Imagine yourself a patient 2400 years ago. By chance, Dr. Hippocrates is your “preferred provider.” You and Dr. Hippocrates have a long standing relationship, and you’ve seen him in person many times, including for a comprehensive check-up and medical history. Since his office is located 20 miles away, getting there requires a Herculean effort. With the help of friends, donkeys, walking and several days of delay you luckily arrive before closing time at 4 pm on Wednesday. You remember well the weekends, the evenings and the holidays that you got to the office sicker than a dog, only to be left in the street until the clinic re-opened.
When you arrive, many sick patients greet you, their expressions fatalistic. All have made similar journeys, and some are very sick. A line strings out the waiting room door that is two hours long. Dr. Hippocrates is rushing to finish the day’s work, see the last person and go home to supper and his family. With so many people to see and not much time, Hippocrates flies through the patient histories, relying only on his memory, knowledge and expertise to prescribe treatments and cures, moving quickly from one patient to the next.
For you, an herb is prescribed and you make the arduous journey home. Two days later you’re feeling worse. Maybe it’s the herb, maybe it’s the wrong diagnosis, maybe it’s the exhaustion from the ordeal. Yet one thing is for sure, taking the trip back to Hippocrates is too daunting to consider.
Fast forward to present day, and consider yourself as patient. Fortunately, the science of medicine has changed exponentially. Sadly the business model and the experience of getting that care is egregiously similar. Every time you need to use health care in today’s world, a gauntlet of obstacles stands between you and the service. First, there’s the receptionist answering the phone, then the scheduler fitting you into a limited number of times to come to the office, with all available slots being at least two days in the future. Upon arriving at the office, a waiting room stuffed full of sick patients greets you. Next, the person at the in-window verifies your insurance eligibility. On to the nurse who greets and reviews your history, then a wait again for the hurried doctor to rush in, and in 10 minutes or less, reduce your problem to a prescription. You’re ushered out and to the window where the co-pay is made and next a follow-up visit scheduled. The bill proceeds to the billing specialist and somewhere along the way (often months later) you might get an insurance adjustment charge. The next day you wake up with a rash. Maybe it’s the drug, maybe it’s the wrong diagnosis, but taking that trip back through that system is going to give you pause and it’s not just the pause of your time or life interrupted. For most day-to-day health care this story has repeated itself ad infinitum from antiquity until today.
A huge unexamined question in primary health care revolves around the requirement of “forced” office visits. Why do you think you are going to the obligatory ritual of the office visit for every medical problem be it a prescription refill, poison ivy rash, allergic runny nose, tick bite, urinary tract infection among thousands of other problems. Do medical experts really need to “see” you to protect you, themselves, or build a relationship?
The answer to this conundrum once analyzed is simple: No. As a matter of fact, the majority (over 50%) of routine primary care health problems can be taken care remotely, by phone, email, IM, or even online chat, if the doctor and patient have a pre-existing relationship. And why don’t more primary care practitioners use the convenience of remote access to get their patients the fastest initial and follow-up treatments possible? It’s about the money. Insurance companies pay a doctor to help you by seeing you face-to-face. Since doctors are beholden to insurance companies payments to cover the cost of your visit and since your copay doesn’t even get close to covering the cost of running the business. So the primary docs elect to put you through The Funnel.
When the idea is first suggested, most people disbelieve that phone consultation alone between a doctor and patient could handle more than 50% of the medical issues sent through the funnel of the mandatory office visit gauntlet. Don’t misread this, talking with your doctor doesn’t mean that you don’t need to be seen in person sometimes too. Likewise, all patient-doctor relationships should begin first with a face-to-face visit, complete with check-up and the discussion of the patient’s prior medical history. However, just open your eyes to the possibility of a new idea. I’ll let this uncomfortable thought settle in for while and will check back on your progress in my next post.
Until next week I remain yours in primary care,
Alan Dappen, MD