House calls on the rise in Ontario
In 2011, Ontario sought to spur physician interest in providing house calls by investing $10 million a year for the past six years in improving access for patients who are defined as “home bound.” It’s a poorly defined term, but generally means a patient with physical limitations that make journeying to a doctor’s office too taxing, or someone with “social frailties” such as psychiatric or cognitive issues that make it difficult to navigate a doctor’s office visit, particularly if unaccompanied.
The funds focused on providing financial incentives for family physicians and specialists to provide care for home-bound patients, increasing payment for a day time house call to $65 – double the payment for an office consultation. That figure rises to $106 if the house call is carried out in the evening.
But Samir Sinha, a geriatrician at Toronto’s Mount Sinai and the provincial lead for the Ontario Seniors Strategy, says it wasn’t enough to merely pay doctors more for house calls – that would have created the mobile equivalent of a walk-in clinic, with doctors providing one-off, on-demand care. “The problem with that is you don’t get the type of house call that you want.”
Instead, funding bonuses are tied to the number of times a physician sees a home-bound patient.
“We saw 42,000 more house calls being provided in Ontario within a year of that change,” Sinha says. “That’s 12,000 more patients receiving house calls.”
Since 2011, the number of house calls in Ontario has grown by nearly 100,000, from less than 270,000 to more than 365,000, according to numbers provided by the Ministry of Health and Long-Term Care (see table, below).
Total number of palliative and non-palliative house calls – FY2011/12 to FY2015/16
|Fiscal Year||# of House Calls||% Change in Total|
(Source: Ontario Ministry of Health & Long-Term Care)
The number of Canadian physicians performing house calls has remained virtually unchanged since the 1940s, when about 40 percent of physicians visited patients at home. The 2010 National Physician Survey showed slightly more than 42 percent of Canadian family doctors performed house calls, down from 48 percent in 2007.
Technology has made it more practical for patients to visit a doctor’s office, where they can access diagnostic equipment and fee-for-service payment models put the emphasis on seeing a high volume of patients. Even in places where other funding models are used, that level of productivity is still expected.
“We know through the literature and experience that a home-visiting physician will probably see about eight patients a day,” says Sinha. An “office-bound” physician, by contrast, might see 30 or 40 patients on a single busy day.
“All the incentives, unfortunately, were working against the home-bound patient because it’s tough to tell doctors we want you to do these calls, but we’re not going to pay you to do them,” Sinha says.
On top of that, home-bound patients tend to be medically complex, taking more time to organize tests or specialist treatment.
But providing house calls is undergoing a revival, partly because of an aging population, but also because evidence is building that it can save health care costs.
“Home-bound patients are more likely to visit emergency departments or need more expensive forms of health care. They are actually an incredibly expensive population to care for if you don’t get more proactive in their care by bringing it to their home,” Sinha says. “If you can’t get care at home, your health issues might fester and grow. You might need to go to hospital and have a very long and protracted hospital stay.”
Spending on house calls can mean saving on preventable hospitalizations, reducing days spent in hospital, or avoiding premature placement in a long-term care facility, particularly when the visiting physician is able to build a relationship with the patient.
Much of the evidence on the value of providing house calls comes from the U.S., where insurers are starting to notice that managing care and keeping people out of hospital can be cheaper in the long-term. A program that includes house calls set up under the Affordable Care Act has reportedly saved Medicare $35 million.
‘Enriching of the doctor and family relationship’
Sandy Buchman remembers being in the Toronto home of a 78-year-old patient with metastatic endometrial cancer and noticing her bottle of pain medication on the kitchen table.
The woman’s husband, nine years older and quite frail himself, had called on their daughter for help. She had arrived from Victoria, B.C., with her 15-year-old son, who had only recently been released from hospital after a suicide attempt.
Buchman quietly coached the family on the importance of storing her OxyContin safely.
“It was just another tragic incident waiting to happen,” he says. And it’s not something he would have noticed had the boy’s grandmother been visiting his office.
