Abstract:
Changes in healthcare are occurring rapidly. The old paradigm of recording the doctor–patient encounter on paper records, being paid for our services on a fee-for-service basis, and having patients routinely wait 30 to 60 minutes in the reception area before they are even placed in an exam room are over and will soon be replaced by a new approach to healthcare. Welcome to the new world, where patients ask about the cost of visits and procedures, where it is necessary to obtain prior authorization before the doctor can treat the patient, where high copays and deductibles are routine, where precision medicine and gene therapy are becoming common, and where we will soon see the use of artificial intelligence to diagnose and treat medical problems. All of these changes will alter the doctor–patient relationship. Doctors who are able to be flexible, who can adapt to new methods of patient care, and who are amenable to shifting gears are the ones who will survive in this new healthcare environment.
Attention to access to care, compassion, and transparency (A.C.T.) will result in significant changes in medical practice in the near future and will allow us to continue providing quality medical care to our patients even with the many, rapid transformations taking place.
Access to Healthcare
Access to healthcare means that a person can see the right medical doctor at the right time and in the right place for a fee paid by payers or a reasonable fee paid by the patient. Patient access to healthcare sets the baseline for all patient encounters with the healthcare industry. When a patient cannot access his or her clinician, it is impossible for that patient to receive medical care, and both patient outcomes and patient satisfaction scores will plummet. Lack of adequate access is a potential healthcare crisis for millions of people in the United States.
Easy and seamless access to the doctor and the practice builds patients’ relationships with providers and is likely to achieve improved patient outcomes. There is an impending physician shortage, which means the situation of access to medical care will only become worse. Patients may face availability issues as older physicians retire at an early age, potentially shrinking the workforce. Provider dissatisfaction also is contributing to this shrinkage of the workforce. In a survey from the Physicians Foundation, 53% of providers reported low job satisfaction and 62% expressed a negative view of the future of the medical profession.(1)
Other solutions to the impending physician shortage include adding to the clinical workforce by expanding the number of available graduate medical education residency slots, expanding medical school loan-forgiveness programs, and removing barriers to immigration so that skilled, foreign-trained physicians are able to practice in the United States.
Access to healthcare involves two major and several minor components. The first and most frequently discussed is the patient’s ability to pay. The second is the availability of healthcare personnel and facilities close to where people live. Other issues to be considered are that the practice must be accessible by transportation, should be culturally acceptable to the patients, and must be capable of providing appropriate care in a timely manner and in a language spoken by those who need assistance.
Telemedicine
Healthcare organizations have been using telemedicine to close care gaps caused by the long distances that many patients must travel to have access to in-person healthcare. Direct-to-consumer telemedicine allows patients to use their own computers or smartphones to conduct a video call with a provider. Many smaller facilities in rural areas also use telemedicine to connect with experts in urban areas. Telemedicine has the potential to keep patients from having to travel great distances to receive intensive or specialized care.
Telemedicine is not only for patients in rural areas. It can help expand access to care for two groups of patients: those in rural areas who live far away from a clinic or hospital; and those who have full schedules and may not be able to see a doctor during the practice’s normal office hours.
Telemedicine also is changing how schools deliver healthcare services for both students and staff. Today’s school districts do not have the funding to put a nurse in every school, and those nurses who do work in schools often are overwhelmed by a variety of issues, from complex emotional and behavioral health cases to children with one or more chronic conditions. School-based telemedicine uses telecommunications, including interactive video conferencing and store-and-forward transmissions, to deliver a variety of healthcare services to students attending that school. The current model of caring for schoolchildren often results in a disruption in learning—a child must be picked up by a parent or caregiver and then spend a half a day or more at the doctor’s office, missing classroom learning.(2)
Telemedicine and remote patient monitoring will become an essential, cost-effective, and reliable means to expand capacity in a healthcare system marked by significant and persistent specialty shortages and geographic disparities between patients and providers. Diagnostic codes and a payment model must be developed for teleconferencing and telemedicine.
Access to care will improve if there is an improvement in the efficiency of the practice. There is a necessity to reduce government and insurance industry compliance and decrease the time- consuming regulatory burdens, such as prior authorization, that detract from patient care and increase costs.
