FUTURE HISTORY

Journal of Gerontology: MEDICAL SCIENCES Copyright 2001 by The Gerontological Society of America
2001, Vol. 56A, No. 10, M603–M608

The Future History of Home Care and Physician

House Calls in the United States
Bruce Leff1,2 and John R. Burton1

Schools of 1Medicine and 2Hygiene and Public Health, Johns Hopkins University, Baltimore, Maryland.

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Over the last 20 years, home care has experienced significant change. The home care industry developed into big
business and a number of innovative models of home care were developed and evaluated. Although physicians
perform many fewer house calls than a half-century ago, there has been a recent revival in house-call training,
education, and practice. In addition, telemedicine and other technologies hold great promise for the future of
home care. However, the future history of home care will depend mostly on the ability of various stakeholders in
the health care system to recognize the value of home care and develop and implement the appropriate incentives
to encourage its proper place in the U.S. health care system.

T HE image of a physician delivering care to a sick pa-

tient at home is one of the essential and enduring im-
ages in the collective consciousness of medicine. It is an im-
age that no doubt once inspired, and perhaps still inspires,
some to pursue a career in medicine. It is an image from
which the medical profession, as a whole, once drew inspi-
ration so as to say “Yes, this is what physicians are about.
Physicians take care of patients.” However, more recently,
when physicians tell colleagues that they make house calls,
they may be looked upon as Luddites. More surprising is the
reaction from patients in need of a house call when told they
can be seen in their home: “I didn’t know anyone did that
anymore.”
It is fascinating how quickly this transition occurred. A
mere 50 years ago, house calls accounted for 40% of all
physician-patient encounters (1). By 1980, house calls ac-
counted for only 0.6% of such encounters (2). The shift in
site of care delivery from the home to clinics and hospitals
was the result of an explosion of biomedical knowledge and
technology, increased access of patients to a growing medi-
cal system, the growth of third-party payers, and heightened
liability concerns (3). In this article, we will discuss recent
history and current developments in home care in the
United States and then speculate on the future history of
home care in America. Semantics in the area of home care
have always been a challenge. We will use the term “house
calls” to refer specifically to physician house calls and mod-
els of home care that include a substantial physician compo-
nent; otherwise, we will use the term “home care,” with the
understanding that there is often substantial overlap be-
tween the two areas.
HOME CARE TODAY
Over the last 20 or so years, several important story lines
have emerged in home care: the growth of the home care in-
dustry into big business; the development and study of a
bevy of home care models; the split between nurse and phy-
sician home care, with a general decline of involvement by
the latter; a recent revival in house call training for physi-
cians and the use of house calls in physician education; and
the development of technology for home care with a recent
explosion of interest in telemedicine. We will review briefly
each of these themes as a prelude to discussing the future
history of home care.
THE BUSINESS OF HOME CARE
Beginning in the late 1980s and continuing through much
of the 1990s, home care became big business. Through the
late 1990s, home care, though a relatively small portion of
Medicare’s budget overall, was the fastest growing compo-
nent of that budget, with expenditures increasing at a rate of
approximately 20% per year, from $3.5 billion in 1989 to
$19 billion by 1997 (4).
This increase in expenditures drew the attention of poli-
cymakers who were concerned that home care, originally
written into Medicare legislation as a supplement to acute
hospital care for patients with skilled nursing needs, was
fast becoming a de facto long-term care, nursing home-type
benefit for frail older persons with chronic illnesses (5). In
addition, this growth ultimately drew the attention of federal
regulators, who were concerned that the rapid increase in
home care expenditures, the increase in the number of home
health agencies entering the field, and significant geo-
graphic discrepancies in the use of the benefit were at least
the result of insufficient supervision of the benefit by physi-
cians, if not outright fraud and abuse.
The federal regulators responded with the Balanced Bud-
get Amendment (BBA) of 1997. The BBA established a
prospective payment reimbursement system to home health
agencies, reduced reimbursement for durable medical
equipment and certain therapeutic interventions (6), and re-
sulted in a marked decrease in Medicare expenditures for
home care that will be detailed later. In addition, the BBA
mandated the collection of data about home care patients
using the Outcomes and Assessment Information Set (OA-
SIS). Initially developed as a means to provide a picture of
the home care patient’s situation and improve the quality of
home care, OASIS is also being used to determine the pro-

