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Doctors trading offices for house calls

Frustrated with the mainstream medical system, Dr. Robert Presse left his busy practice to become a country doctor.
Dr. Robert Prasse makes a house call to his patient Estelle Ashby in Spotsylvania, Va., on Tuesday.
Dr. Robert Prasse makes a house call to his patient Estelle Ashby in Spotsylvania, Va., on Tuesday.Nikki Kahn / The Washington Post
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Zooming down a woodsy, rural road outside Fredericksburg, physician Robert Prasse and his nurse were in something of an unusual medical pickle: They'd lost their patient.

"Weren't we watching the mileage?" Prasse asked, checking the odometer of his bright-blue Pontiac Vibe and realizing the number would not help them find the right house because they'd lost track of the number they'd started with.

"I said it's where there's a whole row of mailboxes!" Dianne Bryant said from the passenger's seat.

"There's a 'whole row of mailboxes' everywhere!' " Prasse said in a pseudo-exasperated tone, poking fun at Bryant and the boonie-fied backdrop of his medical practice.

They eventually found their patient. But in fact, the way isn't entirely clear for Prasse, 48, who two years ago bailed on the mainstream medical system and a busy practice on Route 3 in Orange County to become something both old-fashioned and profoundly contemporary: a country doctor.

With his black bag and his files in the Pontiac's back seat, Prasse spends his days seeing patients in their living rooms, offices or, if they are sick enough, in the hospital.

Although his new lifestyle is a throwback to the mid-20th century -- the last era in which house calls were common in the United States -- the disgust with today's insurance-driven health care paradigm that drove him to quit is right in line with the times. And his decision to bolt a conventional practice is becoming more common, as well.

The number of house calls made by doctors and nurses in the United States increased from 1.5 million in 2000 to more than 2 million last year, according to the American Academy of Home Care Physicians, citing Medicare data. The number of house-call doctors began climbing after 1998, when years of negotiations between Medicare and home health advocates ended with the federal government raising reimbursement rates by 50 percent.

Now, with physicians and patients increasingly frustrated by the system — particularly primary-care doctors, whose profit margins and time with patients are being squeezed ever tighter — more doctors are dropping out of insurance networks in general, according to the Center for Studying Health System Change. But the mechanics of the move are still in the infancy stage for such doctors as Prasse, who are trying to navigate Medicaid, get paid and provide competitive 21st-century care out of a trunk.

A complete doctor
But even though he wishes he had a portable electrocardiogram machine, Prasse said he feels something more advanced has returned to him since he hit the road: an ability to be a complete doctor again. "I've really begun to appreciate using your head," he said during a pit stop at a Spotsylvania Wawa gas station between patients.

His visits last at least a half-hour, and he can see such things as whether a couple's home life seems healthy or whether an elderly woman taking her own blood pressure has the right batteries for the machine she keeps by her rocking chair. Patients' refrigerator calendars show Prasse's appointments written in his handwriting.

Prasse, who was once a veterinarian in rural Kentucky, has a history of rejecting the conventional. He home-schools his children with his veterinarian wife at a horse farm they named Paradocs. His comical personality seems to help him as he feels his way into this unproven business venture, cracking jokes about his "children going hungry."

It also helps as he sees patients in Spotsylvania, Orange and Fauquier counties.

Wearing a tie that has a dollar-bill design as he made rounds one recent afternoon, Prasse joked about Bryant's size ("It's no problem for her to work out of the car since she can practically stand up in there"), swapped recipes for the dessert bananas foster with a patient and yukked about how the first time he went out with his wife-to-be, she had two other dates that night. "Once we went out, she really cut it down," he said, "and now she rarely goes out with other people."

Prasse charges each patient $1,000 annually for their general primary care and the right to call on him whenever they want. He has gone through the complicated paperwork process of completely signing out of Medicare and he doesn't participate in any insurance plans.

His fee doesn't include drugs or hospital bills, but many of his patients are retired or retired military, for whom those costs are covered.

But he is taking the road less traveled, even within this subset of refugee physicians.

Most doctors making a living off of house calls are working within the Medicare system, said Constance Row, executive director of the home care physicians group, based in Edgewood, Md.

Growing need for house calls
Medicare, however, pays for home visits only if the patient is considered too infirm to make it to a doctor's office. But as baby boomers begin to reach their sixties, some physicians believe there is a growing need for services besides dialing 911.

Physician Jeffrey Katz was sick of seeing nurse positions eliminated and medical decisions being made by business executives when he left his job as associate director of the emergency room at Baltimore's Union Memorial Hospital in 1999 to start Physicians' House Calls, which has six doctors who do nothing but visit the homebound in the Washington-Baltimore region.

"When you work for a system, everything is driven by the bottom line and investors, instead of being patient-centered," Katz said. "It's contrary to how doctors see themselves."

Despite the six years it took to hammer out a billing system and the continued complexity of dealing with hospitals with different computer systems, Katz said his life is "incredibly better" since he began making house calls.

Prasse said he opted out of Medicare because it restricts the type of patients that physicians can see and because the payments are low. Medicare reimbursements for house calls are $43 to $197.

Being in a large, rural area, he spends a lot of time on the road between patients and typically makes four or five stops a day. He has about 100 patients and is not sure whether he wants to take on much more than 200. He, however, still is hammering out when to charge extra fees.

"If there's a lot extra, I agree to charge people a little more. Like if someone is in the hospital 12 times in a month, I'm probably going to charge something extra," he said in his typical, Bill Murray-like deadpan. "It depends on how annoying they are."

Bill and Barb Pivarnik started seeing Prasse at the clinic near their home when they moved from Alexandria to Locust Grove in 2001, and they followed him when he began making house calls in July 2004. Between her diabetes, scarred lung and chronic pain disorder and his high blood pressure and arthritis, the couple have seen Prasse dozens of times at home and in the hospital. Last year, Barb Pivarnik said she had to nudge the doctor to accept an extra $140 in payment.

"He says: 'I don't want you to ever go without food or medications or anything to pay my bills. You tell me what you can afford because I don't want to deprive you of anything,' " said Pivarnik, 67, whose husband is 69. "I would have followed him to the ends of the earth."

Prasse said he has taken a pay cut, but he expects that will change eventually. He also plans to open an office so he can see patients who prefer that to a house call.

Some health care groups have expressed concern about physicians dropping out of insurance networks. Many of these doctors have begun opening "concierge" offices that can charge patients from a few-hundred dollars to $20,000 a year, said Alwyn Cassil, spokeswoman for the Center for Studying Health System Change.

"People with money can always get more stuff, so the worry about concierge medicine is that we already have a tiered medical system and this makes it worse," she said.

For Prasse's part, he is certain he is providing his patients with much better care than he used to. And he is happier, even if he works seven days a week and makes less money.

"This way, I don't feel like someone is taking advantage of me all the time," he said. "And I can control that patients no longer have to wait. I just don't have that impending feeling of doom anymore.