Online “symptom checkers have deficits in both diagnosis and triage, and their triage advice is generally risk averse,” according to a new study in BMJ by Harvard researchers. Some of the press coverage of the study has been pretty critical of the symptom checkers, but the study itself is quite balanced.
Symptom checkers are a lot better than “Google Diagnosing” (typing a list of symptoms into Google and seeing what comes up). They’re very similar to nurse triage lines used by health plans, which is no great surprise considering that many of the triage lines use the same logic that drives the symptom checkers. They’re inferior to a primary care physician, but of course physicians aren’t infallible either.
People use symptom checkers to self-diagnose and to figure out if they need to go the emergency department, doctor’s office or can treat at home. Not surprisingly, the symptom checkers err on the side of suggesting patients seek care. No producer of these tools wants to get sued for recommending self-care to someone who should have called an ambulance. But in this regard symptom checkers are similar to nurse triage lines and also –at least in my experience– to physicians who are covering call. Too often they suggest a trip to the ED.
There’s an opportunity to reframe the next generation of symptom checkers as tools for navigating the medical system. That means not just suggesting a diagnosis and level of care, but pointing to an appropriate specialty, facility, or individual clinician to follow up with. This could be especially useful for patients in areas with fewer specialists and sub-specialists, and those with rare or hard to diagnose conditions. Primary care physicians could use such a tool as well to help direct referrals.
I’ve started hearing more about physician practices that are opting out of the health insurance system and taking cash for services. See Cash-only looks good to doctors in Healthcare Finance News as an example. I can understand the appeal. After all, it’s an expensive and frustrating hassle to deal with health plans and Medicare, and can interfere with the doctor/patient relationship. In theory physicians should be able to offer the same level of care while reducing overhead costs and splitting some of the savings with patients. If those patients have high-deductible plans it should work out for everyone.
To some extent in primary care that’s exactly what’s happening, and it’s a trend I support. The logic is especially strong there since third-party reimbursement offers very little in the way of reward for a lot of work. A patient co-pay may equal the amount that gets reimbursed by the health plan; with a high-deductible plan the insurance company may contribute nothing. (Note that this picture is slightly changed by the Affordable Care Act, which mandates full coverage for preventive services –although in my experience the physician office often gets confused about this and ends up collecting a co-pay anyway.)
The Healthcare Finance News article cites a practice in Austin that doesn’t take insurance and has no administrative staff. Result: office visits for $30, which is about the typical co-pay. Well done.
But I do worry about other physicians in both primary care and now specialty care that are moving to more of a concierge model. If it happens in any great numbers there will be a serious capacity problem in the system. That’s because the shift is often accompanied by a dramatic reduction in the number of patients served. It’s sometimes an order of magnitude.
The same article describes a practice that cut its patient panel from 8000 to 1000. I’ve heard of primary care physicians going from 3000 to 350 patients. The big question is what’s going to happen to all the patients who lose access to those physicians –the slack will have to be picked up by other providers. In primary care, maybe the emergence of concierge practices will have a silver lining by boosting compensation for primary care in general and drawing more physicians into the field, helping to correct an historic imbalance in pay ratios between primary care and procedural specialties.
Specialty physicians opting out of insurance is more concerning, but for other reasons. As difficult as insurance companies are, sometimes they do add value by making doctors and patients jump through hoops before approving lucrative –but often unnecessary– procedures like spinal surgery. And there is a tendency to price gouge–which will be only partially mitigated by “transparency” tools that are coming into vogue.
For patients who are willing to spend more money for better care the best value may be in joining a concierge primary care practice rather than opting for cash-only specialists. The primary care doctor will have the time and skill set to consider the patient from a holistic standpoint, to refer to the right specialists and make sure the patient gets seen, to coordinate second opinions and follow-up and to offer their own views about topics such as whether to have surgery.
I’m actually considering a concierge practice for my own care, but I may be too late. A single-doctor primary care practice I spoke with is not taking new patients. Emails I sent to two other local concierge practices inquiring about becoming a patient there were ignored.
photo credit: volperic via photopincc
The November Health Affairs theme issue, Redesigning the Health Care Workforce, is especially good. Much of what I’ve seen written elsewhere on the topic focuses on alleviating a (purported) looming shortages of doctors or nurses by training more of them, or by having people with less training than doctors, e.g., NPs and PAs take on core physician tasks including diagnosis. There are two articles I think are particularly good:
Expanding Primary Care Capacity By Reducing Waste And Improving The Efficiency Of Careby Scott Shipman and Christina Sinsky points out several opportunities for primary care physicians to increase their capacity by setting up more efficient workflows and pushing off administrative and clerical tasks and using better technology. They are right to point out that increasing compliance burdens are falling heavily on physicians. I for one would apply a very stringent test to any proposed regulation that adds burdens to primary care. The authors conclude that efficiency gains could provide capacity for an additional 30 to 40 million primary care visits per year. By way of contrast, the Affordable Care Act is expected to add 15 to 24 million primary care visits.
Accelerating Physician Workforce Transformation Through Competitive Graduate Medical Education Funding notes that GME has changed very little even though there is a consensus that change is long overdue. For example, training remains hospital-focused and highly-paid specialties like radiology continue to grow faster than primary care. Essentially, funding for GME is grandfathered, leading to excessive rigidity and lack of incentives to change. The authors, David Goodman and Russell Robertson propose making institutions compete for GME funding, adopting some of the best practices of the National Institutes of Health funding approach such as public guidance of programs, peer review, competition and long-term funding.
There are some other good pieces included, so read the whole thing if you have a chance!