HEALTH CARE ON WHEELS

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OFFICE OF INSPECTOR GENERAL 
OFFICE OF EVALUATION AND INSPECTIONS 
JULY 1990  HEALTH CARE ON WHEELS

Richard P. Kusserow 
INSPECTOR GENERAL 
OEI-05-89-01332 
JULY 1990  EXECUTIVE SUMMARY 
PURPOSE 
This report provides a description of health care providers that serve medically 
underserved and uninsured populations in public settings
, or that make physician
housecalls. 
BACKGROUND 
This is one in a series of reports on mobile health servces. 
Two other reports provide:
(1) a national overview of the types and prevalence of mobile health servces
, the quality
of these servces, and the degree of regulation; and (2) a description of the prevalence 
conduct and regulation of public cholesterol screening. 
We conducted these studies in response to a request by the Chairman of the House 
Subcommttee on Regulation and Business Opportunities. The studies provide
information concerning mobile health services: servces offered outside the traditional 
settings of a hospital, clinic, or physician s office. 
While gathering background information
, we heard of a few providers attempting to
improve access to health care by taking their servces to patients
, rather than waiting for
patients to come to them. We decided that these 
highly innovative servces deserved
closer look. 
We found in our discussions with these providers that
, while the profit motive was clearly
at play in some instances, there was also a strong undercurrent of altruism. 
They believe
not only that mobile services such as theirs are viable
, but that they constitute the only
way that some people will receive any health care at all. They are 
commtted to 
providing high-quality care, and they also believe that mobile servces like theirs can save 
health care costs, either by preventing or postponing institutional care or by forestalling 
the development of serious health problems. 
METHODOLOGY 
We visited a unique unit run by the National Center for 
Health Statistics. There we
learned about the special characteristics of a mobile operation. We conducted 
interviews 
with 30 individuals, including Federal officials, the Office of Technology Assessment
(OTA), and 19 providers of mobile health servces. We 
also visited three of the housecall
providers to observe the delivery of servces.  FINDINGS 
. A 
few highly innovative providers, using vans, are going to a wide variety of
public settings to deliver health care services to medically underserved and 
uninsured groups.

Some providers, including for-profit companies and non-
profit hospitals
, are
making physician house calls. Most
, though not all, are delivering primary care 
to the elderly.

Few of the mobile health servces described in this report are subject to special 
State or Federal regulations which address their mobile nature. 
Providers say that the greatest benefit of their mobile servces is that they 
reach people who would not otherwse seek or receive health care. 
Providers believe that, by focusing heavily on prevention, their mobile health
servces wil lead to health 
care cost savings in the long run. 
Despite the growing interest in providing mobile health servces
, lack of public
recognition and problems related to financing and Medicare reimbursement 
may limit their future growth.

RECOMMENDATIONS

ublic Health Servce (PHS) should study 
The  the costs and benefits of mobile 
van and
physician housecalls. Particular consideration should be given to supporting 
demonstrations and experimental projects. These should be evaluated with respect to: 
(1) access to care; (2) the quality of servces; (3) the impact of servces

, including the

question of disease prevention; and (4) the costs of servce delivery. 
In implementing the new physician payment system under Medicare
, the Health Care
Financing Administration (HCFA) should carefully consider the appropriate weight for 
payments for physician primary and urgent care housecalls. 
COMMENTS 
The PHS generally supports our recommendation to study the costs and benefits of 
mobile vans and physician housecalls. However
, instead of initiating demonstration
projects, they prefer, through the Agency for Health Care Policy and Research
, to solicit
applications from the health care research community to study 
how mobile health 
servces delivery can impact access on health care, particularily for disadvantaged and
rural populations. 
The HCFA concurs with OUf recommendation and will evaluate medicare reimbursement 
for physician house calls under the new physician payment system. 
We wish to thank those in HCFA and PHS who commented on the report. 
We have
made technical changes based on PHS' 
s comments. A complete text of their comments
can be found in Appendix C.  ....................... 
.......... ........................................... ........... .................................... ................. ........................... 
.......................... ..................... ........ ...... 
TABLE OF CONTENTS 
EXECUTIVE SUMMARY 
INTRODUCTION........................................... ..... ............................... 

......... ................. 1

Purpose.................................................. ......... 

....................... ........... ................. 1

Background.......... .............................. 

........ .................. ................ ............ .......... 1

Methodology...................................................................................................... 2

FINDINGS. ....... 

........ ........... .......... ................. 3

A few highly innovative providers, using vans, are going to a wide
variety of public settings to deliver health care services to medically 
underserved and uninsured groups 
................................................................ 3

Some providers, including for-profit companies and non-
profit
hospitals, are making physician housecalls. Most
, though not all
are delivering primary care to the elderly................................................. 5 
Few of the mobile health services described in this report are

subject to special State or Federal regulations which address

their mobile nature ...... 
............................................. 10

Providers say that the greatest benefit of their mobile services is 
that they reach people who would not otherwise seek or receive 
health care.......................................................................... .............................. 10 
Providers believe that
, by focusing heavily on prevention
, their

mobile services wil lead to health care cost savings in the

long run ... 

Despite the growing interest in providing mobile health services,

lack of public recognition and problems related to financing and

Medicare reimbursement may limit their future growth 

RECOMMENDATIONS .................. .......... ........ .... 

............................................... ...... 14 
APPENDICES 
APPENDIX A: List of Providers Contacted ............................................... 

A-1  .......................................................... 
APPENDIX B: Typical Operating Characteristics of Mobile 
Health Services in Public Settings 
B-1 
APPENDIX C: Health Care Financing Administration and
the Public Health Service Comments 
..................................................... C
 INTRODUCTION

PURPOSE 
This report provides a description of health care providers that serve medically 
underserved and uninsured populations in public settings
, or that make physician
house calls. 
BACKGROUND 
This is one in a series of reports on mobile health servces. 
It constitutes a preliminary
look at these tyes of services. Two other reports provide: (1) a national 
overvew of the 
tyes and prevalence of mobile health servces, the quality of these servces
, and the
degree of regulation; and (2) a description of the prevalence
, conduct and regulation of
public cholesterol screening.

