Return of the House Call

Originally published in Healthcare Dive. 

The days of the kindly, silver-haired doctor with a small medical bag going house-to-house appeared dead and buried, but a new movement is taking shape to return the practice.

The resurgence has a key twist, however, with a heavy dose of 21-century technology.

Healthcare startups have cropped up to provide in-home medical services, including mobile urgent care and doctor appointments. But they’re not the only ones trying house calls. Established providers such as Johns Hopkins are getting into the act and Medicare is testing a home-based primary care model for high-cost chronically ill beneficiaries.

“We see (our house calls) as old-fashioned care with state-of-the-art technology,” Nick Desai, co-founder and CEO at Los Angeles-based Heal, a company that offers the service, told Healthcare Dive.

Mobile urgent care startups now dot the healthcare landscape and big-name private payers like UnitedHealthcare and Anthem, as well as Medicare and Medicaid, are contracting with mobile care companies.

Investors see potential and have put millions into mobile urgent care startup companies. Heal, which offers services in California, Washington, D.C. and northern Virginia, recently announced $20 million in additional funding to raise its total capital collected to more than $69 million.

Mobile care advocates like Desai say providing care in a person’s home is a better alternative than telemedicine or urgent care centers. Both of these avenues are an attempt to offer lower cost settings, but Desai said they are getting in the way of the direct primary care physician-patient connection.

Desai said the healthcare system isn’t going to be helped by “cramming more people into waiting rooms or further distancing doctors from patients.”

Healthcare companies that offer mobile care differ by where they see themselves in the system and who’s making the house calls.

Denver-based mobile urgent care provider DispatchHealth sees itself as supplementing care and as a partner for primary and specialty care. Meanwhile, Heal provides regular care, including primary care, prevention and pediatrics, as well as urgent care.

Johns Hopkins’ Hospital at Home treats patients with pneumonia, heart failure, chronic obstructive pulmonary disease and other conditions.

Home-based models “can be a versatile platform for creating an alternative to skilled-nursing-facility care after hospital discharge, a complement to early-discharge programs, and an option for post-surgical care. And technological advances, such as biometrically enhanced telehealth modalities, will make [them] more viable,”  Bruce Leff, professor of medicine at Johns Hopkins University School of Medicine, wrote in the New England Journal of Medicine.

Leff predicted that the move to value-based care will be a catalyst to “challenge the traditional, facility-based model.”

Longer, but fewer, patient visits

What house calls offer is convenience for the patient, and a potentially longer time with the doctor.   Heal said its average visit is 28 minutes, compared to the national average of 13 minutes.

However, the drawback for a mobile urgent care company is that a clinician sees fewer patients than in an office setting. That means fewer reimbursements. Lower overhead costs is one way to offset that.

Mapping out myriad appointments would be difficult for a human, but mobile care companies have technology that does the work for them. DispatchHealth screens patient appointment requests by using a risk stratification tool that analyzes a person’s age and chief complaint. The proprietary technology maps out the stops based on distance, traffic and a patient’s sickness.

CEO Mark Prather told Healthcare Dive its first market, Denver, has eight vehicles on the road and they can get to most calls within 20 to 25 minutes. “The computer does all that and optimizes all visits to get more visits out of calls per day,” he said.

Heal said it has also removed office-related healthcare costs from the equation. Desai said Heal’s technology platform automates the booking and billing process, which lowers healthcare operating costs and bureaucracy by 65%.

Dispatch expects to care for 55,000 patients this year, which it said would save about $80.8 million in medical costs, such as avoidable 911 transports, emergency room visits and hospitalizations. Heal has delivered more than 60,000 house calls since it launched in March 2015.

Mobile care models vary

Prather said DispatchHealth is designed as a “mobile ER to intervene on acute illnesses” that communicates with the patient’s regular care team. Founded in 2013, DispatchHealth operates in markets in Colorado, Virginia, Arizona, Nevada, Oklahoma and Texas and plans to expand to 10 markets by the end of the year.

A two-person medical team, which includes a medical technician and an ER-trained and board-certified nurse practitioner or physician assistant, go to homes and businesses. They usually arrive within an hour in a vehicle equipped with a certified lab, advanced formulary of medications, IVs and fluids.

Meanwhile, Heal sends a doctor and medical assistant to calls.

Desai said 80% of Heal’s calls are to patient homes. The company also provides employee healthcare. That’s about 15% of its business. The remaining visits are done in senior facilities.

Mobile urgent care is how Heal often acquires patients. Desai said 80% of its users first enter the system through mobile urgent care and then transition to Heal’s primary care, chronic disease management, wellness and pediatrics services.

Social determinants of health

Another potential benefit of mobile urgent care companies: helping providers find potential social determinants of health issues. Payers and providers increasingly see a link between SDOH and overall health outcomes. If a person doesn’t have a car, stable housing or regular nutrition, there’s a good chance they will wind up with health problems.

DispatchHealth includes a SDOH section of its patient report that reviews concerns with primary physicians.

By being in patient homes, mobile urgent care clinicians can spot potential issues, such as smoking, unsafe living conditions and medication issues. For instance, Desai said two-thirds of senior falls are related to medication-related dehydration. Being in the home allows the clinician to review all the medications and make sure they don’t conflict. Conflicting medication can lead to dizziness, falls and hospitalization.

Growth opportunities in senior population

The aging population may be one factor driving the trend.

A majority (60%) of DispatchHealth’s business is in the senior population, which may be redefining on-demand care. “We have a tremendous opportunity to address the healthcare needs in the aging population in a much smarter way,” Prather said.

The U.S. Census Bureau estimates that the country’s senior population will grow to 83.7 million by 2050, nearly doubling. An older population means more chronic illnesses and healthcare needs, leading to more hospitalizations and ER visits.

CMS also sees opportunities with house calls. It is testing primary care services at home through its Independence at Home demonstration. The second year of the program saved Medicare more than $10 million, an average of $1,010 per beneficiary.

Though mobile urgent care is becoming more common, Prather said hospitals shouldn’t worry that it will replace them. Mobile care will be supplemental. There will always be a place for hospitals, but they will increasingly focus on caring for the very ill. Healthcare will need to provide other types of care in lower cost settings, such as the home, he said.

“If you’re a hospital system, you’ve got to look at the landscape and see where it’s headed. It’s not more bricks and mortar,” Prather said.

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