Startups Vie to Build an Uber for Health Care
August 11, 2015 6:34 AM   Subscribe

"House calls, which accounted for 40% of all doctor visits in 1930, dwindled to less than 1% by 1980 as physicians found it far more efficient to see 20 or 30 patients a day in an office than just a handful in their homes. But in-home care is starting to be seen as cost-efficient again—particularly for the most expensive patients." [SLWSJ]
posted by Jacqueline (41 comments total) 11 users marked this as a favorite
 
Finally, a way to kill nursing as an accessible middle class career.
posted by Bulgaroktonos at 6:36 AM on August 11, 2015 [33 favorites]


This isn't "Uber for healthcare", whatever its faults (many), Uber has clearly increased access to underserved populations, particularly minorities and low income people with poor access to traditional transit coverage. This is dial a doctor for the 1% that can pay cash.

The only places where it could be filling an unmet need might be red states that continue to refuse to implement the ACA, where a house call app could conceivably bring some care to uninsured people, but a) how many people that can't afford insurance can afford 75-300$ per call out of pocket? and b) how many of these tech-miracle companies operate in red states?
posted by T.D. Strange at 6:41 AM on August 11, 2015 [1 favorite]


T.D. Strange a) how many people that can't afford insurance can afford 75-300$ per call out of pocket? and b) how many of these tech-miracle companies operate in red states?

That Venn Diagram is going to look an awful lot like two barely touching circles at first glance.
posted by SansPoint at 6:43 AM on August 11, 2015


Have you tried making a doctor's appointment or finding an urgent care clinic outside of your hometown?

Scheduling appointments SUCKS, and I've shown up more than one time to be told that the place doesn't accept my insurance (despite asking that exact question over the phone beforehand).

Despite my (many) misgivings about the "sharing economy," I totally buy that healthcare has a major resource-allocation problem.
posted by schmod at 7:03 AM on August 11, 2015 [10 favorites]


Is there a link that doesn't require a subscription to read?
posted by fiercekitten at 7:10 AM on August 11, 2015 [1 favorite]


Yeah, this isn't for people with "no health insurance" in the sense that they are poor and can't afford health insurance. It's for work-from-home brogrammers who may or may not have insurance, but have enough money to make a doctor's house call seem worthwhile.

Waiting in the doctor's office is for people who have to rely on insurance. Which, incidentally, may be a future signifier of lower-class existence, i.e., having health insurance and not paying out of pocket might be seen as a type of welfare, or the equivalent of shopping at Goodwill.
posted by Avenger at 7:17 AM on August 11, 2015 [1 favorite]


I read a blog post the other day which I can't now find which was a post-mortem on the now defunct MetaMed by one of the employees. They claimed it's a great idea but us consumers are too stupid to appreciate its greatness.
posted by bukvich at 7:23 AM on August 11, 2015


At this point it would probably just be easier to list the things tech startups aren't trying to make into the next Uber.
posted by teponaztli at 7:25 AM on August 11, 2015 [1 favorite]


Is there a link that doesn't require a subscription to read?

It didn't require a subscription for me. Maybe try clearing your cookies?
posted by Jacqueline at 7:26 AM on August 11, 2015


The bit about the Medicare pilot and the resultant cost savings makes me optimistic that insurance companies may begin to cover these sorts of visits, at least for some patients (e.g. those with multiple chronic conditions).
posted by Jacqueline at 7:29 AM on August 11, 2015 [1 favorite]


My health plan just added a thing where we can do a free skype consult with a physician assistant or nurse practitioner: it's sort of like a video nurse line. I think it could be helpful. I don't think I'm going to get in-home visits paid for by insurance, and I don't think that I'm going to be able to afford to pay for them myself except in the most extreme circumstances, but it's nice to be able to show someone my rash or banged-up toe and ask if I should go to urgent care right now or if I can wait and see if it gets better.

