A Doctor in the House

By Lois Gilman

New York City lawyer Judith Kurzweil is juggling a lot of balls. She works full time and has twin daughters, 10, at home--and more than two years ago, her mother Irene, 86 and struggling with her health, moved in with the family. In Kurzweil's mind, a nursing home was not the right choice. But her mother's poor health made getting her to a doctor very difficult. Kurzweil's solution: Dr. Andrew W. Lyons, a New Age Marcus Welby who makes house calls, little black bag--a padded black computer bag--and all. "It's an amazing lifesaver," says Kurzweil. She has time for her daughters and career, and "Dr. Lyons permits my mother to stay with her family."

The house call is making a comeback. Not a decade ago, doctor visits to the home were declared a "vanishing practice" in the New England Journal of Medicine. Now experts predict that as time-strapped baby boomers age--and their parents survive to be superelderly--the demand for doctors who are as comfortable examining patients in the bedroom as in the office will soar. Medicare data show a 37% surge to more than 2 million home visits by physicians from 1995 to 2005. That is partly because Medicare changed the rules for reimbursement in 1998, making house calls an attractive model on which to build a practice. The rules were further altered for 2006, allowing doctors who visit patients in assisted-living facilities to bill the same rates as for residential visits. Current proposals before Congress could reduce those reimbursement rates, however, making home visits a less attractive option for doctors.

That would be a shame, because one of the fastest-growing segments of the U.S. population is those 85 and up. Many are, like Kurzweil's mother, frail and in need of multiple medications and frequent doctor's care. Since it's hard to get around, they often delay seeking treatment until an illness is full blown and then call 911. That becomes time consuming and costly and can lead to a family crisis. "When elderly patients go to the emergency room, doctors are very uncomfortable about sending them home" right away, says Dr. Joseph W. Spooner of Care Level Management in Woodland Hills, Calif. "So they admit them, and patients stay three or four days." Then the sons and daughters are called in to quickly figure out what to do next.

A regimen of at-home doctors' visits can ward off some of those problems. "We get call after call from desperate relatives," says Constance Row, executive director of the American Academy of Home Care Physicians, a national organization based in Edgewood, Md., that lists on its website aahcp.org doctors and other providers, like nurse-practitioners and physician assistants, who make house calls. "Often it's a son or daughter-in-law trying to find care for a parent in another part of the country," she says. "Other times it's the spouse of someone who needs care, and they are unable to find it. The stories are heartbreaking."

Row estimates there are 1,000 full-time house-call practices in the U.S. The doctors typically have a background in internal or family medicine, but other specialties, like geriatrics and emergency-room care, are also represented. Many of the physicians are in small practices. But a few are part of large practices, like New York City's Mount Sinai Visiting Doctors Program, with 11 doctors and a support staff of nurse-practitioners, nurses, social workers and administrative assistants.

The modern-day black bag still contains a stethoscope but also a cell phone and a personal digital assistant like a Palm or laptop with detailed patient histories. Moreover, "most point-of-service diagnostic equipment has become so portable that house-call physicians have the capability of providing care comparable to an urgent-care center in the home," says Dr. George Taler, co-director of the Washington Hospital Center Medical House Call Program in Washington. "Even intravenous therapies, medications and oxygen are readily available at the time of the visit if the physician wishes to offer advanced care for those patients who would prefer to avoid the emergency room or, for that matter, the hospital. It may seem counterintuitive, but many physicians who make house calls an important part of their practice are far more technologically equipped than most of their colleagues who confine their practice to the office. It makes the office seem devoid of information."

Lyons, Irene Kurzweil's physician, started doing house calls six years ago. "This is the only thing that I found really satisfies my desire to be a doctor," he says. "I am involved in my patients' lives and get to know them as people." His black bag includes a Palm computer that has wi-fi for e-mail, a special database for patient histories and lab results, and a customized word-processing program. He also carries a battery-powered electrocardiogram (ECG) machine and portable lab kits to do finger sticks that test blood-glucose levels. The doctors often work with lab services that send out technicians to draw blood and with medical companies that provide portable X-ray machines, scanners and ultrasound devices.

While colleagues in an office-based practice see about 25 patients daily, house callers see just six to eight. "But once you've made one or two house calls, the power of the setting is very clear," says Taler. Dr. Thomas Cornwell of HomeCare Physicians in Wheaton, Ill., has made 19,500 house calls since he started in 1993. While he notes that "we do all our own blood draws because we do not have a service in the area that does blood drawing," he believes that he can do a better physical of his patients at home. "I can't give them a good exam at the office because they can't get out of the wheelchair," he says. "At home in bed, you can examine the whole body." He can also snoop around the house. "We open a lot of refrigerators and look at bathrooms," he says. "You find patients are taking their medications wrong. You try to prevent crises, and nothing can do that better than seeing people in their own environment."

Advocates of house-call medicine say it also saves money. In July 2005 the Centers for Medicare and Medicaid Services awarded California's Care Level Management funding for a three-year demonstration project to provide house-call care to 15,000 Medicare recipients in California, Texas and Florida. This month an additional 13,600 beneficiaries are being given the chance to participate in the program. "If you provide that very intense level of physician service, you can potentially eliminate some very costly hospitalizations or trips to the emergency room," says Jeff Flick, a regional administrator for Medicare services based in San Francisco.

The savings are clear enough to Patricia Guiles, 74, of Palm Bay, Fla., whose husband Harold, 77 and in poor health, fell and couldn't get up. She called 911. But by the time the ambulance arrived, she had talked with her husband's house-call doctor by cell phone. She sent the ambulance away, and the doctor came, checked her husband's heart with an ECG, gave him a shot and adjusted his medication. The next day the doctor sent a technician with a portable electrocardiograph to check his heart. "This is much more intimate care," she says. And she saved thousands of dollars by staying out of the emergency room.

But house-call care isn't really about money. It's about a system that benefits every generation in a close family. "The routine care is irreplaceable," Judith Kurzweil says of Lyons' visits. Because her mother can live at home, Kurzweil says, "my daughters have time with their grandmother. They walk into her room and talk with her, and she lights up when they come in and tell Grammy something." That may be the best medicine of all.