Meet a one-of-a-kind specialist

This internist gave up a successful office practice for house calls. He says it's better for his patients—and for him.

By Berkeley Rice
Senior Editor

Until last year, internist Daniel J. Bonomo had a fairly conventional medical career: He combined a busy solo practice in Yonkers, NY, with part-time work at a nearby hospital's wound care center. Since many of his clinic patients were elderly or bedridden, he began making house calls to treat them. Most suffered from pressure ulcers and other chronic wounds that didn't heal because of problems like diabetes or poor circulation.

As his interest in this subspecialty grew, Bonomo eventually became certified by the American Academy of Wound Care Management. He learned that for chronically ill patients, clinic visits were often impractical, painful, and expensive, costing as much as $700 each way just for the ambulance.

Recognizing a potential niche market, Bonomo, now 45, made what he calls "a leap of faith." Last January, he gave up his office practice to become a full-time house call wound care specialist—possibly the only one in the country.

His colleagues told him he was crazy. But as word of his service spread, his new practice grew quickly, with referrals from physicians, nurses, home care agencies, and wound care clinics. (He still works two mornings a week at the wound care clinic.)

Accompanied by his nurse, Sherma Gruyon, Bonomo makes up to a dozen calls a day in an SUV that serves as his mobile office. While Gruyon drives, Bonomo navigates and checks the next patient's chart. He also works the cell phone, getting lab results, discussing treatment and medication with patients' physicians, and picking up messages from his answering service. (He keeps his records in his home office; Gruyon does billing in the evenings on her home computer.)

At each stop, Bonomo lugs everything he needs in a big blue paramedic bag. While he debrides, cleans, and photographs the wound, he dictates notes. Gruyon then changes the dressing.

Most visits take 20 to 30 minutes. Since they're rarely emergencies, Bonomo keeps his schedule fairly loose, arranging it to minimize driving time and avoid traffic. If he's running late, he calls ahead to warn the next patient or reschedule the visit. "Unfortunately, nearly all these people are bedridden," he explains, "so they're probably not going anywhere."

On his full days, Bonomo works from 8 am to 6 pm. That's a longer workday than before, but he finds it less stressful because he typically gets 10-minute driving breaks between patients.

Bonomo makes frequent presentations on wound care to groups of nurses and home health care agencies. Thanks to such publicity—and to word-of-mouth recommendations from grateful patients—he gains up to 10 new patients a week. Since many of them are very ill, however, he also loses some who die or end up in the hospital.

Bonomo averages about 50 visits a week, seeing each patient every week or two, depending on the severity of the wound. While 85 percent of his patients are on Medicare, some are enrolled in HMOs.

Before calling on new patients, Bonomo is careful to get approval from their primary care physicians, and he sends the doctors monthly reports with photos to document his progress. "We want to be part of the health care team," he explains. "We don't want doctors thinking we're trying to take away their patients."

Compared to his former practice, Bonomo's new one is relatively simple. "I see most patients once a week," he explains, "and since I concentrate on one thing—chronic wounds—billing is pretty straightforward." Medicare's reimbursement rate for wound care home visits ranges from $140 to $200—depending on the severity of the wound—and averages about $150. HMO payments are similar.

"My practice saves everyone a lot of money, especially Medicare," says Bonomo. "Otherwise, they'd have to pay a lot more to have these people transported by ambulance to a surgeon or the hospital."

Although Bonomo earns considerably less from his mobile practice than the $400,000 he grossed last year, he expects his net to remain about the same, because his current expenses are far less than the 50 percent overhead he paid in his office practice.

Equally important, Bonomo finds his new practice more fulfilling. "I can give patients better care in their homes than I could in the office," he explains. "I can keep them out of the hospital and provide more support for their families. I get better results, and my patients are more grateful because I'm making a real difference in their lives. They see me as a Good Samaritan."

 

Berkeley Rice. Meet a one-of-a-kind specialist. Medical Economics Dec. 3, 2001;78:48.