Doctors Making House Calls? ER Direct Does 

The East Bay medical company is one of a small but growing number that is sending doctors to people's homes to provide a more affordable, convenient alternative to emergency-room visits.

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A few weeks ago, when John LeBourgeois' daughter was struck with symptoms of the flu, he figured he had 48 hours to act. If he got her Tamiflu within that time period, he knew she'd have a greater chance of fighting off the virus. But because LeBourgeois doesn't have health insurance, going to the doctor wasn't an option. He also wanted to avoid the emergency room — the last time he'd visited Alta Bates' with his daughter (to put three stitches in a cut finger), he wound up with a $1,400 bill. Instead, he called ER Direct, a house-call service in the East Bay, and within two hours, a physician assistant was at his daughter's bedside, had tested her positive for the flu, and administered Tamiflu. The total bill: $380.

"It's amazing that you can get a house call," said LeBourgeois, a contract software engineer who lives in Emeryville. "... I was really impressed with it. ... They've got some fairly sophisticated gear. I plan to use them for everything, for anything that's not life-threatening."

For people like LeBourgeois — i.e., those who make too much to qualify for Medicaid but can't afford private health insurance — urgent-care house-call services like ER Direct are an increasingly attractive way to get health care. Though once largely the domain of the wealthy, doctors who make house calls are now catering to the populace as a more affordable, convenient, and personable alternative to going to the emergency room.

As a longtime ER physician, Caesar Djavaherian saw first-hand the financial costs of emergency-room visits — both to the health-care system and to patients. "If you're less fortunate and you get sick, you can go to the ER and get all the care you want and then the government will pay for it," he said, referring to the law that requires hospitals to provide emergency care, regardless of a patient's ability to pay for it. "If you're young and unemployed or you're employed but have no insurance and you go to the emergency room, you're saddled with a bill for a couple thousand dollars for something that may not be that significant in the end. We could save those people with being saddled with a huge bill, and we could do it in a more convenient and cost-effective way."

So last January, Djavaherian, who lives in Oakland, launched ER Direct with his partner, physician assistant Sean Parkin, based in Berkeley. Along with another physician assistant, they treat any non-life-threatening urgent-care needs — from the flu to orthopedic injuries (back strains, sprained ankles), urinary tract infections, stomach pains, cuts, and bruises. So far, said Djavaherian, "The response has been pretty phenomenal."

For patients accustomed to voicemail and being put on hold, ER Direct is shockingly accessible. Sometimes the doctors answer the phone themselves. They get between two and eight calls a day, and end up seeing about three or four patients per day, Djavaherian said. (Since they do triage over the phone, it often negates the need for a visit.) They also make a point to see patients quickly. Djavaherian said that from the time they answer the phone to the time they're done with an appointment is usually two hours, and it's not unusual for him to see someone within an hour of the patient calling.

Djavaherian and his partner were partially inspired by the health-care system in Europe, where house calls are much more common. That's one reason why San Francisco physician John Horning decided to cater his urgent-care house-call practice, Urgent Med Housecalls, to foreign tourists. "Tourists are more comfortable with house calls — that's what they're used to," he said. But it was also a practical decision. "US insurance will pay for house calls, but they're not willing to pay a reasonable rate to sustain a living in the Bay Area. ... Foreign travel insurance companies know they're getting a good deal." His clients often come from local hotels, which refer guests to him, plus an airline and even a golf course.

But with European economies suffering setbacks, Horning has seen a decline in tourist patients, especially those coming from Spain. Now, he's seeing more tourists from Brazil, in addition to local attorneys, bankers, young people working in tech, and the elderly. He says his business has been steadily increasing since he started his practice in 2007, and he typically sees about three to four patients per day.

The number of doctors who make house calls in the Bay Area is still limited to just a handful, but it's slowly growing here — and nationwide. Djavaherian said the trend seems to be especially apparent in densely populated areas that are also popular with tourists, such as New York, Orlando, Miami, Chicago, and Los Angeles.

But it's the elderly home-care business that appears to be growing the most. According to Constance Row, the executive director of the American Academy of Home Care Physicians, a national home-care advocacy organization for elderly homebound patients, the number of physician house visits to elderly patients (both at home and assisted-living facilities) increased from 3.6 million in 2006 to 4.7 million in 2010. The reason for the increase, said Row, is that Medicare recognizes that "not only [is it] better care, but it also saves money."

Djavaherian and Horning didn't start their businesses with the intention of catering to the elderly, but they invariably end up treating those patients as well. Horning noted that Medicare increased its reimbursement rate for house calls in 1998, which helped drive the house-call business — but that things tapered off. "They were first excited about house calls and then they backed off," he said. "Once they realized it was gonna keep people alive longer, I'm sure they calculated the future costs."

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