By Christopher Guadagnino, Ph.D.
Alfred E. Stillman, M.D., is co-founder of the Philadelphia-based Home Visit Doctors, and is author of the recently-published Home Visits: A Return to the Classical Role of the Physician
PND: What is your proposal for easing the shortage of geriatricians in the U.S.?
AES: A way to ease the shortage of doctors to take care of elderly homebound patients would be the services of retired physicians to donate one or two half-days a week to help take care of homebound elderly people. I think this would be a win-win situation because retired physicians come from an age when home visits were more commonly done than today. The elderly people of whom I speak also fondly remember the practice of home visits.
PND: Is there an organization that would coordinate those activities?
AES: Not yet. I’m looking to build that kind of organization. I’ve just written a proposal to the Philadelphia County Medical Society and I’ve also recently published a brief outline of what I would propose in David Nash’s Health Policy newsletter which came out in December 2007 and which has a widespread circulation in the U.S. Initially, we would reacquaint our volunteers with the special medical and psychosocial problems of the elderly homebound. We would also supply them with the equipment and personnel needed to accomplish their goal. Our retirees would never operate in a vacuum. There would always be a core of experienced home visit physicians available on whom they could rely for advice and periodic conferences. Finally, we would do our best to insure that medical malpractice premiums for these physicians would be overlooked in view of their invaluable donated experience.
PND: How does reimbursement for home visit compare to an office-based visit?
AES: It’s actually a little bit better than an office based visit – a very little bit better. Patients are almost always insured, either through Medicare or Medicaid HMOs, or through Medicare directly. There are very few patients that I have ever encountered who have no insurance at all. But the problem, as far as total reimbursement goes, is that an office-based practitioner can see 30 or even 40 patients a day in an office, whereas we home visit doctors consider it a big day if we can see eight patients because we have to travel around to our clientele.
PND: How do your expenses compare to those of an office-based visit?
AES: I think our expenses are higher than those who are in office practices. We have to pay rent, we have phone bills and we have personnel costs. Our office employs three full-time secretaries, we have two full-time physician assistants and we also hire a social worker who does not get reimbursed for her services by insurers. It’s a very labor-intensive practice. Although we have only about 600 patients, those are 600 difficult, chronic disease-loaded patients. We receive calls daily from the patients, from their caregivers, from home visit nurses, from physical therapists, occupational therapists, pharmacists, durable medical equipment people, social workers, governmental agencies. All of this gets funneled into our office and my partner and I, and our two physician assistants, field those calls.
PND: It sounds as though the configuration is much like a standard office-based practice, and yet has less than one-third of the patient volume. How do you make it work?
AES: I personally make it fly because 27 years of my professional life were spent as a gastroenterologist in which I was at the high end of the earning spectrum. And my wife, who is also a physician, earns a very handsome salary as a hospital administrator. I think that my partner would have to answer for himself about how he is able to support himself financially. I don’t think this is something that a newly-graduated resident or fellow could afford to do. It’s difficult for somebody getting out of house officer training with a great deal of debt and who may also be married with children to do because they may never climb out of that debt.
PND: Would physicians have to subsidize their costs to do what you are proposing?
AES: No, they wouldn’t have to subsidize anything. However, I don’t think that they would receive much reimbursement either. If this proposal goes through, we would assist them by giving them nurse practitioners or physician assistants to be their eyes and ears for these patients, and they also would have social work help. How much they would get paid, if anything, is really up for grabs. My personal feeling is that this really should be a donation of time. These doctors are retired and hopefully have adequate savings. They are living on what they’ve earned for the previous 50 years. They might be willing to donate one half-day or two half-days a week to this project, in return for feeling that they’re still useful in medicine and have something to contribute. And let me tell you, what they would be doing is supremely useful.
