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Disruptive Innovators: Physician house calls making a return

The return of doctors to homes provides a better model for caring for the frail elderly

It wasn’t so long ago when it was common for a physician to visit patients in their homes. New technologies and a changing healthcare system placed physicians firmly in their offices, forcing patients to go to them. But the adage of everything old becomes new again is proving true. Physician house calls are making a comeback and disrupting today’s healthcare system.

For 15 years, family physician Brian Mathwich worked in an office-based practice in Colorado, feeling like he wasn’t providing the care that many of his sickest patients really needed. These frail patients had a hard time getting to his office, and some couldn’t leave home at all. Minor problems snowballed into serious ones requiring ER visits and hospitalizations.

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Mathwich left office-based practicing and started a house call practice three years ago. He was the sole provider in the beginning, but the demand became so great, his one-man house call practice expanded to six primary care providers and a psychiatrist. In June, Mathwich’s practice was acquired by the Visiting Physicians Association, one of the country’s largest house call companies serving patients in 10 states, and he became the practice’s regional medical director.

Mathwich is not alone in recognizing that the frail elderly population needs a kind of care that is hard to achieve in today’s healthcare system. That’s why returning to physician house calls is the way to go with these patients, says Alex Binder, the chief operating officer of New Jersey-based Visiting Physician Services.

Today’s healthcare system is “industrialized medicine,” Binder said. “It’s everything by algorithm and computer,” which is fine for much of the population, but not everyone.

 “What we have found is there’s a segment of the population – primarily the frail and elderly – where those algorithms and that entire model causes more harm than good. It absolutely causes unnecessary expenditures. It’s not cost effective. It’s not in alignment with what the patient and the family probably would prefer for these last few years of life,” Binder said.

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“What has worked for their first 82 years will not work for their last three.”

From Binder’s perspective, it only makes sense to extract the frail elderly out of the “industrialized medicine” system and put them in a parallel system based on home health services.

The frail elderly, with multiple, chronic conditions, are better served by house calls, Binder said, because they get the medical access they need when they need it and they don’t have to leave home or utilize more costly resources to get it.

“If their only option is to continue to go back into the industrialized system,” he said, “their last three years of life is going to end up costing Medicare a half a million dollars and the outcome is going to be no different, or possibly worse, than it would have been if they were in this alternate environment.”

The potential for cost savings for a population that is one of the biggest drivers of healthcare costs has caught the attention of policy makers. The Affordable Care Act created the Independence at Home Medicare demonstration project. The IAH, a delivery and payment model that uses primary care teams treating patients in their homes, began in 2012 and continues through 2015.

According to the American Academy of Home Care Physicians, home-based primary care has the potential to save Medicare 20 to 40 percent. And while a house call visit may cost more than a visit to a physician’s office, house calls, by preventing visits to the ER and hospital, save money. The cost of 10 house calls is offset by one prevented $1,500 ER visit, says the AAHCP.

Not everyone is enamored of a return to house calls, though, said Constance Row, AAHCP’s executive director.

“I’ve never heard anybody say it’s a bad idea except the people who are completely wedded to their extensive investments in outpatient buildings of one kind or another and who do not want anything that is going to reduce the dependence on this built up infrastructure that, quite frankly, is not doing what the patients need and also isn’t needed any more,” she said.

When doctors didn’t have much in the way of diagnostic tools, they brought their stethoscope and a few supplies to their patients’ homes in their little black bag. The creation of technological tools that couldn’t be easily transported parked those doctors in offices.

Where once technology chained them, the miniaturization of technology – laptops, smartphones, mobile labs, mobile x-rays – is now setting them free, said Row. “Everything can be brought into the home that used to require an office visit,” she said. And with that technology, doctors can keep many patients out of the ER, out of the hospital and out of nursing homes – saving a bundle of money.

“The idea that you could, in fact, have mobile providers who are providing care at the same level, or in some cases, a higher level, than what’s available in the office is in fact mind-boggling, and for that reason, some people just reject it out of hand,” Row said. “But I will tell you, for the people who need it and for the people who are doing it, it’s something that just needs to happen.”