Health Reform and a $10,000 Neighborly Visit

A friend of mine, a family physician, told me about a visit he had with his 93-year-old neighbor recently. This neighbor had known my friend for more than 20 years and was my friend’s patient.  His neighbor is a wonderful man and a big basketball fan. He grew up on a farm in northeast Iowa and remembers when his farm received electricity in the 1930s. He was the electric power supervisor for the district that included downtown Chicago in the 1960s and remembers the riots following the  1968 Democratic Convention there.

The neighbor had a heart valve procedure earlier this year and because of complications, had an evaluation with his cardiologist the day before my friend’s visit. At the cardiologist’s evaluation, the neighbor’s cardiac drug regime was significantly changed. My friend was called by the neighbor’s wife and asked to come over to her home when her husband, the neighbor, was having chest pressure and nausea. The wife had called First Nurse, a 24-hour nurse hotline, and was told to call for an ambulance. My friend, knowing the patient’s previous work up and having been told of the change in the cardiac meds, evaluated the neighbor. Based on the evaluation, my friend had the neighbor lowered his cardiac meds and by the next day, the neighbor was back to the baseline of his cardiac status.

I guarantee you that if the neighbor had been taken to the Emergency Room by ambulance, he would have been admitted to the hospital.  From my experience, I believe a ninety-three-year-old patient with a history of heart valve surgery who was experiencing chest pressure and nausea would always be admitted to the hospital by the emergency department physician.

The rule of thumb is that a physician clinic appointment costs $100; an Emergency Department visit costs $1,000, and a hospitalization costs $10,000. My friend, in evaluating his neighbor, saved Medicare $10,000.

As I said in a previous blog entry, my clinic is in a Medicare Accountable Care Organization (ACO), as well as a Blue Cross Blue Shield ACO. One of the key aspects regarding ACOs is the prevention of unnecessary Emergency Department visits and hospitalizations. In that blog entry, I promoted how the relationship between the family physician and patient would be invaluable in this ACO effort.

In my family medicine practice, I try my best to see my patients on the same day if they call in with an acute illness, which is what we call open access scheduling.  Recently, a patient called in with significant back pain and asked to be seen. I told my nurse to get her into the clinic that day. My nurse told a temporary receptionist who, unfortunately, did not know my policy and scheduled the patient for the next day. Sure enough, the patient went to the Emergency Room that night.

In the world of ACOs, my friend’s intervention was successful; my intervention failed.

At a meeting of different Medicare ACO representatives from across the state of Iowa, I heard that one Medicare ACO was considering using a company that creates a mobile physician service that allows for an enhanced home visit to sick elderly patients on weekends, thus a house call just like Marcus Welby MD, a popular television family physician in the 1960s and 70s.

In the world of higher and higher health care costs leading to higher health insurance premiums and the eventual inability of some individuals to afford health care coverage, I return to my roots believing that good primary care relationships and services are key to helping correct these problems.