Not long ago, many services such as tax accounting were delivered episodically and in-person, as most health care still is today. Periodically, a client and accountant would meet, review financial materials and status and, at the end of the encounter, make an appointment for the next meeting. Increasingly, in-person accountant visits have been replaced by phone or web meetings and do-it-yourself software like TurboTax. There is still a need for accountants and face-to-face meetings, but typically accountants now require such visits for only the more complicated cases that can’t be managed with software or a call.
Health care has proved resistant to a similar transition, although everyone would benefit. While some aspects of care clearly require doctor and patient to be in the same place at the same time, many demonstrably don’t. Nonetheless, even those parts of care that could be freed from the doctor’s office remain tied to it, with schedules optimized for doctors’ productivity rather than what’s best for the patient.
In this article, we identify the barriers slowing the transition of episodic, in-person primary care to innovative models that separate care from location and that empower patients to take on more of their own care. And we describe steps needed to overcome these obstacles, lowering costs and improving quality.
Barriers to Transformation
With the rapid expansion of information connectivity, health care requires much less hands-on work than it used to. Every now and then an examination or a procedure requires physical contact between provider and patient, but many of the important elements of health care have always occurred through oral communication alone and some others — like getting your blood pressure measured or your blood tested — can now just as easily and accurately happen at home or elsewhere outside of a doctor’s office. Much of what used to be restricted to clinical settings can now, from a purely technical perspective, be handled remotely
But let’s imagine that you are ready to video or phone chat with your doctor, recognizing the convenience of never having to leave your house or wait in a waiting room. Unfortunately, your doctor may not be that eager to chat with you. Three forces keep telemedicine from achieving its potential to transform care delivery: the excess workload created for the care provider, the likely change in patients’ health-care-use behavior, and the economics of reimbursement.
Much of the current thinking about new service-delivery models is based on the notion that cost and efficiency of care delivery can be enhanced by directing more patients to primary care. Enthusiasm for this approach largely derives from the appealing and perhaps nostalgic notion that more comprehensive and coordinated primary care could provide better outcomes at lower costs. Indeed, many efforts at health care transformation are built on tying patients more closely to primary care providers. The primary care community has largely embraced these ideas, perhaps because they reinforce the community’s value and centrality to the health care enterprise. The ideas have also been embraced by public policy makers, health plans, and the general public.
Primary care physicians are used to being responsible for all aspects of patients’ care. They are also among the lowest-cost physicians available. For perhaps these same reasons, there aren’t a lot of them. As a result, they are already overworked. In contrast to cardiologists or orthopedists who can limit their responsibility to heart disease or joint- and bone-related issues and triage all other issues back to primary care providers, those providers have no safe harbor. The lower reimbursement and need to provide 24/7 coverage that makes a primary-care-based system so appealing to policy makers and others has long been shown to be a source of burnout
and challenges in getting medical students to choose careers in primary care
. The last thing that this group of providers desires is more responsibility. Just imagine the operational demand if primary care providers also had to actively monitor their patients’ health data between office visits.
From this perspective, the enthusiasm of policy makers and health plans to simply increase access to primary care as a way to address delivery challenges is a cop-out. Rather than do the conceptually hard and convention-challenging reorganizations of systems and finances required to truly transform care, it is easier to suggest tweaking the system and encouraging patients to use more primary care — and let primary care take it from there. That cannot be the solution if, in fact, primary care providers simply can’t take it from there — either because there aren’t enough of them or because they don’t have the support to do one more thing beyond what they are already doing.
The workload problem is further increased by patients’ likely response to enhanced availability, such as what tax accounting and retail customers have enjoyed through digital channels.
The old care model creates friction between the practice and the patient: the difficulties and delays in scheduling visits, the hassle of traveling to the practice and waiting in the waiting room, and the penalty of copays and coinsurance make patients think twice before seeking in-person care.
In our recent studies of how patients responded to the introduction of a portal allowing them to e-mail health concerns to their care team, we found that the e-mail system that was expected to substitute for face-to-face visits actually increased them. Once patients began using the portal, many started sharing health updates and personal news with their care teams. These new channels did not keep the patients out of the office; rather, they encouraged patients to visit the office more frequently. What doctor would dismiss a patient’s e-mail that mentioned chest pain without calling the patient for an in-person visit? Everyone has ups and downs in how they feel. As those downs become easier to report, physicians are alerted to more symptoms. The disease burden is unchanged — but now the aches and pains are given greater voice.
Without the barriers to in-person care
, every skin blemish that can be photographed and sent electronically risks turning from something that patients used to ignore into a demand for medical attention. That’s good if what gets brought to attention is serious and would otherwise have been overlooked. But there is an adage in clinical medicine
: “The great secret, known to internists…but still hidden from the general public is that most things get better by themselves. Most things, in fact, are better in the morning.”
Read more at Harvard Business Review.