“The home environment provides that kind of insight and knowledge and enriching of the doctor and family relationship,” Buchman says. “It makes for really effective health care. It’s not always better, but it’s different and unique and helpful.”
Lack of training
“I think a disincentive is that most modern primary care physicians have not been trained in doing house calls,” Sinha says. “It becomes overwhelming. If they’ve never been exposed to doing house calls – not just doctors but all health care professionals – it’s a scary concept.”
Cameron Barr, a family physician in Edmonton, who performs house calls as part of his work with the Boyle McCauley Health Centre, says he’s learned to wear slip-on loafers and be ready to spend a bit more time talking about health issues outside of what led to the appointment, particularly mental health issues.
“People like to talk when you go into their home, so it tends not to be a short visit,” he said. “Most of the time, it’s not really doing physical exams,” it’s checking how a person is functioning and how they’re getting by.
Sinha, who reserves one day a month for scheduled house calls, laughs about his reputation for performing “fridge biopsies” to get a sense of whether a patient is eating right, and leaving with bags of expired medicines culled during medicine cabinet spot checks.
“It’s high touch and low tech,” says Buchman, who compares it to working in a developing country, where you might have less access to technology or resources. “You depend more on your professional judgement and clinical and communication skills than you do on lab diagnosis or tests. You begin to understand what’s really important to people and the whole physician-patient dynamic changes.”
Although competency in performing house calls is mandated as part of the College of Family Physicians of Canada curriculum, there are still medical trainees who miss out on the opportunity to visit patients in the home.
“If you haven’t done home-based care as part of your training, you don’t see it as part of the job,” Buchman says. “If you’re not trained in that environment, you’re not going to see as part and parcel of your responsibilities.”
Travel times can be challenging, he says. There’s billing to figure out. And some physicians are intimidated by the lack of back-up.
“There are many who would take it on more if they felt that they could turn to someone immediately,” Buchman says, noting that the palliative care community is providing a model worth following by offering just-in-time support to colleagues without as much experience in end-of-life care.
Adding technology to improve efficiency
In the ‘there’s an app for that’ age, house call apps and services have popped up looking to fill a niche. A recent article in the British Columbia Medical Journal showed rampant growth in patients seeking telemedicine, in which patients connect with a care provider from anywhere via telephone or video link. Users more than doubled, going from 8,282 in 2014 to 17,149 a year later.
Depression, anxiety and contraception were the most common request for consultations, but patients also sought help for other issues, including rashes, heartburn and nausea, asthma or allergies. Unlike the typical house call patient, the majority of telemedicine users were under the age of 50. Half were in the Greater Vancouver area.
Other services that bring doctors to patients include virtual consultations for prescription renewals and text-based services like AskTheDoctor.ca, in which patients can pay to receive an answer to a medical question from one of 250,000 doctors rostered worldwide.
AskTheDoctor piloted a house call service in Toronto, but quickly shuttered the business when it proved too difficult to scale up.
“We did this for maybe eight weeks and we were able to see the trend right away,” said Prakash Chand, President & CEO at AskTheDoctor. “Consumers love this type of product, but the limiting factor is the physicians. The unit of economics don’t make sense for a physician.”
There were too many restrictions and not enough experienced physicians willing to provide care. The model wasn’t sustainable because it relied on a highly skilled profession.
“It’s not like this is Uber, where just anybody can deliver something,” he said.
To improve reach and efficiency of house calls, Sinha says the province is exploring the use of telemonitoring, using apps and other technology to monitor things like blood pressure or blood oxygen levels, and responding when readings reach pre-set threshold.
Telemedicine may also help specialists “see” more home-bound patients, by using paramedics or nurse practitioners to perform monitoring, exams and tests while connected with family physicians or specialists to provide guidance and advice.
But Sinha says neither of those services can replace the experience of a face-to-face home visit, which can be powerful for patients and practitioners alike.
“It’s the happiest part of my job,” says Sinha. “You get to connect with patients on such a different level, on their terms, and you’re able to make a much more significant impact by being in their own home and seeing how everything works. You’re much more able to be effective as a practitioner when you can deliver the care where it’s actually needed most.”