New twist on the old house call
CLOSE YOUR EYES and envision a physician carrying his or her black bag to make a house call on a frail elderly person, someone with a disability, or even an aging baby boomer. Does this image seem as outdated as multi-week hospital stays? Actually, house calls, with their potential to lower costs while improving healthcare quality, are more relevant than ever.
Today, a disproportionate percentage of rising healthcare costs are tied to the expense of caring for those with complex chronic illnesses and serious disabilities. This population cannot easily get to the doctor's office or have their needs met in a 20-minute visit. In our approach to caring for these patients, there are many missed opportunities to prevent complications requiring costly hospitalizations and nursing home placements.
In greater Boston, house calls are coming back, but with a 21st century twist. Each month, 500 elderly, disabled, and chronically ill persons who are enrolled in a special primary care program receive visits from clinicians committed to helping them retain their independence and health. The person making the house call, however, is more likely to be a nurse practitioner than a doctor. In addition to a stethoscope, the bag is likely to contain a laptop computer that connects the clinician to physicians, hospitals, and an entire array of support services.
House calls may evoke warm, fuzzy feelings in those of us who remember them, but the reason they should be revived is anything but sentimental. House calls are a crucial resource when the goal is to keep frail older folks in their own homes - and home-based care can help save significant dollars that are currently being spent unnecessarily.
Urban Medical, a Jamaica Plain-based, nonprofit primary care practice that is marking its 30th anniversary, is one organization that is demonstrating the benefits of home-based care. It provides house calls to the 500 individuals mentioned above.
A recent analysis looked at 90 frail elderly Urban Medical patients who are enrolled in the Massachusetts Senior Care Options Program. Their total healthcare costs were 40 percent lower than the cost of care for similar patients not receiving house calls. (Actual costs for the study subjects were compared to Medicare and Medicaid combined premiums, which represent the expected cost of care for patients with similar conditions.) Most of the savings came about because of hospitalizations that were prevented and nursing home placements that were deferred.
Consider these savings in the light of $440 billion in Medicare spending last year and the 78.2 million aging baby boomers, and the potential of this approach becomes obvious.
Urban Medical, along with similar organizations in other cities, illustrates one way to deliver such care. It does this by taking the burden off the individual physician and redistributing it to a team of providers including nurse practitioners, social workers, nonprofessional coordinators, and physicians.
The team approach is more expensive and more resource-rich than the traditional doctor-centric primary care practice. House calls alone cost about $150, or twice as much as office visits, which is why they nearly disappeared in the 1960s in the face of shrinking reimbursements. But the Massachusetts Senior Care Option experience suggests that this additional cost is more than offset when house calls are a part of a system that assures continuous management of all healthcare needs, at all times, through all settings. This model contrasts sharply with the fragmentation and depersonalization of our prevailing healthcare system.
To reintroduce the house call on a meaningful scale, Medicare, Medicaid, and private insurers would need to make fundamental new investments in our endangered primary care system. A few policymakers are just beginning to tackle this challenge. For example, Senate President Therese Murray has proposed legislation to strengthen the primary care system in Massachusetts.
Since 1946, baby boomers have set the pace for our society. The generation that redefined youth is now redefining age. Let's hope the boomers now take up the cause of reforming primary care - and bringing back house calls - as they approach their own golden years.
Dr. Elizabeth Kass is medical director of Urban Medical. Dr. Mark L. Zeidel is chief of medicine at Beth Israel Deaconess Medical Center. 