One thing that I should emphasize is that home visits should be the province of very experienced physicians who have a lot of experience in dealing with chronic disease. This is what afflicts a great majority of these homebound patients. Retired physicians are the ones who should be on the forefront of dealing with our homebound. I have spoken to many retired physicians and the one thread that seems to run through all of their conversations with me is that they miss medicine. No matter what they’re doing, whether they’re playing bridge or on a golf course or reading a book or playing the piano, they miss medicine. And frankly, I don’t see how they could avoid missing medicine. It’s a consuming profession in which they’ve been intensively involved for decades. It’s hard to just pick up and leave. And if they were able to donate a half-day or two half-days a week toward a very worthy cause, it would without a doubt be psychologically beneficial for them and also provide a wonderful service to their community. For this program to flourish, we would need external support from foundations and philanthropic, governmental or granting agencies. However, we believe that we could save a great deal of health care costs by keeping patients out of the emergency department, preventing hospitalizations, decreasing polypharmacy and reducing nursing home placement. these savingswould more than cover the costs associated with this program.
PND: Would they have to pay malpractice insurance for this kind of duty?
AES: That is one of the major unanswered questions. I’m at the very beginning of trying to organize such a program. If I had my way, they would pay nothing. We would have to work this out with PMSLIC, the major malpractice insurer in the state, or with the state board of medicine.
PND: What are the differences with regard to physician satisfaction of this home visit model versus an office-based practice?
AES: First of all, the patients are very grateful because they wouldn’t get medical help any other way until they wound up in an emergency room, a hospital or a nursing home. It is the goal of the home visit physician to keep a person as independent as possible, for as long as possible, on their own home turf. When we do that, we get tremendous satisfaction and gratitude. We can get to know them much better in their own home environment. We can develop a closeness with them that the office physician may not develop in years of seeing that patient. We can develop it within a few visits. I think it is one of the grandest and most satisfying specialties that a person could go into in medicine. I’m speaking to you as somebody who was a consultant gastroenterologist for 27 years. I love what I do now as much as I ever loved GI, and I loved GI a lot.
PND: What type of patients are candidates for home visits?
AES: The patients of whom I am speaking would not be getting medical care at all unless they have physicians who would come into their home. My patients and my partner’s patients are homebound for a variety of reasons. They are physically disabled. They have amputations. They have strokes. They have severe heart or lung disease. They have terrible musculoskeletal problems that make it painful or difficult for them to get out. Or, they may be cognitively deprived or emotionally challenged. For example, if they walked out of the door of their apartment they might not be able to find their way back in. Or they may be so depressed that they have absolutely no desire to get out or socialize. Another large group of people who are not disposed to socialize feel that they have certain disabilities that are going to draw attention to themselves. For example, they fall a great deal, or they’re incontinent of urine or bowels or both, or they can’t hear, or they have very bad vision. Finally there’s another category of people who have none of the above but who have no means of transportation. They don’t live near public transportation facilities. They have no friends or relatives who can or will take them anywhere. What I just described is about 90 percent of our patient population. The other 10 percent comprises two groups of people who are just as intractably homebound: morbidly obese patients and patients with bad neuromuscular disease, people like quadriplegics or those who have severe multiple sclerosis or Parkinson’s disease. These patients are usually younger than my geriatric patients but are just as homebound as the other 90 percent of my patients.
PND: How many homebound patients are there in the U.S.?
AES: In the United States there are at least two million homebound patients. The 600 with whom I and my partner deal, I am confident, are the tip of the iceberg in Philadelphia. As you can imagine, we have a pretty consistent turnover in our practice because of the age of our patients. It’s not uncommon for our patients to die, and we constantly renew that supply. In fact, our practice is growing. So, there must be a lot of patients out there who fit these various categories, who are not yet associated with us and who need people like us.
PND: Do these patients have other primary care physicians?
AES: No, we are their primary care physicians. The alternative would be that, when they get into serious trouble like getting a stroke or heart attack, they would be transported by 911 to an emergency room. However, had they seen a physician like myself, my partner or our two physician assistants years before, we could have instituted measures to help prevent these things. We could have gotten their blood pressure down. We could have corrected their cholesterol. We could have watched their blood sugars. There are so many things that we can do to head off bad news events.
PND: How do you identify and recruit patients?