M603
M604 LEFF AND BURTON
spective payment schedules for home care patients. There
have been problems with OASIS related to privacy, costs,
and data management, but use of OASIS has been reported
to be associated with improved health status outcomes (7).
However, OASIS may be limited in that it is not a compre-
hensive assessment tool, such as the Minimum Data Set for
Home Care, and it lacks the ability to track patients across
various sites of care (8,9).
HOME CARE RESEARCH—DEVELOPMENT OF HOME
CARE MODELS
As home care activity expanded in the nonacademic
world, home care established a modest academic research
base in the creation, evaluation, and limited dissemination
of various models of home care. Hundreds of studies have
been reported and have been summarized in the literature
(10–13). This research has been difficult and criticized for a
number of reasons. Many studies lacked methodological so-
phistication. Studies described and often grouped together
under the rubric of “home care” or “community-based long
term-care” were, in fact, describing many different types of
interventions, some social, others medical, and still others
combining medical and social approaches. In addition, the
studies targeted disparate populations of patients and exam-
ined a variety of outcome measures (14,15).
Despite such difficulties, recent home care research has
demonstrated clearly the effectiveness of several types of
home care models. We will highlight meta-analytic data as
well as data related to specific home care models, such as
interdisciplinary home care, home geriatric assessment,
postacute hospital home-based case management strategies,
including discharge planning, and home hospital.
Meta-analysis of the effects of home care on mortality
and nursing home placement demonstrated a small, benefi-
cial effect of home care on mortality that fell short of statis-
tical significance and stronger evidence of the ability of
home care to reduce nursing home placement (16). Another
meta-analysis found a small to moderate positive impact of
home care in reducing hospital days, ranging from 2.5 to 6
days per 180 days of follow-up (17).
Interdisciplinary home care programs integrate medical
and social supportive services focusing on the care of
chronically disabled older persons. These programs involve
physician visits and an interdisciplinary team approach,
which often includes regular team meetings to discuss pa-
tients and develop mutually conceived management strate-
gies. Randomized controlled trials of these programs sug-
gest that they can be cost effective and associated with
greater caregiver satisfaction, fewer acute hospital readmis-
sions, and, in some cases, fewer nursing home days (18–
21). Home geriatric assessment in a relatively unselected
population has been demonstrated to delay the development
of disability and reduce permanent nursing home stays
among elderly people living in the community (22). In pa-
tients with risk factors for functional decline, home geriatric
assessment has been demonstrated to identify important
new or worsening medical problems (23). Postacute hospi-
tal case management schemes, especially those that focus
on illnesses such as congestive heart failure, which are asso-
ciated with a high rate of acute hospital readmission, have
been well studied and widely replicated throughout the
United States. The intervention in such studies is nurse-
directed with physician back-up and focuses on patient educa-
tion about the illness, dietary counseling, medication man-
agement, and social services consultation. These interven-
tions result in a reduced rate of acute hospital readmissions,
fewer hospital days, and improved quality of life (24,25). In
randomized controlled studies, comprehensive discharge
planning, begun in hospital by advanced practice nurses, and
home follow-up of hospitalized older persons with a variety
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of illness have demonstrated fewer readmissions and fewer
hospital days for those patients for whom such planning was
undertaken (26). In addition, home hospital programs have
been developed. These programs are designed to provide
acute care in the home as a substitute for hospitalization by
bringing critical elements of the acute hospital to the home:
physician visits; nursing visits; intravenous infusions; dura-
ble medical equipment; basic laboratory testing; and diag-
nostics, such as echocardiogram and basic radiograph. Early
studies suggest that such programs are feasible, clinically
sound, cost effective, satisfactory to patients and caregivers,
and associated with lower rates of hospital-associated com-
plications, such as confusion (27–29).
On the whole, this body of research suggests the follow-
ing: home care can be effective when properly structured;
targeting home care interventions to the appropriate patient
population is critical; innovative models require a flexible
approach; there is value in physician involvement in home
care; and, in a health care system that is becoming increas-
ingly fragmented, home care can help bridge gaps in the
continuum of care.
WHO DOES HOME CARE?
Although physicians romanticize the house call, it has
been nurses, therapists, and home health aides who have
been doing the work of home care. At national meetings of
home care professionals, audiences have been reported to
break into uproarious laughter at the mention of physician
involvement in home care, and the available data suggest
that their sense of humor is well placed. Physicians, by and
large, have stopped making house calls. In an analysis of
Medicare claims data in 1997, Meyer (30) estimated that ap-
proximately 727,000 physician house calls were made to
Medicare beneficiaries nationwide in 1993. This corre-
sponded to less than 1% of Medicare beneficiaries receiving
a house call. Patients who received the house calls were
very sick and near death. The reasons cited for the lack of
physician involvement and leadership in house call medical
practice have been reviewed previously (31,32) and include
lack of faculty skilled in house call medicine, inadequate re-
imbursement for physician visits, the inconvenience and
time inefficiency of a house call, concerns about quality of
care delivered in the home, and liability concerns. To a
large extent, liability concerns have been debunked (33).
The Center for Medicare and Medicaid Services (CMS; Health
Care Financing Administration) has made extensive revi-
sions to rules for home visits, including significant changes
in reimbursement to reflect better, although not perfectly,
the nature of home care medicine (34). In addition, recently
published federal regulations will allow physicians to make
