Knock, Knock: The Doc Calls

Dr. Timothy Lee pulled up in front of Genevieve Kvasnicka’s home about 10 minutes before their 1 p.m. appointment. Dressed in slacks, a shirt and tie, he parked his black BMW across the street and, with a stethoscope around his neck and a black leather bag in hand, strode up the driveway of her one-story home in the quiet, Inglewood neighborhood. “She’s one of my favorite patients,” Lee said of Genevieve, 86, who greeted the doctor in her embroidered house dress and white slippers. Instead of a shivering in a sterile white room on a doctor’s table covered with a thin sheet of paper, Genevieve sat comfortably in her living room chair, with her four-wheel walker a foot away. Lee sat in an identical armchair on the other side of a wooden side table. Medical house calls are an old-fashioned concept but a new way of living for patients like Genevieve, who is part of a Care Level Management-Medicare three-year pilot program providing doctor house calls to chronically ill elderly. The program, called Personal Visiting Physician (PVP), began a year ago when the Centers for Medicare and Medicaid Services awarded Care Level Management a contract to test the effects of increased access and quality of care to chronically ill elderly, and to study the effects of doctor house calls on cost savings to Medicare. In October 2005, 15,000 qualified beneficiaries in California, San Antonio, Texas, and the Orlando/Melbourne area of Florida became eligible for the project. Medicare’s selection criteria for qualified beneficiaries included patients with two chronic illnesses and with a history of at least two hospitalizations within the past 12 months. Genevieve suffers from gastritis, severe arthritis and anxiety, which elevates hypertension. “I’m old,” she explains. “I’ve fallen so many times. I’ve hurt myself and I’ve had broken ribs.” Since Genevieve started the PVP program five months ago, Lee has identified some of the sources of her problems and helped alleviate her anxiety. For example, he was able to see for himself that she needed a bed with side rails to prevent her from falling out of bed at night. He also walked around her house to make sure there were no “trip hazards.” Lee sees Genevieve once a month for routine check-ups that last 30 minutes to an hour. Genevieve also has the doctor’s cell phone number for direct, 24-hour access, and he is available to come to her house at any hour of the day, any day of the week. On this recent visit, he chats with her while checking her vital signs. Lee: Are you drinking plenty of water? Genevieve: Three to four bottles a day. Lee: Exercising? Genevieve: Not much. Because the [physical] therapist didn’t come. Lee tells her that it’s important that her caretaker get her outside to walk in the neighborhood. Genevieve’s husband died in June 2005 and her children don’t live in the vicinity, so a caretaker comes three times a week to take her to appointments and run errands. When Lee takes her blood pressure, he is pleased that it’s at 114/78, compared to last month when it was 160. He quickly accesses this data by pulling his laptop computer from his black bag and unfolding it on his lap, where he can then make notes and update her charts. Lee also has an hand-held wireless PDA (personal digital assistant) that he can use to look up hospital files and send e-mails to the office. Lee: How did the appointment with the ophthalmologist go? Genevieve: I was going to have cataract surgery, but now he’s going to try changing my glasses. As Lee talks to Genevieve, who has glaucoma, he discovers that she has stopped taking one of her eyedrop medications and asks her to show him the other medications she’s taking. He does this mainly so that he can observe how she gets up and moves around the house. From the living room, he peers around the doorway at the exact moment he knows she’ll be crossing the hallway into her bedroom. Prior to her experience with the PVP program, Genevieve was frustrated with the health-care system, mainly because her primary care physician “didn’t pay much attention to me.” In recent years, she was in and out of the hospital for six months straight, and says, “They didn’t tell me much. They just let me lie there.” “I think time is the issue,” says Lee, who is board certified in family practice. “With today’s health care system and insurance, medicine is almost a volume practice. You give the best care you can, but you have to keep in mind that you have another five patients to see in that hour. I don’t have the pressure of another patient.” Lee earned his medical degree from UCLA and completed his residency program at USC and California Hospital. A father of three, he closed his private practice last October and joined Care Level Management in November. He is one of about 100 physicians currently employed by the company. “I have a young family,” he explains. “It was time to cut back [hours].” Lee usually makes seven to eight house calls a day. “It’s a different way of helping patients. You establish a rapport with your patients, gain trust faster and meet their families.” When he first took on Genevieve as a patient, Lee says, “She was a very anxious person. Her blood pressure was all over the place. Her appearance was not the best.” Knowing that Lee is a phone call away has helped ease her anxiety. He says she’s more mobile and talkative, and his routine visits have given her something to prepare for. “It’s a social call as well as a medical call,” Lee says. “She’s at home and she’s comfortable. I’m the stranger here. I’m out of my element because I’m not in a white coat.” Equipped with many of the tools one would see in a doctor’s office, including a glucometer to measure blood sugar, eye equipment, and even a portable scale, Lee can perform a variety of tests at a patient’s home. He takes Genevieve’s temperature and measures the oxygenation of her blood with pulse oximetry, a sensor placed on her fingertip. He listens to her lungs and heart with his stethoscope. When Lee presses lightly on Genevieve’s stomach, she tells him that someone brought her a casserole yesterday. Later, he goes to look in her refrigerator and cupboards to make sure she has food and, most importantly, water. Her freezer is stocked with Lean Cuisine meals, and she has water bottles in the cupboards. Genevieve asks Lee to change her sleep medication, which she says isn’t working any more. He encourages her to exercise and says he will try to find her another sleep agent, although he’s hesitant to give her something that might be addictive. “My prescription for sleep is: Tire yourself out during the day,” Lee says. “My guess is you’re just too rested.” With a cell phone attached to his ear, Lee calls in Genevieve’s five refill prescriptions while she watches him closely. “He’s a good doctor,” she says. “He’s kind and he listens.” Visiting physicians are “the eyes and ears for the doctors in the office,” says Lee, who believes that people get better at home faster than in any ER. However, he adds that he would not hesitate to send one of his patients to the ER in an emergency. There are also certain “sensitive” exams and procedures, such as mammograms, that he cannot perform at a patient’s home. Beginning this month, a new group of 13,600 chronically ill patients will be invited to participate in Care Level Management’s PVP program. Medicare estimates that chronically ill elderly make up only 3 to 5 percent of beneficiaries, or approximately 1.5 million Americans. This top 5 percent uses 43 percent of total Medicare costs, primarily through hospitalization. Medicare estimates that the beneficiaries selected for this pilot currently cost the program $800 million annually. Working with managed care operations in six major cities across the nation, the PVP program has reduced acute hospital admission by an average of 60 percent, resulting in an average net savings of 30 percent in institutional costs alone. “House calls,” Lee says, “is a completely different world for patients. They’re getting health care where they would not otherwise have it.” For more information on the PVP program, visit www.carelevel.com.