Correspondence
House Calls
N Engl J Med 1998; 338:1466-1468May 14, 1998
- Article
To the Editor:
Meyer and Gibbons (Dec. 18 issue)1 overstate the house call's fragile condition. In 1996, the Health Care Financing Administration reported charges for 1.6 million house calls. The numbers were essentially the same in 1994 and 1995, well above the 1.1 million the authors extrapolated for 1993. Bayne's2 1988 statistic (1.6 million) cited actual Medicare billings. Though we still need far more house calls, the reported 31 percent drop appears to be an artifact of method.
Campion's editorial3 describes the house call's importance, but he undervalues the 1998 Medicare-payment changes. In 1998, for the first time, new Current Procedural Terminology (CPT) codes describe comprehensive home visits, and along with other substantial increases in relative-value units, this may improve reimbursement rates by 50 percent for those treating sick patients at home. Such major increases reflect hard-won recognition that an important service has long been undervalued. Even managed care shows signs of change. In a few mature markets with many frail elders in risk contracts, house calls are being used to satisfy patients' needs and prevent higher acute care costs. I also challenge Campion regarding technical capability. In the home, one can now match capabilities with most physicians' offices, emergency rooms, and even hospitals.
3 ReferencesPeter A. Boling, M.D.
American Academy of Home Care Physicians, Tacoma, WA 98401-12341
Meyer GS ,Gibbons RV . House calls to the elderly -- a vanishing practice among physicians. N Engl J Med 1997;337:1815-1820
Full Text | Web of Science | Medline2
Bayne G . Emergency house calls -- why, who, and how? Am Acad Home Care Physicians Newsl 1991;3:1, 6-73
Campion EW . Can house calls survive? N Engl J Med 1997;337:1840-1841
Full Text | Web of Science | Medline
To the Editor:
A major question about the future of house calls by physicians is whether academic medicine will adopt a more organized approach to home care by offering specific training and possibly creating a subspecialty in home care comparable to critical or emergency medicine in acute care. The training should include a complete curriculum on home care.
Until academic medicine becomes serious about training physicians in home care, the house call will continue to be an erratic and unpredictable part of organized medical care. Without specific training, physicians will continue to struggle to understand their relationship with home care and hospice agencies.
Joseph S. Rowe, Jr., M.D.
Veterans Affairs Medical Center, Atlanta, GA 30033To the Editor:
The key to home care's future is patient selection. Home visits by physicians should target those who would be hospitalized or would remain so without them and those who require frequent medical reevaluation or the reassurance of constant physician availability but not hospital-based procedures. Multidisciplinary networks of such care, focusing on doctors' house calls, have been termed “hospitals at home.” The Home Hospitalization Program in Jerusalem has provided acute and subacute home care to more than 4000 patients since 1992. It has demonstrated its cost effectiveness in the setting of universal prepaid health insurance1,2 and has been accepted gratefully by both patients and their families. We believe it is a mistake to discount Home Hospitalization's adaptability to a market-based economy. Enhanced compensation for intensive home care based on its duration rather than the number of visits could make this approach attractive to physicians even in the fee-for-service environment, and the subsequent decrease in hospitalizations would offset this payment.1,2
The visiting doctor, traditional black bag in hand, waiting at the doorway, is not a luxurious antique but rather the efficient state of the art.
2 ReferencesRobert Hammerman-Rozenberg, M.D.
Aaron Cohen, M.D.
Jochanan Stessman, M.D.
Hadassah University Hospital, Mt. Scopus, Jerusalem 91240, Israel1
Stessman J ,Ginsberg G ,Hammerman-Rozenberg R , et al. Decreased hospital utilization by older adults attributable to a home hospitalization program. J Am Geriatr Soc 1996;44:591-598
Web of Science | Medline2
Stessman J ,Hammerman-Rozenberg R ,Cohen A . Home hospitalization in the spectrum of community geriatric care. Disabil Rehabil 1997;19:134-141
CrossRef | Web of Science | Medline
To the Editor:
Drs. Meyer and Gibbons suggest that competition in the physician work force and demographic shifts will favor an increase in the frequency with which physicians perform house calls. We are less optimistic. The American Medical Association's effort to educate physicians about house calls has not been very effective. Educational efforts should target medical students and residents. Unfortunately, as recently as 1994, nearly half of all medical schools did not devote any curricular time to house calls.1 House calls are not routinely covered in many training programs.
Dr. Campion expresses concern about safety and the lack of access to technology in the home. In our experience of directing house-call programs in which tens of thousands of visits have been made, we have never had an adverse event. We do educate our physicians in basic safety techniques. Many high-tech diagnostic and therapeutic services are now available for use in the home. An efficient house-call physician can examine a patient and make use of such services to evaluate and treat a debilitated older patient at home in a uniquely dignified and humane manner.
As a teaching venue, the home is without equal. Physicians-in-training who order diagnostic tests and therapies as a routine response to clinical situations learn how to take an appropriate history, perform exacting physical examinations, think critically about differential diagnosis, and make realistic plans not only for “curing” but also for improving function and the quality of life.
