September 16, 2013

No Place Like Home

In a recent NY Times opinion piece, ethicist, oncologist and health policy guru Ezekiel Emanuel lauds the resurgence of the house call. Emanuel says that house calls are bringing back “real personalized medicine” and, as a nice bonus, they’re saving money. But he fails to address why house calls fell into disfavor in the first place—and what we will need to do if we want to change their reputation as second rate medicine and promote their use.

House calls are inefficient (at least when they involve clinicians actually traveling to the home rather than a “virtual” house call that is actually a video call).  Reimbursement for a house call by a primary care physician is modest, though it is greater than for an office visit: the most recent Medicare Physician Fee Schedule reports that the highest possible reimbursement for a home visit to an established patient (someone the doctor has seen before) is $177.50, while the highest reimbursement for an office visit for a similar patient is $141.75. Payment for a procedure like colonoscopy or cataract extraction, by contrast, is 3-5 times greater. But beyond these financial considerations is the crucial recognition that physicians want certainty before they diagnose and treat. This kind of certainty comes from EKGs and blood tests and X-rays, only some of which can conveniently be performed in the home.

Consider a fictional but typical 85-year-old woman with mild dementia who lives with her daughter and son-in-law. Let’s call her Suzanne. One morning, Suzanne is much more confused than usual. She can’t figure out how to get dressed, even after her daughter lays out her clothes for her. She tries to eat her oatmeal with a fork. She babbles about how her husband will be coming to take her out for lunch, though her husband has been dead for twenty years and just the day before, she and her daughter visited his grave. 

Suzanne’s daughter knows something is terribly wrong. She calls her mother’s physician, who insists that she go to the hospital emergency room for evaluation. The doctors in the ER do a battery of blood tests, looking for chemical imbalances in the blood or evidence of a failing liver or failing kidneys, even though Suzanne has never had liver or kidney problems. After two hours, all the blood tests come back normal. While waiting for the blood test results, they do an electrocardiogram, because people who are having a heart attack are sometimes very confused, even though Suzanne has never had heart trouble. The electrocardiogram is normal. And just to be sure that Suzanne has not had any bleeding in the brain, she goes for a CT scan of the head, even though she has not fallen and brain bleeds of the kind the doctors are looking for almost always result from a fall. After being in the ER for 6 hours, the doctors conclude that the most likely cause of Suzanne’s confusion is a urinary tract infection, since a urinalysis shows some abnormalities, though a confirmatory culture will not be available for another 2 days. They send her home on oral antibiotics.

The reality is that Suzanne could have been diagnosed and treated at home. It would have been a good deal cheaper—in 2006, Medicare paid an average of $651 for an emergency room visit compared to $180 for an office visit and the mean ER department charge for a urinary tract infection was a stunning $2398.  It would also have been far less burdensome to Suzanne, who became even more agitated lying on the stretcher in the hospital, or to her daughter, who took off a full day of work to be with her mother in the ER. Her doctor could have avoided sending Suzanne to the hospital. He could have made a house call, checking by physical examination for various possible explanations for her acute confusion such as severe constipation, bruising on her face or head indicating a recent fall, or abnormally low blood pressure. He could have arranged for simple lab tests to be done in her home, including a urinalysis and basic blood chemistries. He could have started Suzanne on oral antibiotics, treating her for the most likely cause of her problem, while waiting for the results. Or he could have sent a visiting nurse to the home and relied on her assessment of Suzanne. Odds are he would have concluded that the most likely cause of her confusion was urinary tract infection—especially if he knew that the last few times Suzanne had developed worsening confusion that’s exactly what the problem had been. 

But he couldn’t be sure that she wasn’t among the few percent of older patients who had something else wrong with her, something serious. And even finding evidence of an infection in the urine wouldn’t have proved that was really the cause of the confusion—almost half of older women routinely have bacteria in their urine, with no discernible effect on their well-being. So to be certain that Suzanne really had just a urinary tract infection, her physician had to order all those other tests such as the CT scan and start treatment only after he had all the results. 

Home visits for certain kinds of patients such as frail elders can be very beneficial. As. Dr. Emanuel points out, studies of innovative home care programs such as the Johns Hopkins Hospital-at-Home program can deliver high quality results and save money. But if we want to see more house calls, we will need to modify the prevailing culture in which both physicians and patients regard certainty as the gold standard of medical care. We need to recognize that achieving certainty comes with a cost—both in dollars and in the sometimes dangerous and often burdensome tests and procedures to which patients are exposed. Physicians will need to talk with patients or their caregivers about how best to balance the risks and benefits of maximizing certainty.

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