A little-known corner of the Affordable Care Act could usher home visits by doctors back into the medical mainstream.
A long time ago, instead of you going to see the doctor, the doctor would come to see you. Instead of sitting in a waiting room with cheesy music, old magazines, and long waits, you stayed in your own bed, and the doctor rang your doorbell. In our modern era of rushed doctor’s visits, it can be hard to believe that there was ever another way, but the house call was once the norm. So I decided to see if I could find a doctor who practiced during the era of the house call, and was still alive to tell me about it.
That search brought me all the way to a nursing home in Easton, Pa.
I caught up with Dr. Jonathan Warren, a retired internist living with his family in Easton, during his break at a busy nursing home where he volunteers his time. Warren remembers the house call fondly.
“I used to go around and see people on my bicycle,” he laughs. “And I had a dog and I used to take my dog sometimes too!”
Warren recounted his first house call: “I had just come to Easton, and I had a partner. He told me someone wanted me to see them at home today. ‘It’s a house call,’ he said.”
“I’ll do anything!” he told his partner.
“So I went to the woman’s house, she had two daughters, they were both there,” he recalled. “They said that she was eating very poorly, and she’d lost weight. Okay, so I go and examine her, and, sure enough, I thought she was in heart failure. She has high blood pressure and she doesn’t take a whole lot of medicine. I had her lie down in bed, I looked at her neck veins, and I looked at the swelling of her legs. And after it was all over, they said, ‘Dr. Warren, we want you to sit now and we’re going to give you a Lebanese lunch.’ And it was wonderful! That was the dream of the whole day!”
Believe it or not, these type of interactions with your doctor used to be the norm. Before the Civil War, journals show that some physicians would make 30 to 40 house calls per day, traveling from Germantown to Chestnut Hill to Roxborough (and that was before there were any bridges over the gorges). By 1930, 40 percent of physician visits included house calls, but, as of 1980, that number had dropped to just one percent.
“People liked it, it was interesting,” Warren remembers. “And you’d get sense of what their lives where like and what their homes were like.”
If a patient had a rash and you saw bed bugs, well, there was your answer. If they offered you dinner, you might taste too much salt. Seeing the patient at home put their disease in the context of their environment, whereas seeing a patient in an office or a hospital is in many ways like seeing a fish out of water.
“At one point in time, it was really fun,” says Warren. “Medicine was really fun. It’s not as much fun anymore.”
But as the power of modern medicine, the X-rays—the blood tests, the surgical procedures, all of it—grew exponentially, it only made sense to abandon the house call model in favor of a more efficient hospital-based system. After all, that’s where doctors actually had the tools to do things. So we changed, because it made sense to, but that special intimacy between doctor and patient was gone, forever.
Or maybe not.
Recently two medical students from Temple University won third place in a national competition sponsored by the Association of American Medical Colleges, in which contestants were asked to make a video that would “envision the medical innovations of tomorrow.” But instead of imagining space ships and laser beams, they had a different vision.
“We were asked to make a video about the future of academic medicine,” says Erin Hickey, one of the students. “And one of the conversations we had in our meeting was, ‘How can we be unique?’ How can we think outside of the box and not just focus on technology, which is inevitably going to get better and better, but how can we bring in something that’s going to throw people off guard and make them say, ‘Wow, that’s awesome!'”
So they imagined a future with house calls.
“So we developed this house call video,” says Nick Osevala, the other medical student, “and the way it worked was that a medical student and a resident showed up at a patient’s house. A woman opens the door, she’s excited to see them. She has had this relationship with them for a long time and she trusts them. They start talking about how she’s feeling, what’s changed since the last visit, and then at that point, they beam in holographically an attending physician from the main university hospital.”
From here, the team uses futuristic technology to read her blood work and send the data back to the hospital. The attending physician advises them remotely.