This study was conducted in response: ) a request by the Chairman of the House 
Subcommttee on Regulation and Business Opportunities
, to provide information
concerning mobile health services: services offered outside the traditional settings of a 
hospital, clinic, or physician s office. 
While gathering background information
, we heard of a few providers attempting to
improve access to health care by taking their servces to patients
, rather than waiting for
patients to come to them. We decided that these highly innovative servces deserved a 
closer look. 
We found in our discussions with these providers that
, while the profit motive was clearly
at play in some instances, there was also a strong undercurrent of altruism. 
They believe
not only that mobile services such as theirs are viable
, but that they constitute the only
way that some people wil receive any health care at all. They express a strong 
commtment to providing high-
quality care, despite the difficulties inherent in a mobile
operation. They also believe that mobile servces like theirs can save health care costs 
either by preventing or postponing institutional care or by forestalling the development 
of serious health problems. 
Federal funding of mobile services such as these is minimal at present. 
The PHS
provides grants to approximately 550 community and migrant health centers and other 
not-for-profit agencies for services to the medically underserved. 
Include in this figure
are 109 Health Care for the Homeless programs created by the Stewart B. McKinney 
Homeless Assistance Act of 1987. While some grantees have developed mobile 
programs which use vans and use these funds for the salaries of staff who work in them 
PHS appears to have awarded few grants for the actual development of programs using 
vans. With regard to house calls
, Medicare covers a variety of servces provided 
in the
home, over and above the home health care benefit. In 1987
, Part B reimbursement for
these servces totalled about $1.1 bilion
, just under 4 percent of all Part B servces. 
How
ever, it is not possible to tell from the data what portion of these 
servces was provided by 
physicians.  METHODOLOGY 
During pre-inspection, we visited a unique mobile unit run by the National Center for 
Health Statistics, which gathers data on the health status of Americans through direct 
physical examination. There we learned first-hand about the special logistical 
characteristics and requirements of a mobile operation. 
Other information was gathered through interviews 
with 30 individuals, including 
officials in PHS, the OTA, and 19 providers of mobile health servces. We also visited 
three of the housecall providers, to observe the delivery of servces and talk with patients 
and staff. 
Appendix A contains a list of the providers contacted in the inspection.  FINDINGS 
A Few Highly Innovative Providers
, Using  ns, Are Going To A Wide  riety Of Public
Settings To Deliver Health Care Services To Medically Under served And 
Uninsured Groups. 
Some providers across the country are using specially equipped vehicles
, which they
commonly call "vans " to provide access to health care to people who cannot or will not 
come to traditional stationary facilities for help. Some vans 
visit the homeless at shelters 
and transitional hotels, food pantries, parks, and "streets under bridges" in cities. Others 
serve migrant workers at the camps where they live during the growing season. 
Stil
others go to people in rural areas, low income housing units, churches, and "crossroads 
anywhere there are people. " Regardless of the tye of provider or target population
respondents seem to share this philosophy: "
If they don t come to us, boy, we go to
them!" 
The providers we contacted, most of them not-for-profit, include community and migrant
health centers, hospitals, county health departments, a social servce agency, and a
private company. Most have used vans for less than 2 years, although one has served
runaway teens with a van for 
17 years. 
Most vans operate a few days a week
, visiting sites on a scheduled basis. Outreach 
workers publicize the van extensively and set .
uP appointments, often with the help of
staff from other community agencies. The servce 
area is usually the county or city where
the provider is based, although one doctor described her servce area as the "
boondocks
of Montana " and a migrant program covers a 72 
000 square mile area with a target 
population of 95 000. 
Most providers use vans to extend their servces to patients who cannot or will not come 
to their permanent facilities for help: "
The van extended the walls of the hospital to the
edge of the county. " Some are also beginning to use their vans in "off" hours on a pilot
basis to reach different patient populations. For example
, a program which serves
homeless children has just begun to serve foster children as well. 
Another program that
serves runaway teens takes their van to elementary schools during the day, to conduct a 
6-week drug education program for students. 
Other providers are using vans to experiment with new approaches to delivering care. 
midwestem university is developing a van program to reach pregnant women in the inner 
city to try to reduce infant mortality. In the east
, a private company visits a few com
munities on a scheduled basis to dispense methadone to heroine addicts from a van. The 
idea of using a van arose as an alternative to building a stationary clinic
, which com
munity residents opposed. The director says that the van not only eliminates the need for
patients to travel far to receive their dosage
, but also frees them from drug dealers or ad
dicts who may prey on them at a stationary site.  Most program prr' ' ide some sort of health assessment and triage. 
But almost everyhere
the ke services are screening and health education
, both focused heavily on diease
prevention. 
Patients seen by these mobile programs reportedly present myriad health problems
, most
of them chronic rather than acute. Elderly patients in rural areas often suffer from heart 
disease, diabetes, or high blood pressure. Migrant workers and the homeless present a 
variety of maladies including wounds and abrasions
, foot and skin infections, respiratory
and gastrointestinal problems, and malnutrition. Homeless children frequently suffer 
from chronic ear infections. Many patients
, adults and children alike
, afe not immunized
or are underimmunized, and subject to a host of diseases. 
Almost all programs provide screening of some sort: to 
detect high blood pressure
hearing and vision problems, diabetes, cholesterol, colo-rectal cancer, cervcal cancer
(Pap smears), dental problems, or even sexually transmitted diseases or human 
immunodeficiency virus (HIV). Dipstick 
urinalysis (done on board) and blood work-ups
are common. Samples are analyzed at a hospital or stationary lab. 
Many programs perform a health assessment
, such as a nursing physical, to evaluate
acute or chronic ilness. Some provide OB-GYN exams, pregnancy tests and well-baby
care, and others provide dental exams and treatment. Many 
also provide triage or
treatment in some form; the most sophisticated of these programs is described by its 
administrator as "a pediatric clinic on wheels." Most programs dispense a 
few simple
over-the-counter medications such as aspirin or antacids
, and provide patients with
prescriptions for other medications. 
Immunization of both adults and children is a key servce 
of many programs. Many
respondents stressed the importance of immunization in terms of preventing 
disease. 
No matter what the mi of services, respondents almost everyhere 
say that "teaching is
probably our biggest thing." Respondents say that patient education is important 
because "it's preventive " and helps patients avoid more serious problems in the future: 
We want to get people sooner rather than later.
" Staff discuss diagnoses and prescribed
regimens with patients, hand out printed information, and teach about hygiene, diet and
nutrition, or " " They talk to admitted drug users about drug treatment and "
safe sex. the
needle issue." They may distribute toothbrushes and toothpaste
, combs, or vitamins in
conjunction with their teaching. 
A ke component of 
every program is refe"al, not only to follow-up medical care but 
also to
non-medical support services. 
Respondents say that while most of their patients do not need hospitalization, many do 
need follow-up medical care of some kind. Providers have developed networks with 
other health care providers and social servce agencies to ensure that their patients get 
the referrals they need. Where possible
, staff refer patients to the provider s stationary
facility. But they also refer them to other providers such as physician 
or city and county
clinics. They try to ensure follow-up by making appointments for patients
, recontacting  them to remid them of appointments, and giving out bus tokens, tax vouchers
actually takng patients to appointments. One program accepts up to three  , or
collect calls a 
month from a patient who wants to ask questions or discuss problems. 
Many patients, particularly the homeless
, are also referred to support servces which can
help them get back on their feet: 
housing, employment assistance and mental health 
servces, for example. Providers have solid ties with other community agencies; some 
respondents commented to the effect that their mobile program is "
a community effort
from beginnng to end. 
" Sometimes there are formal contracts and written procedures.
For example, a university program to combat infant mortality has written memorandums 
of agreement with hospitals and community agencies that will serve as official 
co-sponsors of the van program. 
For the most part, however, providers say that they have
had informal but close working relationships with other agencies for years
, and "we know 
our system pretty well." 
Appendix B contains a description of other 
characteristics of these

