Wheaton doctor delivers medical care at your doorstep

by Satta Sarmah
http://news.medill.northwestern.edu

Dolores Karadimos, 62, has a laundry list of ailments posted on a sheet of copy paper taped to her wall. The list with more than 16 bullet points includes illnesses ranging from fiber myalgia and a herniated disc to asthma, osteoarthritis and ulcers.

A myriad of physical ailments render Karadimos and her 40-year-old daughter, Gina, housebound in the home they share in Bloomingdale. Gina, who jokingly refers to her sedentary state as “La-Z-Boy chair-ridden,� has heart failure, chronic respiratory failure, a detached bladder and diabetes, among other things.

Injuries she suffered in a car accident while traveling to a medical appointment several years ago added to her medical needs. The women take care of each other as much as possible.

“I can’t tell you how many times I have passed up receiving medical care that I really needed because I couldn’t physically get out of the house,� Dolores Karadimos said.

House calls — that time-honored service now so rare in the U.S. health care system — solved their problem. Both Dolores and Gina are patients of HomeCare Physicians, a medical practice based in Wheaton that Dr. Thomas Cornwell started in 1997.

“People like me will wait until we are on death’s door to go to an emergency room,� said Gina Karadimos. “Dr. Cornwell forces people to get the care they need. If he did not come to people’s homes, there would be people who never see a doctor.�

Cornwell, a graduate of the University of Illinois at Chicago School of Medicine, has made over 22,000 house calls, mostly in DuPage and Kane counties. His door-to-door medical practice is difficult to copy, mostly because the current payment system makes home care medicine an unattractive career choice for many primary care doctors.

However, advocates say the practice can save the health care system millions of dollars, despite its limitations compared to medicine practiced in hospitals and office settings.

Cornwell is scheduled to testify before Congress on April 18th to support a health legislation that would promote home health care.

Medicare payments currently don’t cover many of the costs of his practice, so HomeCare Physicians must rely on fundraising and donations to maintain the services. Cornwell’s salary is subsidized by the Central Dupage Physician Group of Central DuPage Hospital in Winfield.

HomeCare Physicians started as a pilot program of the hospital, which continues to sponsor it. Cornwell originally worked on his own, but the practice now includes a nurse practitioner and another physician, Dr. Paul Chiang.

On a typical day, Cornwell leaves his office at 8 a.m. Toting a 10-pound bag filled with patients’ charts and another bag containing a stethoscope, an odoscope, blood pressure cuffs, needles, and vaccines, Cornwell and his medical assistant, Megan Hallivan, get into a Ford Explorer and travel less than two minutes from the office to see Cornwell’s first patient.

She is an elderly woman who suffers from a rare facial pain disorder called trigeminal neuralgia. The woman, who is blind and bed-ridden, tells Cornwell the pain was so bad the night before that she considered suicide. He spends 20 minutes talking to her, soothing her fears and writing prescriptions before he moves on to his next patient, a burn patient living about 10 minutes away.

The woman is a Vietnamese immigrant who suffered first degree burns in an apartment fire that left her lungs badly charred and gave her a perpetual cough. Another patient suffers from dementia, while another is dying of cancer.

“Most doctors might have a handful of patients as complex as ours. Most of their other patients are much healthier,� Cornwell said. “Because most of their patients are much healthier, they’ll see a lot more [patients] in their office than we’ll see� at home.

Cornwell typically sees 10 patients a day, many of whom are referred to him by home health care nurses, hospitals and through word of mouth. Ninety-five percent of Cornwell’s patients are on Medicare, most are more than 80 years old and they have five or more chronic illnesses. They must be homebound to qualify for his services.

Though commuting to patients’ homes is what gives Cornwell’s practice added value, it also makes his practice more challenging and cumbersome.

“One of the huge inefficiencies of house call medicine is travel time,� Cornwell said. “You want to minimize that travel time so we make sure that we only go to a certain area each day of the week. Even in those areas, we tend to group patients by the day so that there is a minimal amount of travel time.�

“Rarely will we travel more than five minutes between patients,� Cornwell said. “It’s inefficient for doctors but it’s incredibly efficient from a cost standpoint for the health system because it costs a lot less to have a doctor go from house to house than to have these patients go to the emergency department.�

Many of Cornwell’s patients and their caregivers said the service has eased both the emotional and physical burden of getting medical care in a clinical setting.

Gina Karadimos, a patient of HomeCare Physicians for five years, said there’s an emotional comfort in receiving medical care in your home.

