Is Healthcare Better Without Doctors?

In all the talk about creating a medical home for every American, it's important to realize that increasingly, consumers are getting their healthcare outside of the traditional physician-based healthcare system. And that may very well be a good thing.

"Access to healthcare does not necessarily mean going to the doctor anymore," says health consultant Mary Kate Scott of Scott & Co. In her report for the California HealthCare Foundation released last week, Scott points to the rapid expansion of drugs and devices to test, monitor, and treat medical conditions without the physician office visit that defined access to healthcare a decade or two ago. In fact, a physician isn't required in the process at all.

"We're going to see an explosion in medical devices, and over-the counter drugs," as well as telemedicine applications for their use, Scott says.

"Consumers can purchase more than 700 over-the-counter medications whose ingredients and dosages were once available only by prescription," she writes in her report. "And in the last 15 years, numerous over-the-counter devices have become available" enabling oneself, or a non-physician to diagnose, monitor and treat a medical condition.

And that is the wave of the future, she predicts. "It's not like consumers love going to the doctor. They actually don't."

A person can now test one's own cholesterol levels for $10 with a store-bought kit, monitor blood glucose, assess blood coagulation to guard against problems with anticoagulant drugs, visit a kiosk to detect a urinary tract infection, and even undergo kidney dialysis at home.

Companies are marketing their DNA test kits directly to the consumer as well. And even though the state of California has outlawed that practice, it's a hard rule to enforce.

Her report, entitled "Health Care Without the Doctor: How New Devices and Technologies Aid Clinicians and Consumers," says the trend is being accelerated by a mushrooming number of companies developing such products. She adds that there is increasing consumer interest in purchasing such products regardless of whether a physician advised it, concerns about privacy and fear of being discriminated against if an employer or insurer learns of a pre-existing condition, the ease and low cost of their use, and more direct-to-consumer marketing.

The trend is getting another push from the fact that today, non-physician providers, specifically mid-level clinicians, "can administer tests that once were the exclusive purview of physicians and laboratories, which makes diagnostic, monitoring, and treatment capabilities more widely accessible."

But there are a number of impediments to the use of these new technologies, Scott warns. Physicians need to encourage their patients to use them, and even inform them of their existence, something they now have no incentive to do.

"The physician centered medical home is a very old-fashion model that means you have to show up in a physician's office. And the more they do for us the more they get paid," she says. That's wrong, she adds.

Scott says health payers need to start reimbursing doctors for health outcomes. "Perhaps a doctor can be rewarded on the overall health of their patient population," not on the basis of how many times they see a patient.

She realizes that organized medicine will not necessarily want this change. "Physicians will not advocate something that's a competitor," she says. "They think ‘I can do a better job; I need to see the patient to diagnose.' And they're also worried about liability."

 "Older physicians tend to favor in-person diagnosis and treatment, while many younger clinicians are comfortable with e-mail communications, video consultations, and self care," she writes in her report.

"Bridging this gulf by determining, for example, what kind of evidence would convince physicians that new technologies and self-care can be beneficial, might speed the shift to more convenient, consumer-friendly diagnosis, monitoring, and treatment technologies."

Additionally, the U.S. Food and Drug Administration needs to more highly prioritize the hundreds of technologies now awaiting approval under the Clinical Laboratory Improvement Amendments waiver process.  And the FDA needs to focus more attention to make sure that the devices are packaged in a way that makes it easy for the consumer to understand and use safely.

One question that remains unanswered in Scott's report is how much money expanding consumer-directed testing and treatment can actually save.

Somehow, health systems need to put in place certain rules, perhaps at the point of sale, to assure that those who purchase and use such drugs, test kits, and devices are competent to do so. 

We know that one-third of all Medicare expenditures are spent in the last year of life, and one-third of those in the last month, a period when patients may not be in a health condition that allows the ability to even go to a store to make a purchase, much less make a sound choice or use the device properly.

But Scott does see significant cost savings. "It's really just a lot like going online to get your boarding pass for a flight," she says. "At first, the industry said ‘consumers will hate this. Because they would much rather engage with a real person at the counter.'" Now, she says, it's rare to find someone who would not prefer to check in online.

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