One of the things that I have learned in meetings with a big health insurance company whose claims data we use in the classroom: emergency room (“ED”) visits are expensive. A long wait followed by a temperature and pulse ox test then advice to take two Tylenols will cost the employer who sponsors a health plan at least $1,000.
One idea that I came up with around a conference table with the insurance folks was to put a doctor and nurse in a motorhome crammed with all of the stuff that one would typically find in a primary care clinic. Tell folks enrolled in the plan “You can go to the hospital and wait two hours to be seen and pay a $125 co-pay. Or you can stay comfortably at home and the doctor will be there in four hours.”
This is plainly a bad idea because it is obvious and yet no insurance company is doing it. Maybe it is bad because the U.S. is so short of physicians that it is intolerably inefficient to have the physician idle when driving from one house to another. France has a lot of doctors per capita and they do still make house calls (see this 2009 article).
Perhaps the idea is a little less bad in the Covid-19 age. Do we want people congregating in hospital waiting areas now that we can be pretty sure that at least one of the waiting patients is plagued? If the patients are seen at home, at least there is no patient-to-patient contact/transmission.
We already have the technology and skills to build the motorhome-based clinics. Matthews Specialty Vehicles seems to have built a bunch, for example. Odulair in Wyoming has everything up to mobile CT and mobile MRI (these are perhaps overengineered for checking on a person who has flu-like symptoms). Laboit says that they can fit a primary care clinic with a single exam room into a 28 ft. Class C RV:
Readers: A year ago we would have said it was stupid to pay Americans more in unemployment than they had been getting paid to work. Has my stupid idea also flipped to brilliant?
There are apparently a few places in the US where this is being done, although I don’t see the motorhome with the equipment:
https://www.housecallsok.com/
In rural America, one doctor wrote a book about his experiences, back in 2013:
“The following twenty-one stories are from actual house calls I have made in three different states during my thirty years of practice as a rural family physician.”
https://www.amazon.com/House-Calls-Stories-Medicine-English/dp/1484050738
Right now, it seems, most of the providers coping with COVID are heavily into telemedicine via the miracle of the Internet. I’ve done this once with my primary care doctor, and it sucks. It was impossible to keep the doctor connected through the app., which I had to restart four or five times during the “visit.” Maybe that’ll improve when everyone is connected via 5G, but in semirural areas like the one I live in, cellphone coverage itself is spotty and trying to send synchronous realtime video is a joke. And this was over a WiFi connection through my businesses’ Verizon account. It still sucked.
Also, in my recent experience, the doctors would rather their exposure to any patients be as close to zero as possible. I just had a primary care visit with the same doctor, in the hospital. I sat in an observation room chair while the doctor called me on the phone from his office 20 feet away, as his assistant took my blood pressure. The call dropped out, he had to call me back, I couldn’t hear him because of poor cellphone reception in the hospital, and finally he saw me in the observation room for about four minutes total.
The Atlantic did a piece on telemedicine recently. It allows the doctor to keep their safe distance while seeing the patient in their natural environment: “And yet, most doctors are trained to practice in sanitized, corporate environments and not in the home—“exposed to violence or viruses or the awkwardness of standing in somebody’s house,” Randolph said.” So telemedicine is preferred because obviously the doctor doesn’t want to actually be there.
My opinion is that you will never get doctors in any coastal health care system to participate in this. It’s a great idea, but they do not want to leave their offices and actually take the risk of visiting the animals in their natural environment, nor do they want to be exposed to people who might have COVID as little as possible. Not going to happen.
Here’s the Atlantic piece. Right now this is the bleeding edge of adaptation, and the physicians are already stretching their muscles to accomplish medicine via cellphone or tablet. They don’t want to get in a truck and roll around all day in the wild. Not what they signed up to do.
https://www.theatlantic.com/health/archive/2020/08/telemedicine-has-resurrected-house-call/614992/
Aside: It is a little funny, though. The hospital where I see my Primary Care physician has an MRI machine that’s housed in a mobile trailer. They had to build a special dock at the back of the hospital, and basically you get into the machine by going through what looks like a warehouse loading dock, complete with metal plates on the floor, a concrete slab, etc.
