URGENT MESSAGE: The proliferation of smartphone-accessible, on-demand healthcare services delivered to patient homes has received a lot of media coverage recently, but the “UBER” model is hardly a practical replacement for walk-in urgent care.
Alan A. Ayers, MBA, MAcc is Vice President of Strategic Initiatives for Practice Velocity, Practice Management Editor for JUCM—The Journal of Urgent Care Medicine, and a member of the Board of Directors of the Urgent Care Association of America.
Uber is a popular “ride-sharing service” which leverages “GPS-equipped smart phones” to match consumers’ needing local transportation with enterprising drivers who have cars and excess time on their hands. Focused on the functionality of the app and the capabilities of cellular technology, entrepreneurs are now translating the concept to medical practice—delivered on-demand to consumers (patients, in this case) at the location of their choice.
Despite high-profile articles in the Wall Street Journal(1), The New York Times(2), and Forbes(3) touting these “healthcare innovations,” the challenge is that the delivery of urgent medical services is far more complex than hailing a taxicab. “Analysts say it’s unclear whether many of the new on-demand services will reduce costs…or mainly make it more convenient for the healthy and wealthy to get care they could have gone without.”(1)
It’s not insignificant that these services have started in the affluent, high-density neighborhoods of Los Angeles and New York. And from the standpoint that the wealthy and powerful residents of Beverly Hills and the Upper East Side have always been able to get a doctor (or just about anyone else, for that matter) to visit their homes to meet their every need, the concept is nothing new. Now, rather than picking up the telephone, they merely summon a doctor on their smartphone.
But for the masses, a black-bag toting Marcus Welby, MD who would make home visits for coughs, colds, flu, ear infections, and other conditions has not existed for over 50 years because today’s physicians do not have the time, the energy, or the resources to travel to each patient’s home. And because these services are not reimbursed by insurance, they are also beyond financial reach of average Americans in need of medical care.
Perhaps reminiscing about the good ol’ days has some people thinking this new technology is “pretty cool,” especially when the doctor comes toting not a black bag with stethoscope, mercury thermometer, and reflex hammer, but rather an array of pocket-sized devices that can take a patient’s vitals, conduct lab tests, and dial in specialists…instantly.
The ability to get a personalized medical encounter without leaving home should be considered a threat by conventional family and urgent care physicians, but “many of the services that bill themselves as an ‘UBER for healthcare’ haven’t sparked the kind of opposition from traditional doctor practices that the ride-sharing service has from taxi drivers.”(1) Perhaps physicians realize the reach of these emerging services is so thin, so niche, that they don’t see them as disruptive to conventional medicine. Or, they may just be so bogged down with patients and the administrative needs of their own practices that they aren’t paying attention.
Why You Should Care, for the Patient’s Sake and Your Own
Physicians and policy makers should be concerned about the quality of care being offered. In the home, there are no clinical controls over the safety of the environment. Some of the services advertised involve procedures, such as casting and laceration repair. Questions about the wisdom (and safety) of this abound:(5)
Where would these be done—on a patient’s kitchen table?
What infection control provisions are in place?
Is there proper lighting?
Air filtration?
Supplies and equipment to deal with unanticipated emergencies?
Will a chaperone be present?
What safeguards are in place to protect the patient and the doctor from the possibility of a sexual harassment claim that could jeopardize the physician’s license and reputation?
Is there physical security to prevent robbery or assault by drug seekers?
An unsupervised visit to a patient’s home environment is wrought with risks for both patient and medical provider.
Concerns over patient safety motivated the Texas Medical Association and other physician groups to support restrictions on the delivery of telemedicine services in that state, requiring doctors to establish a relationship with patients before giving a diagnosis or prescribing drugs, with the Texas Medical Board ruling that “questions and answers exchanged through email, electronic text, or chat or telephonic evaluation of or consultation with a patient are inadequate to establish a doctor-patient relationship.”(4) The move significantly tightened rules that already preclude video consultations except under a narrow set of circumstances.
Particular Concerns for Urgent Care
Clearly for urgent care, a clinical setting with access to necessary diagnostics, supplies, and imaging technologies for treatment is far superior. Carrying all of the tools of a medical professional in a vehicle and bringing that enormous “travel med bag” into a home to treat an acutely rising illness or injury is simply not realistic. But the biggest policy question posed by the model of Uber-like medical services is, “Is this really the most efficient usage of provider resources?”
Uber solves an economic problem—it matches a need (people wanting transportation) with capacity (people who have idle vehicles and time). To the extent that Uber can move people more cost-effectively and with better customer service than taxicabs, it delivers value to consumers and provides income for entrepreneurs. But this same economic problem generally doesn’t exist in medicine because there’s a shortage (not an excess) of primary and urgent care physicians (see Table 1). Therefore, Uber-like medicine is less of a business need being solved by technology and more like a technology in search of a problem to solve.
