Convenient Care and Telemedicine

Policy Reports | Health

No. 305
Wednesday, November 28, 2007
by Devon M. Herrick

Problems with Traditional Physician Care

Many patients have difficulty finding a physician, obtaining an appointment and taking time from work for a traditional office visit.  It is even more difficult to reach a physician by telephone or e-mail, or after office hours.  Some patients are unaware of local urgent-care or after-hours clinics. They don't know what to do about sudden medical problems — including how to reach a doctor or nurse by phone. 1 Often, the only way to reach a physician after hours is in a hospital emergency room — which is both costly and time consuming.  Access to medical care outside of the traditional office setting is particularly important — and particularly difficult — for patients with multiple chronic medical problems.

Patient Barriers to Physician Care

“Doctors are difficult to reach outside their offices.”

Problem: Doctors are hard to see.   A study of medical access between 1997 and 2001 found that seeing a doctor is becoming increasingly difficult:

  • The proportion of people reporting problems seeing their primary care physician rose from less than one-quarter (23 percent) to one-third over the four-year period.
  • Nearly one-quarter reported problems taking time from work to see a physician. 2 [See Figure I.]

Problem: Patients have trouble contacting physicians by telephone or e-mail.  Doctors are difficult to contact outside the office.  Lawyers and other professionals routinely communicate with their clients by telephone and e-mail; very few doctors will consult by telephone and less than one-in-four communicates with patients electronically. 3 [See Figure II.] A Harris Interactive poll shows that most patients with Internet access (90 percent) would like the ability to consult their physician online. 4 But for a routine prescription or answer to even the simplest medical question, patients must usually make an office visit. 5

Why do doctors avoid telephone and e-mail consultations?  The simple answer:  Insurers generally do not reimburse them for phone or e-mail consultations. 6

While phone calls to or from a family physician's office are relatively common, they  tend to be for scheduling appointments or receiving lab test results from an earlier visit.  Often, the patient does not even speak with the physician; instead, a nurse or office manager relays information.

“Most doctors do not use telephones or e-mail to communicate with patients.”

Prescription refills .  When patients attempt to refill a prescription, they sometimes discover the pharmacy will not refill the medication without permission from the prescribing physician.  Generally the pharmacist (or pharmacy tech) calls the physician's office, and a nurse in turn consults with the physician.  When this occurs, the doctor may require an inconvenient and costly office visit before renewing the prescription. Physicians Using E-mail

On-call physicians.  When physicians are out of town or need a break from after-hours phone calls from patients, they often arrange with colleagues to cover for each other.  The on-call physician may not have any relationship with his colleague's patients. And covering physicians rarely have access to patients' medical records when they answer a call.  Yet medical societies approve of the practice because often the only alternative is a local hospital emergency room.

“Rural areas have fewer physicians.”

Problem:  There are too few doctors in rural areas.   Compared to metropolitan areas, there are fewer physicians serving rural patients and patients must travel farther for office visits.  More than 35 million Americans live in areas underserved by physicians, according to government estimates.  The American Medical Association estimates that 16,000 more doctors are needed to fill the gap. 7 Although there are 2.6 physicians per 1,000 residents in the United States, they are not distributed equally among the states.  For example [see Figure III]:

  • Massachusetts has 4.3 doctors per 1,000 residents.
  • At 2.4 per 1,000 residents, Florida is close to the U.S. average for physicians per capita. 8
  • Idaho has only 1.6 physicians per 1,000 residents.

“A majority of emergency room visits are for nonemergencies.”

However, these averages mask wide variations in the number of physicians within states.  For example, in California, the counties of Glenn, Modoc and Yuba have fewer than one physician (0.78) per 1,000 residents.  By contrast, the wealthy suburban counties around San Francisco Bay have about three times as many per thousand (2.33). 9

Rural patients must often travel long distances to see a primary care physician.  They have even more problems finding specialists.