tyical operating 
providers.

It is expensive to establish mobile health programs. 
Start-up funds usually came from local 
sources, including private donations. In some program, Federal 
funding covers some of the
operational costs, usually a portion 
of staff salaries. 
Discussions revealed that it can cost $100 
000 or more to purchase and equip a van
, and

prices are increasing. One respondent said that their van had cost $47

00 in 
1982; when
it was refurbished in 1987, she learned that the same van
, bought new, would cost three

times that much. Maintenance is also 
expensive. The director of the program which has

used vans for 17 years reports that maintenance costs 
between $2 00 and $5 00 a year
depending on the age of the van. To control costs
, respondents emphasize that it is
important to find someone who "
is in love with the van" and will take meticulous care of 
it. "You ve got to be on top of it. 
In starting up their programs
, most providers bought and retrofitted vehicles with funds 
from local sources: agency grants, hospitals, universities, city, State or county funds, or
corporate or foundation grants - in one case
, the local foundation of the wife of a U.
Senator. A few vehicles were donated to providers - by local health departments
rancher, and even a famous singer-songwiter.  , a
Only one provider in our sample had
received Federal funding to purchase a vehicle. Operating funds also frequently come 
from local sources, although community and migrant health centers which receive funds 
sometimes use them to pay the salaries of staff who work 
from  PHS  in a van. A few 
programs receive some Medicaid reimbursement. 
Most of these progfam provide services free of charge or for a nominal fee. 
In Arzona
a doctor reported that patients have paid him in everyhing from pocket change to tortil
las.  , "  , " 
Some Providers, Including Both For-rroJlt Companies And Not-
For-Profit Hospital
Makng Physician HOUsecalls. Most, Though Not All , Are
Elderly.  , Are Delivering Primar Care To The
One private company has made physician housecails for 
 year, providing primary care to
the elderly. 
A company in Kentucky provides physician house 
calls in three cities under a franchise 
arrangement. Its founder and president 
says that a franchise is easy to administer as well
as a good tool to ensure quality control. 
The president has extensive experience in home health care and established her servce 
to provide access to care to the homebound elderly, a population which
special problems for physicians: " , she says, poses
Every doctor has patients who are homebound
been the doctor s dilemma for some time how to accommodate those patients.  , and it 
Every 
home health agency needs a company like mine to fil the gap. 
The servce operates 12 hours a day, 7 days a week
, with a 24-hour anwering servce.
Eighty-five percent of the patients are Medicare recipients; one-third of these Medicare 
patients also receive Medicaid. 
Most patients are referred by their primary care 
physicians. Contracted physicians

usually family practitioners and internists
, use their own cars to visit homes
, carryng only
a bag. Each physician visits between 8 and 10 patients a 
day, providing primary care.
clinical laboratory and a radiology service that also make home visits provide back-up, 
furnishing test results the day of
, or the day after, a visit. The president says that this 
arrangement has worked very well. 
Physicians do not carry drugs
, but call in 
prescriptions to pharmacies that deliver. At the end of each visit
, the physician
completes a chart, as would be done in a regular office
, and a copy is sent to the referring
physician. 
The president described several measures which have been instituted to monitor quality

of care on an ongoing basis: (1) a medical director in each office is responsible for

overseeing care; (2) a retrospective peer review of servces is conducted monthly; and

