Home visits, by then, already had become passé. In the 1930s, doctors saw patients at home about 40 percent of the time. In the 1980s, nearly all visits took place at the physician’s office or at a hospital. Less than 1 percent were house calls. Modern medicine was centralizing, trapping primary care physicians in their own webs of equipment and auxiliary staff.
Boling’s experiences, though, convinced him that there is still a role for medicine in the home, particularly for the frailest of the elderly. These patients need more attention than a 15-minute clinic appointment affords them. For many, just getting to a clinic is a struggle. So a slight complaint is allowed to fester into a crisis, an ambulance and an expensive emergency room visit.
“The idea is to deliver health care where it’s best for the patient,” Boling says. “If the clinic is the right place for them, then come to the clinic. If it’s hard for them to come to the clinic, short-term or long-term, we’ll go to them.”
Boling revs through a turn, sending up a puff of rust-red leaves. He tells the students how he got to this moment today.
Decades ago, he and his colleagues at the American Academy of Home Care Medicine embarked on a saga to spread this very personal way of caring for sick elderly patients. Studies were done. The system saved money. Patients were healthier. Families were happier.
Still, few wanted to pay for this rather old-fashioned model of health care. Medicare reimbursed at a paltry rate for house calls. Most of the house-call outfits ran at a loss, subsidized by grants or a sponsoring hospital. The doctors realized that if they wanted to change how medicine was practiced, they had to change how Americans paid for it.
Their efforts came to a head with the passage of the Affordable Care Act, which funded a three-year incentive program called Independence at Home. Like many of the other cost-saving experiments that the ACA set into motion, Independence at Home does not propose an entirely new way to deliver health care. It just demonstrates a new way to fund it.
The 17 participating house-call practices are to get an annual bonus — dating to 2012 — based on how much money they saved Medicare by keeping their patients healthy and out of the hospital. The results of the first year are expected to come out shortly. Because these house-call teams serve some of Medicare’s sickest — and most expensive — patients, the savings could be huge.
In 2005, the Congressional Budget Office calculated that the top 5 percent of Medicare cases in a given year account for 43 percent of total costs. Overall, Medicare accounts for 14 percent of the national budget, or about $500 billion annually.
For the teams of doctors and nurses participating in the study, those savings would translate into thousands of additional dollars in revenue per patient each year — the kind of money that would allow the teams to hire more staff members and pay a competitive salary.
Boling has another mission. The nation faces a dire shortage of family doctors, especially those who focus on the elderly. And no wonder: Primary care is exhausting. The hours are long and the pay is paltry compared with specialties such as dermatology or plastic surgery.
“One of my goals, my career-long goals when I quit, is to have established an economic model that makes this a desirable mode of practice,” Boling says. He understands that medical school debt is crushing. “But I think if I could pay these guys like a hospitalist, like a junior cardiologist or something, many of them would be flocking to our door.”
All of which explains why, today, Boling is driving two second-year med students to see 93-year-old Helen Shadoan.
Boling and his students pull into the parking lot at Heritage Oaks, a retirement complex 15 minutes from downtown. A tottering ragtime tune issues from the common room piano.
The crowd shuffles inside Shadoan’s spare living room. On a wooden table in the corner, a white Teddy bear leans against an empty flowerpot. An oxygen machine and its tubes are neatly arranged near the entrance.
Shadoan, 93, sits in a pink gown facing the single window. A rotation of home-care aides looks after her round-the-clock. She is blind and hard of hearing, but her voice is still lustrous. She used to be an audiovisual technician, she says, developing photographs and making charts.
“Do you still remember where you used to work?” someone asks.
“Certainly!” she says. “The Veterans Administration — well, I guess it’s Veterans Affairs now.”
Marie Gerardo, the nurse practitioner in charge of her case, begins to tell Boling about Shadoan’s recent brush with pneumonia. Autumn is a perilous time for the elderly. A couple of weeks ago, Shadoan began to run a fever.
“Her temp in the evening was 101.5 and her pressure when I was here was in the 80s over 60s,” Gerardo says. The room inhales all at once. “So I was begging her to go to the emergency room, literally.”
But Shadoan flatly refused.
Boling leans over to talk into Shadoan’s ear. “When you had that pneumonia, you were really sick,” he says. He grew up near Boston but he has worked nearly his entire career in Virginia. These days his voice slips into a slight twang when he talks to patients.
“Did you feel really sick?” he asks.
