Let’s get the disclaimer out of the way:
We love Uber.
As physicians with roots in the Bay Area, we use Uber all the time. The service is convenient, (usually) swift and consistently pleasant. With a few taps of a smartphone, we know where and when we’ll be picked up — and we can see the Uber driver coming to get us in real time.
When the vagaries of San Francisco public transit don’t accommodate our varying schedules, it’s Uber that’s the most reliable form of transportation. (It might be that we like having some immediate gratification.)
So when we caught wind of the news that Uber’s founding architect, Oscar Salazar, has taken on the challenge of applying the “Uber way” to health care delivery, there was quite a bit to immediately like. From our collective vantage point, Uber’s appeal is obvious. When you’re feeling sick, you want convenience and immediacy in your care — two things Uber has perfected.
And who wouldn’t be excited by the idea of keeping patients out of overcrowded emergency rooms and urgent care waiting rooms? The concept of returning those patients to their homes (where they can then be evaluated and receive basic care) seems so simple that it’s brilliant.
Even better, in an era where health care costs are on the minds of many, Uber’s financial structure offers the promise of true price transparency for consumers — a rarity in current American health care. Imagine a system in which, from day one, patients understand how much their care will cost them. That’s the kind of disruptive innovation for which there’s already considerable market demand (as evidenced by the other players in this space); its potential to effect a sea change in health care delivery is even greater.
As physicians deeply immersed in the health policy and innovation arenas, we naturally “get it.” So, then, are we cheering for Uber Health?
Lest you lump us in with Jessica Seinfeld, however, allow us to explain ourselves.
Our concern rests on the potential negative externalities that a disruption like Uber, previously validated in a rational market, can generate when introduced to an irrational one, like health care.
In American medicine these days, many of us are hard at work trying to bend the proverbial cost curve. Considerable research suggests that we can generate significant savings through early, aggressive management of medical problems in the primary care setting — before they lead to the emergency room visits, disease progression, inpatient hospitalizations and subsequent complications that cost billions.
The “Uber way” might tackle part of that challenge, through the avoidance of those expensive ER visits (and, by extension, potential hospitalizations). By encouraging one-off visits from physicians at home, however, that model ignores the longitudinal primary care component that enables the execution of that prevention strategy.
In doing so, it fails to capture a critical aspect of the existing value proposition in health care delivery. Most people, after all, wont’ be calling Uber for an elevated cholesterol level or a screening colonoscopy.
For what it’s worth, other actors in the health innovation arena understand the necessity of that longitudinal component. The blossoming concierge medicine industry offers a primary care home with exclusivity. Meanwhile, health care startups such as Iora Health (where one of us works) and One Medical Group promise radically re-envisioned primary care clinics as a critical element of the next social transformation of American medicine.
Still others, such as Sherpaa and the health insurance startup Oscar, coordinate services similar to the Uber home visits but within the context of insurance coverage, embedding those visits into a comprehensive model of integrated primary and secondary care.
Technological innovation, at face value, is an incredible tool for social change. Many of the nation’s hottest startups often make a moral (or “solutionist“) argument for their work. At times, the products they offer can appear more like innovation for innovation’s sake — technology that is created for no obvious social purpose. But we choose to consider an alternative argument.
We posit that technology has vast potential as a social good — potential that as of yet remains unrealized. The “Uber way,” if considered carefully with a robust medical “home” (be it the patient-centered medical home or otherwise) at its center, could produce positive externalities that impact the lives of millions.
Without that core, however, the Uber model runs the risk of becoming yet another example of innovation forged in a vacuum, providing health care on demand — and ignoring the need to contextualize that care within the longitudinal narrative of one’s overall health. We thus offer a path to mitigate that risk for “Uber Health’s” future customers — and that’s a solution for which we’d be willing to wait.
And let’s not even get started on surge pricing during flu season.
Ali Khan, MD, MPP is an internist at Yale-New Haven Hospital and a clinician-innovator at Iora Health. He currently serves as the chair-elect of the American College of Physicians’ National Council of Resident/Fellow Members.
