The Black Bag is Back

A local doctor leads a trend, making house calls again

Published in Princeton Business Journal, May 16, 2006

By Lauren Otis

MONROE — On a mild spring morning Dr. Howard Cohen gets out of his car, grabs his bag and strides up the short drive of a nondescript one-story bungalow nestled in an older gated development. Cecelia Riddell answers the door and after greetings and pleasantries all around, she and her husband Francis sit down at their kitchen table with Dr. Cohen as he takes out two fat manila folders, a stethoscope, and blood pressure apparatus from his bag, and begins: “All right. So what’s new?”

Dr. Cohen is making a house call, a medical practice familiar to people of a certain age yet one which has declined to the point of extinction in recent decades, a victim of the rise of managed care and other shifts in America’s cultural and medical landscape. Yet, thanks to improvements in electronic communication and record-keeping, reimbursement improvements, and a group of dedicated doctors and advocates for the elderly and homebound, home-based health care is poised to make a comeback.

“The black bag is back,” says Dr. Cohen, who for reasons that are perhaps partly symbolic and partly practical, carries that timeless icon of the house call — the black doctor’s bag — with him on home visits.

“How are you feeling Francis?” asks Dr. Cohen, a soft-spoken man with thick salt-and-pepper hair who dresses in a shirt and tie but no jacket.

Mr. Riddell, 90, sits quietly as Dr. Cohen checks his heart and blood pressure, and takes a blood sample to bring back to his office for analysis.

“He’s been more anxious doctor,” Mrs. Riddell answers for her husband, who suffers from macular degeneration of the eyes and Alzheimer’s among other ailments.

After her husband, Dr. Cohen switches to Mrs. Riddell, a sprightly and loquacious woman who will soon turn 86. He discusses dietary needs, medicine dosages and refills, then inquires about a recent trip the Riddells took to Atlantic City. “What’d you win?” he asks.

“Are you kidding?” Mrs. Riddell rejoins.

She and her husband no longer drive and the couple are plainly grateful for Dr. Cohen’s presence in their home. Car services, their main option for transport to the doctor’s office, can be inconvenient and costly.

“Some of these car services they are a little high. They figure they’ve got you by the neck,” she says.

After bringing a scale from his car and weighing them both, Dr. Cohen sets up an appointment in a month for the Riddells to have a full physical — they’ll have to come to his office for this — then packs up his black bag and says his goodbyes, a little over a half-hour after he arrived.

Dr. Cohen has been seeing the Riddells for close to 20 years, but it is only in the past year that he has begun visiting them at home.

“Previously, I’d do (house calls) but only a couple per year, for people who were patients but needed them, were housebound. I’d do it as a favor,” he said.

Dr. Cohen closed his New Egypt office and consolidated his practice in East Windsor recently, which has enabled him to concentrate more on house calls. Currently, he sets aside Tuesday and Thursday mornings for house calls. He even hopes one day to close his office and devote himself full time to home-based medicine.

With a cell phone, a laptop computer and all his medical records electronic now, Dr. Cohen says his office is effectively portable.

“You still practice medicine the old-fashioned way, but using modern technology to help you,” he said. “You can do an EKG in someone’s home on your laptop.”

Currently, in America, there are approximately 2 million homebound elderly who could benefit from home-based healthcare, and the number will continue to grow as the general population ages, said Constance Row, executive director of the American Academy of Home Care Physicians, based in Edgewood, Md.

“These people lack geographic ongoing primary care for chronic condition management. They must resort to the emergency room and in-hospital services for their care,” Ms. Row said.

By comparison, physicians made approximately 1 million house calls in the past year, she said. Portable electronics and technology advances “make it possible for physicians to move their primary care office into the home,”

Ms. Row said.

Noting that the 5 to 10 percent of the sickest elderly account for 75 percent of Medicare expenditures, Ms. Row said Medicare has become increasingly willing to look at different, more cost-effective ways to supply care, and recently increased its reimbursement levels for house-call visits to more adequately cover them. Low reimbursement of at-home doctor visits compared to in-office or hospital reimbursement, has been a significant hurdle to getting doctors back into the practice of making house calls, she said.