“No, I didn’t feel that bad,” Shadoan says. “I just didn’t have that much energy.”
Boling tells the students that this common among older patients, who often can’t tell how sick they actually are.
“I wanted her in the hospital,” Gerardo continues. “And Ms. Shadoan, at 93, was very emphatic about not going. She’s blind and extremely hard of hearing, so a hospital visit is horrible for her.”
“They just give me a nervous breakdown,” Shadoan says.
That day, Gerardo had acquiesced. She ordered a mobile chest X-ray and started Shadoan on antibiotics. She did not force her patient to go to the emergency room.
This, in the end, was the right call. Shadoan was more comfortable at home. She was spared an unnecessary hospitalization, and Medicare saved money.
“It probably took her a bit longer to get better, but in reality she was probably better served not being in the hospital,” Gerardo says. “She has done really quite well.”
Boling turns to the two student doctors standing near the wall. Shadoan is still recovering a bit from the pneumonia, and Boling wants the students to break out their stethoscopes. How does her chest sound? Do they think Gerardo made the right choice?
When President Obama signed the Affordable Care Act in March 2010, most of the nation focused on how the law would extend health-care coverage to more Americans. Recall the bitterly debated insurance mandates; the push to expand Medicaid that some governors foreswore as federal meddling.
Although concerns about ballooning medical spending had gotten the ball rolling on health-care reform, the actual legislation did not roll out grand plans for containing health-care costs. Instead, the law created the Center for Medicare and Medicaid Innovation to oversee a salvo of demonstration projects, each promising to zap various inefficiencies in the system.
A curious fact about health care in the United States is that most doctors can diagnose its dysfunctions in an instant. They know they should spend more time with their patients, and spend more time following up on them. They want to. They also know they should talk more with nurses, should talk more with social workers, should talk more with psychiatrists, should talk more with pharmacists, and so on.
But by and large, the system can punish those instincts. Most doctors have little opportunity do the kind of coordination and follow-up that leads to better health outcomes. You cannot bill Medicare, for instance, for spending an extra hour on the phone trying to figure out why your patient didn’t get her at-home oxygen tank. But that might be exactly the kind of miscellaneous assistance she needs to get better, and the kind of assistance she might never receive because no one has the time to notice the problem, let alone delegate it to a social worker, if there even is one on staff.
“The system pays for the bricks, but it won’t pay for the cement,” says Bruce Kinosian, a professor of medicine at the University of Pennsylvania.
One of the goals of the ACA is to figure out, in different ways, how to pay for that cement.
Earlier this year, Kinosian co-wrote a study on the house-call programs operated by the Department of Veterans Affairs. He and his colleagues — including Thomas Edes, the VA’s director of geriatrics — compared the medical costs of patients before and after they entered a house-call program. They found that the VA’s house-call teams not only paid for themselves, but they also went on to reduce overall health-care costs by 12 percent. In part this was because patients were 25 percent less likely to go to a hospital.
In the VA study, patients also reported sky-high satisfaction ratings: 83 percentsaid their care was “very good” or “excellent.”
Another study this year, also in the Journal of the American Geriatrics Society, compared patients in a D.C. house-call program to a carefully matched control group with similar diseases and medical histories. The house-call patients cost Medicare 17 percent less. About half of the savings came from reduced hospitalizations, and another chunk from keeping patients out of nursing facilities.
A theme of modern health-care reform has been a process called “aligning incentives.” That means, for instance, fining hospitals that discharge patients who quickly land in the hospital again. It also means paying for results, not for individual procedures. Boling and his colleagues have lobbied hard for the government to recognize the savings and increased satisfaction that their house-call programs generate.
Independence at Home, which is limited to 10,000 patients, is an attempt to show how house-call practices can get a cut of the savings they generate. The Medicare office uses a statistical model to predict how much each patient is expected to cost each year. If a house-call team can bring their patients’ costs below the prediction, through better care or fewer emergency room visits, Medicare will share the savings with that team. Medicare takes the first 5 percent saved each year, and gives the doctors 80 percent of any savings thereafter.
Under this formula, a house-call team might get a couple of thousand of dollars extra per patient per year if it can reduce a costs by 10 to 15 percent — a reduction that’s in line with what the studies predict. The money would be a great boon to these practices, most of which can handle only 200 to 500 of these complex, sick patients. (A typical primary care physician might serve 2,500 regular patients.) In his practice, Boling could use the money to hire a couple of extra social workers or physicians.