Tasce Bongiovanni, MD, MPP is a Robert Wood Johnson Foundation Clinical Scholar at Yale University and a surgical resident at the University of California, San Francisco.
Ali Ansary is the founder of SeventyK.org and a senior medical student at Rocky Vista University.
This post originally appeared in The Huffington Post.
extremely great post, i certainly really like this web site, go on it
Actually, there is a real Uber for doctors. And it was co-created by one of the original Uber team (Oscar Salazar). It’s called Pager. And you can get more info about it here: http://getpager.com. And here: http://prn.to/V7QgoV.
“The state and federal governments account for 44% of national healthcare spending”
So we can agree that that doctors work in a system that is NOT mostly funded by the government.
“Yes, there are incompetent lawyers (many of them government funded) whose incompetence gets people wrongly sent to jail.”
So we can also agree that incompetent lawyers CAN cause serious harm – more than just refiling a case or eating fees. And that doesn’t even take into account civil issues such as loss of custody of a child, or harm to a business, etc.
As for whether most people who are in jail should be in jail …. We incarcerate a lot of people in the US – some for petty drug crimes or other minor crimes. While I am all in favor of keeping violent felons; murderers, rapists, armed robbers, etc. locked up, I think we go overboard on some guys/gals who have a weakness for grass, alcohol, etc.
The phenomenon in medicine is called over treatment. The same phenomenon in law is called “mandatory sentencing guidelines”
Very interesting article and I agree with the general thesis here.
However, it is important to note that the ‘Uber for house calls’ model, much like the retail clinic model, is not meant to replace the PCP but rather should be viewed as a supplement to be used as appropriate when going to a PCP or an ER is neither practicable nor necessary.
The real problem lies less with these delivery model innovations and more with the psychology of individuals who chose to forgo a longitudinal PCP relationship and instead focus on simply treating acute (and what they view as isolated) conditions as quickly as possible. Changing the way people think about managing their own long term health is the key issue.
That said, I very much believe there is an important place for this type of innovation particularly as a supplement to traditional delivery models.
30 years ago, when we picked our Pediatrician, I asked a Pediatric Resident who her choice would be.
She gave me the name of a Pediatrician and she told me that he was a very good Pediatrician and if my child was ill, he would take good care of them. But she also said that he didn’t have a very good personality and some parents didn’t like him.
That proved to be true, my wife came not to like him personally – but we continued to use him as our Pediatrician. There were a number of incidents where he made the diagnosis more quickly and accurately than one of his partners who was covering. These incidents convinced us that, despite his personality deficiencies, he was the Pediatrician for us.
If you kid isn’t seriously ill, it doesn’t really matter what treatment is provided, your kid will get better. However, if your child is seriously ill, you want the best skills, not necessarily the nicest personality.
And now my daughter uses him for her daughter – a tribute to his skill as a Pediatrician, not to his personality.
“And let’s not even get started on surge pricing during flu season.”
Uber’s surge pricing on New Year’s Eve or during a snowstorm is gouging pure and simple. It’s the equivalent of Home Depot quadrupling the price of lumber after Hurricane Dandy or a gas station charging $25 or $30 per gallon for gas during a shortage. I would probably actually pay Uber’s fare under these circumstances but then I would go out of my way to NOT use them during more normal times which, of course, is most of the time.
On the other hand for events that are scheduled long in advance like the Super Bowl, a college graduation weekend, a major convention and the like, it’s perfectly legitimate for hotels and airlines to significantly increase their rates and fares over the normal charge because people are aware of it well ahead of time and know to expect that hotel rooms and airfares will be much more expensive during those times of peak demand.
As for getting an appointment with a PCP or an NP on short notice, we already have urgent care centers that serve walk-ins as well as the retail clinics that can usually treat simpler medical complaints. For a more detailed discussion with a PCP, my preference would be to pay them like lawyers – X dollars per hour. Then I can book as much time as I think I’m likely to need and the doc could schedule that amount of time on his or her calendar.
