Healthcare Services for the Top 1 Percent

In my last post about Uber for doctors, I mentioned the potential targets for such services. A service that costs $199 per visit is not meant for the masses. It is going to hit the top 1 percent of the population, at least at the start (but that doesn’t mean it doesn’t make sense or is viable.) Maybe in time we’ll see an UberX with discounted visits done virtually, or visits for high risk groups that are supplemented by payers or ACOs.

medicast.tweet

One of the companies I mentioned, Medicast, didn’t agree with my conclusion that it’s meant for the top 1 percent. They replied on Twitter.

I see Medicast’s point about the increasing personal responsibility of patients for visits, but l don’t think $150 out of pocket per visit will work for most people. Maybe it’s for the top 5 percent, not just the top 1 percent. It’s also not the same as direct primary care practices like Atlas MD, which I see appealing to a larger part of the population. But still, Atlas doesn’t work for everybody either.

There are other startups targeting the upper tiers of patient populations. Better is a good example. It provides an app for storing medical data and accessing educational content, but the business model is based around users paying for a subscription that enables them to contact a Mayo provider – nurse, nutritionist, and I think physicians. As a supplement like Medicast, this is not meant the vast majority of people. But Better is getting good press and I believe is funded.

If you want to lose weight but need some help and have the money, you can use Retrofit. I’ve talked to people that have used it and the consensus is that it’s awesome. But at $150 per month for the cheapest plan, it’s not for the masses either.

Another company appealing to a specific, high-end, self-pay subset is Analyte Health, or at least it is appealing to that subset with its first offering — an online STD clinic. My take — and that of most people I’ve talked to about STDExpress — is that the appeal of online STD testing is more around anonymity rather than convenience. In fact, you can pay for STD testing with Western Union so there is no paper trail back to the person ordering the test. The concept is brilliant, but it probably won’t solve the major problems with STDs in the US. I think Analyte has a much bigger vision for online clinics and those might have more widespread impact.

Concierge medicine makes a lot of sense, too. People who can afford it love it, as do most of the physicians I know who practice in that model. When I hear about the relationships that concierge docs have with patients, it seems ideal — home visits, work visits, going to specialist appointments to sit in, and shared accountability. But it’s prohibitively expensive for almost everybody, so it’s never going to have a major impact on our health system. I’m also talking about concierge, the predecessor and much more expensive older brother of direct primary care. I have much higher hopes for the impact of direct primary care.

I recently had a conversation with my father-in-law about concierge. He’s been converting practices to concierge models for years and knows the space extremely well. He’s now working on a hybrid practice model. The theory behind it is that a certain portion of the population enjoys high-end experiences — fine wine, flying first class, etc. So a certain population of most medical practices, assuming you’re targeting the right geographic area, would pay to participate in a concierge model with their existing physician. They are in pilot mode with a bunch of practices now, so we’ll see if the theory and numbers hold up.

The point is that nothing works for everybody. There is no “one size fits all” model for care, or “one size fits all” solution in healthcare, because the needs of populations and providers are vastly different based on health conditions, demographics, language, culture, and social conditions. Some groups may embrace ownership of records and self management, while others will not. Some will actively participate in shared decision making and others will want a cowboy to take the reins and run the show. Some will be comfortable with virtual visits and telemedicine while others will crave or require in-person interactions.

It seems increasingly that we’re seeing services targeting the highest-end consumers. There also seems to be a disproportionate amount of funding in this area. Who can blame investors or founders? Those business models are a lot less risky and much easier to navigate.

Some of companies I listed, like Analyte, accept insurance as a payment option, but my gut tells me the vast majority are self pay. Self pay is so much easier than finding a payer or ACO to cover the cost of services for high-risk populations. But maybe these higher touch services will prove themselves out with higher-end, self-pay consumers before leading to more widespread adoption by payers. When that happens we’ll see them make a major impact, as they’ll start to hit the higher-risk patients who are less able to pay. But that’s a way off and it may never happen.

There are models, services, funders, and technologies targeting other segments of the population, but the concierge-like models and services seem to be getting much more interest and traction.

TGphoto

Travis Good is an MD/MBA and co-founder of Catalyze. More about me.

  • Dan

    FYI Better is a collaboration between Mayo and S+C (Mayo is an LP in S+C’s fund). The CEO is the former CTO/COO of Health Hero Network (Geoff Clapp) and there are actually a few former Rock Health interns/employees now working for the company. While they are certainly starting out as a white glove service, Better is part of Mayo’s initiative to reach 200 million people by 2020 (http://www.businessinsider.com/mayo-clinic-ceo-future-of-healthcare-2013-2). Start with the group who will pay today and use the experience to figure out new ways to deliver a similar value at a lower price point. It also service to benchmark the value of a service.

  • I don’t know what the “needs of populations” are, Travis, but I do know what the needs of individual human beings are, and they are very much the same – a great doctor when you need one – and this is the “one size fits all” model that is applicable to everybody. The discrepancy arises not from the variability in “needs”, but from the “diversity” in ability to pay to have those needs met. All the marketing language about values and cultural preferences nonsense is just another way of saying that rich people get Uber doctors on demand, and poor people get specially trained community workers or some other mobile innovation imported from Bangladesh, or wherever children make tee shirts now.

  • travisjgood

    Thanks Margalit! While I agree that the need for access to a good doctor is universal, and that variability in ability to pay is a discrepancy, I was more referring to different services and approaches that provide access – telehealth, virtual visits, follow-up messaging, etc.

    A “great doctor when you need one”, when everyone needs one, is a great aim but it’s not that simple, and not just because of the economics. There is huge variability in trust and comfort level with doctors, and much of this is driven by socio-economic factors. So sometimes those that “need” a good doctor won’t access them until it’s too late.

  • travisjgood

    Thanks Dan! I did know Better and Mayo was a collaboration, but have no idea the extent. Did Mayo invest and/or have an equity stake?

    And I did know Geoff is involved with S+C because my co-founder met with him at the S+C office when we were fundraising. I just didn’t see the funding announcement for Better.

    I did not know Better was part of that initiative. I definitely understand testing these services in easier, willing and able to pay, populations, but my big question is if and how they flip to low cost options. It seems to be there would have to be a compelling business case for the transition as these companies are VC funded and I would assume have growth and exit considerations.

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