- BIOETHICS FORUM ESSAY
Back to the Future: Reviving House Calls
When I was growing up, Dr. Redlich, our family physician, made house calls. Before the era of immunizations for common childhood illnesses, children got sick a lot. A refugee from the Nazis, Dr. Redlich had a thick German accent and a heavy hand with a needle (this was the beginning of the unfortunate shot-of-penicillin-for-everything enthusiasm). “Breeze in and breeze out,” he would command. After listening to my lungs, he would declare sadly, “No school for you, mein kind.” Then he would have tea with my mother and grandmother, and my father would give him some special steaks from our meat market.
How quaint! How premodern! How humane! In the post-modern world of medical care, in tiny cold examining rooms across the country doctors instead of patients breeze in and breeze out. Doctors have less and less time as medical care has become more and more complex. Insurance influences and sometimes determines care. Patients are now urged to be good “consumers” and opt for less care or at least less expensive care. What place is there in this world for the old-fashioned house call?
Quite a bit, it turns out. As the population has aged, and as chronic care has replaced acute care as the dominant health care need, entrepreneurs have returned to the house call as the most cost-effective way to serve homebound and frail patients. Care Level Management, a Woodland Hills, California, company that serves 13,500 chronically ill patients in five states, guarantees to Medicare and private insurers that they will save money by reducing emergency room visits and hospitalizations. Care Level Management gets a flat monthly case rate and a fee for each visit. Doctors are paid an annual salary of about $175,000.
Patients have to meet specific criteria – two chronic illnesses and two hospitalizations within the previous year. Patients and families are enthusiastic about 24-hour access to a physician and a nurse practitioner. While it may be unfair to judge a program from its web site, the company’s home page photo shows a doctor approaching a comfortable private house with a neat garden and an American flag flying from the porch, suggesting a middle-class suburban target population.
House calls are also being revived in urban settings by academic medical centers and doctors in smaller practices. Medical center programs generally serve urban poor populations. The academic programs also train medical students and resident physicians and provide a comprehensive team approach addressing psychosocial needs and family caregivers.
The problem is that, unlike the for-profit sector, they lose money. Hospitals and academic medical centers subsidize this service because they hope to be the destination of choice when the patient does need hospitalization and because they are a prime teaching resource. Since these are the oldest, frailest, sickest patients, hospitalization will likely be necessary at some point no matter how successful the house call program (see K.L. Smith et al., “A Multidisciplinary Program for Delivering Primary Care to the Underserved Urban Homebound,”Journal of the American Geriatrics Society 54 (2006): 1283-89). The Academy of Home Care Physicians is urging Congress to allow home care physicians to bill Medicare on a monthly rate, on the Care Level Model, instead of solely on a fee per visit, which doesn’t cover the costs of a comprehensive service.
If indeed we are going back to the future, it is important to ensure that house call programs address the complete range of needs of the ill or elderly person. Someone who is homebound is almost by definition isolated; so is the person who cares for him or her, usually a family member. In that respect, a recent set of national quality-of-care standards in home-based primary care, created by a committee through a multistep progression of decision trees (Annals of Internal Medicine, February 6, 2007), is discouraging. Even though the article abstract refers to improvements in quality of life, the social and familial context is almost entirely absent. Depression is addressed by several standards but treatment options include only medication and referral to mental health professionals, with electroconvulsive therapy for psychotic depression. When a “caregiver” is mentioned, the references are oblique and fail to identify whether the caregiver is an unpaid family member or a paid home care aide.
Some standards are simply bizarre. The entire standard for “caregiver support and patient safety” under “dementia” reads: “IF a homebound patient with dementia has a caregiver (and, if capable, the patient assents), THEN the physician should discuss or refer the patient and caregiver for discussion about patient safety, provide education on how to deal with conflict at home, and inform them about community resources for dementia” (caps in original). And if the patient dissents? Patient safety goes out the window – literally, perhaps? And the caregiver gets no education? This pro forma nod to patient autonomy ignores the reality of caring for a person with dementia.
Similarly, under “care of the dying patient,” caregiver burden is the final standard: “IF a homebound patient dies at home, THEN assessment of caregiver burden should be documented” (caps in original). Documenting the caregiver’s burden at that point is no help at all. After all the options were voted on, narrowed down, and compiled, did no one read the entire list to pick up non sequiturs and just plain weird formulations?
House calls will never again become a prominent mode of physician practice, as it was when I was growing up. And given the advances in diagnostic medicine and science, that’s a good thing. But house calls are a good option for many people who need frequent monitoring, cannot get to doctors’ offices, cannot tolerate long waits, and cannot “hop up on the examining table.” There should also be time for tea with the family.
Carol Levine is director of the Families and Health Care Project, United Hospital Fund, New York City. She is the editor of Always On Call: When Illness Turns Families into Caregivers(Vanderbilt University Press, 2004); and (with Thomas H. Murray) The Cultures of Caregiving: Conflict and Common Ground among Families, Health Professionals and Policy Makers(Johns Hopkins University Press, 200