Scheduling
Several simple fixes can improve access to providers. Practices that can extend their office hours or stagger appointments in such a way that patients can access their clinicians at convenient times provide greater patient access. Offices that conduct appointments only during traditional work hours (i.e., 9 AM to 5 PM) may not be accessible for those who must be at work during those times. Children who are in school may be unable to see pediatricians who are available only during school hours. Many healthcare organizations offer patients a typical set of office hours for patient visits, but for the working adult or parent, a clinic that is open between 8 AM and 6 PM is not always useful. Patients need convenient office hours that allow them to visit the doctor without interrupting their work or school schedules. An easy solution that can be accomplished with existing staff and no requirement for additional technology is to increase office hours. Access will improve if practices can start at 7 AM or also have early evening and weekend hours.
Making sure patients can make appointments with the right doctor, which can help improve their access to healthcare, ultimately drives more patients to the practice or to the hospital.
Access can be enhanced by improving the scheduling process. When patients do need to access in-person care, they often face find that it is difficult to schedule an appointment. When they contact a provider’s call center or front desk to make an appointment, patients may encounter busy signals, may be placed on hold for a prolonged time, may have to struggle with technological issues such as being disconnected or finding their way through a phone tree, or may have trouble finding a time that meets both the patient’s and the physician’s schedule.(6)
Hospitals and medical practices can consider online appointment scheduling software, which allows patients to view and select appointments with their preferred providers. Online appointment scheduling improves convenience for patients and also allows them to see the right kind of doctor for their medical problems. For example, when a patient with a knee injury books an appointment, he can make sure he sees an orthopedist who specializes in knees rather than one who specializes in shoulders.
Making sure patients can make appointments with the right doctor, which can help improve their access to healthcare, ultimately drives more patients to the practice or to the hospital.
Transportation
About 3.5 million patients go without care because they cannot access transportation to their providers. Transportation is a critical social determinant of health that has recently gained nationwide attention.(3) According to an article published in the Journal of the American Medical Association, ridesharing services such as Lyft and Uber can improve that healthcare disparity and cut down on the $2.7 million the federal government spends each year on nonemergency medical transportation services.(4)
Uber and Lyft have plans to improve access to care arising from medical transportation issues. Both companies will help providers and patients connect with rides to medical appointments.(5)
Compassion
Doctors continue to be challenged to demonstrate compassion for their patients. This is very difficult to do in a 10- to 15-minute appointment accompanied by the requirement to enter data into the EHR. Multiple studies have documented that it is not unusual for a doctor to interrupt a patient only 11 seconds after the doctor initiates the discussion in the examination room.(7)
The healthcare industry, particularly physicians, is getting a bad rap about providing care and compassion compared to doctors of the past. Patients would like to return the days of TV doctors Marcus Welby, MD, or Dr. Kildare, who were quintessential examples of compassion. Today’s physician depends on technology, medications, surgeries, CT scans, radiation therapies, biopsies, and blood tests, and that compassion—the “touchy-feely” part of medicine—appears to have become an afterthought. It is not rare to hear from patients that they had a medical appointment and that the doctor did not touch them or even perform a physical exam.
The Medicinal Value of Tactful Touching
From the time of Hippocrates, tactful touching has been a part of the healer’s armamentarium. The Bible, both Old and New Testaments, contains numerous stories about the healing powers of tactful touching. Harry Harlow, a professor at the University of Wisconsin, performed a famous experiment that showed that primates deprived of touch did not grow and develop normally. It was Professor Harlow’s opinion that essential needs like food, water, and shelter are not enough for survival. Primates, humans included, need to touch and be touched in order to survive and thrive.(8)
Touching provides a vital and necessary role in sustaining life.
Another study conducted in English orphanages during World War II showed that even if infants received adequate food, they failed to thrive unless they were held and cuddled on a frequent basis. Touching does not provide calories; however, it provides a vital and necessary role in sustaining life. Neonatal mortality decreased and growth and development improved when laywomen were brought in to hold and to cuddle the babies for several hours a day.(9)
The number of Americans seeking alternative healthcare providers has been increasing for several years.(10) Patients are seeking healthcare from complementary providers such as chiropractors, acupuncturists, massage therapists, and physical therapists. These complementary providers make ample use of touching in their approach to patients.
Doctors no longer seem to touch their patients during most office visits. It is much easier to order a CT scan or an MRI than to touch or physically examine the patient. All of us remember those amazing physicians in medical school who were able to make a correct diagnosis based on the physical exam alone and were not dependent on technology and imaging. Most physicians have forgotten how to use those physical examination skills.
