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This whole “Uber for doctor house calls” idea is basically doomed

AP Photo/Ed Andrieski
House calls are almost impossible to scale.
This article is more than 2 years old.

Back in September 2007, I created a new kind of doctor practice. The iPhone had come out three months prior, and Google had enabled you to embed your Google Calendar in a website just the month before. I saw a perfect storm of technology leading to an opportunity to do something unprecedented and become my own boss.

As an amateur photographer plugged into the creative community of NYC, I had many friends who were uninsured artists and freelancers who occasionally needed health care. They couldn’t afford to go to the emergency room, and there were no urgent-care centers in New York at the time. They needed an accessible, cost-effective doctor. So I became a doctor-entrepreneur–fresh out of residency, armed with new technology and a mission to make doctors more affordable and convenient.

What I learned makes think that the new wave of startups vying to become “Uber for house calls” are in for a rough ride. (I should mention here that I’m now the co-founder of a digital health-care service called Sherpaa, which offers patients online consultations.)

It was classic disruption: a new idea, a lower cost. Or so I thought.

My idea was perfect for the promise of the mobile Internet, and it was the first of its kind. People would visit the site that I built with Apple iWeb and read my credentials and mission. If they liked what they saw, they’d click “Make an Appointment,” which would bring up my embedded, real-time Google Calendar. Then they’d choose a time, explain their symptoms, attach a photo, and include their apartment’s address, which had to fall in the zip codes of Williamsburg or Greenpoint in Brooklyn. This was all done via a secure form that was configured to send me an email when I had a new patient. When my fancy new iPhone alerted me of a new patient, I’d do an old-fashioned house call.

On September 27th, after investing $1,500 of my own money into this new venture, I launched my practice. Within an hour or two, Seth Godin linked to my site, prompting Gawker to write two posts about me that day. Within a month, 7.5 million people visited to see what all the commotion was about. Fox News, NPR, GQ, Esquire’s Best and Brightest of the Year, TED, Clinton Global Initiative, MSNBC, CBS Nightly News … there was a lot of press. I’d say it was the first and only doctor practice to go viral.

Due to the press, my practice was almost immediately full. I was busting my ass traveling all over Williamsburg and Greenpoint. I was walking, riding my bike, or taking cabs trying to see as many patients as possible while also gathering the supplies I needed. I knew I needed those supplies because I designed the process so the patient would explain their issue in the secure form they also used to schedule the appointment.

Here’s how I spent the day. I’d wake up and hope that I got a few early appointments during the night. I’d read their stories and then email them to arrange the housecall. If I needed to draw blood, I’d ensure the right supplies were in my doctor bag. If I needed vaccines, I’d have to swing by the pharmacy to pick up the vaccine. If I had to draw blood, I’d have to drop that off to be picked up. If I knew a housecall wouldn’t solve the problem, I’d email the patient with a referral recommendation and a reason why. I could do all of this while traveling, which was increasingly being done by cab so I could communicate and travel.

It was classic disruption: a new idea, a lower cost. Or so I thought.

The practice wore me down both physically and financially, and therefore psychologically.

My mission from day one was to be affordable for patients. I charged $100 per visit, payable via PayPal. I did not take insurance because I needed immediate cash flow and couldn’t wait four months to be reimbursed for a fraction of the bill. My expenses were cab fare and the $30 or so per month I paid to the various web services that were powering my practice. I designed my practice to be as low-overhead as possible. Compared to a traditional doctor’s overhead of roughly 70%, mine was essentially free.

But the practice wore me down both physically and financially, and therefore psychologically. And I’m a doctor. I’m used to working 70 or 80 hours a week. But here’s why my own business started with my own brain, sweat, and money wasn’t sustainable for me:

  • Shlepping through New York’s cold and snow all day, every day was grueling.
  • The travel time between patient apartments and back to my apartment or the pharmacy to pick up supplies and refrigeration-sensitive vaccines limited me to only being able to see a maximum of eight patients, or earn $800, a day.
  • I was a professional and hearing about other doctors working in warm offices and getting paid double was more than enough to make me second-guess my daily grind.
  • I witnessed firsthand how limiting the house call was versus an office visit.
  • Fifty to sixty percent of my day was spent on supply logistics and traveling between apartments in two neighborhoods, not seeing patients.
  • I knew, in the back of my head, how financially valuable my time was and how much of a financial sacrifice I was making to be my own boss, especially when I was coming off a Johns Hopkins resident salary.

My practice was ridiculously fun. The neighborhood knew me because they’d seen me on the internet. I’d walk past someone on the sidewalk, somebody I’d never met before, and they’d say “Hi Doc.” I had many patients I’d seen on the internet who are now legendary musicians, comedians, and artists headlining at places like Radio City Music Hall. But despite all the fun, it was just so much a grind that it reminded me of my 20-hour days in residency. At least the hospital where I did those 24-hour shifts was warm and dry. I was 30, and I just needed a break.

Although I wouldn’t change a thing, I quickly realized that this wasn’t something that should exist beyond a cute, little, self-made practice that a young punk, anti-establishment, “do what’s right for the patient” kind of doctor can spend a few months doing. It was $1,500 and seven months well spent.

Short of teleportation, the doctor house call will always be an irresponsibly massive reduction in primary-care efficiency.

But primary-care doctors are a dying breed. We need all of them we can get, and we need them to be safely seeing a maximum amount of patients per day. We need to optimize their realistic daily processes and make them markedly more efficient. Every second the doctor is not seeing patients is wasted time. Doctors already spend roughly 40% of their day documenting and doing other administrative tasks. To waste the other 50-60% of your day traveling between patients is a 50-60% reduction in efficiency.

Short of teleportation, the doctor house call will always be an irresponsibly massive reduction in primary-care efficiency. Patients need us now more than ever. Our “system” is composed of an overwhelming majority of specialists and a minority of generalists. In contrast, the United Kingdom, Canada and other high-performing health-care systems have far more generalists than specialists. And for the last decade or so, only about 10% of residents are choosing primary care, further contributing to a massive primary care shortage.

Traditional primary-care doctors can see 30 or so patients a day in their offices. House call doctors can see seven to eight. Even with a 20% increase in house call efficiency, house call doctors could see a maximum of 10 patients a day.

Very, very few doctors will actually want this kind of life.

House calls are not only unscalable for an absurd litany of reasons, especially outside of hyper-dense New York City, they’re irresponsible for the system. It boils down to two issues: It’s ridiculously inefficient and very, very few doctors will actually want this kind of life. I do think they should exist as a ridiculously expensive option for people who don’t care about money, because America.

But the venture capital subsidy will run out shockingly fast, and doctor house-call visits will no longer cost a massively venture capital-subsidized $29–they’ll be more like $499 or $599. A shockingly small number of consumers will pay that amount for their pink eye. For example, it’s about the same amount of people willing to spend $499 on a cab to the airport. Also, zero health insurers will reimburse $499 for pink eye treatment.

To think that house calls are scalable–a worthwhile venture capital investment–and something as revolutionary as the real Uber is as naive as I was nine years ago fresh out of residency, doing something new, weird, and fun. Nine years ago, I spent $1,500 to figure out it wouldn’t work, which is far less expensive than the $30 million or so being spent today to figure out the same thing. And it’s doing a massive disservice to our system. We need all the doctor efficiency we can get.

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