Doctors at your door

By Laura Ungar
lungar@courier-journal.com
The Courier-Journal

Wearing a red robe and sneakers, Charlina Shaddock sat back in her living room recliner as Dr. J. Michael Benfield checked her blood pressure and heart rate.

She had just survived a bout with pneumonia that landed her in the hospital, then a nursing home.

“I got to feeling bad, Dr. Benfield, and I didn’t realize how bad I felt,” said Shaddock, 83, who lives alone in a small apartment in Louisville.

Benfield listened, and took notes on a laptop. Founder of a Louisville company called MD2U, he is one of a growing number of doctors who are bringing back the house call.

Nationally, there are about 1,000 physicians specializing in house calls, compared with just a handful a decade ago, according to the American Academy of Home Care Physicians. And federal statistics show the number of physician home visits paid for by Medicare, by house-call specialists as well as other doctors, rose 31 percent between 1996 and 2004, to 2.1 million.

In Kentucky and Indiana, the home care association lists five house-call doctors, including Benfield, who serves patients in both states. In Louisville, Norton House Calls provides services similar to Benfield’s company; there are about seven local, private practice physicians who occasionally make house calls in cooperation with Jewish Hospital & St. Mary’s HealthCare’s VNA Nazareth Home Care.

Many services are geared toward seniors or disabled patients who can’t get to doctor’s offices. House calls generally don’t cost more than other doctor visits if they have insurance that the service accepts.

Experts say demographics, plus a growing dissatisfaction among doctors with the usual practice of medicine, are driving the trend. While continued expansion of the field depends partly on Medicare reimbursement levels, home-visit payment rates are expected to go down slightly next year, experts said the need for house calls will be even greater in the future.

“There’s a growing elderly population that will become even larger with the retirement of the baby boomers,” said Constance Row, executive director of the home care academy. “Among the oldest of the old and the sickest of the sick, a great many of them are too sick to get to a physician’s office.”

For Shaddock, the result is the same sort of personalized medicine that she got as a child, when “that’s all they had.” That personal touch, she said, helps keep her well.

On a recent visit, Benfield counseled her about one way to avoid getting pneumonia again.

“You still smoking?” asked the towering 6-foot-6 physician in a gentle voice.

“I’d love to be, doc,” said Shaddock, who quit when she developed pneumonia. “I’d give anything in the world.”

“Here’s why you can’t,” he said. “If you continue to smoke, you’re going to get more pneumonia and be in the same boat you were.”

“I’ve got a lot more living to do,” Shaddock told him. “I’ll forget about the cigarettes. If you say so, I will.”

A natural fit

Treating patients in their homes was a natural career choice for Benfield.

Son of a Baptist minister, the 40-year-old physician grew up visiting homes of congregants with his father in North Carolina. After completing his medical residency at the University of Louisville, he decided to forgo a typical practice, partly because he knew he wouldn’t be able to spend as much time as he wanted with patients.

“The way health care is delivered, the whole system is basically broken,” he said.

Benfield saw his first home-care patients in the summer of 2004, and now has a patient base of more than 600. He employs two nurse practitioners, a patient care coordinator (his sister) and a chief financial officer (his brother-in-law.) He recently traded a home office for space on Frankfort Avenue, and is planning to add another physician and patient care coordinator soon.

Benfield has a couple of patients who pay out-of-pocket at $125 a visit. But the vast majority of the company’s payments come from Medicare, Medicaid and private supplemental insurance, with Benfield taking what they agree to pay. Medicare payments are higher for house calls, $58 for one type, compared with $37 for a comparable office visit, for example. While Benfield doesn’t contract with private insurers, Norton House Calls and some other services do.

Benfield also receives payments reminiscent of an earlier day. “I get turnips and tomatoes,” he said. “You name it, I’ve gotten it.”

Unlike office-based doctors, who might see 25 patients or more a day, he sees about 10 or 12 because he also must travel to their homes or assisted-living facilities. Most are older than 70, he said, and most live in Louisville. But geographically, “we’re going further and further out,” Benfield said. “It’s really an access issue.”

That’s certainly true for the Whittinghills, of Goshen, Ky., who Benfield visits about once a month. Samuel Whittinghill, 71, has diabetes and has been treated for colon cancer and heart disease, while his wife, Jeannette, 66, has Alzheimer’s disease. Benfield’s home visits make it much easier to care for her, Samuel Whittinghill and other family members said, since it’s difficult to take her out of the house. During a recent visit, she spent much of the time curled silently on a recliner.

Samuel Whittinghill said Benfield’s visits also make it easier for him to stay on top of his own health, reminding him to check his blood sugar regularly, for example.

“He keeps me straight,” said Whittinghill, who sent Benfield off with a bag of honey candy. “You got to answer to him.”

A new perspective

Treating people at home also gives Benfield a perspective he said he wouldn’t get in a doctor’s office.

“When I think of Sam and Jeannette, I can picture their home,” he said. “I can see what their lives are like.”

In Shaddock’s apartment, Benfield peered into her kitchen to see how she organized her pills. And he asked Shaddock’s son-in-law, George Doyle of Florida, to help him check her cupboards to make sure she had nutritious food. After finding lots of frozen meals, he suggested she consider receiving Meals on Wheels and drinking a few cans of the nutritional drink Ensure daily to stay healthy as she recovers from pneumonia.

“I want you to realize how fortunate you are,” he told her. “For you to be able to go through that and live independently again is pretty good.”

Kelly Johnson, a registered nurse who worked with Norton House Calls, said services like theirs may help senior residents remain in the community longer.

“We see our patients on a routine basis. We’re proactive,” Johnson said. “We keep their chronic illnesses under control.”

But there can be challenges. Dr. Vidya Kora, a Michigan City, Ind., physician who heads the Indiana State Medical Association, said when he made house calls earlier in his career, it was sometimes difficult to immediately perform certain medical tests or procedures easily handled in an office.

Although this made him curtail his home visits, he and other doctors he knows still occasionally visit long-time, senior patients at home, he said, adding that he expects such visits to become more common as technology improves. “Whenever I have done house calls,” he said, “people have really appreciated it.”

Benfield, Johnson and Row said house calls also provide financial benefits to the entire health-care system, helping reduce costly hospital emergency room visits and nursing home admissions.

All this leads them to see a real future in this old school approach to doctoring.

“If you ask anyone where they want to be when they get older, it’s in their home,” Johnson said. “This is a model that works for everyone.”