The Return of the Doctor House Call

The once-antiquated practice is making a comeback -- and saving states money. But it's not without hurdles.
by | September 2017
Nurse Practitioner Beth Hungate, right, visits her patient Luckie Locke at her home in Richmond, Va. (Photos by David Kidd)

“Do you hear that?” asks Beth Hungate, as she walks into an apartment in the historic neighborhood of Richmond, Va., known as “the Fan.” Hungate, a nurse practitioner at Virginia Commonwealth University’s (VCU) medical center, is there to see a patient of hers, a woman named Luckie Locke. Locke has been in quite a bit of discomfort recently and requested that Hungate stop by. But as Hungate walks through the door, she notices an incessant beeping noise.

Hungate scans the apartment for the source of the beeping; eventually she traces it to a carbon monoxide detector. She calls her clinical coordinator to get a nonemergency fire department truck to come by. “You see? I would have never known this if I wasn’t coming to her house,” Hungate says.

From there, Hungate conducts her visit just as she would in a clinic, taking blood and asking standard medical questions. At one point, she calls Locke’s physical therapist -- who is visiting the home later -- to make sure he’ll address an issue with her wheelchair. The fire department arrives and ultimately determines that there’s no carbon monoxide problem; Locke just needs a new detector.

Locke is a wheelchair-bound patient living with multiple sclerosis and arthritis. There’s a chance she would still be able to make it to VCU’s medical center for her regular check-ups, but it would be difficult. Because she’s enrolled in VCU’s house call program, she gets care in nontraditional ways. As an example, Hungate points to the floorboards in the living room, which have recently been replaced. Locke had been having trouble navigating her wheelchair over the old, uneven floorboards -- and had had a few falls while walking on them -- so Hungate and her medical team worked with Locke’s sister to get new flooring installed.

VCU’s home care program was one of the first to bring back house calls to Richmond’s oldest and sickest starting in the 1980s. Leading the way is a physician of geriatric medicine named Peter Boling. He stumbled into the practice of home-based primary care when a former boss proposed starting a house call program within VCU’s medical center. So Boling put a big map of Richmond on his wall, stuck colored pins where each of his patients were, and started making five house calls a day after his morning clinic work. “Pretty soon there were no more wheelchairs or oxygen tanks in the waiting room,” Boling says. “That was transformative for me. Once I started going to people’s homes, people with limited mobility, I saw that it was a broken system for this group of patients.” Boling noticed that because they had a hard time getting to a clinic, they’d often wind up in the emergency room.

Today, Boling’s a leading national advocate for the benefits of at-home care. “You understand a patient in ways you’ll never understand them in a clinical setting,” he says. “You see how their meds are managed, whether they live in a tidy or chaotic environment, if they have good food or drink a lot of alcohol. And that’s part of the special sauce of what we do.”

 

Hungate conducts her home visits just as she would in a clinic, taking blood and asking standard medical questions.

 

The idea of house calls may evoke 1950s-era images of a cheery doctor knocking on suburban front doors, black medical bag in hand. But not only is home health care considered modern again, it’s expanding across the country. According to the Centers for Disease Control and Prevention, almost 5 million people were enrolled in a home health-care agency in 2013. And the Bureau of Labor Statistics predicts that 1.3 million additional jobs will be added to the field of home health care by 2020, a 69 percent increase from today. That makes home health care the fastest-growing health-care industry -- and one of the fastest-growing workforce industries in any field.

As baby boomers continue to age, they aren’t accepting nursing homes and other institutional care as the only options. In tandem with that is the increasingly popular idea in health care to meet people where they are. And now that more people are insured than ever before, they increasingly want to be met at home. For states, the renewed emphasis on the benefits of house calls brings new challenges -- namely, how to structure these programs, how to ensure they’re working and, crucially, how to pay for them. “I want to make sure that for anyone who needs this kind of service, a doctor can come to you,” Boling says, “and that the doctor can be compensated in a such a way that they could continue to provide it."

 

In 2009, Boling and like-minded health experts helped draft federal legislation that would enable more home care programs. Called Independence at Home, the legislation was then folded into the Affordable Care Act (ACA); in 2012, the Independence at Home model launched at 17 demonstration sites around the country. Centers for Medicare and Medicaid Services (CMS) wanted to test home care broadly, so the awarded sites were a mix of public and private organizations of all sizes. For Richmond’s program, it was a chance to show that the approach they’d been working on for years was successful. Under Independence at Home, CMS would award bonuses to sites that could prove they saved money and provided high-quality care.

It worked. The demonstration sites saved a combined $25 million in the first year, and more than $10 million in the second year. At the time of the results, then-CMS Administrator Andy Slavitt said that they supported “what most Americans already want -- that chronically ill patients can be better taken care of in their own homes.”

The demonstration was originally set to end in late 2015, but Congress unanimously reauthorized it for two more years. There’s legislation currently pending to reauthorize it again. Boling says that despite the current congressional gridlock -- especially when it comes to health care -- he’s tepidly optimistic that the demonstration will be reauthorized based on the previous bipartisan support for the program. Alan Kronhaus, CEO of the Chapel Hill, N.C.-based Doctors Making Housecalls, another site in the demonstration, echoed Boling’s cautious, yet positive outlook. Despite vitriol in Washington, he says, “the practices are quite optimistic that the demonstration will be extended.” Boling says CMS could also just extend it without legislative approval, but the program sites haven’t started negotiations with Seema Verma, the current CMS administrator. (CMS officials had no comment on the Independence at Home demonstration after multiple requests for an interview.)