Another concern is that doctors are under pressure to see more patients and as a result, there is less time to tactfully touch our patients. Tactful touching creates a positive connection between doctor and patient. Sensitivity training coaches may warn against touching our patients, but I know the medicinal value of touching and will continue to use tactful, appropriate touching.
Compassion Is Good Medicine
There is scientific evidence that compassion is good medicine. Trzeciak and Mazzarelli(11) provide overwhelming evidence for the healing power of compassion in their book Compassionomics: The Revolutionary Scientific Evidence That Caring Makes a Difference.
Kindness brings longer, healthier lives—not only for patients, the book argues, but also for healthcare professionals. When a physician is compassionate, patients heal better and more quickly, and the doctors are happier and less subject to burnout.
Studies have shown that warm, supportive interactions with patients from either doctors or nurses right before the patient goes in for surgery result in patients being calmer at the start of surgery and a decrease in the need for opiate medication following surgery. Patients also spent less time in the hospital.(12)
Technology
With the advent of artificial intelligence, we soon may not be required to take a history of the present illness, record the past medical history, or perform the review of systems. With a few clicks and within a few seconds a diagnosis with a rank of probabilities will appear on our computer screen and will recommend what studies to be ordered and what treatment might be appropriate.
Many of us fear the phrase, “The algorithm will see you now!” Medical algorithms, however, are a valuable but currently underutilized resource in healthcare. Their use at the point of care can significantly improve the quality and cost-effectiveness of medical care.
Just as airplane pilots use checklists to safeguard against mistakes and rely on formulas to plot the right speed and trajectory to take off and to get the plane safely to its destination, medical providers can also use algorithms and checklists as a guide. Medical errors are believed to be responsible for more than 100,000 deaths a year.(13) The use of algorithms may well help lower this number and may guide a doctor quickly to the diagnosis. However, an algorithm never will be able to provide compassion, caring, and empathy. If we take the time to talk to our patients, to be good listeners, and to look at patients instead of computers, there will always be a need for doctors.
Transparency
No one would consider staying at a hotel, buying an airline ticket, or buying an automobile without knowing the price of the service or product. Guess what? Patients also want to know the cost of their medical care before they visit the doctor or have the study or the procedure. We are in an era of rising copays, rising deductibles, and more patients having greater financial responsibility for their medical care.
There is a negative impact from not having cost transparency. According to a report from InstaMed, 74% of providers saw an increase in financial responsibility in 2015. High out-of-pocket costs can be prohibitive, causing some patients to skip recommended care.(14)
According to a poll of over 1500 patients, 25% are avoiding medical care due to its high cost.(15)
Another issue regarding price and transparency is patients’ lack of understanding and confidence in the bills they receive from hospitals and medical practices. A review of patients’ confidence in the accuracy of their medical bills demonstrated that just 33% of consumers felt very confident that bills from their hospital or provider are accurate. That feeling seems to have some validity: 47% of respondents also reported a billing or payment issue during their most recent healthcare experience. Such mistakes are among the ways a hospital or health system could jeopardize patient loyalty. In fact, 42% of patients say incorrect or confusing bills would cause them to seek care from a different provider.(16)
The goal of pricing transparency is that, as people have higher deductible plans, they must have the ability to select the best doctor or facility at the best price.
When, for example, patients are given the option to select an MRI provider based on cost, they select a more cost-effective option and reduce the cost by an average of $220 per person. There is proof and evidence that you can lower costs by having people use pricing transparency tools.(17)
Finally, as part of the discussion on transparency, offer your patients various ways to pay their portion of the charges. This means not only accepting, cash, checks, credit cards, and PayPal, either in person or online, but also being able to offer reasonable payment plans. Your staff should understand the practice’s financial policy and apply it consistently to all patients who ask to establish a payment plan. That means being prepared to set up automatic monthly payments for large balances before they become a collection issue.
Bottom Line: The contemporary physician is going to have to adapt and change, which will probably mean learning to embrace technology. But that doesn’t mean we have to forget the basics and why we became doctors in the first place. As long as we focus on the patient and provide access to care, remain compassionate, and have price transparency, we will be successful, have happy patients and a happy staff, and just may be home for dinner!
References
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Health Research & Educational Trust. Social Determinants of Health Series: Transportation and the Role of Hospitals. American Hospital Association. www.aha.org/transportation .
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