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


The ublic Health Servce (PHS) should study 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


question of disease prevention; and (4) the costs of servce delivery. , including the


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 
.......................................................... 

B-1 

APPENDIX B: Typical Operating Characteristics of Mobile 

Health Services in Public Settings 

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 

physicians. servces was provided by 
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 "safe sex. " They talk to admitted drug users about drug treatment and "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, or actually takng patients to appointments. One program accepts up to three 

month from a patient who wants to ask questions or discuss problems. collect calls a 

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

our system pretty well." , and "we know 

Appendix B contains a description of other tyical operating characteristics of these
 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, a rancher, and even a famous singer-songwiter. 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 from PHS sometimes use them to pay the salaries of staff who work 

programs receive some Medicaid reimbursement. in a van. A few 

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 tortillas. 
, 

, 

Some Providers, Including Both For-rroJlt Companies And Not-For-Profit Hospital Makng Physician , Are HOUsecalls. Most, Though Not All 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, she says, poses special problems for physicians: "Every doctor has patients who are homebound been the doctor s dilemma for some time how to accommodate those patients. , and it 

home health agency needs a company like mine to fil the gap. Every 

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 

prescriptions to pharmacies that deliver. At the end of each visit

arrangement has worked very well. Physicians do not carry drugs, but call in 

, 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. 

president recognized that primary care In addition, 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 need their

hospitaliztion but have no personal physician


who have agreed to accept referrals. , the company has a panel of physicians 

She report that community acceptance of her servce has been good. 

perspective From the patients 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 " In the
 , she can guarantee physicians an anual 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 

and growing population of homebound elderly who needed primary care. The large 

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


diabetic man in his 60s recovering from a recent heart attack , and a


, 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 refil a nebulizer.
 The bottle contained bacteria. The doctor said: "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
 kiss know your patients, have tea with them 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


discussed the drug regimen. He found that the patient was taking the , and


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 with the hospital' s agreement 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 whir, the HMO would pay for an ambulance ride. 

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 

their homes. into 

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 

Or Federal Regulations Which Address Their Mobile Nature. To Special State 

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 

through the surface and no one would ever know administratively that you way 

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 

number of Americans who find it difficult to access health care: the growing 

especially the elderly, many of whom are immobilized by chronic(1) people in rural areas

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 "

desperate health care need:, who have often lost their trust of community really 

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. 

example, the director of a program for runaway teens calls her mobile program " For 

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. "

prevented the flooding of emergency rooms with sick The van has 

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 bilion in 1988 - almost a
 three-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

hospital patients, allowing for earlier discharge. , (3) providing aftercare to 
Despite The Growing Interest In Providing Mobile Health 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 

prenatal and other health care servces (so called "Mom Vans 

pregnant women to 

maternal and child health/infant mortality initiative on access. 

). This is part of a special 

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

words of one , but that, in the 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 Of SelVices; (3) The Impact Of SelVices, Including The Question Of Disease Prevention;
 And (4) The Costs Of SelVice Delivery.


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 

The Bridge Over Troubled Waters


CALL-DOC Medical Group, Inc.


Cook County Department of Public Health


Doctors to Your Door 

Habit Management Institute 

Highland County Health Department 

Ilinois Migrant Council 

Indiana University Maternal Outreach Mobile 

Montana Migrant Council 

Mt. Vernon Neighborhood Health Center 

New York Children s Health Project 

St. Francis Hospital 

St. John s Hospital 

Peekskill Community Health Center 

Plan de Salud del Valle 

Swope Parkway Health Center


University of Arizona Rural Health Clinic 

Private Physician (anonymous) 

Oakland, CA 

Boston, MA 

San Diego, CA 

Maywood, IL 

Louisville, KY 

Boston, MA 

Hilsboro, OH 

Chicago, IL 

Bloomington, IN 

Bilings, MT 

Mt. Vernon, NY 

New York, NY 

Evanston, IL 

Cleveland, 0 H 

Peekskill, NY 

Ft. Lupton, CO 

Kansas City, MO 

Tucson, AZ 

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

(;J DEPARTMENT OF HEATH &. HUMAN SER\1	 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 

access to health care services. 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
 technological advances in health care since the earlier services 

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 

to supporting demonstrations and experimental projects. These should be evaluated with respect to 
 ( 1) access 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 

delivery of health care services on wheels. However, we believe it is too early to give particular consideration to supporting 

demonstration projects a8 the report recommends. Rather, 

believe that targeting descriptive research projects and case 

studies for support is more appropriate at this stage. 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, 

AHCPR' s program priori 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 

be addressed by mobile health service delivery. 

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" 

I .
 Memorandum : .3


Gail R. Wilensky. Ph.D. 

AdministratOr 

OIG Draft Repon . Health Care on Wheels, OEI.OS.89-01332 

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