Yes, Doctor, Come On In…

The article, “Having Almost Become Extinct, House Calls Stage A Welcome Recovery,” reports that although doctors making house calls stopped in the 1980s because of lack of insurance coverage, a small group of doctors, nurses, physician assistants, and practitioners are “reviving this once-common practice for keeping Americans healthy and in touch with their doctors.” I say, about time. I miss those days when you could call the doctor late at night and he’d come to your house to check on you, instead of you having to drive to the ER and wait for hours to hear, “Oh, it’s just a cold. Take two aspirin and call me in the morning.” According to the article, “For generations, the home visit was an institution, something a doctor, black bag in hand, just did. In 1930, house calls made up about 40 percent of physician encounters with patients in the United States, according to a recent article in the journal Clinics in Geriatric Medicine. By 1950, that number had dropped to 10 percent. And by 1980, home visits accounted for a mere 1 percent.”

I guess the question here is what are the ethical implications to house visits? How will this affect new regulations, like HIPAA? House calls faded away because of technological advancements, increased non-coverage by private insurance companies, and financial incentives. “As new diagnostic tools and advanced treatments became available in hospitals and clinics, that's where people wanted to go…More doctors chose specialized fields that relied on the technology of hospitals, while those who chose primary care could see easily twice as many patients in offices and clinics as they could traveling from home to home…And then there's the fact that private insurance has rarely fully covered such visits.”

Too, I would suspect that many doctors’ malpractice insurance premiums would drastically increase. With home visits, how will the doctor insure himself against being sued for wrongful deaths and other medical malpractice? Without the supervision of other staff members as well as the necessary tools if something goes wrong while at the home visit, doctors increase their risks for malpractice suits. However, I would think this practice would increase quality of life for the elderly, who have problems making it to doctor’s visits, but need them regularly. According to the article, home visits are increasing quality of life for the “forgotten population,” who don't see a doctor routinely because getting out is so difficult, are “getting much lower-quality care than they should have.” Too, this would also help reduce costs for the elderly by decreasing the amount of co-pays for each clinic visit.

Although the practice of house calls has long been uncommon in the U.S., it is still common practice in other countries, including France, Denmark, Netherlands, and Canada, according to the article. “According to the Clinics article, in Britain, which has a strong tradition of primary care medicine and a national system of subsidized health care, doctors make 10 times as many house calls per 1,000 patients each year as do U.S. doctors.” Though we don’t hear much about doctors making house calls in these times, Medicare modified its billing procedures in 1998 to enable practitioners to easily receive payments for house calls. “Since then, Medicare statistics show a large bump in physician house calls, from 1.5 million in 2000 to almost 2.2 million in 2007.”

Although technological advancements were one reason for the decline in house calls, “Ironically… technology has now made the house call a reasonable alternative to office or hospital visits for certain patients. Doctors still rely on the black bag basics (stethoscope, otoscope, blood pressure cuff, blood-drawing equipment), but now they also come equipped with laptops with electronic medical records and wireless capabilities, portable EKG machines, even bedside X-ray and ultrasound devices that were once found only at a hospital, according to Ernest Brown of Unity Health Care, which mainly serves poor people in the District.” In addition, “Point-of-care testing (where blood, urine and other tests are done at the bedside, with results available in minutes) has become so easy that home-care practitioners can operate very efficiently.”

So, why are more people not taking advantage of this practice? Why are more doctors not making house calls and encouraging this practice among their colleagues? “According to the Clinics article, studies have suggested that house calls may keep people in their homes longer and reduce mortality, particularly in the frail elderly population. That is probably due in part to physicians' being able to identify new or worsening medical problems that, left untreated, could contribute to further disability and even death.” Increased quality of life should be reason enough for physicians’ to begin offering house calls as part of their clinic visits, especially for the elderly who have to see a doctor regularly, but are not able to get out. Not only will this improve quality of care, but it will reduce costs associated with caring for the elderly. The article states that, “Although homebound patients represent only 5 percent of the Medicare population, they consume more than 43 percent of the budget, according to a congressional analysis. An ER visit can be more than 10 times the cost of a typical house call, which Row pegs at $100 to $150.” However, on the other hand, “…the cost-saving benefit of house calls might actually hurt the medical centers that provide them.”

So, the question would be, is it better to increase quality of life by providing house calls or not provide them to maintain quality care at medical centers? Is it better to enhance the life of elderly patients, increasing the length of their lives, or risk decreasing their quality of life for monetary purposes? I know that I’d love it if my mother’s physician provided house calls to her patients, and especially when my father was getting sicker with Alzheimer’s and getting him to office visits became a chore. Many times we had to take him to the ER for non-emergencies that could have been taken care of at home. It would have definitely made life easier. That would have been one less argument and one less frustration.