Doctors find home visits a flexible practice option

When Michael Smothers, MD, decided to start his own practice, he had to make a few trade-offs.

He had to give up his office. But for that sacrifice, he gained nearly unlimited flexibility.

Dr. Smothers, a family physician in Elkhart, Ind., started a full-time home-care business a few years ago, and feels like he's making a good living practicing the type of medicine he's always enjoyed.

"I was disillusioned with the lack of autonomy I had at hospital-based practices," said Dr. Smothers, who operates Housecalls LLC with his wife, a nurse. "I began making house calls in my residency, and no matter what I did, I always tried to include some house calls in my practice because it was the most satisfying part."

While other physicians might not be creating full-fledged home-care businesses, it appears some are finding house calls satisfying and lucrative enough to make them part of their practices.

While membership at the American Academy of Home Care Physicians has remained steady at about 700 over the last few years, the database of physicians providing home care has risen dramatically, said Constance Row, the Edgewood, Md.-based academy's executive director.

When the academy started a directory of home care specialists on its Web site about five years ago, the listings represented only 14 states. Now, close to 40 states, Washington, D.C., and Puerto Rico are covered.

Based on data provided by the Centers for Medicare & Medicaid Services, the academy has calculated the number of submitted house call codes to be about 1.8 million in 2003, up from about 1.7 million in 2002. House call codes were 1.6 million in 2001 and 1.5 million in 2000, according to the academy. Attempts to obtain home visit data from CMS were unsuccessful.

Those numbers are divided among anyone who would be performing house calls, but Row said primary care physicians make up the majority of them. Some are like Dr. Smothers, who finds referrals from sources as varied as churches and home health agencies. He has had to be creative in his marketing strategies to compete with the local hospital for business.

There are many ways to incorporate house calls into your practice. Dr. Smothers, for example, tries to limit his patient population to seniors.

What makes home care a tricky industry financially is dealing with either Medicare or Medicaid populations. Declining reimbursement rates have been squeezing physicians for years. Reimbursement for care in assisted-living facilities, for example, is even lower than what physicians receive for a normal house call, Dr. Smothers said.

Steven Phillips, MD, an internist with geriatric training in Reno, Nev., also limits his care population to Medicare patients. But his practice, Geriatric Care of Nevada, which includes a physician partner, four nurse practitioners and a physician assistant, serves patients in office, home and nursing home settings.

Although he has seen physicians try a full-time house call practice to reduce overhead costs, he advocates a more diversified approach, because it gives you fallback options.

"With health care in general and Medicare specifically, the more options you have for delivery sites, the more opportunities you're going to have to stay gainfully employed," said Dr. Phillips. He added that reimbursement rates were best in the office setting, followed by house calls and nursing facilities.

Dr. Smothers said his income was very close to what he made at his previous practice before adding incentives such as a bonus and health insurance. He now has to pay for his own benefits and his overhead expenses, including the salary of a part-time receptionist, medical liability insurance premiums and some supplies.

The overhead costs are "almost nothing," Dr. Smothers said. But "our practice is very sensitive to Medicare reimbursement rates."

The flexibility of his practice, however, allows Dr. Smothers to supplement his income through part-time urgent care and locum tenens work, which he pursues on a fairly regular basis.

It all adds up to a financially comparable, less stressful work experience, compared with his days of running from office to office.

"This type of practice allows for that," he said. "It allows for travel when I want because I can set my schedule fairly loosely. The lifestyle's a bit easier."