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Thu 14 Feb 2008 04:00 AM

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Doctor in the house

House calls are a new force in Dubai's healthcare sector.Which players are making the early moves?

House calls are a new force in Dubai's healthcare sector.Which players are making the early moves?

Dubai's ‘dial on demand' style hasn't traditionally stretched to medicine. While doorstep deliveries are common in other industries, when it comes to healthcare patients will still take a taxi over the telephone.

Now, thanks to market competition, providers hunting for an edge in the marketplace are getting back to their roots and offering old-fashioned house calls.

Unless insurers have a change of heart...house calls will remain an option only for the wealthy.

At the Sulaiman Al Habib Medical Center we noticed that there is a big need for home healthcare, but very little supply," explains Mazen Slim, the centre's business development manager. Many patients presenting themselves to the emirate's strained emergency departments could be treated at home, so house calls are one way of capitalising on an impatient market, he argues.

There is a need for these services because Dubai is vastly growing in population and hospitals cannot adequately provide care except for the people who are really in need.

It's rare for Dubai to be slow to meet market demand, but the practicalities of delivering house calls can be daunting. Deploying a team of highly-paid physicians to trawl through the city's traffic when they could be three times as productive in a clinic doesn't seem to make economic sense - usually the deciding factor for most private providers.

That physicians are targeting a low-yield, niche service suggests the mainstream is getting ever more crowded. It is also a reflection of how inadequate house call provision currently is, says Dr Piet Bekaert, director of local clinic Dial-A-Doctor. Bekaert established Dial-A-Doctor in 2005 and considers his company the first to specifically target Dubai's home healthcare market.

Before us there were a few GPs and specialists who offered house calls, mainly on a one-off basis, but the market was definitely underserved," he observes. House calls might not be the most glamorous, profitable service, but it is still one that the market is demanding. As practice rivalry hots up in Dubai, providers may have to offer house calls to compete.

A risky call

Most healthcare providers are understandably wary about providing house calls. In the US and Europe, home visits are one of the more highly regulated services, but Dubai is still unsure how to tackle the issue.

"There are normally more rules to govern home healthcare" explains Slim. "For example, you cannot give critical care in a home healthcare setting - you may only give nursing services, family medicine and general medicine services."

Considering that malpractice claims can be prosecuted in Dubai's criminal courts, providers are likely to play it safe. "In this part of the world there are no rules and regulations as to what can and cannot be provided in home healthcare," complains Slim.

Dr Sulaiman Al-Habib Medical Center has decided to avoid entering the market until these guidelines are confirmed. "Once Dubai Healthcare City (DHCC) and the Department of Health and Medical Services (DoHMS) has made it clear we will have the peace of mind to recruit physicians for this - so far we cannot.

Calling names

Once legislation surrounding house calls is cleared up, there is likely to be a sprint to corner the market in Dubai. If past form is anything to go by, the race looks set to be a vicious one. Last August, Dr Bekaert of Dial-A-Doctor considered legal action against a local tabloid newspaper over published claims that Jebel Ali Hospital would be fronting the UAE's first "dial-a-doctor service", which would trade under the name ‘800 Doctor'.

The piece failed to acknowledge that Dial-a-Doctor had been operating in Dubai for more than 18 months. The CEO of Jebel Ali Hospital, Advet Bhambani, told Medical Times he did not know about the service at the time of the interview, but remains adamant that the Jebel Ali service is unique to the UAE.

"First of all, all over the world, house calls is not a revolutionary concept, it has been happening for decades," Bhambani shrugs. Bhambani argues that as his doctors work exclusively as mobile medics for 800-Doctor; they are differentiated from rivals set-ups, where doctors also spend time in clinics.

We're starting up with a team of 10 doctors exclusively for this service," he explains. "They are on call all over Dubai and we are trying to scale that up to over 100 doctors - then we want to go nationwide.

A call to harms

Going nationwide may be the ultimate objective for 800-Doctor, but there are plenty of local logistical issues to solve first. Dubai's multinational population and congested infrastructure make mobile healthcare provision far from straightforward.

