PATIENT JOURNEY
My real estate agent shared a troubling account about a recent sale. He sold a nearby home to a newly retired tech executive from the west coast. The buyer asked the agent about medical care. He had been under the care of five doctors in the large metropolitan city where he had moved from. The agent referred him to his primary care doctor for specialist recommendations and coordinated his care. When the patient went to the new medical office, the doctor noticed the cough the man had. The patient explained that he had had it for years and had had a GI evaluation of his esophagus five years previously which was benign. The new primary care doctor insisted he be re-evaluated by a GI specialist. The endoscopy revealed that the patient had inoperable esophageal cancer with significant spread.
What Happens When No One is In Charge of Healthcare?
This story is unverified hearsay, and the patient's outcome is unknown. The narrator was clearly upset, and the scenario described is definitely plausible in today's fragmented healthcare system. How could five doctors miss a fatal diagnosis? Despite advanced medical technology, significant illnesses are not treated optimally. This essay will explore the causes of this tragedy and potential prevention measures.
Is Having Doctors the Same as Having Care?
This patient likely visited different specialists for various issues, believing they offered the best care. Specialty care in America is advanced, with specialists using the latest equipment and treatments promoted by the medical device and pharmaceutical industries. Specialists focus on a limited number of conditions and perform procedures related to those conditions, providing follow-up care. However, patient non-compliance, wherein the patient doesn't return as instructed, can go unrecognized. Several reasons for patients not returning to specialists include:
The patient sought a second opinion from another specialist.
The co-pay was too high, leading the patient to skip follow-up.
The patient changed insurance plans, and the specialist is not covered.
The patient is in denial about the specialist's recommendations and avoids returning.
The patient lacked a trusted physician to discuss the specialist's advice.
The patient opted to have their condition managed by their primary care physician.
Specialists always ask the patient to return unless the problem is definitively resolved, such as a successful surgical procedure, or there is a clear handoff to the patient’s primary care physician. They do not pursue the patient aggressively to avoid being accused of avarice. The patient’s missed diagnosis of advanced esophageal cancer is unlikely to be the specialist’s fault because the patient was instructed to return and was given an appointment that was not kept. The health system design centering on treatment of illness leads patients to specialists, but is there a better approach?
The Vanishing Primary Care Doctor: A Looming Healthcare Catastrophe
Specialists often focus on specific medical issues, whereas general internists or family doctors consider the overall health of the patient. Specialists typically send summaries of their treatments to the patient's designated doctor, who updates the patient's electronic health record (EHR). The family doctor may discuss the consultation results during subsequent visits for various health concerns. Patients generally visit their primary care office twice a year for acute illnesses, chronic disease management, or preventive examinations. If both the primary care doctor and specialist use the same electronic medical record system, the shared record will reflect all medical issues and note missed or cancelled appointments with all providers.
The patient must not have had a primary care doctor due to various reasons:
Shortage of Primary Care Doctors: In large cities, there is a decline in the number of primary care doctors due to factors such as expensive office overhead, the need for well-compensated staff, and insurer price controls that limit reimbursement. A metropolitan primary care practice is generally not a viable business in today’s healthcare system.
High Costs: The high costs associated with medical care, including co-pays and insurance changes, can deter patients from maintaining a consistent relationship with a physician. Employers have sought to cut costs which means patients pay more to see their doctor or don’t have a doctor at all, preferring Urgent Care Centers (UCC). Limitations of UCCs are discussed in Is Urgent Care a Temporary Bandage.
Insurance Issues: Changes in insurance plans or doctors being dropped from insurers' preferred lists can disrupt the continuity of care. The deceptive practices of insurance plan are discussed in How Do Health Insurers Raise Costs, Reduce Access, and Lower Quality.
Relocation: Health system contracts and other factors may force doctors to relocate, leaving patients without a primary care physician as discussed in Why Won't Your Doctor See You Now.
ANECDOTE
Our office considered the patient first, not the profit. Our office was a certified Patient Centered Medical Home (PCMH). It is more expensive to operate a PCMH because of greater staffing needs and more time spent coordinating care. Medicare and some other insurers are beginning to pay more for PCMH quality, but the adminstrivia to be reimbursed is onerous.