AES: We don’t recruit any. People refer them to us. Our main referral sources are visiting nurse services, governmental or social agencies like Philadelphia Corporation for Aging, and senior health centers. The only thing that would prevent us from taking a patient is if they lie outside of our geographical area. Sometimes we’re referred patients by other physicians who realize that they can’t do justice to their homebound population because they have no time to get out of their office. And sometimes we’re referred patients by other patients who have been pleased with our service.
PND: Do you have a sense of how scarce, or perhaps common, a practice like yours is? You can’t be the only one in the Philadelphia region, can you?
AES: No, but we’re darn near the only one that is exclusively devoted to home bound patients. Our practice is the largest in the Delaware Valley. I can tell you there are about 450 physicians in the entire U.S. who make their living exclusively from home visits. Now, to be sure, there are plenty of doctors around who will occasionally, as a favor to a long-standing patient who becomes homebound, go and visit that patient in their home. But this is an exception. There are very few physicians who make their living doing what we do. The demand is growing astronomically just as the geriatric population is growing astronomically.
PND: What do you learn about a patient during a home visit that would be difficult to learn during an office visit?
AES: When I go in, I greet them. I regard them as friends. I know that’s hard to imagine, but in my type of practice, friendship is established rather early. You can find out so much more about a patient from visiting them in their home. There are so many things that are evident as soon as you walk in the front door. For example, you can immediately gauge their financial resources. You can tell whether their house is clean or dirty. You can tell what kind of food supplies they have. You can tell if their living environment is safe. Are there stairs that they have to climb? Are there fall risks? Do they have alcohol around? Do they have ashtrays full of cigarettes? Do they have people around on whom they can rely? Do they have family living with them? What is the relationship between them and their family? Is it friendly? Is it antagonistic? These are all things that are difficult for anyone to hide. During an initial visit we first meet the patient and their caregivers if there are any, and we have an opportunity to learn about their finances, their sources of support, all of their medical and surgical history, and their medications. This could last two hours. A follow-up visit, if it’s a relatively well patient, could be a half an hour. If it is a more complicated patient with a lot of things to follow-up on, it could be an hour. And of course, in between is the time spent in the car when you go from one patient to another.
PND: What are some of the practical obstacles of rendering in care in the home setting, compared to an office setting?
AES: Virtually none. The most important asset that doctors have is what’s between our ears – our experience, our knowledge, and our examination skills. William Osler, the great clinician of over a hundred years ago, said that 85 percent of diagnoses can be made by talking to the patient. And he’s still right. Another 10 percent, he said, were made by physical examination and five percent were made by the laboratory. Of course, a hundred years ago the laboratory was pretty rudimentary compared to what we have today. But he is still correct. We don’t have the ability in a person’s home to just look down the hall and say, “Hey Joe I need your advice on this, would you please come over and examine this patient’s heart and tell me what you think?” We don’t have the ability to say, “Madam please go down the hall to get this X-ray or blood count and I’ll have the result in 10 minutes.” But we can get these things done in the home the next day, and there are companies who do this. We can get EKGs, X-rays, echocardiograms, Holter monitors, Dopplers for arterial in venous systems. Of course, we can’t get an MRI or a CT in the home, but we can get all these other things, including any blood test and urinalyses you can possibly want. We are also capable of getting consultants into the home – podiatrists, opticians, audiologists, even psychiatrists and cardiologists.
PND: Home health care is typically done by nurses and other non-physician practitioners. What is it that a physician can do that they cannot, which would justify physicians doing this?
AES: For most patient complaints, advanced nurse practitioners and physicians can offer the same services. But, when you’re dealing with difficult problems like the confluence of congestive heart failure, renal disease, hypertension and the myriad of drugs from which to choose to treat them, I think the physician’s experience and knowledge base is invaluable. A physician offers more sophisticated diagnostic skills and more sophisticated therapeutic skills. After all, we haven’t been trained for that amount of time and have those decades of experience for nothing.
PND: What roles do the two physician assistants in your practice play?
AES: They do not see patients for the first time – that’s something only my partner and I do. After we brief them about the problems that each individual patient presents, then they go out and see the patient, and we go over their findings and their therapeutic decisions when they come back. They are essential and invaluable members of our team.