One place where this could really be helpful is with infectious diseases. I've gone to urgent care a couple of times with things like bronchitis, and I've worried that I've infected the whole waiting room. I'm thinking maybe they could have a deal where you could call the video nurse-line and if you needed to be seen in person the nurse could approve a home visit so you didn't spread your germy germs to the whole universe.
posted by ArbitraryAndCapricious at 7:35 AM on August 11, 2015 [9 favorites]


I guess that I don't see how this has the issues that Uber does. The problem with Uber is that it's doing an end-run around regulation, and many of the regulations exist to protect workers and consumers. But these people will still have to be licensed healthcare professionals. They aren't any less regulated than doctors, nurses, and PAs who work out of traditional offices. It's also in a lot of ways an extension of the growth of Urgent Care clinics, and I don't think those have devalued the work of nurses. They've just made it a lot easier to get a flu shot if you have a 9 to 5 job and have trouble scheduling appointments when your doctor's office is open. I'm not necessarily sure I see how this presents the issues that sharing-economy companies do, although it's entirely possible that I'm missing something.
posted by ArbitraryAndCapricious at 8:01 AM on August 11, 2015 [10 favorites]


There's definitely an unmet need among poor people, who often find themselves housebound-- think of disabled folks, elderly, diabetic patients, people with kids at home. Waiting in a doctor's office is enjoyable for nobody, and nearly impossible for some. Some social-medicine pioneers have been bringing back the house call, and without the concierge-floor luxury angle. And pace the dittohead comments on the WSJ site, this is perfectly in the spirit of Obamacare, even funded by it as a pilot study.
posted by homerica at 8:07 AM on August 11, 2015 [7 favorites]


I do wonder what a doctor is able to actually do on a housecall?
posted by I-baLL at 8:09 AM on August 11, 2015


I do wonder what a doctor is able to actually do on a housecall?

About ninety percent of what a doctor does in an office, if you're a fairly healthy person. Check your vitals, make sure that your sniffles are just a basic flu, write a prescription, wrap up your sprained ankle, etc.
posted by Etrigan at 8:13 AM on August 11, 2015 [3 favorites]


> One place where this could really be helpful is with infectious diseases. I've gone to urgent care a couple of times with things like bronchitis, and I've worried that I've infected the whole waiting room.

And the flip-side, too: allowing immunocompromised patients to be treated at home, rather than waiting in a room full of sick people.
posted by Westringia F. at 8:34 AM on August 11, 2015 [19 favorites]


It would be nice if this became mandatory for parents who refuse to vaccinate their kids. Willfully unvaccinated kids mixing in waiting rooms with infants too young to be vaccinated can kill the latter.
posted by Jacqueline at 8:39 AM on August 11, 2015 [2 favorites]


Technically, wouldn't an Uber for healthcare involved home visits by random unlicensed folks toting around the contents of their home medicine cabinet? It's the sharing economy, after all, I think I have some expired codeine from my root canal two years ago.
posted by Existential Dread at 9:03 AM on August 11, 2015 [21 favorites]


Sit, Uber, sit.

Bad doc!
 
posted by Herodios at 9:11 AM on August 11, 2015 [1 favorite]


Pager, which has treated about 5,000 patients in New York’s five boroughs since its founding last year, says a typical patient is a young mother with one sick child and others she doesn’t want to bring along to the doctor’s office too or leave at home.

New York City is not a place full of rich red-staters who don't want to pay their Obamacare insurance. I'm sure these "young mothers" aren't the really poor ones, who have the time to wait in a doctor's office but not the money to pay for a house call, but it's great to have these services available for the middle class anyway.
posted by Rangi at 9:28 AM on August 11, 2015 [3 favorites]


Something like this has existed in Ontario for many years, since the 80s at least, I think. You make the arrangements by phone, not internet, and I believe it is from a business-organization-perspective just a referral/arrangment/broker service. The doctor pays Medvisit for the referral. The cost of the healthcare itself is paid for by our provincial health insurance. So the whole thing is free to the sick person.

I used to beg my mom to use this when I was little, because I kind of imagined it would be like Doc Bakker coming to your house (yes, my entire world view is Little House on the Prairie Based). She always thought it better to go to our actual doctor, which I think most people agree with. I note that it says they have 100 doctors on their list, which isn't very many for a province this size (even given that it's limited to a few urban areas). If 100 doctors is enough to cover the demand then I assume most people prefer to schlep out to their own doctor with whom they have a relationship. I only know one person who has ever used this service, and she's a bit of an oddball in lots of ways.

