Saturday, July 11, 2009

House calls

Several months ago i was thinking about the current situation we find ourselves in regarding health care and hit upon an idea that i felt was worth socializing, so i dropped it into my twitter and fb streams. Now that our illustrious federal legislative bodies are considering health care policy, i would like to do everything i can to bring attention to this simple idea and some of the principles it embodies.

i should say, up front, my concern with health care is the cost. i would much prefer that the state not get involved in health care, itself. i'm very left-leaning as far as my political views go, but i have a lot of basic misgivings about the state getting involved in health care -- largely because my views about what is healthy seem very far from what i take to be mainstream views on what is healthy. As one example, all of my children were born at home, with a midwife present at the birthing. This was the natural and correct choice for my children and my family, from which we have derived lasting benefits. While the country, as a whole, has moved closer to supporting this kind of choice, i could just as easily see it drifting away from it again. So, i'd simply not like to have the state deciding for me what constitutes proper health care and what doesn't; and, as soon as they get involved in providing health care, that is a natural next step, given the way this country tends to operate.

Therefore, i'd rather focus on cost, and rather than spending a lot of time analyzing cost, i want to propose a very simple suggestion that i think could mitigate some of that cost, and have other benefits, too. Part of why i'd like to address it this way is that there are many, many factors that go into the ridiculous cost of health care in this country; but, much of what is at the root of it, in my view, is an unnatural and unsustainable view of what is healthy. That's not something i think we can address head on, at this time, in a way that can lead to workable consensus around effective measures to reduce cost. There are practices, however, that i believe might be recognized as absurd by a fair majority. Here's a recent example from my life. Around Christmas of 2007, my little boy, Gabriel, who was 4 at the time, got his thumb mashed in a door. i was working at the time, and my wife decided to take him to the emergency room where they proceded to give him both a local anaesthetic and high powered pain killers and then stitch on his nail -- that everyone knew was going to pop off in a week or so. For this we were charged 1000 USD -- after the insurance paid the bulk of the cost. i guess i've turned into a walking cliche, but when i was 4, the doctor would have wrapped up my mashed thumb, told me a story to make me laugh, told me another story about being brave and explained what was going to happen to my thumbnail and sent me on my way -- probably with a popcycle or lollipop to take my mind off the pain. Cliche or not, i think many people reading this will agree that both the treatment and the cost were absurd.

There are obvious pressures on emergency room and hospital staff that lead them to behaviors that are more fiscally than medicinally motivated. Again, rather than go into a detailed investigation of those pressures, i would like to observe that had we been able to request a house call, i think things would have gone very differently. For one thing, of the two nurses, orderly and doctor that attended this mashed up thumb, only one of them would be likely to make the house call. It would also have been much less likely that a wide array of pain killers and anaesthetics would have fit into a doctor's bag -- and those that did would probably be conserved for the cases that really called for them. Expensive tests and expensive procedures don't travel well. In short, i think a house call would have cost us less, and cost the health care provider less, as well.

And, that's my simple proposal: reinstate the house call. i think we should make it a part of public policy that patients may a make a determination that they would prefer the health care provider come to their home. The key is to put the choice in the hands of the person or family needing care. Despite the potential for litigious nightmares, i believe there are ways to craft sufficient protection for both patient and health care providers, and that's why i want this idea to enter into public debate and why i want my representatives in Congress and the Senate to give it some time.

i think this idea scales well. Think about the possible reduction in carbon footprint. Instead of 20 people driving 20 cars to go to a waiting room (which is itself taking up precious resources), 1 car goes out and -- of necessity -- plans an efficient route to visit 20 homes. Moreover, the doctor goes out into the community and sees how that community lives and what sort of health problems that community has -- in context. It's amazing how standing in someone's home can give you a much clearer idea of who they are and how you can best serve them. i could cite all kinds of supporting evidence, but i would rather appeal to my reader's native common sense. It's much easier to compartmentalize and distance oneself from one's clients when they come to you. It's a different experience altogether when you go to them: enter their homes; see how they live; see the ills they suffer in the places where they are suffering them.

To my mind that's the kind of change that could bring on a qualitative shift in health care. It allows for a more whole view of the people and families that need healing. That's what i think we need, a view that is more whole and more wholesome; but, i think we can only get there in small, specific steps that lead to more or less immediate feedback and positive outcomes. That's what i think is embodied in the house call: a small step to lower cost by bringing the healing home.


mukaramutara said...

excellent idea. i vote for it.
send it as a personal letter to Obama.

leithaus said...

