Modern Medicine isn't Always Modern

7 days after falling off of his mountain bike he decided his shoulder injury was more than a bruise. He had significant pain and swelling over his collarbone so I ordered an x-ray. He walked in the next day with the images on a CD. My staff loaded the images and the fracture was readily apparent. While the fracture was obvious I was not certain about the treatment. I wondered if surgery was indicated.

I wanted a quick answer, so I took a picture of the image and texted it to my orthopedic surgeon colleague. The answer came back in minutes- the injury needed surgery. Two quick test messages and instead of waiting a few days for an answer the patient walked out of the office knowing immediately what was needed.

A few days later I received a call from the daughter of a patient with dementia. Her mom was not doing well. The daughter said she was more confused, unsteady on her feet and declining. As it was hard for her to bring her mom to the office she wondered if I could make a house call. My willingness to stop by the board and care where the patient lived was blunted by geography. The patient lived almost 20 minutes away. The 40 minute round trip was too far to go during a lunch hour. As the daughter had an iPhone I proposed a compromise. I suggested a FaceTime consult. Two days later I had a “face to face” conversation with the patient. She had improved slightly but was still unsteady in her gait. I ordered an in home physical therapy assessment and made arrangements to check on the patient the following week. The daughter was greatly relieved.

Another evening that week I received a text message from a patient. He had what appeared to be a blister on the surface of his eye and was wondering if he needed to go to the emergency room. I had him send me a photo and quickly made the diagnosis of chemosis, edema of the surface of the eye caused by an allergy. There was no reason for him to go to the emergency room for the problem and I promised to see him in the office the next morning. Two text messages taking less than a minute saved him a lot of time and expense.

Friday afternoon brought another text medicine diagnosis. A patient was smoking and wasn’t paying attention. Hot ashes fell from the tip of the cigarette and landed on her chest. The resulting burn was painful and she was worried about how to treat it. She called the office and the receptionist gave her the number to our office iPhone. Shortly thereafter I was looking at the photo and texting back treatment instructions.

Interactions such as these should represent the future of medicine. They are accurate, efficient, cost-effective and convenient. They are also incredibly rare, as very few physicians offer such services. One may wonder why these innovative services are not more commonly provided. The answer is simple. Doctors are rarely paid for them. Insurance reimbursement lags innovation and insurers have not figured out how to pay physicians for electronically delivered care.

The dominant insurance reimbursement model is based on office based services for in person care. Patients are weighed, vital signs are measured and the patient is questioned and examined and providers are compensated based on the complexity of the condition treated. Doctors typically charge $65-$85 dollars for simple office visits. Since most insurers do not pay for electronic consults physicians who provide such services are forced to either provide them for free or charge the patient directly. When insurers do pay for digital care they reimburse physicians only a fraction of a standard office visit. The predictable result- most patients choose to come to the office and pay a $20 co-payment instead of the full charges for an electronic visit, and most physicians choose to call a patient in to the office instead of providing discounted digital services.

What is overlooked by all is the hidden costs of the current system. If one takes into consideration travel and wait times, a 15 minute office visit can take 3-4 hours out of a patient’s work day. If the visit is done electronically, a 15 minute visit takes up only 15 minutes! For conditions such as the ones I described above, and for conversation based visits to treatconditions such as depression, migraines, hypertension and even diabetes there is often no reason for a patient to physically be in the office. The current system is incredibly wasteful.

As wasteful as it is change, if it is coming at all, is coming an incredibly slow pace. If the delivery of medical care is going to evolve it will require a concurrent evolution in the manner in which medical care is reimbursed. The traditional fee for service approach must change.

At present the best hope for change can be found in Health Maintenance Organizations which pay physicians monthly fees to care for the patients, regardless of setting. The HMO model, which is focused on outcomes, is more likely to be open to innovations in care delivery. Accountable Care Organizations, a new type of care delivery model that also focuses on outcomes, represent another possible source for promoting change. Even with new care models the impetus for change will ultimately come from patients. As more and more people become aware of the advantages digital care brings the demand is likely to increase.

Some may wonder, given the current state of affairs, how it is that I am able to provide digital care. I decided years ago that I wanted to be an innovator and to embrace change. Three years ago I began offering FaceTime and Skype visits to patients. I did so at no charge to HMO patients and at the price of my least expensive office visit to my fee for service patients. The response was initially slow but as co-payments have increased more and more patients are choosing the digital option for their care. For me, even though digital visits do not pay as much as standard office visits the personal rewards of knowing I am doing what is best for my patients has made it all worthwhile.

The future is coming, and I intend to be a part of it.

- Bart

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