But...they have been in business for a long time, so I guess somebody is calling them. But yeah...even when it's essentially free, I'm not sure most people want their healthcare from a one-off person who just shows up at your door, doesn't know you from Adam, and whom you'll never see again.

Finally, why is the guy in the article calling a doctor when he and his family members have colds? What's a doctor supposed to do about that?
posted by If only I had a penguin... at 9:33 AM on August 11, 2015


"make sure that your sniffles are just a basic flu"

See, that's what I don't get. You do that by running tests. Blood tests and urine tests. Does the doctor just carry your blood and urine samples with them until they end up at the local lab or has medical testing technology gotten more portable in the past decade or so since the advent of smartphones?
posted by I-baLL at 9:41 AM on August 11, 2015


Does the doctor just carry your blood and urine samples with them until they end up at the local lab or has medical testing technology gotten more portable in the past decade or so since the advent of smartphones?

From the article:
Registered nurse Eve Rorison brought all the gear she needed to check his blood sugar, blood pressure, cholesterol, heart rate and BMI, in her backpack. About 15 minutes and one finger prick later, she declared, “You’re very healthy—keep up the good work.”
Sniffles vs. flu might not have been the best example, but the vast majority of my doctor visits could easily have been taken care of in a non-clinical setting, and those are the low-hanging fruit that services like these want to pick.
posted by Etrigan at 9:44 AM on August 11, 2015 [2 favorites]


there are home-visit nursing care services in the US (mostly for elderly/hospice patients, but also chronically ill). what i have is a local NP, and occasionally a visiting phlebotomist. it's covered by medicare.

when i had a visiting PA i really disliked, there was no other choice, because these services are so rare and difficult to find. i'd love to see them become more common, for those who can pay and those of us who can't--chronic illness/mobility problems can make a traditional doctor appt extremely difficult. for me, going to the doctor is an exertion that can take up to a month to recover from. (i have ME/CFS)
posted by JBD at 10:18 AM on August 11, 2015 [1 favorite]


my issues with my home-visit NP: she doesn't know my condition well (tho that makes her little different from most docs), and the one time i had acute pain the service couldn't help--they just told me to go to the ER, which i couldn't/wouldn't do.

i've not heard of home-visit specialists (and i've looked!), but that would be very helpful as well.
posted by JBD at 10:27 AM on August 11, 2015


> Something like this has existed in Ontario for many years, since the 80s at least, I think. [...] So the whole thing is free to the sick person.

When my Mum used this a couple of decades ago, I'm pretty sure there was a $10 copay. :-) It was awesome, my sister wasn't even that sick, the doctor showed up, said, "Oh, it's the same flu other people have. It's taking a little longer than usual for people, if she's not well by Tuesday or if things get worse..." and then had a cup of tea with us since she had a gap till the next appointment.

She said that she loved the house calls, for the exercise (walking around Ottawa) but also from a public health perspective of actually having a ground-level view of things.

Under socialized medicine, these things cost a tiny amount of money compared to even a small battleship and the resulting value in terms of health and security to the general populace is huge.
posted by lupus_yonderboy at 10:46 AM on August 11, 2015 [5 favorites]


There's definitely an unmet need among poor people, who often find themselves housebound-- think of disabled folks, elderly, diabetic patients, people with kids at home.

My folks moved into Assisted Living a few years ago, and their new GP has no office: she travels from nursing home to ALF, seeing patients. It works out fabulously for us: I can get my father an appointment with her on less than 2 days notice, and I don't have to take time off work to shuttle him anywhere (unlike all his specialist appointments).

It's an enormous convenience, and seems to work for this doctor, given how she can concentrate her patients in various centralized locations. She doesn't have to pay a nurse or receptionist, either.
posted by suelac at 10:47 AM on August 11, 2015 [3 favorites]


"From the article"

...yeah, maybe I should rtfa next time.

/hangs head in shame
posted by I-baLL at 10:49 AM on August 11, 2015 [1 favorite]


Not to derail, but in conversations like this, I always want to ask: "do you have Kaiser Permanente as an option for your employer and location?"

They don't have docs or nurses that come to you, but they have a great nursing line that's empowered to actually prescribe in some cases, and the Kaiser centers are generally better staffed and easier to get into than any private offices I've gone to. They also have Urgent Care options that are about $40 and open nights and weekends.

