Primary Care After Covid-19

Michael L. Barnett is a primary care doctor at Brigham and Women’s Hospital and an assistant professor of health policy and management at the Harvard T.H. Chan School of Public Health. He wrote in the Washington Post that the pandemic is changing assumptions and providing new insights into how primary care can work without traditional office visits. “Across the country, covid-19 is providing a vivid illustration that not every patient needs to be seen in person for every health-care issue,” he writes. “Good riddance. The dominance of the office visit, driven purely by how we pay for health care, distorts so much of what doctors do.”

While office visits and in-person interactions between doctor and patient will obviously always be essential, the pandemic is demonstrating just how much can be done in other, less cumbersome, or costly ways.

Dr. Barnett stated, “Covid-19 is giving us a sense of how much of our work we can do without tethering doctors to an exam room. At my hospital, we still run a daily “non-covid” clinic for patients who need to see a doctor in person. Any primary care physician in our large group can refer a patient to come in. To my astonishment, no more than 5 percent of our hundreds of daily telemedicine visits are being referred for these in-person visits. No doubt the deadly virus lurking in any corner pushes down the number of referrals: It’s understandable that patients might want to avoid in-person visits and doctors might be reluctant to push them. But we never thought the number would be that low. When the non-covid clinic opened, we staffed it with six doctors, but only two patients showed up. Now, it turns out that a single doctor can manage the typical afternoon’s load, though we staff two so that there is no pressure to rush visits.”

Barnett points out that healthy patients can mostly be managed by phone, or even with occasional patient portal messages. Much preventive care, including screening for colon cancer or even cervical cancer, can happen at home. Patients with chronic illness can use common devices such as home blood pressure cuffs and glucose monitors to gather basic data. And up to one-third of referrals to specialists could be resolved with ‘eConsults’ without an additional appointment. All of this is possible with the right payment system that rewards doctors for providing the level of care that patients need, not what insurance will pay for.

            Dr. Barnett continued, ´The degree to which the system values doctor convenience over patient health leads to endless absurdities. Under current insurance rules, it’s easier to pay to transport a frail, immobile patient across town in a stretcher than to have a doctor visit them at home. Patients come to the office just to ask me to email their specialist because their appointment is weeks off and they can’t reach their other doctor any other way. Other patients on my worry list I almost never see, because they can’t take two hours off work or child care to brave traffic, parking and the waiting room.

This is not to say that we should eliminate in-person conversations between doctors and patients. But finding the right combination of interactions — whether emails, home visits or in-office appointments — between doctors and patients should be the norm.

Of course, seeing a doctor in person is still essential. We can’t transition to other methods of doctor-patient conversations until patients have access to and feel comfortable with the technology that makes those interactions possible. But the intimacy and rapport that can develop in an exam room can’t happen if the patient can’t come to an appointment at all.