Besides Independence at Home, the ACA encourages home-based primary care by incentivizing managed care models over the traditional fee-for-service model of payment. Every state now has some sort of home- and community-based care program, although most have waiting lists.

While Independence at Home is a positive sign that states can save money if they expand home offerings, budget officials are still figuring out how to pay for the programs. California Gov. Jerry Brown earlier this year proposed shifting the costs of his state’s In-Home Supportive Services -- the largest home care program in the country -- to the counties. County leaders pushed back, and Brown eventually offered them an additional $400 million to administer the program. Meanwhile in Missouri, facing sluggish revenue growth, Gov. Eric Greitens’ 2018 budget cut $250 million in overall spending. Home health care was one of the biggest casualties, leaving 8,300 beneficiaries without in-home care in the coming years. State lawmakers tried to avoid that cut by passing a separate bill that would move money around from other areas to keep home health-care services fully funded, but Greitens vetoed it.

In addition to funding, state health officials must confront other questions as well, including how to recruit more new doctors into home care programs. It’s a problem with no easy answer, says Minnesota Human Services Commissioner Emily Piper. If anyone has any good ideas, it’d likely be Piper: Minnesota is ranked No. 2 on LongTermScorecard.Org, a website that tracks such offerings in states and is funded by AARP and the Commonwealth Fund. Piper says she’s been working with communities in Minnesota to identify workforce needs and to build a career ladder around those needs. But perhaps more than that, she says that getting residents out of institutional care doesn’t always take a large workforce of doctors -- it can be as simple as ensuring someone that they can get their groceries delivered. The state has a program called “Return to Community” that helps people in nursing homes identify and address the barriers to returning home. For some seniors, that might mean building a wheelchair ramp to their door. Others might just need their errands done for them.

Minnesota’s commitment to getting people back home, no matter what, seems to be working: 69 percent of Medicaid money for long-term care in Minnesota goes to home- and community-based services, compared to the national average of 41 percent. It was recognized by Harvard University’s Ash Center for Democratic Governance and Innovation as a 2017 Bright Ideas initiative. “Those small changes can bring people out of nursing homes,” Piper says. “And we know it’s cost effective. Our average annual spend for someone over the age of 65 in home care is $17,000. It’s $36,000 in an institutional setting.”

Besides funding and workforce shortages, there are also some more practical considerations: House calls may require physicians to travel into dangerous neighborhoods, and patient homes can be considerably less hygienic environments than doctors’ offices. At VCU, Marcia Megginson, the clinical coordinator, tells doctors and nurses to work smart. “For a high-crime area, go early in the morning, and don’t go by yourself. Only take what you know you need in to the house. We have jumpsuits and disposable stethoscopes you can throw away after one use,” she says.

Residents in rural areas present another challenge. Arguably, these are the patients who could benefit the most from a home care program. Not only do rural Americans live farther away from clinics and hospitals, but they also tend to be older and are more likely to die of preventable diseases. But coordinating house call programs in these areas is difficult. A study from the Rural Health Research Center at the University of Washington found that rural areas continually struggle to implement home care programs. Challenges include retaining physicians, a lack of specialty care providers that home care enrollees often need, and the strain of long drives -- known as “windshield time” -- to see rural patients.

 

Peter Boling, chair of geriatric medicine at VCU, says that when he first started making house calls, it “was transformative for me.”

 

Telemedicine can help to a degree. Health experts across the board say that telemedicine will play an increasingly important role in home- and community-based care going forward -- whether in a rural area or not. But rural areas are also going to have to get creative to shore up their workforce, concludes the University of Washington study. Various solutions include offering student loan repayment plans to bring in young doctors, tapping into resources from school clinics and hospitals, and contracting with other regional home health agencies.

Glenn Melnick, a health-care economist with the University of Southern California, thinks that public-private partnerships in the world of contracting will be a big piece to solve the rural home health puzzle. “I think we’ll soon see new entrepreneurs coming into the market, like a ‘High-Risk Patients “R” Us’ company that specializes in these expensive populations,” he says. Rural county health departments could contract with such companies to get medical providers to far-flung patients.

 

Not everyone is convinced that states should jump to expand house call offerings. “If I were to look at it from a purely economics perspective, I’d be skeptical,” says Ateev Mehrotra, an associate professor of health-care policy at Harvard Medical School. “If you drive from site to site and see 10 patients a day, there’s a lack of efficiency.” If states can demonstrate that house calls really do result in better population health outcomes, then they’re worth it, Mehrotra says. “But there are a lot of times where it could be considered low-value care.”

National data on home health care is still relatively spotty, and that’s why some health economists remain skeptical on just how much money home care saves and just how efficient it’ll be in the long run. But there is one undeniable fact about home-based primary care: Patients really, really like it. The University of Washington study noted that home health care “has one of the highest patient satisfaction ratings of any care delivery model.”

As states, research hospitals and health organizations grapple with how to best serve complex patients, there’s a new expectation that older populations will insist on aging in place. “It’s the future. It’s happening now. The more we continue to have all these innovations in health care and new medications, people are going to continue to live longer and with more illnesses,” VCU’s Megginson says. “It’s a process, but the world is identifying that we need this service more and more.”