The rise of house calls
Peter Boling, M.D., graduated from medical school almost 40 years ago, and his career has been driven by a single question.
“Is the hospital emergency room and the inpatient ward the best way to solve the problems of an immobile 80-year-old with complex multimorbid conditions who can't get around within her own house very easily, never mind getting out of the house?” he says.
It might have been an honest question in 1984 when he established the VCU Medical Center House Calls program in Richmond, Va., to deliver home-based primary care to patients too frail or disabled to get to a doctor’s office without considerable duress. But these days, it’s a rhetorical question; research has documented that house calls for frail and elderly patients improve care — and reduce costs.
Despite that, home-based primary care has been slow to catch on. About 2 million older Americans are effectively homebound because of their health, but fewer than 12 percent receive primary care services at home, according to a study published in JAMA Internal Medicine in 2015. That’s because house calls are expensive to deliver, health care payment systems do not adequately support them and the workforce is severely limited.
But as the concept of value gains traction in health care, home-based primary care for frail and elderly patients is proving itself to be a Triple Aim winner. The nation’s largest payer — Medicare — is finding that house-call providers in the Independence at Home shared savings demonstration are saving the government money. And some Medicare Advantage plans and accountable care organizations see house calls as a value-based strategy.
Linda DeCherrie, M.D., a geriatrician who directs the largest academic house-call program in the country, believes that the payment hurdle is about to be crossed, prompting home-based primary care for frail and elderly patients to spread quickly.
“There is a lot of movement right now to be able to pay for house calls,” says DeCherrie, director of Mount Sinai Visiting Doctors at Mount Sinai Health System in New York. “[Provider organizations] need to get ready because this is really better care for patients, ideally at less cost, and this is what patients want.”
House calls in action
House calls seem rare, but there are actually many programs across the country, most of which have grown up organically as provider organizations try to meet the needs of very sick patients.
DeCherrie’s Visiting Doctors is a primary care and palliative care program serving patients older than 18; the average patient age is about 85. Its staff includes seven interdisciplinary teams — each team includes two physicians, a nurse practitioner, a social worker and an administrative assistant — and office-based nurses who triage new patients who call in for appointments and provide phone management for existing patients in the program.
Patients typically are seen by a physician every eight to 12 weeks for routine visits, but physicians are also available for urgent visits in between. The program is certified to direct paramedics who, supported by video link to the physician on call, make emergency visits 24 hours a day. “We try to work with the patient to avoid any unnecessary emergency department visits,” DeCherrie says. “One of the most important things is that everyone knows the patient’s goals of care.”
Meanwhile, dozens of other house-call practices have emerged in recent years, each of which has a slightly different approach. In Philadelphia, Penn Medicine’s house-call program makes about 1,500 home visits to patients 60 and older. Housecall Providers, a nonprofit medical group in Portland, Ore., provides both primary care and hospice services for homebound patients of all ages. MedStar House Call Program serves about 550 patients a month, all of whom are 65 or older.
The staffing models, payer mix and after-hours protocols all differ, but they generally have one thing in common. “Most house-call programs are not breaking even under fee for service,” says K. Eric De Jonge, M.D., co-founder of the MedStar House Call Program at MedStar Washington (D.C.) Hospital Center.
The value of house calls
Like many of its peers, De Jonge’s program relies heavily on philanthropic support and subsidies from the health system, in addition to payments from Medicare, Medicaid and commercial insurance, none of which pay enough to cover the costs of care.
About one-third of MedStar’s house-call patients are Medicare beneficiaries covered via the hospital’s participation in the IAH demonstration. In the first year of that demonstration, 17 provider organizations saved Medicare more than $25 million — an average of $3,070 per participating beneficiary, according to the Centers for Medicare & Medicaid Services. In the second year, 15 practices saved more than $10 million, or an average of $1,010 per beneficiary. The average savings reported in the demonstration’s first two years reflect both the big savings — as much as 20 percent compared with that of a control group — from some longstanding house-call programs and the poorer performance of some programs new to house calls, some of which dropped out of the demonstration.
“We did see, pretty much across the board, that hospitalization rates declined across the entire span of all of these programs across the country,” Boling says.
In New York, DeCherrie’s program did not participate in the IAH demonstration, but an internal evaluation, conducted every couple of years, has steadily proved its value. Although the program is not self-sustaining on its own revenues, DeCherrie says, it reduces avoidable admissions and readmissions among high-risk patients, some of whom are covered by value-based contracts.
“Those are outcomes that Mount Sinai looks at to help understand our financial picture and why we have been supported all this time,” she says.
Thus, advocates point to two ways to consider the value of house-call programs: shared savings, which help to support high-quality programs, or reduced hospital utilization, which helps organizations that work in value-based contracts.
DeCherrie and other advocates are eagerly awaiting federal legislation that would convert the IAH demonstration, which ended in September, into a permanent national Medicare program. A Senate bill to do so — the Independence at Home Act — was introduced in 2017 by two Republicans and two Democrats, encouraging the advocates that bipartisan support will lead to its passage.
