Doctor's house calls: Back to the future

About a year ago Dr. Edward Ratner went to the home of a patient, Louis Salloway, and started counting pills.

He knew that Salloway, then 90, was supposed to be taking medication for his blood pressure.

But the pillbox told a different story. Ratner could see that Salloway was skipping doses -- there were too many pills left. That came as a shock to Salloway's family.

"My dad just kept telling us that he was taking his medication, and as family members we all believed him," said daughter Sheri Yarosh of St. Paul. "I didn't recognize that he couldn't do that anymore."

Because of Ratner, the family was able to step in and help. That, she said, is one of the benefits of having a doctor who still makes house calls.

He may seem like the last of a dying breed. But Ratner believes that house calls are poised for a comeback. In his view, they are the best and cheapest way to care for the frail elderly, especially at a time of soaring costs. In fact, Medicare paid for 2 million house calls in 2006, up from 1.5 million in 1995. A new proposal in Congress could open the door to many more.

Fifteen years ago, Ratner, an associate professor at the University of Minnesota Medical School, quit his office practice to concentrate "on people who couldn't or shouldn't" leave home to see him.

"That's the era I grew up in," said Ratner, 52, who was raised in St. Louis Park. "If you had some sickness, the doctor came by the house. In many ways, I'm trying to recreate" that.

In some parts of the country, such as New York and Florida, house calls are flourishing.

Even in Minnesota, HMOs and insurers will cover house-calls in limited circumstances, says Julie Brunner, executive director of the Minnesota Council of Health Plans.

But, like many people, Brunner is skeptical that they will really save money.

"That's a really expensive use of a physician's time," she said. As a practical matter, home visits by nurses or other caregivers are much more common and affordable, she noted. "We would all love to be seen by a physician in our home, but ... we're being killed in health care costs in this country right now. There's a crisis, so we may not have [that] luxury."

To Ratner, it's not a luxury at all.

The problem, he says, is that many elderly people suffer in isolation with chronic or disabling illnesses that could be managed with a doctor's help. But because they find it hard to get to a doctor's office, they don't seek medical care until a crisis hits and they end up in the emergency room.

"The way you're providing service [now] is fabulously more expensive than any other thing you can think of," said Constance Row, executive director of the American Academy of Home Care Physicians, which represents doctors such as Ratner and has more than 1,000 members.

An average house call, she said, might cost $150. "Find me an ER visit that is under something between $1,000 and $3,000."

Last year, a proposal to encourage house calls was introduced in Congress. The Independence at Home Act would allow doctors to pocket some of the savings if, by making home visits, they reduced their patients' Medicare costs by more than 5 percent.

Ratner, a past president of the academy, says everyone wins with house calls -- the patient, the family and the people paying the bill. But he's something of a lonely voice in Minnesota -- a Marcus Welby, as one colleague put it, in a challenging time.

Looking for clues

In late February, Ratner knelt on the carpet in Louis Salloway's living room in St. Louis Park and gently removed the older man's shoes and socks.

He looked up at his patient, who had recently been in the hospital. "Do you think the pneumonia is gone?" Ratner asked, lifting his voice. "I think so," Salloway replied softly.

To Ratner, a house call is more than a checkup. It's also a chance to examine the home for clues to his patient's well-being.

"When I learned how to make a house call," he said, "they told me the two most important things to do: Look at the feet and look in the refrigerator."

Are the toenails clipped or neglected? That's a window into overall personal hygiene. Is there food in the kitchen? Is it spoiled? In an office visit, Ratner says, a doctor might suspect cancer if the patient has lost weight. In the home, he might see that the refrigerator is empty. The solution isn't always medical; sometimes it's a social worker or home health aide.

There's also something about being on his patients' home turf, surrounded by their books and photos of their grandchildren, that gives him fresh insight. It shows "what they were like before; what they value," he said. "The ability to understand what's going on with the patient is extraordinarily better when you a see a patient in their home."

Once, he noticed a woman's religious artifacts and asked if she went to church. Not anymore, she replied. When he asked why, she said she was taking a diuretic, or water pill, and couldn't sit through the service without a bathroom break. His solution: Take the pill after church.

Most of Ratner's patients are past 85 and have multiple problems that could easily land them, or keep them, in a nursing home. Donna Brochin of Golden Valley said Ratner's visits made it much easier for her 90-year-old husband, Joseph, to come home from a nursing home last month. A retired pharmacist, he can no longer walk and has multiple health problems, but home aides are helping care for him.

"I think bringing him home was an excellent idea," Donna Brochin told Ratner at a recent home visit.

"It's worked better than any of us thought," Ratner replied. "You're doing a great job."

Sometimes, he's as much chaplain as physician.

"So, anything we can do to make things better?" he asked.

Donna Brochin smiled. "Well, unless you're God, I don't think so."

Skeptics remain

A year ago, Ratner joined North Clinic in Robbinsdale to start a house-call service, funded in part by a state grant. So far, that part of the practice hasn't really taken off, said Dr. Nick Schneeman, who runs the clinic's geriatric program. There are only about 50 patients enrolled, mainly because of difficulty getting insurers to pay a "case management fee" to cover the costs.

"I'm a little disappointed," said Schneeman, "but I am absolutely not giving up on it."

Ratner knows that many doctors are skeptical. The big criticism is that house calls are inefficient. An office doctor can see four or five patients an hour. "I hear that frequently," he said. "All they're saying is 'I'm not paid enough per hour or per visit to do that.'"

He thinks that's shortsighted. Medicare pays about $50 to $160 for a home visit, but "compared to office practice, my overhead is insignificant," he said. Ratner, who is also medical director of a home health agency and does research and teaching as well as house calls, says he earns about the same hourly rate at all his jobs.

For him, at least, house calls are here to stay. "It's hard for me to imagine going back to an office setting," he said. "It would be like working with one hand tied behind my back."

Maura Lerner • 612-673-7384