Doctors Deciding to Go Home Again

Frustrated by Health System, Va. Physician Reflects the Rise in House Calls

Zooming down a woodsy, rural road outside Fredericksburg, physician Robert Prasse and his nurse were in something of an unusual medical pickle: They'd lost their patient.

"Weren't we watching the mileage?" Prasse asked, checking the odometer of his bright-blue Pontiac Vibe and realizing the number would not help them find the right house because they'd lost track of the number they'd started with.

"I said it's where there's a whole row of mailboxes!" Dianne Bryant said from the passenger's seat.

"There's a 'whole row of mailboxes' everywhere!' " Prasse said in a pseudo-exasperated tone, poking fun at Bryant and the boonie-fied backdrop of his medical practice.

They eventually found their patient. But in fact, the way isn't entirely clear for Prasse, 48, who two years ago bailed on the mainstream medical system and a busy practice on Route 3 in Orange County to become something both old-fashioned and profoundly contemporary: a country doctor.

With his black bag and his files in the Pontiac's back seat, Prasse spends his days seeing patients in their living rooms, offices or, if they are sick enough, in the hospital.

Although his new lifestyle is a throwback to the mid-20th century -- the last era in which house calls were common in the United States -- the disgust with today's insurance-driven health care paradigm that drove him to quit is right in line with the times. And his decision to bolt a conventional practice is becoming more common, as well.

The number of house calls made by doctors and nurses in the United States increased from 1.5 million in 2000 to more than 2 million last year, according to the American Academy of Home Care Physicians, citing Medicare data. The number of house-call doctors began climbing after 1998, when years of negotiations between Medicare and home health advocates ended with the federal government raising reimbursement rates by 50 percent.

Now, with physicians and patients increasingly frustrated by the system -- particularly primary-care doctors, whose profit margins and time with patients are being squeezed ever tighter -- more doctors are dropping out of insurance networks in general, according to the Center for Studying Health System Change. But the mechanics of the move are still in the infancy stage for such doctors as Prasse, who are trying to navigate Medicaid, get paid and provide competitive 21st-century care out of a trunk.

But even though he wishes he had a portable electrocardiogram machine, Prasse said he feels something more advanced has returned to him since he hit the road: an ability to be a complete doctor again. "I've really begun to appreciate using your head," he said during a pit stop at a Spotsylvania Wawa gas station between patients.

His visits last at least a half-hour, and he can see such things as whether a couple's home life seems healthy or whether an elderly woman taking her own blood pressure has the right batteries for the machine she keeps by her rocking chair. Patients' refrigerator calendars show Prasse's appointments written in his handwriting.

Prasse, who was once a veterinarian in rural Kentucky, has a history of rejecting the conventional. He home-schools his children with his veterinarian wife at a horse farm they named Paradocs. His comical personality seems to help him as he feels his way into this unproven business venture, cracking jokes about his "children going hungry."