Dr. Roberta Miller hits the road at 8 a.m. to see her patients.
Many are too old or sick to go to the doctor. So the doctor comes to them.
She's put 250,000 miles on her Honda minivan going to their homes in upstate New York. Home visits make a different kind of care possible.
"You can evaluate the person as a whole," says Miller, who has been a home care physician in Schenectady, N.Y., for more than 20 years. "You see everything that influences their health and well-being: the environment, the surrounding people, the support system, whether they had or didn't have food."
Miller spends about an hour at each house call. Conversation with patients and their family members flows so naturally that it's easy to miss that she's also checking vital signs, gently stretching a hand, noting which pill bottles are empty.
Although Miller's practice may harken back to the country doctor of decades past, it could be the future of medicine. In 2013, about 2.6 million Medicare claims were filed for patient home visits and house calls. That's up from 2.3 million visits in 2009 and 1.4 million visits in 1999, according to Medicare statistics.
"That's just the nature of the population we treat," Miller says. "They're extremely ill. Homebound patients often have up to 12 or 13 problems, not just one."
And they're often invisible. These people could be living just down the block, and you'd never know it. Many of them never leave their homes.
Miller's patients include a 55-year-old woman with ALS who can communicate only with her eyes, a 27-year-old former quarterback left quadriplegic and in a coma after surgery on an Achilles tendon, a 92-year-old woman cared for by her daughter, and a severely depressed man who lives alone.
After the Affordable Care Act took effect in 2014, Miller saw a spike in new patient requests after Medicare reimbursements increased for people who are disabled or 65 and older.
"Now we can afford to see them and take care of them. Because they haven't had medical care, they have multiple medical needs and psychosocial needs," she says. "It has given us access to a group of people, but more importantly, they have access to us."
But reimbursements declined in 2015 because of sequestration. And now Medicaid reimbursements rates are starting to fall as well.
Editor's note: This is an abbreviated version of a story that ran on Sunday, Nov. 8.
Photographer Misha Friedman says he tries "looking beyond the facts, searching for causes, and asking complex and difficult questions." His work has been featured by many media organizations, including NPR, The New Yorker, Sports Illustrated, Der Spiegel and GQ.
Freelance writer Nadia Whitehead contributed to this report.
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