The Coordinated Cure: How Team-Based Care Can Transform Patient Outcomes
There are significant benefits to a PCMH like my office that could have helped this patient.
Patient-Centric Approach
The care at my office was holistic, respecting the unique needs, culture, values, and preferences of each patient. We discussed specific patient needs during daily staff meetings. Patients are encouraged to actively participate in their care, and we took time to listen to them fully. Patients want to he listened to by someone. All our staff tried to listen. Patients remarked how quiet and unhurried the office seemed to be. Our AI systems were designed to make us more efficient so there were fewer people moving around as shown in What Should a Medical Office Visit Be Like.
Comprehensive Care:
The care team handles most patients' physical and mental health needs, including preventive, acute, and chronic care. We addressed common issues ourselves rather than referring to specialists. For instance, we performed minor surgeries, sutured wounds, treated fractures, and managed mental disorders. Insurance paid us significantly less than they would pay a specialist for these same services.
Care coordination
Care is coordinated across all elements of the broader healthcare system, including specialty care, hospitals, home healthcare, and community services. We maintained a productive relationship with consultants, enabling us to request advice on ordering tests and diagnosing conditions efficiently. For instance, surgeons like to operate and appreciate receiving cases that are prepped for surgical intervention rather than patients who need to be told they do not need surgery. We spent the time sending them well-prepared cases. In return they readily provided us with free clinical advice, which helped us treat patients more effectively. Billing for this approach is onerous and almost always denied so we didn’t bother.
Enhanced access
Analytics Based Scheduling
We did not schedule weeks in advance. Instead, we analyzed visits over time and adjusted open appointment slots per doctor: Monday-12, Friday-7, Wednesday-5, Tuesday-4, and Thursday-3. The newer concept of Open Scheduling leaves all time slots open for same-day appointments for every patient no matter their diagnosis.
Internet as the dial tone of the practice
25 years ago, we launched an internet-based after-hours care system using expert software to replace telephone triage. The website asked structured questions based on patient responses, directing severe cases to the hospital and assessing non-emergency cases like in-person interviews. The software sent our doctors patient data in medical record format for quick review, allowing us to schedule appointments, email prescriptions, or call patients for further clarification.
Doctor and Patient Communication
The process of doctors taking messages from their own patients improved access for patients and proved to be minimally inconvenient to providers. Providers were much more familiar with their own patients, so it took less time for them. Each provider set specific hours to respond to their patients. For example, patients were informed that they would be contacted between 7-8 AM if they reached out after 10 PM. If the issue was more urgent, patients were advised to visit the Emergency Department. Few patients chose to do so, as they preferred to wait for advice from their own doctor. Our office processes1 saved insurers money and was appreciated by patients who avoided going to the ER.
Quality and Safety Focus
PCMHs focus on quality improvement, performance measurement, and implementing evidence-based practices. Patients received a copy of their medical record during each visit to the office. They could review the collected information, as well as interpretations and recommendations. Patients were able to correct any mistakes in their records and gain a complete understanding of their condition.
Team-based care
The partnership and communication between patients and their healthcare providers was a topic frequently discussed during team meetings. Each morning before seeing patients the team reviewed the pre-visit information about patients coming that day. Occasionally, patients were called to reschedule appointments based on pre-visit screenings, which indicated they required a longer visit than the day's schedule allowed. Sometimes patients were called and told we could probably treat them without a visit. This approach is less profitable than seeing everyone who calls.
Summary
Patient Centered Medical Home model aims to improve patient outcomes and satisfaction by providing comprehensive, coordinated, and patient-centered care. The PCMH model has been shown to improve quality of care, enhance patient experience, increase staff satisfaction, and reduce healthcare costs. The PCMH can only be attained by adding new AI Assistants to make the job caring for large numbers of complex patients easier for doctors.
OPINION
I don’t know if having a primary care doctor practicing in a PCMH with AI Assistants could have prevented the tragedy unfolding in patient Case #4, but it is hard to imagine how the outcome could be worse. The current system is broken, but until the reimbursement model changes to prioritize patients instead of profits, the outcome for patient Case #4 will recur.
Preview
The next essay will discuss Direct Primary Care and Concierge Medicine that offer a new cash-pay model and will likely become a dominant form of care in the future unless health systems begin to support primary care with AI systems.