Worklife Doctor on demand How app culture is reviving the house call
Alison Mintzer and her family were on a flight from New York to Los Angeles when her daughter complained that she felt sick. By the time they landed, Mintzer’s normally uncomplaining six-yearold said that her neck and ears hurt. When a fever soon followed, it was enough to convince her parents that she needed to see a doctor.
Thousands of miles from their pediatrician, and unable to find one quickly in L.A., Mintzer didn’t know what to do. Then a family friend suggested an app called Heal that could use new technology to drum up a relic from the past: doctors who make house calls.
Once upon a time, a visit with the doctor meant welcoming one into your home, rather than heading out to a clinic or hospital waiting room. But around the 1960s, the house call fell out of favour as doctors’ offices sought to become more efficient, and the doctorpatient relationship changed from Marcus Welby to something less personal with the rise of hospitals and modern insurance plans.
Now, however, the trend for on-demand service in the age of Uber could revive the house call. Services such as Heal – which launched in the D.C. area in June after operating in California since 2014 – and competitors such as Pager and Curbside Care are expanding their footprints across the U.S. And research suggests that house calls can provide a Eight-year-old Claire Bennett watches as Dr. Adam Lowry examines her at her family’s home in Great Falls, Va. better standard of care for some patients than a hospital visit. A University of Southern California study of a house call program in the state found that hospitalization rates dropped for patients who were enrolled in the program for six months: of 1,000 patients, 96 were hospitalized after being enrolled, down from 159 before the program.
Costs can also drop, since patients can avoid hospital visits. A 2013 Brookings Institution report said a Department of Veterans Affairs analysis of its home-based care program found a “25 per cent reduction in hospital admissions, a 36 per cent reduction in hospital days, and a 13 per cent reduction in combined costs.”
The chief executive of Heal, Nick Desai, co-founded the start-up with his wife, Renee Dua, a physician. Their own parental trip to the emergency room inspired the service, after the couple, unable to contact their regular pediatri- cian, sat in an emergency room for seven hours with their feverish three-month-old son.
“My wife turned to me and said, ‘There’s got to be a better way,’” Desai recalled. So Heal was born – a service that can work with patients’ insurance. For those without insurance, a visit costs up to $99.
“Our No. 1, main goal is that, five years from now, you won’t have to go to the doctor’s office,” Desai said.
That’s certainly been the case for Tony Rogers, a 57-year-old Heal patient in Orange County, Calif., whose health problems have made it progressively more difficult for him to leave his home. Just after Christmas in 2015, he decided he’d paid his last visit to the doctor he’d seen for 35 years, because it was too hard to get to the office. His sister found out about Heal online and recommended it to him.
Rogers said it has been a revelation. He can now see a doctor on his front porch; he even had an ultrasound taken in his own bed. When he received a diabetes diagnosis, his physician took an immediate audit of his kitchen, pointing out which foods were fine to eat and which weren’t. She was also able to look at the laundry detergent he was using and recommend brands that would not irritate his skin.
“She told me, ‘This is good, this is not.’ It was a really nice teaching experience,” Rogers said.
For others, the fact that Heal appointments can easily fit into their lives is key. Barbara Bennett, director of the D.C. market for Heal, recently used the service to schedule a last-minute physical at her Great Falls, Va., home for her daughter, Claire. An appointment with her normal pediatrician would have required waiting at least a week – past the deadline to submit forms for summer camp. With Heal, Bennett scheduled a same-day appointment.
The convenience was a big plus, she said. “I didn’t feel drained. I hadn’t sat in traffic. I just picked up and kept going on with the day,” she said. And the forms? They arrived that night, allowing her to turn everything in on time.
There are many things Heal and other on-demand doctor apps can’t deliver. For one, apps are not a substitute for emergency care. (They can cut down on unnecessary trips to the emergency room – which advocates say is a benefit of the service.) If patients input symptoms into Heal that indicate an emergency, they will be directed to call 911. At a patient’s home, doctors can provide a range of standard care but can’t cart around heavier or more complex equipment, such as an MRI ma- chine. Nor can they do something major, such as surgery or procedures that require highly specialized equipment or expertise.
Heal also isn’t a solution to providing care in places where doctors are scarce, as its current markets are heavily urban. Desai said Washington is an attractive market in part because of its density and its transient population, which means there are probably a lot of people in the area who don’t have a regular primary-care doctor.
And finally, while some people, such as Rogers, have used Heal for consistent care, Heal isn’t specifically designed for intense, long-term care in the home. But other house-call programs, such as Hospital at Home at Johns Hopkins University’s medical school, have demonstrated many of the same benefits that Heal claims for its patients.
Mattan Schuchman, a Johns Hopkins physician specializing in geriatrics, makes regular monthly or bimonthly house calls to housebound patients. Programs such as his, he said, are more specialized to treat those with chronic conditions.
“I do think we are set up to be more of a primary-care service,” he said, particularly for house-bound patients who need consistent attention. He agrees that house calls give doctors more context and can help them build better relationships with patients, if a service allows for them to see the same physician regularly. In his experience, house calls always give doctors more time with patients than appointments in a clinic.
Desai said Heal doctors see an average of 14 patients a day, which works out to slightly less than the weekly average estimated by the American Academy of Family Physicians. For Schuchman and other doctors who make house calls, that’s a positive. But it can be an economic challenge for doctors who give up practices where they can charge by service and see patients in rapid succession.
Plus, house calls involve travel, which can feel like wasted time, said Eric Topol, a physician and director at the Scripps Translational Science Institute. While Topol is a strong proponent of house calls, he notes that this was one reason they fell out of fashion in the first place.
“Efficiency was a big part of the equation,” Topol said. “And it’s not efficient for doctors to be roving around like an Uber or Lyft driver.”
— Nick Desai, chief executive of Heal
For Mintzer, the close relationships emphasized by Heal turned out to be a potential lifesaver – though in conjunction with a more traditional hospital experience. The on-demand physician not only treated her daughter but also was concerned enough to come back the next day and urge the family to seek further treatment for their six-year-old from a specialist.
The doctor told Mintzer about a lump and said he believed an ear and throat infection had caused an abscess in her daughter’s throat that needed further inspection. Without the Heal doctor’s advice – something more personal than she might have gotten in urgent care, Mintzer said – she would not have known to take her daughter in as quickly.
“We got her into the hospital and onto her IV antibiotics earlier than we would have,” Mintzer said. “Without that, it would have gotten worse much faster.”