(A version of this Health Alert was published by Forbes.)
“Connected care” refers to a large and growing portfolio of digital tools, from video consultations with psychiatrists to in-home sensors passively detecting when a senior falls to devices that measure diabetics’ blood glucose and send messages to their families’ or doctors’ smartphones when intervention might be needed.
One very valuable service is telehealth, whereby physicians use email, phone, text, or video for consultations, reducing the need for time-consuming in-office visits. The benefit of this is illustrated by the story of Felipe Perez, a patient of the Sharp Rees-Stealy Medical Group in San Diego County, who used to have to take a five-hour long bus and trolley trip to get to his appointments.
However, we should not fall into the trap of all-or-nothing thinking, expecting patients only to see their doctors either in the office or remotely. With a little creativity, we can envision mobile health technology leading to the restoration of an almost forgotten medical tradition: The house call. Imagine the connected doctor travelling to patients as needed, with a portfolio of cloud-enabled diagnostic, therapeutic, and decision-support tools at her disposal.
House calls used to make up 40 percent of U.S. doctors’ visits in the 1940s, before going into decline in the 1960s. These days, they comprise less than one percent of consultations. Many believe that more house calls would increase quality of care at low cost, which led Medicare to launch an “Independence at Home” demonstration project for seniors with multiple chronic conditions in 15 states. Starting in 2012, the project has had promising results.
This invites the question: Why did house calls decline? In a recent tweet, Jay Parkinson, MD, founder of the extremely innovative Sherpaa medical service claimed: “There’s a reason why house calls went out of fashion. Grossly inefficient use of very expensive doctor time + extremely limited capability.”
Dr. Parkinson’s identifying house calls as an inefficient use of doctors’ time is a very limited view of costs in health care. The almost complete elimination of house calls has not increased efficiency, it has only transferred the cost of travelling and waiting from doctors to patients.
Keith Wagstaff of ABC News covered this very well in his discussion of a study estimating the average American lost $43 in wasted time waiting for a scheduled appointment – more than the amount of the out-of-pocket payment! Further, the time spent actually consulting the doctor has shrunk to maybe 15 minutes. So, from a patient’s perspective, the ratio of productive time to wasted time has declined.
Although Dr. Parkinson insists that we also wait in barbershops and lawyers’ offices, I beg to differ. Like most men, I drop in for a haircut, and can therefore ensure I wait at the least expensive time for me. My wife, who makes appointments, would never tolerate waiting as long for her hairdresser as for her doctor. Nor do lawyers keep clients with scheduled appointments waiting for an hour or more to read old magazines in a “waiting room.” (In other sectors of society, they are called “reception areas.”)
The most significant factor explaining the shift in costs from doctors to patients is patients’ having lost control of paying doctors. According to the National Health Expenditure Accounts, private patients (not those enrolled in programs like the military, veterans’ benefits, or workers’ compensation) paid 67 percent of the aggregate bill for consultations in 1960. By 2014, that had collapsed to 11 percent. Private insurance increased to half of spending on physicians in 1992 and has stayed around that share since. By 2014, Medicare paid 27 percent, and Medicaid and Children’s Health Insurance Program 13 percent [Chart I].
As patients’ lost control of payment, they lost the ability to signal how much they valued their time, and house calls declined. Remarkably, this was over a period when people’s time became more valuable as our incomes increased, and our tolerance for queuing and visiting different vendors shrank. This is one reason for the rise of department stores, supermarkets, and (later) big box stores.
Remarkably, Dr. Parkinson’s own business, Sherpaa, is a solution to this problem:
We’re doctors and insurance guides, empowered by our first-of-its-kind secure communication and care coordination platform, who diagnose, treat and partner with your employees to get them better fast.”
Sherpaa uses innovations such as mobile technology to deliver faster, better care to clients’ employees. Those clients don not care about the doctors’ time. They care about their employees’ time.
As long as we allow the system, instead of patients, to control spending on doctors, house calls and connected care of all types will struggle to maximize their value.