Sunday, March 19, 2017

Access to health CARE vs access to health INSURANCE

A dear friend who follows this blog sent me an email about the two posts I wrote last week about my own recent medical experiences (here & here). With my friend's permission I've copied the message he sent, edited to protect confidentiality and to highlight the themes I want to emphasize:
Thank you for the very informative posts. In general, however, I think the blog doesn't describe the experience of patients who are not MDs and/or are not in an integrated group practice such as the one you belong to. In my own experience, PCPs defer to specialists and won't contradict them. Further, the placebo effect of the PCP relationship is reduced if not nullified by the patient's difficulty in contacting the PCP over the phone. I can never get an appointment on short notice with my PCP; I can only count on seeing him if the appointment is made months in advance, or if I am in an emergency ward or am admitted to a hospital as an inpatient. If I have an immediate problem that is not an emergency (e.g., burn, sprain/suspected fracture, bronchitis), I have to work through two layers on the phone (secretary, medical assistant) -- and then the outcome will be an examination by a nurse practitioner. I therefore now prefer to use the XYZ Hospital's Walk-In Clinic rather than even trying to reach my PCP's office by phone. Finally, your encomium to the email system doesn't apply to the sharing of medical records between hospitals on different systems (e.g., XYZ hospital and ABC, where I have also had care) or to practice groups that are located in one and the same hospital office building but that don't share the same medical records system.
My friend is well insured - s/he [I'm deliberately disguising gender] has no problem with insurance access. And the community where s/he  lives is replete with medical services.

In a follow up conversation I will ask my friend about experience with the nurse practitioner. Over the decades of my clinical practice, and in my own care, I've had terrific experiences with nurse practitioners and physician assistants. Assuming that the NP is indeed a skillful clinician, the PCP can foster trust and comfort with the NP by explaining how they collaborate and demonstrating how they work together.

My positive experiences have definitely been fostered by the fact that I'd been a clinician in the group practice from which I was getting my care. But I'm convinced that a patient who had not had a career in health care and had not been part of the group could have a comparably positive clinical experience if they had the same skills I have in managing my care experience.

I anticipate that in the future, patients will routinely have electronic access to their own medical records. That kind of access, combined with a robust secure communication system with and within the practice, would promote more secure connection to the medical home than my friend experienced.

From 1975 until I ended my clinical practice I was paid a salary. That meant I was not dependent on billing for each in-person service for my compensation. One of my patients who had significant depression and was dealing with major stressors strongly preferred the convenience of electronic interchange rather than coming to my office. After we had gotten to know each other in 5-6 in-person appointments, we switched to email, which we used for ten years. When we met to say goodbye in person when I retired from practice, we felt we knew each other very well, but neither remembered what the other looked like, which made for some amusing uncertainty in the waiting room. Being paid by salary meant that I was not "penalized" for providing care to my patient with so few in-person meetings.

It's not likely that we will have enough PCPs to ensure prompt access for all patients in the foreseeable future. To provide the kind of secure connection my friend was looking for we'll have to manage the process of team collaboration better than s/he has experienced, and make use of electronic forms of communication to augment connection between the patient and the team.

The generation moving into adulthood is schooled in making electronic connection with their peers. They will demand that kind of opportunity in their medical care.

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