Doctors Feeling Right at Home

With his office hours completely booked one recent weekday, Dr. Kenneth Saul decided he would rather see a 7-year-old asthma patient at his home than make the boy wait a day.

So on his lunch hour, the Thousand Oaks pediatrician drove several miles to check up on Jonathan Zindrick, who had suffered an acute asthma attack the night before.

For Saul and other physicians, house calls have not totally gone the way of the horse and buggy. In fact, some doctors are devoting their entire practices to them.

Although financial barriers and time restraints have made house calls a rarity in recent decades, both doctors and patients agree that the service is needed.

“In pediatrics there are a lot of times when the child has a lot of pain or fever or sore throat, where you don’t want to have to have them wait until the next business day,” Saul said. “I didn’t want to see care delayed because of my convenience. It was just as easy for me to go to their house with my black bag than for both of us to go to the hospital.”

But it is not always easy. Despite advances in technology and an improvement in Medicare reimbursements for home visits in recent years, most medical care continues to be done in the doctor’s office, where a physician can see up to 40 patients a day.

Saul, who makes several home visits a month, fits them in on weekends or after office hours.

“When patients are in the office, you can see one and go on to the next room,” he said. “If you did all house calls, it would be too inefficient. But to do house calls like I do after hours or on weekends, I’m not wasting any time. Instead of sitting at my desk returning phone calls after hours, I can return the calls on the way to a house.”

An estimated $1.5 million worth of house calls are billed to Medicare every year, and industry leaders say the numbers will increase as the country’s aging population grows. But health systems and physician groups have been slow to sign on to something that they say still is not financially viable.

The Health Care Financing Administration raised physician reimbursement rates for house calls by nearly 50% in 1998, removing some financial barriers, but a physician’s drive time to and from a patient’s home is not covered--time when doctors could be seeing more patients in the office.

“It all boils down to the physician’s time,” said Gresham Bayne, a San Diego physician who started one of the few successful house call-only medical groups in the country in 1984. “We call it windshield time. Medicare still doesn’t pay for the time and cost of transportation of a house call. They still assume we beam ourselves there at no cost.”

Bayne’s Call Doc group now has 20 doctors who make an average of 2,000 house calls a month and have the equipment to perform electrocardiograms and lab tests from a patient’s home. No advance appointments are necessary and individuals who call the 800-number receive same-day service.

To help move doctors efficiently, Call Doc has sought out venture capital for a $12-million customized system with electronic charting and mobile computers in each vehicle to track the best traffic patterns.

A nationwide survey by the American Medical Assn. in 1990 found that more than half of family physicians make some house calls, but the vast majority made home visits only one afternoon a week or once a month.

Still the interest in physicians’ home visits caught the eye of the AMA, which has published guidelines for managing home-care patients, said Joanne Schwartzberg, director of the AMA’s department of aging and community health.

Bayne said his San Diego group receives calls from at least two physicians across the country a week asking how to set up a house-call practice or incorporate home visits into an office-based practice.

“House calls need to be integrated into existing practices,” Bayne said. “Ultimately that is the way it should happen. . . . Physicians already have an office patient base, so when patients grow old or too sick they can be incorporated into home visits.”

Ventura family physician Stanley Frochtzwajg has found himself making about one house call a week for patients who cannot make it to the hospital or to his office with ease.

“If I have a family with a child who has an earache at 9 p.m., I can either have them drag that child down to the emergency room, where they will spend an enormous amount of time, or I can just leave my home and be there in five minutes with my black bag,” Frochtzwajg said.

Little research has been done to show how much in-home care can cut down on emergency room visits, hospitalization and nursing home stays, but industry leaders say physicians’ home visits could dramatically lower health-care costs.

Although the cost of emergency room visits can run into thousands of dollars, Medicare reimburses physicians between $150 and $225 for a house call, depending on the care provided.

For Medicare patients, house calls are covered in the same manner as visits to an office-based doctor. Oftentimes, house calls are covered by a preferred provider plan as an “out-of-network” benefit, while health maintenance organizations may not cover a home visit at all.

“If the whole system thought about the cost of it, there would be no question that house calls would be economical,” Schwartzberg said. “But no one really adds up the total cost of the ambulance ride, the emergency visit, the hospital stay and how much easier it is to send a doctor to the home to treat it before it becomes critical.”

It is the elderly or chronically ill who often resort to a trip to the emergency room, said Colleen House, director of the Ventura County Area Agency on Aging.

“Frequently the emergency room is used by individuals who are unable to get to and from physician offices or have some difficulty just accessing regular care,” House said. “They will use the emergency room because they want care immediately.”

Dr. Robert Zylstra started his full-time house call practice nine years ago after working as an emergency room physician. “I recognized that about 85% of the people who were admitted were treated and sent home. They were using the emergency room as an open clinic because they had no access.”

Zylstra now drives his minivan around Santa Barbara and Ventura counties seeing five to 10 patients a day in their homes.

“It’s a completely different experience--you spend an hour with a patient, and in an office you spend five minutes,” said Zylstra, who has kept his practice afloat by eliminating the overhead of an office and staff.

Physician Travels to Ventura Once a Month

He travels to Ventura once a month to see 93-year-old Felipa Salazar, a diabetic who had a stroke two years ago that made it difficult for her to get out.

“He comes once a month whether she needs it or not,” said Salazar’s daughter, Maxine Mesinoff, who has been caring for her mother in her second-story duplex for the past two years.

“I was so grateful I found him because I didn’t know what I was going to do,” Mesinoff said. “Mom needs 24-hour care and to not take her out to a doctor means just one less thing I have to do. It’s hard and stressful, but we feel triumphant that we’ve been able to keep our mom at home so far. And a lot of it has to do with Dr. Zylstra.”

Physicians who make home visits say that added time in a patient’s home is invaluable. By seeing what the home is like, a doctor can gain insight into a patient’s life and care needs.

“It’s a completely different experience than seeing a patient in an office,” Zylstra said. “You see how they live. You get an idea of what their lives are like.”

Physicians say house calls can be rewarding for them as well as the patients.

“What really rounds it out is my ability to give the kind of care and service I like to give,” Frochtzwajg said. “I love making house calls. It gives me insight into the patient’s life in ways that I could never get just by talking to them. I get to see what their home is like. I can see when a woman with a fractured hip has throw rugs down on her waxed floors. Those subtle insights are very difficult to pick up in an office.”

For families like the Zindricks in Thousand Oaks, Saul’s extra effort has made all the difference. On his last visit to their home, the doctor even took the time to play the family’s piano for Lisha Zindrick’s two sons, who suffer from chronic asthma and other medical complications. “He gave us a little concert. Something from his fifth-grade piano recital, I think,” Zindrick said. “He knows my kids so well, so when he sits down at the piano with them or talks to them about baseball, he can really tell how they are doing.”

It is something Zindrick has come to rely on. “Sometimes I would get a little panicky when things would get really bad, and it’s nice knowing he will be here for my kids,” she said.

“He has a lot of energy, so for him stopping off at someone’s house on the way home from the hospital is like a walk in the park,” she said. “But for me and my kids it makes all the difference.”