Problem:  Patients overuse emergency rooms.  Fifty-five percent of the 114 million visits to hospital emergency rooms in a given year are for nonemergencies. 10 Even patients judged their conditions as nonurgent.  A 2006 survey of California hospitals found that nearly half of ER patients thought they could have resolved their medical problem with a visit to their doctor,  but they were unable to obtain timely access to care. 11 [See Figure IV.] Patients who seek nonurgent care in the hospital emergency room waste significant resources because the ER is one of the most costly ways to obtain routine treatments. 12 Medical Doctors Per 1,000 Population

Overall, the total cost of unnecessary physician office visits and unnecessary emergency room visits is just under $31 billion annually, or about $300 per American household per year. 13

Why do people with health coverage visit an emergency room for nonurgent care?  Because they cannot easily obtain care from their primary physician outside office hours.  According to the 2006 California survey of recent emergency room patients:

  • Seventy-one percent of Medicaid enrollees and 63 percent of privately insured visitors claimed seeking Emergency Room care was more convenient than seeking care from their doctor.
  • More than half of both groups experienced symptoms after normal office hours or on a weekend, when their physician was not available.
  • Nearly half of patients who visited an ER said they could not get a timely doctor's appointment. [See Figure V.]

“Insured emergency room patients say the ER is more convenient.”

Problem: Patients have difficulty getting information during office visits.  The average time physicians spend with individual patients has not fallen significantly, but the amount of information physicians need to convey to patients during an office visit has grown.  This includes discussing prevention, potential medical treatments, possible drug interactions, safety warnings and so forth.  The proportion of physicians saying they do not have enough time to spend with patients rose nearly 24 percent between 1997 and 2001, from 28 percent to 34 percent of doctors surveyed. 14 Unnecessary ER Visits

According to a recent article in the Journal of the American Medical Association , patients usually want more information about their medical condition than they receive from their doctors.  For instance:

  • During a 20-minute office visit, physicians spend less than one minute planning treatment, on the average.
  • Doctors discuss options and help patients arrive at a treatment based on their preferences during fewer than one in 10 office visits.
  • About half the time, doctors fail to ask patients whether they have questions. 15

“Most patients agree medical errors are preventable.”

A Harris Poll found that even when physicians offer to answer patients' questions, 60 percent of patients forget some of the questions they meant to ask. 16 Moreover, patients retain only a fraction of the information they receive from their physician during an office visit. 17 Patients perceive that this lack of communication negatively affects the quality of patient care.  For instance, more than two-thirds of the public (72 percent) think “insufficient time spent by doctors with patients” is one cause of preventable medical errors, and three-fourths (78 percent) think that the occurrence of medical errors could be reduced if physicians spent more time with patients. 18 [See Figure VI.]

Problem:  Fragmented care.  P atient medical records are often handwritten and are usually maintained and stored separately by each physician, clinic or hospital they use.  Consequently, conditions affecting the patient may be unknown at the time of treatment. Because most patients see a number of physicians over time, care is fragmented, and doctors and other medical providers often must treat a patient with limited information. This lack of care coordination often leads to medical errors, adverse drug events and redundant medical tests. 19 Patient Beliefs About Preventable Medical Errors

Problem: Treating the chronically ill is especially difficult.   The estimated cost of chronic diseases in the United States, including treatment and lost productivity, is $1.3 trillion per year. 20 Unless this trend is reversed, by 2023 the cost will swell to $4.2 trillion.

More than 125 million Americans have chronic medical conditions. 21 Most are not receiving appropriate care from their physicians. 22 For instance, less than one-quarter of patients with high blood pressure control it adequately.  Twenty percent of Type-1 diabetic patients do not see a doctor annually. Twice that number do not test their blood sugar level regularly, and 40 percent do not receive recommended yearly retinal examinations. 23 [See Figure VII.]  One reason for this poor compliance with recommended care is that physicians often lack an integrated system to monitor their patients' chronic conditions. 24

“Many patients with chronic illnesses get inadequate care.”

Helping patients properly manage a chronic condition — especially diabetes, which often results in complications such as heart disease — is often complex and time-consuming. 25 In fact, millions of people have multiple chronic conditions. When multiple physicians are treating a patient for multiple conditions, a case manager must ensure that they are coordinating their efforts. However, such close monitoring and interaction is labor-intensive and costly. Insurers rarely reimburse these management tasks, or reimburse them at rates lower than the cost of providing the services.

Patient Beliefs About Preventable Medical Errors

Care for Diabetes Patients

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