Curbside Consult with Dr. Jayne 10/15/18

As an urgent care physician, I enjoy the satisfaction of being able to make a bad day better for many of my patients. Although I live in a major metropolitan area, there is a relative shortage of primary care physicians (at least ones taking new patients). For those patients who have primary physicians, there’s a shortage of same-day and after-hours appointments that mesh with patients’ busy schedules and their desire for convenience.

I’m happy we can meet our patients’ needs, but I’m often conflicted about the fact that delivering what is essentially primary care in an urgent care setting often contributes to the fragmentation of care. That’s in addition to the cost contribution, because a visit with us typically costs more than a visit to a primary care physician due to negotiated contract rates with payers and higher co-pays for patients.

The fragmentation could potentially be reduced through better technology, particularly better interoperability. Our EHR allegedly has all the interoperability bells and whistles, but local hospitals and their owned physician groups aren’t too keen on sharing data with competitors despite our desire to deliver better patient care. Our state HIE’s provider-centric pricing model makes it cost prohibitive for us to connect, given that the majority of our providers are part time. Even if it were more economical, our HIE is largely read-only, which doesn’t do a lot for the efficiency or accuracy of being able to bring patient data to life in the chart.

A good chunk of our patient volume happens before 9 a.m. and after 5 p.m., which is a testament to the fact that patients want to receive care at a time that is convenient for them, even if it might be more expensive. They also like being able to get care same day and not have to wait for 3-5 days for an appointment for straightforward medical problems. Many of our patients are hourly workers who don’t have paid sick time, and even those who have sick days may be challenged to find two or three hours to visit their primary physician during the work day.

I often think of the reasons behind why people choose to get their care when and where they do, so this Kaiser Health News article caught my attention.

The article covers the idea that millennials are at the forefront of wanting convenience when selecting their care and tend to choose urgent care, telemedicine, and retail clinic options. A poll of 1,200 adults found that younger patients were less likely to have a primary physician, ranging from 45 percent of patients ages 18 to 29 and declining to 12 percent for those age 65 and older. We see that play out in practice, whether it’s strictly due to the convenience angle or whether it’s due to a lack of available primary care capacity.

However, I’m seeing more patients in the Baby Boomer demographic who may have a primary physician, but choose to come to urgent care because they’re busy in their retirement and don’t want their schedules upset by needing to seek medical care.

I have several friends who are dabbling in telemedicine as an adjunct to their regular primary care practices. They report that patients have discussed their desire to handle medical issues at the time and place of their choosing, whether they actually get to interact with the physician face to face or not. Patients are used to transacting the business of their lives online, whether it’s banking or retail, and since healthcare has become a commodity, it’s no different.

One colleague notes that while the patients are glad she’s offering the service, many of them would be just as happy seeing any other physician and not specifically her. We’ve moved into a generation where patients no longer have a primary care physician for life. They may have one for three or four years and then have to change because their employer selected a different network, or they may change due to relocation and the more fluid lives that people tend to live now.

There are concerns that moving away from that continuity where physicians know their patients not only drives up costs, but also leads to inappropriate antibiotic use or misdiagnosis. We see patients who come in specifically because “my primary wouldn’t call me out a Z-pack” and spend a lot of time educating them about viral illnesses. At least we can send them home with medications to help with their symptoms, which makes them feel like they’ve done something to get better even if it’s not an antibiotic. There’s a powerful psychology in that.

We also see patients who have been to their primary care physician and also a subspecialist, but feel like their problem isn’t being addressed so they come to us “for another opinion.” It’s difficult to explain that we’re not experts and if they’ve been to a subspecialist at one of the local academic medical centers and there’s not an answer, that we’re unlikely to find one at the urgent care with our limited testing and radiology capabilities.

I’m particularly interested in the concept of delivering regular primary care via telemedicine, rather than just care for urgent and acute issues. Virtual visits have the power to revolutionize what we do, adding convenience for both patients and providers. In order to be successful, though, we have to get payers and policies aligned to pay for them so that physicians will be more likely to offer them. We also have to get technology aligned, including robust patient portals, the ability for patients to upload their own health data and documents, and better understanding from mid-career physicians that telemedicine isn’t going to suck away their evening and weekend hours.

I think about all the hours that my practice spent trying to track down patients and get them to come in for appointments back when I was in the primary care trenches. I would bet that at least half just disliked the process of going to the doctor and would have been game to do a virtual visit.

I’m excited about projects that pair community health workers with physicians to deliver a combination of in-home contacts with virtual physician visits, particularly in rural areas. A friend of mine recently received a grant in that regard, and I can’t wait to hear how it plays out in real life. I know she is having some challenges figuring out how to actually deliver the services, whether to try to integrate something with her EHR or to use a third-party telemedicine solution. It sounds like the options among vendors vary dramatically, so she is going to keep me posted on her progress.

Are you a physician who regularly incorporates virtual visits into care, or a healthcare IT person who supports one? I’d love to hear from you. Leave a comment or email me.

Email Dr. Jayne.