The good news is, with such changes, the number of doctors and nurse practitioners making house calls, and the number of house calls made, will continue to grow, she said. “Our goal would be to increase the number of house calls made by primary care physicians over the next five years by 50 percent, from 1 million to 1.5 million,” Ms. Row said.

“Will the growth ever match the need? We can only hope,” she said.

Mary Kay Krokowski, a registered nurse and certified geriatric care manager who operates Aging Advisors LLC in Pennington, said most elderly people “much prefer to remain at home” rather that in assisted living or other facilities. Home-based health care is one of the critical pieces to enabling this to happen in many cases, said Ms. Krokowski who is president of the New Jersey chapter of the Geriatric Care Managers association.

Citing the huge need for home-based care, Ms. Krokowski noted, “I’m seeing more doctors in the area who will make house calls, which wasn’t the case a few years ago.”

Dr. Cohen said both from a medical and personal standpoint, house calls are beneficial for the elderly and other homebound patients, or those like the Riddells, who aren’t homebound but for whom travel to a doctor is difficult or expensive.

From a doctor’s perspective, seeing a patient in their home is valuable because “you kind of get a feel for the way they live and the hardships they have,” Dr. Cohen said. By seeing a patient’s home environment — who visits, what they eat, how clean and safe the home is — a doctor gets a much better picture to inform his or her care, Dr. Cohen notes.

Even if a patient’s insurer will not pay any of the costs of a house call, it may make sense from a quality of life standpoint, said Dr. Cohen.

“When someone has a $50 co-pay to the emergency room and a house call is $100, it is only $50 more and they don’t have to waste their whole day in the emergency room,” he said.

And health insurers, including some private companies and Medicare, have grown more cognizant of the benefits of home health care, and more willing to reimburse more for them, understanding that house calls reduce the huge costs from homebound elderly who must rely on ambulance transport and emergency room and hospital care for even basic medical needs, like the treatment of an ear infection, because they have no alternative, Dr. Cohen said.

Within the medical community, much still remains to be done to reverse the attitude that house calls are a thing of the past.

“As it stands now, most (medical) residents who go through training don’t even know how to make house calls,” said Ms. Row of the American Academy of Home Care Physicians.

As a result the AAHCP is looking to obtain grant funding to expand a program begun in 2001 to develop a distance learning curriculum that could be distributed to medical school program directors—via compact disc or the Internet — that would enable them to offer interested residents training in the making of house calls, Ms. Row said.

This initiative grew out of a series of four or five home care training seminars the AAHCP gave at medical schools with strong geriatric programs. One of these seminars was given at Hackensack Medical Center in New Jersey in 2001, Ms. Row said. She said the New Jersey seminar attracted resident program directors from about 20 hospitals from all over New Jersey.

“It was gratifying,” she said of the response to the New Jersey seminar. ”If they didn’t have (a home care program) they started one, if they had one they expanded it.”

Still, the number of doctors making house calls is a small fraction of all those who practice medicine. Ms. Row said currently “we have at least one house call provider in 40 states.” New Jersey has only a handful of doctors making house calls, said Dr. Cohen, who estimates that only 5,000 to 6,000 of all the doctors in the country will make house calls.

Offering house calls again does entail a change in the attitude doctors often have towards patients these days, noted Dr. Cohen. Making a house call does take more of a doctor’s time, and it requires more of a willingness to chat with and listen to patients beyond the current parameters of a five minute office visit, he said. “You are treating people as people, not as numbers at the deli counter as I like to describe it,” he said.

“It does take time because you are traveling around, but it is something I like to do,” Dr. Cohen said. “It breaks up the monotony of being in the office all day. It brings back that old feeling, of going to someone’s house and saying, ‘Hi, how are you doing?’ That feeling that has been lost from medicine.”