Not just to advertise for them, but to point out that health care can be run better than it is in many places. There are better options that the traditional insurance model.
posted by mercredi at 11:00 AM on August 11, 2015 [1 favorite]


Does the doctor just carry your blood and urine samples with them until they end up at the local lab

Nearly every lab I've ever had (outside of things like rapid strep/HIV tests) has been sent to a third-party company like Quest anyway, so this wouldn't actually be super different.
posted by en forme de poire at 11:10 AM on August 11, 2015 [1 favorite]


Another service that I have seen where I live, very awesome for elderly or sick or people with any transportation problems, is a mobile veterinarian, in an RV, that comes to your location. I don't know what the cost is though.
posted by thelonius at 11:25 AM on August 11, 2015 [1 favorite]


In spite of living in health-care paradise, this is something I would pay for apart (and actually did pay for in more than one occasion). Back in the day I was a single mum on a part time income. At the time there were no private options, but I would have paid up to 100 dollars to have a doctor come to our house when one child had a high fever and the other was sleeping. Taking two kids to the hospital with only one child sick more than once cost be my free-lance pay in terms of lost work.
Later on I did pay very high fees to get private doctors to the bedside of my ailing gran. It turned out I was right in believing that waiting for the emergency doctor would have killed her. When I read here that there might be a business model for home-calls, I'm 100% positive. What is not to love?
Now, I'm insured into outer space. But there is still the issue of options - doctors who do home-calls are scarce, and regardless of your insurance, you still need to find them.
posted by mumimor at 12:53 PM on August 11, 2015 [1 favorite]


This isn't "Uber for healthcare", whatever its faults (many), Uber has clearly increased access to underserved populations, particularly minorities and low income people with poor access to traditional transit coverage. This is dial a doctor for the 1% that can pay cash.

The only places where it could be filling an unmet need might be red states that continue to refuse to implement the ACA, where a house call app could conceivably bring some care to uninsured people, but a) how many people that can't afford insurance can afford 75-300$ per call out of pocket? and b) how many of these tech-miracle companies operate in red states?
posted by T.D. Strange at 6:41 AM on August 11


Yeah, this isn't for people with "no health insurance" in the sense that they are poor and can't afford health insurance. It's for work-from-home brogrammers who may or may not have insurance, but have enough money to make a doctor's house call seem worthwhile.

Waiting in the doctor's office is for people who have to rely on insurance. Which, incidentally, may be a future signifier of lower-class existence, i.e., having health insurance and not paying out of pocket might be seen as a type of welfare, or the equivalent of shopping at Goodwill.
posted by Avenger at 7:17 AM on August 11


Word to both of you.

There's an unfortunate trend where people who make some money (like, say technology rank and file and/or middle managers) think they're making enough to completely check out of the pooled resource commons upon which so much of society is built (at least, in progressive, advancing, 1st world societies). Like who needs healthcare - I've got my concierge medicine. Or who needs the public school system when there are all these elite private schools. The logical conclusion to all this is seen in affluent parts of the 3rd world - gated communities with armed guards, private highways, etc.

The reality is that even people doing pretty well in silicon valley still need at least one sizable exit, otherwise they need to choose between retiring or sending their kids to college.
posted by NoRelationToLea at 1:02 PM on August 11, 2015 [2 favorites]


When my Mum used this a couple of decades ago, I'm pretty sure there was a $10 copay. :-)

That would be more than two decades ago, then, since co-pays have been illegal in Ontario since the early/mid-80s (remember the whole "extra billing" that was all over the news back then? Those were co-pays).

Anyway, this post has left me feeling like a dolt because while I was saying "Who would want to do that instead of going to your doctor" I can see now that I was doing that from a position and assumption of privilege. Obviously people who have mobility issues or chronic illness that makes going to the doctor difficult would want to do that. I just never thought about that because I've never had to.
posted by If only I had a penguin... at 1:03 PM on August 11, 2015


Something I don't understand -- why aren't such services covered by insurance? Is it that these startups don't want to take insurance (because negotiating with the insurers it would impede their profit model), or that the insurance companies refuse to work with them, or that there are regulatory issues that would require them to be classified as paramedics or something if they did (a la Uber skirting being regulated as a taxi)?

