For 15 years, Dr. William Gee operated a solo medical practice in St. Louis. "It was going quite well," Gee says. But Gee was busy, a little too busy. He felt "pressure to see more and more patients with less and less time" and experienced mounting overhead costs.
"I got tired of that," Gee said.
In early 2003, Gee decided to act. He closed his office, laid off two employees, converted his house into a makeshift office and asked his wife to take over secretarial duties. Then Gee set out to see patients in their homes, becoming one of a handful of local doctors who make house calls.
Most of Gee's patients are elderly and homebound, suffering from dementia, strokes or any number of chronic diseases. "Some of them are homebound because they can't get the attention they need in an office setting," Gee said. A board-certified cardiologist, Gee feels he can glimpse "the big picture" of a patient's health and lessen the need for visits to specialists.
"I don't always get them back out of the house. But I think I do good job of getting them more stable," Gee said of his patients.
Keeping patients stable is also the goal of Dr. John Morley, director of Saint Louis University geriatrics, and other home-care physicians at St. Louis University. "When I was a kid, my family practitioner used to come see me at home. But that died sometime when I was becoming a physician," Morley said.
But house calls have made a comeback at SLU. In early July, SLU began offering physician house calls for seniors with end-stage heart failure. Previously, nurses would visit patients after their release from the hospital to check on their health and ensure they were taking the correct medications. Under the new program, geriatricians from SLU and Des Peres hospitals will also check up on patients at home.
According to Morley, between 17 and 30 percent of heart failure patients are later readmitted to hospitals. SLU would like to lower that number by allowing doctors to monitor patients at home. Hospital visits not only increase Medicare costs, they also worsen patients' quality of life.
"We're really trying to make life more enjoyable for people who are struggling toward the end of their life," Morley said.
In addition, for 20 years, SLU has offered a home-care service for housebound elderly patients. Twelve geriatricians and a team of nurses and geriatricians-in-training make house calls to those who cannot reach a doctor's office.
"Those people need good home nursing care, but they also occasionally need a good doctor going out," Morley said.
Dr. Wit Jamry, one of SLU's home-care geriatricians, regularly drives across the city to see patients. During a recent house call, a bullet shattered one of his car windows. But such incidents have not slowed Jamry's efforts to restore dignity to the homebound.
"Our goal is to keep the patient at home as long as possible. To put them in a nursing home should be the last resort," he said
Jamry emigrated from Poland 30 years ago and has spent the past 15 years in home care. He speaks animatedly about his desire to help homebound patients. Thank-you notes and pictures of patients line the walls of his office, including one of Leola Washington, 109, who, Jamry says, is his oldest patient and Missouri's oldest resident.
When he first adds patients, Jamry visits their homes himself. But for routine follow-ups, Jamry assigns a nurse from one of 15 nursing companies with which he works. The nurses then meet with him each week to report on patients' progress. This system allows him to reach 600 to 800 patients, many more than he could handle on his own.
Like Morley, Jamry highlighted the promise of home care to help the homebound avoid hospital stays, which can be traumatic for patients and cost Medicare thousands of dollars. "It's better for the patient, (and) it's better for the government because we save money," Jamry said.
Congress agrees. In the much-discussed health-care bill passed in March, legislators included a provision (the Independence at Home Act) that calls for an exploratory home-care program. Under the new initiative, the Department of Health and Human Services will offer a small number of home-care practices a spending target. If the practices keep Medicare costs for their patients at least 5 percent below the target, Medicare will present them with a bonus.
For many of the home visits, Jamry uses a team of nurses, shown here in his office during a weekly meeting to go over cases.
"The hope is --and the very strong likelihood is -- that it will reduce the number of hospital visits and reduce the number of emergency room visits," said Tim Greaney, co-director of SLU's Center for Health Law Studies.
By offering an incentive to keep patients out of hospitals, Congress hopes to save taxpayer dollars, Greaney said. The health-care law contains many similar trial programs, which will be carefully monitored to determine whether they help patients and cut Medicare costs.
"The bill is throwing a lot of spaghetti against the wall," Greaney said. If the home-care program sticks, it could be expanded to all home-care doctors, making house calls much more lucrative than they are currently.
Until then, home-care doctors seeking to turn a profit may have to follow Dr. Elizabeth Laffey's model. Laffey is part of the growing trend of "concierge," or "boutique," medicine, in which patients pay a flat fee in return for greater access to their physicians. She requires patients to pay an annual fee of $1,500 (plus $1,000 for each additional family member), which is not covered by insurance. Medicare and other insurance can only be used for additional procedures and tests.
In return for the annual fee, Laffey answers patients' phone calls and emails, accompanies them to specialists' offices and, unlike many concierge physicians, actually visits patients at their home or office. Laffey said three types of patients are attracted to her practice: families with young children, busy executives who want to skip lines at the doctor's office, and elderly patients like the ones seen by Gee and Jamry.
"I decided to practice medicine this way because it is how I would want my family treated," Laffey said. "Most people can't get that level of service, only because physicians are so busy." Laffey caps her number of patients at 200, far below the average for most doctors, which she estimated to be between 3,000 to 5,000 patients. "That means I have time to answer questions," she said.
"Is personalized health care worth the price of a latte a day?" she asks. Laffey thinks so. "It is well worth it for patients and for me, but I doubt it is sustainable outside of private pay in some way," she said of house calls.
Gee and Jamry, who accept insurance, both said their practices are not very profitable. Medicare, which covers most of Gee's and Jamry's patients, pays about $30 more for a home visit than an office visit. Despite the higher reimbursements, house-call doctors find it difficult to make a profit because they see many fewer patients than doctors in offices. Gee said he sees about one patient an hour instead of the three he would see in an office.
"Basically, it is difficult to swing financially unless you're really willing to cut costs," he said of home care. "My income is less than your average internist. It's not a way to make a lot of money."
But Gee is unwilling to switch to Laffey's "concierge" model. "I don't do convenience calls. That's really not part of my mission," he said. "I have a lot of lower- and middle-class patients that I really enjoy taking care of who would not be able to participate in such a practice."
Gee has also considered applying for the new home-care program in the health-care law. To qualify, he would need to expand his practice, but says he would only hire doctors "motivated by patient welfare rather than business."
"I am not much of an entrepreneur," he said.
For now, Gee and Jamry are committed to helping the homebound despite the financial challenges. "Money is important, but not most important in life," Jamry said, smiling.
Hodiah Nemes, a summer intern at the Beacon, is a student at Yale University.
This article originally appeared in the St. Louis Beacon.