(3) patients are phoned 2 weeks after a call to evaluate the outcome. 
In addition
president recognized that primary care  , the
physicians might be concerned lest visiting
physician "steal" their patients
, so visiting doctors are not allowed to give patients 
addresses and phone numbers or follow them into the hospital. For patients who nethedei r
hospitaliztion but have no personal physician

, the company has a panel of physicians 
who have agreed to accept referrals. 
She report that 
community acceptance of her servce has been good. 
From the patients
perspective  it's a very popular service. 
" Recruitment of visiting physicians has been
easy, since, in her view  many physicians today prefer to wOfk 
in health maintenance
organizations (HMOs), group practices and other alternatives to private practice. 
State where she operates, she can guarantee physicians an anual  " In the

salary of over $70
for 8 calls a day, 5 days a week. 
Demand is reportedly growing. The president projects
that, in one city alone, visits will grow from 12 000 in 1988 to as many as 20 00 
in 1989.  Some hospital-based programs are also making housecalls, to deliver primary care to the 
frail elderly.

We visited two not-for-profit hospitals that have been making house 
calls to the frail
elderly for 4 to 5 years. At one hospital
, the program is a component of the hospital'
multi-faceted senior servces program, at the other, the program is a department of the
hospital. Both programs were established upon the recognition that there was a 
large 
and growing population of homebound elderly who needed primary care. The 
administrator of one program, which began as a model with a special grant from a 
community agency, said: "We realized that we had an underserved population with 
disjointed care.

Patients are the frail, homebound elderly: anyone over 65 "
who cannot or will not go out
and has a physical or psychosocial disability. 
" Many are in their 
80s and 90s. Two of the
patients seen during our visits were a woman in her 80s who 
takes 14 prescription

medications due to her heart condition and numerous other health problems

, and a

diabetic man in his 60s recovering from a recent heart attack
, who had an ulcer on his
foot. All of the patients we 
saw were being cared for by a family member or 
other live
caregIver. 
About a quarter of the patients are referred by physicians
, the rest by community
agencies, friends, or family. A physician and nurse with experience in geriatric medicine 
use vans to visit homes on a scheduled basis
, delivering primary care. A portable x-ray
servce provides back-up, and blood and urine 
samples are analyzed back in the hospital.
One program initially did some lab work in the van but gave it up after a year
, not
satisfied with the quality of test results and finding that they needed to do more 
testing than was possible within the confines of the van.  tyes of
Neither program dispenses

prescription drugs
, although one respondent noted that they are considering doing so.

Charts are kept at the hospital, carried to homes and updated back at the hospital
following visits. One program also keeps a 
folder in the home with progress notes
updated by the team as well as visiting nurses
, which respondents find helpful in
coordinating care. One van has a telephone
, which staff say is indispensable in
communicating with patients and caregivers as well as responding to pages from the 
hospital. 
Staff exame and treat patients
, review medications on the spot
, counsel and support
caregivers, and assess the living situation of patients. 
They often pick up subtle clues on
how a patient is doing. One nurse found handmarks on the wall which indicated that a 
patient had become unstable on her feet. And a 
physician noticed that a patient plagued
by persistent pneumonia was using the same bottle over and over to 
The bottle contained bacteria. The doctor said: " refil a nebulizer.

I wouldn t have known had I not seen
it. " 
Delivering care in the home poses special problems such as poor lighting or marginal 
hygienic conditions. A doctor noted: "
I may have a sterile field
, but I can t control the
roaches. " Also, it can be emotionally wrenching for staff to see patients cryng 
from  loneliness, or to tell a patient that he must go to a nursing home. A program 
director
said: "You must have a dedicated group of physicians. It 
s not for everyone. 
Despite the problems, respondents believe that "we are providing better care
, and can do
a better job in the home setting. We know how they (the patients) get 
by day to day, why
they may be depressed. We observe the social issues.
" They demonstrate excellent

rapport with patients and seem to enjoy their work. "
You get out of the office
, get to

know your patients, have tea with them 
kiss them good-bye. " Patients and caregivers
seemed to like the service and be grateful for it. 
Respondents say there is another key facet to the success of their programs: close

coordination with community agencies that provide non-medical support 

servces to
patients. They say that this "holistic" approach to meeting both the medical and social

servce needs of their patients helps keep them at home 
as long as possible, avoiding

unnecessary, and expensive, hospital or nursing home care. 
Demand for servces is reportedly strong and 
growing. One respondent projected 1 
500
visits for 1989, and another noted that her program 
s patient load grew from 600 in 
1984 
to a projected 1 300 in 1988. "There s a huge demand out there. We could be swamped.
They wil add a second van soon. 
A private company in the 
West runs a "comprehensive housecall" service, using a specially

equipped van to visit people of all ages in their homes to provide urgent care.

We visited a company in California developed by a physician who saw the need for a 
servce which provided physician care in the home for patients who were injured 
chronically il, or suffering from non-life-threatening medical problems. He labels his
servce a "comprehensive housecall." 
The founder describes his service this 
way: "I built a van that gave a doctor his tools and
put emergency physicians into the van. We can take an 
x-ray, and do an EKG and blood
tests and have the results immediately. We can 
sew up somebody s wounds, give
injections and dispense medications.
" A specially trained technician works with the
physician. 
The company has a non-financial contract with a local hospital
, where it is based. The
hospital' s name appears on the van, and the service refers some patients who need
hospitalization to them. The service operates 
12 hours a day, 7 days a week
, and serves
the entire community. Patients may 
call for help themselves or be referred by their
physician. 
The van cares extensive diagnostic and treatment equipment
, and 55 prepackaged
medications. The physician uses a cellular phone to talk with patients and the base office
while under way. Charting and biling are completely computerized
, which the president
considers one of the best and most unique features of the servce. 

