BY SHERI PORTER
 With her living room as a backdrop, Michele Toussaint, right, says "ah" as Andrea Brand, M.D., investigates a complaint of swollen glands. |
"If the patient has an office sitting there waiting for you, why rent space for $5,000 a month?"
That's the question FP Andrea Brand, M.D., of Longboat Key, Fla., asked when she found herself out of work in late 2002. A New York native, Brand was squeezed out of the position that brought her to Florida. Brand wanted to set up a solo practice but knew she couldn't afford the overhead expense of maintaining an office.
So in January 2003, after 27 years in traditional-style practices, Brand launched a house-calls-only practice on this 10-mile-long island. Her first patient suffered from an ingrown toenail.
Physician interest grows
Brand isn't the only doctor starting a house-calls-only practice. Constance Row, executive director of the American Academy of Home Care Physicians (online at http://www.aahcp.org), said her organization has nearly 700 members. She estimates that more than 50 percent of them are doing house calls full time. Eliminating the office overhead "is what makes this an economic model that works," said Row.
Some physicians have come up with innovative ways of drastically reducing overhead, agreed FP Fredric Leary, M.D., M.B.A., of Oak Park, Ill. "Even the best-run practices are finding that overhead now eats up far more than 50 percent of their gross revenues. As this financial noose tightens, physicians are forced to drive volume through the office in order to cover costs," he said. A high volume of patients can cause havoc with unfettered patient access and patient safety, added Leary, and for some physicians, housecalls are the answer.
Take Robert Shannon, M.D., an internist in Bear Lake, Mich., who's been running his home-care practice for nearly a year. "Most office doctors are paying a lot of money to keep their offices open," said Shannon. For 20 years, he worked 12 - 14 hours a day. Now, he travels the back roads of this rural area for three to four hours each afternoon seeing patients. He said he enjoys practicing medicine again.
FP Jim Van Hare, M.D., of Kalamazoo, Mich., said he retired in May 2003 because "I basically couldn't make a living at it anymore." He cited malpractice insurance, high overhead and decreasing payments from third-party payers. "Trying to extract some profit was like trying to eat soup with my fingers," he said. He donated his office equipment to a church that was setting up an indigent clinic and kept his doctor's bag. "I now have a part-time home-visit practice of slightly over 100 patients," said Van Hare. "I love it, and my patients love it."
Practice particulars
 Squatting behind the trunk of her car, Andrea Brand, M.D., double-checks to make sure she has the medical instruments and paperwork she needs to see her next house-call patient. |
On Longboat Key, Brand said she can produce the same income seeing four to six patients a day as when her daily patient load topped 25. Brand runs a cash-only practice, although she does provide forms for patients to file their own insurance. "I have no accounts receivable; my patients are 100 percent payers," said Brand.
She had to opt out of Medicare because Medicare requires documentation that proves the necessity of a home visit. However, her Medicare-eligible patients that need additional tests, x-rays and procedures can have those billed by the entity that provides the services, said Brand.
She offers patients online consultations (perfect for tracking chronic illnesses and offered at a reduced fee) and secure online messaging. She also follows up every acute patient visit with a phone call within 48 hours, even the out-of-state visitors. "Most patients are shocked and say they've never had a doctor do that," said Brand.
"I also have no piles of paper," she said. When a lab report is faxed to her, Brand calls the patient with the results, even if it's 7 p.m. on Saturday. Brand cut nearly $25,000 in overhead when she dropped malpractice insurance (she meets Florida's criteria for doing so). "Going bare is scary, but I had no choice," said Brand, whose largest overhead expenses are her cell phone and advertising. "My idea is to simplify as much as possible," she said.
This house-call practice is growing as Brand targets the baby boomers that flock to the Florida coast. She has a full-time panel of patients numbering close to 125 and an equal number of temporary charts -- seasonal visitors who need a visit from the doctor when they're away from home. When she reaches 500 patients, she'll have met her goal.
Patient care a priority
Brand says her practice model is more about patient care than about making a profit. She doesn't see more than six patients a day, so she can spend more time -- 30 - 45 minutes -- with each patient.
"This is my personal answer to how health care can and should be delivered," said Brand. She has a cadre of physicians to refer to, including a surgeon, a rheumatologist, a gastroenterologist and a hospitalist. Her networking system has worked without a glitch. Patients in serious pain -- one with polymyalgia rheumatica and one with appendicitis -- were seen promptly by Brand (both on weekends) and then were put on proper medication or began surgery within hours.
"For getting immediate service, you can't beat this model," said Brand, who offers 24-hour care seven days a week. "I have 100 percent open access," she said. Brand doesn't do invasive procedures, stitching or injections. She carries everything she needs, including a portable EKG with a computerized readout, in the trunk of her convertible.
Queries coming in
This house-call doc has received e-mails from physicians around the country who are intrigued by her practice (read more about Brand's practice at http://www.DrBrand.medem.com).
New York: "I couldn't help but admire your newest enterprise. I've been looking for a way to get off the treadmill for some time."
Virginia: "I see your style of practice as a possible innovation to the traditional office-based setting."
Washington, D.C.: "Patients deserve more than a quick 'in and out' visit."
Illinois: "I'm very interested in an alternative practice situation. I sure have been feeling at odds lately, and I'm only out of residency since 2000."
As for Brand, she said she hasn't felt this good about doctoring for decades. Gone are the hassles -- bureaucratic and economic -- that created barriers between physician and patient. "I've found here what has been missing since my residency in the '70s. I feel like I'm a family doctor again."
To reach writer Sheri Porter, e-mail sporter@aafp.org.
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