Health system reform expected to boost house calls
■ One project set to launch in 2012 provides payment incentives for primary care teams offering such services.
For a time during his 17 years of running a house call-based practice, the pay was so bad for Tom Cornwell, MD, that his family lived off his wife's income. But physicians like Dr. Cornwell say they are finding themselves much more in demand.
During the last decade, Medicare has increased its rates for house call visits as an aging population has necessitated more of them. The program paid for more than 2.3 million house calls in 2009, compared with more than 1.5 million in 1995.
"I started my practice at a time when many people doing this were going bankrupt, and we were being paid half what we are being paid now," Dr. Cornwell, a family physician in Wheaton, Ill., said. "Medicare has realized the value of this."
But experts say several aspects of health system reform will make house call practices more common.
"The home as a venue to provide care is becoming more important," said Steven Landers, MD, MPH, director of the Center for Home Care and Community Rehabilitation at the Cleveland Clinic. "And physician leadership in home care is essential. First and foremost, physicians will have to take on more of the responsibility for leading the team."
Independence at Home
One program mandated by the health system reform law signed into law in March 2010, Independence at Home, supports expanding house call medicine. The rules and regulations are being written, but some important aspects already are spelled out.
Independence at Home, which will launch Jan. 1, 2012, provides payment incentives for primary care teams providing house calls. Physicians and health care practitioners would receive a portion of the money saved by improving health outcomes and reducing preventable hospitalizations, readmissions and emergency department visits. Decreasing the number of duplicative diagnostic and laboratory tests and improving patient and caregiver satisfaction will be taken into account.
Because it is a demonstration project meant to reduce expenses related to care of the highest-cost Medicare beneficiaries, the program will be limited initially to 10,000 patients who live in parts of the country with high health care costs.
Experts say smaller practices or those focused on providing house calls are more likely to take part in the program. Only 200 patients per practice are needed, considered the average patient load for a team comprised of a physician and a nurse practitioner that makes only house calls, with no in-office care. The patients may be split among several medical professionals at the same practice.
"This is designed for relatively small practice groups to participate," said Peter Boling, MD, professor of medicine and interim chair of the division of internal medicine at Virginia Commonwealth University School of Medicine in Richmond, who advocated for the Independence at Home program to be part of health system reform. "We are very excited, and we really hope it will become a national program."
Component of ACOs
Physicians who work in house call medicine believe that at least two other aspects of health reform, even though they do not mention house calls, will lead to more of this type of care.
Many expect institutions to incorporate house calls within the accountable care organizations that are due to launch on Jan. 1, 2012. House calls could be used as one part of an ACO's efforts to lower costs as part of the Medicare Shared Savings Program. Participation in ACOs will provide financial bonuses to groups of health institutions and medical professionals that work together to manage and coordinate care for Medicare fee-for-service beneficiaries.
There is no upper limit on the number of patients who eventually will be enrolled in various ACOs across the country, but each qualifying ACO needs to enroll a minimum of 5,000 patients.
"We're expanding rather rapidly" in anticipation of ACOs and other aspects of health reform, said Mike Tudeen, president and CEO of Inspirus. The company, which is based in Brentwood, Tenn., and has offices in several other states, expects to care for 30% to 40% more patients in their homes in the next year and expand its staff of 120 physicians and nurse practitioners. Inspirus is aiming to participate in Independence at Home, but linking with other health care entities to become part of an accountable care organization is possible.
The company will not participate in both Independence at Home and ACOs because it is not allowed under health reform. Inspirus said it is looking at both possibilities in case it does not get to participate in Independence at Home.
ACOs are viewed as the more likely venue for house call practices affiliated with hospitals or large health systems. For instance, Dr. Landers' program at the Cleveland Clinic has grown from four physicians to five during the past year in preparation for the institution's ACO designation.
Several medical societies, including the American Medical Association, are advocating for ACO rules that minimize the barriers for small practices to participate.
A hospital that is not part of an ACO still will need strategies to lower readmission rates and avoid penalties if they are high, another part of the health reform law, which takes effect Oct. 1, 2012. Not all will turn to sending physicians to patients' homes to monitor and provide follow-up care, but some will.
For example, Dr. Cornwell said his two-physician HomeCare Physicians in Wheaton, Ill., which is affiliated with nearby Central DuPage Hospital in Winfield, Ill., will expand to help the facility do just that.
Not for every doctor
Although house call practices are expanding and the physicians say the work is very satisfying, they caution that this type of medicine may not suit everyone.
Some physicians may prefer to spend more time in an office rather than working out of a car. House call patients tend to be complex, with multiple medical conditions. Physicians often need to spend significant time completing paperwork and accessing federal, state and local programs to qualify these patients for a hospice and to receive home health care, durable medical equipment and social services. Many of the patients are on Medicare, but a significant number also are on Medicaid, creating more complications.
The job can be emotionally taxing given the frailty of many of the patients involved. House call physicians say more than 20% of their patients die each year.
"Doctors are our No. 1 referral source, and they are always apologizing because they refer really difficult patients," Dr. Cornwell said. "I tell them that if they are not really difficult, we won't accept them."