To use a retail analogy, a concept exists called the “long last mile home.” This means the most costly segment of the supply chain is delivering a product to someone’s front door. Generally speaking, even with the most efficient pick, pack, and ship operations, it’s always cheaper for consumers to drive to a store like Walmart or Costco and buy items off a shelf than to pay for delivery via FedEx or UPS.
A grocery home delivery service in a high-density urban area is a luxury and a real convenience for the rich who can afford the service. But it’s not a solution to the nation’s hunger problems. Likewise, doorstep medical providers are not a solution to the nation’s healthcare problems, which include rising costs and a growing scarcity of physicians, especially in low-density rural areas.
Considering even the most efficient Uber-like model of home visitation utilizing sophisticated software for routing, the provider still has to drive to a home, unpack supplies, set up equipment, then treat the patient, only to repack and still document the visit. At best, a provider could see one, maybe two patients per hour. By contrast, a provider in a highly efficient urgent care center can see three or four patients per hour.
So, what does Uber medicine look like? “Right now the house call services are not hyper localized. That is you can’t see where the doctor is in relation to you by looking at the app on your cell phone. Also, unlike Uber, they don’t automatically connect the closest doctor with the closest patient.”(3) In addition, “the house call doctor does not have access to your electronic medical history.”
This is not a picture of efficiently delivered medical care.
If Uber-like medicine were to be implemented on a large scale, the most likely outcome (given the less efficient use of clinical labor) would be higher, not lower, costs for the U.S. healthcare system.
However, there might be a role in Uber-like medicine in reducing the cost for caring for the nation’s aging population, patients less capable of coming into an urgent care center and who rely on ambulance transportation and emergency departments for acutely rising, but non–life-threatening conditions. If Medicare would pay for it, there could be a fleet of geriatric, Uber-like medical providers with their own patient rosters, since the rising number of elderly patients will need more monitoring and more care.
For the homebound elderly—and as a luxury service for the wealthy, which is nothing new—the new Uber-like medical technology can add convenience, assuming they can pay for it out of pocket. However, lasting solutions for the nation’s healthcare woes require utilizing resources most efficiently on a consistent basis, which includes encouraging more people to undergo physician training, and utilizing the physicians we already have in the most efficient manner. That would induce more urgent care centers working in conjunction with EDs to offer efficient care for the entire patient population―which includes all of us at some point in time.
Table 1: Severity of the Nation’s Primary and Urgent Care Physician Shortage
Physicians are a finite resource in the US. Currently, the nation faces a primary care physician shortage. A March 2015 study entitled “The Complexities of Physician Supply and Demand: Projections from 2013 to 2025” by the Association of American Medical Colleges demonstrates that demand for physicians continues to grow faster than supply:
- Total physician demand is projected to grow by up to 17%
- By 2025, demand for physicians will exceed supply by a range of 46,000 to 90,000
- Total projected shortages for 2025 vary by specialty grouping and include
- A shortfall of between 12,500 and 31,100 primary care physicians
- A shortfall of between 28,200 and 63,700 non-primary care physicians, including
- 5,100 to 12,300 medical specialists
- 23,100 to 31,600 surgical specialists
- 2,400 to 20,200 other specialists
The study concludes, “The physician shortage will persist under every likely scenario. Because physician training can take up to a decade, a physician shortage in 2025 is a problem that needs to be addressed in 2015.”
Link: https://www.aamc.org/download/426242/data/ihsreportdownload.pdf. Accessed August 29, 2015.
References
1. Beck M. Startups vie to build an Uber for health care. Wall Street Journal. August 11, 2015. Available at: http://www.wsj.com/articles/startups-vie-to-build-an-uber-for-health-care-1439265847. Accessed August 29, 2015.
2. Jolly J. An Uber for doctor housecalls. The New York Times. May 5, 2015. Available at: http://well.blogs.nytimes.com/2015/05/05/an-uber-for-doctor-housecalls/. Accessed August 29, 2015.
3. Goodman JC. What does Uber medicine look like? Forbes. July 24, 2015. Available at: http://www.forbes.com/sites/johngoodman/2015/07/24/what-does-uber-medicine-look-like. Accessed August 29, 2015.
4. Goodnough A. Texas medical panel votes to limit telemedicine practices in state. The New York Times. April 10, 2015. Available at: http://www.nytimes.com/2015/04/11/us/texas-medical-panel-votes-to-limit-telemedicine-practices-in-state.html?_r=0. Accessed August 29, 2015.
5. Allen J. Denver-based dispatch hopes to be Uber for health care. ABC-7 News, Denver. August 12, 2015. Available at: http://www.thedenverchannel.com/news/local-news/denver-based-dispatch-health-hopes-to-be-uber-for-health-care. Accessed August 29, 2015.
