Lockdown Lesson: When Life Gets In The Way Of Medical Care

You've heard of house calls. The post below suggests to me that we may need a new term: "The house-to-house call," in which both the doctor and the patient are at home. An appealing idea, but as Dr. Lee H. Schwamm writes below, it will need to overcome some obstacles to take off. Dr. Schwamm is the executive vice chairman of neurology at Massachusetts General Hospital and medical director of Mass General TeleHealth.

By Dr. Lee Schwamm
Guest contributor

Last Friday was a day that Boston stood still, as the city and its hospitals coped with the aftermath of the tragedy at the Boston Marathon.

But in smaller ways, for many patients who had waited weeks or months for their previously scheduled doctors' appointments that day, it was also a challenge. There were few if any routine visits to the doctor last Friday in Boston.

For one lucky patient, however, the visit still took place. A Massachusetts General Hospital patient — let’s call him Mr. Jones to protect his privacy — had recently been diagnosed with a disabling neurological condition and was eager to have his follow-up visit with Dr. Eric Klawiter, a neurologist at MGH and one of a group of younger physicians participating in a new initiative called Mass General TeleHealth.

Even though Dr. Klawiter was confined to his home and Mr. Jones was unable to drive into the city under Governor Patrick’s request to shelter in place, at the appointed time both men turned on their laptop computers, pressed a few keys, and were instantly connected to one another.

Dr. Klawiter was able to gather the history, evaluate some of the neurological complaints, and even review the results of Mr. Jones’ brain scans by sharing the actual images over the screen and highlighting areas of concern or reassurance.

'This sounds like a success story all around, but there is a catch.'

For Mr. Jones, the entire visit occurred in the comfort and convenience of his home, and the information that was shared was no different, and perhaps a bit better in some ways, than what would happen in a typical office visit.

Both were delighted with the visit, the first one that MGH has performed using a new “video visit” model for routine home-based neurological followup. While the MGH Stroke Service has been providing emergency TeleStroke evaluation for acute stroke care to over 30 hospitals in New England for over a decade, this was the first time we applied a scaled-down version to the home for a non-emergency condition.

Granted, there was no checking of his blood pressure, and we can’t yet stick a tongue depressor in your throat over a laptop, but for many encounters with a provider, this isn’t the main focus of the visit. When it is needed, many of these simple procedures can also be done beforehand in other venues such as the local pharmacy or nearby shopping mall, allowing this information to be reassembled at the doctor visit.

With growing shortages of neurologists and other specialists, we are under increasing pressure to make access to specialty care more effective and affordable. With specialists increasingly concentrated in big cities, disparities in access to specialty care are on the rise. So this sounds like a success story all around, but there is a catch.

Under current Medicare and commercial insurance rules, neither the hospital nor Dr. Klawiter got paid a penny for this visit. And none of the providers in our other recently launched video visit pilots did either.

Even though there are five pending bills before the Massachusetts state legislature trying to change this, Massachusetts General Hospital needed to absorb all the costs of this new care model. While we hope that in the future, payment models will be designed to address the needs of populations of patients and keeping them healthy, in today’s reality, hospitals that want to forge new models of care delivery like this that are patient-centered, convenient and affordable must do so based on the conviction that it’s the right thing for patients.

Certainly, last Friday, it was the right thing to do for Mr. Jones.

We hope that nothing ever, ever happens again that would force us to lock down an entire city, and we learned many new important lessons about medical care from our experiences last week.

But this event taught me one thing I hadn’t anticipated, which is that life gets in the way of people’s ability to seek proper medical care every day, and that our obligation to fix that problem is just as imperative as our ability to ensure access for the most critically ill.

Related CommonHealth post: Will health reform finally push doctors to email and Skype?