“At that point they sort of close them out, beam them back out again, the medical student and the resident shook hands with the patient and were on to the next house,” says Osevala. “We wanted to bring the house call back, because we thought it might be the best way to tie in the technological advances of the next 20 to 30 years but maintain that level of personal care that I think is the reason why we all decided to get into this in the first place.”
Even though these students have never met Dr. Warren, it’s as if they are instinctively seeking that sense of “fun” that he feels has been lost.
But the students’ “vision” of medicine’s future turns out to be very real. As the population gets older and frailer, and as hospital infection rates go up, there is a new incentive to bring healthcare back to the home. Yep, believe it or not, house calls are happening right now in Philadelphia.
I’m with Bruce Kinosian, he’s a primary care doctor and associate professor of Medicine at Penn. And he makes house calls.
Dr. Bruce Kinosian, a primary care doctor and associate professor of medicine at Penn, let me tag along on a recent house call to visit with his patient James Singleton, a retired army veteran who lives in West Philly. Last year, Singleton had a stroke with multiple medical complications that left him bed bound, but with a year of house calls from a multidisciplinary team, he has been steadily improving.
We got right into business by asking James how he was feeling, getting vitals, and changing bandages. But the conversation soon veered into directions no regular office visit would take. We discussed new construction we saw on his porch – his daughter told us it was to allow him to get his wheelchair outside. When James complained of constipation, we took a look in his fridge and noticed a lot of dairy.
Dr. Kinosian: How would you feel with trying lactose free ice cream and milk for a week?
Singleton: OK, I can do that.
When we looked at his medicine cabinet, Dr. Kinosian laughed, “You can see what medicines they have…you can also see all the other medicines they have that they didn’t bring in that you didn’t know about.”
Then Dr. Kinosian broke out his medicine bag, and what came out was anything but retro. Pulse oximeter, glucometer, there are pocket ultrasound devices that because of smart software can double as an echocardiogram, as an abdominal ultrasound, as a doppler looking for a blood clot in the leg, there’s a blood analyzer.”
Maybe the temple students’ video wasn’t that far off after all.
“You can pretty much be a walking Emergency Room with equipment you carry in your pockets,” says Kinosian who had Singleton hold an iPhone which has a case with metal leads on it. He opens an EKG app, and determines that Singleton has a conduction problem, he has a right bundle branch block. When asked what he thinks about this technology, Singleton replies, “Amazed.”
“Yeah, its more efficient for my time if I sit there and people come to me and I spend 10 minutes with them,” theorizes Kinosian, “but there’s a whole lot that goes on to get all those individuals there, to get all that information there, that’s sort of off the books. And particularly for very frail and ill folks, the logistics of moving the patients can be challenging and actually quite expensive. There’s actually a large demonstration, another part of the Affordable Care Act, called Independence At Home that’s ongoing.”
Independence At Home is a little known three-year experiment—or “demo”—written into the Affordable Care Act. It’s purpose is to beta test the house call as a way to deal with the 10 percent of Medicare patients who account for two-thirds of Medicare’s expenditures. The theory is that, for these high cost patients, house calls might actually be more efficient, more effective, and ultimately cheaper. The Independence At Home demo is now in its 2nd year.
“It saved the Medicaid program about 25 percent,” says Kinosian, “people live longer and almost all that life was spent outside of nursing homes. Yeah, it saves money and it gives people a higher quality of life, so it’s sort of a general win/win.”
In fact, ten years of data from the Penn house call team were a big part of getting Independence At Home into the Affordable Care Act in the first place. It was their results with VA patients like James Singleton that convinced senators that a demo was warranted. Right now, the demo is limited to 10,000 patients, but if, after three years, the results show overall savings for Medicare, that cap could be removed.
“I think that Independence At Home is going to radically transform how healthcare gets delivered and gets paid for in his country. There’s probably 1.5 million medicare beneficiaries that are eligible for Independence At Home.”
In other words, the house call might be coming back, in a big way.