Is there a doctor in the house? Not yet

HCFA raises fees, but few MDs knock on doors

The memory of television's Marcus Welby, MD, taking his little black bag into a patient's home might be appealing to the Health Care Financing Administration, but don't expect to see the house call making a comeback anytime soon - unless you catch the TV reruns. The doctor's home visit, like Marcus Welby, MD, has been out of prime time for quite awhile.

And despite HCFA's increase in 1998 Medicare physician home visit fees, there's been no rush nationally among MDs to visit home care patients. Because of the current office-visit mindset of the medical profession, few home care providers predict doctors will go home again, while Peter Boling, MD, president of the 1,000-member American Academy of Home Care Physicians (AAHCP), hopes for renewed interest in the once-venerable practice.

"My argument is that the more doctors know about home care, the more they'll refer," says Boling, whose group successfully lobbied HCFA for the new rates last year.

HCFA responded by expanding and revising its home visit codes for 1998. [42 Fede Reg, 59,090 (Oct. 31, 1997)] Previously, there were six codes. Now there are nine, reflecting more accurately the wide range of home care services available, HCFA says. Visit fees range from about $45 to more than $140 for visits to an established patient, while visits to new patients range from $58 to $173, according to the American Medical Association (AMA). (See chart, p. 66.)

The new fee schedule shows a marked increase. The AAHCP says the 1996 average Medicare allowable charges for established patients ranged from $44 to $71, while the range for new patients was $56 to $92. All of HCFA's new home care Physicians' Current Procedural Terminology (CPT) codes have higher physician work values (Work RVUs) than recommended by the AMA's Relative Value Scale Update Committee (RUC). HCFA accepted 96% of the RUC's 1998 recommendations but said that by equating house calls to office visits, the RUC underestimated the pre-, intra-, and post-service intensities associated with the home visit codes."

Is HCFA sending home care another message?

Boling sees another advantage in having a doctor in the home.

"With this whole issue of fraud and abuse, while doctors who go into the home won't be the police of home care, they will be more knowledgeable about what can be done. They can determine what's appropriate and what's not," he says, adding that the presence of a physician perhaps will "stop agencies from making inappropriate visits."

Yet no matter how promising that all seems, house calls are still not being made in large numbers, according to a study published in The New England Journal of Medicine (1997; 337:1,815-1,820). Taken from a 1993 sample of Medicare Part B claims data for beneficiaries over the age of 65, the study concluded that "a very small percentage (0.88%) of elderly Medicare patients, mainly those who are very sick or near the end of life, receive house calls from physicians."

The study went on to say, "despite the growth in other home health services, the number of house calls by physicians has declined dramatically during this century."

According to the AMA, only about 1.5 million home visits were made by physicians in 1996, and physician payments for home care visits represented only 0.2% of Medicare outlays for physician services for that year.

Such findings do not surprise home care providers like Lorraine Waters, BSN, C, MA, director of Southern Home Care in Jeffersonville, IN. "I don't think the doctors really care about house calls. The ones that make them go to see their very sickest patients, the one's whom they've known forever, or to the ones who are terminal."

Although she is in favor of doctors making home visits, Waters doesn't see that happening. "I would really like to see a cooperative effort," she says. "Having the doctor and nurse collaborate - wouldn't that be wonderful? But not in my lifetime!" she says.

And even Boling concedes that even with the new fee increases, "it remains to be seen how physicians will respond." Boling is cautious because of the historical resistance of physicians to house calls and the perception of the practice as being inefficient and not under-reimbursed.

Waters argues that there is little incentive even now for a doctor to make a home visit. "A house call is not going to make up for lost time in the office, especially when you consider they can see patients - what - every 10 minutes?"

Some, however, radiate optimism, predicting that a boom in house calls is just around the corner. Gresham Bayne, MD, owner of CALL DOC, a mobile physician service in San Diego, also an active player in changing the reimbursement rates, believes that with nine different reimbursement codes for a house call, "there's going to be a huge change in the market." In his own practice, he expects that his $99 house call will now "go up to $190, and there's a huge, pent-up demand for this service that just isn't appreciated."

The Academy is also asking that nurse practitioners making house calls be reimbursed at the same rate.

The Home Health Care Nurses Association (HHCNA) in Pensacola, FL, embraces higher reimbursement rates for doctors and hopes that this will provide a greater incentive for doctors to make house calls.

"It will be a positive development," says Arlene J. Blaha, MPH, RN, president of HHCNA. "The collaboration between physician and nurse will increase, and this can lead to more cost-effective patient care."

Seeking a 'symbiotic relationship'

Nancy McCoy, RN, director of clinical services at the University of California, San Diego Medical Center's Home Health unit, has found through her experience working with CALL DOC that doctors in the field make "significant referrals to home health care, but we also make a lot of referrals to them. It can be a symbiotic relationship. The visiting doctors push for home care; they recognize the need more. In reality, when we have a doctor in the house, we will see the patient more often," she says.

She notes that current visiting physician practices like CALL DOC, might see more competition from office-based practices, but she doesn't expect to see large numbers of doctors out in the field. McCoy doubts that the chronically ill patient is going to receive a great number of visits from the doctor.

"A doctor isn't going to sit there and drip blood for three hours or put in a PICC line," she says.

Mark Mitchell, owner of Visiting Physicians, a Southfield, MI, company employing 42 full-time doctors, points out that 55% of his practice is seeing patients who are bedridden. The doctors try to see each patient every four to six weeks but rely heavily on home health care in between visits.

"When we move into a new community, the home care agencies just love us," he says. "We give them hundreds of referrals."

Diane Baker, Administrator of Premiere Home Health Care in Southfield, MI, estimates that Visiting Physicians sees 25% of her patients. She's found that "the doctor really counts on the word of the nurse, and both rely on each other in caring for the patient."

However, Baker says that nurses still will be needed for monitoring and regular care. "I don't see the doctor replacing the nurse in the home."

McCoy agrees, adding that, "It'll be interesting to see whether HCFA will determine criteria on when it's appropriate for either a doctor or nurse to go out on a home visit."

McCoy also suspects that managed care isn't going to be authorizing many doctors' house calls. Bayne acknowledges that some insurance companies or Medicaid are "embargoing" house calls. Most of his referrals are from home health nurses.

But Boling hopes that managed care may soon see the cost-cutting advantage of having a physician make a house call.

"The added value," he believes, "is when a $150 visit is compared to a $500 ambulance ride. For many bed-bound people, the only alternative is calling 911."