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<p>A Raleigh physician, frustrated with the standard way care gets practiced, goes back to making housecalls and finds her niche.
By Jennifer Ferris
MedPage Today/ North Carolina Health News
There was a time when Jerry Bell, 72, hadn’t seen a doctor in more than two decades. Despite having a pack-a-day smoking habit and critically high blood pressure, the Chapel Hill retiree refused to walk through the doors of a medical office.
Nine years ago, lying in her bed, suffering a case of bronchitis so bad she couldn’t sit up, Bell finally told her husband, “OK, I’ll go in.” But Bell’s husband had a better solution. He called Shohreh Taavoni, a neighbor in their golf course community who made house calls as part of her practice.
Taavoni treated the initial case of bronchitis and went on to solve Bell’s blood pressure issues, skin concerns and cholesterol problems – all without a single office visit. And Bell has never been healthier.
“We’ve taken [Bell] off many, many medications in the past few months,” Taavoni said proudly, sitting at the oak table in Bell’s spacious kitchen. “We’ve been able to monitor her cholesterol and taper all her medicines as her blood work changed.”
Bell is one of thousands of patients cared for by Taavoni’s practice, Doctors Making Housecalls. Although for some doctors the idea of home visits seems antiquated, improved outcomes like Bell’s mean even Medicare is taking notice. In a little over a decade, the practice has exploded in popularity, with Taavoni and more than 40 other providers in North Carolina innovating new ways to bring health care home.
The practice has tracked patient outcomes and costs for two years as part of a Medicare demonstration project exploring at-home care for complex and elderly patients. In that time, patients have spent less time in hospitals, had fewer emergency room visits and have spent less on health care overall.
Taavoni said that although she built the practice for patient convenience, she now sees it as a solid solution to both provider burnout and the rising cost of consumer health.
In the late 1980s, after finishing her residency at the University of Hawaii and a fellowship in rheumatology at the University of North Carolina-Chapel Hill, Taavoni was still unsure how she wanted to practice medicine. She worked short-term locum tenens assignments for three and a half years, trying to find a practice that she loved. She studied each office she worked in, noting whether she liked the doctors and if the patients seemed happy.
When she finally settled down at Capitol Family Medicine in Raleigh, Taavoni said, she was sure she’d found a solid fit. But she quickly became disenchanted with that practice’s shortcomings.
“Patients were calling, saying they were too sick to come in,” Taavoni explained. “We had elderly patients who couldn’t come in. They were too fragile to move or they had no one to bring them.”
Taavoni reflected on the medical care she experienced as a small child in Iran. She fondly remembered a doctor coming to her house to treat illness or injury. “It was just how it was done there,” she said. “That way people weren’t exposed to other viruses or bacteria in an office.”
Taavoni then turned to her husband, a physician and entrepreneur, and asked, “What if I did something different? Could we do house calls?”
Defining a new model of care
Alan Kronhaus has dedicated his professional life to researching and implementing creative ways to reach underserved communities. When his wife, Taavoni, asked him if they could bring medical care back to a home environment, he said he had an “a-ha” moment.
One of the two doctors who helped pioneer the practice of locum tenens in the 1970s, Kronhaus knew a bit about how to found an unconventional medical practice. KRON Medical, the country’s first locum tenens staffing firm, opened in 1980, and in 1992 reported $25 million in earnings. Kronhaus sold the practice in 1993, giving him the capital he needed when several years later he decided to help fund his wife’s big idea.
“We didn’t start off committed to making it a big thing,” he said. “It was almost like a lark. Kind of a small community give-back.”
Although today Taavoni and her husband both say they make “above average” pay for a family-practice physician, that wasn’t always the case. It took four years before the team cut their first paycheck, living off savings to pursue their dream.
The first few years of the practice were slow, Taavoni remembers. She and Kronhaus would throw the children in the back of the station wagon and drive around to see patients on weekends. That was in 2002. By 2005, Doctors Making Housecalls hired its first part-time doctor outside the family.
