls for selected patients in exchange for a cut of the resulting savings on hospital visits. An entrepreneur and a physician launched Care Level in 2001, and they say it has been profitable since 2003.

Care Level physicians are paid fixed salaries starting at about $165,000 a year. They care for no more than 120 patients each and control how and when they pay visits. The patients all live in urban areas and are grouped by proximity to limit doctors’ drive times.

“It’s a dream for them,” said Care Level’s co-founder and chief executive, Raouf Khalil. “We offer them the best package out there.”

There is one catch: Physicians must be available around the clock, seven days a week. They get out of bed at 3 a.m. if a patient calls.

“Chronic disease is a 24/7 business,” Khalil said. “You have to have access. Otherwise, they are going to go to the E.R. The more barriers you put between these patients and the doctor, the more costly it’s going to be.”

Khalil’s pitch to insurance companies is this: Allow our physicians to take care of your sickest patients, and we will save you money. Care Level is so confident that its ounce-of-prevention approach will save a pound of cure that it promises to rebate fees if it does not deliver a savings.

In the company’s first four years, “that has never happened,” Khalil said. “And it never will.”

Timely care makes all the difference, Khalil said. For example, if a patient with a heart condition develops symptoms of pneumonia after office hours, she may resort to going to the emergency room, where she may wait for hours before being seen.

Hospital physicians unfamiliar with her history would probably order a battery of tests. Then they might recommend a course of intravenous antibiotics administered in the hospital, where, according to a recent study, the average cost for treating pneumonia is at least $6,900.

With Care Level, that same patient could call a physician familiar with her health who would examine her in her home. The physician could order an in-home intravenous antibiotic treatment and make a follow-up visit -- all at a cost of $750, according to Care Level.

Better yet, said Care Level co-founder Dr. Henri Becker, a house-call doctor could catch the symptoms early, avoiding the need for an IV.

Some of the care by these doctors could not be provided in an office or hospital. They weed out expired drugs from the medicine cabinet, for example, and get rid of throw rugs that could trip elderly patients.

“We can spend sometimes hundreds of thousands of dollars on a patient in the hospital and discharge them, and the house has no food or is poorly lit,” said Sheldon Zinberg, a physician and founder of CareMore Medical Group in Downey, which also sends doctors to the homes of “frequent fliers.”

*

“Hello, Sunshine!” Dr. Henry shouts as she walks into Bonnie Jones’ garden apartment in Garden Grove. Striding into a bedroom in back, she finds her patient sitting in a blue recliner in a bright spot in front of a sliding glass door. Jones, 79, is struggling to sort pills from a dozen bottles into a plastic tray with compartments for each day of the week.

Henry drops her bag and helps Jones figure out which pills go where.

“How’s your appetite?” Henry asks.

“I never really feel hungry, but I know I have to eat,” Jones says.

Jones had a cancerous piece of her jaw removed and replaced with bone from her leg. House calls help her return to the comfort of her home -- and stay there -- each time she finishes a round of chemotherapy in the hospital.

“What do you eat besides mashed potatoes, pudding and soup?” Henry asks. “How about a sweet-potato pie?”

“Oh yeah,” Jones says, her eyes lighting up.

“Are you drinking enough?”

Jones grabs a water bottle from the floor next to her recliner and shows Henry how much she’s had this morning. Then, for good measure, she takes a gulp.

Henry listens to her heart and lungs and then puts the stethoscope to her stomach.

“You’ve been through so much,” Henry says, telling her how much she admires her spirit.

“I’m not going to let this get me down,” Jones replies. “I think I’m more fortunate than most people -- I have plenty, including you.”

Standing to leave, Henry says, “OK, Sunshine -- let me give you a hug.”

*

Care Level sends physicians to the homes of patients covered by about 10 insurers in parts of Southern California, the Bay Area, Arizona, Texas and Florida. Because of the expense, insurers offer the service only to the sickest 1% to 5% of their elderly HMO patients -- at no extra charge.

“We just can’t offer it to our total membership -- it’s just too costly,” said Mark Kiffer, a medical officer with health insurer Humana Inc.

But for about 700 Humana Medicare members in Phoenix and San Antonio, where the insurer has contracts with Care Level, the house calls have “made a remarkable difference,” Kiffer said.

“Hospital inpatient care is the costliest portion of our healthcare delivery system today,” he said, “so by avoiding unnecessary hospital admissions we’re able to reduce the overall cost of care.”

Care Level’s round-the-clock house call coverage has reduced hospital admissions among frequent fliers by 60%, the company says. A study commissioned by Care Level found that one insurer saved $7 million in six months last year after it enrolled 318 of its 15,000 members in the house-call program.

Such results have caught the attention of the nation’s biggest health plan -- Medicare. The agency recently awarded Care Level a three-year demonstration project to serve as many as 15,000 patients in California, Texas and Florida. Like private insurers who work with Care Level, Medicare will share some of its savings with the company during the trial, said Jeff Flick, Medicare’s administrator for the Western region.

“If this works, we can structure other things like this in other parts of the country,” he said.

As far as Mary and James Conner are concerned, the benefits of house calls already are proven.

“How are you feeling?” Henry asks James during her recent visit to the couple’s South L.A. bungalow.

“Oh, I’m all right,” he says.

“You don’t complain about anything, though,” she says, turning toward Mary. “How’s he been doing?”

“He’s tired, real tired on dialysis days,” Mary says. “And I’m concerned about his foot after they took the nail off.”

Henry moves in to have a look. Diabetics are prone to infections and often feel no symptoms. Henry values Mary’s insights into her husband’s condition and takes care to draw them out.

“In an office, you may forget something,” Mary said. “But at home, you think of everything because you are more comfortable.”

James’ toe is healing fine, Henry says, grabbing her pocket computer and pulling up his chart. She notes that he has brought his blood sugar level into the range she had targeted.

“That’s great -- I’ll take 140 and run with it,” Henry says. “What did you have for breakfast?”

“Bacon, ham and oatmeal.”

“I wish I could get that,” Henry quips, glancing at Mary.

Like many of Henry’s patients, Mary tries to feed her almost every time she comes by. She has promised to make the 32-year-old doctor a cake for her bridal shower in the fall.

“She acts like she’s my daughter,” Mary says. “I’m real comfortable with her.”