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House Calls

Physicians treating patients at home may be an age-old concept, and nearly extinct, but it's getting new life now that companies are starting to offer the service as part of their benefits packages.

Thursday, January 1, 2009
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With her 18-month-old daughter Andersen sneezing, pulling at her ears and rubbing her eyes -- not to mention registering a high fever -- Susan Wagner knew her child needed medical attention.

At 8 p.m. on a Sunday, she figured getting treatment meant a trip to the emergency room, and she didn't like the idea of dragging her 4- and 12-year-old children into the hospital too, especially during what she anticipated would be a busy night, considering most doctors' offices were closed.

"At 8 o'clock on a Sunday night, just shoot me before you make me go," says Wagner.

If that weren't enough, the real estate and facilities regional director of the Americas for Microsoft had an 8 a.m. flight the next morning, traveling from her home in the Seattle area to Fargo, N.D., for a series of meetings. She vowed to cancel her trip if her daughter's health remained in danger, but the very thought of it -- added to the prospect of an emergency room visit -- was more than she could bear.

Unlike the majority of workers who get healthcare through their employer, however, Wagner had an alternative to heading to a hospital -- getting a doctor to make a house call.

Through a partnership with Carena, a Seattle-based medical-care company, Microsoft employees who may need a primary-care physician at odd times or have minor ailments that aren't emergencies, can now call Carena representatives to schedule an old-fashioned doctor house call. Needless to say, before the service became available, many were taking those non-emergency problems to emergency rooms.

Wagner called Carena via the company's health hotline, spoke to a nurse who performed a triage -- an assessment of the medical situation -- and determined that an emergency room visit would not be necessary, but a house call would.

Soon after, a doctor called Wagner to discuss her daughter's problem further, then came to her house about two hours after her initial call. No gathering the kids into the car. No driving. No waiting room. No reason to make her children -- especially her sick daughter -- get dressed and leave comfy beds and toys.

"For my child, it's a much more comfortable situation to be in her own home as opposed to a hospital," says Wagner. "I think for any kid, that would be a preferred environment."

The doctor even carried a black medical bag, indicative of a time when doctor visits were the norm, and he spent more than an hour with the patient and family. After performing a quick test, he was able to determine that young Andersen did not have strep throat, but did have infections in her throat, eyes and ears. Not only did he prescribe antibiotics, but he was armed with a list of 24-hour pharmacies in the area where Wagner could buy medicine.

"For me, that particular experience was pretty key in making sure that I could do what I needed to do at work while, at the same time, take care of my family," says Wagner, who flew out to Fargo the following morning with the understanding that her child's health was under control.

Although it may seem like something out of a Norman Rockwell painting and a bygone era of Americana, medical house calls are making a comeback through employers such as Microsoft. Companies offering the benefit through their health plans believe it will lead to lower health expenses by cutting down on unnecessary ER visits, which tend to be a costly part of any package.

In Many Cases, ER "Not Necessary"

Nationally, trips to the ER for non-emergency situations seem to be running rampant. The Centers for Disease Control and Prevention reported that, of the 11,919,100 emergency room visits in 2006 (the most recent statistics available), just 15.9 percent were deemed immediate, meaning the patient should be treated without delay, or emergent, meaning the patient should be seen within one to 15 minutes. The rest did not have to be seen instantly and 12.1 percent were deemed non-urgent.

According to the data, emergency rooms are being overrun like never before -- and not by the uninsured, but by insured people who aren't facing emergency situations. From 1996 to 2006, emergency room visits in the United States went up 32 percent to 119 million, according to the Atlanta-based CDC.

A report in the Annals of Emergency Medicine entitled "Are the Uninsured Responsible for the Increase in Emergency Department Visits in the United States?" says the uninsured have been going to emergency rooms at a steady rate from 1996 to 2003 (down from 15.5 percent to 14.5 percent over that time period). Families whose incomes were greater than 400 percent of the poverty level accounted for 29 percent of visits, up from 21.9 percent.

"The rise in ED [emergency department] visits between 1996 and 2003 cannot be primarily attributed to the uninsured," says the report. "Major contributors to increasing ED utilization appear to be disproportionate increases in use by non-poor persons and by persons whose usual source of care is a physician's office."

Ralph Derrickson, CEO of Carena, says many people head to the ER just because it's nighttime or a weekend, or they simply can't get a doctor's appointment.

"In most cases, the emergency room isn't necessary for treatment," he says.

Carena's service -- now used by 140,000 members at eight companies, including Microsoft, Costco and the Commonwealth of Kentucky -- can save companies big dollars, according to Derrickson. For a home doctor visit, Carena charges $583, while a typical ER visit in the Seattle area costs a company's health plan $850 to $880, he says.

The national average for an ER visit was $688 in 2006, according to the Medical Expenditure Panel Survey, part of the U.S. Department of Health and Human Services.

For employers that enroll more and more workers in the plan, Carena offers an even lower price. The service is available 24 hours a day, seven days a week.

At Microsoft, ER spending rose 70 percent from 2003 to 2006, says Julie Sheehy, director of U.S. health, wellness and productivity benefits at the Redmond, Wash.-based technology giant. By partnering with Carena in April of 2006 and specifically targeting non-necessary ER visits, the company has saved about 20 percent on its health expenses, she says.

