What We Can Learn From Mobile Health Care

There are many Boston neighborhoods where a person can get world-class health care—stately Beacon Hill, home to Massachusetts General Hospital, or the Longwood area, which houses five major hospitals and Harvard Medical School. But Roxbury, a community of 54,000 just southeast of Longwood, is better known for its health problems. Its rates of hospitalizations, emergency-room visits, and nonfatal gunshot wounds and stabbings are the city's highest. So it was a little jarring to hear one resident, 72-year-old John Jackson, recently describe a local program as the "poster child" for good health.

Jackson, who has private health insurance and a regular family physician, gets many of his medical needs met in his home neighborhood by choice. Every fourth Tuesday for the last several years he has trekked down Warren Street, ducked into an RV outside the local McDonald's, and received what amounts to a checkup, with an emphasis on keeping his blood pressure steady. To get such service from his regular doc he'd have to schedule each appointment six months in advance. Also, he would have a $10 copay. The people in the van don't charge him anything, and they let him drop in whenever he wants. This is how you get good, cost-effective, preventive health care, he says: "You drop your dignity and come to a free clinic in the ghetto."

This particular clinic—the Family Van, a nonprofit affiliated with Harvard Medical School—has been operating for 18 years now, but it is only in the last year that many people have begun to realize what Jackson figured out a long time ago: "mobile health clinics" like the Family Van don't just provide health care to people who don't have any. They also help a lot of people who can get traditional health care by other means, and they do so in an astonishingly cost-effective and efficient way. In other words, they solve one of the most pressing problems facing the new health-care-reform law: how to expand access while controlling costs. In Massachusetts the need is particularly acute; spending on health care has increased by 52 percent since the state enacted its own major health reform in 2006.

That number would be even higher if not for the Family Van. For every dollar invested in the van's operations, an estimated $36—in avoided ER visits, in prevention of diseases, in management of chronic illnesses that can spiral out of control—has been saved. The Family Van spared the health-care system more than $20 million last year, and it did that on a meager budget of half a million dollars.

When Nancy Oriol, now the dean for students at Harvard Med, founded the program, she wasn't trying to cut costs: her goal was simply to bring health care to the city's neediest. She and her cofounder, Cheryl Dorsey, hit the streets for two years surveying locals about their needs before buying an RV and outfitting it with basic medical supplies and equipment. Oriol hired some of those locals to staff the project and persuaded private investors such as Boeing to fund it.

Twelve years passed before one of the project's major funders, Putnam Investments, asked Oriol what kind of results the van might be delivering, financially speaking. "They wanted to know about the ROI—the return on investment," she says. "But I didn't know what ROI was. They don't teach you that in medical school." Oriol's students cobbled together an informal way of assessing the van's performance, but it took several years and some extensive number crunching before the Harvard group could come up with a more rigorous formula for measuring the cost-effectiveness of mobile health. It was published last year, and even the van's staffers were a little surprised at the 36-to-1 figure that popped out when they applied it to their own operation. (Investment in conventional preventive medicine tends to have an ROI more like 3 to 1.) The algorithm has now been applied to 10 other mobile health programs around the country. The data are as yet unpublished, but they're impressive: $20 saved for each dollar of funding.

Given how expensive most medicine is, how do mobile health clinics manage to save the system so much cash? Part of the reason is their sharp focus on a set of cheap, portable screening tools and questionnaires—for diabetes, obesity, high cholesterol, hypertension, alcohol abuse, and depression—that are proven money savers. (Not all preventive medicine saves the system money; some types of screening cost a great deal.)

Another part is the vans' emphasis on long, sometimes meandering conversations between patients and health-care providers, which are often the best way to suss out what's bothering a patient and what can be done about it. Conventional primary-care doctors often can't afford to discuss their patients' issues in depth, since they're not reimbursed for that time. Van staffers, on the other hand, don't have to worry about insurance and Medicare reimbursement: their salaries are paid by donations.

Still another reason that mobile health clinics succeed where traditional primary care fails is convenience. Once the Family Van has parked in a neighborhood for the morning or afternoon, it's there to provide whatever is needed. It takes only walk-ins. Some people simply swing by occasionally to pick up free condoms. Others, like Jackson, come regularly to get updates on chronic conditions. Because Massachusetts's health-care-reform law requires citizens to have health insurance, most Family Van patients—82 percent—do have coverage, and well over half have regular primary-care providers. In a sense, that should mean they don't need to come to the van. But having a relationship with a doctor isn't the same thing as having him or her on call for you reliably once a week.

Finally, there is the fact that the Family Van provides medicine without doctors. Instead, it hires people with some certification and trains them further to provide every medical service it offers. (If complex medical care is needed, it makes referrals.) That keeps labor costs low, and, more important, says executive director Jennifer Bennet, it puts patients at ease. "We have somehow, by bringing this care to the curbside, managed to avoid the barriers you see in traditional health care," says Bennet. "Think about it: in a doctor's office, you go in and get naked, and the other person's fully clothed and standing above you. There's a power dynamic. We're not doing that. We don't even wear white coats."

There are now more than 2,000 mobile health clinics across the country. But they can do only so much. Obviously, there's a limit to the services a van can provide without doctors, and to the amount of money that can be funneled into such projects, either through philanthropy or (as with some other vans) government grants. Still, it's worth looking at the advantages of the Family Van and asking why these can't be applied to conventional health care, too. It's great that John Jackson has access to cheap, convenient, effective preventive care in a relaxed and friendly atmosphere. Shouldn't we all?