House calls as cost-saver in health care reform?

[November 02, 2009]  RICHMOND, Va. (AP) -- The doctor doesn't look like much of a crusader, bent over the frail frame of 90-year-old Alberta Scott.

He has a lavender stethoscope strung round his neck and some serious bedside manner at work on this stubborn nonagenarian who wants to be anywhere but where she is: in a nursing home bed, hoping to heal and get back home.

"Squeeze my hand," Dr. Peter Boling prods. "Squeeze my hand. Come on. Hard!"

This is Boling's day job, providing medical care to some of Richmond's oldest and sickest patients. A geriatrician and head of general medicine at Virginia Commonwealth University Medical Center, he visits nursing home patients with a smile and an encouraging word, and he leads a team of specialists who take to the road, medical bags in hand, to see patients where and when they need it most -- in their own homes, before a crisis lands them in the ER or a nursing facility.

Boling and his team make house calls.

And now he is on a mission: to convince Congress that the old-fashioned house call could be a fresh answer to the modern-day health care reform dilemma.

There are house-calls programs here and there. San Diego. Boston. The Veterans Health Administration cares for thousands in their own homes, saving money by reducing unnecessary hospitalizations and emergency room visits.

But Boling wants to bring house calls to the masses -- up to 3 million of the most high-risk, high-cost Medicare patients in the country. The idea is not just cost savings, but to provide a financial incentive to persuade more doctors to return to this kind of work. It's also about improving access and providing patients the independence they so desire.

Mostly, it's about people like Alberta Scott and the questions that first came to Boling's mind when he heard she'd been admitted to an institution for treatment of a blood infection.

In a few weeks, if all goes well, can she go home? If so, who will take care of her?

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At 55, Boling has a vague memory of his own pediatrician standing in the kitchen of his childhood home. It's not an image many of us can conjure in an era of overcrowded ERs and specialty clinics and the type of "managed care" that often means a long wait in a sterile reception room followed by a hasty examination.

The visiting doc went out not long after the horse and buggy, as technology advanced and institutionalized health care became the norm. In 1930, house calls accounted for 40 percent of doctor-patient encounters. By 1980, that had dropped to less than 1 percent. Today, about 4,000 of the nation's 800,000-plus doctors make house calls a substantial part of their practices, although nurses and physician assistants have picked up some of the slack, the American Academy of Home Care Physicians reports.

Boling was just a young doc himself, finishing up his residency, when a mentor persuaded him to spend half his time doing clinic work, and the other half developing a house-calls program. Like most medical students today, Boling had never thought about making house calls a part of his practice. He nevertheless hung a giant map of Richmond on his office wall and began identifying patients who lived within a 15-mile radius of the downtown VCU medical center.

Each home was marked on the map with colored pins, and visits were scheduled by geography -- north, south, east, west -- to maximize Boling's time. It took only a few stops, and some memorable patients, for Boling to recognize that home care made sense.

There was the stroke victim restricted to a second-floor bedroom in his home. Time and again his wife had to call an ambulance, whose crew carried him by stretcher down rickety stairs to an emergency room -- for a bloated gastrointestinal tract, high fevers and vomiting. Turns out, the patient had low blood potassium levels.

Boling began drawing blood at the house and prescribed a medication that stabilized his potassium, and staved off ER visits.

"It was so stark," says Boling, "the contrast between what he needed and what (the health care system was) giving him."

There was another stroke survivor, also blind and diabetic, who was being shuttled to a vascular surgery clinic to have surgeons scrape away foot ulcers. Boling began stopping by once a month, using his scalpel to do the very same work in the patient's home.

These are the types of patients Boling envisions being cared for under the proposal now pending in Congress. The so-called "Independence at Home" provision is but one small piece of the comprehensive health care reform measures being debated in the House and Senate.

Where other proposals have divided lawmakers, the house-calls idea is winning support from Republicans and Democrats alike. Perhaps because it targets the bane of the health care system: a Medicare program on the verge of insolvency and the small percentage of patients who account for the bulk of the program's costs.

"This legislation offers a higher quality and more cost-effective way for these patients to get the coordinated care they need in the comfort of their own homes," says North Carolina Sen. Richard Burr, a conservative Republican.

The provision calls for the Medicare program to partner with home-based primary care teams like Boling's for a pilot project to test whether house calls would reduce preventable hospitalizations and readmissions, ER visits and duplicative diagnostic tests for high-cost, chronically ill patients.

That means patients with at least two chronic conditions -- congestive heart failure, diabetes, dementia, stroke and so on -- who have been hospitalized in the past year and require assistance for at least two daily living activities, such as bathing, dressing, walking or eating.

Patients with multiple chronic conditions account for some two-thirds of Medicare, the almost $500 billion federal health insurance program for those 65 and older or disabled.

Medicare officials declined to discuss the idea, but Mark McClellan, who ran Medicare under President George W. Bush, called the proposal one that "could lead to cost-savings and better outcomes" for patients.

"It's definitely worth trying," said McClellan, adding that the strength of the proposal is that practitioners must demonstrate savings in their patients' medical costs in order to get a portion of that savings back from Medicare.

That might be easier said than done. Participating practitioners would have to coordinate care in a way that actually reduces all those visits to various doctors and hospitals and, McClellan said, "that's hard to implement in real-world health care."