"We were looking to see if there was a way we could target that and get people to seek care in a more appropriate venue for themselves and for their issue, rather than going to the emergency room, which is the most costly place to get care and it's also not the best experience for an employee or a family member who's ill either," says Sheehy, who adds that the house-call service is offered to about 85,000 Microsoft employees in and around the Seattle area.

Another company offering physician visits is Sickday Medical House Calls, which currently serves Manhattan, sending doctors to homes as well as offices. While the bulk of its business is through individuals paying privately for the service, the company has been increasingly partnering with employers that offer its service as a benefit. Kate Dessault, Sickday's chief marketing officer, estimates such partnerships now represent 20 percent of its business.

In addition to law firms and advertising agencies, Sickday works with hotel chain AKA, as well as the European Commission and Italian Commission, both of which bring people to New York to work with the United Nations. In total, Sickday currently partners with 10 companies, mostly large employers.

And like Carena, Sickday is helping companies cut down on high ER costs, which in New York can climb well above the $688 national average. Sickday, however, only charges a flat fee of $250, and the charge is just $200 for corporations.

Depending on the company and the benefits package, the cost of an in-home doctor visit can be paid in full by the company -- such as at Microsoft -- or shared with employers.

Sickday also sets up clinics for companies on their premises, promoting wellness or treating employees who may feel sick. Such clinics can also help employees with smoking cessation or dieting programs. Often times, companies don't get widespread participation in these programs, says Dessault, who notes that Sickday can work one-on-one with employees to set up specific plans and make sure to follow up.

Reluctance Still Reigns

For all its merits, though, many companies are hesitant to implement a house-call program. Dr. Michael Cryer, senior medical director at Lincolnshire, Ill.-based Hewitt Associates, says the large- and medium-sized companies he works with haven't bought in to the idea because they don't think it'll be cost-effective.

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"What they're worried about is the fact that, if they offer [house calls], they won't get enough reduction in cost to really cover the cost of having the service available," says Cryer. "They anticipate that people will use the service more frequently because it's more available and it's convenient, but they don't really anticipate that it's going to lower their ER visits that much."

Cryer says the initial costs to implement are also a factor, with house-call providers asking for a retainer, guaranteed minimums or payment of a certain amount of money per employee. Also bear in mind, he says, that while house calls cost less than ER visits, they do cost more than visits to the doctor's office.

When it comes to liability, traveling doctors will surely carry malpractice insurance, and house-call companies cover themselves when performing triage over the phone, says Dr. Russell Robbins, a principle at the consulting company Mercer.

Also, companies like Sickday specify on their Web sites that they don't treat emergencies such as chest pains, head trauma, shortness of breath or loss of consciousness- -- people with those symptons are told to go right to the ER.

Whether a company is ready to launch or is merely considering the benefits of such a program, initial due diligence is, of course, necessary. When Microsoft was entertaining the idea of implementing a house-call program, HR was tasked with performing benchmarking studies and analyzing the cost of health claims from employees. Through that process, the company recognized the rising cost of ER visits.

"If we could understand why people are opting to go to the ER rather than seeing their [primary care physician] or getting the issue treated more appropriately, we felt that we could probably, through communication, really help people more effectively than we were," says Sheehy.

Microsoft then rolled out a pilot house-call program to the HR department. The reaction was overwhelmingly positive.

To initiate it to all Seattle-area staff -- which encompasses most of the company's workers -- HR promoted it through the company's internal Web site, a newsletter and a mass mailing.

Now, it's safe to say the offering has been a hit with employees, Sheehy says.

"The benefits of this program have been much more far-reaching than we originally thought and, certainly, the feedback we get from employees has been just tremendously positive," she says. "They absolutely love this benefit."

HR currently administers the program, she adds, running it just like any other employee benefit. Derrickson insists that house calls from Carena or other providers are not replacements for the emergency room.

Oftentimes, in fact, the nurse assessing the situation on the phone will recommend going to a hospital as the best option. Other times, the patient does not need either a trip to the ER or a house call.

"Very often, what happens is the doctor is able to give them some information, some advice and some reassurance [over the phone], and actually, they don't need either [treatment option]," says Sheehy. "In that case, we're saving the whole cost of the emergency room visit [and a doctor's call], which is fantastic."

Also beneficial to employees is the sheer amount of time spent with the doctor. A typical home visit lasts about one hour -- plenty more time than people generally get in an emergency room -- and, says Derrickson, a doctor inside the home for that long can lead to better healthcare down the road.

Since doctors are armed with a list of Microsoft's benefits, a doctor noticing a lingering problem, such as smoking or obesity, can suggest that the employee utilize Microsoft's smoking cessation or gym-membership benefit.

"Our consumers don't go on and get more unnecessary care because the encounter fully educated them and set them up to be a better healthcare consumer," he says.

And patients using the Sickday service certainly enjoy the cost savings, but are even more excited about the peace of mind it brings, says Dessault.

"Most people are telling us that the biggest benefit is the comfort that people have in the office, that they know they have someone they can call after hours and on weekends," says Dessault, "and that the company has gone out of its way to make sure that is provided to them."

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