Finally, with respect to the wellness issue, there is an article in the most recent issue of Health Affairs which discusses the experience at PepsiCo. The bottom line is that wellness does not save money on healthcare costs but disease management does.
Thank you for pointing out the Pepsi study.
To be more precise, the return on Pepsi’s wellness work, over 7 years, was $0.48 for every dollar invested. If you took into account the fees paid vendors and benefits consultants, it would likely be a negative number.
The import of the Pepsi work is clear: you can only save medical care dollars by finding ways to improve the care of the people who are actually spending them. .
All of the technology in the world won’t change the fact that a good doctor is a good doctor, regardless of how patients reach them.
In a large clinical environment, efficiency and quality control is *critical*. But primary care doctors’ job involves a lot more long-term relationship building that can complemented (not replaced) by certain technologies.
– Nate –
You seem to be salivating at the prospect of being able to rate physicians – those mean, uncaring, corrupt people (who have failed you so many times). You want to be able to have people “jamming their own smartphone-based, consumer-driven rating system down the industry’s throat”.
And I believe that one important element of medical care is patient satisfaction. However, beware of what the ratings actually tell you. One of the best ways to improve patient satisfaction is to give patients what they want – regardless of whether it is good medical practice:
– Patients who have just received a large prescription for OxyContin are typically very satisfied.
– Patients leaving a “Doc in the Box” with antibiotics for a viral infection (which is not treated by antibiotics) are also typically very satisfied.
The fact is that the current Internet physician rating systems are worse than useless. Most physicians have been rated by too few patients for there to be any statistical significance. And there are companies out there that, for a fee, will fix your ratings – i.e. some ratings are corrupt.
It is also well known that the patients that fill out ratings tend to be either very happy or very disappointed. The vast majority of patients, whose experience has been neither superb nor dismal simply don’t fill out the survey. I have received letters from patients touting me as the next best thing to Jesus and ones telling me I am a step down from Saddam Hussein.
So enjoy your new found feeling of power. Just don’t make the mistake of believing your own sh#t.
Sorry you had to stoop to profanity to make your point. It’s likely left your useful vocabulary exhausted.
As for your lament about the tiny proportion of patients gaming the system to get drugs, we don’t have to talk about the criminals in white coats (both physician and pharmacists) enabling them. Yes, the rating systems are indeed deficient, but it isn’t going to stay that way.
Lamenting the poverty of rating systems was a virtual gospel for American car company executives in the latter 20th century, as Consumer Reports and JD Power were consistently demonstrating what garbage US auto manufacturers produced. Auto execs were blithely dismissive of the little black and red dots and the satisfaction awards until one day they and we woke up and realized that the American consumer was sick of buying junk.
By then, however, the damage was done: we were stuck with a bloated, arrogant, dysfunctional industry that was selling people a bill of goods instead of delivering the goods. And, lo and behold, it was deemed too big to fail. So, instead a good old-fashioned capitalist housecleaning, we were treated to bailouts and investment losses by the government on behalf of taxpayers and consumers. Now, that would never happen in healthcare would it?
Does this mean you won’t be inviting me to your birthday party?
And I actually agree with you about wellness programs. Most of them are a bunch of “shoot” (don’t want to offend your tender sensibilities)
However, I will repeat – if you are looking for a good doctor, don’t pay too much attention to the online reviews. The validity of these is VERY MUCH in question.
When and if online ratings of doctors are ever performed the way that Consumer Reports and JD Power rate cars, I will be interested in what they report.
My dear departed mother was very firm in her convictions about the quality of hospitals:
“I knew it was a good hospital. The girl who drew my blood was very good and the floors were clean”
Of course you can come to my birthday party. Just bring a really good Scotch (both blends and single malts are welcome) and some mixed nuts. We can get toasted and curse at each other then.
We are in agreement that ratings today are too weak to be credible and useful. In my upcoming e-book, Your Personal Affordable Care Act, my advice on how to find a good physician is to do detective work, starting with talking to people whose life situations mirror your own, to learn which providers they use, like and trust.