 HOME CARE AND PHYSICIAN HOUSE CALLS
referrals to home health agencies with which they have a fi-
nancial relationship and removed a $25,000 cap for com-
pensation for physician medical direction of a home health
agency. This cap had often precluded full- or even half-time
medical direction for a home health agency (35).
A lack of physician education has also been cited as a
barrier to physician participation in home care medicine. A
survey of U.S. medical schools in the early 1990s found that
only half devoted even a single hour to home care in the
course of a 4-year curriculum and only 3 of 123 schools re-
quired five or more home visits during the clinical years
(36). More recently, however, this too has begun to change.
When the John A. Hartford Foundation issued a request for
proposals to develop curricula in home care for medical stu-
dents, over half of U.S. medical schools applied and ten
schools received funding. In addition, a certification exami-
nation in home care medicine has been created to respond to
the growth in home care and the need for physician knowl-
edge and involvement in this area (37). Such an examina-
tion should legitimize further physician involvement in
house call medicine.
TECHNOLOGY
Technological advances have also facilitated the expan-
sion of home care. Intravenous infusion technology, radiog-
raphy, ultrasound, feeding pumps, ventilators, pulse oxi-
meters, hand-held blood analysis devices, and other
technologically advanced devices, once found only in the
hospital, are now relatively commonplace in the home and
expand the capabilities of home care and the ability of the
house call physician to provide quality care in the home.
In addition to technology in the form of devices such as
infusion therapy, the greatest technological advances that
may influence the future of home care are just beginning to
be seen in the area of telemedicine (38). The definition of
telemedicine is fairly broad but includes programmed tele-
communication; interactive videos; programmed computer
guides to diagnosis, treatment, and prevention; e-mail ac-
cess to the physician; virtual offices at home with video-
phones for the interview; examination and testing of the pa-
tient; and others (39). Such telemedical services have been
evaluated and more are being developed and tested. Studies
suggest that telemedicine in various forms can improve dia-
betic management (40), provide access to specialists for
nursing home patients with dementia (41), assist in the eval-
uation and treatment of pressure sores (42), and improve
blood pressure control (43). The Kaiser Permanente tele-
medicine home health research project evaluated the use of
remote video technology in home health care for patients
with chronic medical illnesses. The technology was effec-
tive, well received by patients, and demonstrated a potential
for cost savings (44). Data suggest that a substantial propor-
tion of home nursing visits would be suitable for telemedi-
cine (45,46). And, although some suggest that telemedicine
may change the physician-patient relationship because of a
lack of touch and privacy, others suggest that the “advent of
telemedicine has provided the opportunity to develop a hy-
brid home care delivery system that incorporates the best
aspects of the old and new home health care models” (47).
Aside from the glitzy technology side of telemedicine, one
M605
of the most interesting potential uses of it may be to coordi-
nate, through Internet-based information portals, the variety
of social and medical services required to properly care for
frail homebound older persons. Such models are being de-
veloped (L.C. Burton, personal communication, January 9,
2001).
HOME CARE—FUTURE HISTORY
What will be the future history of home care? The home
care industry has grown and developed (48), as have several
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effective models of home care. Reimbursement for physi-
cian home visits has increased, and some restrictive regula-
tions concerning physician relationships with home health
agencies are easing. The education of medical students and
residents in house calls and the development of faculty to
develop further the academic base of home care and teach it
are on the rise. Technology to facilitate delivery of quality
home care medicine has improved and telemedicine, though
not a panacea for home care (or geriatrics) (49), seems
ready to explode (50).
That these factors augur well for home care is clear.
However, a utopian future for home care is by no means as-
sured. In fact, it may not even be an even money bet. The
field is full of romantics (51,52). However, sentiment alone
will change little. As a keen observer of the home care field
recently told an audience of the home care faithful “it’s the
incentives, stupid. That is what produces change” (53). That
is, getting the health care system to simply do the right thing
because in the opinion of patients and certain physicians it
is the right thing to do is insufficient incentive for the health
care system to change. Home care will succeed, as will any
other element of the health care system, when appropriate
incentives exist so that it makes sense to provide it (see Ta-
ble 1).
It may be argued that the following trends may or will
provide positive incentives for the future development of
home care: the sociodemographics of the aging population;
greater awareness of home care services and activism by
home care patients and their families and caregivers; tech-
nological advances to facilitate home care; increased man-
aged care; shortened hospital stays; a decline in nursing
home use and growth of assisted-living facilities and con-
tinuing-care retirement communities; and a strong prefer-
ence of elderly persons for home care rather than institu-
tional care (54). However, in an environment where home
care policy is mired in budget economics and health care
politics rather than in a debate about the type of health care
Americans would like to receive in their old age, economic
incentives may be the most powerful. Witness the effect
wrought by the changes in home care reimbursements under
the BBA on the provision of home care. The amendment au-
thorized the CMS to extend prospective payment to home
care agencies and curtailed reimbursement. Two thousand
home health agencies went out of business, and the length
of stay and average number of visits per episode of care de-
creased markedly. Medicare spending on home health care
dropped 45% from 1997 to 1999, and the number of benefi-
ciaries receiving home health services dropped from 3.6 to
3.0 million in the same time frame. Given those incentives,
the director of the Center for Medicare Advocacy was quoted
M606 LEFF AND BURTON