Boling, who chairs the geriatrics division at VCU’s medical school, runs two house-call teams at the university. He staffs each with a handful of physicians and nurse practitioners, along with social workers, triage nurses and, recently, a pharmacist. Once a week, the teams assemble to discuss their patients and various aspects of their lives.
This is the kind of health care that Boling thinks millions of elderly Americans should have access to: comprehensive, in-depth and insistent.
“We get into every little part of their medical history and their social history,” says Susanna Payne, a nurse practitioner. “I know how many grades she completed in school, I know what she used to do for work. I know how how many kids she has, how many are still alive. How many are actually involved in her care.”
The program is not for everyone. Boling’s doctors focus on the most complex cases: people with multiple chronic illnesses, who rarely leave the house. These are the ones who benefit most from the careful services they provide.
On a recent Thursday, with her colleagues gathered around a conference table, Payne runs down the information on one of her newer charges. Mary is an 82-year-old with high blood pressure, a pacemaker and impaired vision from macular degeneration, with a history of vertigo and stroke. She recently went to the emergency room because she felt dizzy and her urine was dark. The doctors there diagnosed her with a urinary tract infection and sent her home. (Mary’s last name has been withheld for privacy reasons.)
These are the kinds of unnecessary ER visits that the team tries to prevent. Someone could have helped her over the phone, or with a quick visit. The team always has someone on call 24/7.
For five years, Payne says, Mary has been relying on the emergency room for her primary care. “She’s used to calling 911 and going to these hospitals when she really needs something,” Payne tells the group.
It takes “a little while for people to get used to having access to care, to learn to rely on us,” Boling says. “It doesn’t usually take too terribly long for people to find that they don’t like the ER experience as much as having someone come to their house.”
On a recent house call, Mary complained of painful calluses on her feet. Payne arranged a visit from a podiatrist. Mary also showed Payne a $200 bill for a medical bracelet that she could not afford. Payne immediately e-mailed the team’s social worker to see if she could get the bracelet for free.
“When you go into someone’s house, you stumble across these things that you wouldn’t necessarily stumble across in clinic, that really do cause a great deal of anxiety,” Payne says.
Treating very frail elderly patients often requires treating families. Physician Amy Paul brings up another patient she’s worried about, a bedbound 87-year-old woman who lives with her daughter and grandchildren. The daughter, who looks after her mother, is supposed to be seeing a psychiatrist, but she hasn’t been going. The daughter’s blood-sugar levels also recently were so high that she needed a shot of insulin from the ER. But during her home visit, Paul saw the daughter having sweet tea with crackers and Doritos — terrible foods for someone with high blood sugar.
“It’s going to take a couple of visits with a lot of education,” Paul says.
In Helen Shadoan’s apartment, kneeling in the afternoon light, Sarah Hughes lifts her stethoscope to the elderly woman’s chest.
All med students at VCU are required to sign up for a house call. Hughes wants to become a pediatrician. She’s used to being in clinics, where she says the pace is much quicker — 20 minutes per patient, tops. By now, they’ve already been in Shadoan’s room for 35.
Gerardo instructs her to lean closer and talk in a deeper voice so that Shadoan can hear her.
“Hi, Ms. Shadoan,” Hughes says. “I’m a student. My name is Sarah. Can I listen to your heart?”
“Certainly,” Shadoan says. “Just tell me what you want me to do.”
“You just sit there. You’re doing great,” Hughes says.
“You guys have been remembering to observe when you walked in, right?” Boling says, as the students wrap up. “You noticed the oxygen tubing and the walker. Now, Ms. Shadoan can’t see, so she’s already adapted her environment to some extent. She knows where everything is in this apartment, exactly.”
The conversation turns to her daily routine. She wakes up at 5 or 6 every morning and switches on MSNBC. She likes political talk shows, “Morning Joe” in particular.
She voted for Sen. John McCain (R-Ariz.) in the 2008 presidential race, and Obama in 2012. “Well as far as I’m concerned, he’s okay,” Shadoan says of the president. “He’s not the best one we ever had. He’s certainly isn’t the worst.”
“Oh my, I don’t know,” she says. “Maybe FDR. He’s the first one I ever voted for.”
Someone asks for her thoughts on the Affordable Care Act.
“Well, I don’t quite understand it,” she says, pausing. “My son’s thoroughly against it. But I think there must be some good parts to it.”