The Department of Veterans Affairs launched its own house-calls program back in the '70s targeting an expanding population of older veterans suffering from multiple chronic conditions. There are now some 20,000 vets enrolled, and a 2002 internal study showed a 24 percent total reduction in their cost of care. Another analysis of one program in Missouri showed costs going from $45,000 per patient per year to $17,000, said Dr. Thomas Edes, who runs the VA program.

Boling and some other house-calls physicians came up with "Independence at Home" in partnership with the American Academy of Home Care Physicians. They've visited with Medicare officials to try to sell it, had sit-downs with members of Congress, urged friends to "write their congressman" to drum up support.

True believers, Boling calls these docs-turned-lobbyists. Urban cowboys in tweed jackets. People like Dr. Gresham Bayne, a former chief of emergency medicine at the Naval Regional Medical Center in San Diego who started his "Call Doctor" program in 1985, after determining that many of the folks he saw in ERs didn't need immediate physician attention.

"We've never made any money, but we've never had any regrets," Bayne says of the effort.

Boling takes a "Field of Dreams" approach to the money side of things. If Medicare shared the savings, house-calls teams could recoup more expenses and pay better -- and the doctors would come.

But another challenge is persuading doctors to return to a practice that is unfamiliar now to many and looks much different in today's world than the romanticized house-calls practice of old.

Technology has certainly made the job easier. Electronic medical records are available via laptop computers. One bulky bag can carry diagnostic tools to test blood, urine and oxygen levels, a blood pressure cuff, an eye chart. Portable, digital X-ray machines are also available, as are portable EKG machines.

But Dr. Linda Abbey, a member of Boling's house-calls team for two decades, has also carried a few non-medical items, just in case: an emergency whistle, pepper spray -- though she's never had to use it -- and dog biscuits to keep strays at bay.

Cathi Smigelski, a VCU nurse practitioner who's been doing house calls for nine years, noted there's never been any violence against home health care workers in the Richmond area. Still, she says, "All of us have had occasions where we've gone into areas that have a lot of drug trafficking, and you have to sometimes say I can't go anymore."

But that hasn't turned her off what she sees as a worthwhile endeavor.

"I believe in what we do, and I know that we do make a difference for the patients that we take care of. Peter always says, if all of you docs just did a few, we wouldn't have a phenomenal need. You're going to build a relationship with somebody special. And that person is going to get to a point where they're not going to be able to come see you. Do you say, 'Sorry, I don't want to see you anymore'? Or do you say, 'Well, let me catch you on my way home'?"

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Boling's one-man show has grown into a nine-person effort, with three doctors, five nurse practitioners and a social worker caring for about 275 patients and 50 waiting to get into the program.

Abbey traded an office practice for house calls. She puts 25,000 miles a year on her Honda Civic visiting one to six folks a day, patients like 83-year-old Edith Taylor, who's lived in the same gray clapboard house for 60 years -- save the 2 1/2 years that she spent in a nursing home following a stroke.

"It wasn't nice. I was determined to come back to my home," Taylor said after a recent checkup. For the past six years, Abbey's been knocking on Taylor's door and examining her in the middle of a mint green living room decorated with silk flowers and ceramic figurines. "She calls me. She gives me plenty of time to prepare for her. It's a great thing, that's all I can say."

During the latest visit, Abbey took her blood pressure, listened to her lungs. But there are always important tidbits Abbey picks up just from being in a patient's home. When Abbey ventured into Taylor's kitchen to check her medicine box, she noticed some pills had gone untouched.

"You can learn so much about people, not just socially but also medically. You look at what they have. You see the interaction with caregivers. You look at the pills," Abbey says. "It's much easier to develop a medical plan of care if you know all these things."

Such was the case with Smigelski and Alberta Scott.

The day before Boling visited the 90-year-old, Smigelski briefed the team. She first saw Scott in her home in late August, after she'd been released from the hospital for treatment of a low heart rate. The spunky woman told Smigelski that she had plenty of help from her friends at church and a boarder who rented an upstairs room.

It took only a couple of visits for Smigelski to see that while Scott talked a good game, she was worse off than she let on.

"She's not eating the way she should. She's not participating in her personal care needs," Smigelski says. "You start to see the ripple of health problems and how they get more complex."

Scott quickly deteriorated. She returned to the hospital for a small bowel obstruction and was discharged again only to come down with a urinary tract infection. Back in the hospital, doctors also detected the blood infection that requires two weeks of intravenous antibiotics, resulting in her transfer to the nursing home where Boling saw her.

That afternoon, as Boling examined her, Scott seemed small but still had fight. When he told her to squeeze his hand, she squeezed so hard Boling responded with an "Ow!"

Her niece, Mary Cotton, was visiting from Washington, D.C., and told Boling that Scott desperately wants to remain independent at home.

"What do you think is the right thing to do?" Boling asked Cotton, herself 79 years old.

"It's hard to make that decision," she said, noting that her aunt couldn't afford to pay someone to stay with her round the clock.

So Boling's team is working to get Medicaid to cover a personal care aide. That could take up to 60 days. Should Scott recover from the infection before that, Smigelski has arranged for temporary housing in an assisted living facility.

Ultimately, Smigelski and Boling hope that Scott can return home. If she does, she'll become a regular on the house-calls rotation. Boling knows exactly why.

"When I started making visits ... and I saw how poorly we were doing taking care of them and how much happier they were when we changed their care from the clinic to their home, I realized that for that group of people, it was just better," Boling says.

"It was just better to do."

[Associated Press; By PAULINE ARRILLAGA]

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