It was not that long ago, even within the memory of grandparents, that many doctors’ visits were house calls. You can see it in movies. Someone says call the doctor. He shows up with a black satchel and gets to work and renders a verdict to the family as the sick person sleeps.
This was the common way medicine worked for the first half of the 20th century, even up to the mid-1960s.
Today it is rather unthinkable. Which is to say that no one expects it.
Can you provide an explanation why? I will attempt this starting from most to least important.
1. Medicare and Medicaid came about in the 1960s and have taken an increasingly significant place in the revenue stream of the medical profession. They have always tied reimbursement to office visits. This skewed the patterns of service provision.
2. At the same time, employer-provided insurance plus centralization came to be favored over cash disbursements. These had the same institutional biases: offices over home visits, for a variety of factors that included the following:
3. Medical care more and more depended on access to diagnostic equipment and other features of the office that simply cannot be carried in a black bag from house to house.
4. The old-style “family doctor” came to be replaced by the general practitioner or what is called primary care but specialization reduced their availability more and more. Health maladies started falling into neat buckets which in turn encouraged ever more specialization.
5. The rise of the cost of medical care and the administrative tangles thereof selected against careful and time-consuming house visits in favor of an assembly-line culture timed down to the minute: get ’em in and get ’em out. The drive to maximize revenue over expenses, and limit liabilities, pushed out more resource-consuming modes of service.
The result is that today hardly anyone expects a doctor to make a house call. In my own family’s case, my mother had a need to see a doctor and I have a personal friend who is a direct primary care provider who stepped up to see her. My own brother was in shock that anything like this was even possible in these times.
Looking further into this, I do see that there are growing numbers of medical practitioners who are classified as direct primary care or DPCs: there are now some 2,100 DPC practices across 48 states. They have subscribers who pay several hundred dollars per month in cash in exchange for which they have constant access to a doctor who can help. This seems like a wonderful model to supplement if not entirely replace normal health insurance.
How scalable is this? I do not know. It seems like there would be a market but whether it is lucrative and sustainable is another matter. House calls disappeared for economic reasons, and one can presume that the same factors precluded its reemergence even under the most innovative models.
A close proxy, one for which we should all be grateful, are the services provided by many doctors for online visits that are not expensive. For $50 to $100 a month, you can get a provider to talk you through whatever health problem you have and perhaps give a prescription online, sending it to your local pharmacy. This method of seeing a doctor is now hugely popular, and one can understand why.
That said, they cannot check your vitals or otherwise make any precise diagnosis. They can recommend specialists for you to see. But let’s face it: for most common medical issues, such a service actually does suffice. We are often warned that this is no real substitute for a primary care physician but it works often enough to relieve some pressure on the system.
A criticism of both telehealth and house calls is that neither have access to the machinery of modern medical diagnostics. I’m hearing that but also thinking maybe this isn’t such a bad thing. We wildly overuse medical services today, and there is a culture out there that encourages a belief that anything and everything wrong with us, physically or mentally, can be fixed with a prescription or some other product.
A major theme driving the Make America Healthy Again agenda is that this bias has caused as many problems as it has fixed. Americans are drug-addicted and neglectful of natural methods of health improvement. Eating right, staying away from substance abuse, and exercise go a very long way toward improving health. No specialist or prescription can substitute for old-fashioned self-discipline and basic nutrition.
This is a painful lesson for most people but the time has come to take it seriously.
All of this raises a more fundamental issue concerning medical delivery services in the United States. You will notice a decline in the amount of political interest in serious reform. The debates surrounding Obamacare, which ended up making a bad system worse, seemed to have exhausted public appetite for all future reforms.
Neither side—those who favor single-payer or the free-market reforms—have gained traction in recent years. There seems to be a real quagmire affecting all such efforts.
What is the solution? We are hearing ever more about the path of parallel systems. Direct primary care is one such path.
Another is the growing movement to liberalize generic therapeutics from prescription control and make them over-the-counter. People are not idiots, though the United States’ prescription system presumes they are.
Fourteen states are working toward making Ivermectin and other common medicines like hydroxychloroquine more available, thus liberating people from dependency on medical services.
Also, in many countries, pharmacies have nurses and doctors available for diagnostics, which seems like a much better system than ours. It is far easier to get routine medical care in Mexico than it is in the United States.
Other changes:
Allow employers to give employees an opt-out of mandated health insurance. This is hugely expensive for employers. Allowing their workers an extra $5,000 or so in salary and wages would be accepted by many and give the direct primary care industry a boost.
Permit anyone to make contributions toward a Health Savings Account, not just people with high-deductible health plans.
Permit insurers to offer catastrophic-only plans to people of all ages.
These small steps would go a long way toward reforming a broken system. There are far-reaching reforms I would like to see, such as putting actuaries to work not just on large groups of people but on individuals and permit premiums to adjust based on actual health risks.
Such a change, however, has been made taboo by the craze for non-discrimination against pre-existing conditions, a presumption that converts insurance into entitlement and thus explodes costs. Putting actuaries to work would cause a huge reduction in health-insurance premiums for most people, plus strongly incentivize healthier living.
There is little political appetite for the dramatic changes we need, but small changes, combined with innovative solutions among providers, could still take us in the right direction.
A robust and liberalized parallel system could eventually come to replace the decrepit mainstream system and provide a humane alternative if or when the dominant paradigm collapses.
Yes, that could include bringing back the house call.