The physician dictates
a chart in the van at the end of each visit. It is transcribed back at the hospital and copies 
are sent to both the patient and his or her primary care 
physician. The computer also
generates coded bils ready to be dropped in an envelope and 
mailed.  .Jvml; Vi mc pauems we met were: 
(1) a man in his 70s who had fallen at home and cut
his head; the cut was sewed up in a 23 minute call
, avoiding an emergency room visit; (2)
an 81-year-old woman living alone, recovering from a broken pelvis; an x-ray taken with
the patient lying on her bed showed that she was healing 
satisfactorily; and, (3) a frail
80-year-old heart patient and his wife. The technician processed a cholesterol test while 
the doctor treated a wound, reviewed a blood pressure log kept by the wife

, and

discussed the drug regimen. He found that the patient was taking the 
wrong dosage of
one of the medications. 
To ensure high-quality servces, the medical director routinely reviews all charts using
procedures followed in hospital emergency rooms. A detailed log is kept of all 
medications dispensed. In the van 
s mini-lab, detailed quality assurance procedures are
followed and a second set of controls is run against hospital values to ensure accuracy. 
Laboratory equipment is as 
fail-safe as possible, much of it with solid state circuitry, and
some was redesigned for use in the van. The van was designed around the equipment

and is insulated and climate-controlled.

The president believes that other features of his servce also enhance the quality of 
servces: (1) medical risk 
is greatly decreased because physicians can diagnose and then
treat immediately; (2) seeing patients
' living situations first-hand often provides
important information for both diagnosis and treatment; and
, (3) supplying patients with
a complete, readable copy of their charts is invaluable in helping them comply with

prescribed regimens.

Besides offering high-quality care, the president believes that "
the comprehensive
housecall" leads to significant cost savings 
by enabling patients to avoid visits to the
emergency room or ambulance rides. To ilustrate
, he points to his company 
s agreement
with the hospital' s Medicare HMO. The servce will 
visit HMO patients, upon referral
from their physician
, who face a non-lie-threatening emergency, at a flat fee of $200 per
visit. The HMO paid almost a million 
dollars last year for unauthorized emergency room
visits for its patients. Besides keeping patients within the hospital network
, this
arrangement is an attempt to cut those costs. The flat fee will not 
only save an average of
$70 per patient as compared with last year
, but in some cases will save $272 
HMO would pay for an ambulance ride.  whir, the
Patients reportedly have fesponded very positively to the servce
, although the president
has found a need to market more 
aggressively than he expected to potential 
patients.
Some elderly people fear alienating their primary care physicians 
by using his servce.
Others are proud, and afaid of being seen 
as sick or old if a van appears at 
their house.
Stil others assume that the servce is too 
expensive for them. As for younger people
many have had no prior experience with housecalls or are reluctant to let people 
into 
their homes. 
The president believes that his 
tye of servce can be used in a number of ways, such as
providing care to workers who are injured on the job
, providing aftercare to patients
discharged from the hospital
, and providing primary care to the seriously or chronically  ill. The company is poised on the brink of a multi-
million dollar national expansion. It
was featured on a national television program in August 
1989 and has also been the 
subject of articles in national publications. 
Few Of The Mobile Health Services Described In This Report Are Subject 
To Special State 
Or Federal Regulations Which Address Their Mobile Nature. 
In response to questions concerning how they are regulated
, respondents at all but two
programs which target the medically underserved or uninsured pointed out that 
, as
medical facilities, their institutions already comply with State licensure requirements 
and
guidelines and are subject to routine inspection. When asked how they 
safeguard the
quality of their mobile servces, they said that they apply the same protocols and 
procedures used in their stationary facilities. They added that nurse practitioners or 
physician assistants who work on vans are backed up in accordance with State 
physician at a stationary site.  law by a 
Two programs did have to meet special regulatory requirements: 
(1) the methadone
program obtained a State license in order to comply with Federal requirements; the 
director noted that State regulators were somewhat 
nonplussed by the mobile operation:
They couldn t fit us into a box;" and (2) a program which serves homeless children went
through the State s certificate of need (CON) process; the administrator said that State 
officials were very "supportive." (State CON requirements vary widely, although all
programs require that health care facilities justify to the State the 
need for purchasing
major medical equipment or building new additions or modifying their facilities. The 
CON process is slowly being phased out. 
It exists in 38 States. 
With respect to the house 
call servces, only the company in Kentucky is subject to any
regulation as a mobile servce
, per se. It went through the State CON process and is
licensed as a mobile health servce. 
The president said: "
It was easy to represent the
need for a house call servce in the CON process. 
" She endorses CON because it
provides a measure of protection to the public. 
" In contrast, the president of the other
company said that, while he has inquired about regulation with several public agencies 
and private insurers, "there has been nothing in any form for Medicare
, malpractice
insurance, workman s comp, insurance for the offce or personnel
, or certifcation that
ever come up that allows me to describe what I do. It means you could slide all the 
way 
through the surface and no one would ever know administratively that you 
re on four
wheels. " 
Providers Say That The Greatest Benefit Of Their Mobile 
Services Is That They Reach
People Who Would Not Otherwise Seek Or Receive Health Care. 
Providers believe that their mobile programs overcome immobilty, physical and mental 
frailty, poverty, language or cultural barriers
, and fear or mistrust of providers which
serve as barriers to accessing health care for some people. 
Providers who work with the medically underserved express concern about 
the growing 
number of Americans who find it difficult to access health care: 
(1) people in rural areas
especially the elderly, many of whom are immobilized by chronic
ilness and live in  , "  , " 
isolated areas with few health care providers; (2) the "
working poor" or "notch

population, " who lack 'health insurance or adequate coverage
, do not qualify for

