There was a time when a person could ring up the doctor’s office and arrange for their physician to see them in their home. The image of the black bag-toting doctor was ubiquitous in primary care. But that changed as the healthcare system evolved and medicine became more high-tech. Now, the house call is trying to make a comeback via a slew of apps that promise convenient, same-day diagnosis and treatment at a fixed price.
But one question lingers: Is it the best way to use physicians’ time and skills?
Some say house calls are time-sucks
“House calls for physicians are more convenient for patients and they allow the doctor to avoid the overhead of a physical office,” Harvard health policy professor Ateev Mehrotra said via email. “However, they are inherently inefficient because the visit reimbursement has to cover both time of the doctor in the visit and the travel time.”
Physician Jason Parkinson, who launched a solo practice offering house calls in New York City in 2007, agrees.
Writing in the online magazine Quartz, Parkinson says up to 60% of his day was spent traveling between apartments in two neighborhoods and to and from the pharmacy or his apartment for supplies and vaccines. While a typical primary care doctor can see about 30 patients a day in the office, the maximum number he saw in a day was eight.
“Doctors already spend roughly 40% of their day documenting and doing other administrative tasks,” he wrote. “To waste the other 50-60% of your day traveling between patients is a 50-60% reduction in efficiency.”
Parkinson adds: “Short of teleportation, the doctor house call will always be an irresponsibly massive reduction in primary-care efficiency.” He has since co-founded a digital healthcare service called Sherpaa, which provides online consultations for patients.
Triage is essential for success
Andrew Chomer, vice president of marketing for Uber-offshoot Pager, acknowledges the concern, but believes there is a sustainable model for house call apps.
“If it was just a house call service, that time is kind of inoperable,” Chomer tells Healthcare Dive. Pager’s doctors use Uber to get to and from patients, so travel time is frequently used to follow up with patients or for a telehealth call.
Pager’s platform offers three possible care paths. As soon as they hit the button on the app, the user is connected with a nurse who assesses what the problem is and the level of care that is appropriate. If the issue can be handled by a phone call or videoconference, then it is triaged to telemedicine. If it can’t be resolved via phone or internet chat, the next step is to consider a house call. If Pager doesn’t feel the problem is within the scope of its services, the patient is referred to a specialist or emergency room. The company, which operates in and around New York City using its own medical practice, has partnerships with Weill Cornell Medicine and New York Presbyterian Hospital.
Chomer says about 60% of calls are handled by telemedicine and 40% are house calls. Overall, about 10% lead to referrals. Pager, which fielded “in the tens of thousands” of calls from individual and enterprise clients last year, boasts a 99% customer satisfaction rate.
Triage is essential if physician house call businesses are going to succeed, says Gorkim Sevinc, managing director of Johns Hopkins Medicine Technology Innovation Center, who doesn’t want to see healthcare “commoditized like a cab ride.”
Not all health concerns require an actual doctor visit, so the question is “how do we become a little bit more smart about deciding who should be seen and who should not be seen?” he says. Not every house call app provides a filtering process.
Sevinc also worries the rise of house call services like Pager, Mend, and Dispatch Health will erode the traditional patient-doctor relationship.
“The biggest thing about a primary care [physician] and a patient is to start to establish trust and have a relationship between them,” he says. While these apps are great and they fill a certain demand demographic (the individual can’t venture out, they need to see someone right away), in most instances “I would prefer to go to my PC because I have an established relationship with them,” Sevinc adds. “How am I going to establish a relationship when I am swiping left and right on an app?”
As more of these apps spring up across the country, there are other concerns, too, such as patient safety.
“Some of these services that are talking about being able to sew someone up at their kitchen table — is that a sanitary environment? Is the lighting good? Is the proper equipment available to handle some type of medical emergency that might occur?” urgent care expert Alan Ayers asked ABC 7 in Denver.
Spared no expense?
Patient access is also an issue. On the one hand, house calls lower the barriers to access by allowing anybody to request a doctor and have them there quickly. On the other hand, most, if not all, are not covered by insurance and require cash payment upfront. For an in-patient visit, Pager charges $50 the first time and $200 for each subsequent visit. Other companies report fees in the $150-$200 price range.
The issue comes back to value and the best use of doctors’ time, says Sevinc. “If I’m paying out of pocket for this, if my insurance is not covering it, what is that sweet amount that I am okay with paying that is also value enough for the physician to actually travel to me?
The insurance picture may be changing. According to Chomer, Pager is in the process of becoming in-network with some “well-known” carriers and expects to roll that out in the third or fourth quarter of this year. The company is also looking at possible opportunities with Medicare and Medicaid in the future, he says.
According to Healthcare Finance News, the American Academy of Home Care Physicians estimates that home-based primary care could save Medicare between 20% and 40% by preventing unnecessary ER visits. If you figure that one diverted ER visit saves about $1,500, then that would offset 10 house calls, the group said.
That still doesn’t resolve the basic question of whether house calls are an efficient use of primary care doctors.
“Everyone talks about Uber for healthcare, which is great,” says Sevinc. “Healthcare needs to be modernized, and a lot of startup companies are trying to do this, but we need to do so without lowering the value of our healthcare providers.”