Preparing for a tipping point
With more than 32,000 house calls under his belt since 1993, Thomas Cornwell, M.D., started the Home Centered Care Institute, a nonprofit organization based in Schaumburg, Ill., to advance home-based primary care for frail and elderly patients. He’s been a tireless advocate for the Independence at Home Act, but payment to support house calls is not the only barrier at hand.
“What is the biggest roadblock to this? It’s workforce,” he says.
Using data from a study published in Health Affairs, Cornwell estimates that the majority of home-based primary care visits in the U.S. are delivered by only about 1,000 physicians, nurse practitioners and physician assistants. HCCI’s goal is to train 5,000 clinicians — as well as practice managers — within the next five years.
Starting in 2017, HCCI partnered with eight academic medical centers and health systems — Cleveland Clinic, Icahn School of Medicine at Mount Sinai, MedStar Health, the Northwestern University Feinberg School of Medicine, Perelman School of Medicine at the University of Pennsylvania, The University of Arizona Health Sciences' Arizona Center on Aging, University of Arkansas for Medical Sciences and the University of California, San Francisco — to help develop a house-call workforce.
The partner organizations — called Centers of Excellence — are delivering HCCI’s curriculum to help providers and practice managers learn how to start and maintain home-based primary care practices. The curriculum includes classroom instruction, group mentorship through webinars and online courses, and hands-on experience with an existing house-call program.
Mount Sinai’s first classroom training attracted 20 students from across the country, including geriatricians and other physicians, nurse practitioners, health care administrators and a social worker, DeCherrie says.
“Some of them have just started home-based primary care practices, and some of them have not yet started, so I’m excited to see what happens to these folks in the next year or two because of our course and the rest of the curriculum,” she says.
Looking ahead
Even if the IAH legislation passes, it will not mean automatic house-call coverage for every homebound Medicare patient. As the bill is written, patients would be eligible only if they have had a hospitalization and a rehabilitation stay in the past year.
“IAH is extremely important and will make a huge difference for all practices,” DeCherrie says. “But practices also need to think about entering into value-based contracts and per-member, per-month contracts — that’s the kind of thinking you have to do to be able to sustain the whole practice.”
While the payment picture gets sorted out, the number of homebound Americans continues to grow. The U.S. population 85 and older is expected to quadruple by 2050; Boling projects that house-call programs will become routine long before that.
“I’m going to say that, within five years, the hospital that doesn’t have a program would probably be less appealing than its competitors that do,” he says.
A successful house-call program is one that reduces hospital use, which may worry trustees who are concerned about the financial viability of their hospital. But Boling points out that the patients served by house-call programs typically would not be hospitalized for their care anyway — and do not benefit the hospital’s success metrics. And because of their frailty, they are likely to be readmitted within 30 days if they are admitted.
“If I were a hospital CEO or a trustee, [a house-call program] would be a way to reduce my exposure to patients that are less financially beneficial to my organization while providing better quality of care and [achieving] higher patient satisfaction,” he says.
Lola Butcher is a contributing writer to Trustee.
House calls not just for the homebound
It’s not just frail and elderly patients who are being examined by their health care providers in the comfort of their homes. Some leading health systems are introducing house calls as a new way for younger patients to receive care for such common issues as flulike symptoms, insect bites and urinary tract infections.
Patients use a smartphone app to request an appointment, and a nurse practitioner, after calling to verify that the patient’s need can be met by a home visit, shows up on the doorstep within two hours.
Providence Health & Services introduced house calls in Los Angeles and Seattle in 2016 as part of a broad strategy to expand access to care, says Sunita Mishra, M.D., vice president of Express Care at Home and consumer innovation. Along with two other innovations — walk-in clinics and telehealth — house calls allow Providence to provide quick access to care, even if a patient’s regular primary care clinic is fully booked.
“We are connected across the continuum by the medical record,” Mishra says. “So any time one of our own patients is seen — whether it is virtually or at home or in a walk-in clinic — their primary care doc gets a note and knows what’s going on.”
Vanderbilt University Medical Center quickly followed suit by launching Vanderbilt Health OnCall. Jennifer Mitchell, A.P.R.N.-B.C., VUMC’s director of advanced practice, says house calls are a good way to introduce Vanderbilt to new residents moving into fast-growing Nashville. And they are a two-way value for Vanderbilt’s huge workforce: Employees who need minor medical attention avoid leaving their desks for medical appointmenta — and, by getting care, their condition is less likely to worsen.
“Urgent care visits and [emergency department] visits [for their own employees] are very costly from the health system’s perspective,” Mitchell says. “When we’re able to help patients avoid the ED, we can save the health system money and the patient money.”
Both organizations file insurance claims for home visits, so patients are responsible only for their standard co-payments or coinsurance. Providence charges self-pay patients a flat fee of $199; Vanderbilt charges $99 for the visit, with additional charges for lab tests, first-dose medications and other services. — Lola Butcher