The payoff in house calls

Despite a recent raise in Medicare rates for home visits, physicians say they don't make money on them. But they can be valuable in other ways.

By Ken Terry
Senior Editor

Physicians are making more house calls than they did a few years ago, according to the Centers for Medicare & Medicaid Services. After declining in the late '90s, the number of home visits made to Medicare patients rose 15 percent from 1999 to 2001.

Some news reports have suggested that increased Medicare reimbursement accounts for the jump. Although it's true that the average charge CMS allowed for physician home visits climbed from $76 to $95 between 1999 and 2001—a 25 percent increase—most physicians we polled in a minisurvey were unaware of the rate hike. Even those who knew about it said that Medicare and commercial insurers still don't pay enough to make home visits financially worthwhile.

Nevertheless, most of the doctors we polled told us they do make some home visits, usually to terminally ill and homebound patients. A few have made house calls a regular feature of their practices. All those who make house calls say they do so because it's good for patient care and more convenient for some patients.

None of the doctors earn much for home visits. Except for one: FP Bernd A. Wollschlaeger of North Miami Beach, FL, who doesn't accept Medicare and has mostly self-pay patients. Wollschlaeger charges $95 to $140 for a home visit—the higher amount is for weekend visits. His average house call lasts 25 to 30 minutes—longer than his average office visit—and he travels for up to half an hour to see patients at home. The premium he charges for house calls compensates him for the time he spends away from the office, he says. Altogether, home visits bring in 10 to 20 percent of his revenue, depending on the season.

Most of Wollschlaeger's house-call patients aren't elderly. "They're middle-aged or younger people with busy schedules, and they want to see a physician at a convenient time at home. Some have young families and can't leave the house because one of the kids is sick. So I see more of the 'professionally challenged' than the disabled. They like the convenience."

Medicare rates are still too low

Robert W. Patterson, a solo family physician in Sanford, NC, practices in an area that's very different from North Miami. Many of his patients are on Medicare or Medicaid or have commercial insurance. Yet Patterson regularly makes house calls to those who need the service.

Medicare has raised its home care rates from "punitive to more reasonable levels," he says. But the fees still don't come close to compensating him for his time. Patterson devotes up to an hour to each home visit, and it sometimes takes him an hour to travel to a patient's house. He usually makes house calls at the beginning or the end of the day, or on his lunch hour, leaving a PA in the office to handle some patients while he's gone.

Only half of the patients whom Patterson visits at home are on Medicare. He makes house calls to the terminally ill, to people who've recently had surgery or who have disorders that limit their mobility, and to patients with chronic problems that he wants to analyze in their home environment.

One of his patients, for example, was a closet alcoholic. He denied that he drank, until the doctor offered to stop by his home one day when he was scheduled for an office appointment. "I was able to see what was going on with him. He was drinking like a fish, and his family was scared to death."

Other physicians also find that home visits reveal things they'd never discover in the office. Wollschlaeger, for instance, often makes dietary recommendations to elderly patients. But when he sees the kitchens of some patients, he realizes they have no utensils and aren't cooking meals. So he advises them to contact Meals on Wheels. Similarly, he says, people with allergies may live in homes that are very dusty because of dirty air ducts.

Home health nurses: a mixed blessing?

Some rural physicians make house calls because no home health services are available. Other doctors make them because they distrust home health nurses. One physician in Rochester, MI, who prefers to remain anonymous, says he occasionally makes house calls because some nurses "don't have a clue" and can't give him even basic information about a patient's condition.

Internist Jeffrey M. Kagan of Newington, CT, makes home visits twice a year to a handful of bedridden patients, partly because he doesn't want to authorize nurses to take care of them without seeing them himself. As a side benefit, he finds that home visits sometimes induce caregivers and their friends to come to him as new patients. But on the whole, he says, house calls aren't financially viable. "If I had to do this half a day every week, it would probably kill me economically."

Even if physicians were paid more for house calls, Kagan doubts many would make them. "You're so limited in what you can do at a patient's house. If you see someone with an acute problem like chest pain, you can't evaluate them with stat labs, ECG, or X-rays like you might in the ER or even the office."

But for some, money and time away from the office remain the key issues. "If the reimbursement were better, I would consider doing house calls for a certain subsection of my patient panel, including newborns and at-risk elderly, mentally challenged, and noncompliant patients," says FP Stella King, who practices in a multispecialty group in Sarasota, FL.

Will technology change things? Robert Patterson says he'll keep making house calls even if telemedicine progresses dramatically.

"The science is wonderful, but nothing will ever replace the art of sitting beside the bed of somebody who's dying when the whole family's there. You're able to hold their hand and comfort the family. You form a bond with the patient and the patient's family that lasts for generations. I don't think a TV monitor is going to allow you to do that."

Did Medicare discourage house calls?

FP Robert Patterson of Sanford, NC, used to make more home visits than he does now. But Medicare discouraged it, he says.

How? By paying doctors less for this service than it paid home health agencies for nursing visits. This led to a proliferation of such agencies, which soon learned how to maximize their fees, says Patterson. So Medicare didn't save anything by keeping physician reimbursement low. When the government realized that, he says, it raised rates for physician home visits while reducing payments to home health agencies.

Two years ago, the Centers for Medicare & Medicaid Services did indeed begin curbing payments to home health agencies to restrain the growth in home health spending. But a CMS spokesperson denies that the government raised payments to doctors to encourage them to make more home visits. "We're required by law to pay for physician visits based on the resources required to provide them, not as an incentive or disincentive," she says.

The home visit rates went up partly because the AMA recommended, and Medicare adopted, new CPT codes that reflect more intensive levels of service in the home, notes the CMS source. And payments for most nonhospital-based services have increased since 1999 because that's when CMS began applying a resource-based system to the practice expense component of relative-value units, she says.

Ken Terry. The payoff in house calls.

Medical Economics

2003;6:63.