“People are afraid that they’ll go to the hospital and never come out,� she said. “It’s that fear of calling 9-1-1 and never coming home.�

Patricia Marks, 68, of Bloomingdale, suffers from severe arthritis in both knees and relies on an oxygen pump to breathe. She is homebound, which qualifies her for home health care, and said she finds it distressing to go to the hospital.

“In an office the doctor is always rushed,� Marks said. “I’m more comfortable here. I get nervous in a hospital. I look at that woman [in the next bed] and think to myself ‘I could be just like her.’�

Family caregivers also said they’ve benefited from the house call service.
Lura Bowens took early retirement to care for her 103-year-old grandmother, Lillie Williams, one of Cornwell’s patients for five years. Bowens has cancer and has to worry about her own medical care.

“Just think about the things you have to do. You have to use your time and your gas getting [to the doctor] and getting back. You can have an accident going and coming,� Bowens said. “There are just simple basic things that I don’t have to do [because of the house call service], like getting her in the wheelchair, out the door, taking her out of the wheelchair, putting her in the car and taking her to the doctor’s office. Can you imagine how many times?�

But doctors like Cornwell aren’t easy to find. Only about 1,000 doctors performing house calls full-time or nearly full-time in the United States, according to The American Academy of Home Care Physicians, based in Maryland.

Though it only costs Medicare an average of $120 per visit for Cornwell to see patients in their homes compared to $2,000 a night for a hospital stay, the current Medicare reimbursement system doesn’t give doctors an incentive to practice house call medicine.

Payments are determined by Medicare and are based on the complexity of each patient. Most of Cornwell’s patients qualify as a level four out of five and Medicare pays about $169 for each visit to these patients. As of 2007, the physician fee schedule for Medicare ranged from $54.14 to $186.12 for a home visit to a new patient.

Medicare also imposes other limitations on Cornwell’s practice. House call doctors can’t perform complicated medical procedures in the home and patients must go to the hospital to get certain treatment. And some of the treatment people can receive at home is limited by Medicare regulations.

For example, while updating Mark on the progress she’s made with physical therapy, Cornwell told her, “There’s good news and bad news. The good news is that you’re doing well. The bad news is that, when you’re doing well, Medicare doesn’t pay well.� Medicare only covers physical therapy and other procedures and services deemed medically necessary. What is or isn’t medically necessary is determined by Medicare and not by doctors.

Despite these challenges, advocates say home care medicine can save Medicare and the health system money by providing preventive care to the most at-risk patients more frequently, which would lead to fewer people in emergency rooms.

Five percent of Medicare beneficiaries account for 52 percent of Medicare spending, according to data from the Health Care Financing Administration of U.S. Department of Health and Human Services. This means the sickest patients cost the health care system the most money.

But Medicare reform is necessary to allow house calls to continue, said Constance Row, executive director of the American Academy of Home Care Physicians.

“With regard to the adequacy of the fee schedule, generally it doesn’t cover the total costs of making house calls,â€? Row said. “The problem that exists is that it is at best a marginal business. Most physicians have to try to make it on the revenues that they can generate under the fee schedule. Most of these patients who are served are Medicare patients–the sickest, frailest patients.â€?

“These are the highest cost, highest risk patients so it’s sort of penny-wise, a pound foolish not to allow the payment system to pay these physicians adequately so that they can keep patients out of higher cost settings,� Row said.

Row and other medical professionals are backing the proposed Independence at Home Act before Congress to address these Medicare issues. Doctors practicing in areas with shortages of physicians receive a 5 percent bonus payment from Medicare. The home health care proposal is aimed at encouraging more doctors to practice house call medicine, which would cover some of these areas.

The proposal also targets the most at-risk, elderly patients—those with two or more chronic diseases, previous high cost hospitalization and measurable disabilities— in an effort to avoid increased hospitalization and unneeded expenses.

“It’s an example of an approach called the high risk approach,� Row said. “In other words, you go after the high-risk, high-cost Medicare beneficiaries and offer them an enriched program with cost savings results that are then shared with the physicians who manage to pull this off.�

The benefits to his patients keep Cornwell going, he says. he said more doctors in home health care could help so many people and the entire Medicare system.

“If Medicare paid enough where you could do this for a living, it wouldn’t be so unique,� Cornwell said. “If Medicare payments were enough to support it [house call medicine], you’d see a lot more of it.�

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