By Robin Shulman
Washington Post Staff Writer
Wednesday, March 14, 2007
NEW YORK -- The doctor is cruising downtown on Eighth Avenue in his black BMW when he gets the first in a string of text messages from his patient. "No one here?" reads the last one. The doctor is late.
The doctor texts back, one thumb flying over his Verizon Pocket PC, the other hand on the wheel. Natan Schleider, 31, then drives onto the curb to get around a car blocking his, parks illegally, props up the "Emergency Housecall" sign on his dashboard, and soon -- dressed in black scrubs, toting a black bag and black laptop -- is buzzing the bell of a West Village walkup.
This is the Manhattan house call. It is part retro trend, harking back to days when doctors had personal relationships with patients and dispensed care in the home. But it is also a technology-based New York convenience in a city where people expect laundry, DVDs and late-night sushi brought to their doors.
In fact, the house call is on the rise nationwide, mostly because of an aging population, increasingly portable medical devices and lab tests, and changes in Medicare in the late 1990s that allowed for higher reimbursement rates for doctors' visits to homes.
From 1998 to 2004, the number of Medicare house calls for the homebound elderly increased 43 percent, to more than 2 million visits, according to a study in the November 2005 issue of the Journal of the American Medical Association.
But another kind of house call -- call it the convenience call -- also has growing appeal for young, relatively healthy professionals in New York and other high-income locales. They summon a doctor or physician's assistant with a cellphone call and a wait ranging from minutes to hours, and their demand fuels several Manhattan-based practices.
Schleider, a soft-spoken man with a sympathetic way, charges $500 for the first visit and $400 thereafter, payable with major credit cards. He does not accept insurance.
"This is ideal medical care," Michael Harrison, 28, a commodity futures trader, said during an examination from Schleider in which he smoked and played with his dog in his studio apartment. "When you want it, when you need it. That's what New York City is about."
Harrison also owns a fashion company and a record label and says he makes thousands of dollars before lunch. Almost one year ago, he became dependent on painkillers after a liposuction surgery.
For a time, the baby-faced, hyperkinetic Harrison was taking narcotic cocktails of five or six different drugs a day, including perhaps 40 Percocets, he said. Schleider researched addiction and went through special training to be certified to dispense his patient the drug buprenorphine, or Subuxone, a kind of new-generation methadone that weans addiction to opioids and narcotics.
It is difficult to get Subuxone, because so few doctors are certified, and there is often a waiting list. Schleider is in demand -- he estimates 10 percent of his practice is now Subuxone treatment, a way for genteel drug addicts to avoid dingy, depressing methadone clinics.
More than half of Americans polled are unhappy with the traditional health-care system. Convenience-call patients such as Harrison say they wait too long to see conventional physicians, and then doctors hustle them in and out to see the next one. Health plans often do not provide for a family doctor who can liaise among specialists. Tests are not ordered, or ordered without cause. A practice such as Schleider's seems like a stopgap answer.
"My vision was for a regular family health clinic," said Schleider later, back in the car, heading to the Bronx. "That was my ideal, rather than hustling around. But this is the business."
He sees perhaps six patients a day. His practice grosses $25,000 a month, he says, with 20 percent overhead costs. And that is after less than two years and including rent on a Park Avenue office.
His accessories are mostly old-fashioned; his black bag contains probes and scopes and meters. In his downtown studio apartment, a cabinet contains a supply of medications, since a person who pays for a bedside doctor does not take a taxi into the night to find a pharmacy: Vicodin and Tramsdol, Hydrocodone and Acetamin. But he looks up diagnoses and prescriptions on his phone and keeps patient records on his laptop.
Once, Schleider got a call from a woman in her 70s who was short of breath. Within 30 minutes, a radiology technician with an SUV full of equipment had arrived at her building, carried his 100-pound X-ray machine into her apartment, taken chest X-rays and e-mailed results to a lab. Schleider knew the results before he arrived at her side.
Yet some say the house-call visit shows the inequities of the health-care system and of New York City. A two-tiered health-care system is already in place, said Jeremy Boal, the executive director of the Mount Sinai Visiting Doctors Program, one of the largest in the country to do house calls for the homebound elderly who might not otherwise get to a doctor.
He said a house call can deliver the kind of careful attention that every patient deserves. "Until our society chooses a system that's more equal and fair, anything that gets care to patients is a positive," he said.