This does not, however, absolve the profession and the industry of blame for not helping a meaningul ratings system evolve. You can hide behind the “oh-we’re-doctors-and-we’re-just-so-special-that-you-can’t-rate-us” canard for only so long. Physicians are vendors, fixers, people providing a commodity service for the most part (a billion physician visits in the US annually and the number one diagnostic code on claims is “cough”).
Consumer Reports and JD Power succeeded because of volume in the case of CR and sampling methods in the case of JDP. One of those two obstacles is going to be overcome in the next five years, and it will be great to see poorly run medical entities dry up and blow away, which is the way the market should work.
My mom, too, understood the value of the aesthetics. She was not hospitalized much in the years before her death, but was in physician offices frequently. Her metric? Were people polite, funny, engaging? They often were not, acting as though they were doing a favor when caring for this incredibly hard working woman who was dying a hard death. I haven’t forgotten.
Thanks for spelling my name correctly.
(I presume it is Vikram)
To ask that all people in the Medical field be funny and engaging is unrealistic. I think it is reasonable for patients to expect to be treated courteously and kindly. But there are some very good doctors who are simply not funny nor engaging. That doesn’t mean that they can’t do a good job.
And, you need to look at it from the other side too. Some of the patients we see aren’t so great either. Its hard to be “chipper” when seeing patients who are drug seekers, non complaint and just downright unpleasant. Of course that does not absolve us of our responsibility to treat them in a courteous and professional manner. But it does tend to make being funny and engaging harder.
I’m told that most people choose doctors, especially PCP’s, based on the three A’s – affability, availability and, last and least, ability. I define ability in the PCP context as both diagnostic ability and communication skills. That would be my top priority with availability (able to get an appointment on a timely basis) second with affability a pleasant addition if it’s there but not critical if it isn’t.
In the case of surgeons, I would even be willing to tolerate some arrogance if the guy is really good at surgery. For inpatient hospital care, patients often don’t know and have little or no role in choosing radiologists, anesthesiologists, pathologists and ER doctors.
Regarding patient reviews, I once checked to see if there were any reviews for my longtime cardiologist / PCP. I think he’s an absolute genius and a great guy who seems to know everything and has a wide network of very capable specialists to refer me to when needed. He has taken great care of me and many of my former colleagues as well all of whom think he’s terrific. The one review that I found was extremely negative. As they stand today, I put little stock in patient reviews or patient satisfaction scores.
Like many medical care professionals, the authors see the value of social media much differently than do critics like me who’ve been in this industry for decades and think that, for the most part, it sucks. It costs too much, is too complex for average folks to navigate successfully, is an utter and abject failure at population health, and is too dependent on a professional class that, outside of celebrities and athletes, is the most richly compensated in our culture. That prima donna mentality has not prevented physicians from continuing to believe that everything thing is about them and their artifices like let’s “produce positive externalities that impact the lives of millions.” Are you kidding me?
Social media’s biggest value in healthcare is not cultivation of “a robust medical “home” (be it the patient-centered medical home or otherwise)…” Rather, what social media should be helping us do is blow up provider (and plan) expectations and comfort zones.
What Uber ought to do is create an instant rating system for healthcare providers and health plans, so that consumers could pinpoint quickly and efficiently both the jerks and the gems and provide an instantly recognizable badge of achievement that tells other users whether the service received provided a perceived value commensurate with the cost. Were the people providing the service rude and unhelpful or did they go above and beyond the call of duty? Did the hospital’s app say that the wait was only 15 minutes, but it turned out to be 2 hours without any explanation at all to everyone jamming the clinic waiting room? Did the doc refer you for a scan, and only after you danced through the radiation field did you discover that he/she has an undisclosed ownership interest in the facility? Because the HIPAA privacy rule essentially prohibits providers from talking about their interactions with the people they treat, consumers should use this codified informational asymmetry to their advantage and start jamming their own smartphone-based, consumer-driven rating system down the industry’s throat.
Can you imagine the dyspepsia in any community’s medical establishment when they realize that their practices are being adorned on a virtual map with Consumer Reports-style red or black dots, as patients vote with both their feet and their fingertips? That will do more to drive transparent pricing, disclosure of conflicts, and heightened (incredibly overdue) attention to customer service than any of the obtuse academic mewling in this post.
