Doctors Deciding to Go Home Again

It also helps as he sees patients in Spotsylvania, Orange and Fauquier counties.

Wearing a tie that has a dollar-bill design as he made rounds one recent afternoon, Prasse joked about Bryant's size ("It's no problem for her to work out of the car since she can practically stand up in there"), swapped recipes for the dessert bananas foster with a patient and yukked about how the first time he went out with his wife-to-be, she had two other dates that night. "Once we went out, she really cut it down," he said, "and now she rarely goes out with other people."

Prasse charges each patient $1,000 annually for their general primary care and the right to call on him whenever they want. He has gone through the complicated paperwork process of completely signing out of Medicare and he doesn't participate in any insurance plans.

His fee doesn't include drugs or hospital bills, but many of his patients are retired or retired military, for whom those costs are covered.

But he is taking the road less traveled, even within this subset of refugee physicians.

Most doctors making a living off of house calls are working within the Medicare system, said Constance Row, executive director of the home care physicians group, based in Edgewood, Md.

Medicare, however, pays for home visits only if the patient is considered too infirm to make it to a doctor's office. But as baby boomers reach their sixties, some physicians believe there is a growing need for services besides dialing 911.

Physician Jeffrey Katz was sick of seeing nurse positions eliminated and medical decisions being made by business executives when he left his job as associate director of the emergency room at Baltimore's Union Memorial Hospital in 1999 to start Physicians' House Calls, which has six doctors who do nothing but visit the homebound in the Washington-Baltimore region.

"When you work for a system, everything is driven by the bottom line and investors, instead of being patient-centered," Katz said. "It's contrary to how doctors see themselves."

Despite the six years it took to hammer out a billing system and the continued complexity of dealing with hospitals with different computer systems, Katz said his life is "incredibly better" since he began making house calls.

Prasse said he opted out of Medicare because it restricts the type of patients that physicians can see and because the payments are low. Medicare reimbursements for house calls are $43 to $197.

Being in a large, rural area, he spends a lot of time on the road between patients and typically makes four or five stops a day. He has about 100 patients and is not sure whether he wants to take on much more than 200. He still is hammering out when to charge extra fees. "If there's a lot extra, I agree to charge people a little more. Like if someone is in the hospital 12 times in a month, I'm probably going to charge something extra," he said in his typical, Bill Murray-like deadpan. "It depends on how annoying they are."