Medicaid, and often postpone seeking health care because of the expense; and

, (3)
homeless people, for whom the need for health care is often overshadowed by the search 
for food and shelter; respondents describe the lives of the homeless as "
chaotic " and
express special concern about homeless children
, whose parents, they say, often fail to
recognize that the children need care. 
These providers say that rn0hile servces enable them to reach people with "
really 
desperate health care need:, who have often lost their trust of community 
agencies and
refuse to actively seek help. One said that "
the van has brought a lot of disenfranchised
people back into the health care system 
who need it. " They also point out that vans serve
as an entree to non-medical servces which can help people get back on their feet. 
For 
example, the director of a program for runaway teens calls her mobile program "
the best
outreach we do. " To ilustrate, she said that while the van had about 2 
300 medical visits 
in 1988, there were over 7 000 non-medical visits, where teens were counseled or
referred elsewhere for housing or other help. 
Housecall providers say that housecalls fil a large and growing gap in health care 
especially given the increasing numbers of elderly in the population. 
One respondent
noted further that  I think doctors are becoming more interested
, also, given the groWth
of the older population. 
Providers Believe That, By Focusing Heavily On Prevention, Their Mobile 
Will Lead To Health Care  Health Services 
Cost Savings In  The  Long Run. 
Those who target the medically underserved believe that their servces save health care 
costs in the long run by preventing disease or the development of serious health 
problems which would require emergency care or hospitalization. "
The van has 
prevented the flooding of emergency rooms with sick 
people because we have treated
them before they got worse. I think we have 
saved immeasurable dollars.

the cost of health care provided to indigents " In discussing

said that, across the U.  , a January article in the  Washington Times

such care cost hospitals $8.3 
three- bilion in 1988 - almost a

fold increase over 1980.

These respondents also tout the benefits of using 
vans for health education: ' 
:A far as
prevention, if you don 
t have a way to go to the people
, especially if they aren t reading
papers and watching 1V and getting mail
, you ve got to have a van." They point to
pregnant teens, or people with AIDS
, as examples of people who will not visit traditional
providers, and say: "You ve got to get out there to where they are. 
Housecall providers contend that
, if globally accepted, house calls could lead to 
significant cost savings relative to institutional care by: 

(1) keeping patients out of the
hospital or nursing home as long as possible; (2) enabling some patients to avoid 
unnecessar ambulance rides or emergency room visits; and
, (3) providing aftercare to 
hospital patients, allowing for earlier discharge.  Growing Interest In Providing Mobile Health 
Despite  The  SelVices, Lack 
Of Public
Recognition And Problems Related To 
FinancingAnd Medicare Reimbursement May Limit 
Their Future Growth. 
To date, the tyes of mobile health services described in this study appear to be few in 
number and at an embryonic stage of development. Respondents 
seek recognition that
their servces are both necessary and effective, not only from the general public
, but from
the health care community, the insurance industry, and government agencies. Many 
express disappointment that their programs remain largely unkown 
outside the

geographic areas they serve.

With respect to providers who target the medically underserved
, we talked to PHS staff
in the Bureau of Health Care Delivery and Assistance
, Division of Primary Care for their
Jpinions regarding the viability of such services and their attitudes towards funding them.
On the question of viability, these respondents expressed 
mied opinions, especially
about the delivery of primary care by mobile programs. While they acknowledge the 
existence of a growing transient population for whom traditional medical models are not 
appropriate, they also look somewhat askance at mobile programs because "
people need
access (to care) all the time. 
" Mobile programs, by their very nature, do not provide such
continuity of care. 
While it appears that these reservations
, along with concerns about the costs of mounting 
van-based programs, have led the office to deny most of the requests received to date for 
funds to purchase vans, this may be changing. The FY 1991 budget projects a $2 million
increase in funding for community and migrant health centers. The funds are for the 
purchase of vehicles which will increase access for mothers and 
pregnant women to 
prenatal and other health care servces (so called "
Mom Vans 
). This is part of a special 
maternal and child health/infant mortality initiative on 
access. 
All of the house call providers say that low reimbursement
, especially Medicare
reimbursement, hampers their expansion. They say that Medicare reimbursement rates 
are inadequate because they fail to take into account their special administrative costs 
such as screening and otherwse handling calls, or developing and monitoring contracts
with staff physicians. The president of the comprehensive housecall company said 
further that Medicare reimbursement codes are "
totally inappropriate" because they are
based on the assumption that the .physician is providing primary, not urgent
, care. 
The issue of inadequate Medicare reimbursement is particularly important to the 
hospital program, since the bulk of their reimbursement comes from Medicare and 
Medicaid. One respondent said that it has been hard to interest some physician in 
working for the program because Medicare reimbursement is lower for her program 
housecalls than for home visits made by the local visiting nurse agency. Both programs 
survve because of supplemental grants from local agencies and the willngness of the 
hospitals to carry the deficit, perhaps in part because
, according to respondents, the
programs generate admissions.  , "

The presidents of both house 
call companies said that they have made numerous attempts
to discuss reimbursement with both Government agencies and insurers
, but that, in the
words of one  it was not of great interest to them.
" In their view, until existing
reimbursement mechanisms
, especially Medicare
, are adjusted to match the special
characteristics of their servces, physician housecalls will not become a viable form of
health care delivery.  RECOMMENDATIONS

The PHS Should Study The Costs And Benefits Of Mobile 
Vans find Physician Housecalls.
Panicular Consideration Should Be Given To Supponing 
Demonstrations And Experimental
Projects. These Should 
Be Evaluated With Respect To:  (1)  Access To Care;  (2)  The Quality
The Impact Of SelVices, Including The Question Of Disease Prevention;

Of SelVices;  (3) 
And  The Costs Of SelVice Delivery.

