Disrupting business models is in vogue; wherever you turn there’s a new startup, a new idea, and another way to turn healthcare on it’s head. The symbol of this new way of thinking, a veritable talisman representing the crux of disruption, is a company called Uber, a yardstick by which every enterprise must be measured. It’s become hard to pick up any media without reading about the “uberification” of healthcare, the ways in which these disruptive business models will fundamentally remold medical care delivery, but does the hype exceed our expectation?
Today I’m going to run through some crucial areas where I believe healthcare and Uber diverge.
Before the true believers gather their pitchforks, let me be clear on my goal. I’m not suggesting that disruption is not useful in healthcare; in fact I think it’s fair to say that disruption may be the most important thing that has ever happened in healthcare. I am concerned, however, that Uber really isn’t the ideal model of disruption to follow.
So, let’s explore that a little.
One of the more naive applications of the Uber concept to healthcare involves summoning a doctor with your healthcare app. After answering the call (in their ample spare time) the Doctor appears at your bedside and “fixes” you. The bill is paid in bitcoin or some other internet currency and the encounter neatly ends with a happy patient who’s medical records are accumulated in the application for future use.
Doesn’t get much simpler than that really, does it?
As you read this description you should be thinking about the fee-for-service model that is so disparaged in current healthcare economics. Hang on a minute though? Isn’t that exactly what Uber is all about?
Current research suggests that longitudinal approaches to patient care are inherently more cost efficient on both a social and individual basis, and one of the major efforts in our health care system today is to move away from paying for individual encounters, the very antithesis of the Uber approach.
You don’t need to read the research to understand why this makes sense. If an individual is paying out of pocket there is little incentive to think of long-term health, and as Dr Ali Kahn dryly commented, “most people, after all, won’t be calling Uber for an elevated cholesterol level or a screening colonoscopy.”
There is a shortage of physicians in the United States today, particularly in the primary care arena, and Uber’s approach of so-called “surge pricing” is one way to mediate the disparity between supply and demand; yet perhaps not the one most people would choose. Let’s apply the methodology literally and posit that you have injured your back on Saturday night at 11 o’clock, a time that has traditionally been peak in emergency rooms. Would you be willing to pay seven times the list price to talk to a physician? More importantly, would you have the means to do so?
Surge pricing has been highly controversial, especially when implemented during the New Year’s Eve Sydney 2014 hostage. Users were slapped with a fourfold increase and complained vociferously. There have been many reported events on social media where travelers have been charged fares they were not expecting, some rising above $500. If you talk to an economist, this pricing accurately reflects the difference of supply and demand, but when we are dealing with chronically sick patients, who are, after all, the most frequent users of the health system, raising prices at time of crisis seems immoral.
One of the most complicated elements of healthcare is insurance, a model that emerged in the early 20th century as employers sought to give employees additional benefits, and was subsequently redefined in the accountable care act. Understanding health insurance prices is something of an art, in part because they rarely have anything in common with reality, and also because they are largely invisible to the consumer. Most of us have no idea how much procedures cost, and strangely, neither does our physician.
There is no provision in Uber’s model for dealing with third-party entities such as primary, secondary, and even tertiary insurance companies. It’s all about out-of-pocket payments and attempting to recover the money later. With most people in this country living paycheck to paycheck it’s unlikely that this payment approach can ever achieve anything more than marginal success.
Finally we arrive at regulation, an area in which Uber has shown scant regard, particularly in application to user or driver privacy. On February 27th, 2015, Uber committed it had suffered a data breach involving approximately 50,000 license plates and driver names. Compared to healthcare this may seem like a love tap, but let’s consider their so-called “god mode” that allows tracking of users with no auditing. That’s probably not going to fly in healthcare.
In 2014, Senator Al Franken, chairman of the United States Senate Judiciary subcommittee on privacy, technology and the law, sent Uber a letter stating that the company had “a troubling disregard for customer privacy”, and stated that “on prior occasions your company has condoned use of customer’s data for questionable purposes”.
I wouldn’t be so concerned about their regulatory approach, if their actions did not speak so highly of a culture of non-compliance. To the observer it seems that they first evaluate a market, then launch a service and wait to see if it’s legal. In the event that the local government show signs of curtailing their activities, they unleash a massive media blitz through their app and social media. When faced with pressure from local journalists they have employed tactics to suppress their voice, including the idea of hiring a team of opposition researchers and journalists with a million-dollar budget, to dig into the personal lives and backgrounds of media figures who report negatively about Uber.
To conclude, there are some really great things about the disruptive model which Uber represents, yet the connections to healthcare don’t map particularly well. Yes, it’s great to have apps by which we can schedule appointments with medical practitioners, and for those of us who can afford the out-of-pocket costs this approach offers extreme convenience. However, the model does not translate to large-scale populations including the chronically sick, and the financially disadvantaged.