ASK DR. BAUGHAN January 2, 1998
HOUSE CALLS
The December 18, 1997 issue of the New England Journal of Medicine contains an article entitled, “House Calls to the Elderly - A Vanishing Practice Among Physicians.” The title is a bit dramatic, but the article documents that since 1988, there has been a 30% reduction in the number of house calls billed to Medicare. House calls were more frequent in rural New England than elsewhere in the country. The article describes some of the financial disincentives to home care. Until recently, the reimbursement for home visits was less than for office visits. Now it is a little more, but not sufficient to cover the time costs of transportation, and physicians get paid less for home visits than nurses, physical therapists or speech therapists. When I taught in medical school and asked students and residents about home visits, the idea was universally received with aversion. When I pressed further, their first image of a home visit was going to someone’s home in the middle of the night to diagnose a child’s cold. Next they would express reluctance to evaluate a patient without lab and X-ray facilities at their elbows. After working through these biases and insecurities, we could have reasonable discussions of an interesting topic, which this article does, too.
Home care is a booming industry, with visiting nurses, therapists and sometimes even intravenous medications being given in the home. Patients are often more comfortable. There is less risk of catching an infection from other patients, like there would be in a hospital. It is also a lot less expensive for the government or insurance companies, and consequently the public. When do physicians need to get involved, though? In my experience, in discussion with colleagues in the area, and as documented in the article, there are several valuable occasions for home visits.
1. Terminal Care - if a family is trying to care for a family member at home with a terminal illness, I have found it to be medically useful, and humanely invaluable, to visit in the home. The family wants to know that they are providing care as well as it can be done. In our society, we are not familiar with dying, so we turn to the medical establishment for guidance in dying with as much dignity and grace and possible. Occasionally I might have a medical suggestion, but particularly if hospice personnel are involved, my role as a physician usually is one of support and reassurance. When a patient is not necessarily going to die soon, but the family is trying to care for them at home instead of admitting to a nursing home, my visit may be a factor in assessing that they are doing okay, or it may become apparent that they are emotionally overwhelmed or do not have the physical resources that the person needs for comfort.
2. Chronic illnesses - if a patient is essentially confined to the home due to paralysis, severe arthritis or some other disease that makes getting out of the home very difficult, then house calls for periodic monitoring of their conditions can be humane and efficient. This type of visitation may be done just as well by a visiting nurse, but often a team approach is optimal. The need for such a visit I judge by the “church and grocery rule” - if they are able to get out of the home to go to church or to the store, they are able, and it is probably good for them, to get out of the house to go to my office.
3. Incomplete Pictures - The 10 foot by 10 foot examinations rooms in my office give narrow windows into people’s lives. Occasionally there will be a physical or psychological issue that just is not fitting together based on the information I can obtain in the office. Then I may decide that I need a more complete view of the world the patient lives in, and a home visit (sometimes a work-site visit) can clear up a mystery.
Home visits are not very useful for acute illness. If a person is “too sick to go to the doctor,” they are more likely to need lab or x-ray tests to diagnose and treat the problem. So until we have Dr. McCoy’s hand-held diagnose-everything gizmo to wave over the body we will need office or hospital facilities for most acute illnesses. But as long as the population continues to age, there will still be a need for physicians to occasionally sees patients in their homes, so I doubt house calls will vanish.