I keep thinking what a huge benefit it would be to people who are immunocompromised, people with mobility issues, people who have PTSD triggered by hospitals/dr's offices -- basically anyone who puts off going to the doctor until things are dire. The savings from treating things early & simply (without an ER admission) may very well compensate for the cost of driving from patient to patient. In fact, I sorta wonder why insurance companies aren't creating & pushing such services themselves, at least for patients they know have limited mobility or unusual patterns of ER use.
posted by Westringia F. at 2:02 PM on August 11, 2015 [2 favorites]


The current levels of inefficiency I experience every time I take my kid to the doctor would drive me into a program like this. Even if the program was just "we're going to fucking see you on time, when you made your appointment.

It would be markedly better for me and the kid if his doctor would make a house-call. I'm not exactly sure what my cutoff for pricing would be; if the charge wasn't too bad…yeah, I would totally do this until he's a bit older. Hell, I'd even settle for the ability to text a picture of my kid's rash to a nurse, instead of…*takes a deep breath*…Calling the doctors office, waiting on hold for at least 30 minutes, then getting a last minute appointment made, because jesus christ they can't do anything over the phone for us at all, packing the sick kid up onto the bike (because we only have one car) or if we're lucky, the bus, waiting in the gross waiting room for…goddamnit, sometimes an hour later than our appointment was made for (why do they even bother with appointment times? Its functionally a queue at this point…), get a nurse to show us to our exam room, ask the same questions they've asked every time, then wait another 20 minutes for the doctor to show, then the doctor to tell us 'oh geeze, yeah. here's some steroid cream, you'd better get your ass down to your local pharmacy, because we don't call shit in to pharmacies anymore…you'll probably have to wait there for an hour to get this shit filled! HAHAHAHAHAHAA, SEE YOU NEXT TIME, THIS HAS BEEN A GREAT 5 MINUTES I SAW YOU.'

If I was that inefficient at my job…sweet jesus I'd be fired so goddamn fast.

I would enroll in something like this in a heartbeat because I'm guessing the doctor would be closer to on time than not, and if not, I just get to hang with the sick kid on his home turf, which is markedly better for everyone involved. If my kid's office started offering this, I would sign up immediately.

But on a slightly different tack, I also wonder if this would change the dynamic for a 'doctors office' in terms of overhead. Is there anything in your general GP's medical practice that can't fit inside a mobile unit? Why can't a 'doctors office' just be a decommissioned or non-emergency ambulance? Shit's good enough to keep you alive on the way to the hospital; why not have a checkup in it? I'm not going to even start to think I know how a medical office runs entirely, but if you could outsource your scheduling, wouldn't it be cheaper not to have the overhead of the building in lieu of a big-ass van? It works in the food truck/restaurant dynamic. Why not apply that directly to the doctors office model? Wouldn't this work great for both pretty spread out rural and rather dense urban areas?

All I'm saying is that I'd be just as comfortable eating tamales from a food truck, as I would be getting medical care from one. Maybe not the same one.
posted by furnace.heart at 2:19 PM on August 11, 2015 [2 favorites]


If I was that inefficient at my job…

I think you're missing the point. Your doctor's office IS efficient. That's exactly the problem. They maximized the proportion of your time that was spent interacting with lower-paid rather than higher-paid workers. They minimized the amount of their most valuable commodity (the doctor's time) that you consumed. They externalized as many costs as they possibly could (on to you (wasting your time on hold, not the receptionists, making you wait rather than having enough staff to see people on time) and the on to the pharmacy). Efficiency is achieving in outcome with a little effort and resources as possible. Your problem is not that your doctor's office is inefficient.