House calls represent the best in medicine for many frail older patients. The American Academy of Home Care Physicians, P.O. Box 1037, Edgewood, MD 21040, can provide further information.
1 ReferencesBruce Leff, M.D.
John R. Burton, M.D.
Johns Hopkins Geriatrics Center, Baltimore, MD 21224R. Knight Steel, M.D.
University of Medicine and Dentistry of New Jersey, Newark, NJ 071031
Steel RK ,Musliner M ,Boling PA . Medical schools and home care. N Engl J Med 1994;331:1098-1099
Full Text | Web of Science | Medline
To the Editor:
The article by Meyer and Gibbons on house calls and Dr. Campion's editorial were most informative, but they left me with the kind of feeling one gets when reading the postmortem findings on a personally dear patient. I am a New York City physician who (still) makes house calls, and I have served for many years as an attending physician of the Chelsea–Village Home Health Care Program of St. Vincent's Hospital, educating house officers.
Although I readily agree that the financial inequities are a factor contributing to the decline in house calls, the real inequity is the lack of curriculum time and role models who can properly venerate the inherent trust and value that such intimate moments with patients provide.
Many of the house calls that are still made are related to the dying process. The current attention to the inadequacy of training in death and dying seems a good point of departure for addressing house-call training, because the home is where death ideally should occur.
Anthony J. Lechich, M.D.
Terence Cardinal Cooke Health Care Center, New York, NY 10029Author/Editor Response
The authors reply:
To the Editor: Dr. Boling's figure includes a number of house-call services that we excluded from our analyses, including services provided to younger Medicare beneficiaries, those provided to beneficiaries enrolled in Medicare health maintenance organizations (HMOs), and a considerable proportion of house calls that were provided outside the United States and the District of Columbia. In addition, we were careful to exclude redundant billing and services provided outside private homes, which we found were sometimes coded by the CPT scheme as “house calls.” In our comparisons documenting the continuing decline in the numbers of house calls by physicians between 1993 and 1996, we focused on the same population defined in our 1993 analysis.
Boling and Leff et al. mention the availability of new, highly portable forms of technology, and we noted this availability as one of the important factors that could favor a resurgence in house calls. Limitations on the data prevented us from comparing the provision of house calls to patients who were enrolled in Medicare HMOs with that to patients who were not, but the growth of managed care may also favor physician house calls. The recognition that house calls can obviate the need for more expensive care in hospitals and emergency rooms should favor their adoption under managed care. The judicious application of physician house calls to appropriate populations may indeed define the future state of the art, an example of which is the Home Hospitalization Program in Jerusalem described by Hammerman-Rozenberg et al.
We agree with the correspondents that including house-call experience in physician training represents an extraordinary opportunity for learning and may be the key to preserving the practice. The responses to the most recent Liaison Committee on Medical Education Medical School Questionnaire are encouraging, as they showed that 83 percent of schools offered some of their students the opportunity to participate in house calls (Barzansky B: personal communication). It is unlikely, however, that educational exposure and role-modeling will be enough to preserve physician house calls. Educational efforts on all levels of physician training, integrated with the appropriate application of home-based technologies, reasonable reimbursement, and a recognition of the value of house calls in the care of the frail elderly, will ensure that the unique quality engendered by house calls for both patients and providers continues.
(The opinions and assertions contained in this letter represent the private views of the authors and are not to be construed as official or as reflecting the views of the Department of the Army, the Department of the Air Force, or the Department of Defense.)
Gregg S. Meyer, M.D.
Uniformed Services University of the Health Sciences, Bethesda, MD 20814Robert V. Gibbons, M.D., M.P.H.
Madigan Army Medical Center, Tacoma, WA 98431Author/Editor Response
Dr. Campion replies:
As several letter writers point out, it is now possible to bring much of modern medical equipment into the home. However, particularly if reimbursement is linked to the use of technology, the challenge may be to control the technology so that the severely ill and dying will still sense the care of the physicians who come to their homes. It will be unfortunate if, instead, patients see their bedrooms turned into remote monitoring stations connected by long wires to an intensive care unit.
The recently announced increases in Medicare's payment schedule for house calls are encouraging, but for most physicians house calls form only a very small part of their practices. One should not expect to see a resurgence of house calls as a result of the higher Medicare fees. Probably more important is the work of those who demonstrate and teach how house calls can still be a part of what physicians do.
Edward W. Campion, M.D.
- Citing Articles (3)
Citing Articles
1
Colleen A. Matter, Jenny A. Speice, Robert McCann, Daniel Ari Mendelson, Kevin McCormick, Susan Friedman, Annette Medina-Walpole, Nancy S. Clark. (2003) Hospital to Home. Academic Medicine 78:8, 793-797
CrossRef2
Yoram Maaravi, Aaron Cohen, Robert Hammerman-Rozenberg, Jochanan Stessman. (2002) Home Hospitalization. Journal of the American Medical Directors Association 3:2, 114-118
CrossRef3
J. James Cotter, Wally R. Smith, Peter A. Boling. (2002) Transitions of care: the next major quality improvement challenge. British Journal of Clinical Governance 7:3, 198-205
CrossRef
