A prospective patient of mine missed his first appointment in my primary care clinic. In addition to getting a thorough checkup, he was scheduled to get some vaccinations, including one against the viral infection known as shingles.
I got a call from the man two months later. He apologized profusely for missing the appointment. And unfortunately, he had another reason for calling: he had developed a painful rash across his left lower torso, the hallmark of shingles.
It took two weeks of treatment before his rash disappeared, and he suffered months of pain. But it could have been avoided if he’d been able to get a shingles vaccine without having to leave his home.
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Providing health care at home is on the minds of many doctors and health system CEOs who are coming to realize that the traditional model of hospital- and clinic-centric care may not be financially viable. A recent analysis by Modern Healthcare showed that profits in large hospitals and clinics declined in 2014 despite an improving economy.
There is a stark parallel between this trend and the decline of traditional retail stores. Take Walmart as an example. In the late 1990s, Walmart expanded its large department stores. These supercenters forced out many smaller mom-and-pop retailers. But the company recently announced it was closing 154 stores in the United States, and more overseas. This move was sparked in part by the disruptive influence of Amazon and other online retailers, which let people shop from the comfort of their homes.
Similarly, large health systems have been consolidating health care into their own “supercenters” — hospitals and medical centers. This consolidation has come at the expense of care in patients’ homes. In the 1940s, house calls represented 40 percent of all doctors’ visits. Today they represent less than 1 percent of all consultations.
Just as online retailers have threatened the dominance of Walmart, new entrants into the health care market threaten the dominance of clinic- and hospital-based doctors. San Francisco-based Doctor on Demand provides access to video-based doctors who can treat common conditions like colds, sore throats, urinary tract infections, and sports injuries for a flat fee of $40 per visit. Boston-based American Well offers telemedicine solutions for employers and health systems. And transportation innovator Uber has completed its second round of testing of UberHEALTH, an on-demand service delivering flu shots in 35 cities. A proof-of-concept study of the first round, published in the Annals of Internal Medicine, showed that more than 2,000 individuals received flu shots at home — one of the most common reasons for a clinic visit.
Even Walmart is getting into the act. It has created more than 100 in-store retail clinics staffed by nurse practitioners and branded as “one-stop shops” for primary care.
As a future primary care provider, I hope that our system can bridge the divide between our traditional medical behemoths and these innovative organizations. Doctors learn to practice medicine in the environments in which they are taught. In medical school and residency, I’ve learned in the safe confines of the hospital and primary care clinic. But I also hope to practice in a novel delivery system that cares for patients where they are — not where it’s most convenient for me to provide care.
We need new ways to care for our patients. When they miss primary care appointments, we make no effort to understand why — until it is too late. And we make no effort to address those reasons by shifting where we provide care. Instead, we send them phone calls and emails: “You missed your last primary care visit. If you continue to miss your visits, we may drop your from this practice.” For my patient with shingles, I should have been able to employ a service like UberHEALTH to deliver his vaccines to him, when he needed them. It could have prevented a prolonged, painful condition.
Instead of “firing” customers who are no longer stepping through its Supercenter doors, Walmart is working to find ways to serve them. Hospitals and medical clinics should make a similarly large investment to bring health care to our patients — or risk losing them to the Amazons of our own field.
Ravi Parikh is a resident in internal medicine and primary care at Brigham and Women’s Hospital in Boston.