Table 1. Potential Advantages and Disadvantages of Home Care by Stakeholder

Stakeholder Potential Advantages Potential Disadvantages
Patient Convenient, humane care Quality concerns
Caregiver satisfaction
Access to care
Better care—identification of important problems not found in
office visits
Reduced hospital and nursing home use
HCFA Assures access to care for frail older persons Fraud and abuse
Quality concerns

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Private physician with house call
practice
Managed care organization
medical director or executive
Hospital CEO
Geriatric department or division
director
Trainees
Potential for home care to morph into long-term care
benefit
High costs, if widely used
Markedly reduces pratice overhead costs Logistics and efficiency
Job satisfaction Reimbursement improved, but still insufficient
Scorn of colleagues
Favorable public relations Attracts frail older persons for whom appropriate case-mix
Development of geriatrics programs adjustments don’t yet exist
Reduces acute hospital utilization Unfavorable public relations
Increases market share
Fills gaps in continuum of care, which facilitates early hospital
discharge
Potential source for philanthropy
Favorable public relations Need to provide funds to support administrative aspects of
Development of geriatrics programs program
Increases market share
Fills gaps in continuum of care, which facilitates early hospital
discharge
Potential source for philanthropy
Favorable public relations Will require funds for administrative support
Development of faculty Need to protect faculty time for education and research
Brings admissions to hospital
Potential grant revenue
Potential source for philanthropy
Excellent training for fellows
Learn geriatrics Unfavorable attitudes towards elderly persons if not well-
Learn holistic approach to medicine mentored
Improves patient education and counseling skills
Improves clinical skills
Develops meaningful relationships with patients and caregivers

Note: HCFA  Health Care Financing Administration.

