Should Your Docs Be Making House Calls?

One DC-based physician says making house calls is the only way he can maintain his solo practice. Demand is heavy and his business is growing. Should hospitals get into this business line, too?

Could house calls be a major business opportunity for your health system?

It has been for Stephen Kinney, MD, who calls on the homes of dozens of patients a week through his own private practice, Metro Direct Care Medical in Washington, D.C. He provides same-day service and is available 24 hours a day, seven days a week.

Not that he's getting rich off his business model, for which he eschews commercial insurance but accepts Medicare. He isn't. But at about $200 a visit, he does make a comfortable living and says his services are less than many other physicians in his area that are performing the service.

Could this model work for a large-scale implementation by a medical group from a hospital or health system?

Well, it depends. If you are far along in your journey toward value-based care, I don't see why not. Kinney says he's been able to keep dozens of patients out of the hospital in his time doing house calls, and keeping patients from needing high-cost care that a hospital provides is a key metric for success in risk-based contracting.

Like many physicians, Kinney grew tired of dealing with work in a traditional physician practice, where he took insurance and had to see patients every 15 minutes in order to make ends meet.

"As I got older I felt like I needed to spend more time with my patients, and I was getting more worried I might make a mistake in that environment. I got the idea of doing house calls," he says. "The number one reason was I'd have my own business and schedule patients as I want to."

Startup costs were very low. Although he has an office location in an office park, he doesn't see patients there.

"It's just an address," he says.

Reduced Hospital Admissions
Through home visits, Kinney says, he gets much more information on how a patient lives day-to-day—critical information that's key to whether they are likely to need home health assistance, better chronic care, or other needs that don't fit into the medical spectrum, but that could affect whether or how quickly they will recover, as well as affect whether they might need to be hospitalized.

"I see how people live, and I'm shocked and amazed day-to-day," he says. "I get to know family members and understand better why a person has a problem, where in an office setting you don't get to see that."

He also says he believes that the aging of the population, among other factors, is driving a trend toward more interest in house calls. He says he's amazed at how well he's kept "really sick" patients out of the hospital compared to his previous work in an office-based practice setting. That alone would be key to any hospital strategy that might incorporate house calls into the management of care for the chronically ill.

Kinney's virtual office is minimalist, but incorporates an electronic medical record system as well as several time-saving tools, such as temporal artery thermometers and pulse oximiters for oxygen saturation. He also does Skype calls on some patients. He keeps patient charts on his home computer and links it with an IPad with keyboard to see patients.

"I can do this all mobile and it works pretty well," he says. "It's really logical and all the charts are in front of me."

He says that thanks to his technological helpers, he can do almost everything at a patient's home that he could in the office.

Limitations Are Minor
"I can't do GYN in house calls and I can't do a 12-lead EKG right now, but that's about it," he says. "I'm sort of nurse and doctor. Blood work is an issue, but I have a phlebotomist who comes to the patient's home who will do labs. I am also limited with urine cultures."

Still, those are minor issues, for the most part, and he thinks that they will be surmounted by technology in time.

What Kinney is doing is not a concierge practice, with a set amount of patients, and an annual fee.

"Right now, I don't do that," Kinney says. "I don't want to make it so people who don't have money can't afford to see me."

The question for healthcare leaders, however, is whether this model is viable in larger practices or even hospital-based practices.

Although I've found little research on the issue, the house call model appears to be a profitable line of business for a hospital or health system. The key, it seems to me, is whether the underlying hospital or health system has reached the tipping point on transforming from volume-based to value-based reimbursement.

Most are not there [yet], but once health systems become responsible for the care of populations, I can envision how it would be cost effective to deploy a certain number of physicians, care coordinators, and physician assistants, not to mention lab workers, to work in a mobile setting. Some systems are dabbling in mobile medicine already, but I have not seen many who incorporate house calls into their service repertoire.

Still, it seems to me that if you're responsible for keeping patients out of high-cost areas of care in the future, this could be a worthy investment.

Keep the Basket As Full as Possible
One health system COO recently described to me the way he got his employees to understand the shift that is going on in medicine by using a basket as a visual aid. He placed an empty basket on a table and said, "this was our job in the past: There's an empty basket that represents revenue that needed to be filled by the end of the year. This is our job for the future: The basket is full of money at the beginning of the year, and after you treat all the patients you're responsible for during the year, we get to keep what's left."

It's a great, simple analogy. Hospitals and systems that are well on their way to transforming from volume to value, might have house calls in their future. Though Kinney's business is supported by his location in a big urban market with lots of international travelers and others who have money but not insurance, the economics behind house calls might still be very cost effective in a closed system.

At least you should investigate whether it's a viable option for at least part of your patient population.

Kinney is convinced that house calls are a growing business. And it will continue to grow with or without you.

"I won't go back unless I find I can't survive doing this," he says. "I'm not making a huge amount of money, but every month I surpass the month before."