Bringing medicine to Morris' 'elderly elderly'

BY LORRAINE ASH
DAILY RECORD
http://www.dailyrecord.com/

When Orlando Serino opened the front door of his daughter’s Madison home, the 86-year-old smiled from ear to ear.

“Doctor,” he said, “you come in.”

Dr. Milton “Mickey”Mintz entered, a medical bag in each hand.

“Hello, Orlando. I’ll head right on up to your wife,” he said. “Then I want to check your blood pressure. Every three weeks. Got to do it.”

Serino never stopped smiling. For two years the retired mason, originally from Italy, has spent his days and nights by the side of his bedridden wife.

“When I got married the priest said, ‘for better or worse,'” Serino said, picking up a group family picture in which his wife stands next to him. It was taken four years ago. “Look how nice everything was.”

Dr. Mickey, as he is known, is the only doctor the family has been able to find to tend to 87-year-old Luisa Serino. They say he saved her life in February when she was on the verge of pneumonia, and he got her antibiotics on a Saturday morning. Then he checked on her the next Saturday. Within a week her vitals were much improved.

There, in a microcosm, is an ever-growing problem facing the nation. Mintz is answering a call to bring medicine to the “elderly elderly”who are too frail to leave their homes. The day he called on the Serino family, he had 10 other house calls to make. (See story, Morris Life.)

In Morris County there are 7,804 homebound elderly people such as Luisa Serino, according to a U.S. Census report released Tuesday. They represent 13.8 percent of the 56,559 people over 65 in the county.

“Dr. Mintz is a godsend,”said Teresa Davis, director of the county Division on Aging, Disabilities and Veterans. “A lot of our caseworkers go into homes and the people haven’t been to a doctor in a decade, and they have chronic health issues.”

Their conditions worsen until one day they dial 911, appear in an emergency room and are admitted for a hospital stay. The cost of not providing ongoing medical care for them is huge in terms of human suffering and medical expense.

Pilot program

Chronically ill elderly make up 5 percent of all Medicare beneficiaries and account for 43 percent of the program’s costs, primarily through hospitalization, according to Lisa Spicer, spokeswoman for Care Level Management, a California company contracted in October 2005 by Medicare to conduct a three-year Personal Visiting Physician (PVP) pilot program.

More than 20,000 of Medicare’s sickest beneficiaries in California, Texas and Florida volunteered to participate in PVP, which gives them free 24/7 access to a doctor who makes house calls.

“These are the people who otherwise would use the ER as a first line of defense,” Spicer said.

At the first sign of pneumonia, for example, a patient on the PVP program who has a history of congestive heart failure can make a call and be tested and treated with antibiotics at home. Such a patient could stave off pneumonia, avoid suffering and be treated for $750, according to Care Level. If his pneumonia is allowed to develop until he needs hospitalization, his treatment likely would cost $6,900.

But Medicare patients who are not on the pilot program, or do not have a doctor who comes to their homes, have another reality to deal with, as this statistical snapshot shows:

• In 2000, the 85-plus population in the United States was 34 times as large as it was in 1900, thanks to medical advances and low fertility rates, according to the U.S. Census.

• From 2000 to 2005, the 85-plus population in New Jersey alone increased by 24 percent to 170,896, according to U.S. Census Statistician Wan He.

• In 2005, 2 million house calls were covered by Medicare — less than 20 percent of the number needed, according to the American Academy of Home Care Physicians.

“The United States is the only industrialized country that does not have a fully developed infrastructure to support people aging in place,”said Constance Row, executive director of the academy. “It’s because of our emphasis on the institutional, which is unhealthy and expensive.”

All things considered, there are more doctors making house calls in New Jersey than in most other states, according to Row. New Jersey is well represented in the American Academy of Home Care Physicians.

“It’s not that there is somebody on every street corner. Far from it,” she said. “But New Jersey seems to be blessed with a number of courageous, committed physicians who know the need and are trying to do things that are good for their patients.”

Reimbursements

In 1998, Medicare increased its reimbursements for physician house calls by nearly 50 percent, helping spark a 43 percent rise in house calls from 1998 to 2004, according to the Nov. 16, 2005, issue of the Journal of the American Medical Association.

As of Jan. 1 of this year, however, reimbursements for all nine house call codes went down, according to Ellen Griffith-Cohen, spokeswoman for the Centers for Medicare & Medicaid Services. Calls are reimbursed in relation to the thoroughness and level of medical complexity they require. Reimbursement for a basic home visit to a new patient in North Jersey, for instance, went from $64.53 last year to $60.07 this year. Travel expenses still are not covered.

In part, the dip in reimbursement was at the recommendation of the American Medical Association, which advocated for increased reimbursement for mid-level office visits for established patients. Reimbursement for one of those kinds of visits went from $59.87 to $67.25 this year.

Budget neutrality is applied to the Medicare budget, Griffith-Cohen explained. So when reimbursement goes up for one billable service, all other services are decreased to make up the difference. In other words, as payment for office visits goes up, payment for house calls goes down.

“A physician may still have an increase in 2007 under the current payment system even if he is getting less for home visits,” Griffith-Cohen said. “It depends on his practice mix.”

Most family practitioners have practices that combine home and office visits, according to Dr. Tom Holland of Madison, a preceptor at the Overlook Hospital Family Practice Residency Program, which teaches residents how to make house calls. One reason for the higher number of mobile doctors in the Garden State may be the proliferation of such programs here, Holland speculated.

“Most family doctors have a small clientele they will periodically visit at home,” Holland said.

“Usually, these are patients that have been members of the practice for a while. The physician has a relationship with them and feels obliged to continue to provide them care.”

To make a home visit economically acceptable, though, some doctors perform tests and services for which they can submit charges, such as removing ear wax and cutting toenails, he added.

“It seems to me,” Holland said, “a physician shouldn’t have to do these gimmicky things to justify the expense.”

Though many people have fond memories of doctors making house calls in the 1940s and 1950s, that era was more romantic in retrospect than reality. There were no coronary care units in hospitals until the 1960s, Holland said. Before that, doctors even treated patients with heart attacks in their homes, usually with diuretic injections to remove fluid that accumulates with heart failure.

“There wasn’t so much we could medically offer patients other than educating them,” he said, “or addressing their worries.”

Today, he agreed, the challenge is finding a fitting blend of technology, office and home visits that reaches every patient.
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