Housecalls Are Back and Booming. Are They a Threat to PCPs?

Neil Chesanow

Disclosures

July 20, 2016

In This Article

Housecalls for Chronic-Care Patients

Doctors Making Housecalls (DMH), a primary care group based in Durham, North Carolina, has specialized in making housecalls to complex, frail, largely elderly patients for 14 years. It isn't an Uber startup and it has no app. The more than 75 participating doctors and other clinicians are contacted by phone.

"We specialize in caring for patients onsite in assisted-living communities," explains CEO Dr Kronhaus. "Just as hospitalists go from room to room in a hospital, we're 'residentialists,' going from room to room in communal settings."

"We see relatively few patients per day—10 to 15," he says. "In a private residence, it's even less—maybe five to eight patients per day."

"The most frequent number of comorbid conditions for a resident in assisted living is eight," Dr Kronhaus reports. "In addition to multiple physical conditions, there's a very significant burden of mental illness in many of our patients. We actively manage patients' problems—I call it 'proactive primary care'—instead of reacting and waiting for a crisis, like most physicians are forced to do, in which case the patients never make it to the doctor's office. They get shipped off to the emergency room, and then often to an acute-care hospital and rehab. This is very expensive and often can be prevented."

Unlike the new housecall firms, which are seeking acceptance from commercial insurers—some with early but limited success—DMH is in-network for most commercial insurers; about 30% of its patients are in Medicare Advantage plans, Dr Kronhaus says.

Moreover, the practice has gained acceptance from CMS and sees regular Medicare patients. DMH has just begun its fifth year as a CMS Independence at Home Demonstration, and is the only practice specializing in housecalls in the program.[6]

"CMS hasn't given any of the practices in the project a dime to fund receivables," Dr Kronhaus says. "But we do get a share of the savings. We probably save CMS several thousand dollars for a patient who costs about $40,000 a year."

Transitioning From Urgent to Chronic Care

DMH was managing chronic-care patients long before app-based housecalls appeared. But one former housecalls-on-demand firm— Atlanta-based MedZed, which began operation in 2014—has made the transition from seeing urgent-care patients on an ad hoc basis to seeing chronic-care patients.

"The easiest place for me to get experience and start to use technology was in a direct-to-consumer business focused on young children," recalls Scott Schnell, MedZed's CEO. Internist Neil Solomon, MD, the medical director, envisioned a firm focused instead on chronic-care patients, a more complex undertaking, but he did not join MedZed until mid-2015, when he began spearheading the transition.

MedZed's model is designed to do what venture capitalist Tom Rodgers maintains that a firm offering housecalls must do to succeed long term: bend the cost curve. To that end, of the 25 people that MedZed employs, about half are clinical staff—NPs, licensed vocational nurses (LVNs), and registered nurses. The rest are support staff.

"Physicians are often not the best ones to help patients pay attention to self-care, nutrition, medication adherence, motivational communication, and related issues," explains Dr Solomon. "They're not trained to do it. It's not their initial predisposition. And it becomes rather expensive to ask them to do those things, which is why a lot of doctors don't do them in their offices today."

"In addition, putting a doctor in a car on the road is a very expensive use of their time," Dr Solomon continues, "and it's not something doctors would like or want to do. So if we can create a business model that allows us to see more patients by using lower-level, lower-priced care providers in the home, it allows people to practice at the top of their licenses, and that allows us to scale the business."

A MedZed NP and an LVN visit a new patient to establish a personal relationship. Thereafter, it's usually the LVN who goes on the housecall, toting a backpack filled with wireless diagnostic equipment, supplies, and a tablet.

The first part of a visit is devoted to data collection and conversation with the patient. For example, how is the patient doing with smoking cessation? Are there any changes in health status? In medication status?

In the second part of a visit, the LVN links to the NP at a remote location. The NP uses video chat to review the data the LVN has collected and conducts a remote physical examination of the patient with the LVN's help.

In the third part of a visit, the LVN reviews with the patient the care plan the NP has prescribed and ensures that the patient is able to adhere to it. For example, if the NP has prescribed more exercise, the LVN might map out a walking route and might even walk the route with the patient to ensure that it is doable.

MedZed's primary client is a managed care company called SynerMed, located in Monterey Park, California, which has 1 million members throughout the state. SynerMed contracts with MedZed and reimburses MedZed for the housecalls it provides to SynerMed members.

"We've had conversations with risk-bearing delivery systems," says Schnell. "Hospitals also have an interest, because they're concerned about readmission rates and being penalized. We've had conversations with insurers with Medicare Advantage plans. We're also talking to insurers about providing primary care to their members who are not attributed to a primary care doctor today."

In 2015, MedZed raised $3.2 million from investors.[7]

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