The Return of House Calls

Like barbershop quartets and galoshes, house calls seemed a thing of the past—until fairly recently. Over the last decade, a small but growing number of physicians and other medical professionals have begun making home visits, primarily to older and disabled patients. While still modest, the number of house calls to Medicare beneficiaries has risen significantly, from roughly 1.6 million in 1996 to nearly 2.1 million in 2006, according to the American Academy of Home Care Physicians (AAHCP).

A boost in Medicare payments for home visits in the late 1990s made house calls more economically viable and was a key contributor to renewed interest in the practice. So was the accelerating rise in the number of older Americans. The increase in home visits parallels an increase in demand for community-based LTC services in general. Along with the number of older adults in need of LTC, demand for community- and home-based long-term care services— as well as facility-based care—continues to rise. A growing number of providers, including LTC facilities, are offering community-based and at-home services, such as occupational and physical therapy and medication dispensing. Home health has become the fastest-growing segment of Medicare's budget.

House calls are cost-effective, research finds. For disabled and homebound patients, who are less likely to see their doctors and other healthcare professionals for regular checkups and preventive care, they can help avert complications, ER visits, and hospitalizations. “All of those are expensive things that Medicare is trying to prevent,” notes Alfred E. Stillman, MD, who recently published Home Visits: A Return to the Classical Role of the Physician and is co-founder of Home Visit Doctors, a Philadelphia practice that does house calls exclusively. Most of Dr. Stillman’s patients are elderly and homebound due to disability resulting from strokes, lung or heart disease, hearing or vision loss, cognitive or emotional problems like dementia or depression, or, most often, a combination of these. Thanks to technological innovations, clinicians making house calls can provide most everything in the home that can be done in the office. And going into patients’ homes, Dr. Stillman notes, gives healthcare providers a unique opportunity to see how they live and how this affects their health. By visiting his patients, he explains, he can see whether they’ve left their pill boxes untouched for days, whether there are slippery scatter rugs at the top of their stairs, and whether their family caregivers are on the verge of collapse and in need for respite care.

Although Medicare increased home visit reimbursement in the ‘90s, reimbursement has failed to keep pace with expenses. In fact, in 2007, Medicare proposed what the AAHCP estimates would have amounted to a 13% cut in payments in 2008—a drop that the AAHCP predicted would make home visits untenable for many practitioners. Following an advocacy campaign, involving the AAHCP, the American Geriatrics Society and other organizations, on behalf of adequate payment, the Centers for Medicare & Medicaid Services agreed to increase reimbursement this year.

However, earning a living by making home visits is still challenging. Because disabled and homebound patients tend to have a particularly high burden of complex, chronic illnesses, house calls are extremely time-consuming. While the average office-based practitioner may see 20 patients a day, Dr. Stillman can manage no more than five to eight patients daily.

For most physicians, house calls-only practices are unlikely to be practical, says Rebecca Conant, MD, director of the Housecalls Program and an assistant clinical professor of geriatrics at the University of California at San Francisco School of Medicine. All third-year UCSF medical students in family and community medicine learn to conduct home visits through the Housecalls Program, however, and Dr. Conant hopes that graduates will make at least some home visits. “I think the more common model is to have a mix—an office practice with some homebound patients,” she notes.

To further increase older homebound patients’ access to home visits, Dr. Stillman recommends offering retired physicians, who are unencumbered by medical school loans, a short, intensive course covering the medical and social problems of such patients, and assistance with malpractice insurance costs, so that they can launch second careers making house calls to the frail elderly.

As the number of older and old-old Americans rises, boosting access to home visits—by ensuring adequate reimbursement for house calls and investigating innovative avenues to recruiting practitioners who will make home visits—will become increasingly important.