(4) 
The Secretary has established three special initiatives which we 
believe are relevant to
the servces described in this report: (1) make 
long-term reforms in the health care
system to improve access overall; (2) improve access to health care for minority women 
and children; and, (3) better assist homeless families and children. 
All of the respondents in this study believe that their mobile servces improve access to 
health care, and are cost-effective in doing so. While some of them say that they have 
data which, they believe, support that contention, none has yet conducted a controlled
study documenting the actual costs and impact of their servces. 
We recommend that PHS conduct demonstration projects and controlled studies of a 
broad range of mobile servces: servces to underserved populations, including the
working poor, homeless, migrants and people in rural areas; and house calls
, including
their use in the provision of hospital aftercare. The following factors
, at a minimum
should be assessed: the number and 
tyes of patients served and the health problems
they present; the cost of servce delivery; the quality of servces; and
, the impact of

services, especially the degree to which they prevent disease
, and prevent or delay a need

for institutional care.

In Implementing The New Physician Payment 
System Under Medicare, HCFA Should
Carefully Consider The Appropriate 
Weight For Payments For Physician Primary And
Urgent Care Housecalls. 
The housecall providers contacted for this study all 
say they experience problems relative
to inadequate Medicare reimbursement. We 
recommend that HCFA, when
implementing the new physician payment system under Medicare
, should determine if
reimbursement for physician housecalls
, as they are described in the report
, is fair and
appropriate. 
COMMENTS 
The PHS generally agrees with this recommendation. However
, instead of supporting
demonstration and experimental projects
, they would prefer to support further research
and examine more case studies of mobile providers such as described in this report. To 
accomplish this, they intend to solicit
, through the Agency for Health Care Policy and
Research, applications focusing on how mobile health servces delivery can impact on 
health care, particularly for the disadvantaged and rural populations.  The HCFA agrees with our recommendation and will evaluate the appropriateness of 
reimbursement for physician house 
calls under the new physician payment system. The 
complete text of the PHS and HCFA comments
, can be found in Appendix C.  APPENDIX A

List of Providers Contacted 
Alameda County Health Care Services 
Oakland, CA 
The Bridge Over Troubled Waters
 Boston, MA 
CALL-DOC Medical Group, Inc.

San Diego, CA 
Cook County Department of Public Health

Maywood, IL 
Doctors to Your Door 
Louisville, KY 
Habit Management Institute 
Boston, MA 
Highland County Health Department 
Hilsboro, OH 
Ilinois Migrant Council 
Chicago, IL 
Indiana University Maternal Outreach Mobile 
Bloomington, IN 
Montana Migrant Council 
Bilings, MT 
Mt. Vernon Neighborhood Health Center 
Mt. Vernon, NY 
New York Children s Health Project 
New York, NY 
St. Francis Hospital 
Evanston, IL 
St. John s Hospital 
Cleveland, 0 H 
Peekskill Community Health Center 
Peekskill, NY 
Plan de Salud del Valle 
Ft. Lupton, CO 
Swope Parkway Health Center
 Kansas City, MO 
University of Arizona Rural Health Clinic 
Tucson, AZ 
Private Physician (anonymous) 
North Dakota  APPENDIX B

Typical Operating Characteristics of Mobile Health Services in Public Settings 
Vehicles 
Vehicles, often referred to as "vans" by providers no matter what the tye
, include
specially designed or retrofitted vans
, recreational vehicles, school buses, and even
trucks. Most are brightly painted with the provider 
s name or logo. This often attracts
considerable attention and even curiosity on site
, which helps draw in some patients who
might normally be reticent to seek help. 
Vans tyically contain an intervew or waiting
room; one or two examination rooms; a laboratory area with a sink
, centrifuge and
supplies; and, a bathroom or changing room. Often
, one area is designated for
counseling or patient education, and there may also be a separate office where records 
are kept. 
Some vans carry a portable dental x-ray, and one carries ultrasound 
equipment for
examining pregnant women. Some have phones
, which staff use to consult with
physicians back at a stationary site or to make follow-up appointments. 
Most vans have a
generator, although providers prefer to connect to power at a stationary site because 
generators are often noisy and expensive to run. Most vans also have air conditioners
heaters, and water tanks, though the water is mostly used to wash hands and equipment 
rather than for drinking. Only a 
couple of vans have a wheelchair lift; some respondents
say that lack of a lift has been a problem in 
servng the elderly or handicapped. 
Staffng 
Core staff often consists of a nurse practitioner or physician assistant
, with physician
back-up at a stationary site; an intake-worker or clerk
, who may also drive the van; and
, a
nurse. Physicians, dentists and dental hygienists, community health workers, health
educators, outreach or social servce workers, drug, alcohol, and mental health workers
and even nutritionists work on vans. So do medical
, dental or nursing students; in
Arizona, a female pre-med student both administers the program and drives the 33' ten 
ton truck. Some programs also use volunteers, whether health professionals or
community residents. 
When asked what attributes are necessary for staff who 
work on vans, many respondents
made comments such as this: "It takes a really special person to work this unit - good 
communication skills, good sound knowledge, a strong ego and the abi'lty to use their
skills without someone else to critique for them. . . staff 
have to be willing and enjoy
what they do.
" Staf reportedly view problems as a challenge and "love working in the
van." A physician described her work as: "
an adventure. . . very 'frontier . . . sort of a
pioneer, covered-wagon feeling.  Logitical an Administrative Problems 
While all providers carry some sort of vehicle insurance
, in some cases the cost of
malpractice insurance is prohibitive. One project 
director said that some physicians wil
not volunteer their servces on the van because the program cannot 
afford malpractice
insurance. Elsewhere, a State university assumed title to the vehicle so that staff who 
work in it can be insured under the 
school's policy. 
Logistically, the most common problem of operating in a van is an obvious one: lack 
space. Scheduling and traffic control are critical to ensure that the flow of patients 
through the van is smooth. Sometimes
, intake or counseling must be done outside the 
van, such as in a transitional hotel for the homeless
, to relieve congestion in the van. 
There are other problems as well. For example
, since most vans observe a somewhat
complicated schedule of dates and sites
, scheduling and coordination by administrators
can be a lot of work " and very time-consuming. However, it appears that this becomes
easier as support staff become more familiar with a program and administrators find 
more effcient ways to plan. 
Recordkeeping is also a challenge. Many providers keep duplicate records
, storing the
original record at their home base and a copy in the van
, which is manually updated after
a visit. Recordkeeping can become backlogged 
given the crush of patients. Records also
require considerable storage space
, which is at a premium in a van. For these reasons
many respondents are computerizing, or plan to computerize
, their records. Two of them
say that they have heard of companies which are developing computerized recordkeeping 
systems specifically for use by providers serving transient 
populations. 
Inclement weather, insects, and bad roads must be contended with. Mechanical 
problems are often a headache. Many providers described problems with generators 
which they say are noisy and prone to breakdown. 
To bring the point home
, one
respondent jokingly said: "
Sometimes we yell 'Kill it!' because we can t hear a patient
heart. ... People wonder what s happening to the patient back there!" 
Some respondents report that other providers who are interested in developing mobile 
programs such as theirs have been discouraged to learn of both the expense and the work 
involved.  APPENDIX C

