by Ryan Basen
Staff Writer, MedPage Today March 12, 2017
On a Saturday afternoon in February, Renee Dua, MD, visited with a 40-something man in Los Angeles. The nephrologist diagnosed a sprained ankle, fitted the patient with a brace and left. When she checked on the man a bit later, he reported to be recovering fine, she said.
This is what today’s housecall looks like. The patient “paged” Dua for medical service via a smartphone app called Heal, and she climbed out of a car and knocked on his door later that day. On the heels of Heal — its reported success and recent expansion — many young doctors have taken to making similar housecalls, seeing opportunities to earn extra income, focus more on their patients, and observe Homo sapiens in their natural habitats, like amateur anthropologists.
But other physicians remain holdouts, questioning whether housecalls can really return to the bygone era mythologized by Normal Rockwell paintings.
“It’s still (often) going to require additional visits the next day, next few days,” said Chris Koutures, MD, a pediatric sports medicine specialist in southern California.
More providers are making house calls to Medicare Part B patients, reports the American Academy of Home Care Medicine, with rates surging from 2006-2013, especially among internal medicine and family medicine physicians, and podiatrists. Rates also soared among nurse practitioners and physician assistants. (Data on housecall breakdowns via app were not available; Heal providers have examined more than 16,000 patients in two years, according to a company press release).
One reason for this trend: “Home visits have also been shown to increase patient and caregiver satisfaction,” a group of family medicine specialists (led by Tomoko Sairenji, MD, of the University of Washington School of Medicine) wrote in a recent Journal of Graduate Medical Education article.
Who Wants Housecalls?
Patients are leveraging apps such as Heal, PAGER and Curbside Cares in major cities including Los Angeles, New York and Philadelphia. Who are they? Many of the same people who have embraced Uber and similar on-call ride-sharing apps. Heal’s “core team” bio page features eight executives making faces ranging from contemplative (the product director looks to the sky with his left index finger resting on his stubbled chin) to childish (Dua sticks out her tongue).
Companies apply different models; Heal for example connects patients with on-call doctors daily, including weekends, and also offers evening appointments. It accepts insurance and charges roughly the cost of an office visit.
Heal boasts full-time physicians and others who moonlight for the company, who receive an hourly salary to cover time they spend traveling between patients’ homes in addition to the visits. Gabriel Niles, MD, a full-time family medicine doctor in L.A., works Tuesday-Saturday from 7:30 a.m. to 7:30 p.m., for example, seeing up to a dozen patients daily. Shauntelle Bonman, DO, a part-time family medicine physician in southern California, usually works a pair of 12-hour shifts weekly.
“To see them in their natural habitat, in an environment that’s more comfortable and intimate, you see a different side of people when they let their guard down and you’re seeing their home too,” Niles said. “It says a lot about who they are and what health challenges they may be dealing with.”
“I worked a lot in outpatient where the emphasis was on volume over quality of care, and for me that’s a conflict,” said Bonman, who has practiced in a few different settings since finishing her residency in 2012. “My primary goal is always to take care of the patient and be comprehensive … It’s nice to know that I have more than three minutes to spend with patients.”
Making housecalls also allows physicians to discuss more preventive care with patients, said Sam Kim, MD, Heal’s pediatrics director, and keeps them out of overburdened ER’s and urgent care centers.
But other physicians still do not make housecalls and question if they ever will. Susan Hingle, MD, an internal medicine professor at Southern Illinois University, typically starts a day with paperwork at 7 a.m., sees patients from 8 a.m.-6 p.m., then does more paperwork. “Just figuring out where you would fit it in is a big issue,” she said.
The top three barriers to making housecalls, according to residents surveyed by Sairenji and co-authors, were scheduling difficulties, faculty time, and resident time. “Obviously it’s wonderful for those families to have somebody come to your doorstep, but if you’re looking to efficiently provide medical care, it’s not efficient for the provider,” Koutures said. “There’s fleeting times I think about it, but in the greater scheme, how do you put that into your professional or personal life? That’s where it becomes more complicated.”
Koutures worries that the trend embodies a larger movement towards customer service within medicine. He is also concerned about the qualifications and skills of the doctors on-call. Many primary care physicians are treating sports injuries in children when making housecalls, for example. “It really boils down to training, since musculoskeletal training in the U.S. is variable,” he said. “That’s where I’m kind of dubious … unless it’s somebody who’s taken time to get training.”
Hingle also worries about the impact on treatment. “What’s missing in this is a continuity relationship, and that was the best thing we have found (affecting treatment),” she said. “It’ll be interesting to see over time how patients like or don’t like not knowing the doctor they’re going to be seeing.”
This trend seems poised to continue, at least in the short-term. “Given the ‘quadruple aim,'” Sairenji and co-authors wrote, as well as residents’ interest, “aging demographics, and growing financial incentives, the need for practitioners who can provide home visits will likely increase.”
There’s also patient motivation. Bonman herself is re-evaluating taking her three small children to the doctor’s office. Punching information into an app and waiting for a provider to show up at her home is a lot more appealing, she said. “It is cumbersome to do anything,” she said, “let alone go to to the doctor’s office.”
That’s one reason she foresees “practicing home-based care for likely the entirety of my career” (and Niles “for an extended period of time.”)
“But,” she added, “it’s hard to predict exactly what that will look like.”
It won’t look like a “have it your way” campaign, Dua said: “It’s not Burger King. You may think you need this test, but we are thinking as professionals, this is how we are going to manage your case.”
However it looks, one-on-one time will likely be featured. “Everybody is sick and tired of the brokenness of our healthcare system today,” Kim said. “The beauty of Heal is it’s taking healthcare back to what it was: doctor and patient.”