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Friday Oct 14, 2016

Could Self Care or Telehealth Curb Overuse of Health Care?

The leaves are changing colors and pumpkin spice lattes are a morning staple; autumn is here. Fall also marks the beginning of upper respiratory infection season -- the coughing, cold, pharyngitis and congestion family physicians are intimately familiar with.

Patients with upper respiratory infections (URIs) represent somewhat of a break in my schedule, which is usually filled with more complex conditions. It's clinically simple to diagnosis URIs and differentiate who will benefit from supportive care versus which patients may need something more.

Acute URI is one of the most common reasons for outpatient visits in primary care(www.cdc.gov). However, one study found about 72 percent of these office visits are unnecessary(www.ncbi.nlm.nih.gov). Why? They usually end with supportive care and the patients recovering on their own.

Analysis of patient utilization behavior is growing at a time when more people have insurance but there is a shortage of physicians to care for them. The disparate reality is we have a culture of overconsumption of health care and limited resources. Much of the analysis has focused on decreasing emergency department or specialty utilization with diversion to primary care.

However, our country faces a shortfall of up to 31,000 primary care physicians by 2025.

A group in the U.K. has already explored this issue. The Self Care Forum(www.selfcareforum.org), started by a group of physician advocates, encourages patients to self-treat minor illnesses rather than immediately seeking a doctor. The campaign includes educational materials(www.selfcareforum.org) on conditions like URIs, heartburn, constipation and eczema. Patients are advised to follow up with a physician only if symptoms don't improve after a trial of treatment, generally over-the-counter or supportive.

"This does not mean denying treatment to those who are sick, but making sure that people receive the services they actually need. That's clinical need, not demand – and there's a difference," according to the organization's manifesto(www.selfcareforum.org).

The authors' reasoning centers on issues that also plague our health care system. With limited resources, it's unsustainable for every patient to be seen by a physician for every health ailment.

However, the self-care movement has faced criticism because it's the clinician's job to diagnose, not the patient's.

The self-care approach is paradoxical for me. I am entrenched in the notion of publicly encouraging everyone to "follow up with your family doctor." We are best suited to ensure that what feels like a simple case of heartburn isn't something more dangerous. But I'm also aware seeing a family physician for every minor ailment is not a sustainable approach to health care.

Another solution is to properly direct patients to more cost-effective services. Telehealth is a promising approach(www.thinkbrg.com), with the potential to reduce demand for physician services by 25 percent. Patients who can access clinicians through email, phone, video or even an app can avoid an unnecessary office visit. And of course, the clinicians could be nonphysician members of a physician-led health care team.

This virtual approach to care has been a cornerstone of success in my office for a variety of conditions, including allergies, yeast infections and colds. Patients say they feel more connected to us because we are wholly accessible. And patients follow up if they don't improve quickly.

Of course, there are two limitations to this approach: payment and liability. In a fee-for-service model, virtual services are often not reimbursable despite the fact that they take precious time. Additionally, in our litigious culture it is presumed safer for a physician to evaluate a patient in person to avoid a misdiagnosis.

Nonetheless, the self-care movement in the U.K. has evolved to include even chronic disease management, with telephone coaching and group visits. Improving health literacy in communities is another goal for success of the movement.

The more dire outcome of the primary care physician shortage in the United States is a migration of patients to retail health centers when primary care physicians are unavailable. Retail health centers actually increase patient utilization of health services (content.healthaffairs.org) and drive up health care spending.

So while it breaks from dogma, this season I will be telling my patients with a cold to stay home, get better and not follow up with their family doctor (unless necessary). But our team is available via app if they need us.

Natasha Bhuyan, M.D., is a board-certified family physician in Phoenix. You can follow her on Twitter @NatashaBhuyan(twitter.com).

Posted at 03:39PM Oct 14, 2016 by Natasha Bhuyan, M.D.

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