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Trends in House Calls to Medicare Beneficiaries
To the Editor: A 1997 analysis declared house calls a "vanishing practice."1 Home nursing and rehabilitation services have increased in recent decades, but a concurrent decline in physician home care has been observed.2-3 However, a number of factors may lead to a comeback in house calls. These include the aging of the United States population4; advances in portable medical devices, information technology, point-of-service laboratory tests, and handheld computers5; and the 1998 Medicare increase of nearly 50% in allowable reimbursement for home visits. The 2004 allowed charge for a "comprehensive" visit to an established patient is approximately $110.6 We examined trends in annual house call volume and expenditures, as well as the types of clinicians making house calls to fee-for-service Medicare beneficiaries.
Methods
We analyzed aggregated fee-for-service Medicare physician/supplier data from 1998-2004, including all years for which free-of-charge public use files are available. The main outcome measures were annual number of house calls, house calls per 1000 enrollees, allowed charges for house calls, house calls by clinician type, number of house call visits and their charges as a percentage of outpatient evaluation and management services, and changes in these data over time. Only Medicare-approved charges and visits were counted.
House call and office visit volume and charges from 1998-2004 were determined from the Medicare Part B physician/supplier data by Berenson-Eggers Type of Service Code.7 House calls as a percentage of outpatient visits were calculated by dividing the number of home visits by the total number of home and office visits for the year. Medicare enrollment was obtained from Centers for Medicare and Medicaid Services; fee-for-service enrollment was obtained by subtracting the Medicare Advantage enrollment.8
The number of house calls provided by specialty was determined using the Medicare Evaluation and Management Codes by Specialty files.9 Allowed services for home visit evaluation and management codes included Current Procedural Terminology (CPT) codes 99341-99350. For 1998, CPT codes 99351-99353, for home visits only, were also included. Because podiatrists, nurse practitioners, and physician assistants bill for house calls using the same CPT codes as physicians, their charges are included in this analysis. Enrollment and specialty-specific data for 2004 were not available. Data represent the entire population of Medicare enrollees for each year reported, so that inferential statistics were not used. Data analysis was performed using Microsoft Excel 2003 (Microsoft Corp, Redmond, Wash).
Results
From 1998 to 2004 the annual number of house calls increased 43%, from 1 442 395 to 2 060 029. Allowed charges for house calls increased 118%, from $74 million to $161 million. House calls increased from 0.78% of outpatient evaluation and management services in 1998 to 0.90% in 2004. They increased from 1.40% to 1.67% of allowed charges for outpatient visits over the same period. House calls per 1000 enrollees by specialty are presented in the Table. In 2003, more than 50% of house calls to Medicare beneficiaries were provided by primary care physicians. From 1998 to 2003 there was rapid growth in house calls by nurse practitioners and physician assistants and a decline in house calls by podiatrists, psychiatrists, and general surgeons.
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Table. Annual House Calls Among the 10 Highest-Volume Specialties, per 1000 Fee-for-Service Medicare Enrollees—1998-2003
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Comment
House calls to Medicare beneficiaries became more common from 1998 to 2004. Although still relatively infrequent, these results indicate a reversal in the downward trend in house calls that was reported in a 1997 analysis.1 Factors that may have contributed to this change include the 1998 increase in Medicare reimbursement for home visits, growth in hospital-based house call programs, early hospital discharge programs, and efforts to increase the role of house calls in medical education.2 The rapid growth in the volume of house calls provided by nurse practitioners is consistent with the reported success of multidisciplinary home-based models of care that rely on nurse practitioners.2
Limitations in these data include that they are from de-identified aggregated billing files. Characteristics of the individuals receiving house calls, such as age, health, number of house calls received, and geographic location were not available. House calls to Medicare Advantage enrollees were not included, and house calls that were not billed or allowed were not accounted for, so the estimates likely underrepresent the actual number of house calls. Further studies are needed to better understand patient- and physician-level factors contributing to the changes, as well as the impact of house calls on patient care and public health.
Access to Data: Dr Landers had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Financial Disclosures: None reported.
Funding/Support: This study was supported in part by grant K12 HD049091 from the National Institutes of Health, National Institute of Child Health and Human Development, Multidisciplinary Clinical Research Career Development Programs.
Role of the Sponsor: The National Institutes of Health had no role in the design and conduct of the study; the collection, management, analysis, and interpretation of the data; or the preparation, review, or approval of the manuscript.
Steven H. Landers, MD, MPH
steven.landers{at}uhhs.com
Paul W. Gunn, BS;
Susan A. Flocke, PhD;
Antonnette V. Graham, PhD;
George E. Kikano, MD
Department of Family Medicine
Case Western Reserve University School of Medicine
Shirley M. Moore, RN, PhD
Frances Payne Bolton School of Nursing
Case Western Reserve University
Kurt C. Stange, MD, PhD
Department of Family Medicine
Case Western Reserve University School of Medicine
Cleveland, Ohio
1. Meyer GS, Gibbons RV. House calls to the elderly—a vanishing practice among physicians. N Engl J Med. 1997;337:1815-1820.
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2. Leff B, Burton JR. The future history of home care and physician house calls in the United States. J Gerontol A Biol Sci Med Sci. 2001;56:M603-M608.
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3. Levine SA, Boal J, Boling PA. Home care. JAMA. 2003;290:1203-1207.
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4. Besdine R, Boult C, Brangman S, et al, American Geriatrics Society Task Force on the Future of Geriatric Medicine. Caring for older Americans: the future of geriatric medicine. J Am Geriatr Soc. 2005;53:S245-S256.
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5. Taler G. House calls for the 21st century. J Am Geriatr Soc. 1998;46:246-248.
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6. Centers for Medicare and Medicaid Services. Medicare Physician Fee Schedule Look-Up. Available at: http://www.cms.hhs.gov/physicians/mpfsapp/. Accessed September 25, 2005.
7. Centers for Medicare and Medicaid Services. Berenson-Eggers Type of Service (BETOS) Codes. Available at: http://www.cms.hhs.gov/data/betos/. Accessed September 25, 2005.
8. Centers for Medicare and Medicaid Services. CMS Statistics: Medicare Enrollment. Available at: http://www.cms.hhs.gov/statistics/enrollment/. Accessed May 5, 2005.
9. Centers for Medicare and Medicaid Services. Medicare Utilization for Part B (Supplementary Medical Insurance SMI). Available at: http://www.cms.hhs.gov/statistics/feeforservice/. Accessed May 5, 2005.
Letters Section Editor: Robert M. Golub, MD, Senior Editor.
JAMA. 2005;294:2435-2436.
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