And, it is ludicrous on its face that any clear thinking, modestly educated adult should go to a medical practice for guidance how to stay healthy and out of the medical care system. That’s like asking the guy your Jiffy Lube about whether changing your oil every 3,000 miles is really worth it. During the course of my adult life, I have never met a single physician in any specialty who could advise me about primordial prevention and provide information that met all the critical standards of being credible, actionable, and sustainable.
“Because the HIPAA privacy rule essentially prohibits providers from talking about their interactions with the people they treat, consumers should use this codified informational asymmetry to their advantage and start jamming their own smartphone-based, consumer-driven rating system down the industry’s throat.”
LOL. That is a thing of beauty.
Though, haven’t there been reports of litigation aimed at patients who diss a doc with bad reviews on one of those rating sites?
“That’s like asking the guy your Jiffy Lube about whether changing your oil every 3,000 miles is really worth it.”
And, I HATE that upsell schtick they always throw at you during the course of servicing your car.
(I hate the word “upsell” too. It was a staple jargon term at the credit card bank where I worked in credit risk).
Always a good day when I reads me some Vik.
Bobby: if the service is on a scale 1 through 5 and you don’t single people out, but merely grade the experience that should be sufficient. And the grading could be along multiple parameters. If you are going to name names, don’t slander or defame. Say only things that you know you can objectively back up, such as with a smartphone recording of the interaction. 🙂
You havent been paying attention.
I count no less than 10 websites that rate ONLY doctors.
How many websites out there rate lawyers or accountants?
Doctors already have much more public rating scrutiny on them than any other profession save perhaps politicians.
Hmm, lawyers and accountants vs doctors, how do they differ, let me count the ways. Doctors work in a system funded directly or indirectly mostly by taxpayers. When a lawyers screws up, he refiles the brief or eats some fees; at worst, he gets fired. When my accountant makes a mistake on my tax return, we file an amended return. When a doctor screws up, patients get hurt either because he/she did too much, not enough, or did it negligently. There are thousands of unemployed lawyers because the legal market (a private market in which there is virtually no government funding) is saturated. Physicians have unique abilities to induce demand and feed the public frenzy for ever increasing amounts of care.
Are the physician rating systems consistent? Has anyone validated them? How do we know that the information they provide is useful? How many markets do the function in? Does the rating include pricing? Insurance contract participation? Do they help expunge bad apples from the system (because, lord knows, physicians appears completely incapable of pushing their less competetent peers out the door)? Do they take into account conflicts of interest? Who knows about them, besides you?
“Doctors work in a system funded directly or indirectly mostly by taxpayers”
Has the government share of health care costs exceeded that of individuals (directly and through their insurance)? In my practice, Medicare and Medicaid as a minority of payments. Reference please.
“When a lawyers screws up, he refiles the brief or eats some fees; at worst, he gets fired”
No! People go to jail. Suggest you take a look at The Innocence Project website. http://www.innocenceproject.org/
The state and federal governments account for 44% of national healthcare spending (http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/downloads/highlights.pdf) and that does not take even into account the cost of tax advantages for the healthcare industry: pre-tax health insurance premiums, tax-advantaged savings accounts, and tax-exempt hospitals, health systems, and health plans.
In my experience (having worked in prison healthcare), most people who go to jail belong there. Yes, there are incompetent lawyers (many of them government funded) whose incompetence gets people wrongly sent to jail. For them, and especially people given the death penalty, groups like Innocence Project are literally lifesavers. Of course, this is not the majority of the private legal market in the US (which is, in sum, less than $500BN). The private legal market has still not recovered from the recession. Let’s hope it never does.
“I myself am pretty healthy and I don’t feel that my PCP at Kaiser knows much about me…how could she, she’s met me once in two years and it was a visit that started with her briskly walking in and telling me that we have time to address 2 concerns and what do I want to talk about. If I need someone to help me with health and wellness, I’d start with someone who has more time to talk to me.
