Doctor at the door

By ANN POTEMPA
Anchorage Daily News
http://www.adn.com

Lynn Stevens shuffled into the crafts room at Chester Park Senior Housing, which she calls home. She set her walker aside, sat down and pulled off her blue sneakers, baring feet worn from walking for nine decades. Dr. Donna Klecka picked both up in her hands and tended to Stevens’ nails and skin.

Even though this isn’t a doctor’s office, it’s definitely a doctor visit. Just as in the old days, this is a house call — Klecka’s specialty.

Ten years ago, Klecka moved her podiatry practice north from Seattle. In Alaska, she did something unconventional: She opened a medical practice in Eagle River but not an office. Patients don’t come to her; she goes to them. The little sign on her black Toyota Prius reads: “Traveling Foot Doctor.”

She’s not the only one trying it. Fred May, a physician assistant, recently started a business called House Calls of Eagle River.

From 1998 to 2004, yearly house calls for the nation’s elderly and disabled on Medicare jumped 43 percent, or more than 600,000 total visits, according to a 2005 article in the Journal of the American Medical Association.

Just a decade ago, the New England Journal of Medicine called what Klecka and May do a “vanishing practice.”

Then things started changing. Baby boomers began entering their retirement years, and some became homebound. Medical tools became portable, and doctors received a late-1990s boost in Medicare payments for house calls, according to JAMA and local doctors.

Even though house calls are on the rise, medical journals say they still represent only a small fraction of all doctor visits.

DOCTORS WITHOUT OFFICES

It’s difficult to know just how many doctors, physician assistants and nurse practitioners make house calls in Alaska. The American Academy of Home Care Physicians, a professional organization for physicians who make house calls, has a membership of about 700 people nationwide.

But not all physicians offering this type of service are registered with the group; Klecka and May, for example, aren’t listed as members.

Doctors across the country have many reasons for focusing their practice on house calls, said Constance Row, executive director of the American Academy of Home Care Physicians in Maryland. They’re often internal medicine or family doctors who have found a way to make their practice portable.

Medical equipment has been converted into smaller, mobile tools that can be carried out of doctors’ offices and into patients’ homes.

Klecka carries an orange tackle box filled with drills, files and scalpels that she uses on patients’ feet. May carries a stethoscope and tools for blood tests as well as a portable scale to measure weight and a mobile exam table.

“I have about four bags that I carry right now,” he said.

May said he’s planning to buy a mobile electrocardiogram (EKG) machine to detect heart problems; it will cost him about $4,000, he said.

Yet another reason doctors do house calls is that they see a great need for them, Row said. Many patients have disabilities or they’re elderly and struggle to get out of the house for a doctor’s appointment.

“They are not being seen in offices because they can’t get there,” Row said.

Stevens, Klecka’s patient at Chester Park Senior Housing, said she depends on her children to drive her places, including the doctor’s office. She hesitates to go outside when it’s icy because she might slip and fall.

Many of Klecka’s patients are older people whose nails, corns and calluses need tending, but they have trouble bending to reach their feet. Patients of any age call her to construct customized orthotic shoe inserts while avoiding a trip to the doctor.

May is a physician assistant who specializes in family practice. His patients, he said, range in age from 1 to 60.

MAKING THINGS SIMPLE

For May and Klecka, choosing house calls over an office practice comes down to simplifying their businesses, their personal lives or both.

Klecka is a single mother of three children. A doctor who focuses on house calls can be more flexible about family, she said. She schedules her patients around her children’s needs.

After years of working in a clinic, May said, he’s trying to build a practice centered on house calls because he thinks he’ll be able to spend more time with patients in their homes.

“Primarily, it’s to get a closer relationship with my patients,” he said. “I’ll have far fewer patients, so I’ll get to know them better.”

“It’s just not so rushed.”

At a clinic, physicians typically spend about 15 minutes with patients, May said. In his new business, he wants to commit about 45 minutes to each person he sees at home.

CUTTING OVERHEAD

Not opening a medical office also means cutting overhead expenses that many doctors say is going up as reimbursement for medical care is falling. Neither May nor Klecka pays monthly rent or utilities for space they don’t regularly use. Even so, both use other doctors’ offices if their patients don’t want to be seen at home.

When you’re a doctor who does house calls, you do the work of the entire office.

Klecka doesn’t employ an office manager to answer phone calls. Instead, she carries a cell phone and schedules her own appointments. At home, her children answer the phone by saying “Dr. Klecka’s.” Her home answering machine delivers a similar message.

Klecka doesn’t hire a billing staff anymore. She does that on her own and has slimmed down the paperwork because she doesn’t participate in the Medicare program and hands patients documents with which they can bill private insurance companies themselves.

At the end of a visit, her patients reach for their pocketbooks. They pay in cash or check, not credit cards.

When doing house calls, May doesn’t see Medicare patients. He does, however, bill patients using private insurance. A lack of staff means May takes a patient’s blood pressure, does blood tests and fills out insurance paperwork — tasks physicians usually assign to nurses, medical assistants and office managers.

May and Klecka say cutting overhead means saving money. For Klecka it also means reduced fees. Klecka said she charges $55 to $85 for a basic visit that focuses on nail and foot care. The cost depends on how many patients she sees at one place and how far she has to drive. Klecka has driven a couple of hours to see a patient, and that amount of driving adds up. Her car odometer recently passed 64,000 miles, and the car’s just two years old.

While Klecka sees patients in Anchorage and beyond, May said he has limited his practice, and driving, to Eagle River, Peters Creek and Chugiak.

He charges $105 for a typical home visit — an average fee for an office visit in the area. He said he’s not the lowest-priced physician assistant in town, but some patients are willing to pay for the added convenience of having him come to them. It’s worth it to them to avoid driving across town and then sitting in a waiting room until a physician or assistant is ready.

So far, focusing on house calls hasn’t made for a profitable business, however. Klecka said she works five or six hours a day — which brings in enough money to pay a home mortgage and support the family but not to save much. May said about two-thirds of his revenue had to be paid out in expenses last year.

But May is building his practice slowly. A typical workday now means seeing one patient at home. May said he hopes more patients will start requesting house calls.

Editors’s Note: This article originally appeared on the Alaska Dispatch website. They have either moved or deleted it, and since we cannot find the original, we will archive it on Cunningham Group’s website. If you have found this page and are in need or a medical malpractice insurance quote in Alaska, click here.

About