HCFA and PHS Comments 
C-l
 SER\1	
(;J  DEPARTMENT OF HEATH &. HUMAN  Public Health Service 
Memorandum 
Dllte 
From	 Assistant Secretary for Health 
Subject	 Office Of Inspector General (OIG) Draft Report "Health Care on 
Wh eel s , " - 0 E I - 05 - 89 - 0 1 332 
Iuspector General , OS

At t a c he d are the PHS co mm en t s  on the sub j e c t 0 I G d r aft  e po r t . 
We gene  ally concur with the report  s recommendatiou to study
alternative approaches to providiug health care particularly to 
the underserved populations. In that regard, the Agency for

Health Care Policy and Research will inform 
the health care

research community that it is accepting applications on

innovative approaches to h alth care delivery.

(). Ik
Mason , M.  , Dr. 
AttachlDeC\t  COMMENTS OF THE FUBLIC HEATH SERVICE (PHS)

ON THE OFFICE OF INSPECTOR GENERA (OIG)

DRAT REPORT " HEATH CARE ON WHEELS"

OEI-OS-89-01332, FEBRUARY 1990 
General Comments

We generally agree with the intent of the report to improve 
services. 
access to health care  While mobile health services 
have been used and studied in the past, they have not been
rigorously evaluated in terms of their impact on health benefits 
and on costs. Consequently, further examination of mobile health 
services delivery is warranted because of the emergence of

populations and problems which differ in kind, severity or

magni tude from those in earlier years. Also, there have been

health care since the earlier services 
technological advances  in 
were delivered and their impact on the effectiveness and 
efficiency of such services must be considered. 
OIG Recommendation 
The PHS should study the costs and benefits of mobile vans and 
physician housecalls. particular consideration should be given 
projects. 
to supporting demonstrations and experimental  These 
( 1) access 
should be evaluated with respect to 
 to care 1 (2) the
qua Ii ty of services; (3) the impact of services, including the 
question of disease prevention; and (4) the costs of service
delivery. 
PHS Conuents

We concur with the intent of this recommendation to study the 
wheels. 
delivery of health care services on  However, we believe 
too early to give particular consideration to supporting 
it  is 
demonstration projects a8 the report recommends. Rather, 
believe that targeting descriptive research projects and case 
stage. 
studies for support is more appropriate at this  For 
example, we should seek to know: 
How extensive the services are? How many patients are
served? 
What are the characteristics of the patients
and of the providers? 
What areas are the services 
located in? To what extent is follow-up care, where
indicated, actually provided? 
What are the funding
sources? 
What quality assurance measures are employed? 
What is the quality of care provided? How do these 
factors vary in different models of health service
deli very? 
C-3  ... ...
page 
The Agency for Health Care Policy and Research (AHCPR) is 
accepting applications on various innovative approaches to health 
care and AHCPR plans to inform the health service research 
communi ty of this through program announcementS. In particular, 
s program priori 
AHCPR'  ties in research on rural health care and 
on health care for the disadvantaged (including the elderly, the 
handicapped, and the poor) encompass issues of access which may 
delivery. 
be addressed by mobile health service 
Technical Comments

Page 1 , last paragraph, line 3 should read " 109 He4l th  re for 
the Homeless Programs are funded by the Public Hea  Serv1ce 
under the Stewart S. McKinney Homeless Assistance Act of 1987" 
Page 7 , first paragraph, line 1 states that  ... 2 programs run
by not-far-
profit hospitals  the report should clarify 
whether one or two different hospitals are being referred to in 
the next sentence beginning with "One is a component 
C-4
 ... -:- -':.:: ._"" :. 
=' I

;) E P 'R  T"  E " :-11 F H E  H L \\ \ " "E R \ ICE" 
Memorandum
I .

: .3
 D. 
Gail R. Wilensky. Ph.
AdministratOr 
OIG Draft Repon .  OEI.OS.89-01332 
Health Care on Wheels, 
The Inspector General 
Office of the Secretary

We have reviewed the subject draft report. Ths report provides a description of 
health care providers that serve medically underserved and uninsured populations in 
public settings, or that make physician housecalls. 
The report recommends that in implementing the new physician payment system 
under Medicare, HCF A should carefully consider the appropriate weight for 
payments for physician primary and urgent care house calls. We agree with this 
recommendation. 
We also believe that there are potentially significant costs to Medicaid as well. 
given recent Omnibus Budget Reconciliation Act of 
1989 expansions of the Early 
and Periodic Screening, Diagnosis and Treatment programs and maternal and child 
benefits. It would be helpful if the report could also evaluate the impact of mobile 
health services on these Medicaid programs. 
Thank you for the opportunity to comment on this draft report. 
Please advise us 
whether you agree with our position at your earliest convenience. 
c-s