A few years ago I developed a bad sore throat and fever, while out of town for a conference. I went to the CVS Minute Clinic. Fast, not too expensive, and the NP provided guideline-concordant care.”
This is why primary care will continue to wither away under our current system. NPs and PAs at CVS can do most of what primary care is turning into these days. (provide guideline-concordant cookbook care)
If we want something more personal and individualized, we need new models, not Kaiser-care expanded everywhere.
“A few years ago I developed a bad sore throat and fever, while out of town for a conference. I went to the CVS Minute Clinic. Fast, not too expensive, and the NP provided guideline-concordant care.”
You should have gone to see my recently deceased mother during her (medical) heyday (50’s and 60’s). She was very good with Pediatric rashes having seen; Measles, German Measles, Scarlet Fever, Impetigo, etc. many times.
And having raised 3 children to adulthood (without losing a single one) she had many “innovative” treatments for viral URIs and gastroenteritis. Salt water gargles, patent medicines, chicken soup and a variety of other motherly remedies were her mainstays.
She was also an expert in preventive medicine and valued keeping us healthy. Various bits of medical advice included:
“Eat your vegetables”
“Wear a hat or you will get a head cold”
“Don’t go outside right after a bath since your pores are open and you will catch a cold”
“Don’t go swimming right after you eat or you will get a stomach cramp and die”
Years later in Medical School I found out that virtually everything she believed in had no scientific basis. Yet all her advice was delivered with love and concern and my patient satisfaction was very high (what alternative did I have?)
And her treatments were probably concordant with the guidelines of the 50s and 60s. Thank goodness we have set the bar so high in our evaluation of the CVS Minute Clinic.
I don’t understand what Uber is proposing to do. Is it their intent to get you an immediate appointment with a primary care doctor?
If you already have a doctor, presumably you have already called his/her office. In that situation, what does Uber bring to the table?
If you don’t have a doctor perhaps they can get you an appointment with a primary care doc more quickly and efficiently that you can yourself. Hopefully, once you have been treated by this doctor, you will go back to him/her unless you were really unimpressed. In that case they will be a one time service.
What am I missing?
Agree with the authors that we need to shore up primary care, and that good primary care is essential, especially for people with chronic illness or medical complexity.
And agree that the new services providing doctors on demand — whether in the home or via text or video — could have problematic consequences. To begin with, if they succeed they’ll be siphoning off the “easier” patients that primary care practices have often relied on for easier visits. There’s also the risk that more medically complex patients will turn to these services and get healthcare that isn’t as good for them in the long run…or that people who have hypertension or diabetes will turn to these short-term encounters when they really need long-term healthcare support.
On the other hand, we shouldn’t ignore the signals of what individual people say they want. There is a disconnect between what the experts perceive as good for the population, or at a public health level, and what individual patients think they want for themselves.
For people who are relatively healthy, primary care has historically been the way we deliver preventive medical services, wellness support, and also urgent care. I don’t like the idea of giving this up, but then again, maybe it’s worth thinking outside the box. I myself am pretty healthy and I don’t feel that my PCP at Kaiser knows much about me…how could she, she’s met me once in two years and it was a visit that started with her briskly walking in and telling me that we have time to address 2 concerns and what do I want to talk about. If I need someone to help me with health and wellness, I’d start with someone who has more time to talk to me.
A few years ago I developed a bad sore throat and fever, while out of town for a conference. I went to the CVS Minute Clinic. Fast, not too expensive, and the NP provided guideline-concordant care.
“my PCP at Kaiser … visit that started with her briskly walking in and telling me that we have time to address 2 concerns and what do I want to talk about.”
I’m newly the Muir system. Same problem. Both the PCP and the specialist I got referred to. They’re on the Productivity Treadmill. And, the specialist was focused solely on HIS specialty, I was just the walking Chief Complaint sent his way.
Exactly right. And yet …
this dumbass idea is going to attract a ridiculous amount of attention and buzz (it already has, from the sounds of it) distracting from much better, reality-based, smart ideas that really could make a difference
Thanks for writing this, guys