The inside could be like those automated public toilets that do a spray down disinfecting after every use.
Better yet, have the doctor travel in a smaller truck and let the doctor examine the patient in a one-use disposable tent.
I say again: these are going to be some very brave doctors indeed. I think Philip’s idea is great from a technological, feasibility and cost point of view, but my primary care physician is 60+ years old. He is *not* going to get in a motorhome and drive out into the sticks (or the city, for that matter) to see patients where they live. In my recent visit, I felt like I was contaminated with plutonium, and I’ve been tested negative for COVID twice in the past month. Those records are in the hospital’s system, he could see them, and it didn’t matter. The hospitals are protecting the doctors and the staff, period. They’re more afraid of catching COVID than the teacher’s unions.
A modern ER with imaging and a few patient rooms sprung up on a suburban highway near me. It arrived on 5 or 6 flatbed trucks but it took several weeks to assemble during the lockdown. I went last week for some stitches, it is immaculate and well staffed, has remote admission by iPad(the only digital innovation) and is slow as traditional ER’s.
It should be fairly easily to provide everybody with a temperature, pulse ox, heart monitor, blood pressure and etc smart device that interfaces with your smart phone over Bluetooth. In fact the Apple smart watch and other activity trackers probably have a number of these functions already. I bet that you could estimate a persons health by analyzing about a months worth of data from one of these activity trackers. Have the technology companies, Apple, Google, Microsoft and etc design and manufacture the devices, then offer a subsidy either through the health plan or government. Then most doctor visits could be done remotely, no need for travel unless it is a serious case. You would schedule a doctor appointment and your doctor would take a look at your last week or month of activity and parameters or suggest some more measurements and then you would have a remote video call with your doctor. If anything looked different than your baseline or you had more serious problems then you would go and visit your doctor or hospital. No need for the motor home unless a CT scan, MRI or ultrasound is required.
Since I basically trashed the first idea (and yeah, I’m angry, because I’ve had other very important medical procedures delayed by COVID and it’s not because the hospitals are overwhelmed – it’s because they’re delaying everything), I felt I should offer an alternative that might be useful:
Since tests for COVID are basically useless for contact tracing after 48-72 hours, getting people tested in hotspot areas as quickly as possible and returning the results rapidly could help. So why not outfit the motorhomes for COVID testing, maybe with onboard PCR machines? Then you could drive the testing from place to place and get the results back faster. It would also serve a psychological purpose, because people would see the testing truck in their area, wouldn’t have to get in a car and drive to a pop-up center and wait in a line, etc.
At my annual physical exam last week, I was instructed to wait in my car until called for my appointment. After 30 minutes I drove off and re-scheduled for Dec. 2022.
I did similar, had a doctors appointment scheduled and they called me up and asked if I wanted in person or telemedicine. I canceled, I figure anything they do can via telemedicine I can do by looking in the mirror.
There is a theory that doctors develop non conscious powers of observation, seems plausible, if true I doubt it works over phone cameras.
What’s so expensive about emergency rooms? The rent? The doctors? I don’t see how this solves either problem. The van has to cost more than renting a room, with the gas and the depreciation. And aren’t the doctors idle most of the time if they’re in a van?
https://www.cbsnews.com/news/60-minutes-overtime-on-the-road-with-the-health-wagon/
Do you yourself yearn to have the same health care system as the “working poor of Appalachia”?
I had Pavel’s exact idea, and maybe if you sign up for health insurance plan, the insurance company should provide you with such a device. You only go to a clinic or hospital to be tested for the non-standard stuff and for surgery.
If this was implemented, there would probably eventually be less jobs available for doctors or nurses. For the patient, there is too thin a line between describing symptoms over a telephone and getting a diagnosis, and just researching them yourself using the internet or a medical encyclopedia. But you would still need medical professionals, as I noted earlier, for surgery, tests for less standard conditions, to get fitted with devices, for prescriptions, and for sick notes and their equivalents.