Drawing on the Past and Looking to the Future: The Role of House Calls in the Age of Modern Medicine

Though it may seem like part of a bygone era or an episode of “Little House on the Prairie,” the house call is not just an image of American medicine’s past; it may also be the way of the future. With patient bases increasing in age and more and more people having mobility issues — transportation and other limitations — house calls are on the rise after a staggering drop in previous decades.

Between 1930 and 1950, the number of physician encounters taking place in homes dropped from 40 percent to 10 percent. By 1980, that figure stood at a mere 1 percent.¹ It seemed the house call was part of a dying breed of medicine, until the trend once again shifted. Between 1999 and 2009, the number of house calls actually increased by 64 percent, from 1.4 million to 2.3 million encounters, according to data from Medicare Part B billings.²

A review of several house call practices reveals their benefits for patients, clinicians and practices that want to move to or incorporate home-based care.

Three House Call Models, One Common Goal

Founded in 2002, Doctors Making Housecalls is a medical practice comprising 62 clinicians who make more than 75,000 home visits each year to private residences, retirement communities, apartment buildings and independent and assisted facilities in areas of North Carolina.^3,4 And those numbers are increasing. The practice had 42 clinicians last fall,⁴ which means it has grown by more than 47 percent in the past year alone.

Shohreh Taavoni, MD, and Alan Kronhaus, MD, started Doctors Making Housecalls after Dr. Taavoni realized how many patients were too ill or too fragile or lacked the transportation necessary to make office visits viable. She remembered the medical care she received as a child in Iran, where doctors routinely visited patients in their homes to avoid exposing them to the pathogens present in the office setting.⁶ The practice, which began as a small undertaking, now operates from a 15,000-square-foot headquarters and has grown well beyond Drs. Taavoni and Kronhaus.⁵

For seven years, Andrea L. Brand, MD, operated a cash-only house call practice just over a decade ago. She traded in her salaried position, complete with all the tools, services and benefits of a traditional practice, for what she describes as “a cash-only, house call practice that [relied] mostly on a car, a doctor’s bag, paper charts, a simple fee structure and cash, which I collect[ed] at the time of service.” Brand says she could do about 95 percent of what she did in an office setting. She describes her visits with her patients as comfortable interactions in the living room or at the kitchen table of each patient. “The medical office creates many physical and emotional barriers between doctors and patients; the house call removes them,” Dr. Brand explains.⁶

Physicians are also incorporating house calls into their traditional practices. Samantha Pozner, MD, began making house calls in 2002 as part of her practice in New Jersey. Her reason for doing so was that she had patients who could no longer make it in to see her. It started with one patient who was too ill to come into the office. Dr. Pozner would leave for work early, which gave her time to visit the patient at home on the way in. Over the past decade, she has seen about 30 patients in their homes. “Once you have it in your head you can do that, the opportunities present themselves,” says Dr. Pozner.²

The Benefits and Challenges of the House Call Practice

One benefit of making house calls is that healthcare comes to those who are unable to visit a doctor’s office or who would have difficulty doing so. Doctors Making Housecalls states that it can do more tests and procedures in a patient’s home or place of business than most primary care physicians perform in the traditional office setting. The practice keeps costs down by contracting with insurance companies and being an in-network provider with nearly every plan.4 A two-year patient outcome tracking effort as part of a Medicare demonstration project exploring at-home care for complex and elderly patients showed that patients at Doctors Making Housecalls spent less time in hospitals, had fewer emergency room visits and spent less on healthcare overall.

Dr. Taavoni built the practice for patient convenience and has also come to see it as a solid solution to provider burnout and the rising cost of consumer health. She says the practice grew slowly for the first few years. During this period, savings were used to sustain the practice. Now, Doctors Making Housecalls is flourishing, and overhead is lower than in other practices. Dr. Taavoni credits this low overhead for the practice’s success, saying the model allows its clinicians to spend more time with patients.⁵

Dr. Brand has a similar story. In an article for Family Practice Management, she explains that her overall income was lower with her new house call-based practice, but her hourly income was higher. She says she kept the volume low by design, which allowed her to provide better service to her patients.⁶ She was also able to act as her own boss and create her own schedule.² In addition, her overhead, while higher at the beginning, declined over time. Using an array of portable medical tools and equipment, as well as drug samples, she says she could provide services that rivaled her level of in-office care with 30 percent of the overhead.⁶

Dr. Pozner says her house calls have kept many of her patients out of the hospital. She also attributes home visits with giving her more insight into her patients’ lives — including their environments and their caregivers — as well as developing better relationships with patients and their families.⁷ She attributes her success to making home visits work for her. She only visits patients who live in convenient locations such as between her home and office. She also fits her home visits around her office practice rather than setting aside a dedicated time frame for house calls.²

Establishing a House Call Practice

Though still relatively low compared with overall office visits, the uptick in house calls is something traditional practices might want to keep on their radar. If a practice wants to incorporate a small number of home visits into an existing practice, little to no marketing is required. The clinicians will know which of their existing patients will be in need of such services. Dr. Pozner says providing house calls has actually been its own form of marketing for the traditional side of her practice. She estimates that she gained 100 new in-office patients as a result of recommendations given by the family of a single house call patient.⁷

Another model that practices can adopt is a concierge approach to home visits. With this model, patients who are able to visit the office but want the convenience of home visits pay out of pocket for the service. For these patients, the fee is necessary because most insurance companies won’t reimburse the practice for the added cost of the home visit.⁷

For those who want to create a practice that’s dedicated to house calls, the start-up process can pose unique challenges. Though building a house call practice doesn’t require the same volume of patients as a traditional practice, finding those patients isn’t always straightforward. Referrals from other traditional practices are rare. In addition, many traditional forms of marketing don’t work well for this business model. Instead, talking with social workers, home nursing agencies, local aging councils and other individuals and entities who serve the populations that are most likely to be homebound and in need of home-based services might be more effective.⁷ Word of mouth has been reported as the main form of marketing for dedicated house call practices.

Having an established patient base and reputation within a community can also facilitate the transition to a house call practice.^6,7 Dr. Brand offers additional advice for capitalizing on one’s existing reputation and practice. She recommends sending a letter to patients and colleagues that explains the house call practice and why it’s being implemented. She also suggests reaching out to local media outlets. Offering to write an article for the local paper or make an appearance on a local news channel is another way to spread the word about a house call practice.⁶

A Calling for House Calls

If the past few years are any indication, house calls are here to stay and will most likely continue to rise with the country’s growing geriatric population. House calls are just one important component in the array of options available to practices and clinicians. Whether large or small, stand-alone or incorporated into an office-based practice, or part of concierge or traditional care, the house call practice is making inroads and changing lives for the better.