From community paramedicine programs to house calls arranged by a provider or ordered through an app, mHealth and telehealth are showing that technology doesn't have to separate the doctor from the patient.
mHealth and telehealth have often been pitched as replacements for the in-person healthcare encounter, but some providers and payers now see mobile health as a means of improving the face-to-face visit.
In many cases, they’re reviving the time-honored tradition of the house call.
"House calls go back to the origins of medicine, but in many ways I think this is the next generation," Dr. Patrick Conway, who heads the Center for Medicare and Medicaid Innovation, told Kaiser Health News in May 2016.
Conway was speaking of the center’s year-old Independence at Home project, involving 14 providers around the country, who pledged to make house calls to at least 200 patients with traditional Medicare who have been hospitalized and received rehab or other home healthcare within the past year. In that first year, the Centers for Medicare and Medicaid Services reported overall savings of $25 million, while paying out about $12 million in bonuses to participating providers.
Aside from receiving a house call reimbursement from Medicare, doctors in the Independence at Home project get a bonus if patients have at least 5 percent lower total Medicare costs than what is expected for a similar group of beneficiaries. According to Kaiser, “Medicare keeps the first 5 percent of the savings and the house call providers can receive the rest. The doctors must meet at least three of the six performance goals -- such as reducing emergency room visits and hospital readmissions, and monitoring patients' medications for chronic conditions such as diabetes, asthma and high blood pressure.”
While CMS is still working to fine-tune the Independence at Home program, others are taking the house call concept in different directions.
Much like the transportation, food and retail industries are using mobile apps to create on-demand services, some innovative mHealth companies and healthcare providers are using the platform to bring healthcare to the patient’s door.
Hospitals, health plans and EMS providers, meanwhile, are launching mobile health programs to check in on so-called “frequent flyers” – people who frequently use 911 or visit the local ER for non-emergency issues – and help post-discharge of homebound patients or those with chronic conditions. The concept is popularly known as mobile integrated health or community paramedicine.
Some 260 EMS programs across the country are now using some sort of community paramedicine program, up from 100 programs in 2014, according to the National Association of Emergency Medical Technicians. The programs are often borne out of partnerships between providers looking to cut down on unnecessary ER use and EMS providers looking to make sure their emergency calls are for real emergencies.
In New Mexico, Blue Cross Blue Shield of New Mexico launched its program in 2016, targeting the Medicaid population. BCBSNM officials say more than 1,100 Medicaid members has participated in the program, leading to a 62 percent reduction in ER use, a 63 percent reduction in ambulance use, and an estimated $1.7 million reduction in medical costs to the state Medicaid program.
Dr. Duane Ross, BCBSNM’s medical director, says the payer first targeted members who were using the ER as a primary care service, along with those identified as most at risk to return to the hospital within 30 days of discharge. Those population are the most expensive for healthcare providers, both in terms of costs for treatment and for non-reimbursed services.
“To make this work, we had to find something very measurable and definable,” he says, pointing to the data gathered in the program’s first year.
The program, in its current state, doesn’t provide healthcare services. Rather, EMS providers visit a member’s home to coordinate future care, including assessing the patient’s living conditions and mobility and offering education. The idea is to form a more personal connection with people and nudge them toward healthier habits and lifestyles.
“They’re not providing direct care at this point – they’re more our eyes and ears” into the member’s home environment,” Ross says. “We want to focus now on education.”
To get the program off the ground, Ross says the payer had to forge partnerships with local EMS providers.
“Insurance companies have not yet quite figured out how to contract with ambulance companies and pay for them,” he says. “This is not a typical relationship.”
“We’re basically paying for a service that is preventing future unnecessary utilization,” he adds.
Ross says the program replaces the traditional model of mailing out flyers or making phone calls to members. And it’s much more effective and personal.
“Mailings are the worst, phone calls are better, but face-to-face is the best,” he says.
In Texas, Memorial Hermann Health and Houston and Baylor Scott & White in Dallas are both using the Q.care app, developed by Dallas-based PediaQ, to connect parents to the local health system’s pediatrics department, which can dispatch a nurse practitioner for a house call.
“Parents really like that (option) of having someone come to the home and see the child,” Dr. Victoria Regan, vice president of Memorial Hermann’s women and children’s service line, told mHealthIntelligence.com in an interview last year. “And our nurse practitioners like the opportunity to provide one-on-one care.”
PediaQ launched in 2014 and now covers all of Texas with health system partnerships and a consumer-facing service. While the nursing triage service is free, the house call app charges a $25 convenience fee alongside an insurance co-pay, or $150 and the convenience fee for those who are uninsured. Company officials say the service is now covered by most major payers, including BlueCross BlueShield of Texas, UnitedHealthcare, Aetna and Cigna.
Several mHealth vendors are also getting into the house call market, with apps that connect a consumer to an online site that can dispatch a doctor or nurse to the home.
One of the largest is Heal, launched in Los Angeles two years ago with backing from, among others, Lionel Richie, Qualcomm executive chairman Dr. Paul Jacobs and the Ellison family of Oracle fame. The company is now expanding to the East Coast, beginning in the Washington D.C./northern Virginia area.
“The doctor’s office is dead,” company co-founder Nick Desai said in a recent press release announcing the company’s expansion. “No longer is great medicine tied to bureaucracy or buildings. Quality care is available at your home, on-demand. With each new market, we’re closer to making affordable, high-quality healthcare a reality for all Americans.”
Renee Dua, MD, Heal’s co-founder and chief medical officer, says the platform seeks to improve the primary care experience for both patients and doctors.
“The entire model bases itself on redefining the doctor-patient model of care,” she says, noting the service attracts patients who want to see their doctors in person and doctors who want to spend the time it takes to make the patient feel better.
By creating a service in which a doctor can invest more time with a patient, Dua says the house call often leads to a better patient experience and improved outcomes.
“We have the kind of doctor who answers a question the patient didn’t even think to ask,” she adds.
Dua says on-demand platforms like Heal are working to make the primary care physician’s practice more attractive. Today’s healthcare climate is tilted toward high-paying specialties, creating a shortage of family practice and pediatric doctors and offering no incentives to bolster those professions.
The challenge, she says, is that CMS and some payers don’t reimburse for house calls, so Heal has to focus at this point on self-insured companies and individuals and those who can pay in cash. That leaves out a large portion of the market who could greatly benefit from house calls.
“We’re not a concierge service – we want to be available to all patients,” she says.
And that’s where Heal’s expansion might serve to expand the thinking of DC policymakers. Dua says the mHealth-enabled house call is just another facet of continuity of care that should be embraced by the healthcare ecosystem. It takes advantage of mobile and telehealth technology to create a quality-based interaction between doctor and patient, lowering costs and improving outcomes.
“If they (policymakers) see what this is, maybe it will make a difference,” she says.