Traffic is a major problem - and it is going to be a major problem for another three more years," concedes Ayub Kalaff, managing director of DHCC-based Health Call. The company's doctors are currently scattered across prime locations.

We have one in the Marina, one in Jumeirah, one in Burjuman area, and the two new doctors that are joining us will be in Arabian Ranches and Mirdif," explains Kalaff. Widespread coverage will have to be a must for providers looking to enter the house call market. Doctors are not paid by the hour, and for the venture to succeed, providers will have to clock up consultations and keep windscreen time to a minimum.

Between them, Health Call's doctors speak five languages, which is a fair indication of the communication challenges facing visiting physicians.

Triaging patients becomes crucial when you are sending doctors into unknown territories, explains Kalaff: "If we are sending a female doctor during the night we have to send a security guard with them, especially if it is a remote area - that is why, when we triage over the phone, we have to screen very carefully." Unfortunately, prank calls also remain a problem in Dubai and doctors are often sent on wild goose chases, he adds.

Price wars

As a cash-on-demand service, the market for house calls is currently small. For most patients, paying over the odds for a consultation they are unlikely to be able to claim back through their insurer isn't an attractive proposition.

Health Call claim to be at the lower end of the pricing scale and their home visits start at AED400, rising to AED600 during the night. Kalaff alleges that competitors on the market are charging up to four times as much for a visit. As a result, house calls are out of reach for the majority of patients and, unless insurers have a change of heart, will remain an option only for the wealthy.

Mandatory insurance is going to impact every aspect of Dubai's healthcare, and it may be a stumbling block for house calls. Convenience comes at a price, and at the moment, it is not a price the Gulf's insurance providers are willing to pay. Third-party payers, concerned about policy abuse for patients, view domiciliary care sceptically. "Currently, they are not covering it here and this is a big factor in why it is not growing," says Mazen Slim.

This reluctance is indicative of a wider mistrust between providers and insurers, claims Slim: "Right now, in most of the region, insurance companies don't cover home healthcare - they are not convinced that the people are really sick; they think they should come to the hospital." If home healthcare is covered under the upcoming mandatory insurance plans, however, it will be a huge boost to the sector, he adds.

Too close to call

The market may be ripe for house calls, but that does not mean it is ready to supply them. Providing sophisticated, mobile medical care is not something local providers have historically concerned themselves with. Mazen Slim believes that once DoHMS and DHCC agree on guidelines for domiciliary care the market will be wide open for established foreign companies.

"If a British company comes here that is specialised in home healthcare and they already have the equipment, so will not need great start-up costs, then they will be very difficult to compete with.

Despite the current gap in the market, Dubai's population is unlikely to provide a proportionately large house call market in the long term.

There is a need for the treatment of chronic diseases, like diabetes or hypertension," admits Slim, "but if you look at the demographic of Dubai you will notice very clearly it is young people who are living here...people who come to Dubai do so to make some money and to avoid the taxes, then they return to their own country to grow old".

The fight for the house call market may well be a brief one, but it will be worth a great deal to the victor's reputation. Dubai will have to wait to see who makes it through the traffic first.

THE FACTS: Care in the communityHouse calls may be a niche service in Dubai, but, if implemented correctly, they could be a market leader in primary healthcare, argues Dr Bekaert of Dial-a-Doctor. Bekaert bases his service on SOS Médecins, a fixed-fee house call service that visits 300,000 patients a year in Paris and 40,000 in Brussels.

What has made them so successful is their autonomy and their speed of action," explains Bekaert.

The greatest advantage for a fledgling healthcare system is that house calls can delay committing to the construction of expensive facilities. "Providing home service to patients is something that makes even more sense for the small or out-of-reach communities - you don't need to build costly buildings and staff them, which can be very expensive," Bekaert states.

For physicians, the added benefits include less paperwork, much lower overhead costs and a fixed fee at the end of the consultation. As a cash-only service, practices can avoid negotiating with third-party payers and running the risk of a reduced end fee. Home healthcare may be a small market but if a company can get it right, it can make for a robust business.

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