I’m currently reading Jonathan Bush’s new book Where Does It Hurt? and it definitely got me thinking about a lot of issues in health care. More on that to come for sure, but in the meantime a little story.
A few weeks ago, a good friend of mine had an allergic reaction to something he ate. He broke out in hives, and his face became swollen. Out of concern for his health, he visited the Emergency Department at a local community hospital. His story continues from here and highlights the failings of our health care system and questions why our system can’t and won’t perform better.
My friend spent four hours in the Emergency Department before he finally gave up and left. In the intervening four hours, he had to recount his full health history, his religious affiliation and his emergency contact information multiple times. (Anyone reading this is probably not surprised – having to recount your story multiple times is pretty much a standard when visiting a hospital.) An EKG was performed, he never actually saw a physician and the nurse assigned to take care of him was minimally present. He left without a prescription for prednisone.
After leaving the Emergency Department, he texted me in desperation asking for a prescription for prednisone. As a general rule, I don’t like writing random prescriptions for people who’s medical history I don’t actually know. My friend was desperate though because it was Sunday. His physician’s office was closed, the on call physician refused to help (a problem all in its own), and the local community health center was also closed. I finally convinced him to come to the Emergency Department at my hospital after promising to call down to the ED so his wait would be shorter and checking to see how busy things in the ED were. I’m thankful he had a good experience – though I imagine part of that was because I told colleagues in the ED that he would be showing up – but why should it be so hard? Why couldn’t the system take care of a non-life threatening medical problem on a weekend without requiring a trip to the Emergency Department?
Every aspect of my friend’s story illustrates yet another failing of the health care system. There are so many things wrong that it’s almost hard to know where to start. For example, the community hospital didn’t have access to my friend’s health records – something that likely would have decreased the number of questions he was asked in the Emergency Department. But the hospital and his primary care doctor do not share an electronic medical record, barring the hospital access to the most important information in his health history. The simple solution is a nationwide electronic medical record, so that any physician anywhere could access your health information when needed. More to come on that too.
The greater failing is that my friend couldn’t access health care outside of an Emergency Department on a weekend. But how many of us have had a non-life threatening medical event occur “after hours” and had to go to the Emergency Department to get care? You’re more likely to find a plumber or electrician available in the wee hours of the night than a physician. Health problems occur 24/7, so why has our system, and the American people, become comfortable with a medical profession that doesn’t provide 24 hour outpatient comprehensive care? When did we let the Emergency Department become the default?
In days long since gone, physicians saw their patients in their homes. Time, cost, and reimbursement concerns moved the physician visit out of the home and into a centralized office, and in the process physician hours changed. There has been some movement to change that; for medical practices to be certified as a Patient Centered Medical Home, “extended hour” appointments with “medical professionals” out of the normal work day are required – a regulation brought about by the Affordable Care Act. But that’s hardly enough incentive (and truthfully, being fully patient centered would mean going back into the home). Jonathan Bush comments in his book on the need for business outsiders to enter into the health care industry in order to change the status quo, create competition, and hopefully lower prices. These outsiders will begin by focusing on the medical system’s inefficiencies and finding ways to profit. Enter the pharmacy based clinic.
Pharmacy based clinics only came about because some smart entrepreneur or thinker at CVS and Walgreens saw an opportunity to profit off of the medical system’s inadequacies. They realized that people get sick all hours of the day, not just from 8am to 5pm, and that you can’t plan on getting sick and making an appointment. They realized that people would love having a convenient located option to get a flu shot or check for strep throat that didn’t require a doctor’s appointment, wait time, and price tag. People with chronic illnesses could easily stop at a “Minute Clinic” to have their blood pressure checked or their diabetes meds altered. After all – the pharmacy is five feet away. And CVS and Walgreens had the resources to overcome the health care system’s intense regulatory environment. Physicians initially derided these clinics as money-making opportunities headed by nurse practitioners and physician assistants with less training than physicians (with the undertone being worse quality), but we should take note. These clinics were born out of our failure as a profession to offer convenient, comprehensive service to the public.
If you argue that health care needs to change in slow incremental changes, then it’s only a matter of time before some other corporation keys into another growth opportunity in health care – and one that could have much wider reverberations and affect far more than just the physician’s office. If there’s any good news, it’s that the outsiders are slowly revolutionizing medicine, chipping away at the Berlin Wall that the status quo has for so long help up in their way. One day they will succeed in turning the industry upside down, and health care as we know it will be forever changed.