as saying that home health agencies “do not want to keep
patients who have long-term needs” (55). Pernicious incen-
tives indeed!
However, there is at least one example in the health care
system today where home care flourishes because eco-
nomic, political, and social incentives are well aligned. It is
the Program of All Inclusive Care for the Elderly (PACE),
in which community-dwelling, nursing home–eligible pa-
tients who qualify for both Medicare and Medicaid may be
cared for in a fully capitated model. A PACE site, which op-
erates using a day health center model, receives the Medi-
care and Medicaid capitation and is at full financial risk for
all patient care, including long-term care. Being at financial
risk for long-term care is a critical bit of incentive because
as these frail patients become increasingly frail, the eco-
nomic incentive for PACE and the desire of the patient to
stay at home, in lieu of acute hospital care or a long-term
care facility, are perfectly matched. PACE programs are
heavy users of home care services. PACE programs can be
proactive and don’t need to wait for a skilled need to appear
before implementing home care. PACE has been successful
at helping patients avoid hospital admission and nursing
homes (56). Unfortunately, PACE programs care for rela-
tively few persons across the country and there are substan-
tial obstacles to expanding the model to the millions who
could benefit from it (57).
Medicare managed care is another setting where incen-
tives, at least in theory, are reasonably well aligned toward
home care. A Medicare managed care plan receives a capi-
tation from the CMS based on a person’s age, sex, income,
type of residence (nursing home or independent dwelling),
and geographic location. In such a capitated system, it
might be reasonable to predict that the Medicare managed
care plan would utilize home care services to help prevent
hospitalizations among their frail and often high-cost bene-
ficiaries. Unfortunately, research suggests poorer outcomes
for home care in managed care compared with fee-for-ser-
vice care (58). Some of the home care models highlighted
previously, such as interdisciplinary home care and home
hospital, would be advantageous for a Medicare managed
care plan. However, the plans haven’t adopted these models
on a large scale. The reasons for this are complex; however,
Boult and colleagues (59) suggest that economic and orga-
nizational forces mitigate against their adoption. Such
 HOME CARE AND PHYSICIAN HOUSE CALLS
forces include the inability of Medicare to appropriately
risk-adjust capitation payments for the frail elderly popula-
tion. Thus, implementing systems that attract chronically ill
older persons may be ill advised from an economic view-
point; many plans rely instead on “favorable selection” of
enrollees. In addition, the models of home care themselves
are insufficient; they cannot be pulled off a shelf. To imple-
ment such models and realize their full potential, Medicare
managed care plans will need to integrate such programs
into coordinated systems of care, develop comprehensive
data management systems, train personnel in geriatrics, and
develop teams of providers who can work across the contin-
uum to provide care to frail older persons.
In the absence of widespread dissemination of a PACE
model, the ability or inclination of Medicare managed care
plans to implement home care programs on a large scale, or
the adoption of a new national heath care policy that values
home care, the future of home care may depend mostly on
the ability of local health care entities in the fee-for-service
sector, such as physician groups, hospitals, and academic
centers, to recognize and adapt to the incentives that exist
presently in the system. Physician practices devoted to
home care that eliminate the office-based component of
practice are increasing in number because they recognize
that in doing so they can reduce substantially office over-
head expenses (G. Taler and K. E. DeJonge, personal com-
munication, June 2000). Hospitals and academic centers
may expand their home care systems because they recog-
nize that in order to capture the necessary market share to
stay solvent they need a home care service as much as they
need a cardiac catheterization lab; that they need to develop
house call physicians and faculty as much as they need an
interventional cardiologist. This brand of hospital-based
home care can assure a hospital of a substantial admission
stream of patients as it fills gaps in the continuum of care. In
addition, the ability of such programs to extend home care
to the growing assisted-living environment may, regulations
permitting, provide economies favorable to such programs.
Last, these centers may recognize that home care programs
are excellent sources of favorable press and philanthropy.
CONCLUSIONS
That home care will survive into the future is a certainty.
What is less certain is the nature of the home care system
that will evolve. It will depend on the ability of Americans
to recognize and fight for a health care system that reflects
their purported values. If Americans truly value widespread
access to high-quality humane care that meets their needs,
delivered on a personal and humane basis, in whatever
venue is most appropriate, then the correct incentives can be
built into the system to ensure the proper development of
home care and other areas of the medical system. If such
values are not widely held or cannot be translated into fa-
vorable policy, then the outcome for home care and house
calls is bleak. In such a scenario, home care will become in-
creasingly fragmented, medicalized, available only to those
with the means to pay, and informal; that is, the responsibil-
ity for providing home care will fall increasingly on family
caregivers.
M607
One additional item deserves mention. A bit of disso-
nance that has always been troubling is that unlike other
forms of primary care, home care has always had to prove
its “worth.” Ambulatory or nursing home visits (required at
least every 60 days by law) have never had to prove their
value in quite the same way. Home care can provide access
to care for those whose access to care would otherwise
come only by an ambulance ride to the emergency room or
not at all. People die for lack of such access to care (60). If
nothing else, home care can provide that (61). As we con-
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template incentives to build the home care systems of the
future, we should try not to forget that.
Acknowledgments
The authors thank Dr. Knight Steel for his thoughtful comments and
suggestions.
Address correspondence to Bruce Leff, MD, Associate Professor of
Medicine, Johns Hopkins Geriatrics Center, Johns Hopkins University
School of Medicine, 5505 Hopkins Bayview Circle, Baltimore, MD 21224.
E-mail: bleff@jhmi.edu
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Received April 9, 2001
Accepted April 30, 2001
Decision Editor: John E. Morley, MB, BCh