Dear Mukaramutara,

Thanks for the suggestion. i left a comment on the open health care reform thread at .

Best wishes,


Luke said...

Greg -
Boy, this speaks to me on a number of levels. Three of our four children were born at home. Our midwife attended two of these births. The last happened a bit faster than expected and I ended up catching the baby. And, no, I did not "deliver" the baby. My wife did the work. Heck - she *talked* me through through the entire process (and this was after running a 10K race in the morning, but that's another story).

Having worked for a number of years providing consulting services to transportation and logistics solution providers, I can see the logic of your proposal (efficiency). But, unfortunately, having worked to promote healthy living, I can envision some concerns, such as people requesting house calls when they're simply not needed. (And some locations do make house calls).

I'd love to see if we can leverage to help in shaping the debate on health care.

Taking a step back, I'm basing what follows on the idea that we simply won't have enough money to support any health care plan. I don't really care if the Democrats or the Repulicans are promoting a plan, the reality is that we just won't be able to afford all components of the plan. We need to prioritize.

Which is precisely the purpose of the Innovation Game Buy a Feature. This game enables a group of people to collaboratively prioritize a group of features by working together to purchase the items that they feel are most useful. The game aligns personal interests with collective interests, as only those features that have sufficient group support are purchased. By analyzing who has purchased what, you can determine key trends of group behavior.

I'd love to sponsor a trial game to try out this theory. We'd need a list of between 12-16 health care initiatives, each described in terms of benefits and each containing a relative cost to each other. We could have a panel of experts help us in determining the costs of the various initiatives.

Then, we'd open our game to the public, inviting as many people as possible to play the game. We'd need some help in managing the actual participants, to ensure that we've invited a representative sample of the American population. With some help, I'm confident that we could assemble players that would provide us with a rich set of data to mine and analyze.

The last step is making all of this data available for public inspection and analysis. Our system is designed, from the ground up, for this purpose: Public games are completely free. By making this data free, I'm hopeful that we'd encourage others to explore these data to help discover trends that matter.

We can also expand this to a large list of healthcare initiatives that are prioritized by millions of people.

This is just a sketch, and needs to be developed further. Will you help us?

Luke Hohmann
Founder and CEO, Enthiosys

JDP said...

I'm no apologist for the Cuban regime, but they seem to be doing something right in health care. Two points: First, there is a much higher ratio of health care providers to population than in the U.S., which has the benefit of making more time available for healers to spend with patients, and also of reducing the perception of doctors as aristocrats with rarefied skills - it tends to democratize medicine. I would like to see the U.S. triple the number of medical and nursing schools and likewise the number of graduates and practitioners. I suspect that 3/4 or more of what most doctors do on a daily basis could be done by someone with paramedic, EMT, or nurse practitioner training. Second, the Cuban model is explicitly one of community health - the typical doctor, as I understand the situation, spends their day out and about, not necessarily visiting the sick and injured but also just listening and observing for signs of disease outbreaks and unhealthy lifestyles, and counseling and consulting in the community on that basis. As a corollary, and specifically regarding costs, I would like to see drug companies, hospitals and care facilities, medical schools, and insurance companies all organized as true not-for-profit businesses without stock sales, quarterly distributions, or rock-star CEOs.

A Breaking Change said...

I have only one anecdote to add: we recently needed some surgery. We asked the doctor how much he would bill the insurance company. He said X. We then asked how much he would charge if we paid cash. He said "we don't accept cash." We said, "please try to find a way to accept cash." He said "ok, come back in a couple of weeks." We did and he quoted us X/3, that is, one-third of what he would charge the insurance co. Happy, joy, we paid cash, got excellent surgery, and saved everyone everywhere lots of time, energy, angst, and money.

So, Greg, along with your idea of house calls, an excellent one, I would add "let's go back to a simple, transactional model, where X can pay Y for what's needed and wanted and get the non-converging series of middlemen, public and private, out of the deal."

LorentzFrame said...

Here's a nice example of a government proposal to reduce costs

under the assumption that all the agents on the chart other than the health-care providers are going to work for free or out of the goodness of their hearts?

I'm so confused by all this.