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Doctors struggle to visit Medicare patients at home

The program's payment rates are among the obstacles.

By Markian Hawryluk, amednews staff. Oct. 6, 2003.

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Washington -- The average patient seen by Leslee Cochrane, MD, is 83 years old, has multiple chronic conditions, is in the last two years of life and rarely leaves home.

The Riverside, Calif., family physician is one of a slow trickle of doctors reviving the age-old tradition of house calls to treat nontraditional Medicare patients -- those who are too sick to leave their homes to see a doctor. Yet despite a commitment to serve this vulnerable group of beneficiaries, Dr. Cochrane and others like him are struggling with Medicare's home care policies.

"Medicare does not appear to have a way to look at doctors by virtue of their practice population," he said. "What they do is compare me to other family practice doctors in Riverside County. I look like a big bull's eye."

Computer software used by his Medicare contractor continually flags Dr. Cochrane as having a more complex case load than is typical for his specialty. That's often a sign of fraud.

But in Dr. Cochrane's case, it's another sign that Medicare hasn't adequately fit patients with chronic conditions and the physicians who treat them into its payment structure. So physicians who make house calls are having claims routinely denied.

"The most commonly cited reason is frequency," he said. "If you take a frail, homebound elderly person, chances are they are sick enough they need to see a doctor more frequently" than elderly healthy people able to drive cars to see their doctors.

Dr. Cochrane can take some solace in the fact that the vast majority of claims denials are overturned through the fair hearing process. But that can delay payments up to a year. And it takes precious time away from his practice to fight the battle. "I'm up to fair hearing No. 13 so far in the past calendar year," he said.

The problems have almost put him out of business. Last year, his practice was subjected to prepayment chart review. That slowed his cash flow to only 15% of normal levels and forced Dr. Cochrane and his wife to take out a loan to continue to pay the practice's other doctors and staff.

Last August, out of money and out of hope, Dr. Cochrane called a meeting to tell his staff they were shutting down the practice. During the meeting, he received a fax from Medicare stating that electronic payment would be restored and that a four-month evaluation had found nothing wrong.

"We were within five minutes of being nothing more than a blip on a radar screen," he said. "What does that mean to Medicare? Not much. To the frail, homebound patients we serve, that was going to be a life-or-death issue."

Medicare established separate codes and higher payment levels for home visits in 1998. It has remained a small portion of overall Medicare spending for physician services, peaking at $151 million in 2001. But many home care physicians say the Medicare definition of practice expenses never envisioned house calls.

"It doesn't cover some very real expenses of the house-call practice," said George Taler, MD, director of long-term care at Washington (D.C.) Hospital Center and co-founder of the hospital's Medical Housecall program. Medicare rates don't account for travel, time spent counseling the patient's family, phone time, or meetings with other parts of the care team.

Dr. Taler and co-founder Eric De Jonge, MD, have created an integrated house call program that uses a variety of funding streams, including a Medicaid waiver and hospital savings. Housecall now treats more than 400 patients and has led to marked patient care improvements. When comparing patients in the years before and after admission to the program, emergency department visits declined by at least 10% and the average length of stay dropped from 8.3 days to 5.9 days. That is achieved with the sickest 10% of Medicare patients who use about 70% of Medicare resources.

"We've created a system of care to address the particular needs of that population," Dr. Taler said. "It is easier to transport health care providers than sick patients."

The program would have been much tougher to run 10 years earlier. Recent technological advances have made it feasible to bring the equipment required by these frail patients into their homes, Dr. Taler said.

Looking for help

But it might take advances on Capitol Hill for house calls to make a real comeback. Dr. Taler and the American Academy of Home Care Physicians are working with lawmakers to improve proposals to expand Medicare's chronic care management.

AAHCP has proposed a system in which physicians would be paid a monthly fee to manage the chronic care needs of Medicare patients. Physicians would be required to meet certain quality benchmarks to continue to receive the care management fee, and doctors who exceeded the benchmarks could receive a quality incentive payment.

The Medicare reform bill passed by the House envisions a competitive bidding process to find two contractors in each region that would work to improve chronic care management. AAHCP said that likely would limit participation to large disease-management firms, not individual doctors.

The Senate bill calls for a three-year demonstration program in six sites in which a principal care physician would manage beneficiaries' complex clinical conditions. A separate provision requires the government to develop a demonstration program to provide care coordination in the fee-for-service program for Medicare beneficiaries with multiple chronic illnesses. AAHCP would prefer to see an established benefit, rather than just the demonstration.

Although both bills include provisions backed by the group, AAHCP maintains that, if passed, they are unlikely to generate the kind of impact home care physicians could have on costs or quality of care.

Home care doctors also face cuts in practice expenses included in the physician fee schedule rule proposed by CMS in August. That rule is open for comment, and home care physicians could provide CMS with data to justify higher practice expense payments. Otherwise cuts of 9% to 10% in practice expense pay could be implemented Jan. 1, 2004.

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