The sheer efficiency of it all is exactly what I hated most about the healthcare I received in the US (maybe...there were other things, too). But, related to your other point, what I hated most about healthcare in the US in general (not the care I received), was going into the doctor's office, a practice open only to people with my own kind of insurance, and walking right past a truck/RV providing healthcare to the homeless on the street. I was always thinking "hey, there's a big doctor (super-efficient!) doctor's office right here. Why can't they go in there instead of suffering this kind of indignity?" So I guess I would think it a little weird if people actually wanted to get their healthcare from a truck. I mean I see your point about how it could work, but I associate it so strongly with exclusion that I'm having trouble seeing it as desirable.
posted by If only I had a penguin... at 3:02 PM on August 11, 2015 [3 favorites]


I discovered that home doctors were available in my city after I had a kid, through a Facebook mother's group. Oh my god, it is the best. It's only available after 4pm (presumably because you can go to your regular clinic earlier) but because the service has an app, into which I've already put my family's details, all I have to do is press a button saying "request doctor". They call me within a few minutes to find out what's wrong and then again when the doctor is on the way - so far this has taken anywhere from 15 minutes to 2 hours. No more emergency room visits with a sick and unhappy toddler for us! It's free too, as the service is bulk-billed (I'm in Australia) but I would be happy to pay $70 up front (the cost of a clinic visit, which is partly refunded by Medicare anyway). I haven't really looked into but seeing as there is multiple services, I'm assuming they are run privately rather than being a government thing. I always ask the doctors how they like working for the service and they all love it - it's on call, they get to see the patient in their home environment and one even brings his wife (also a doctor) as a fun couple activity.
posted by Wantok at 7:18 PM on August 11, 2015 [1 favorite]


Yes Wantok, I was just coming in here to say this - my friend worked as a home doctor GP in Melbourne.

It's completely free (all residents have a Medicare card, and foreigners with private health insurance also get to bulk bill it so it's "free" for them too to call) and it's a godsend for anxious parents with young kids who are ill or old grandparents who are ill, and you really don't want to drag them out into the night in search of an emergency room if it turns out it's nothing urgent.

They'll send a doctor to your location, and from what I've heard, depending on the GP network, there's an online thing where they can get patient history (drugs etc) and they can log notes in for your regular GP to follow up on as well so there is continuity of care and knowledge of what drugs you're currently on and what pre-existing conditions they have to look out for.

Apparently every unnecessary ED trip saved to the public hospital system via this home GP thing is a huge amount of money saved for the healthcare system.
posted by xdvesper at 8:38 PM on August 11, 2015


It's interesting to hear the Australian perspective - home visits have been a part of UK GP services since before the NHS, and they are loathed.

We do have a good GP out of hours service (run out of dedicated clinics, often next to but not part of hospital A&Es), but also patients have the right to insist on a GP home visit if they can't make it into the centre. That right is widely abused - a big complaint among my friends is parents who don't want to get their other children out of bed and so claim they can't drive, and when the GP arrives there are two cars on the drive. Or the patient's gone out to the shops.

Emergency home visits are seen as unsafe. There is no access to the patient notes, and you are often assessing acutely sick children by the light of a 40W bedside light, whilst tripping over scattered toys. If the child is actually sick, you do not have the equipment or drugs you would have in a surgery (GPs carry an emergency bag, but clearly they can't carry a nebuliser, blood pressure monitor, ECG machine and all the rest of it). It's also wildly inefficient - you can see 5-10 patients an hour in a GP surgery, or one patient an hour on a home visit. So patients end up waiting 6hrs or more to be visited which is fine if it's just a cough but if it's meningitis they'll be dead.

Non-emergency home visits do add a lot to things like comprehensive geriatric or OT assessments (you get a lot of extra context from a patient's home environment). Nursing home residents, palliative care patients and any other patients who are truly housebound are always seen at home for obvious practical reasons. But it is really not great for proper emergencies - if you're that sick just go to hospital, and if you aren't you'll get a much more thorough assessment in the OOH centre.
posted by tinkletown at 9:44 AM on August 12, 2015


Everyone always talks about the relationship between Doctors and their patients and how vital it is. But I feel lucky if I get to see the same doctor twice. Despite being at the same company for 5 years, every year the insurance changes. Half the time my last doctor is no longer in network and I have to find a new one. My last one told me not to come in for checkups on my chronic illness but then ditched my file when I didn't come in for two years. Every visit is a re-explanation of my entire health history anyway, I'd rather it be in the comfort of my own home. Also, atleast the price is upfront. It has been a hard learned lesson that if you are doing anything with healthcare to get the bill before the service. Doctors and administrators will lie to you about coverage, so you'd better do your due diligence before you get a a $16,000 bill for an unnecessary test.
posted by sidewinder at 10:55 AM on August 16, 2015


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