“Our overhead is a lot lower than other practices.” Taavoni said, explaining why their model succeeded. “And in this practice, we can spend a lot more time with our patients, and our patients appreciate our work. Like any medical practice, it’s not easy. But it is fulfilling.”
More than 4,000 doctors now spend at least some of their hours in patients’ bedrooms, kitchens or dens. A 2013 Brookings Institute study on the subject found that patients who receive care at home use fewer services and spend less time in hospitals. Taavoni said doctors in her practice work flexible schedules for a higher salary and are far happier than those working in traditional clinics.
Keeping the office running
Before they could open, Taavoni and Kronhaus had to sort through a number of issues. Chief among them: how to bill for services. They found quite a few doctors across the country in concierge practices who made house calls for a flat fee, but that wasn’t what they envisioned. They envisioned an egalitarian clinic that could reach everyone, not just busy executives with more money than time.
Billing turned out to be simpler than the team expected. The vast majority of house call services can be billed with patient billing codes similar to those used in the office. One of the biggest differences is the amount of time spent with the patient: Instead of eight to 10 minutes in an exam room, Taavoni spends nearly an hour with each of her patients. Her practice adds a flat $95 fee to each call, a price she said most patients happily pay.
There are certain procedures that have no at-home code, so those patients must travel to the Doctors Making Housecalls’ corporate headquarters in Durham or to another established clinical facility. For procedures like the osteoporosis treatment that can’t be billed at home, Taavoni maintains a small exam room just outside her second-floor administrative office at the 15,000-square-foot headquarters.
However, her real office is the back of her Mercedes R350, where she keeps a small file box, a plastic tub of supplies and a rolling suitcase filled with her otoscope, blood pressure cuff, bandages and other medical necessities.
Although she didn’t anticipate it when she first started making house calls, the majority of Taavoni’s patients – and those of her 45 fellow doctors in the practice – live at residential care facilities. When she visits an assisted or independent living home, she waves the $95 fee, and can often spend an entire day rounding from one patient’s room to the next.
The Medicare experiment
Doctors Making Housecalls’ patient population is more than 90 percent geriatric; it’s essential that they bill Medicare. Nearly all private insurers in North Carolina work with Taavoni’s practice, but the vast bulk of the office’s billing goes to Medicare.
Kronhaus initially worried about billing the federally subsidized health insurance. He feared the bureaucracy, paperwork and claim denials that are par for the course when working with the government. It soon became clear that the partnership would boost his business while furthering the course of government research on profit sharing and at-home care.
Medicare already had a number of billing codes for house calls and home-based services. But beyond that, administrators of the program had a deep curiosity about how to better serve their clients.
When, in 2012, Doctors Making Housecalls joined 15 other practices throughout the country in a demonstration project for Medicare, Kronhaus welcomed the opportunity to evangelize about his model. The shared-savings arrangement operates by offering participating practices a bonus based on how much they save over Medicare’s calculated cost of a standard patient.
In the two years since the project began, Kronhaus said, they’ve shown a significant cost savings when patients are seen in their homes. This yielded a bonus both for his practice and for Medicare, which saves money in the long term when patients avoid the hospital. He hopes this research will pave the way for policy favorable to his and other home-care practices
Doctors Making Housecalls has not only lowered costs for its Medicare patients but improved outcomes as well. Taavoni said her patients are healthier, go to the emergency room far less and are admitted to the hospital far less than an average Medicare patient. The difference, she said, is time.
“Most of our patients are more complex,” Taavoni said. “We are able to spend more time with them and have a more comprehensive visit. As opposed to doctors who see patients every seven minutes, we can take care of the whole patient.”
Even for Bell, whose medical needs aren’t complex, the extra time spent with Taavoni has both restored her health and her faith in the medical profession.
“My father was a doctor, and I remember seeing him leave with his leather bag to go see patients,” Bell said. “I never thought I’d get that same experience today. I can see her at home, I don’t have to go sit in a waiting room with sick people and it’s so nice to be one-on-one.”
This story is part of a partnership between MedPage Today and North Carolina Health News. The collaboration will make it possible for us to publish regular profiles of health care professionals from North Carolina.[/box]