More Doctors Rearranging Schedules for House Calls

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 some other physicians, house calls have not completely gone the way of the horse and buggy. 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 . . . I’m not wasting any time. Instead of sitting at my desk returning phone calls . . . 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 is not covered.

“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 toll-free number receive same-day service.

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.

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, and health maintenance organizations might not cover a home visit at all.

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 throughout 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.

He travels to Ventura once a month to see 93-year-old Felipa Salazar, a diabetic who had a stroke two years ago.

“He comes once a month whether she needs it or not,” said Salazar’s daughter, Maxine Mesinoff, who has been caring for her mother for 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.”